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2013 Florida Statutes
Chapter 409
SOCIAL AND ECONOMIC ASSISTANCE
SOCIAL AND ECONOMIC ASSISTANCE
TITLE XXX
SOCIAL WELFARECHAPTER 409
SOCIAL AND ECONOMIC ASSISTANCE
PART I
SOCIAL AND ECONOMIC ASSISTANCE(ss. 409.016-409.5093)
PART II
KIDCARE(ss. 409.810-409.821)
PART III
MEDICAID(ss. 409.901-409.9205)
PART IV
MEDICAID MANAGED CARE(ss. 409.961-409.985)
PART I
SOCIAL AND ECONOMIC ASSISTANCE409.016 Definitions.
409.017 Revenue Maximization Act; legislative intent; revenue maximization program.
409.031 State agency for administering social service funds.
409.141 Equitable reimbursement methodology.
409.145 Care of children; quality parenting; “reasonable and prudent parent” standard.
409.1451 The Road-to-Independence Program.
409.1452 Collaboration with Board of Governors, Florida College System, and Department of Education to assist children and young adults who have been or are in foster care.
409.1453 Design and dissemination of training for foster care caregivers.
409.146 Children and families client and management information system.
409.147 Children’s initiatives.
409.153 Implementation of Healthy Families Florida program.
409.165 Alternate care for children.
409.166 Children within the child welfare system; adoption assistance program.
409.167 Statewide adoption exchange; establishment; responsibilities; registration requirements; rules.
409.1671 Foster care and related services; outsourcing.
409.16713 Allocation of funds for community-based care lead agencies.
409.16715 Therapy treatments designed to mitigate out-of-home placement for dependent children.
409.16745 Community partnership matching grant program.
409.1675 Lead community-based providers; receivership.
409.1676 Comprehensive residential group care services to children who have extraordinary needs.
409.1677 Model comprehensive residential services programs.
409.1678 Safe harbor for children who are victims of sexual exploitation.
409.1679 Additional requirements; reimbursement methodology.
409.175 Licensure of family foster homes, residential child-caring agencies, and child-placing agencies; public records exemption.
409.1753 Foster care; duties.
409.1755 One Church, One Child of Florida Corporation Act; creation; duties.
409.1757 Persons not required to be refingerprinted or rescreened.
409.176 Registration of residential child-caring agencies and family foster homes.
409.179 Family-friendly workplace initiative.
409.212 Optional supplementation.
409.221 Consumer-directed care program.
409.2355 Programs for prosecution of males over age 21 who commit certain offenses involving girls under age 16.
409.2551 Legislative intent.
409.2554 Definitions; ss. 409.2551-409.2598.
409.2557 State agency for administering child support enforcement program.
409.25575 Support enforcement; privatization.
409.2558 Support distribution and disbursement.
409.2559 State disbursement unit.
409.256 Administrative proceeding to establish paternity or paternity and child support; order to appear for genetic testing.
409.2561 Support obligations when public assistance is paid; assignment of rights; subrogation; medical and health insurance information.
409.2563 Administrative establishment of child support obligations.
409.25635 Determination and collection of noncovered medical expenses.
409.2564 Actions for support.
409.25641 Procedures for processing interstate enforcement requests.
409.2565 Publication of delinquent obligors.
409.25656 Garnishment.
409.25657 Requirements for financial institutions.
409.25658 Use of unclaimed property for past due support.
409.25659 Insurance claim data exchange.
409.25661 Public records exemption for insurance claim data exchange information.
409.2567 Services to individuals not otherwise eligible.
409.2569 Continuation of support services for recipients of public assistance when benefits are terminated.
409.257 Service of process.
409.2571 Court and witness fees; bond.
409.2572 Cooperation.
409.2574 Income deduction enforcement in Title IV-D cases.
409.2575 Liens on motor vehicles and vessels.
409.2576 State Directory of New Hires.
409.2577 Parent locator service.
409.2578 Access to employment information; administrative fine.
409.2579 Safeguarding Title IV-D case file information.
409.2581 Use of clearing accounts and revolving funds.
409.2584 Interest on obligations due; waiver.
409.259 Filing fees in Title IV-D cases; electronic filing of pleadings, returns of service, and other papers.
409.2594 Record requirements.
409.2597 Retention of actions.
409.2598 License suspension proceeding to enforce support order.
409.2599 Data processing services; interagency agreement.
409.25995 State Title IV-D agency; contracts.
409.2673 Shared county and state health care program for low-income persons.
409.26731 Certification of local funds as state match for federally funded services.
409.285 Opportunity for hearing and appeal.
409.352 Licensing requirements for physicians, osteopathic physicians, and chiropractic physicians employed by the department.
409.401 Interstate Compact on the Placement of Children.
409.402 Financial responsibility for child.
409.403 Definitions; Interstate Compact on the Placement of Children.
409.404 Agreements between party state officers and agencies.
409.405 Court placement of delinquent children.
409.406 Interstate Compact on Adoption and Medical Assistance.
409.407 Interstate agreements between the Department of Children and Family Services and agencies of other states.
409.408 Interstate Compact for the Placement of Children.
409.409 Effect of existing compact provisions.
409.4101 Rulemaking authority.
409.441 Runaway youth programs and centers.
409.508 Low-income home energy assistance program.
409.509 Definitions; weatherization of low-income residences.
409.5091 Department responsible for weatherizing agencies; energy assessment.
409.5093 Replacement agency.
409.016 Definitions.—As used in this chapter:
(1) “Department,” unless otherwise specified, means the Department of Children and Family Services.
(2) “Secretary” means the secretary of the Department of Children and Family Services.
(3) “Social and economic services,” within the meaning of this chapter, means the providing of financial assistance as well as preventive and rehabilitative social services for children, adults, and families.
History.—s. 1, ch. 70-255; s. 2, ch. 78-433; s. 110, ch. 97-101.
409.017 Revenue Maximization Act; legislative intent; revenue maximization program.—
(1) SHORT TITLE.—This section may be cited as the “Revenue Maximization Act.”
(2) LEGISLATIVE INTENT.—
(a) The Legislature recognizes that state funds do not fully utilize federal funding matching opportunities for health and human services needs. It is the intent of the Legislature to authorize the use of certified local funding for federal matching programs to the fullest extent possible to maximize federal funding of local preventive services and local child development programs in this state. To that end, the Legislature expects that state agencies will take a proactive approach in implementing this legislative priority. It is the further intent of the Legislature that this act shall be revenue neutral with respect to state funds.
(b) It is the intent of the Legislature that revenue maximization opportunities using certified local funding shall occur only after available state funds have been utilized to generate matching federal funding for the state.
(c) It is the intent of the Legislature that participation in revenue maximization is to be voluntary for local political subdivisions.
(d) Except for funds expended pursuant to Title XIX of the Social Security Act, it is the intent of the Legislature that certified local funding for federal matching programs not supplant or replace state funds. Beginning July 1, 2004, any state funds supplanted or replaced with local tax revenues for Title XIX funds shall be expressly approved in the General Appropriations Act or by the Legislative Budget Commission pursuant to chapter 216.
(e) It is the intent of the Legislature that revenue maximization shall not divert existing funds from state agencies that are currently using local funds to maximize matching federal and state funds to the greatest extent possible.
(f) It is the intent of the Legislature to encourage and allow any agency to engage, through a competitive procurement process, an entity with expertise in claiming justifiable and appropriate federal funds through revenue maximization efforts both retrospectively and prospectively. This claiming may include, but not be limited to, administrative and services activities that are eligible under federal matching programs.
(3) REVENUE MAXIMIZATION PROGRAM.—
(a) For purposes of this section, the term “agency” means any state agency or department that is involved in providing health, social, or human services, including, but not limited to, the Agency for Health Care Administration, the Department of Children and Family Services, the Department of Elderly Affairs, the Department of Juvenile Justice, the Department of Education, and the State Board of Education.
(b) The Agency for Health Care Administration may develop a procurement document and procedure to claim administrative federal matching funds for state-provided educational services. The agency shall then competitively procure an entity with appropriate expertise and experience to retrospectively and prospectively maximize federal revenues through administrative claims for federal matching funds for state-provided educational services.
(c) Each agency shall establish programs and mechanisms designed to maximize the use of local funding for federal programs in accordance with this section.
(d) The use of local matching funds under this section must be limited to public revenue funds of local political subdivisions, including, but not limited to, counties, municipalities, and special districts. To the extent permitted by federal law, funds donated to such local political subdivisions by private entities, such as, but not limited to, the United Way, community foundations or other foundations, and businesses, or by individuals are considered to be public revenue funds available for matching federal funding.
(e) Subject to paragraph (g), any federal reimbursement received as a result of the certification of local matching funds must, unless specifically prohibited by federal law or state law, including the General Appropriations Act, and subject to the availability of specific appropriation and release authority, be returned within 30 days after receipt by the agency by the most expedient means possible to the local political subdivision providing such funding, and the local political subdivision must be provided an annual accounting of federal reimbursements received by the state or its agencies as a result of the certification of the local political subdivision’s matching funds. The receipt by a local political subdivision of such matching funds must not in any way influence or be used as a factor in developing any agency’s annual operating budget allocation methodology or formula or any subsequent budget amendment allocations or formulas. If necessary, agreements must be made between an agency and the local political subdivision to accomplish that purpose. Such an agreement may provide that the local political subdivision must: verify the eligibility of the local program or programs and the individuals served thereby to qualify for federal matching funds; shall develop and maintain the financial records necessary for documenting the appropriate use of federal funds; shall comply with all applicable state and federal laws, regulations, and rules that regulate such federal services; and shall reimburse the cost of any disallowance of federal funding previously provided to a local political subdivision resulting from the failure of that local political subdivision to comply with applicable state or federal laws, rules, or regulations.
(f) Each agency, as applicable, shall work with local political subdivisions to modify any state plans and to seek and implement any federal waivers necessary to implement this section. If such modifications or waivers require the approval of the Legislature, the agency, as applicable, shall draft such legislation and present it to the President of the Senate and the Speaker of the House of Representatives and to the respective committee chairs of the Senate and the House of Representatives by January 1, 2004, and, as applicable, annually thereafter.
(g) Each agency, as applicable, before funds generated under this section are distributed to any local political subdivision, may deduct the actual administrative cost for implementing and monitoring the local match program; however, such administrative costs may not exceed 5 percent of the total federal reimbursement funding to be provided to the local political subdivision under paragraph (e). To the extent that any other provision of state law applies to the certification of local matching funds for a specific program, the provisions of that statute which relate to administrative costs apply in lieu of the provisions of this paragraph. The failure to remit reimbursement to the local political subdivision will result in the payment of interest, in addition to the amount to be reimbursed at a rate pursuant to s. 55.03(1) on the unpaid amount from the expiration of the 30-day period until payment is received.
(h) Each agency, respectively, shall annually submit to the Governor, the President of the Senate, and the Speaker of the House of Representatives, no later than January 1, a report that documents the specific activities undertaken during the previous fiscal year under this section. The report must include, but is not limited to, a statement of the total amount of federal matching funds generated by local matching funds under this section, reported by federal funding source; the total amount of block grant funds expended during the previous fiscal year, reported by federal funding source; the total amount for federal matching fund programs, including, but not limited to, Temporary Assistance for Needy Families and Child Care and Development Fund, of unobligated funds and unliquidated funds, both as of the close of the previous federal fiscal year; the amount of unliquidated funds that is in danger of being returned to the Federal Government at the end of the current federal fiscal year; and a detailed plan and timeline for spending any unobligated and unliquidated funds by the end of the current federal fiscal year.
History.—s. 1, ch. 2003-146; s. 48, ch. 2004-5; s. 2, ch. 2008-143; s. 299, ch. 2011-142.
409.031 State agency for administering social service funds.—The department is designated as the state agency responsible for the administration of social service funds under Title XX of the Social Security Act.
History.—s. 1, ch. 78-433.
409.141 Equitable reimbursement methodology.—
(1) To assure high standards of care and essential residential services as a component of the services continuum for at-risk youth and families, the Department of Children and Family Services shall adopt an equitable reimbursement methodology. This methodology, which addresses only those children placed in nonprofit residential group care by the department and funded through public appropriations, shall consist of a standardized base of allowable costs of a provider’s actual per diem rate costs. The actual percentage of base costs met through this methodology shall be determined by the availability of state funding. The full utilization of the department’s Children, Youth and Families Purchase of Residential Group Care Appropriation Category shall be used to fund this methodology. Definitions of care and allowable costs shall be based upon those mandated services standards as set out in chapter 10M-9, Florida Administrative Code (Licensing Standards Residential Child Care Agencies), plus any special enhancements required by the specific treatment component. Actual costs shall be verified through the agency’s annual fiscal audit for the 2 prior calendar years.
(2) This adopted rate control method shall include a consumer price index factor to acknowledge both the postaudit time lapse of the allowable costs methodology and the universal cost variables beyond the control of the group care providers.
(3) This methodology shall assure that the existing disparities between actual costs of care and the current state reimbursement levels are addressed in a fair and systematic manner, while recognizing that nonprofit residential group care providers shall provide the remaining percentage of their program costs. Cost containment measures shall be included through the allowable costs definition and verification process.
(4) The Department of Children and Family Services shall develop administrative rules in full cooperation with the Florida Group Child Care Association to carry out the intent and provisions of this section.
History.—s. 1, ch. 90-204; s. 111, ch. 97-101.
409.145 Care of children; quality parenting; “reasonable and prudent parent” standard.—The child welfare system of the department shall operate as a coordinated community-based system of care which empowers all caregivers for children in foster care to provide quality parenting, including approving or disapproving a child’s participation in activities based on the caregiver’s assessment using the “reasonable and prudent parent” standard.
(1) SYSTEM OF CARE.—The department shall develop, implement, and administer a coordinated community-based system of care for children who are found to be dependent and their families. This system of care must be directed toward the following goals:
(a) Prevention of separation of children from their families.
(b) Intervention to allow children to remain safely in their own homes.
(c) Reunification of families who have had children removed from their care.
(d) Safety for children who are separated from their families by providing alternative emergency or longer-term parenting arrangements.
(e) Focus on the well-being of children through emphasis on maintaining educational stability and providing timely health care.
(f) Permanency for children for whom reunification with their families is not possible or is not in the best interest of the child.
(g) The transition to independence and self-sufficiency for older children who remain in foster care through adolescence.
(2) QUALITY PARENTING.—A child in foster care shall be placed only with a caregiver who has the ability to care for the child, is willing to accept responsibility for providing care, and is willing and able to learn about and be respectful of the child’s culture, religion and ethnicity, special physical or psychological needs, any circumstances unique to the child, and family relationships. The department, the community-based care lead agency, and other agencies shall provide such caregiver with all available information necessary to assist the caregiver in determining whether he or she is able to appropriately care for a particular child.
(a) Roles and responsibilities of caregivers.—A caregiver shall:
1. Participate in developing the case plan for the child and his or her family and work with others involved in his or her care to implement this plan. This participation includes the caregiver’s involvement in all team meetings or court hearings related to the child’s care.
2. Complete all training needed to improve skills in parenting a child who has experienced trauma due to neglect, abuse, or separation from home, to meet the child’s special needs, and to work effectively with child welfare agencies, the court, the schools, and other community and governmental agencies.
3. Respect and support the child’s ties to members of his or her biological family and assist the child in maintaining allowable visitation and other forms of communication.
4. Effectively advocate for the child in the caregiver’s care with the child welfare system, the court, and community agencies, including the school, child care, health and mental health providers, and employers.
5. Participate fully in the child’s medical, psychological, and dental care as the caregiver would for his or her biological child.
6. Support the child’s school success by participating in school activities and meetings, including Individual Education Plan meetings, assisting with school assignments, supporting tutoring programs, meeting with teachers and working with an educational surrogate if one has been appointed, and encouraging the child’s participation in extracurricular activities.
7. Work in partnership with other stakeholders to obtain and maintain records that are important to the child’s well-being, including child resource records, medical records, school records, photographs, and records of special events and achievements.
8. Ensure that the child in the caregiver’s care who is between 13 and 17 years of age learns and masters independent living skills.
9. Ensure that the child in the caregiver’s care is aware of the requirements and benefits of the Road-to-Independence Program.
10. Work to enable the child in the caregiver’s care to establish and maintain naturally occurring mentoring relationships.
(b) Roles and responsibilities of the department, the community-based care lead agency, and other agency staff.—The department, the community-based care lead agency, and other agency staff shall:
1. Include a caregiver in the development and implementation of the case plan for the child and his or her family. The caregiver shall be authorized to participate in all team meetings or court hearings related to the child’s care and future plans. The caregiver’s participation shall be facilitated through timely notification, an inclusive process, and alternative methods for participation for a caregiver who cannot be physically present.
2. Develop and make available to the caregiver the information, services, training, and support that the caregiver needs to improve his or her skills in parenting children who have experienced trauma due to neglect, abuse, or separation from home, to meet these children’s special needs, and to advocate effectively with child welfare agencies, the courts, schools, and other community and governmental agencies.
3. Provide the caregiver with all information related to services and other benefits that are available to the child.
(c) Transitions.—
1. Once a caregiver accepts the responsibility of caring for a child, the child will be removed from the home of that caregiver only if:
a. The caregiver is clearly unable to safely or legally care for the child;
b. The child and his or her biological family are reunified;
c. The child is being placed in a legally permanent home pursuant to the case plan or a court order; or
d. The removal is demonstrably in the child’s best interest.
2. In the absence of an emergency, if a child leaves the caregiver’s home for a reason provided under subparagraph 1., the transition must be accomplished according to a plan that involves cooperation and sharing of information among all persons involved, respects the child’s developmental stage and psychological needs, ensures the child has all of his or her belongings, allows for a gradual transition from the caregiver’s home and, if possible, for continued contact with the caregiver after the child leaves.
(d) Information sharing.—Whenever a foster home or residential group home assumes responsibility for the care of a child, the department and any additional providers shall make available to the caregiver as soon as is practicable all relevant information concerning the child. Records and information that are required to be shared with caregivers include, but are not limited to:
1. Medical, dental, psychological, psychiatric, and behavioral history, as well as ongoing evaluation or treatment needs;
2. School records;
3. Copies of his or her birth certificate and, if appropriate, immigration status documents;
4. Consents signed by parents;
5. Comprehensive behavioral assessments and other social assessments;
6. Court orders;
7. Visitation and case plans;
8. Guardian ad litem reports;
9. Staffing forms; and
10. Judicial or citizen review panel reports and attachments filed with the court, except confidential medical, psychiatric, and psychological information regarding any party or participant other than the child.
(e) Caregivers employed by residential group homes.—All caregivers in residential group homes shall meet the same education, training, and background and other screening requirements as foster parents.
(3) REASONABLE AND PRUDENT PARENT STANDARD.—
(a) Definitions.—As used in this subsection, the term:
1. “Age-appropriate” means an activity or item that is generally accepted as suitable for a child of the same chronological age or level of maturity. Age appropriateness is based on the development of cognitive, emotional, physical, and behavioral capacity which is typical for an age or age group.
2. “Caregiver” means a person with whom the child is placed in out-of-home care, or a designated official for a group care facility licensed by the department under s. 409.175.
3. “Reasonable and prudent parent” standard means the standard of care used by a caregiver in determining whether to allow a child in his or her care to participate in extracurricular, enrichment, and social activities. This standard is characterized by careful and thoughtful parental decisionmaking that is intended to maintain a child’s health, safety, and best interest while encouraging the child’s emotional and developmental growth.
(b) Application of standard of care.—
1. Every child who comes into out-of-home care pursuant to this chapter is entitled to participate in age-appropriate extracurricular, enrichment, and social activities.
2. Each caregiver shall use the reasonable and prudent parent standard in determining whether to give permission for a child living in out-of-home care to participate in extracurricular, enrichment, or social activities. When using the reasonable and prudent parent standard, the caregiver must consider:
a. The child’s age, maturity, and developmental level to maintain the overall health and safety of the child.
b. The potential risk factors and the appropriateness of the extracurricular, enrichment, or social activity.
c. The best interest of the child, based on information known by the caregiver.
d. The importance of encouraging the child’s emotional and developmental growth.
e. The importance of providing the child with the most family-like living experience possible.
f. The behavioral history of the child and the child’s ability to safely participate in the proposed activity.
(c) Verification of services delivered.—The department and each community-based care lead agency shall verify that private agencies providing out-of-home care services to dependent children have policies in place which are consistent with this section and that these agencies promote and protect the ability of dependent children to participate in age-appropriate extracurricular, enrichment, and social activities.
(d) Limitation of liability.—A caregiver is not liable for harm caused to a child who participates in an activity approved by the caregiver, provided that the caregiver has acted in accordance with the reasonable and prudent parent standard. This paragraph may not be interpreted as removing or limiting any existing liability protection afforded by law.
(4) FOSTER PARENT ROOM AND BOARD RATES.—
(a) Effective January 1, 2014, room and board rates paid to foster parents are as follows:
Monthly | 0-5 Years | 6-12 Years | 13-21 Years |
$429 | $440 | $515 |
(b) Foster parents shall receive an annual cost of living increase. The department shall calculate the new room and board rate increase equal to the percentage change in the Consumer Price Index for All Urban Consumers, U.S. City Average, All Items, not seasonally adjusted, or successor reports, for the preceding December compared to the prior December as initially reported by the United States Department of Labor, Bureau of Labor Statistics. The department shall make available the adjusted room and board rates annually.
(c) The amount of the monthly foster care board rate may be increased upon agreement among the department, the community-based care lead agency, and the foster parent.
(d) Community-based care lead agencies providing care under contract with the department shall pay a supplemental room and board payment to foster care parents for providing independent life skills and normalcy supports to children who are 13 through 17 years of age placed in their care. The supplemental payment shall be paid monthly to the foster care parents on a per-child basis in addition to the current monthly room and board rate payment. The supplemental monthly payment shall be based on 10 percent of the monthly room and board rate for children 13 through 21 years of age as provided under this section and adjusted annually.
(5) RULEMAKING.—The department shall adopt by rule procedures to administer this section.
History.—s. 1, ch. 69-268; ss. 19, 35, ch. 69-106; s. 1, ch. 70-255; s. 26, ch. 73-334; s. 3, ch. 76-168; s. 273, ch. 77-147; s. 1, ch. 77-457; s. 4, ch. 78-190; s. 5, ch. 78-433; s. 101, ch. 79-164; s. 1, ch. 80-174; ss. 2, 3, ch. 81-318; ss. 1, 3, 4, ch. 83-250; s. 39, ch. 88-337; ss. 3, 4, ch. 93-115; ss. 46, 55, ch. 94-164; s. 42, ch. 97-103; s. 37, ch. 98-280; s. 77, ch. 2000-139; s. 49, ch. 2000-153; s. 1, ch. 2000-180; s. 9, ch. 2000-217; s. 49, ch. 2001-62; ss. 2, 9, ch. 2002-19; s. 991, ch. 2002-387; s. 7, ch. 2013-178.
1409.1451 The Road-to-Independence Program.—
(1) LEGISLATIVE FINDINGS AND INTENT.—
(a) The Legislature recognizes that most children and young adults are resilient and, with adequate support, can expect to be successful as independent adults. Not unlike many young adults, some young adults who have lived in foster care need additional support and resources for a period of time after reaching 18 years of age.
(b) The Legislature finds that while it is important to provide young adults who have lived in foster care with education and independent living skills, there is also a need to focus more broadly on creating and preserving family relationships so that young adults have a permanent connection with at least one committed adult who provides a safe and stable parenting relationship.
(c) It is the intent of the Legislature that young adults who choose to participate in the program receive the skills, education, and support necessary to become self-sufficient and leave foster care with a lifelong connection to a supportive adult through the Road-to-Independence Program, either through postsecondary education services and support, as provided in subsection (2), or aftercare services.
(2) POSTSECONDARY EDUCATION SERVICES AND SUPPORT.—
(a) A young adult is eligible for services and support under this subsection if he or she:
1. Was living in licensed care on his or her 18th birthday or is currently living in licensed care; or was at least 16 years of age and was adopted from foster care or placed with a court-approved dependency guardian after spending at least 6 months in licensed care within the 12 months immediately preceding such placement or adoption;
2. Spent at least 6 months in licensed care before reaching his or her 18th birthday;
3. Earned a standard high school diploma or its equivalent pursuant to s. 1003.428, s. 1003.4281, 2s. 1003.429, s. 1003.435, or s. 1003.438;
4. Has been admitted for enrollment as a full-time student or its equivalent in an eligible postsecondary educational institution as provided in s. 1009.533. For purposes of this section, the term “full-time” means 9 credit hours or the vocational school equivalent. A student may enroll part-time if he or she has a recognized disability or is faced with another challenge or circumstance that would prevent full-time attendance. A student needing to enroll part-time for any reason other than having a recognized disability must get approval from his or her academic advisor;
5. Has reached 18 years of age but is not yet 23 years of age;
6. Has applied, with assistance from the young adult’s caregiver and the community-based lead agency, for any other grants and scholarships for which he or she may qualify;
7. Submitted a Free Application for Federal Student Aid which is complete and error free; and
8. Signed an agreement to allow the department and the community-based care lead agency access to school records.
(b) The amount of the financial assistance shall be as follows:
1. For a young adult who does not remain in foster care and is attending a postsecondary school as provided in s. 1009.533, the amount is $1,256 monthly.
2. For a young adult who remains in foster care, is attending a postsecondary school, as provided in s. 1009.533, and continues to reside in a licensed foster home, the amount is the established room and board rate for foster parents. This takes the place of the payment provided for in s. 409.145(4).
3. For a young adult who remains in foster care, but temporarily resides away from a licensed foster home for purposes of attending a postsecondary school as provided in s. 1009.533, the amount is $1,256 monthly. This takes the place of the payment provided for in s. 409.145(4).
4. For a young adult who remains in foster care, is attending a postsecondary school as provided in s. 1009.533, and continues to reside in a licensed group home, the amount is negotiated between the community-based care lead agency and the licensed group home provider.
5. For a young adult who remains in foster care, but temporarily resides away from a licensed group home for purposes of attending a postsecondary school as provided in s. 1009.533, the amount is $1,256 monthly. This takes the place of a negotiated room and board rate.
6. The amount of the award may be disregarded for purposes of determining the eligibility for, or the amount of, any other federal or federally supported assistance.
7. A young adult is eligible to receive financial assistance during the months when enrolled in a postsecondary educational institution.
(c) Payment of financial assistance for a young adult who:
1. Has chosen not to remain in foster care and is attending a postsecondary school as provided in s. 1009.533, shall be made to the community-based care lead agency in order to secure housing and utilities, with the balance being paid directly to the young adult until such time the lead agency and the young adult determine that the young adult can successfully manage the full amount of the assistance.
2. Has remained in foster care under s. 39.6251 and who is attending postsecondary school as provided in s. 1009.533, shall be made directly to the foster parent or group home provider.
3. Community-based care lead agencies or other contracted providers are prohibited from charging a fee associated with administering the Road-to-Independence payments.
(d)1. The department must advertise the availability of the stipend and must provide notification of the criteria and application procedures for the stipend to children and young adults leaving, or who were formerly in, foster care; caregivers; case managers; guidance and family services counselors; principals or other relevant school administrators; and guardians ad litem.
2. If the award recipient transfers from one eligible institution to another and continues to meet eligibility requirements, the award shall be transferred with the recipient.
3. The department, or an agency under contract with the department, shall evaluate each Road-to-Independence award for renewal eligibility on an annual basis. In order to be eligible for a renewal award for the subsequent year, the young adult must:
a. Be enrolled for or have completed the number of hours, or the equivalent, to be considered a full-time student under subparagraph (a)4., unless the young adult qualifies for an exception under subparagraph (a)4.
b. Maintain standards of academic progress as defined by the education institution, except that if the young adult’s progress is insufficient to renew the award at any time during the eligibility period, the young adult may continue to be enrolled for additional terms while attempting to restore eligibility as long as progress towards the required level is maintained.
4. Funds may be terminated during the interim between an award and the evaluation for a renewal award if the department, or an agency under contract with the department, determines that the award recipient is no longer enrolled in an educational institution as described in subparagraph (a)4. or is no longer a resident of this state.
5. The department, or an agency under contract with the department, shall notify a recipient who is terminated and inform the recipient of his or her right to appeal.
6. An award recipient who does not qualify for a renewal award or who chooses not to renew the award may apply for reinstatement. An application for reinstatement must be made before the young adult reaches 23 years of age. In order to be eligible for reinstatement, the young adult must meet the eligibility criteria and the criteria for award renewal for the program.
(3) AFTERCARE SERVICES.—
(a) Aftercare services are available to a young adult who has reached 18 years of age but is not yet 23 years of age and is:
1. Not in foster care.
2. Temporarily not receiving financial assistance under subsection (2) to pursue postsecondary education.
(b) Aftercare services include, but are not limited to, the following:
1. Mentoring and tutoring.
2. Mental health services and substance abuse counseling.
3. Life skills classes, including credit management and preventive health activities.
4. Parenting classes.
5. Job and career skills training.
6. Counselor consultations.
7. Temporary financial assistance for necessities, including, but not limited to, education supplies, transportation expenses, security deposits for rent and utilities, furnishings, household goods, and other basic living expenses.
8. Financial literacy skills training.
The specific services to be provided under this paragraph shall be determined by an assessment of the young adult and may be provided by the community-based care provider or through referrals in the community.
(c) Temporary assistance provided to prevent homelessness shall be provided as expeditiously as possible and within the limitations defined by the department.
(4) APPEALS PROCESS.—
(a) The department shall have a procedure by which a young adult may appeal the department’s refusal to provide Road-to-Independence Program services or support, or the termination of such services or support if funds for such services or support are available.
(b) The appeal procedure must be readily accessible to young adults, must provide for timely decisions, and must provide for an appeal to the department. The decision of the department constitutes final agency action and is reviewable by the court as provided in s. 120.68.
(5) PORTABILITY.—The services provided under this section are portable across county lines and between lead agencies.
(a) The service needs that are identified in the original or updated transition plan, pursuant to s. 39.6035, shall be provided by the lead agency where the young adult is currently residing but shall be funded by the lead agency who initiated the transition plan.
(b) The lead agency with primary case management responsibilities shall provide maintenance payments, case planning, including a written description of all services that will assist a child 16 years of age or older in preparing for the transition from care to independence, as well as regular case reviews that conform with all federal scheduling and content requirements, for all children in foster care who are placed or visiting out-of-state.
(6) ACCOUNTABILITY.—The department shall develop outcome measures for the program and other performance measures in order to maintain oversight of the program. No later than January 31 of each year, the department shall prepare a report on the outcome measures and the department’s oversight activities and submit the report to the President of the Senate, the Speaker of the House of Representatives, and the committees with jurisdiction over issues relating to children and families in the Senate and the House of Representatives. The report must include:
(a) An analysis of performance on the outcome measures developed under this section reported for each community-based care lead agency and compared with the performance of the department on the same measures.
(b) A description of the department’s oversight of the program, including, by lead agency, any programmatic or fiscal deficiencies found, corrective actions required, and current status of compliance.
(c) Any rules adopted or proposed under this section since the last report. For the purposes of the first report, any rules adopted or proposed under this section must be included.
(7) INDEPENDENT LIVING SERVICES ADVISORY COUNCIL.—The secretary shall establish the Independent Living Services Advisory Council for the purpose of reviewing and making recommendations concerning the implementation and operation of the provisions of 3s. 39.6015 and the Road-to-Independence Program. The advisory council shall function as specified in this subsection until the Legislature determines that the advisory council can no longer provide a valuable contribution to the department’s efforts to achieve the goals of the services designed to enable a young adult to live independently.
(a) The advisory council shall assess the implementation and operation of the Road-to-Independence Program and advise the department on actions that would improve the ability of these Road-to-Independence Program services to meet the established goals. The advisory council shall keep the department informed of problems being experienced with the services, barriers to the effective and efficient integration of services and support across systems, and successes that the system of services has achieved. The department shall consider, but is not required to implement, the recommendations of the advisory council.
(b) The advisory council shall report to the secretary on the status of the implementation of the Road-to-Independence Program, efforts to publicize the availability of the Road-to-Independence Program, the success of the services, problems identified, recommendations for department or legislative action, and the department’s implementation of the recommendations contained in the Independent Living Services Integration Workgroup Report submitted to the appropriate substantive committees of the Legislature by December 31, 2013. The department shall submit a report by December 31 of each year to the Governor, the President of the Senate, and the Speaker of the House of Representatives which includes a summary of the factors reported on by the council and identifies the recommendations of the advisory council and either describes the department’s actions to implement the recommendations or provides the department’s rationale for not implementing the recommendations.
(c) Members of the advisory council shall be appointed by the secretary of the department. The membership of the advisory council must include, at a minimum, representatives from the headquarters and regional offices of the Department of Children and Families, community-based care lead agencies, the Department of Juvenile Justice, the Department of Economic Opportunity, the Department of Education, the Agency for Health Care Administration, the State Youth Advisory Board, Workforce Florida, Inc., the Statewide Guardian Ad Litem Office, foster parents, recipients of services and funding through the Road-to-Independence Program, and advocates for children in care. The secretary shall determine the length of the term to be served by each member appointed to the advisory council, which may not exceed 4 years.
(d) The department shall provide administrative support to the Independent Living Services Advisory Council to accomplish its assigned tasks. The advisory council shall be afforded access to all appropriate data from the department, each community-based care lead agency, and other relevant agencies in order to accomplish the tasks set forth in this section. The data collected may not include any information that would identify a specific child or young adult.
(e) The advisory council report required under paragraph (b) must include an analysis of the system of independent living transition services for young adults who reach 18 years of age while in foster care before completing high school or its equivalent and recommendations for department or legislative action. The council shall assess and report on the most effective method of assisting these young adults to complete high school or its equivalent by examining the practices of other states.
(8) PERSONAL PROPERTY.—Property acquired on behalf of a young adult in this program shall become the personal property of the young adult and is not subject to the requirements of chapter 273 relating to state-owned tangible personal property. Such property continues to be subject to applicable federal laws.
(9) MEDICAL ASSISTANCE FOR YOUNG ADULTS FORMERLY IN CARE.—The department or community-based care lead agency shall document that eligible young adults are enrolled in Medicaid under s. 409.903(4).
(10) RULEMAKING.—The department shall adopt rules to administer this section.
History.—s. 3, ch. 2002-19; s. 44, ch. 2003-1; s. 6, ch. 2003-146; s. 1, ch. 2004-362; s. 3, ch. 2005-179; ss. 11, 17, ch. 2006-194; s. 2, ch. 2007-147; s. 1, ch. 2008-122; s. 118, ch. 2010-102; s. 4, ch. 2010-158; s. 300, ch. 2011-142; s. 4, ch. 2013-21; s. 39, ch. 2013-35; s. 8, ch. 2013-178.
1Note.—
A. As amended by s. 39, ch. 2013-35, and amended and substantially reworded by s. 8, ch. 2013-178. Former paragraph (3)(a) and subsection (10) were also amended by s. 4, ch. 2013-21, without reference to the substantial rewording of the section by s. 8, ch. 2013-178. As amended by s. 4, ch. 2013-21, only, paragraph (3)(a) and subsection (10) read:
(a) It is the intent of the Legislature for the Department of Children and Families to assist older children in foster care and young adults who exit foster care at age 18 in making the transition to independent living and self-sufficiency as adults. The department shall provide such children and young adults with opportunities to participate in life skills activities in their foster families and communities which are reasonable and appropriate for their respective ages or for any special needs they may have and shall provide them with services to build life skills and increase their ability to live independently and become self-sufficient. To support the provision of opportunities for participation in age-appropriate life skills activities, the department shall:
1. Develop a list of age-appropriate activities and responsibilities to be offered to all children involved in independent living transition services and their foster parents.
2. Provide training for staff and foster parents to address the issues of older children in foster care in transitioning to adulthood, which shall include information on high school completion, grant applications, vocational school opportunities, supporting education and employment opportunities, and opportunities to participate in appropriate daily activities.
3. Establish the authority of foster parents, family foster homes, residential child-caring agencies, or other authorized caregivers to approve participation in age-appropriate activities of children in their care according to a reasonable and prudent parent standard. Foster parents, family foster homes, residential child-caring agencies, or other authorized caregivers employing the reasonable and prudent parent standard in their decisionmaking shall not be held responsible under administrative rules or laws pertaining to state licensure or have their licensure status in any manner jeopardized as a result of the actions of a child engaged in the approved age-appropriate activities. Goals and objectives for participation in extracurricular, enrichment, and social activities, as well as specific information on the child’s progress toward meeting those objectives, shall be incorporated into the agency’s written judicial social study report and shall be reviewed by the court at each hearing conducted pursuant to s. 39.701.
4. Provide opportunities for older children in foster care to interact with mentors.
5. Develop and implement procedures for older children to directly access and manage the personal allowance they receive from the department in order to learn responsibility and participate in age-appropriate life skills activities to the extent feasible.
6. Make a good faith effort to fully explain, prior to execution of any signature, if required, any document, report, form, or other record, whether written or electronic, presented to a child or young adult pursuant to this chapter and allow for the recipient to ask any appropriate questions necessary to fully understand the document. It shall be the responsibility of the person presenting the document to the child or young adult to comply with this subparagraph.
* * * * *
(10) RULEMAKING.—The department shall adopt rules to administer this section. The rules must provide caregivers with as much flexibility as possible to enable the children in their care to participate in normal life experiences and must reflect the considerations listed in s. 39.4091(3)(b) in connection with the reasonable and prudent parent standard established in that section. The department shall engage in appropriate planning to prevent, to the extent possible, a reduction in awards after issuance. The department shall adopt rules to govern the payments and conditions related to payments for services to youth or young adults provided under this section.
B. Section 12, ch. 2013-178, provides that “[e]ffective January 1, 2014, a child or young adult who is a participant in the program shall transfer to the program services provided in this act, and his or her monthly stipend may not be reduced, the method of payment of the monthly stipend may not be changed, and the young adult may not be required to change his or her living arrangement. These conditions shall remain in effect for a child or young adult until he or she ceases to meet the eligibility requirements under which he or she entered the Road-to-Independence Program. A child or young adult applying or reapplying for the Road-to-Independence Program on or after January 1, 2014, may apply for program services only as provided in this act.”
3Note.—Section 39.6015 does not exist; the intended reference is to s. 39.6251, which relates to continuing care for young adults.
409.1452 Collaboration with Board of Governors, Florida College System, and Department of Education to assist children and young adults who have been or are in foster care.—Effective July 1, 2013, the Department of Children and Families shall work in collaboration with the Board of Governors, the Florida College System, and the Department of Education to help address the need for a comprehensive support structure in the academic arena to assist children and young adults who have been or continue to remain in the foster care system in making the transition from a structured care system into an independent living setting. The State University System of Florida and the Florida College System shall provide postsecondary educational campus coaching positions that will be integrated into Florida College System institutions’ and university institutions’ general support services structure to provide current and former foster care children and young adults with dedicated, on-campus support. The Department of Children and Families has the sole discretion to determine which state college or university will offer a campus coaching position, based on departmental demographic data indicating greatest need. These campus coaching positions shall be employees of the selected educational institutions, focused on supporting children and young adults who have been or continue to remain in the foster care system. The Chancellors of the Florida College System and the Board of Governors shall report annually to the Department of Children and Families specific data, subject to privacy laws, about the children and young adults served by the campus coaches, including academic progress, retention rates for students enrolled in the program, financial aid requested and received, and information required by the National Youth in Transition Database.
History.—s. 11, ch. 2013-178.
409.1453 Design and dissemination of training for foster care caregivers.—The Department of Children and Families in collaboration with the Florida Foster and Adoptive Parent Association and the Quality Parenting Initiative will design and disseminate training for caregivers on skill building on the life skills necessary for youth in the foster care system.
History.—s. 13, ch. 2013-178.
409.146 Children and families client and management information system.—
(1) The Department of Children and Family Services shall establish a children and families client and management information system which shall provide information concerning children served by the children and families programs.
(2) The children and families client and management information system shall provide, at a minimum, an integrated service delivery information system to implement comprehensive screening, uniform assessment, case planning, monitoring, resource matching, and outcome evaluations for all of the following program services categories and related program components as defined in s. 20.19 and chapter 39:
(a) Child welfare and prevention and diversion services.
(b) Child care services.
(3) The system shall be designed to promote efficient and effective use of resources and accountability designed to provide the most appropriate, least restrictive services for all clients in the children and families programs. It shall contain, at a minimum, that information deemed to be essential for ongoing administration of service delivery and outcome evaluation systems, as well as for the purpose of management decisions.
(4) The system shall be operated in such a manner as to facilitate the service delivery goals of the children receiving the children and families programs and services.
(5) The Department of Children and Family Services shall employ accepted current system development methodology to determine the appropriate design and contents of the system, as well as the most rapid feasible implementation schedule as outlined in the information resources management operational plan of the Department of Children and Family Services.
(6) The Department of Children and Family Services shall aggregate, on a quarterly and an annual basis, the information and statistical data of the children and families client and management information system into a descriptive report and shall disseminate the quarterly and annual reports to interested parties, including substantive committees of the House of Representatives and the Senate.
(7) Whenever feasible, the system shall have online computers and shall be available for data entry and retrieval at the unit level of organization by program component counselors.
(8) Children and families program staff responsible for services shall be trained in the use of the system.
(9) The Department of Children and Family Services shall provide an annual report to the President of the Senate and the Speaker of the House of Representatives. In developing the system, the Department of Children and Family Services shall consider and report on the availability of, and the costs associated with using, existing software and systems, including, but not limited to, those that are operational in other states, to meet the requirements of this section. The department shall also consider and report on the compatibility of such existing software and systems with an integrated management information system. The report shall be submitted no later than December 1 of each year.
History.—s. 41, ch. 90-306; s. 11, ch. 91-158; s. 8, ch. 92-58; s. 69, ch. 94-209; s. 31, ch. 95-267; s. 112, ch. 97-101; s. 34, ch. 2011-34.
409.147 Children’s initiatives.—
(1) LEGISLATIVE FINDINGS AND INTENT.—
(a) The Legislature finds that:
1. There are neighborhoods in the state where the infrastructure and opportunities that middle-class communities take for granted are nonexistent or so marginal that they are ineffective.
2. Children living in these neighborhoods are not read to by an adult on a regular basis and attend a prekindergarten education program at a much lower rate than children in other communities. These children experience below-average performance on standardized tests and graduate from high school in fewer numbers. Most of these children are eligible for the free or reduced-price school lunch program.
3. Children in these neighborhoods often suffer from high rates of asthma, a higher risk of lead poisoning, and inadequate health care, and they are routinely exposed to violence and crime.
4. In spite of these obstacles, these neighborhoods are many times home to strong individuals and institutions that are committed to making a difference in the lives of children and their families.
(b) It is therefore the intent of the Legislature to assist disadvantaged areas within the state in creating a community-based service network that develops, coordinates, and provides quality education, accessible health care, youth development programs, opportunities for employment, and safe and affordable housing for children and families living within its boundaries.
(2) POLICY AND PURPOSE.—It is the policy of this state to provide the necessary means to assist local communities, the children and families who live in those communities, and the private sector in creating a sound educational, social, and economic environment. To achieve this objective, the state intends to provide investments sufficient to encourage community partners to commit financial and other resources to severely disadvantaged areas. The purpose of this section is to establish a process that clearly identifies the severely disadvantaged areas and provides guidance for developing a new social service paradigm that systematically coordinates programs that address the critical needs of children and their families and for directing efforts to rebuild the basic infrastructure of the community. The Legislature, therefore, declares the creation of children’s initiatives, through the collaborative efforts of government and the private sector, to be a public purpose.
(3) DEFINITIONS.—As used in this section, the term:
(a) “Governing body” means the commission or other legislative body charged with governing a county or municipality.
(b) “Ounce” means the Ounce of Prevention Fund of Florida, Inc.
(c) “Planning team” means a children’s initiative planning team established under this section.
(d) “Resident” means a person who lives or operates a small community-based business or organization within the boundaries of the children’s initiative.
(4) CHILDREN’S INITIATIVE NOMINATING PROCESS.—A county or municipality, or a county and one or more municipalities together, may apply to the Ounce to designate an area as a children’s initiative after the governing body:
(a) Adopts a resolution that:
1. Finds that an area exists in such county or municipality, or in the county and one or more municipalities, that chronically exhibits extreme and unacceptable levels of poverty, unemployment, physical deterioration, as well as limited access to quality educational, health care, and social services.
2. Determines that the rehabilitation, conservation, or redevelopment, or a combination thereof, of the area is necessary in the interest of improving the health, wellness, education, living conditions, and livelihoods of the children and families who live in the county or municipality.
3. Determines that the revitalization of the area can occur only if the state and the private sector invest resources to improve infrastructure and the provision of services.
(b) Establishes a children’s initiative planning team as provided in subsection (5).
(c) Develops and adopts a strategic community plan as provided in subsection (6).
(d) Creates a corporation not for profit as provided in subsection (7).
(5) CHILDREN’S INITIATIVE PLANNING TEAM.—
(a) After the governing body adopts the resolution described in subsection (4), the county or municipality shall establish a children’s initiative planning team.
(b) The planning team shall include residents and representatives from community-based organizations and other community institutions. At least half of the members of the planning team must be residents.
(c) The planning team shall:
1. Develop a planning process that sets the direction for, builds a commitment to, and develops the capacity to realize the children’s initiative concept.
2. Develop a vision of what the children’s initiative will look like when the challenges, problems, and opportunities in the children’s initiative are successfully addressed.
3. Identify important opportunities, strengths, challenges, and problems in the children’s initiative.
4. Develop a strategic community plan consisting of goals, objectives, tasks, the designation of responsible parties, the identification of resources needed, timelines for implementation of the plan, and procedures for monitoring outcomes.
(d) The planning team shall designate working groups to specifically address each of the following focus areas:
1. Early development and care of children.
2. Education of children and youth.
3. Health and wellness.
4. Youth support.
5. Parent and guardian support.
6. Adult education, training, and jobs.
7. Community safety.
8. Housing and community development.
(6) CHILDREN’S INITIATIVE STRATEGIC COMMUNITY PLAN.—After the governing body adopts the resolution described in subsection (4), the working groups shall develop objectives and identify strategies for each focus area. The objectives, specified by focus area, for a working group may include, but not be limited to:
(a) Early development and care of children.
1. Providing resources to enable every child to be adequately nurtured during the first 3 years of life.
2. Ensuring that all schools are ready for children and all children are ready for school.
3. Facilitating enrollment in half-day or full-day prekindergarten for all 3-year-old and 4-year-old children.
4. Strengthening parent and guardian relationships with care providers.
5. Providing support and education for families and child care providers.
(b) Education of children and youth.
1. Increasing the level and degree of accountability of persons who are responsible for the development and well-being of all children in the children’s initiative.
2. Changing the structure and function of schools to increase the quality and amount of time spent on instruction and increase programmatic options and offerings.
3. Creating a safe and respectful environment for student learning.
4. Identifying and supporting points of alignment between the children’s initiative community plan and the school district’s strategic plan.
(c) Health and wellness.
1. Facilitating enrollment of all eligible children in the Florida Kidcare program and providing full access to high-quality drug and alcohol treatment services.
2. Eliminating health disparities between racial and cultural groups, including improving outcomes and increasing interventions.
3. Providing fresh, good quality, affordable, and nutritious food within the children’s initiative.
4. Providing all children in the children’s initiative with access to safe structured and unstructured recreation.
(d) Youth support.
1. Increasing the high school graduation rate.
2. Increasing leadership development and employment opportunities for youth.
(e) Parent and guardian support.
1. Increasing parent and adult literacy.
2. Expanding access for parents to critical resources, such as jobs, transportation, day care, and after-school care.
3. Improving the effectiveness of the ways in which support systems communicate and collaborate with parents and the ways in which parents communicate and collaborate with support systems.
4. Making the services of the Healthy Families Florida program available to provide multiyear support to expectant parents and persons caring for infants and toddlers.
(f) Adult education, training, and jobs.
1. Creating job opportunities for adults that lead to career development.
2. Establishing a career and technical school, or a satellite of such a school in the children’s initiative, which includes a one-stop career center.
(g) Community safety.
1. Providing a safe environment for all children at home, in school, and in the community.
2. Eliminating the economic, political, and social forces that lead to a lack of safety within the family, the community, schools, and institutional structures.
3. Assessing policies and practices, including sentencing, incarceration, detention, and data reporting, in order to reduce youth violence, crime, and recidivism.
(h) Housing and community development.
1. Strengthening the residential real estate market.
2. Building on existing efforts to promote socioeconomic diversity when developing a comprehensive land use strategic plan.
3. Promoting neighborhood beautification strategies.
(7) CHILDREN’S INITIATIVE CORPORATION.—After the governing body adopts the resolution described in subsection (4), establishes the planning team as provided in subsection (5), and develops and adopts the strategic community plan as provided in subsection (6), the county or municipality shall create a corporation not for profit which shall be registered, incorporated, organized, and operated in compliance with chapter 617. The purpose of the corporation is to facilitate fundraising, to secure broad community ownership of the children’s initiative, and, if the area selected by the governing body is designated as a children’s initiative, to:
(a) Begin to transfer responsibility for planning from the planning team to the corporation.
(b) Begin the implementation and governance of the children’s initiative community plan.
(8) CREATION OF MIAMI CHILDREN’S INITIATIVE, INC.—
(a) There is created within the Liberty City neighborhood in Miami-Dade County a 10-year project that shall be managed by an entity organized as a corporation not for profit which shall be registered, incorporated, organized, and operated in compliance with chapter 617. An entity may not be incorporated until the governing body has adopted the resolution described in subsection (4), has established the planning team as provided in subsection (5), and has developed and adopted the strategic community plan as provided in subsection (6). The corporation shall be known as the Miami Children’s Initiative, Inc., and shall be administratively housed within the Department of Children and Family Services. However, Miami Children’s Initiative, Inc., is not subject to control, supervision, or direction by the Department of Children and Family Services in any manner. The Legislature determines, however, that public policy dictates that the corporation operate in the most open and accessible manner consistent with its public purpose. Therefore, the Legislature specifically declares that the corporation is subject to chapter 119, relating to public records, chapter 286, relating to public meetings and records, and chapter 287, relating to procurement of commodities or contractual services.
(b) This initiative is designed to encompass an area that is large enough to include all of the necessary components of community life, including, but not limited to, schools, places of worship, recreational facilities, commercial areas, and common space, yet small enough to allow programs and services to reach every willing member of the neighborhood.
(9) CREATION OF THE NEW TOWN SUCCESS ZONE.—
(a) There is created within the City of Jacksonville Council District 9 in Duval County a 10-year project that shall be managed by an entity organized as a corporation not for profit that is registered, incorporated, organized, and operated in compliance with chapter 617. The New Town Success Zone is not subject to control, supervision, or direction by any department of the state in any manner. The Legislature determines, however, that public policy dictates that the corporation operate in the most open and accessible manner consistent with its public purpose. Therefore, the Legislature declares that the corporation is subject to chapter 119, relating to public records, chapter 286, relating to public meetings and records, and chapter 287, relating to procurement of commodities or contractual services.
(b) This initiative is designed to encompass an area that is large enough to include all of the necessary components of community life, including, but not limited to, schools, places of worship, recreational facilities, commercial areas, and common space, yet small enough to allow programs and services to reach every member of the neighborhood who is willing to participate in the project.
(10) CREATION OF THE PARRAMORE KIDZ ZONE.—
(a) There is created within the City of Orlando in Orange County a 10-year project managed by an entity organized as a corporation not for profit that is registered, incorporated, organized, and operated in compliance with chapter 617. The Parramore Kidz Zone program is not subject to the control, supervision, or direction of any department of the state. The Legislature determines, however, that public policy dictates that the corporation operate in the most open and accessible manner consistent with its public purpose. Therefore, the Legislature specifically declares that the corporation is subject to chapter 119, relating to public records, chapter 286, relating to public meetings and records, and chapter 287, relating to procurement of commodities or contractual services.
(b) This initiative is designed to encompass an area that is large enough to include all of the necessary components of community life, including, but not limited to, schools, places of worship, recreational facilities, commercial areas, and common space, yet small enough to allow programs and services to reach every member of the neighborhood who is willing to participate in the project.
(11) IMPLEMENTATION.—
(a) The Miami Children’s Initiative, Inc., the New Town Success Zone, and the Parramore Kidz Zone have been designated as Florida Children’s Initiatives consistent with the legislative intent and purpose of s. 16, chapter 2009-43, Laws of Florida, and as such shall each assist the disadvantaged areas of the state in creating a community-based service network and programming that develops, coordinates, and provides quality education, accessible health care, youth development programs, opportunities for employment, and safe and affordable housing for children and families living within their boundaries.
(b) In order to implement this section for the Miami Children’s Initiative, Inc., the Department of Children and Families shall contract with a not-for-profit corporation, to work in collaboration with the governing body to adopt the resolution described in subsection (4), to establish the planning team as provided in subsection (5), and to develop and adopt the strategic community plan as provided in subsection (6). The not-for-profit corporation is also responsible for the development of a business plan and for the evaluation, fiscal management, and oversight of the Miami Children’s Initiative, Inc.
History.—s. 1, ch. 2008-96; s. 16, ch. 2009-43; s. 1, ch. 2013-81.
409.153 Implementation of Healthy Families Florida program.—The Department of Children and Family Services shall contract with a private nonprofit corporation to implement the Healthy Families Florida program. The private nonprofit corporation shall be incorporated for the purpose of identifying, funding, supporting, and evaluating programs and community initiatives to improve the development and life outcomes of children and to preserve and strengthen families with a primary emphasis on prevention. The private nonprofit corporation shall implement the program. The program shall work in partnership with existing community-based home visitation and family support resources to provide assistance to families in an effort to prevent child abuse. The program shall be voluntary for participants and shall require the informed consent of the participants at the initial contact. The Kempe Family Stress Checklist shall not be used.
History.—s. 1, ch. 98-175.
409.165 Alternate care for children.—
(1) Within funds appropriated, the department shall establish and supervise a program of emergency shelters, runaway shelters, foster homes, group homes, agency-operated group treatment homes, nonpsychiatric residential group care facilities, psychiatric residential treatment facilities, and other appropriate facilities to provide shelter and care for dependent children who must be placed away from their families. The department, in accordance with established goals, shall contract for the provision of such shelter and care by counties, municipalities, nonprofit corporations, and other entities capable of providing needed services if:
(a) The services so provided are available;
(b) The services so provided are more cost-effective than those provided by the department; and
(c) Unless otherwise provided by law, such providers of shelter and care are licensed by the department.
It is the legislative intent that the funds appropriated for the alternate care of children as described in this section may be used to meet the needs of children in their own homes or those of relatives if the children can be safely served in their own homes, or the homes of relatives, and the expenditure of funds in such manner is calculated by the department to be an eventual cost savings over placement of children.
(2) The department may cooperate with all child service institutions or agencies within the state which meet the rules for proper care and supervision prescribed by the department for the well-being of children.
(3) With the written consent of parents, custodians, or guardians, or in accordance with those provisions in chapter 39 that relate to dependent children, the department, under rules properly adopted, may place a child:
(a) With a relative;
(b) With an adult nonrelative approved by the court for long-term custody;
(c) With a person who is considering the adoption of a child in the manner provided for by law;
(d) When limited, except as provided in paragraph (b), to temporary emergency situations, with a responsible adult approved by the court;
(e) With a person or agency licensed by the department in accordance with s. 409.175; or
(f) In a subsidized independent living situation, subject to the provisions of 1s. 409.1451(4)(c),
under such conditions as are determined to be for the best interests or the welfare of the child. Any child placed in an institution or in a family home by the department or its agency may be removed by the department or its agency, and such other disposition may be made as is for the best interest of the child, including transfer of the child to another institution, another home, or the home of the child. Expenditure of funds appropriated for out-of-home care can be used to meet the needs of a child in the child’s own home or the home of a relative if the child can be safely served in the child’s own home or that of a relative if placement can be avoided by the expenditure of such funds, and if the expenditure of such funds in this manner is calculated by the department to be a potential cost savings.
History.—s. 1, ch. 69-268; ss. 19, 35, ch. 69-106; s. 1, ch. 70-255; s. 3, ch. 76-168; s. 275, ch. 77-147; s. 1, ch. 77-457; s. 6, ch. 78-433; s. 102, ch. 79-164; ss. 2, 3, ch. 81-318; ss. 2, 3, 4, ch. 83-250; s. 40, ch. 88-337; s. 4, ch. 91-183; ss. 3, 4, ch. 93-115; ss. 48, 53, ch. 94-164; ss. 4, 9, ch. 2002-19; s. 49, ch. 2006-1.
1Note.—Section 409.1451 was substantially reworded by s. 8, ch. 2013-178; the section no longer contains text that equates to material formerly in s. 409.1451(4)(c).
409.166 Children within the child welfare system; adoption assistance program.—
(1) LEGISLATIVE INTENT.—It is the intent of the Legislature to protect and promote each child’s right to the security and stability of a permanent family home. The Legislature intends to make adoption assistance, including financial aid, available to prospective adoptive parents to enable them to adopt a child in the state’s foster care system who, because of his or her needs, has proven difficult to place in an adoptive home.
(2) DEFINITIONS.—As used in this section, the term:
(a) “Special needs child” means:
1. A child whose permanent custody has been awarded to the department or to a licensed child-placing agency;
2. A child who has established significant emotional ties with his or her foster parents or is not likely to be adopted because he or she is:
a. Eight years of age or older;
b. Developmentally disabled;
c. Physically or emotionally handicapped;
d. Of black or racially mixed parentage; or
e. A member of a sibling group of any age, provided two or more members of a sibling group remain together for purposes of adoption; and
3. Except when the child is being adopted by the child’s foster parents or relative caregivers, a child for whom a reasonable but unsuccessful effort has been made to place the child without providing a maintenance subsidy.
(b) “Adoption assistance” means financial assistance and services provided to a child and his or her adoptive family. Such assistance may include a maintenance subsidy, medical assistance, Medicaid assistance, and reimbursement of nonrecurring expenses associated with the legal adoption. The term also includes a tuition exemption at a postsecondary career program, community college, or state university.
(c) “Child within the child welfare system” or “child” means a special needs child and any other child who was removed from the child’s caregiver due to abuse or neglect and whose permanent custody has been awarded to the department or to a licensed child-placing agency.
(d) “Department” means the Department of Children and Family Services.
(e) “Licensed child-placing agency” has the same meaning as in s. 39.01.
(f) “Maintenance subsidy” means a monthly payment as provided in subsection (4).
(3) ADMINISTRATION OF PROGRAM.—
(a) The department shall establish and administer an adoption program for children to be carried out by the department or by contract with a licensed child-placing agency. The program shall attempt to increase the number of persons seeking to adopt children and the number of finalized adoptions and shall extend adoption assistance, when needed, to the adoptive parents of a child.
(b) The department shall collect and maintain the necessary data and records to evaluate the effectiveness of the program in encouraging and promoting the adoption of children.
(4) ADOPTION ASSISTANCE.—
(a) A maintenance subsidy shall be granted only when all other resources available to a child have been thoroughly explored and it can be clearly established that this is the most acceptable plan for providing permanent placement for the child. The maintenance subsidy may not be used as a substitute for adoptive parent recruitment or as an inducement to adopt a child who might be placed without providing a subsidy. However, it shall be the policy of the department that no child be denied adoption if providing a maintenance subsidy would make adoption possible. The best interest of the child shall be the deciding factor in every case. This section does not prohibit foster parents from applying to adopt a child placed in their care. Foster parents or relative caregivers must be asked if they would adopt without a maintenance subsidy.
(b) The department shall provide adoption assistance to the adoptive parents, subject to specific appropriation, in the amount of $5,000 annually, paid on a monthly basis, for the support and maintenance of a child until the 18th birthday of such child or in an amount other than $5,000 annually as determined by the adoptive parents and the department and memorialized in a written agreement between the adoptive parents and the department. The agreement shall take into consideration the circumstances of the adoptive parents and the needs of the child being adopted. The amount of subsidy may be adjusted based upon changes in the needs of the child or circumstances of the adoptive parents. Changes shall not be made without the concurrence of the adoptive parents. However, in no case shall the amount of the monthly payment exceed the foster care maintenance payment that would have been paid during the same period if the child had been in a foster family home.
(c) The department may provide adoption assistance to the adoptive parents, subject to specific appropriation, for medical assistance initiated after the adoption of the child for medical, surgical, hospital, and related services needed as a result of a physical or mental condition of the child which existed before the adoption and is not covered by Medicaid, Children’s Medical Services, or Children’s Mental Health Services. Such assistance may be initiated at any time but shall terminate on or before the child’s 18th birthday.
(5) ELIGIBILITY FOR SERVICES.—
(a) As a condition of providing adoption assistance under this section, the adoptive parents must enter into an adoption-assistance agreement with the department which specifies the financial assistance and other services to be provided.
(b) A child who is handicapped at the time of adoption shall be eligible for services through the Children’s Medical Services network established under part I of chapter 391 if the child was eligible for such services prior to the adoption.
(6) WAIVER OF ADOPTION FEES.—The adoption fees shall be waived for all adoptive parents who adopt children in the custody of the department. Fees may be waived for families who adopt children in the custody of a licensed child-placing agency or who adopt children through independent adoptions, and who receive or may be eligible for maintenance subsidies through the department. Retroactive reimbursement of fees is not required for families who adopt children in the custody of licensed child-placing agencies.
(7) REIMBURSEMENT FOR EXPENSES.—The department is authorized to reimburse, retroactive to January 1, 1987, up to $1,000 in nonrecurring expenses related to the adoption of a child which have been incurred by adoptive parents. For purposes of this subsection, “nonrecurring expenses” means one-time expenses, such as attorney’s fees, court costs, birth certificate fees, travel expenses, agency fees, and physical examination fees.
(8) RULES.—The department shall adopt rules to administer this section.
History.—ss. 1, 2, 3, 4, 5, 6, ch. 76-203; s. 1, ch. 77-174; s. 1, ch. 77-293; s. 1, ch. 78-362; s. 1, ch. 83-246; s. 17, ch. 84-254; s. 5, ch. 91-99; s. 24, ch. 92-96; s. 113, ch. 97-101; s. 43, ch. 97-103; s. 181, ch. 99-8; s. 50, ch. 2000-153; s. 5, ch. 2007-124; s. 112, ch. 2008-4; s. 7, ch. 2010-158.
409.167 Statewide adoption exchange; establishment; responsibilities; registration requirements; rules.—
(1) The Department of Children and Family Services shall establish, either directly or through purchase, a statewide adoption exchange, with a photo listing component, which shall serve all authorized licensed child-placing agencies in the state as a means of recruiting adoptive families for children who have been legally freed for adoption and who have been permanently placed with the department or a licensed child-placing agency. The exchange shall provide descriptions and photographs of such children, as well as any other information deemed useful in the recruitment of adoptive families for each child. The photo listing component of the adoption exchange must be updated monthly.
(2)(a) Each district of the department shall refer each child in its care who has been legally freed for adoption to the adoption exchange no later than 30 days after the date of acceptance by the department for permanent placement. The referral must be accompanied by a photograph and description of the child.
(b) The department shall establish criteria by which a district may determine that a child need not be registered with the adoption exchange. Within 30 days after the date of acceptance by the department for permanent placement, the name of the child accepted for permanent placement must be forwarded to the statewide adoption exchange by the district together with reference to the specific reason why the child should not be placed on the adoption exchange. If the child has not been placed for adoption within 3 months after the date of acceptance by the department for permanent placement, the district shall provide the adoption exchange with the necessary photograph and information for registration of the child with the adoption exchange and the child shall be placed on the exchange. The department shall establish procedures for monitoring the status of children who are not placed on the adoption exchange within 30 days after the date of acceptance by the department for permanent placement.
(3) In accordance with rules established by the department, the adoption exchange may accept, from licensed child-placing agencies, information pertaining to children meeting the criteria of this section, and to prospective adoptive families, for registration with the exchange.
(4) The adoption exchange shall provide the photo listing service to all licensed child-placing agencies and, in accordance with rules established by the department, to all appropriate citizen groups and other organizations and associations interested in children’s services.
(5) Children who are registered with the statewide adoption exchange and for whom there is no available family resource shall be registered with existing regional and national adoption exchanges.
(6) The department shall adopt rules governing the operation of the statewide adoption exchange.
History.—s. 2, ch. 83-246; s. 47, ch. 94-164; s. 114, ch. 97-101.
409.1671 Foster care and related services; outsourcing.—
(1)(a) It is the intent of the Legislature that the Department of Children and Family Services shall outsource the provision of foster care and related services statewide. It is further the Legislature’s intent to encourage communities and other stakeholders in the well-being of children to participate in assuring that children are safe and well-nurtured. However, while recognizing that some local governments are presently funding portions of certain foster care and related services programs and may choose to expand such funding in the future, the Legislature does not intend by its outsourcing of foster care and related services that any county, municipality, or special district be required to assist in funding programs that previously have been funded by the state. Counties that provide children and family services with at least 40 licensed residential group care beds by July 1, 2003, and provide at least $2 million annually in county general revenue funds to supplement foster and family care services shall continue to contract directly with the state and shall be exempt from the provisions of this section. Nothing in this paragraph prohibits any county, municipality, or special district from future voluntary funding participation in foster care and related services. As used in this section, the term “outsource” means to contract with competent, community-based agencies. The department shall submit a plan to accomplish outsourcing statewide, through a competitive process, phased in over a 3-year period beginning January 1, 2000. This plan must be developed with local community participation, including, but not limited to, input from community-based providers that are currently under contract with the department to furnish community-based foster care and related services, and must include a methodology for determining and transferring all available funds, including federal funds that the provider is eligible for and agrees to earn and that portion of general revenue funds which is currently associated with the services that are being furnished under contract. The methodology must provide for the transfer of funds appropriated and budgeted for all services and programs that have been incorporated into the project, including all management, capital (including current furniture and equipment), and administrative funds to accomplish the transfer of these programs. This methodology must address expected workload and at least the 3 previous years’ experience in expenses and workload. With respect to any district or portion of a district in which outsourcing cannot be accomplished within the 3-year timeframe, the department must clearly state in its plan the reasons the timeframe cannot be met and the efforts that should be made to remediate the obstacles, which may include alternatives to total outsourcing, such as public-private partnerships. As used in this section, the term “related services” includes, but is not limited to, family preservation, independent living, emergency shelter, residential group care, foster care, therapeutic foster care, intensive residential treatment, foster care supervision, case management, postplacement supervision, permanent foster care, and family reunification. Unless otherwise provided for, the state attorney shall provide child welfare legal services, pursuant to chapter 39 and other relevant provisions, in Pinellas and Pasco Counties. When a private nonprofit agency has received case management responsibilities, transferred from the state under this section, for a child who is sheltered or found to be dependent and who is assigned to the care of the outsourcing project, the agency may act as the child’s guardian for the purpose of registering the child in school if a parent or guardian of the child is unavailable and his or her whereabouts cannot reasonably be ascertained. The private nonprofit agency may also seek emergency medical attention for such a child, but only if a parent or guardian of the child is unavailable, his or her whereabouts cannot reasonably be ascertained, and a court order for such emergency medical services cannot be obtained because of the severity of the emergency or because it is after normal working hours. However, the provider may not consent to sterilization, abortion, or termination of life support. If a child’s parents’ rights have been terminated, the nonprofit agency shall act as guardian of the child in all circumstances.
(b) It is the intent of the Legislature that the department will continue to work towards full outsourcing in a manner that assures the viability of the community-based system of care and best provides for the safety of children in the child protection system. To this end, the department is directed to continue the process of outsourcing services in those counties in which signed startup contracts have been executed. The department may also continue to enter into startup contracts with additional counties. However, no services shall be transferred to a community-based care lead agency until the department, in consultation with the local community alliance, has determined and certified in writing to the Governor and the Legislature that the district is prepared to transition the provision of services to the lead agency and that the lead agency is ready to deliver and be accountable for such service provision. In making this determination, the department shall conduct a readiness assessment of the district and the lead agency.
1. The assessment shall evaluate the operational readiness of the district and the lead agency based on:
a. A set of uniform criteria, developed in consultation with currently operating community-based care lead agencies and reflecting national accreditation standards, that evaluate programmatic, financial, technical assistance, training and organizational competencies; and
b. Local criteria reflective of the local community-based care design and the community alliance priorities.
2. The readiness assessment shall be conducted by a joint team of district and lead agency staff with direct experience with the start up and operation of a community-based care service program and representatives from the appropriate community alliance. Within resources available for this purpose, the department may secure outside audit expertise when necessary to assist a readiness assessment team.
3. Upon completion of a readiness assessment, the assessment team shall conduct an exit conference with the district and lead agency staff responsible for the transition.
4. Within 30 days following the exit conference with staff of each district and lead agency, the secretary shall certify in writing to the Governor and the Legislature that both the district and the lead agency are prepared to begin the transition of service provision based on the results of the readiness assessment and the exit conference. The document of certification must include specific evidence of readiness on each element of the readiness instrument utilized by the assessment team as well as a description of each element of readiness needing improvement and strategies being implemented to address each one.
(c) The Auditor General and the Office of Program Policy Analysis and Government Accountability (OPPAGA), in consultation with The Child Welfare League of America and the Louis de la Parte Florida Mental Health Institute, shall jointly review and assess the department’s process for determining district and lead agency readiness.
1. The review must, at a minimum, address the appropriateness of the readiness criteria and instruments applied, the appropriateness of the qualifications of participants on each readiness assessment team, the degree to which the department accurately determined each district and lead agency’s compliance with the readiness criteria, the quality of the technical assistance provided by the department to a lead agency in correcting any weaknesses identified in the readiness assessment, and the degree to which each lead agency overcame any identified weaknesses.
2. Reports of these reviews must be submitted to the appropriate substantive and appropriations committees in the Senate and the House of Representatives on March 1 and September 1 of each year until full transition to community-based care has been accomplished statewide, except that the first report must be submitted by February 1, 2004, and must address all readiness activities undertaken through June 30, 2003. The perspectives of all participants in this review process must be included in each report.
(d) In communities where economic or demographic constraints make it impossible or not feasible to competitively contract with a lead agency, the department shall develop an alternative plan in collaboration with the local community alliance, which may include establishing innovative geographical configurations or consortia of agencies. The plan must detail how the community will continue to implement community-based care through competitively procuring either the specific components of foster care and related services or comprehensive services for defined eligible populations of children and families from qualified licensed agencies as part of its efforts to develop the local capacity for a community-based system of coordinated care. The plan must ensure local control over the management and administration of the service provision in accordance with the intent of this section and may include recognized best business practices, including some form of public or private partnerships.
(e) As used in this section, the term “eligible lead community-based provider” means a single agency with which the department shall contract for the provision of child protective services in a community that is no smaller than a county. The secretary of the department may authorize more than one eligible lead community-based provider within a single county when to do so will result in more effective delivery of foster care and related services. To compete for an outsourcing project, such agency must have:
1. The ability to coordinate, integrate, and manage all child protective services in the designated community in cooperation with child protective investigations.
2. The ability to ensure continuity of care from entry to exit for all children referred from the protective investigation and court systems.
3. The ability to provide directly, or contract for through a local network of providers, all necessary child protective services. Such agencies should directly provide no more than 35 percent of all child protective services provided.
4. The willingness to accept accountability for meeting the outcomes and performance standards related to child protective services established by the Legislature and the Federal Government.
5. The capability and the willingness to serve all children referred to it from the protective investigation and court systems, regardless of the level of funding allocated to the community by the state, provided all related funding is transferred.
6. The willingness to ensure that each individual who provides child protective services completes the training required of child protective service workers by the Department of Children and Family Services.
7. The ability to maintain eligibility to receive all federal child welfare funds, including Title IV-E and IV-A funds, currently being used by the Department of Children and Family Services.
8. Written agreements with Healthy Families Florida lead entities in their community, pursuant to s. 409.153, to promote cooperative planning for the provision of prevention and intervention services.
9. A board of directors, of which at least 51 percent of the membership is comprised of persons residing in this state. Of the state residents, at least 51 percent must also reside within the service area of the lead community-based provider.
(f)1. The Legislature finds that the state has traditionally provided foster care services to children who have been the responsibility of the state. As such, foster children have not had the right to recover for injuries beyond the limitations specified in s. 768.28. The Legislature has determined that foster care and related services need to be outsourced pursuant to this section and that the provision of such services is of paramount importance to the state. The purpose for such outsourcing is to increase the level of safety, security, and stability of children who are or become the responsibility of the state. One of the components necessary to secure a safe and stable environment for such children is that private providers maintain liability insurance. As such, insurance needs to be available and remain available to nongovernmental foster care and related services providers without the resources of such providers being significantly reduced by the cost of maintaining such insurance.
2. The Legislature further finds that, by requiring the following minimum levels of insurance, children in outsourced foster care and related services will gain increased protection and rights of recovery in the event of injury than provided for in s. 768.28.
(g) In any county in which a service contract has not been executed by December 31, 2004, the department shall ensure access to a model comprehensive residential services program as described in s. 409.1677 which, without imposing undue financial, geographic, or other barriers, ensures reasonable and appropriate participation by the family in the child’s program.
1. In order to ensure that the program is operational by December 31, 2004, the department must, by December 31, 2003, begin the process of establishing access to a program in any county in which the department has not either entered into a transition contract or approved a community plan, as described in paragraph (d), which ensures full outsourcing by the statutory deadline.
2. The program must be procured through a competitive process.
3. The Legislature does not intend for the provisions of this paragraph to substitute for the requirement that full conversion to community-based care be accomplished.
(h) Other than an entity to which s. 768.28 applies, any eligible lead community-based provider, as defined in paragraph (e), or its employees or officers, except as otherwise provided in paragraph (i), must, as a part of its contract, obtain a minimum of $1 million per claim/$3 million per incident in general liability insurance coverage. The eligible lead community-based provider must also require that staff who transport client children and families in their personal automobiles in order to carry out their job responsibilities obtain minimum bodily injury liability insurance in the amount of $100,000 per claim, $300,000 per incident, on their personal automobiles. In lieu of personal motor vehicle insurance, the lead community-based provider’s casualty, liability, or motor vehicle insurance carrier may provide nonowned automobile liability coverage. This insurance provides liability insurance for automobiles that the provider uses in connection with the provider’s business but does not own, lease, rent, or borrow. This coverage includes automobiles owned by the employees of the provider or a member of the employee’s household but only while the automobiles are used in connection with the provider’s business. The nonowned automobile coverage for the provider applies as excess coverage over any other collectible insurance. The personal automobile policy for the employee of the provider shall be primary insurance, and the nonowned automobile coverage of the provider acts as excess insurance to the primary insurance. The provider shall provide a minimum limit of $1 million in nonowned automobile coverage. In any tort action brought against such an eligible lead community-based provider or employee, net economic damages shall be limited to $1 million per liability claim and $100,000 per automobile claim, including, but not limited to, past and future medical expenses, wage loss, and loss of earning capacity, offset by any collateral source payment paid or payable. In any tort action brought against such an eligible lead community-based provider, noneconomic damages shall be limited to $200,000 per claim. A claims bill may be brought on behalf of a claimant pursuant to s. 768.28 for any amount exceeding the limits specified in this paragraph. Any offset of collateral source payments made as of the date of the settlement or judgment shall be in accordance with s. 768.76. The lead community-based provider shall not be liable in tort for the acts or omissions of its subcontractors or the officers, agents, or employees of its subcontractors.
(i) The liability of an eligible lead community-based provider described in this section shall be exclusive and in place of all other liability of such provider. The same immunities from liability enjoyed by such providers shall extend as well to each employee of the provider when such employee is acting in furtherance of the provider’s business, including the transportation of clients served, as described in this subsection, in privately owned vehicles. Such immunities shall not be applicable to a provider or an employee who acts in a culpably negligent manner or with willful and wanton disregard or unprovoked physical aggression when such acts result in injury or death or such acts proximately cause such injury or death; nor shall such immunities be applicable to employees of the same provider when each is operating in the furtherance of the provider’s business, but they are assigned primarily to unrelated works within private or public employment. The same immunity provisions enjoyed by a provider shall also apply to any sole proprietor, partner, corporate officer or director, supervisor, or other person who in the course and scope of his or her duties acts in a managerial or policymaking capacity and the conduct that caused the alleged injury arose within the course and scope of those managerial or policymaking duties. Culpable negligence is defined as reckless indifference or grossly careless disregard of human life.
(j) Any subcontractor of an eligible lead community-based provider, as defined in paragraph (e), which is a direct provider of foster care and related services to children and families, and its employees or officers, except as otherwise provided in paragraph (i), must, as a part of its contract, obtain a minimum of $1 million per claim/$3 million per incident in general liability insurance coverage. The subcontractor of an eligible lead community-based provider must also require that staff who transport client children and families in their personal automobiles in order to carry out their job responsibilities obtain minimum bodily injury liability insurance in the amount of $100,000 per claim, $300,000 per incident, on their personal automobiles. In lieu of personal motor vehicle insurance, the subcontractor’s casualty, liability, or motor vehicle insurance carrier may provide nonowned automobile liability coverage. This insurance provides liability insurance for automobiles that the subcontractor uses in connection with the subcontractor’s business but does not own, lease, rent, or borrow. This coverage includes automobiles owned by the employees of the subcontractor or a member of the employee’s household but only while the automobiles are used in connection with the subcontractor’s business. The nonowned automobile coverage for the subcontractor applies as excess coverage over any other collectible insurance. The personal automobile policy for the employee of the subcontractor shall be primary insurance, and the nonowned automobile coverage of the subcontractor acts as excess insurance to the primary insurance. The subcontractor shall provide a minimum limit of $1 million in nonowned automobile coverage. In any tort action brought against such subcontractor or employee, net economic damages shall be limited to $1 million per liability claim and $100,000 per automobile claim, including, but not limited to, past and future medical expenses, wage loss, and loss of earning capacity, offset by any collateral source payment paid or payable. In any tort action brought against such subcontractor, noneconomic damages shall be limited to $200,000 per claim. A claims bill may be brought on behalf of a claimant pursuant to s. 768.28 for any amount exceeding the limits specified in this paragraph. Any offset of collateral source payments made as of the date of the settlement or judgment shall be in accordance with s. 768.76.
(k) The liability of a subcontractor of an eligible lead community-based provider that is a direct provider of foster care and related services as described in this section shall be exclusive and in place of all other liability of such provider. The same immunities from liability enjoyed by such subcontractor provider shall extend as well to each employee of the subcontractor when such employee is acting in furtherance of the subcontractor’s business, including the transportation of clients served, as described in this subsection, in privately owned vehicles. Such immunities shall not be applicable to a subcontractor or an employee who acts in a culpably negligent manner or with willful and wanton disregard or unprovoked physical aggression when such acts result in injury or death or such acts proximately cause such injury or death; nor shall such immunities be applicable to employees of the same subcontractor when each is operating in the furtherance of the subcontractor’s business, but they are assigned primarily to unrelated works within private or public employment. The same immunity provisions enjoyed by a subcontractor shall also apply to any sole proprietor, partner, corporate officer or director, supervisor, or other person who in the course and scope of his or her duties acts in a managerial or policymaking capacity and the conduct that caused the alleged injury arose within the course and scope of those managerial or policymaking duties. Culpable negligence is defined as reckless indifference or grossly careless disregard of human life.
(l) The Legislature is cognizant of the increasing costs of goods and services each year and recognizes that fixing a set amount of compensation actually has the effect of a reduction in compensation each year. Accordingly, the conditional limitations on damages in this section shall be increased at the rate of 5 percent each year, prorated from the effective date of this paragraph to the date at which damages subject to such limitations are awarded by final judgment or settlement.
(2)(a) The department may contract for the delivery, administration, or management of protective services, the services specified in subsection (1) relating to foster care, and other related services or programs, as appropriate. The department shall retain responsibility for the quality of contracted services and programs and shall ensure that services are delivered in accordance with applicable federal and state statutes and regulations. The department must adopt written policies and procedures for monitoring the contract for delivery of services by lead community-based providers. These policies and procedures must, at a minimum, address the evaluation of fiscal accountability and program operations, including provider achievement of performance standards, provider monitoring of subcontractors, and timely followup of corrective actions for significant monitoring findings related to providers and subcontractors. These policies and procedures must also include provisions for reducing the duplication of the department’s program monitoring activities both internally and with other agencies, to the extent possible. The department’s written procedures must ensure that the written findings, conclusions, and recommendations from monitoring the contract for services of lead community-based providers are communicated to the director of the provider agency as expeditiously as possible.
(b) Persons employed by the department in the provision of foster care and related services whose positions are being outsourced under this statute shall be given hiring preference by the provider, if provider qualifications are met.
(3)(a) In order to help ensure a seamless child protection system, the department shall ensure that contracts entered into with community-based agencies pursuant to this section include provisions for a case-transfer process to determine the date that the community-based agency will initiate the appropriate services for a child and family. This case-transfer process must clearly identify the closure of the protective investigation and the initiation of service provision. At the point of case transfer, and at the conclusion of an investigation, the department must provide a complete summary of the findings of the investigation to the community-based agency.
(b) The contracts must also ensure that each community-based agency shall furnish information on its activities in all cases in client case records.
(c) The contract between the department and community-based agencies must include provisions that specify the procedures to be used by the parties to resolve differences in interpreting the contract or to resolve disputes as to the adequacy of the parties’ compliance with their respective obligations under the contract.
(d) Each contract with an eligible lead community-based provider shall provide for the payment by the department to the provider of a reasonable administrative cost in addition to funding for the provision of services.
(e) Each contract with an eligible lead community-based provider must include all performance outcome measures established by the Legislature and that are under the control of the lead agency. The standards must be adjusted annually by contract amendment to enable the department to meet the legislatively established statewide standards.
(4)(a) The department, in consultation with the community-based agencies that are undertaking the outsourced projects, shall establish a quality assurance program for privatized services. The quality assurance program shall be based on standards established by the Adoption and Safe Families Act as well as by a national accrediting organization such as the Council on Accreditation of Services for Families and Children, Inc. (COA) or CARF—the Rehabilitation Accreditation Commission. Each program operated under contract with a community-based agency must be evaluated annually by the department. The department shall, to the extent possible, use independent financial audits provided by the community-based care agency to eliminate or reduce the ongoing contract and administrative reviews conducted by the department. The department may suggest additional items to be included in such independent financial audits to meet the department’s needs. Should the department determine that such independent financial audits are inadequate, then other audits, as necessary, may be conducted by the department. Nothing herein shall abrogate the requirements of s. 215.97. The department shall submit an annual report regarding quality performance, outcome measure attainment, and cost efficiency to the President of the Senate, the Speaker of the House of Representatives, the minority leader of each house of the Legislature, and the Governor no later than January 31 of each year for each project in operation during the preceding fiscal year.
(b) The department shall use these findings in making recommendations to the Governor and the Legislature for future program and funding priorities in the child welfare system.
(5)(a) The community-based agency must comply with statutory requirements and agency rules in the provision of contractual services. Each foster home, therapeutic foster home, emergency shelter, or other placement facility operated by the community-based agency or agencies must be licensed by the Department of Children and Family Services under chapter 402 or this chapter. Each community-based agency must be licensed as a child-caring or child-placing agency by the department under this chapter. The department, in order to eliminate or reduce the number of duplicate inspections by various program offices, shall coordinate inspections required pursuant to licensure of agencies under this section.
(b) Substitute care providers who are licensed under s. 409.175 and have contracted with a lead agency authorized under this section shall also be authorized to provide registered or licensed family day care under s. 402.313, if consistent with federal law and if the home has met the requirements of s. 402.313.
(c) A foster home licensed under s. 409.175 may be dually licensed as a child care home under chapter 402 and may receive a foster care maintenance payment and, to the extent permitted under federal law, school readiness funding for the same child. The department may adopt rules necessary to administer this paragraph.
(6) Beginning January 1, 1999, and continuing at least through June 30, 2000, the Department of Children and Family Services shall outsource all foster care and related services in district 5 while continuing to contract with the current model programs in districts 1, 4, and 13, and in subdistrict 8A, and shall expand the subdistrict 8A pilot program to incorporate Manatee County. Planning for the district 5 outsourcing shall be done by providers that are currently under contract with the department for foster care and related services and shall be done in consultation with the department. A lead provider of the district 5 program shall be competitively selected, must demonstrate the ability to provide necessary comprehensive services through a local network of providers, and must meet criteria established in this section. Contracts with organizations responsible for the model programs must include the management and administration of all outsourced services specified in subsection (1). However, the department may use funds for contract management only after obtaining written approval from the Executive Office of the Governor. The request for such approval must include, but is not limited to, a statement of the proposed amount of such funds and a description of the manner in which such funds will be used. If the community-based organization selected for a model program under this subsection is not a Medicaid provider, the organization shall be issued a Medicaid provider number pursuant to s. 409.907 for the provision of services currently authorized under the state Medicaid plan to those children encompassed in this model and in a manner not to exceed the current level of state expenditure.
(7)(a) The department, in consultation with the Florida Coalition for Children, Inc., shall develop and implement a community-based care risk pool initiative to mitigate the financial risk to eligible lead community-based providers. This initiative shall include:
1. A risk pool application and protocol developed by the department that outline submission criteria, including, but not limited to, financial and program management, descriptive data requirements, and timeframes for submission of applications. Requests for funding from risk pool applicants shall be based on relevant and verifiable service trends and changes that have occurred during the current fiscal year. The application shall confirm that expenditure of approved risk pool funds by the lead community-based provider shall be completed within the current fiscal year.
2. A risk pool peer review committee, appointed by the secretary and consisting of department staff and representatives from at least three nonapplicant community-based care providers, that reviews and assesses all risk pool applications. Upon completion of each application review, the peer review committee shall report its findings and recommendations to the secretary providing, at a minimum, the following information:
a. Justification for the specific funding amount required by the risk pool applicant based on current year service trend data, including validation that the applicant’s financial need was caused by circumstances beyond the control of the lead agency management;
b. Verification that the proposed use of risk pool funds meets at least one of the criteria in paragraph (c); and
c. Evidence of technical assistance provided in an effort to avoid the need to access the risk pool and recommendations for technical assistance to the lead agency to ensure that risk pool funds are expended effectively and that the agency’s need for future risk pool funding is diminished.
(b) Upon approval by the secretary of a risk pool application, the department may request funds from the risk pool in accordance with s. 216.181(6)(a).
(c) The purposes for which the community-based care risk pool shall be used include:
1. Significant changes in the number or composition of clients eligible to receive services.
2. Significant changes in the services that are eligible for reimbursement.
3. Continuity of care in the event of failure, discontinuance of service, or financial misconduct by a lead agency.
4. Significant changes in the mix of available funds.
(d) The department may also request in its annual legislative budget request, and the Governor may recommend, that the funding necessary to carry out paragraph (c) be appropriated to the department. In addition, the department may request the allocation of funds from the community-based care risk pool in accordance with s. 216.181(6)(a). Funds from this pool may be used to match available federal dollars.
1. Such funds shall constitute partial security for contract performance by lead agencies and shall be used to offset the need for a performance bond.
2. The department may separately require a bond to mitigate the financial consequences of potential acts of malfeasance, misfeasance, or criminal violations by the provider.
(e) The department may issue an interest-free loan to the Florida Coalition for Children, Inc., for the purpose of creating a self-insurance program pursuant to law. The loan shall be secured by the cumulative contractual revenue of the community-based care lead agencies participating in the self-insurance program. The amount of the loan shall be in an amount equal to the amount appropriated by the Legislature for this purpose. The terms of the repayment of the loan shall be based on the economic viability of the self-insurance program.
(8) A contract established between the department and a community-based care lead agency under this section must be funded by a grant of general revenue, other applicable state funds, or applicable federal funding sources. A community-based care lead agency may carry forward documented unexpended state funds from one fiscal year to the next; however, the cumulative amount carried forward may not exceed 8 percent of the total contract. Any unexpended state funds in excess of that percentage must be returned to the department. The funds carried forward may not be used in any way that would create increased recurring future obligations, and such funds may not be used for any type of program or service that is not currently authorized by the existing contract with the department. Expenditures of funds carried forward must be separately reported to the department. Any unexpended funds that remain at the end of the contract period shall be returned to the department. Funds carried forward may be retained through any contract renewals and any new procurements as long as the same community-based care lead agency is retained by the department.
(9) The method of payment for a fixed-price contract with a community-based care lead agency shall provide for a 2-month advance payment at the beginning of each fiscal year and equal monthly payments thereafter.
(10) Notwithstanding the provisions of s. 215.425, all documented federal funds earned for the current fiscal year by the department and community-based agencies which exceed the amount appropriated by the Legislature shall be distributed to all entities that contributed to the excess earnings based on a schedule and methodology developed by the department and approved by the Executive Office of the Governor. Distribution shall be pro rata based on total earnings and shall be made only to those entities that contributed to excess earnings. Excess earnings of community-based agencies shall be used only in the service district in which they were earned. Additional state funds appropriated by the Legislature for community-based agencies or made available pursuant to the budgetary amendment process described in s. 216.177 shall be transferred to the community-based agencies. The department shall amend a community-based agency’s contract to permit expenditure of the funds.
(11) Notwithstanding subsection (10), the amount of the annual contract for a community-based care lead agency may be increased by excess federal funds earned in accordance with s. 216.181(11).
(12) The department may outsource programmatic, administrative, or fiscal monitoring oversight of community-based care lead agencies.
(13) Notwithstanding any other provision of law, a community-based care lead agency may make expenditures for staff cellular telephone allowances, contracts requiring deferred payments and maintenance agreements, security deposits for office leases, related agency professional membership dues other than personal professional membership dues, promotional materials, and grant writing services. Expenditures for food and refreshments, other than those provided to clients in the care of the agency or to foster parents, adoptive parents, and caseworkers during training sessions, are not allowable.
(14) Each district and subdistrict that participates in the model program effort or any future outsourcing effort as described in this section must thoroughly analyze and report the complete direct and indirect costs of delivering these services through the department and the full cost of outsourcing, including the cost of monitoring and evaluating the contracted services.
(15) The lead community-based providers and their subcontractors shall be exempt from state travel policies as set forth in s. 112.061(3)(a) for their travel expenses incurred in order to comply with the requirements of this section.
(16) A lead community-based provider and its subcontractors are exempt from including in written contracts and other written documents the statement “sponsored by the State of Florida” or the logo of the Department of Children and Family Services, otherwise required in s. 286.25, unless the lead community-based provider or its subcontractors receive more than 35 percent of their total funding from the state.
History.—s. 49, ch. 94-164; s. 5, ch. 96-402; s. 193, ch. 97-101; s. 1, ch. 98-180; s. 14, ch. 99-168; s. 2, ch. 99-206; s. 9, ch. 2000-139; s. 10, ch. 2000-217; s. 4, ch. 2001-68; s. 8, ch. 2001-191; s. 4, ch. 2002-219; s. 17, ch. 2002-402; s. 7, ch. 2003-146; ss. 26, 27, ch. 2003-399; s. 49, ch. 2004-5; s. 12, ch. 2004-6; ss. 6, 7, 76, ch. 2004-269; s. 2, ch. 2004-356; s. 1, ch. 2005-105; s. 3, ch. 2005-222; s. 1, ch. 2006-30; s. 19, ch. 2008-245; s. 6, ch. 2010-158; s. 16, ch. 2010-210.
409.16713 Allocation of funds for community-based care lead agencies.—
(1) As used in this section, the term:
(a) “Core services funding” means all funds allocated to community-based care lead agencies operating under contract with the department pursuant to s. 409.1671, with the following exceptions:
1. Funds appropriated for independent living;
2. Funds appropriated for maintenance adoption subsidies;
3. Funds allocated by the department for protective investigations training;
4. Nonrecurring funds;
5. Designated mental health wrap-around services funds; and
6. Funds for special projects for a designated community-based care lead agency.
(b) “Equity allocation model” means an allocation model that uses the following factors:
1. Proportion of children in poverty;
2. Proportion of child abuse hotline workload;
3. Proportion of children in care; and
4. Proportion of contribution in the reduction of out-of-home care.
(c) “Proportion of children in poverty” means the average of the proportion of children in the geographic area served by the community-based care lead agency based on the following subcomponents:
1. Children up to 18 years of age who are below the poverty level as determined by the latest available Small Area Income and Poverty Estimates (SAIPE) from the United States Census Bureau;
2. Children eligible for free or reduced-price meals as determined by the latest available survey published by the Department of Education; and
3. The number of children in families receiving benefits from the federal Supplemental Nutrition Assistance Program (SNAP) in the most recent month as determined by the department.
(d) “Proportion of child abuse hotline workload” means the weighted average of the following subcomponents:
1. The average number of initial and additional child abuse reports received during the month for the most recent 12 months based on child protective investigations trend reports as determined by the department. This subcomponent shall be weighted as 20 percent of the factor.
2. The average count of children in investigations in the most recent 12 months based on child protective investigations trend reports as determined by the department. This subcomponent shall be weighted as 40 percent of the factor.
3. The average count of children in investigations with a most serious finding of verified abuse in the most recent 12 months based on child protective investigations trend reports as determined by the department. This subcomponent shall be weighted as 40 percent of the factor.
(e) “Proportion of children in care” means the proportion of the sum of the number of children in care receiving in-home services and the number of children in out-of-home care at the end of the most recent month as reported in the child welfare services trend reports as determined by the department.
(f) “Proportion of contribution in the reduction of out-of-home care” means the proportion of the number of children in out-of-home care on December 31, 2006, minus the number of children in out-of-home care as of the end of the most recent month as reported in the child welfare services trend reports as determined by the department.
(2) The equity allocation of core services funds shall be calculated based on the following weights:
(a) Proportion of children in poverty shall be weighted as 30 percent of the total;
(b) Proportion of child abuse hotline workload shall be weighted as 30 percent of the total;
(c) Proportion of children in care shall be weighted as 30 percent of the total; and
(d) Proportion of contribution to the reduction in out-of-home care shall be weighted as 10 percent of the total.
(3) Beginning in the 2013-2014 state fiscal year, 90 percent of the recurring core services funding for each community-based care lead agency shall be based on the prior year recurring base of core services funds and 10 percent shall be based on the equity allocation model.
(4) Unless otherwise specified in the General Appropriations Act, any new core services funds shall be allocated based on the equity allocation model. Such allocations must be proportional to the proportion of funding based on the equity model and allocated only to the community-based care lead agency contracts if the current funding proportion is less than the proportion of funding based on the equity model.
History.—s. 1, ch. 2011-62; s. 2, ch. 2013-47.
409.16715 Therapy treatments designed to mitigate out-of-home placement for dependent children.—The Department of Children and Family Services may serve dependent children deemed to be in need of family-centered, cognitive-behavioral interventions designed to mitigate out-of-home placements. Treatment services may be evidenced-based with family therapy and group therapy components for youth for whom these services are appropriate. Dependent youth at risk of out-of-home placement or currently within the foster care system are eligible for these family therapy and group therapy services. The services shall be provided as an alternative to specialized therapeutic foster or group care. A child who has been adjudicated delinquent, had adjudication withheld, or committed any violent crime, except for females adjudicated delinquent for domestic violence, any first-degree felony, or any felony direct-filed in adult court, may not be served by the program. The department and each participating dependency court may jointly develop eligibility criteria to identify youth appropriate for services in this program.
History.—s. 8, ch. 2010-158.
409.16745 Community partnership matching grant program.—It is the intent of the Legislature to improve services and local participation in community-based care initiatives by fostering community support and providing enhanced prevention and in-home services, thereby reducing the risk otherwise faced by lead agencies. There is established a community partnership matching grant program to be operated by the Department of Children and Family Services for the purpose of encouraging local participation in community-based care for child welfare. Any children’s services council or other local government entity that makes a financial commitment to a community-based care lead agency is eligible for a grant upon proof that the children’s services council or local government entity has provided the selected lead agency at least $250,000 from any local resources otherwise available to it. The total amount of local contribution may be matched on a two-for-one basis up to a maximum amount of $2 million per council or local government entity. Awarded matching grant funds may be used for any prevention or in-home services provided by the children’s services council or other local government entity that meets temporary-assistance-for-needy-families’ eligibility requirements and can be reasonably expected to reduce the number of children entering the child welfare system. Funding available for the matching grant program is subject to legislative appropriation of nonrecurring funds provided for the purpose.
History.—s. 2, ch. 2001-232; s. 5, ch. 2002-397; s. 8, ch. 2003-146; s. 53, ch. 2005-152.
409.1675 Lead community-based providers; receivership.—
(1) The Department of Children and Family Services may petition a court of competent jurisdiction for the appointment of a receiver for a lead community-based provider established pursuant to s. 409.1671 when any of the following conditions exist:
(a) The lead community-based provider is operating without a license as a child-placing agency.
(b) The lead community-based provider has given less than 120 days’ notice of its intent to cease operations, and arrangements have not been made for another lead community-based provider or for the department to continue the uninterrupted provision of services.
(c) The department determines that conditions exist in the lead community-based provider which present an imminent danger to the health, safety, or welfare of the dependent children under that provider’s care or supervision. Whenever possible, the department shall make a reasonable effort to facilitate the continued operation of the program.
(d) The lead community-based provider cannot meet its current financial obligations to its employees, contractors, or foster parents. Issuance of bad checks or the existence of delinquent obligations for payment of salaries, utilities, or invoices for essential services or commodities shall constitute prima facie evidence that the lead community-based provider lacks the financial ability to meet its financial obligations.
(2)(a) The petition for receivership shall take precedence over other court business unless the court determines that some other pending proceeding, having statutory precedence, has priority.
(b) A hearing shall be conducted within 5 days after the filing of the petition, at which time interested parties shall have the opportunity to present evidence as to whether a receiver should be appointed. The department shall give reasonable notice of the hearing on the petition to the lead community-based provider.
(c) The court shall grant the petition upon finding that one or more of the conditions in subsection (1) exists and the continued existence of the condition or conditions jeopardizes the health, safety, or welfare of dependent children. A receiver may be appointed ex parte when the court determines that one or more of the conditions in subsection (1) exists. After such finding, the court may appoint any person, including an employee of the department who is qualified by education, training, or experience to carry out the duties of the receiver pursuant to this section, except that the court shall not appoint any member of the governing board or any officer of the lead community-based provider. The receiver may be selected from a list of persons qualified to act as receivers which is developed by the department and presented to the court with each petition of receivership.
(d) A receiver may be appointed for up to 90 days, and the department may petition the court for additional 30-day extensions. Sixty days after appointment of a receiver and every 30 days thereafter until the receivership is terminated, the department shall submit to the court an assessment of the lead community-based provider’s ability to ensure the health, safety, and welfare of the dependent children under its supervision.
(3) The receiver shall take such steps as are reasonably necessary to ensure the continued health, safety, and welfare of the dependent children under the supervision of the lead community-based provider and shall exercise those powers and perform those duties set out by the court, including, but not limited to:
(a) Taking such action as is reasonably necessary to protect or conserve the assets or property of the lead community-based provider. The receiver may use the assets and property and any proceeds from any transfer thereof only in the performance of the powers and duties set forth in this section and by order of the court.
(b) Using the assets of the lead community-based provider in the provision of care and services to dependent children.
(c) Entering into contracts and hiring agents and employees to carry out the powers and duties of the receiver under this section.
(d) Having full power to direct, manage, hire, and discharge employees of the lead community-based provider. The receiver shall hire and pay new employees at the rate of compensation, including benefits, approved by the court.
(e) Honoring all leases, mortgages, and contractual obligations of the lead community-based provider, but only to the extent of payments that become due during the period of the receivership.
(4)(a) The receiver shall deposit funds received in a separate account and shall use this account for all disbursements.
(b) A payment to the receiver of any sum owing to the lead community-based provider shall discharge any obligation to the provider to the extent of the payment.
(5) A receiver may petition the court for temporary relief from obligations entered into by the lead community-based provider if the rent, price, or rate of interest required to be paid under the agreement was substantially in excess of a reasonable rent, price, or rate of interest at the time the contract was entered into, or if any material provision of the agreement was unreasonable when compared to contracts negotiated under similar conditions. Any relief in this form provided by the court shall be limited to the life of the receivership, unless otherwise determined by the court.
(6) The court shall set the compensation of the receiver, which shall be considered a necessary expense of a receivership and may grant to the receiver such other authority necessary to ensure the health, safety, and welfare of the children served.
(7) A receiver may be held liable in a personal capacity only for the receiver’s own gross negligence, intentional acts, or breaches of fiduciary duty. This section shall not be interpreted to be a waiver of sovereign immunity should the department be appointed receiver.
(8) If the receiver is not the department, the court may require a receiver to post a bond to ensure the faithful performance of these duties.
(9) The court may terminate a receivership when:
(a) The court determines that the receivership is no longer necessary because the conditions that gave rise to the receivership no longer exist; or
(b) The department has entered into a contract with a new lead community-based provider pursuant to s. 409.1671, and that contractor is ready and able to assume the duties of the previous provider.
(10) Within 30 days after the termination, unless this time period is extended by the court, the receiver shall give the court a complete accounting of all property of which the receiver has taken possession, of all funds collected and disbursed, and of the expenses of the receivership.
(11) Nothing in this section shall be construed to relieve any employee of the lead community-based provider placed in receivership of any civil or criminal liability incurred, or any duty imposed by law, by reason of acts or omissions of the employee prior to the appointment of a receiver; nor shall anything contained in this section be construed to suspend during the receivership any obligation of the employee for payment of taxes or other operating or maintenance expenses of the lead community-based provider or for the payment of mortgages or liens. The lead community-based provider shall retain the right to sell or mortgage any facility under receivership, subject to the prior approval of the court that ordered the receivership.
History.—s. 10, ch. 2000-139.
409.1676 Comprehensive residential group care services to children who have extraordinary needs.—
(1) It is the intent of the Legislature to provide comprehensive residential group care services, including residential care, case management, and other services, to children in the child protection system who have extraordinary needs. These services are to be provided in a residential group care setting by a not-for-profit corporation or a local government entity under a contract with the Department of Children and Family Services or by a lead agency as described in s. 409.1671. These contracts should be designed to provide an identified number of children with access to a full array of services for a fixed price. Further, it is the intent of the Legislature that the Department of Children and Family Services and the Department of Juvenile Justice establish an interagency agreement by December 1, 2002, which describes respective agency responsibilities for referral, placement, service provision, and service coordination for dependent and delinquent youth who are referred to these residential group care facilities. The agreement must require interagency collaboration in the development of terms, conditions, and performance outcomes for residential group care contracts serving the youth referred who have been adjudicated both dependent and delinquent.
(2) As used in this section, the term:
(a) “Child with extraordinary needs” means a dependent child who has serious behavioral problems or who has been determined to be without the options of either reunification with family or adoption.
(b) “Residential group care” means a living environment for children who have been adjudicated dependent and are expected to be in foster care for at least 6 months with 24-hour-awake staff or live-in group home parents or staff. Each facility must be appropriately licensed in this state as a residential child caring agency as defined in s. 409.175(2)(j) and must be accredited by July 1, 2005. A residential group care facility serving children having a serious behavioral problem as defined in this section must have available staff or contract personnel with the clinical expertise, credentials, and training to provide services identified in subsection (4).
(c) “Serious behavioral problems” means behaviors of children who have been assessed by a licensed master’s-level human-services professional to need at a minimum intensive services but who do not meet the criteria of s. 394.492(7). A child with an emotional disturbance as defined in s. 394.492(5) or (6) may be served in residential group care unless a determination is made by a mental health professional that such a setting is inappropriate. A child having a serious behavioral problem must have been determined in the assessment to have at least one of the following risk factors:
1. An adjudication of delinquency and be on conditional release status with the Department of Juvenile Justice.
2. A history of physical aggression or violent behavior toward self or others, animals, or property within the past year.
3. A history of setting fires within the past year.
4. A history of multiple episodes of running away from home or placements within the past year.
5. A history of sexual aggression toward other youth.
(3) The department, in accordance with a specific appropriation for this program, shall contract with a not-for-profit corporation, a local government entity, or the lead agency that has been established in accordance with s. 409.1671 for the performance of residential group care services described in this section. A lead agency that is currently providing residential care may provide this service directly with the approval of the local community alliance. The department or a lead agency may contract for more than one site in a county if that is determined to be the most effective way to achieve the goals set forth in this section.
(4) The lead agency, the contracted not-for-profit corporation, or the local government entity is responsible for a comprehensive assessment, residential care, transportation, access to behavioral health services, recreational activities, clothing, supplies, and miscellaneous expenses associated with caring for these children; for necessary arrangement for or provision of educational services; and for assuring necessary and appropriate health and dental care.
(5) The department may transfer all casework responsibilities for children served under this program to the entity that provides this service, including case management and development and implementation of a case plan in accordance with current standards for child protection services. When the department establishes this program in a community that has a lead agency as described in s. 409.1671, the casework responsibilities must be transferred to the lead agency.
(6) This section does not prohibit any provider of these services from appropriately billing Medicaid for services rendered, from contracting with a local school district for educational services, or from earning federal or local funding for services provided, as long as two or more funding sources do not pay for the same specific service that has been provided to a child.
(7) The lead agency, not-for-profit corporation, or local government entity has the legal authority for children served under this program, as provided in chapter 39 or this chapter, as appropriate, to enroll the child in school, to sign for a driver’s license for the child, to cosign loans and insurance for the child, to sign for medical treatment, and to authorize other such activities.
(8) The department shall provide technical assistance as requested and contract management services.
(9) The provisions of this section shall be implemented to the extent of available appropriations contained in the annual General Appropriations Act for such purpose.
(10) The department may adopt rules necessary to administer this section.
History.—s. 5, ch. 2001-68; s. 5, ch. 2002-219.
409.1677 Model comprehensive residential services programs.—
(1) As used in this section, the term:
(a) “Residential group care” means a living environment for children who have been adjudicated dependent and are expected to be in foster care for a minimum of 6 months with 24-hour-awake staff or live-in group home parents or staff. Beginning July 1, 2001, all facilities must be appropriately licensed in this state, and they must be accredited by July 1, 2005.
(b) “Serious behavioral problems” means behaviors of children who have been assessed by a licensed master’s-level human-services professional to need at a minimum intensive services but who do not meet the criteria of s. 394.492(6) or (7). A child with an emotional disturbance as defined in s. 394.492(5) may be served in residential group care unless a determination is made by a mental health professional that such a setting is inappropriate.
(2) The department shall establish a model comprehensive residential services program in Manatee and Miami-Dade Counties through a contract with the designated lead agency established in accordance with s. 409.1671 or with a private entity capable of providing residential group care and home-based care and experienced in the delivery of a range of services to foster children, if no lead agency exists. These model programs are to serve that portion of eligible children within each county which is specified in the contract, based on funds appropriated, to include a full array of services for a fixed price. The private entity or lead agency is responsible for all programmatic functions necessary to carry out the intent of this section.
(3) Each model must include:
(a) A focus on serving the full range of children in foster care, including those who have specialized needs, such as children who are unlikely to be reunited with their families or placed in adoptive homes; sibling groups; children who have serious behavioral problems; and children who are victims of sexual abuse.
(b) For each child who is in care, the provision of or arrangements for a comprehensive assessment; residential care; transportation; behavioral health services; recreational activities; clothing, supplies, and miscellaneous expenses associated with caring for these children; educational services; necessary and appropriate health and dental care; legal services; and aftercare services.
(c) A commitment and ability to find and use innovative approaches to address the problems in the traditional foster care system, such as high caregiver turnover, disrupted and multiple placements, runaway behavior, and abusive or nontherapeutic care.
(d) The provision of a full range of residential services tailored to the individual needs of each child in care, including group homes for initial assessment and for stabilization; professional and traditional foster homes; residential group care provided in a setting that is homelike and provides care in residences housing no more than 12 children and staffed with full-time, appropriately trained house parents; and independent living apartments. The programs are designed for children who must enter the foster care system, but the use of placement with relatives as part of a child’s care is encouraged.
(e) The provision of the full range of administrative services necessary to operate the program.
(f) Specific eligibility criteria established in the contract, including a “no-reject-no-eject” commitment with the described eligible children, unless the court determines that the placement is not in a child’s best interest.
(g) An ability, through its trained, multidisciplinary staff, to facilitate the achievement of the permanency goals of the children who are in care.
(h) The design and utilization of a retired-volunteer mentor program that would make use of the skills of retired individuals in helping to meet the needs of both the children in care and their caregivers.
(i) The willingness and ability to assume financial risk for the care of children referred to the program under the contract.
(j) The willingness and ability to serve as a research and teaching laboratory for departmental and community-based care programs throughout the state in an effort to improve the quality of foster care.
(4) This section does not prohibit any provider of these services from appropriately billing Medicaid for services rendered, from contracting with a local school district for educational services, or from earning federal or local funding for services provided, as long as two or more funding sources do not pay for the same specific service that has been provided to a child.
(5) The lead agency, not-for-profit corporation, or local government entity has the legal authority for children served under this program, as provided in chapter 39 or this chapter, as appropriate, to enroll the child in school, to sign for a driver’s license for the child, to cosign loans and insurance for the child, to sign for medical treatment, and to authorize other such activities.
(6) The department shall provide technical assistance as requested and contract management services.
(7) The provisions of this section shall be implemented to the extent of available appropriations contained in the annual General Appropriations Act for such purpose.
History.—s. 6, ch. 2001-68; s. 113, ch. 2008-4.
409.1678 Safe harbor for children who are victims of sexual exploitation.—
(1) As used in this section, the term:
(a) “Child advocate” means an employee of a short-term safe house who has been trained to work with and advocate for the needs of sexually exploited children. The advocate shall accompany the child to all court appearances, meetings with law enforcement officials, and the state attorney’s office and shall serve as a liaison between the short-term safe house and the court.
(b) “Safe house” means a living environment that has set aside gender-specific, separate, and distinct living quarters for sexually exploited children who have been adjudicated dependent or delinquent and need to reside in a secure residential facility with staff members who are awake 24 hours a day. A safe house shall be operated by a licensed family foster home or residential child-caring agency as defined in s. 409.175, including a runaway youth center as defined in s. 409.441. Each facility must be appropriately licensed in this state as a residential child-caring agency as defined in s. 409.175 and must have applied for accreditation within 1 year after being licensed. A safe house serving children who have been sexually exploited must have available staff or contract personnel who have the clinical expertise, credentials, and training to provide services identified in paragraph (2)(b).
(c) “Secure” means that a facility providing services is supervised 24 hours a day by staff members who are awake while on duty.
(d) “Sexually exploited child” means a dependent child who has suffered sexual exploitation as defined in s. 39.01(67)(g) and is ineligible for relief and benefits under the federal Trafficking Victims Protection Act, 22 U.S.C. ss. 7101 et seq.
(e) “Short-term safe house” means a shelter operated by a licensed residential child-caring agency as defined in s. 409.175, including a runaway youth center as defined in s. 409.441, that has set aside gender-specific, separate, and distinct living quarters for sexually exploited children. In addition to shelter, the house shall provide services and care to sexually exploited children, including food, clothing, medical care, counseling, and appropriate crisis intervention services at the time they are taken into custody by law enforcement officials or department personnel.
(2)(a) Notwithstanding any other provision of law, pursuant to rules of the department, each circuit of the department shall address the child welfare service needs of sexually exploited children as a component of the circuit’s master plan. This determination shall be made in consultation with local law enforcement officials, runaway and homeless youth program providers, local probation departments, local community-based care and social services, local guardians ad litem, public defenders, state attorney’s offices, and child advocates and services providers who work directly with sexually exploited youth.
(b) The lead agency, not-for-profit agency, or local governmental entity providing safe-house services is responsible for security, crisis intervention services, general counseling and victim-witness counseling, a comprehensive assessment, residential care, transportation, access to behavioral health services, recreational activities, food, clothing, supplies, infant care, and miscellaneous expenses associated with caring for these children; for necessary arrangement for or provision of educational services, including life skills services and planning services for the successful transition of residents back to the community; and for ensuring necessary and appropriate health care and dental care.
(c) This section does not prohibit any provider of these services from appropriately billing Medicaid for services rendered, from contracting with a local school district for educational services, or from obtaining federal or local funding for services provided, as long as two or more funding sources do not pay for the same specific service that has been provided to a child.
(d) The lead agency, not-for-profit agency, or local governmental entity providing safe-house services has the legal authority for children served in a safe-house program, as provided in chapter 39 or this chapter, as appropriate, to enroll the child in school, to sign for a driver license for the child, to cosign loans and insurance for the child, to sign for medical treatment of the child, and to authorize other such activities.
(e) All of the services specified in this section may, to the extent possible provided by law and with funding authorized, be available to all sexually exploited children whether they are accessed voluntarily, as a condition of probation, through a diversion program, through a proceeding under chapter 39, or through a referral from a local community-based care or social service agency.
(3) The local circuit administrator may, to the extent that funds are available, in conjunction with local law enforcement officials, contract with an appropriate not-for-profit agency having experience working with sexually exploited children to train law enforcement officials who are likely to encounter sexually exploited children in the course of their law enforcement duties on the provisions of this section and how to identify and obtain appropriate services for sexually exploited children. Circuits may work cooperatively to provide such training, and such training may be provided on a regional basis. The department shall assist circuits in obtaining any available funds for the purposes of conducting law enforcement training from the Office of Juvenile Justice and Delinquency Prevention of the United States Department of Justice.
(4) The department may adopt rules necessary to administer this section.
History.—s. 6, ch. 2012-105.
409.1679 Additional requirements; reimbursement methodology.—
(1) Each program established under ss. 409.1676 and 409.1677 must meet the following expectations, which must be included in its contracts with the department or lead agency:
(a) No more than 10 percent of the children served may move from one living environment to another, unless the child is returned to family members or is moved, in accordance with the treatment plan, to a less-restrictive setting. Each child must have a comprehensive transitional plan that identifies the child’s living arrangement upon leaving the program and specific steps and services that are being provided to prepare for that arrangement. Specific expectations as to the time period necessary for the achievement of these permanency goals must be included in the contract.
(b) Each child must receive a full academic year of appropriate educational instruction. No more than 10 percent of the children may be in more than one academic setting in an academic year, unless the child is being moved, in accordance with an educational plan, to a less-restrictive setting. Each child must demonstrate academic progress and must be performing at grade level or at a level commensurate with a valid academic assessment.
(c) Siblings must be kept together in the same living environment 100 percent of the time, unless that is determined by the provider not to be in the children’s best interest. When siblings are separated in placement, the decision must be reviewed and approved by the court within 30 days.
(d) The program must experience a caregiver turnover rate and an incidence of child runaway episodes which are at least 50 percent below the rates experienced in the rest of the state.
(e) In addition to providing a comprehensive assessment, the program must provide, 100 percent of the time, any or all of the following services that are indicated through the assessment: residential care; transportation; behavioral health services; recreational activities; clothing, supplies, and miscellaneous expenses associated with caring for these children; necessary arrangements for or provision of educational services; and necessary and appropriate health and dental care.
(f) The children who are served in this program must be satisfied with the services and living environment.
(g) The caregivers must be satisfied with the program.
(2) Notwithstanding the provisions of s. 409.141, the Department of Children and Family Services shall fairly and reasonably reimburse the programs established under ss. 409.1676 and 409.1677 based on a prospective per diem rate, which must be specified annually in the General Appropriations Act. Funding for these programs shall be made available from resources appropriated and identified in the General Appropriations Act.
History.—s. 7, ch. 2001-68; s. 120, ch. 2010-102.
409.175 Licensure of family foster homes, residential child-caring agencies, and child-placing agencies; public records exemption.—
(1)(a) The purpose of this section is to protect the health, safety, and well-being of all children in the state who are cared for by family foster homes, residential child-caring agencies, and child-placing agencies by providing for the establishment of licensing requirements for such homes and agencies and providing procedures to determine adherence to these requirements.
(b) Nothing in this section gives any governmental agency jurisdiction or authority to regulate, control, or supervise the form, manner, or content of any religious curriculum or teachings of a family foster home or of a child-caring or child-placing agency, provided the health, safety, or well-being of the child is not adversely affected.
(2) As used in this section, the term:
(a) “Agency” means a residential child-caring agency or a child-placing agency.
(b) “Boarding school” means a school that is registered with the Department of Education as a school that provides a residential service for students and that is either:
1. Accredited for academic programs by the Florida Council of Independent Schools, the Southern Association of Colleges and Schools, an accrediting association that is a member of the National Council for Private School Accreditation, or an accrediting association that is a member of the Florida Association of Academic Nonpublic Schools, and that is accredited for residential programs by the Council on Accreditation, the Commission on Accreditation of Rehabilitation Facilities, or the Coalition for Residential Education; or
2. Accredited by one of the organizations specified in subparagraph 1. as a boarding school that includes both an academic and residential component in its accreditation.
(c) “Child” means any unmarried person under the age of 18 years.
(d) “Child-placing agency” means any person, corporation, or agency, public or private, other than the parent or legal guardian of the child or an intermediary acting pursuant to chapter 63, that receives a child for placement and places or arranges for the placement of a child in a family foster home, residential child-caring agency, or adoptive home.
(e) “Family foster home” means a private residence in which children who are unattended by a parent or legal guardian are provided 24-hour care. Such homes include emergency shelter family homes and specialized foster homes for children with special needs. A person who cares for a child of a friend for a period not to exceed 90 days, a relative who cares for a child and does not receive reimbursement for such care from the state or federal government, or an adoptive home which has been approved by the department or by a licensed child-placing agency for children placed for adoption is not considered a family foster home.
(f) “License” means “license” as defined in s. 120.52(10). A license under this section is issued to a family foster home or other facility and is not a professional license of any individual. Receipt of a license under this section shall not create a property right in the recipient. A license under this act is a public trust and a privilege, and is not an entitlement. This privilege must guide the finder of fact or trier of law at any administrative proceeding or court action initiated by the department.
(g) “Operator” means any onsite person ultimately responsible for the overall operation of a child-placing agency, family foster home, or residential child-caring agency, whether or not she or he is the owner or administrator of such an agency or home.
(h) “Owner” means the person who is licensed to operate the child-placing agency, family foster home, or residential child-caring agency.
(i) “Personnel” means all owners, operators, employees, and volunteers working in a child-placing agency, family foster home, or residential child-caring agency who may be employed by or do volunteer work for a person, corporation, or agency that holds a license as a child-placing agency or a residential child-caring agency, but the term does not include those who do not work on the premises where child care is furnished and have no direct contact with a child or have no contact with a child outside of the presence of the child’s parent or guardian. For purposes of screening, the term includes any member, over the age of 12 years, of the family of the owner or operator or any person other than a client, over the age of 12 years, residing with the owner or operator if the agency or family foster home is located in or adjacent to the home of the owner or operator or if the family member of, or person residing with, the owner or operator has any direct contact with the children. Members of the family of the owner or operator, or persons residing with the owner or operator, who are between the ages of 12 years and 18 years are not required to be fingerprinted, but must be screened for delinquency records. For purposes of screening, the term also includes owners, operators, employees, and volunteers working in summer day camps, or summer 24-hour camps providing care for children. A volunteer who assists on an intermittent basis for less than 10 hours per month shall not be included in the term “personnel” for the purposes of screening if a person who meets the screening requirement of this section is always present and has the volunteer in his or her line of sight.
(j) “Residential child-caring agency” means any person, corporation, or agency, public or private, other than the child’s parent or legal guardian, that provides staffed 24-hour care for children in facilities maintained for that purpose, regardless of whether operated for profit or whether a fee is charged. Such residential child-caring agencies include, but are not limited to, maternity homes, runaway shelters, group homes that are administered by an agency, emergency shelters that are not in private residences, and wilderness camps. Residential child-caring agencies do not include hospitals, boarding schools, summer or recreation camps, nursing homes, or facilities operated by a governmental agency for the training, treatment, or secure care of delinquent youth, or facilities licensed under s. 393.067 or s. 394.875 or chapter 397.
(k) “Screening” means the act of assessing the background of personnel and includes, but is not limited to, employment history checks as provided in chapter 435, using the level 2 standards for screening set forth in that chapter.
(l) “Summer day camp” means recreational, educational, and other enrichment programs operated during summer vacations for children who are 5 years of age on or before September 1 and older.
(m) “Summer 24-hour camp” means recreational, educational, and other enrichment programs operated on a 24-hour basis during summer vacation for children who are 5 years of age on or before September 1 and older, that are not exclusively educational.
(3)(a) The total number of children placed in each family foster home shall be based on the recommendation of the department, or the community-based care lead agency where one is providing foster care and related services, based on the needs of each child in care, the ability of the foster family to meet the individual needs of each child, including any adoptive or biological children or young adults remaining in foster care living in the home, the amount of safe physical plant space, the ratio of active and appropriate adult supervision, and the background, experience, and skill of the family foster parents.
(b) If the total number of children in a family foster home will exceed five, including the family’s own children, an assessment of each child to be placed in the home must be completed by a family services counselor and approved in writing by the counselor’s supervisor prior to placement of any additional children in the home, except that, if the placement involves a child whose sibling is already in the home or a child who has been in placement in the home previously, the assessment must be completed within 72 hours after placement. The assessment must assess and document the mental, physical, and psychosocial needs of the child and recommend the maximum number of children in a family foster home that will allow the child’s needs to be met.
(c) For any licensed family foster home, the appropriateness of the number of children in the home must be reassessed annually as part of the relicensure process. For a home with more than five children, if it is determined by the licensure study at the time of relicensure that the total number of children in the home is appropriate and that there have been no substantive licensure violations and no indications of child maltreatment or child-on-child sexual abuse within the past 12 months, the relicensure of the home shall not be denied based on the total number of children in the home.
(4)(a) A person, family foster home, or residential child-caring agency may not provide continuing full-time child care or custody unless such person, home, or agency has first procured a license from the department to provide such care. This requirement does not apply to a person who is a relative of the child by blood, marriage, or adoption, a permanent guardian established under s. 39.6221, a licensed child-placing agency, or an intermediary for the purposes of adoption pursuant to chapter 63.
(b) A person or agency, other than a parent or legal guardian of the child or an intermediary as defined in s. 63.032, shall not place or arrange for the placement of a child in a family foster home, residential child-caring agency, or adoptive home unless such person or agency has first procured a license from the department to do so.
(c) A state, county, city, or political subdivision shall not operate a residential group care agency, or receive children for placement in residential group care facilities, family foster homes, or adoptive homes without a license issued pursuant to this section.
(d) This license requirement does not apply to boarding schools, recreation and summer camps, nursing homes, hospitals, or to persons who care for children of friends or neighbors in their homes for periods not to exceed 90 days or to persons who have received a child for adoption from a licensed child-placing agency.
(e) The department or licensed child-placing agency may place a 16-year-old child or 17-year-old child in her or his own unlicensed residence, or in the unlicensed residence of an adult who has no supervisory responsibility for the child, provided the department or licensed child-placing agency retains supervisory responsibility for the child.
(5)(a) The department shall adopt and amend licensing rules for family foster homes, residential child-caring agencies, and child-placing agencies. The department may also adopt rules relating to the screening requirements for summer day camps and summer 24-hour camps. The requirements for licensure and operation of family foster homes, residential child-caring agencies, and child-placing agencies shall include:
1. The operation, conduct, and maintenance of these homes and agencies and the responsibility which they assume for children served and the evidence of need for that service.
2. The provision of food, clothing, educational opportunities, services, equipment, and individual supplies to assure the healthy physical, emotional, and mental development of the children served.
3. The appropriateness, safety, cleanliness, and general adequacy of the premises, including fire prevention and health standards, to provide for the physical comfort, care, and well-being of the children served.
4. The ratio of staff to children required to provide adequate care and supervision of the children served and, in the case of foster homes, the maximum number of children in the home.
5. The good moral character based upon screening, education, training, and experience requirements for personnel.
6. The department may grant exemptions from disqualification from working with children or the developmentally disabled as provided in s. 435.07.
7. The provision of preservice and inservice training for all foster parents and agency staff.
8. Satisfactory evidence of financial ability to provide care for the children in compliance with licensing requirements.
9. The maintenance by the agency of records pertaining to admission, progress, health, and discharge of children served, including written case plans and reports to the department.
10. The provision for parental involvement to encourage preservation and strengthening of a child’s relationship with the family.
11. The transportation safety of children served.
12. The provisions for safeguarding the cultural, religious, and ethnic values of a child.
13. Provisions to safeguard the legal rights of children served.
(b) The requirements for the licensure and operation of a child-placing agency shall also include compliance with the requirements of ss. 63.0422 and 790.335.
(c) The department shall randomly drug test a licensed foster parent if there is a reasonable suspicion that he or she is using illegal drugs. The cost of testing shall be paid by the foster parent but shall be reimbursed by the department if the test is negative. The department may adopt rules necessary to administer this paragraph.
(d) In promulgating licensing rules pursuant to this section, the department may make distinctions among types of care; numbers of children served; and the physical, mental, emotional, and educational needs of the children to be served by a home or agency.
(e) The department shall not adopt rules which interfere with the free exercise of religion or which regulate religious instruction or teachings in any child-caring or child-placing home or agency; however, nothing herein shall be construed to allow religious instruction or teachings that are inconsistent with the health, safety, or well-being of any child; with public morality; or with the religious freedom of children, parents, or legal guardians who place their children in such homes or agencies.
(f) The department’s rules shall include adoption of a form to be used by child-placing agencies during an adoption home study that requires all prospective adoptive applicants to acknowledge in writing the receipt of a document containing solely and exclusively the language provided for in s. 790.174 verbatim.
(6)(a) An application for a license shall be made on forms provided, and in the manner prescribed, by the department. The department shall make a determination as to the good moral character of the applicant based upon screening.
(b) Upon application, the department shall conduct a licensing study based on its licensing rules; shall inspect the home or the agency and the records, including financial records, of the agency; and shall interview the applicant. The department may authorize a licensed child-placing agency to conduct the licensing study of a family foster home to be used exclusively by that agency and to verify to the department that the home meets the licensing requirements established by the department. Upon certification by a licensed child-placing agency that a family foster home meets the licensing requirements, the department shall issue the license.
(c) A licensed family foster home, child-placing agency, or residential child-caring agency which applies for renewal of its license shall submit to the department a list of personnel who have worked on a continuous basis at the applicant family foster home or agency since submitting fingerprints to the department, identifying those for whom a written assurance of compliance was provided by the department and identifying those personnel who have recently begun working at the family foster home or agency and are awaiting the results of the required fingerprint check, along with the date of the submission of those fingerprints for processing. The department shall by rule determine the frequency of requests to the Department of Law Enforcement to run state criminal records checks for such personnel except for those personnel awaiting the results of initial fingerprint checks for employment at the applicant family foster home or agency.
(d)1. The department may pursue other remedies provided in this section in addition to denial or revocation of a license for failure to comply with the screening requirements. The disciplinary actions determination to be made by the department and the procedure for hearing for applicants and licensees shall be in accordance with chapter 120.
2. When the department has reasonable cause to believe that grounds for denial or termination of employment exist, it shall notify, in writing, the applicant, licensee, or summer or recreation camp, and the personnel affected, stating the specific record which indicates noncompliance with the screening requirements.
3. Procedures established for hearing under chapter 120 shall be available to the applicant, licensee, summer day camp, or summer 24-hour camp, and affected personnel, in order to present evidence relating either to the accuracy of the basis for exclusion or to the denial of an exemption from disqualification.
4. Refusal on the part of an applicant to dismiss personnel who have been found not to be in compliance with the requirements for good moral character of personnel shall result in automatic denial or revocation of license in addition to any other remedies provided in this section which may be pursued by the department.
(e) At the request of the department, the local county health department shall inspect a home or agency according to the licensing rules promulgated by the department. Inspection reports shall be furnished to the department within 30 days of the request. Such an inspection shall only be required when called for by the licensing agency.
(f) All residential child-caring agencies must meet firesafety standards for such agencies adopted by the Division of State Fire Marshal of the Department of Financial Services and must be inspected annually. At the request of the department, firesafety inspections shall be conducted by the Division of State Fire Marshal or a local fire department official who has been certified by the division as having completed the training requirements for persons inspecting such agencies. Inspection reports shall be furnished to the department within 30 days of a request.
(g) In the licensing process, the licensing staff of the department shall provide consultation on request.
(h) Upon determination that the applicant meets the state minimum licensing requirements, the department shall issue a license without charge to a specific person or agency at a specific location. A license may be issued if all the screening materials have been timely submitted; however, a license may not be issued or renewed if any person at the home or agency has failed the required screening. The license is nontransferable. A copy of the license shall be displayed in a conspicuous place. Except as provided in paragraph (j), the license is valid for 1 year from the date of issuance, unless the license is suspended or revoked by the department or is voluntarily surrendered by the licensee. The license is the property of the department.
(i) A license issued for the operation of a family foster home or agency, unless sooner suspended, revoked, or voluntarily returned, will expire automatically 1 year from the date of issuance except as provided in paragraph (j). Ninety days prior to the expiration date, an application for renewal shall be submitted to the department by a licensee who wishes to have the license renewed. A license shall be renewed upon the filing of an application on forms furnished by the department if the applicant has first met the requirements established under this section and the rules promulgated hereunder.
(j) Except for a family foster group home having a licensed capacity for more than five children, the department may issue a license that is valid for longer than 1 year but no longer than 3 years to a family foster home that:
1. Has maintained a license with the department as a family foster home for at least the 3 previous consecutive years;
2. Remains in good standing with the department; and
3. Has not been the subject of a report of child abuse or neglect with any findings of maltreatment.
A family foster home that has been issued a license valid for longer than 1 year must be monitored and visited as frequently as one that has been issued a 1-year license. The department reserves the right to reduce a licensure period to 1 year at any time.
(k) The department may not license summer day camps or summer 24-hour camps. However, the department shall have access to the personnel records of such facilities to ensure compliance with the screening requirements.
(7)(a) The department may issue a provisional license to an applicant who is unable to conform to the licensing requirements at the time of the study, but who is believed able to meet the licensing requirements within the time allowed by the provisional license. The issuance of a provisional license shall be contingent upon the submission to the department of an acceptable written plan to overcome the deficiency by the expiration date of the provisional license.
(b) A provisional license may be issued when the applicant fails to meet licensing requirements in matters that are not of immediate danger to the children and the agency has submitted a corrective action plan which is approved by the department. A provisional license may be issued if the screening material has been timely submitted; however, a provisional license may not be issued unless the applicant is in compliance with the requirements in this section for screening of personnel.
(c) A provisional license shall not be issued for a period in excess of 1 year and shall not be subject to renewal; and it may be suspended if periodic inspection by the department indicates that insufficient progress has been made toward compliance with the requirements.
(8)(a) Authorized licensing staff of the department who are qualified by training may make scheduled or unannounced inspections of a licensed home or agency at any reasonable time to investigate and evaluate the compliance of the home or agency with the licensing requirements. All licensed homes and agencies shall be inspected at least annually.
(b) The department shall investigate complaints to determine whether a home or agency is meeting the licensure requirements. The department shall advise the home or agency of the complaint and shall provide a written report of the results of the investigation to the licensee.
(9)(a) The department may deny, suspend, or revoke a license.
(b) Any of the following actions by a home or agency or its personnel is a ground for denial, suspension, or revocation of a license:
1. An intentional or negligent act materially affecting the health or safety of children in the home or agency.
2. A violation of the provisions of this section or of licensing rules promulgated pursuant to this section.
3. Noncompliance with the requirements for good moral character as specified in paragraph (5)(a).
4. Failure to dismiss personnel found in noncompliance with requirements for good moral character.
5. Failure to comply with the requirements of ss. 63.0422 and 790.335.
(10)(a) The department may institute injunctive proceedings in a court of competent jurisdiction to:
1. Enforce the provisions of this section or any license requirement, rule, or order issued or entered into pursuant thereto; or
2. Terminate the operation of an agency in which any of the following conditions exist:
a. The licensee has failed to take preventive or corrective measures in accordance with any order of the department to maintain conformity with licensing requirements.
b. There is a violation of any of the provisions of this section, or of any licensing requirement promulgated pursuant to this section, which violation threatens harm to any child or which constitutes an emergency requiring immediate action.
3. Terminate the operation of a summer day camp or summer 24-hour camp providing care for children when such camp has willfully and knowingly refused to comply with the screening requirements for personnel or has refused to terminate the employment of personnel found to be in noncompliance with the requirements for good moral character as determined in paragraph (5)(a).
(b) If the department finds, within 30 days after written notification by registered mail of the requirement for licensure, that a person or agency continues to care for or to place children without a license or, within 30 days after written notification by registered mail of the requirement for screening of personnel and compliance with paragraph (5)(a) for the hiring and continued employment of personnel, that a summer day camp or summer 24-hour camp continues to provide care for children without complying, the department shall notify the appropriate state attorney of the violation of law and, if necessary, shall institute a civil suit to enjoin the person or agency from continuing the placement or care of children or to enjoin the summer day camp or summer 24-hour camp from continuing the care of children.
(c) Such injunctive relief may be temporary or permanent.
(11)(a) The department is authorized to seek compliance with the licensing requirements of this section to the fullest extent possible by reliance on administrative sanctions and civil actions.
(b) If the department determines that a person or agency is caring for a child or is placing a child without a valid license issued by the department or has made a willful or intentional misstatement on any license application or other document required to be filed in connection with an application for a license, the department, as an alternative to or in conjunction with an administrative action against such person or agency, shall make a reasonable attempt to discuss each violation with, and recommend corrective action to, the person or the administrator of the agency, prior to written notification thereof. The department, instead of fixing a period within which the person or agency must enter into compliance with the licensing requirements, may request a plan of corrective action from the person or agency that demonstrates a good faith effort to remedy each violation by a specific date, subject to the approval of the department.
(c) Any action taken to correct a violation shall be documented in writing by the person or administrator of the agency and verified through followup visits by licensing personnel of the department.
(d) If the person or agency has failed to remedy each violation by the specific date agreed upon with the department, the department shall within 30 days notify the person or agency by certified mail of its intention to refer the violation or violations to the office of the state attorney.
(e) If the person or agency fails to come into compliance with the licensing requirements within 30 days of written notification, it is the intent of the Legislature that the department within 30 days refer the violation or violations to the office of the state attorney.
(12)(a) It is unlawful for any person or agency to:
1. Provide continuing full-time care for or to receive or place a child apart from her or his parents in a residential group care facility, family foster home, or adoptive home without a valid license issued by the department if such license is required by subsection (5); or
2. Make a willful or intentional misstatement on any license application or other document required to be filed in connection with an application for a license.
(b) It is unlawful for any person, agency, summer day camp, or summer 24-hour camp providing care for children to:
1. Willfully or intentionally fail to comply with the requirements for the screening of personnel or the dismissal of personnel found not to be in compliance with the requirements for good moral character as specified in paragraph (5)(a).
2. Use information from the criminal records obtained under this section for any purpose other than screening a person for employment as specified in this section or to release such information to any other person for any purpose other than screening for employment as specified in this section.
(c) It is unlawful for any person, agency, summer day camp, or summer 24-hour camp providing care for children to use information from the juvenile records of any person obtained under this section for any purpose other than screening for employment as specified in this section or to release information from such records to any other person for any purpose other than screening for employment as specified in this section.
(d)1. A first violation of paragraph (a) or paragraph (b) is a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.
2. A second or subsequent violation of paragraph (a) or paragraph (b) is a felony of the third degree, punishable as provided in s. 775.082 or s. 775.083.
3. A violation of paragraph (c) is a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(13) If the department finds that any violation of this section or the rules promulgated pursuant to this section places the children served by the person or agency in immediate danger, the department may take the resident children into custody and place them in the care of another family foster home or residential child-caring agency.
(14)(a) In order to provide improved services to children, the department shall provide or cause to be provided preservice training for prospective foster parents and emergency shelter parents and inservice training for foster parents and emergency shelter parents who are licensed and supervised by the department.
(b) As a condition of licensure, foster parents and emergency shelter parents shall successfully complete a minimum of 21 hours of preservice training. The preservice training shall be uniform statewide and shall include, but not be limited to, such areas as:
1. Orientation regarding agency purpose, objectives, resources, policies, and services;
2. Role of the foster parent and the emergency shelter parent as a treatment team member;
3. Transition of a child into and out of foster care and emergency shelter care, including issues of separation, loss, and attachment;
4. Management of difficult child behavior that can be intensified by placement, by prior abuse or neglect, and by prior placement disruptions;
5. Prevention of placement disruptions;
6. Care of children at various developmental levels, including appropriate discipline; and
7. Effects of foster parenting on the family of the foster parent and the emergency shelter parent.
(c) In consultation with foster parents, each district or lead agency shall develop a plan for making the completion of the required training as convenient as possible for potential foster parents and emergency-shelter parents. The plan should include, without limitation, such strategies as providing training in nontraditional locations and at nontraditional times. The plan must be revised at least annually and must be included in the information provided to each person applying to become a foster parent or emergency-shelter parent.
(d) Prior to licensure renewal, each foster parent and emergency shelter parent shall successfully complete 8 hours of inservice training. Periodic time-limited training courses shall be made available for selective use by foster parents and emergency shelter parents. Such inservice training shall include subjects affecting the daily living experiences of foster parenting as a foster parent or as an emergency shelter parent, whichever is appropriate. For a foster parent or emergency shelter parent participating in the required inservice training, the department shall reimburse such parent for travel expenditures and, if both parents in a home are attending training or if the absence of the parent would leave the children without departmentally approved adult supervision, either the department shall make provision for child care or shall reimburse the foster or emergency shelter parents for child care purchased by the parents for children in their care.
(15)(a) The Division of Risk Management of the Department of Financial Services shall provide coverage through the Department of Children and Family Services to any person who owns or operates a family foster home solely for the Department of Children and Family Services and who is licensed to provide family foster home care in her or his place of residence. The coverage shall be provided from the general liability account of the State Risk Management Trust Fund, and the coverage shall be primary. The coverage is limited to general liability claims arising from the provision of family foster home care pursuant to an agreement with the department and pursuant to guidelines established through policy, rule, or statute. Coverage shall be limited as provided in ss. 284.38 and 284.385, and the exclusions set forth therein, together with other exclusions as may be set forth in the certificate of coverage issued by the trust fund, shall apply. A person covered under the general liability account pursuant to this subsection shall immediately notify the Division of Risk Management of the Department of Financial Services of any potential or actual claim.
(b) This subsection may not be construed as designating or not designating that a person who owns or operates a family foster home as described in this subsection or any other person is an employee or agent of the state. Nothing in this subsection amends, expands, or supersedes the provisions of s. 768.28.
(16)(a)1. The following information held by the Department of Children and Family Services regarding a foster parent applicant and such applicant’s spouse, minor child, and other adult household member is exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution:
a. The home, business, work, child care, or school addresses and telephone numbers;
b. Birth dates;
c. Medical records;
d. The floor plan of the home; and
e. Photographs of such persons.
2. If a foster parent applicant does not receive a foster parent license, the information made exempt pursuant to this paragraph shall become public 5 years after the date of application, except that medical records shall remain exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
3. This exemption applies to information made exempt by this paragraph before, on, or after the effective date of the exemption.
(b)1. The following information held by the Department of Children and Family Services regarding a licensed foster parent and the foster parent’s spouse, minor child, and other adult household member is exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution:
a. The home, business, work, child care, or school addresses and telephone numbers;
b. Birth dates;
c. Medical records;
d. The floor plan of the home; and
e. Photographs of such persons.
2. If a foster parent’s license is no longer active, the information made exempt pursuant to this paragraph shall become public 5 years after the expiration date of such foster parent’s foster care license except that:
a. Medical records shall remain exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
b. Exempt information regarding a licensed foster parent who has become an adoptive parent and exempt information regarding such foster parent’s spouse, minor child, or other adult household member shall remain exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
3. This exemption applies to information made exempt by this paragraph before, on, or after the effective date of the exemption.
(c) The name, address, and telephone number of persons providing character or neighbor references regarding foster parent applicants or licensed foster parents held by the Department of Children and Family Services are exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
(17) Boarding schools are subject to the following requirements:
(a) A boarding school currently in existence or a boarding school opening and seeking accreditation has 3 years after the date of registration with the Department of Education to complete the accreditation requirements of paragraph (2)(b).
(b) Effective July 1, 2013, the Department of Education shall remove from registration and its website any boarding school that has not completed the accreditation requirements of paragraph (2)(b) or has not provided to the department letters verifying that boarding school’s application for accreditation within 270 days after registration. Those verification letters must be provided by an accrediting agency pursuant to paragraph (2)(b).
(c) A boarding school must provide proof of accreditation or documentation of the accreditation process upon request by the department. The boarding school must provide an annual report to the department regarding its accreditation status pursuant to paragraph (2)(b). The first report is due 1 year after the date the boarding school registered with the Department of Education. A boarding school that has been accredited pursuant to paragraph (2)(b) is not subject to the reporting requirements required under this subsection.
(d) A boarding school that cannot produce the required documentation in accordance with this subsection, is not registered with the Department of Education, or has not obtained the accreditation required under paragraph (2)(b) shall be considered to be providing residential group care without a license. The department may impose administrative sanctions or seek civil remedies as provided under paragraph (11)(a).
(e) A boarding school shall require employees and contracted personnel with direct student contact upon employment to undergo level 2 background screening pursuant to chapter 435. The term “direct student contact” means unsupervised access to a student for whom the boarding school is responsible. The department may grant exemptions from disqualification from working with children as provided in s. 435.07.
(f) A boarding school shall follow established school schedules and provide holiday breaks and summer recesses provided by other public and private school programs. The students in residence must customarily return to their family homes or legal guardians during school breaks and, except for students who are citizens of foreign countries, must not be in residence year-round. The parents of a child attending a boarding school shall retain custody of and planning and financial responsibility for their child.
History.—s. 1, ch. 69-268; ss. 19, 35, ch. 69-106; s. 1, ch. 70-255; s. 3, ch. 76-168; s. 276, ch. 77-147; s. 1, ch. 77-457; s. 7, ch. 78-433; s. 5, ch. 80-102; ss. 2, 3, ch. 81-318; ss. 3, 5, ch. 83-250; ss. 1, 20, 21, ch. 84-311; s. 35, ch. 85-54; s. 28, ch. 87-238; s. 1, ch. 87-535; s. 41, ch. 88-337; s. 2, ch. 90-225; s. 42, ch. 90-306; s. 11, ch. 91-33; s. 29, ch. 91-57; s. 2, ch. 91-71; s. 56, ch. 91-220; s. 4, ch. 91-429; s. 29, ch. 93-39; s. 15, ch. 93-156; s. 23, ch. 94-134; s. 23, ch. 94-135; s. 19, ch. 95-152; s. 16, ch. 95-158; s. 42, ch. 95-228; s. 132, ch. 95-418; s. 13, ch. 96-268; s. 6, ch. 96-402; ss. 251, 252, ch. 96-406; s. 194, ch. 97-101; s. 1018, ch. 97-103; s. 1, ch. 98-29; s. 23, ch. 2000-122; s. 11, ch. 2000-217; s. 5, ch. 2000-265; ss. 97, 155, ch. 2000-349; s. 8, ch. 2001-68; s. 6, ch. 2002-219; ss. 1, 2, ch. 2003-83; s. 9, ch. 2003-146; s. 442, ch. 2003-261; s. 19, ch. 2004-267; s. 12, ch. 2006-194; s. 18, ch. 2008-104; ss. 1, 2, ch. 2008-169; s. 20, ch. 2008-245; s. 2, ch. 2010-6; s. 23, ch. 2010-114; s. 9, ch. 2013-178; s. 1, ch. 2013-219.
409.1753 Foster care; duties.—The department shall ensure that, within each district, each foster home is given a telephone number for the foster parent to call during normal working hours whenever immediate assistance is needed and the child’s caseworker is unavailable. This number must be staffed and answered by individuals possessing the knowledge and authority necessary to assist foster parents.
History.—s. 12, ch. 2000-217.
409.1755 One Church, One Child of Florida Corporation Act; creation; duties.—
(1) SHORT TITLE.—This section may be cited as the “One Church, One Child of Florida Corporation Act.”
(2) LEGISLATIVE INTENT.—The Legislature finds and declares that there is an increasing number of black children in foster care waiting to be adopted. Black children are disproportionately overrepresented in the foster care system and remain in foster care longer. A black child is more likely to be referred for neglect or abuse and remain in permanent custody of the state because he or she is less likely to be adopted. It is the intent of the Legislature that a nonprofit corporation, to be known as the “One Church, One Child of Florida Corporation,” be organized for the purpose of providing services to adoptable black children and increasing the child’s potential for placement in a permanent family home; participating in charitable work; involving persons with religious and clerical expertise; providing literacy and educational guidance; and promoting child welfare services to black children available for adoption.
(3) CORPORATION AUTHORIZATION; DUTIES; POWERS.—
(a) There is hereby authorized the “One Church, One Child of Florida Corporation,” which shall operate as a not-for-profit corporation and shall be located within the Department of Children and Family Services for administrative purposes. The department shall provide administrative support and services to the corporation to the extent requested by the executive director and to the extent that resources are available.
(b) The corporation shall:
1. Provide for community awareness and involvement by utilizing the resources of black churches to help find permanent homes for black children available for adoption.
2. Develop, monitor, and evaluate projects designed to address problems associated with the child welfare system, especially those issues affecting black children.
3. Develop beneficial programs that shall include, but not be limited to, community education, cultural relations training, family support, transition support groups, counseling, parenting skills and education, legal and other adoption-related costs, and any other activities that will enhance and support the adopted child’s transition into permanency.
4. Provide training and technical assistance to community organizations such as black churches, social service agencies, and other organizations that assist in identifying prospective parents willing to adopt.
5. Provide, in conjunction with the Department of Children and Family Services, a summary to the Legislature by September 1 of each year on the status of the corporation.
6. Secure staff necessary to properly administer the corporation. Staff costs shall be funded from general revenue, grant funds, and state and private donations. The board of directors is authorized to determine the number of staff necessary to administer the corporation, but the staff shall include, at a minimum, an executive director and a staff assistant.
(c) The corporation shall have all powers necessary or convenient to carry out the purposes and provisions of this section, including, but not limited to, the power to receive and accept grants, loans, and advances of funds from any public or private agency for, or in aid of, the purposes of this section, and to receive and accept contributions from any source of money, property, labor, or any other thing of value, to be held, used, and applied for such purposes.
(4) BOARD OF DIRECTORS.—
(a) The One Church, One Child of Florida Corporation shall operate subject to the supervision and approval of a board of directors consisting of 23 members, with two directors representing each service district of the Department of Children and Family Services and one director who shall be an at-large member.
(b) Each member of the board of directors shall be appointed by the Governor for a 3-year term. The board shall appoint the executive director, who shall be responsible for other staff as authorized by the board.
(c) If any member of the board is in violation of the provisions of this section or bylaws adopted thereto, the board may recommend to the Governor that such member be removed.
(d) Board members shall receive no compensation, but shall be entitled to receive per diem and travel expenses as provided in s. 112.061.
(e) There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member of the board, or its employees or agents, for any action taken by them in performance of their powers and duties under this section.
History.—s. 74, ch. 90-306; s. 27, ch. 91-201; s. 5, ch. 91-429; s. 47, ch. 95-196; s. 116, ch. 97-101.
409.1757 Persons not required to be refingerprinted or rescreened.—Any law to the contrary notwithstanding, human resource personnel who have been fingerprinted or screened pursuant to chapters 393, 394, 397, 402, and this chapter, teachers who have been fingerprinted pursuant to chapter 1012, and law enforcement officers who meet the requirements of s. 943.13, who have not been unemployed for more than 90 days thereafter, and who under the penalty of perjury attest to the completion of such fingerprinting or screening and to compliance with this section and the standards for good moral character as contained in such provisions as ss. 110.1127(2)(c), 393.0655(1), 394.457(6), 397.451, 402.305(2), 409.175(6), and 943.13(7), are not required to be refingerprinted or rescreened in order to comply with any caretaker screening or fingerprinting requirements.
History.—s. 1, ch. 87-128; s. 1, ch. 87-141; s. 30, ch. 93-39; s. 52, ch. 2000-153; s. 10, ch. 2002-219; s. 992, ch. 2002-387; s. 50, ch. 2004-5; s. 3, ch. 2012-73; s. 16, ch. 2012-215.
409.176 Registration of residential child-caring agencies and family foster homes.—
(1)(a) A residential child-caring agency or family foster home may not receive a child for continuing full-time care or custody, and a residential child-caring agency may not place a child for full-time continuing care or custody in a family foster home, unless it has first registered with an association that is certified by a Florida statewide child care organization which was in existence on January 1, 1984, and which publishes, and requires compliance with, its standards and files copies thereof with the department as provided in paragraph (5)(b). For purposes of this section, such an association shall be referred to as the “qualified association.”
(b) For the purposes of this section, the terms “child,” “family foster home,” “screening,” and “residential child-caring agency” are defined as provided in s. 409.175(2), and the terms “personnel,” “operator,” and “owner” as they pertain to “residential child-caring agency” are defined as provided in s. 409.175.
(c) As used in this section, the term “facility” means a residential child-caring agency or a family foster home.
(2)(a) Registration shall consist of annually filing with the qualified association, on forms provided by the qualified association, the name and address of the facility; the capacity of, and the number of children being cared for in, the facility; the names and addresses of the officers and the board of directors or other governing body of the organization, if applicable; the name of the officer or person in charge of the facility; and proof that the facility is in compliance with the minimum health, sanitary, and safety standards required by applicable state law or local ordinance, and the uniform firesafety standards required by chapter 633, and in compliance with the requirements for screening of personnel in s. 409.175 and chapter 435. A separate registration form shall be filed for each such facility.
(b) As part of the registration application, each child-caring agency and each family foster home shall annually provide to the qualified association the names and ages of children being cared for in the facility; the names of children who have been received from out of state or who have been sent out of state during the past calendar year; the names of children who have left the facility during the past year, the lengths of their stays, and the nature of the placements; the names of all personnel; and proof that the facility is in compliance with published minimum standards that are filed with the department under the provisions of paragraph (5)(b). The agency shall also attest to the good moral character of the personnel of the facility by providing proof of compliance with the screening requirements of s. 409.175 and chapter 435 and provide the name of any member of the staff having a prior felony conviction.
(c) Upon verification that all requirements for registration have been met, the qualified association shall issue without charge a certificate of registration valid for 1 year.
(3) Access shall be provided at reasonable times for the appropriate state and local officials responsible for the maintenance of fire, health, sanitary, and safety standards to inspect the facility to assure such compliance.
(4) Facilities licensed under the provisions of s. 409.175 shall be classified as “Type I” facilities. Facilities registered under the provisions of this section shall be classified as “Type II” facilities.
(5) The licensing provisions of s. 409.175 do not apply to a facility operated by an organization that:
(a) Is a religious organization that does not directly receive state or federal funds or is a family foster home that is associated with such an organization and does not directly receive state or federal funds.
(b) Is certified by a Florida statewide child care organization which was in existence on January 1, 1984, and which publishes, and requires compliance with, its standards and files copies thereof with the department. Such standards shall be in substantial compliance with published minimum standards that similar licensed child-caring agencies or family foster homes are required to meet, as determined by the department, with the exception of those standards of a curricular or religious nature and those relating to staffing or financial stability. Once the department has determined that the standards for child-caring agencies or family foster homes are in substantial compliance with minimum standards that similar facilities are required to meet, the standards do not have to be resubmitted to the department unless a change occurs in the standards. Any changes in the standards shall be provided to the department within 10 days of their adoption.
(c) Has been issued a certificate of registration by the qualified association.
(6) Each child served by a Type II facility shall be covered by a written contract, executed at the time of admission or prior thereto, between the facility and the parent, legal guardian, or person having legal custody of the child. Such person shall be given a copy of the contract at the time of its execution, and the facility shall retain the original contract. Each contract shall:
(a) Enumerate the basic services and accommodations provided by the facility.
(b) State that the facility is a Type II facility.
(c) Contain the address and telephone number of the qualified association.
(d) Specify the charges, if any, to the parent, legal guardian, or person having legal custody of the child.
(e) Contain a clear statement regarding disciplinary procedures.
(f) State that the goal of the facility is to return the child it serves to the parent, legal guardian, or person having legal custody of the child, within 1 year from the time the child enters the facility.
(g) Authorize the facility administrator or his or her designee to consent to routine and emergency medical care on behalf of the parent, legal guardian, or person having legal custody of the child, provided the facility administrator shall immediately notify the parent, legal guardian, or person having legal custody of the child of medical care being provided on his or her behalf. Authorization of this power shall be granted only upon the separate consent in the contract of the parent, legal guardian, or person having legal custody of the child.
A copy of the contract signed by the parent, legal guardian, or person having legal custody of the child shall be filed with the qualified association within 10 days after the child enters the facility.
(7) Any facility registered under the provisions of this section shall notify the department immediately if it has in its care a child with serious developmental disabilities or a physical, emotional, or mental handicap for which the facility is not qualified or able to provide treatment.
(8) The provisions of chapters 39 and 827 regarding child abuse, abandonment, and neglect and the provisions of s. 409.175 and chapter 435 regarding screening apply to any facility registered under this section.
(9) The qualified association may deny, suspend, or revoke the registration of a Type II facility which:
(a) Fails to comply with this section;
(b) Is found to have willfully or intentionally provided false or misleading information in its registration forms or service contracts; or
(c) Violates the provisions of chapter 39 or chapter 827 regarding child abuse, abandonment, and neglect or the provisions of s. 409.175 or chapter 435 regarding screening.
The qualified association shall notify the department within 10 days of the suspension or revocation of the registration of any Type II facility registered under this section.
(10)(a) The qualified association shall notify the department within 24 hours after the qualified association finds there is a violation of any of the provisions of this section which threatens harm to any child or which constitutes an emergency requiring immediate action.
(b) The qualified association shall notify the department within 3 calendar days after the qualified association finds that a person or facility continues to care for children without a certificate of registration issued pursuant to this section, a license pursuant to s. 409.175, or registration as a boarding school pursuant to s. 409.175. The department shall notify the appropriate state attorney of the violation of law and, if necessary, shall institute a civil suit to enjoin the person or facility from continuing the care of children.
(c) The department may institute injunctive proceedings in a court of competent jurisdiction to:
1. Enforce the provisions of this section; or
2. Terminate the operation of a facility in which any of the conditions described in paragraph (a) or paragraph (b) exist.
Such injunctive relief may be temporary or permanent.
(11)(a) The department is authorized to seek compliance with the registration requirements of this section to the fullest extent possible by reliance on administrative sanctions and civil actions.
(b) If the department determines that a person or facility is caring for a child without a valid certificate of registration issued by the qualified association or has made a willful or intentional misstatement on any registration application or other document required to be filed in connection with an application for a certificate of registration, the qualified association, as an alternative to or in conjunction with an administrative action against such person or facility, shall make a reasonable attempt to discuss each violation with, and recommend corrective action to, the person or the administrator of the facility, prior to written notification thereof.
(c) Any action taken to correct a violation shall be documented in writing by the person or administrator of the facility and verified by the qualified association.
(d) If the person or facility has failed to remedy each violation by the specific date agreed upon with the qualified association, the qualified association shall notify the department which shall within 30 days notify the person or facility by certified mail of its intention to refer the violation or violations to the office of the state attorney.
(e) If the person or facility fails to come into compliance with the registration requirements within 30 days of written notification, the qualified association shall notify the department which shall within 30 days refer the violation or violations to the office of the state attorney.
(12) It is unlawful for any person or facility to:
(a) Provide continuing full-time care for or to receive or place a child apart from her or his parents in a residential group care facility or a family foster home without a valid certificate of registration issued by the qualified association if such certificate is required by subsection (1).
(b) Make a willful or intentional misstatement on any registration application or other document required to be filed in connection with an application for registration.
(c) Willfully or intentionally fail to comply with the requirements for the screening of personnel or the dismissal of personnel found not to be in compliance with the requirements for good moral character as specified in paragraph (2)(b).
(d) Use information from the criminal records obtained under s. 409.175 or this section for any purpose other than screening a person for employment as specified in chapter 435, s. 409.175, or this section or to release such information to any other person for any purpose other than screening for employment as specified in chapter 435, s. 409.175, or this section.
(e) Use information from the juvenile records of any person obtained under chapter 435, s. 409.175, or this section for any purpose other than screening for employment as specified in chapter 435, s. 409.175, or this section or to release information from such records to any other person for any purpose other than screening for employment as specified in chapter 435, s. 409.175, or this section.
A first violation of paragraph (a), paragraph (b), paragraph (c), or paragraph (d) is a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083. A second or subsequent violation of paragraph (a), paragraph (b), paragraph (c), or paragraph (d) is a felony of the third degree, punishable as provided in s. 775.082 or s. 775.083. A violation of paragraph (e) is a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(13) Any facility registered or meeting the requirements of registration under this section may apply for a license under this chapter. A facility which has applied for and received a license is no longer eligible to operate under the provisions of this section.
(14) Registration under this section, including the issue of substantial compliance with published minimum standards that similar licensed child-caring facilities or family foster homes are required to meet, as provided in paragraph (5)(b), is subject to the provisions of chapter 120.
(15) The qualified association issuing certificates of registration for Type II facilities under this section shall annually report to the department the following information:
(a) The number of Type II facilities registered during the most recent calendar year, the names and addresses of the facilities, and the name of each facility’s administrator.
(b) The total number of children served by each facility during the calendar year.
The department may impose an administrative fine against the qualified association not to exceed $250 per violation for failure to comply with the requirements of this section.
History.—ss. 3, 21, ch. 84-311; s. 36, ch. 85-54; s. 30, ch. 91-57; s. 3, ch. 91-71; s. 4, ch. 91-429; s. 2, ch. 94-257; s. 3, ch. 96-402; s. 253, ch. 96-406; s. 1019, ch. 97-103; s. 147, ch. 98-403; s. 11, ch. 2000-139; s. 9, ch. 2001-68; s. 2, ch. 2013-219.
409.179 Family-friendly workplace initiative.—Recognizing that employers play a key role in helping families balance work and family responsibilities, the Executive Office of the Governor, in consultation with members of the business community, may establish a family-friendly workplace initiative. The Executive Office of the Governor may develop a program to annually collect information regarding the state’s eligible small employers with 50 or fewer employees, and eligible large employers with 51 or more employees in the state, providing the most family-friendly benefits to their employees. The same program may be established for public employers. The criteria for determination of the eligible employers may include, but not be limited to:
(1) Consideration of the dependent care scholarship or discounts given by the employer.
(2) Flexible work hours and schedules.
(3) Time off for caring for sick or injured dependents.
(4) The provision of onsite or nearby dependent care.
(5) Dependent care referral services.
(6) In-kind contributions to community dependent care programs.
Those employers chosen by the Executive Office of the Governor may be recognized with annual “family-friendly workplace” awards and a statewide information and advertising campaign publicizing the employers’ awards, their contributions to family-friendly child care, and the methods they used to improve the dependent care experiences of their employees’ families.
History.—s. 86, ch. 96-175.
409.212 Optional supplementation.—
(1) There may be monthly optional supplementation payments, made in such amount as determined by the department, to any person who:
(a) Meets all the program eligibility criteria for an assisted living facility or for adult foster care, family placement, or other specialized living arrangement; and
(b) Is receiving a Supplemental Security Income check or is determined to be eligible for optional supplementation by the department.
(2) The base rate of payment for optional state supplementation shall be established by the department within funds appropriated. Additional amounts may be provided for mental health residents in facilities designed to provide limited mental health services as provided for in s. 429.075. The base rate of payment does not include the personal needs allowance.
(3) Assisted living facilities, adult family-care homes, family placement, or any other specialized living arrangement accepting residents who receive optional supplementation payments must comply with the requirements of 42 U.S.C. s. 1382e(e).
(4) In addition to the amount of optional supplementation provided by the state, a person may receive additional supplementation from third parties to contribute to his or her cost of care. Additional supplementation may be provided under the following conditions:
(a) Payments shall be made to the assisted living facility, or to the operator of an adult family-care home, family placement, or other special living arrangement, on behalf of the person and not directly to the optional state supplementation recipient.
(b) Contributions made by third parties shall be entirely voluntary and shall not be a condition of providing proper care to the client.
(c) The additional supplementation shall not exceed two times the provider rate recognized under the optional state supplementation program.
(d) Rent vouchers issued pursuant to a federal, state, or local housing program may be issued directly to a recipient of optional state supplementation.
(5) When contributions are made in accordance with the provisions of subsection (4), the department shall not count such supplements as income to the client for purposes of determining eligibility for, or computing the amount of, optional state supplementation benefits, nor shall the department increase an optional state supplementation payment to offset the reduction in Supplemental Security Income benefits that will occur because of the third-party contribution.
(6) The optional state supplementation rate shall be increased by the cost-of-living adjustment to the federal benefits rate provided the average state optional supplementation contribution does not increase as a result.
(7) The department may adopt rules to administer this section relating to eligibility requirements for optional state supplementation.
History.—s. 10, ch. 78-433; s. 9, ch. 89-294; s. 16, ch. 90-295; s. 32, ch. 91-263; s. 31, ch. 95-210; s. 16, ch. 95-418; s. 10, ch. 97-82; s. 5, ch. 97-98; s. 44, ch. 97-103; s. 12, ch. 98-148; s. 8, ch. 98-152; s. 10, ch. 2000-163; s. 47, ch. 2000-256; s. 79, ch. 2006-197.
409.221 Consumer-directed care program.—
(1) SHORT TITLE.—This section may be cited as the “Florida Consumer-Directed Care Act.”
(2) LEGISLATIVE FINDINGS.—The Legislature finds that alternatives to institutional care, such as in-home and community-based care, should be encouraged. The Legislature finds that giving recipients of in-home and community-based services the opportunity to select the services they need and the providers they want, including family and friends, enhances their sense of dignity and autonomy. The Legislature also finds that providing consumers choice and control, as tested in current research and demonstration projects, has been beneficial and should be developed further and implemented statewide.
(3) LEGISLATIVE INTENT.—It is the intent of the Legislature to nurture the autonomy of those citizens of the state, of all ages, who have disabilities by providing the long-term care services they need in the least restrictive, appropriate setting. It is the intent of the Legislature to give such individuals more choices in and greater control over the purchased long-term care services they receive.
(4) CONSUMER-DIRECTED CARE.—
(a) Program established.—The Agency for Health Care Administration shall establish the consumer-directed care program which shall be based on the principles of consumer choice and control. The agency shall implement the program upon federal approval. The agency shall establish interagency cooperative agreements with and shall work with the Departments of Elderly Affairs, Health, and Children and Family Services and the Agency for Persons with Disabilities to implement and administer the program. The program shall allow enrolled persons to choose the providers of services and to direct the delivery of services, to best meet their long-term care needs. The program must operate within the funds appropriated by the Legislature.
(b) Eligibility and enrollment.—Persons who are enrolled in one of the Medicaid home and community-based waiver programs and are able to direct their own care, or to designate an eligible representative, may choose to participate in the consumer-directed care program.
(c) Definitions.—For purposes of this section, the term:
1. “Budget allowance” means the amount of money made available each month to a consumer to purchase needed long-term care services, based on the results of a functional needs assessment.
2. “Consultant” means an individual who provides technical assistance to consumers in meeting their responsibilities under this section.
3. “Consumer” means a person who has chosen to participate in the program, has met the enrollment requirements, and has received an approved budget allowance.
4. “Fiscal intermediary” means an entity approved by the agency that helps the consumer manage the consumer’s budget allowance, retains the funds, processes employment information, if any, and tax information, reviews records to ensure correctness, writes paychecks to providers, and delivers paychecks to the consumer for distribution to providers and caregivers.
5. “Provider” means:
a. A person licensed or otherwise permitted to render services eligible for reimbursement under this program for whom the consumer is not the employer of record; or
b. A consumer-employed caregiver for whom the consumer is the employer of record.
6. “Representative” means an uncompensated individual designated by the consumer to assist in managing the consumer’s budget allowance and needed services.
(d) Budget allowances.—Consumers enrolled in the program shall be given a monthly budget allowance based on the results of their assessed functional needs and the financial resources of the program. Consumers shall receive the budget allowance directly from an agency-approved fiscal intermediary. Each department shall develop purchasing guidelines, approved by the agency, to assist consumers in using the budget allowance to purchase needed, cost-effective services.
(e) Services.—Consumers shall use the budget allowance only to pay for home and community-based services that meet the consumer’s long-term care needs and are a cost-efficient use of funds. Such services may include, but are not limited to, the following:
1. Personal care.
2. Homemaking and chores, including housework, meals, shopping, and transportation.
3. Home modifications and assistive devices which may increase the consumer’s independence or make it possible to avoid institutional placement.
4. Assistance in taking self-administered medication.
5. Day care and respite care services, including those provided by nursing home facilities pursuant to s. 400.141(1)(f) or by adult day care facilities licensed pursuant to s. 429.907.
6. Personal care and support services provided in an assisted living facility.
(f) Consumer roles and responsibilities.—Consumers shall be allowed to choose the providers of services, as well as when and how the services are provided. Providers may include a consumer’s neighbor, friend, spouse, or relative.
1. In cases where a consumer is the employer of record, the consumer’s roles and responsibilities include, but are not limited to, the following:
a. Developing a job description.
b. Selecting caregivers and submitting information for the background screening as required in s. 435.05.
c. Communicating needs, preferences, and expectations about services being purchased.
d. Providing the fiscal intermediary with all information necessary for provider payments and tax requirements.
e. Ending the employment of an unsatisfactory caregiver.
2. In cases where a consumer is not the employer of record, the consumer’s roles and responsibilities include, but are not limited to, the following:
a. Communicating needs, preferences, and expectations about services being purchased.
b. Ending the services of an unsatisfactory provider.
c. Providing the fiscal agent with all information necessary for provider payments and tax requirements.
(g) Agency’s and departments’ roles and responsibilities.—The agency’s and the departments’ roles and responsibilities include, but are not limited to, the following:
1. Assessing each consumer’s functional needs, helping with the service plan, and providing ongoing assistance with the service plan.
2. Offering the services of consultants who shall provide training, technical assistance, and support to the consumer.
3. Completing the background screening for providers.
4. Approving fiscal intermediaries.
5. Establishing the minimum qualifications for all caregivers and providers and being the final arbiter of the fitness of any individual to be a caregiver or provider.
(h) Fiscal intermediary roles and responsibilities.—The fiscal intermediary’s roles and responsibilities include, but are not limited to, the following:
1. Providing recordkeeping services.
2. Retaining the consumer-directed care funds, processing employment and tax information, if any, reviewing records to ensure correctness, writing paychecks to providers, and delivering paychecks to the consumer for distribution.
(i) Background screening requirements.—All persons who render care under this section must undergo level 2 background screening pursuant to chapter 435 and s. 408.809. The agency shall, as allowable, reimburse consumer-employed caregivers for the cost of conducting background screening as required by this section. For purposes of this section, a person who has undergone screening, who is qualified for employment under this section and applicable rule, and who has not been unemployed for more than 90 days following such screening is not required to be rescreened. Such person must attest under penalty of perjury to not having been convicted of a disqualifying offense since completing such screening.
(j) Rules; federal waivers.—In order to implement this section:
1. The agency and the Departments of Elderly Affairs, Health, and Children and Family Services and the Agency for Persons with Disabilities are authorized to adopt and enforce rules.
2. The agency shall take all necessary action to ensure state compliance with federal regulations. The agency shall apply for any necessary federal waivers or waiver amendments needed to implement the program.
History.—s. 11, ch. 2002-223; s. 3, ch. 2006-15; s. 52, ch. 2006-227; s. 95, ch. 2007-5; s. 134, ch. 2007-230; s. 57, ch. 2009-223; s. 122, ch. 2010-102; s. 24, ch. 2010-114; s. 4, ch. 2012-73.
409.2355 Programs for prosecution of males over age 21 who commit certain offenses involving girls under age 16.—Subject to specific appropriated funds, the Department of Children and Family Services is directed to establish a program by which local communities, through the state attorney’s office of each judicial circuit, may apply for grants to fund innovative programs for the prosecution of males over the age of 21 who victimize girls under the age of 16 in violation of s. 794.011, s. 794.05, s. 800.04, s. 827.04(3), or s. 847.0135(5).
History.—s. 11, ch. 96-215; s. 196, ch. 97-101; s. 53, ch. 2000-153; s. 12, ch. 2008-172.
409.2551 Legislative intent.—Common-law and statutory procedures governing the remedies for enforcement of support for financially dependent children by persons responsible for their support have not proven sufficiently effective or efficient to cope with the increasing incidence of financial dependency. The increasing workload of courts, prosecuting attorneys, and the Attorney General has resulted in a growing burden on the financial resources of the state, which is constrained to provide public assistance for basic maintenance requirements when parents fail to meet their primary obligations. The state, therefore, exercising its police and sovereign powers, declares that the common-law and statutory remedies pertaining to family desertion and nonsupport of dependent children shall be augmented by additional remedies directed to the resources of the responsible parents. In order to render resources more immediately available to meet the needs of dependent children, it is the legislative intent that the remedies provided herein are in addition to, and not in lieu of, existing remedies. It is declared to be the public policy of this state that this act be construed and administered to the end that children shall be maintained from the resources of their parents, thereby relieving, at least in part, the burden presently borne by the general citizenry through public assistance programs.
History.—s. 1, ch. 76-220; s. 140, ch. 86-220.
409.2554 Definitions; ss. 409.2551-409.2598.—As used in ss. 409.2551-409.2598, the term:
(1) “Department” means the Department of Revenue.
(2) “Dependent child” means any unemancipated person under the age of 18, any person under the age of 21 and still in school, or any person who is mentally or physically incapacitated when such incapacity began prior to such person reaching the age of 18. This definition shall not be construed to impose an obligation for child support beyond the child’s attainment of majority except as imposed in s. 409.2561.
(3) “Court” means the circuit court.
(4) “Court order” means any judgment or order of any court of appropriate jurisdiction of the state, or an order of a court of competent jurisdiction of another state, ordering payment of a set or determinable amount of support money.
(5) “Health insurance” means coverage under a fee-for-service arrangement, health maintenance organization, or preferred provider organization, and other types of coverage available to either parent, under which medical services could be provided to a dependent child.
(6) “Obligee” means the person to whom support payments are made pursuant to an alimony or child support order.
(7) “Obligor” means a person who is responsible for making support payments pursuant to an alimony or child support order.
(8) “Public assistance” means money assistance paid on the basis of Title IV-E and Title XIX of the Social Security Act, temporary cash assistance, or food assistance benefits received on behalf of a child under 18 years of age who has an absent parent.
(9) “Program attorney” means an attorney employed by the department, under contract with the department, or employed by a contractor of the department, to provide legal representation for the department in a proceeding related to the determination of paternity or the establishment, modification, or enforcement of support brought pursuant to law.
(10) “Prosecuting attorney” means any private attorney, county attorney, city attorney, state attorney, program attorney, or an attorney employed by an entity of a local political subdivision who engages in legal action related to the determination of paternity or the establishment, modification, or enforcement of support brought pursuant to this act.
(11) “Support,” unless otherwise specified, means:
(a) Child support, and, when the child support obligation is being enforced by the Department of Revenue, spousal support or alimony for the spouse or former spouse of the obligor with whom the child is living.
(b) Child support only in cases not being enforced by the Department of Revenue.
(12) “Administrative costs” means any costs, including attorney’s fees, clerk’s filing fees, recording fees and other expenses incurred by the clerk of the circuit court, service of process fees, or mediation costs, incurred by the IV-D agency in its effort to administer the IV-D program. The administrative costs which must be collected by the department shall be assessed on a case-by-case basis based upon a method for determining costs approved by the Federal Government. The administrative costs shall be assessed periodically by the department. The methodology for determining administrative costs shall be made available to the judge or any party who requests it. Only those amounts ordered independent of current support, arrears, or past public assistance obligation shall be considered and applied toward administrative costs.
(13) “Child support services” includes any civil, criminal, or administrative action taken by the Title IV-D program to determine paternity, establish, modify, enforce, or collect support.
(14) “Undistributable collection” means a support payment received by the department which the department determines cannot be distributed to the final intended recipient.
(15) “Unidentifiable collection” means a payment received by the department for which a parent, depository or circuit civil numbers, or source of the payment cannot be identified.
History.—s. 2, ch. 76-220; s. 1, ch. 82-140; s. 1, ch. 85-178; ss. 86, 141, ch. 86-220; s. 15, ch. 87-95; s. 10, ch. 88-176; s. 18, ch. 92-138; s. 5, ch. 94-124; s. 88, ch. 96-175; s. 45, ch. 97-170; s. 40, ch. 97-173; s. 148, ch. 98-403; s. 39, ch. 2000-139; s. 92, ch. 2000-165; s. 25, ch. 2001-158; s. 19, ch. 2008-61; s. 4, ch. 2009-90; s. 9, ch. 2010-209.
409.2557 State agency for administering child support enforcement program.—
(1) The department is designated as the state agency responsible for the administration of the child support enforcement program, Title IV-D of the Social Security Act, 42 U.S.C. ss. 651 et seq.
(2) The department in its capacity as the state Title IV-D agency shall have the authority to take actions necessary to carry out the public policy of ensuring that children are maintained from the resources of their parents to the extent possible. The department’s authority shall include, but not be limited to, the establishment of paternity or support obligations, as well as the modification, enforcement, and collection of support obligations.
(3) SPECIFIC RULEMAKING AUTHORITY.—The department has the authority to adopt rules pursuant to ss. 120.536(1) and 120.54 to implement all laws administered by the department in its capacity as the Title IV-D agency for this state including, but not limited to, the following:
(a) Background screening of department employees and applicants, including criminal records checks;
(b) Confidentiality and retention of department records; access to records; record requests;
(c) Department trust funds;
(d) Federal funding procedures;
(e) Agreements with law enforcement and other state agencies; National Crime Information Center (NCIC) access; Parent Locator Service access;
(f) Written agreements entered into between the department and support obligors in establishment, enforcement, and modification proceedings;
(g) Procurement of services by the department, pilot programs, and demonstration projects;
(h) Management of cases by the department involving any documentation or procedures required by federal or state law, including but not limited to, cooperation; review and adjustment; audits; interstate actions; diligent efforts for service of process;
(i) Department procedures for orders for genetic testing; subpoenas to establish, enforce, or modify orders; increasing the amount of monthly obligations to secure delinquent support; suspending or denying driver’s and professional licenses and certificates; fishing and hunting license suspensions; suspending vehicle and vessel registrations; screening applicants for new or renewal licenses, registrations, or certificates; income deduction; credit reporting and accessing; tax refund intercepts; passport denials; liens; financial institution data matches; expedited procedures; medical support; and all other responsibilities of the department as required by state or federal law;
(j) Collection and disbursement of support and alimony payments by the department as required by federal law; collection of genetic testing costs and other costs awarded by the court;
(k) Report information to and receive information from other agencies and entities;
(l) Provide location services, including accessing from and reporting to federal and state agencies;
(m) Privatizing location, establishment, enforcement, modification, and other functions;
(n) State case registry;
(o) State disbursement unit;
(p) Administrative proceedings to establish paternity or establish paternity and child support, orders to appear for genetic testing, and administrative proceedings to establish child support obligations; and
(q) All other responsibilities of the department as required by state or federal law.
History.—s. 3, ch. 76-220; s. 19, ch. 92-138; s. 4, ch. 94-318; s. 20, ch. 98-397; s. 26, ch. 2001-158; s. 9, ch. 2002-173; s. 2, ch. 2002-239; s. 22, ch. 2005-39.
409.25575 Support enforcement; privatization.—
(1) It is the intent of the Legislature to encourage the Department of Revenue to contract with private entities for the provision of support enforcement services whenever such contracting is cost-effective.
(2) The department shall contract for the delivery, administration, or management of support enforcement activities and other related services or programs, when appropriate. The department shall retain responsibility for the quality of contracted services and programs and shall ensure that services are delivered in accordance with applicable federal and state statutes and regulations.
(3)(a) The department shall establish a quality assurance program for the privatization of services. The program must include standards for each specific component of these services. The department shall establish minimum thresholds for each component. Each program operated pursuant to contract must be evaluated annually by the department or by an objective competent entity designated by the department under the provisions of the quality assurance program. The evaluation must be financed from cost savings associated with the privatization of services. The quality assurance program must be financed through administrative savings generated by this act.
(b) The department shall establish and operate a comprehensive system to measure and report annually the outcomes and effectiveness of the services that have been privatized. The department shall use these findings in making recommendations to the Governor and the Legislature for future program and funding priorities in the support enforcement system.
(4)(a) Any entity contracting to provide support enforcement services under this section must comply with all statutory requirements and agency regulations in the provision of contractual services.
(b) Any entity contracting to provide support enforcement services under this section must also participate in and cooperate with any federal program that will assist in the maximization of federal supports for these services, as directed by the department.
History.—s. 46, ch. 97-170; s. 27, ch. 2001-158; s. 123, ch. 2010-102.
409.2558 Support distribution and disbursement.—
(1) DISTRIBUTION OF PAYMENTS.—The department shall distribute and disburse support payments collected in Title IV-D cases in accordance with 42 U.S.C. s. 657 and regulations adopted thereunder by the Secretary of the United States Department of Health and Human Services.
(2) ELECTRONIC DISBURSEMENT OF PAYMENTS.—Any payments made to the State Disbursement Unit that are owed to the obligee in a Title IV-D case shall be disbursed electronically. The obligee may designate a personal account for deposit of payments. If the obligee does not designate a personal account, the State Disbursement Unit shall deposit any payments into a stored value account that can be accessed by the obligee.
(3) UNDISTRIBUTABLE COLLECTIONS.—
(a) The department shall establish by rule the method for determining a collection or refund to be undistributable to the final intended recipient. Before determining a collection or refund to be undistributable, the department shall make reasonable efforts to locate persons to whom collections or refunds are owed so that payment can be made. Location efforts may include disclosure through a searchable database of the names of obligees, obligors, and depository account numbers on the Internet in compliance with the requirements of s. 119.01(2)(a).
(b) Collections that are determined to be undistributable shall be processed in the following order of priority:
1. Apply the payment to any financial liability incurred by the obligor as a result of a previous payment returned to the department for insufficient funds; then
2. Apply the payment to any financial liability incurred by the obligor as a result of an overpayment to the obligor which the obligor has failed to return to the department after notice; then
3. Apply the payment to any financial liability incurred by the obligee as a result of an overpayment to the obligee which the obligee has failed to return to the department after notice; then
4. Apply the payment to any assigned arrears on the obligee’s case; then
5. Apply the payment to any administrative costs ordered by the court pursuant to s. 409.2567 associated with the obligee’s case; then
6. When the obligor is subject to a valid order to support another child in a case with a different obligee and the obligation is being enforced by the department, the department shall send by certified mail, restricted delivery, return receipt requested, to the obligor at the most recent address provided by the obligor to the tribunal that issued the order, a notice stating the department’s intention to apply the payment pursuant to this subparagraph, and advising the obligor of the right to contest the department’s proposed action in the circuit court by filing and serving a petition on the department within 30 days after the mailing of the notice. If the obligor does not file and serve a petition within the 30 days after mailing of the notice, or upon a disposition of the judicial action favorable to the department, the department shall apply the payment toward his or her other support obligation. If there is more than one such other case, the department shall allocate the remaining undistributable amount as specified by s. 61.1301(4)(c); then
7. Return the payment to the obligor; then
8. If the obligor cannot be located after diligent efforts by the department, the federal share of the payment shall be credited to the Federal Government and the state share shall be transferred to the General Revenue Fund.
(c) Refunds to obligors that are determined to be undistributable shall be processed in the following manner:
1. The federal share of the refund shall be sent to the Federal Government.
2. The state share shall be credited to the General Revenue Fund.
(d) If a payment of less than $1 is made by a paper check on an open Title IV-D case and the payment is not cashed after 180 days, or if less than $1 is owed on a closed Title IV-D case, the department shall declare the payment as program income, crediting the federal share of the payment to the Federal Government and the state share of the payment to the General Revenue Fund, without attempting to locate either party.
(4) UNIDENTIFIABLE COLLECTIONS.—
(a) The department shall establish by rule the method for determining a collection to be unidentifiable.
(b) Upon being determined to be unidentifiable, the federal share of unidentifiable collections shall be credited to the Federal Government and the state share shall be transferred to the General Revenue Fund.
(5) RECLAIMING COLLECTIONS DECLARED TO BE UNDISTRIBUTABLE OR UNIDENTIFIABLE.—At such time as an undistributable or unidentifiable collection that has been transferred to the Federal Government and to the General Revenue Fund in the relevant method above becomes distributable or identified, meaning either the obligor or the obligee is identified or located, the department shall retrieve the transferred moneys in the following manner:
(a) Offset the next credit to the Federal Government in an amount equal to the share of the collection which had been transferred; and
(b) Offset the next transfer to the General Revenue Fund in an amount equal to the state share of the collection which had been transferred to the General Revenue Fund.
The collection shall then be processed, as appropriate.
(6) RECONSIDERATION OF DISTRIBUTION AND DISBURSEMENT.—A recipient of collection and distribution services of the department’s Child Support Enforcement Program may request a reconsideration by the department concerning the amount collected, the date collected, the amount distributed, the distribution timing, or the calculation of arrears. The department shall establish by rule a reconsideration procedure for informal review of agency action in distributing and disbursing support payments collected by the department. The procedures must provide the recipients of services with an opportunity to review the department’s actions before a hearing is requested under chapter 120.
(7) OVERPAYMENT.—If the department’s records indicate that a support obligee has received an overpayment of support from the department due to either mistake or fraud, the department may take action to recover the overpayment. The department may establish by rule a procedure to recover overpayments.
(8) ORDER REDIRECTING PAYMENTS TO THE PERSON WITH WHOM THE CHILD RESIDES.—
(a) If the department determines in a Title IV-D case that a child for whom a support order has been entered by a tribunal of this state resides with a person other than the obligee or obligor, the department may not disburse current support payments for the child to the obligee without a further order from the tribunal that entered the support order. For purposes of this section, “tribunal” means either the circuit court or the department.
(b) A determination by the department under paragraph (a) must be based on one or more of the following factors:
1. Public assistance records that show a person other than the obligee or obligor is receiving public assistance for the child.
2. A statement by the obligee that the child resides with a person other than the obligee or obligor is submitted to the department.
3. A sworn statement or written declaration signed under penalty of perjury by a person who has personal knowledge that the child resides with a person other than the obligee or obligor is submitted to the department.
4. Government records that show the obligee is incarcerated.
5. Evidence that the obligee has left the community where the child resides is submitted to the department.
6. Other credible information that indicates the child resides with a person other than the obligee or obligor is submitted to the department.
(c) When the department determines that a child as specified in paragraph (a) resides with a person other than the obligee or obligor, the department shall submit by regular mail to the obligee, the obligor, and, if known, the person with whom the child resides a notice that states:
1. The facts on which the determination is based.
2. The name and address of the person with whom the child resides, if known, unless disclosure is prohibited under s. 409.2579(3) or (4) or the child is in foster care.
3. That the department will not disburse current support payments for the child without a further order from the tribunal that entered the support order.
4. If the support order was entered by the circuit court:
a. That the department will file a motion and proposed order with the court that asks the court to order that the obligor’s current support payments be disbursed to the person with whom the child resides, determine arrearages, and order repayment of arrearages;
b. That the obligee, the obligor, and the person with whom the child resides may file an objection in court to the proposed order or a motion to compel disbursement; and
c. That the obligee, the obligor, and the person with whom the child resides will be mailed a copy of the department’s motion and notified of any court hearing.
5. If the support order was entered by the department:
a. That the department intends to disburse the current support payments to the person with whom the child resides, if known, determine arrearages, and order repayment of arrearages;
b. The effective date of the intended action to disburse current support payments to the person with whom the child resides, the amount of arrearages owed to the obligee and the person with whom the child resides, and the amount of the order for periodic repayment of arrearages;
c. That the obligee, the obligor, and the person with whom the child resides may contest the intended action by filing with the department a petition for an administrative hearing within 30 days after the date of mailing of the notice;
d. That if a timely petition for an administrative hearing is filed, the parties will be given advance notice of the date, time, and place of the hearing; and
e. That if the notice of intended action is not timely contested, the department will enter a final order based on what is stated in the notice.
(d) The tribunal that entered the support order shall determine whether support payments not disbursed by the department and current support must be paid to the obligee, paid to the person with whom the child resides, or refunded to the obligor. The person with whom the child resides is deemed a party to the proceedings. The tribunal is not required to hold a hearing unless a party has filed a timely objection to the proposed order or a timely petition for an administrative hearing. If the department is the tribunal and a timely petition for an administrative hearing is filed, the hearing shall be conducted by the Division of Administrative Hearings and the administrative law judge shall enter a final order. If a hearing is not required, the tribunal shall enter an order within 30 days after the department’s motion is filed or the notice of intended action is mailed. If a timely objection or petition for an administrative hearing is filed, a hearing shall be conducted and an order entered within 30 days after the objection or petition is filed.
(e) If the tribunal finds by a preponderance of the evidence that the child does not reside with the obligee, the tribunal shall enter an order that redirects the obligor’s current support payments due under the support order to the person with whom the child resides, determine arrearages owed to the obligee and the person with whom the child resides, and order repayment of arrearages. The tribunal need not recompute the obligor’s support obligation under the child support guidelines. If the person with whom the child resides is unknown and the obligor owes no arrearages or costs, the tribunal shall enter an order that refunds the payments not disbursed by the department to the obligor. If the child resides with the obligor, the person with whom the child resides is unknown, or the child’s place of residence is unknown, the tribunal shall consider whether to abate, terminate, or modify the support order.
(f) A tribunal that enters an order that redirects or refunds support payments shall file a copy of the order with the depository that serves as official recordkeeper for payments due under the support order. The depository shall maintain separate accounts and separate account numbers for individual payees.
(9) RULEMAKING AUTHORITY.—The department may adopt rules to administer this section.
History.—s. 21, ch. 98-397; s. 10, ch. 99-375; s. 28, ch. 2001-158; s. 10, ch. 2004-334; s. 23, ch. 2005-39; s. 8, ch. 2005-82; s. 20, ch. 2008-61; s. 4, ch. 2008-92; ss. 23, 54, ch. 2008-153; s. 124, ch. 2010-102; s. 6, ch. 2010-187.
409.2559 State disbursement unit.—The department shall establish and operate a state disbursement unit by October 1, 1999, as required by 42 U.S.C. s. 654(27).
History.—s. 22, ch. 98-397.
409.256 Administrative proceeding to establish paternity or paternity and child support; order to appear for genetic testing.—
(1) DEFINITIONS.—As used in this section, the term:
(a) “Another state” or “other state” means a state of the United States, the District of Columbia, Puerto Rico, the United States Virgin Islands, or any territory or insular possession subject to the jurisdiction of the United States. The term includes:
1. An Indian tribe.
2. A foreign jurisdiction that has enacted a law or established procedures for issuance and enforcement of support orders which are substantially similar to the procedures under this act, the Uniform Reciprocal Enforcement of Support Act, or the Revised Uniform Reciprocal Enforcement of Support Act, as determined by the Attorney General.
(b) “Caregiver” means a person, other than the mother, father, or a putative father, who has physical custody of a child or with whom the child primarily resides. References in this section to the obligation of a caregiver to submit to genetic testing mean that the caregiver is obligated to submit the child for genetic testing, not that the caregiver must submit to genetic testing.
(c) “Filed” means a document has been received and accepted for filing at the offices of the Department of Revenue by the clerk or an authorized deputy clerk designated by the department.
(d) “Genetic testing” means a scientific analysis of genetic markers which is performed by a qualified technical laboratory only to exclude an individual as the parent of a child or to show a probability of paternity.
(e) “Paternity and child support proceeding” means an administrative action commenced by the Department of Revenue to order genetic testing, establish paternity, and establish an administrative support order pursuant to this section.
(f) “Paternity proceeding” means an administrative action commenced by the Department of Revenue to order genetic testing and establish paternity pursuant to this section.
(g) “Putative father” means an individual who is or may be the biological father of a child whose paternity has not been established and whose mother was unmarried when the child was conceived and born.
(h) “Qualified technical laboratory” means a genetic-testing laboratory that may be under contract with the Department of Revenue, that uses tests and methods of a type generally acknowledged as reliable by accreditation organizations recognized by the United States Department of Health and Human Services, and that is approved by such an accreditation organization. The term includes a genetic-testing laboratory used by another state, if the laboratory has comparable qualifications.
(i) “Rendered” means that a signed written order is filed with the clerk or a deputy clerk of the Department of Revenue and served on the respondent. The date of filing must be indicated on the face of the order at the time of rendition.
(j) “Respondent” means the person or persons served by the Department of Revenue with a notice of proceeding pursuant to subsection (4). The term includes the putative father and may include the mother or the caregiver of the child.
(k) “This state” or “the state” means the State of Florida.
(2) JURISDICTION; LOCATION OF HEARINGS; RIGHT OF ACCESS TO THE COURTS.—
(a) The department may commence a paternity proceeding or a paternity and child support proceeding as provided in subsection (4) if:
1. The child’s paternity has not been established.
2. No one is named as the father on the child’s birth certificate or the person named as the father is the putative father named in an affidavit or a written declaration as provided in subparagraph 5.
3. The child’s mother was unmarried when the child was conceived and born.
4. The department is providing services under Title IV-D.
5. The child’s mother or a putative father has stated in an affidavit, or in a written declaration as provided in s. 92.525(2), that the putative father is or may be the child’s biological father. The affidavit or written declaration must set forth the factual basis for the allegation of paternity as provided in s. 742.12(2).
(b) If the department receives a request from another state to assist in the establishment of paternity, the department may serve an order to appear for genetic testing on a person who resides in this state and transmit the test results to the other state without commencing a paternity proceeding in this state.
(c) The department may use the procedures authorized by this section against a nonresident over whom this state may assert personal jurisdiction under chapter 48 or chapter 88.
(d) If a putative father, mother, or caregiver in a Title IV-D case voluntarily submits to genetic testing, the department may schedule that individual or the child for genetic testing without serving that individual with an order to appear for genetic testing. A respondent or other person who is subject to an order to appear for genetic testing may waive, in writing or on the record at an administrative hearing, formal service of notices or orders or waive any other rights or time periods prescribed by this section.
(e) Whenever practicable, hearings held by the Division of Administrative Hearings pursuant to this section shall be held in the judicial circuit where the person receiving services under Title IV-D resides or, if the person receiving services under Title IV-D does not reside in this state, in the judicial circuit where the respondent resides. If the department and the respondent agree, the hearing may be held in another location. If ordered by the administrative law judge, the hearing may be conducted telephonically or by videoconference.
(f) The Legislature does not intend to limit the jurisdiction of the circuit courts to hear and determine issues regarding establishment of paternity. This section is intended to provide the department with an alternative procedure for establishing paternity and child support obligations in Title IV-D cases. This section does not prohibit a person who has standing from filing a civil action in circuit court for a determination of paternity or of child support obligations.
(g) Section 409.2563(2)(e), (f), and (g) apply to a proceeding under this section.
(3) MULTIPLE PUTATIVE FATHERS; MULTIPLE CHILDREN.—If more than one putative father has been named, the department may proceed under this section against a single putative father or may proceed simultaneously against more than one putative father. If a putative father has been named as a possible father of more than one child born to the same mother, the department may proceed to establish the paternity of each child in the same proceeding.
(4) NOTICE OF PROCEEDING TO ESTABLISH PATERNITY OR PATERNITY AND CHILD SUPPORT; ORDER TO APPEAR FOR GENETIC TESTING; MANNER OF SERVICE; CONTENTS.—The Department of Revenue shall commence a proceeding to determine paternity, or a proceeding to determine both paternity and child support, by serving the respondent with a notice as provided in this section. An order to appear for genetic testing may be served at the same time as a notice of the proceeding or may be served separately. A copy of the affidavit or written declaration upon which the proceeding is based shall be provided to the respondent when notice is served. A notice or order to appear for genetic testing shall be served by certified mail, restricted delivery, return receipt requested, or in accordance with the requirements for service of process in a civil action. Service by certified mail is completed when the certified mail is received or refused by the addressee or by an authorized agent as designated by the addressee in writing. If a person other than the addressee signs the return receipt, the department shall attempt to reach the addressee by telephone to confirm whether the notice was received, and the department shall document any telephonic communications. If someone other than the addressee signs the return receipt, the addressee does not respond to the notice, and the department is unable to confirm that the addressee has received the notice, service is not completed and the department shall attempt to have the addressee served personally. For purposes of this section, an employee or an authorized agent of the department may serve the notice or order to appear for genetic testing and execute an affidavit of service. The department may serve an order to appear for genetic testing on a caregiver. The department shall provide a copy of the notice or order to appear by regular mail to the mother and caregiver, if they are not respondents.
(a) A notice of proceeding to establish paternity must state:
1. That the department has commenced an administrative proceeding to establish whether the putative father is the biological father of the child named in the notice.
2. The name and date of birth of the child and the name of the child’s mother.
3. That the putative father has been named in an affidavit or written declaration that states the putative father is or may be the child’s biological father.
4. That the respondent is required to submit to genetic testing.
5. That genetic testing will establish either a high degree of probability that the putative father is the biological father of the child or that the putative father cannot be the biological father of the child.
6. That if the results of the genetic test do not indicate a statistical probability of paternity that equals or exceeds 99 percent, the paternity proceeding in connection with that child shall cease unless a second or subsequent test is required.
7. That if the results of the genetic test indicate a statistical probability of paternity that equals or exceeds 99 percent, the department may:
a. Issue a proposed order of paternity that the respondent may consent to or contest at an administrative hearing; or
b. Commence a proceeding, as provided in s. 409.2563, to establish an administrative support order for the child. Notice of the proceeding shall be provided to the respondent by regular mail.
8. That, if the genetic test results indicate a statistical probability of paternity that equals or exceeds 99 percent and a proceeding to establish an administrative support order is commenced, the department shall issue a proposed order that addresses paternity and child support. The respondent may consent to or contest the proposed order at an administrative hearing.
9. That if a proposed order of paternity or proposed order of both paternity and child support is not contested, the department shall adopt the proposed order and render a final order that establishes paternity and, if appropriate, an administrative support order for the child.
10. That, until the proceeding is ended, the respondent shall notify the department in writing of any change in the respondent’s mailing address and that the respondent shall be deemed to have received any subsequent order, notice, or other paper mailed to the most recent address provided or, if a more recent address is not provided, to the address at which the respondent was served, and that this requirement continues if the department renders a final order that establishes paternity and a support order for the child.
11. That the respondent may file an action in circuit court for a determination of paternity, child support obligations, or both.
12. That if the respondent files an action in circuit court and serves the department with a copy of the petition or complaint within 20 days after being served notice under this subsection, the administrative process ends without prejudice and the action must proceed in circuit court.
13. That, if paternity is established, the putative father may file a petition in circuit court for a determination of matters relating to custody and rights of parental contact.
A notice under this paragraph must also notify the respondent of the provisions in s. 409.2563(4)(m) and (o).
(b) A notice of proceeding to establish paternity and child support must state the requirements of paragraph (a), except for subparagraph (a)7., and must state the requirements of s. 409.2563(4), to the extent that the requirements of s. 409.2563(4) are not already required by and do not conflict with this subsection. This section and s. 409.2563 apply to a proceeding commenced under this subsection.
(c) The order to appear for genetic testing shall inform the person ordered to appear:
1. That the department has commenced an administrative proceeding to establish whether the putative father is the biological father of the child.
2. The name and date of birth of the child and the name of the child’s mother.
3. That the putative father has been named in an affidavit or written declaration that states the putative father is or may be the child’s biological father.
4. The date, time, and place that the person ordered to appear must appear to provide a sample for genetic testing.
5. That if the person has custody of the child whose paternity is the subject of the proceeding, the person must submit the child for genetic testing.
6. That when the samples are provided, the person ordered to appear shall verify his or her identity and the identity of the child, if applicable, by presenting a form of identification as prescribed by s. 117.05(5)(b)2. which bears the photograph of the person who is providing the sample or other form of verification approved by the department.
7. That if the person ordered to appear submits to genetic testing, the department shall pay the cost of the genetic testing and shall provide the person ordered to appear with a copy of any test results obtained.
8. That if the person ordered to appear does not appear as ordered or refuses to submit to genetic testing without good cause, the department may take one or more of the following actions:
a. Commence proceedings to suspend the driver’s license and motor vehicle registration of the person ordered to appear, as provided in s. 61.13016;
b. Impose an administrative fine against the person ordered to appear in the amount of $500; or
c. File a petition in circuit court to establish paternity and obtain a support order for the child and an order for costs against the person ordered to appear, including costs for genetic testing.
9. That the person ordered to appear may contest the order by filing a written request for informal review within 15 days after the date of service of the order, with further rights to an administrative hearing following the informal review.
(d) If the putative father is incarcerated, the correctional facility shall assist the putative father in complying with an administrative order to appear for genetic testing issued under this section.
(e) An administrative order to appear for genetic testing has the same force and effect as a court order.
(5) RIGHT TO CONTEST ORDER TO APPEAR FOR GENETIC TESTING.—
(a) The person ordered to appear may contest an order to appear for genetic testing by filing a written request for informal review with the department within 15 days after the date of service of the order. The purpose of the informal review is to provide the person ordered to appear with an opportunity to discuss the proceedings and the basis of the order. At the conclusion of the informal review, the department shall notify the person ordered to appear, in writing, whether it intends to proceed with the order to appear. If the department notifies the person ordered to appear of its intent to proceed, the notice must inform the person ordered to appear of the right to contest the order at an administrative hearing.
(b) Following an informal review, within 15 days after the mailing date of the department’s notification that the department shall proceed with an order to appear for genetic testing, the person ordered to appear may file a request for an administrative hearing to contest whether the person should be required to submit to genetic testing. A request for an administrative hearing must state the specific reasons why the person ordered to appear believes he or she should not be required to submit to genetic testing as ordered. If the person ordered to appear files a timely request for a hearing, the department shall refer the hearing request to the Division of Administrative Hearings. Unless otherwise provided in this section, administrative hearings are governed by chapter 120 and the uniform rules of procedure. The administrative law judge assigned to the case shall issue an order as to whether the person must submit to genetic testing in accordance with the order to appear. The department or the person ordered to appear may seek immediate judicial review under s. 120.68 of an order issued by an administrative law judge pursuant to this paragraph.
(c) If a timely request for an informal review or an administrative hearing is filed, the department may not proceed under the order to appear for genetic testing and may not impose sanctions for failure or refusal to submit to genetic testing until:
1. The department has notified the person of its intent to proceed after informal review, and a timely request for hearing is not filed;
2. The person ordered to appear withdraws the request for hearing or informal review; or
3. The Division of Administrative Hearings issues an order that the person must submit to genetic testing, or issues an order closing the division’s file, and that an order has become final.
(d) If a request for an informal review or administrative hearing is not timely filed, the person ordered to appear is deemed to have waived the right to a hearing, and the department may proceed under the order to appear for genetic testing.
(6) SCHEDULING OF GENETIC TESTING.—
(a) The department shall notify, in writing, the person ordered to appear of the date, time, and location of the appointment for genetic testing and of the requirement to verify his or her identity and the identity of the child, if applicable, when the samples are provided by presenting a form of identification as prescribed in s. 117.05(5)(b)2. which bears the photograph of the person who is providing the sample or other form of verification approved by the department. If the person ordered to appear is the putative father or the mother, that person shall appear and submit to genetic testing. If the person ordered to appear is a caregiver, or if the putative father or the mother has custody of the child, that person must submit the child for genetic testing.
(b) The department shall reschedule genetic testing:
1. One time without cause if, in advance of the initial test date, the person ordered to appear requests the department to reschedule the test.
2. One time if the person ordered to appear shows good cause for failure to appear for a scheduled test.
3. One time upon request of a person ordered to appear against whom sanctions have been imposed as provided in subsection (7).
A claim of good cause for failure to appear shall be filed with the department within 10 days after the scheduled test date and must state the facts and circumstances supporting the claim. The department shall notify the person ordered to appear, in writing, whether it accepts or rejects the person’s claim of good cause. There is not a separate right to a hearing on the department’s decision to accept or reject the claim of good cause because the person ordered to appear may raise good cause as a defense to any proceeding initiated by the department under subsection (7).
(c) A person ordered to appear may obtain a second genetic test by filing a written request for a second test with the department within 15 days after the date of mailing of the initial genetic testing results and by paying the department in advance for the full cost of the second test.
(d) The department may schedule and require a subsequent genetic test if it has reason to believe the results of the preceding genetic test may not be reliable.
(e) Except as provided in paragraph (c) and subsection (7), the department shall pay for the cost of genetic testing ordered under this section.
(7) FAILURE OR REFUSAL TO SUBMIT TO GENETIC TESTING.—If a person who is served with an order to appear for genetic testing fails to appear without good cause or refuses to submit to testing without good cause, the department may take one or more of the following actions:
(a) Commence a proceeding to suspend the driver’s license and motor vehicle registration of the person ordered to appear, as provided in s. 61.13016;
(b) Impose an administrative fine against the person ordered to appear in the amount of $500; or
(c) File a petition in circuit court to establish paternity, obtain a support order for the child, and seek reimbursement from the person ordered to appear for the full cost of genetic testing incurred by the department.
As provided in s. 322.058(2), a suspended driver’s license and motor vehicle registration may be reinstated when the person ordered to appear complies with the order to appear for genetic testing. The department may collect an administrative fine imposed under this subsection by using civil remedies or other statutory means available to the department for collecting support.
(8) GENETIC-TESTING RESULTS.—The department shall send a copy of the genetic-testing results to the putative father, to the mother, to the caregiver, and to the other state, if applicable. If the genetic-testing results, including second or subsequent genetic-testing results, do not indicate a statistical probability of paternity that equals or exceeds 99 percent, the paternity proceeding in connection with that child shall cease.
(9) PROPOSED ORDER OF PATERNITY; COMMENCEMENT OF PROCEEDING TO ESTABLISH ADMINISTRATIVE SUPPORT ORDER; PROPOSED ORDER OF PATERNITY AND CHILD SUPPORT.—
(a) If a paternity proceeding has been commenced under this section and the results of genetic testing indicate a statistical probability of paternity that equals or exceeds 99 percent, the department may:
1. Issue a proposed order of paternity as provided in paragraph (b); or
2. If appropriate, delay issuing a proposed order of paternity and commence, by regular mail, an administrative proceeding to establish a support order for the child pursuant to s. 409.2563 and issue a single proposed order that addresses paternity and child support.
(b) A proposed order of paternity must:
1. State proposed findings of fact and conclusions of law.
2. Include a copy of the results of genetic testing.
3. Include notice of the respondent’s right to informal review and to contest the proposed order of paternity at an administrative hearing.
(c) If a paternity and child support proceeding has been commenced under this section and the results of genetic testing indicate a statistical probability of paternity that equals or exceeds 99 percent, the department may issue a single proposed order that addresses paternity as provided in this section and child support as provided in s. 409.2563.
(d) The department shall serve a proposed order issued under this section on the respondent by regular mail and shall provide a copy by regular mail to the mother or caregiver if they are not respondents.
(10) INFORMAL REVIEW; ADMINISTRATIVE HEARING; PRESUMPTION OF PATERNITY.—
(a) Within 10 days after the date of mailing or other service of a proposed order of paternity, the respondent may contact a representative of the department at the address or telephone number provided to request an informal review of the proposed order. If an informal review is timely requested, the time for requesting a hearing is extended until 10 days after the department mails notice to the respondent that the informal review has been concluded.
(b) Within 20 days after the mailing date of the proposed order or within 10 days after the mailing date of notice that an informal review has been concluded, whichever is later, the respondent may request an administrative hearing by filing a written request for a hearing with the department. A request for a hearing must state the specific objections to the proposed order, the specific objections to the genetic testing results, or both. A respondent who fails to file a timely request for a hearing is deemed to have waived the right to a hearing.
(c) If the respondent files a timely request for a hearing, the department shall refer the hearing request to the Division of Administrative Hearings. Unless otherwise provided in this section or in s. 409.2563, chapter 120 and the uniform rules of procedure govern the conduct of the proceedings.
(d) The genetic-testing results shall be admitted into evidence and made a part of the hearing record. For purposes of this section, a statistical probability of paternity that equals or exceeds 99 percent creates a presumption, as defined in s. 90.304, that the putative father is the biological father of the child. The presumption may be overcome only by clear and convincing evidence. The respondent or the department may call an expert witness to refute or support the testing procedure or results or the mathematical theory on which they are based. Verified documentation of the chain of custody of the samples tested is competent evidence to establish the chain of custody.
(11) FINAL ORDER ESTABLISHING PATERNITY OR PATERNITY AND CHILD SUPPORT; CONSENT ORDER; NOTICE TO OFFICE OF VITAL STATISTICS.—
(a) If a hearing is held, the administrative law judge of the Division of Administrative Hearings shall issue a final order that adjudicates paternity or, if appropriate, paternity and child support. A final order of the administrative law judge constitutes final agency action by the Department of Revenue. The Division of Administrative Hearings shall transmit any such order to the department for filing and rendering.
(b) If the respondent does not file a timely request for a hearing or consents in writing to entry of a final order without a hearing, the department may render a final order of paternity or a final order of paternity and child support, as appropriate.
(c) The department shall mail a copy of the final order to the putative father, the mother, and the caregiver, if any. The department shall notify the respondent of the right to seek judicial review of a final order in accordance with s. 120.68.
(d) Upon rendering a final order of paternity or a final order of paternity and child support, the department shall notify the Office of Vital Statistics of the Department of Health that the paternity of the child has been established.
(e) A final order rendered pursuant to this section has the same effect as a judgment entered by the court pursuant to chapter 742.
(f) The provisions of s. 409.2563 which apply to a final administrative support order rendered under that section apply to a final order rendered under this section when a child support obligation is established.
(12) RIGHT TO JUDICIAL REVIEW.—A respondent has the right to seek judicial review, in accordance with s. 120.68, of a final order rendered under subsection (11) and an order issued under paragraph (5)(b). The department has the right to seek judicial review, in accordance with s. 120.68, of a final order issued by an administrative law judge under subsection (11) and an order issued by an administrative law judge under paragraph (5)(b).
(13) DUTY TO PROVIDE AND MAINTAIN CURRENT MAILING ADDRESS.—Until a proceeding that has been commenced under this section has ended, a respondent who is served with a notice of proceeding must inform the department in writing of any change in the respondent’s mailing address and is deemed to have received any subsequent order, notice, or other paper mailed to that address, or the address at which the respondent was served, if the respondent has not provided a more recent address.
(14) PROCEEDINGS IN CIRCUIT COURT.—The results of genetic testing performed pursuant to this section are admissible as evidence to the same extent as scientific testing ordered by the court pursuant to chapter 742.
(15) GENDER NEUTRAL.—This section shall be construed impartially, regardless of a person’s gender, and applies with equal force to the mother of a child whose paternity has not been established and is not presumed by law.
(16) REMEDIES SUPPLEMENTAL.—The remedies provided in this section are supplemental and in addition to other remedies available to the department for the establishment of paternity and child support obligations.
(17) RULEMAKING AUTHORITY.—The department may adopt rules to implement this section.
History.—s. 24, ch. 2005-39; s. 5, ch. 2008-92; s. 7, ch. 2010-187; s. 93, ch. 2012-184.
409.2561 Support obligations when public assistance is paid; assignment of rights; subrogation; medical and health insurance information.—
(1) Any payment of temporary cash or Title IV-E assistance made to, or for the benefit of, any dependent child creates an obligation in an amount determined pursuant to the child support guidelines. In accordance with 42 U.S.C. s. 657, the state shall retain amounts collected only to the extent necessary to reimburse amounts paid to the family as assistance by the state. Such amounts collected shall be deposited into the General Revenue Fund up to the level specified in s. 61.1812. If there has been a prior support order or final judgment of dissolution of marriage establishing an obligation of support, the obligation is limited to the amount provided by such support order or decree. The extraordinary remedy of contempt is applicable in child support enforcement cases because of the public necessity for ensuring that dependent children be maintained from the resources of their parents, thereby relieving, at least in part, the burden presently borne by the general citizenry through the public assistance program. If there is no prior support order, the court, or the department as provided by s. 409.2563, shall establish the liability of the obligor, if any, by applying the child support guidelines. The department may apply for modification of a support order on the same grounds as either party to the cause and shall have the right to settle and compromise actions brought pursuant to law.
(2)(a) By accepting temporary cash assistance or Title IV-E assistance, the recipient assigns to the department any right, title, and interest to support the recipient may be owed:
1. From any other person up to the amount of temporary cash assistance or Title IV-E assistance paid where no court order has been entered, or where there is a court order it is limited to the amount provided by such court order;
2. On the recipient’s own behalf or in behalf of another family member for whom the recipient is receiving temporary cash or Title IV-E assistance; and
3. At the time that the assignment becomes effective by operation of law.
(b) The recipient of public assistance appoints the department as her or his attorney in fact to act in her or his name, place, and stead to perform specific acts relating to the establishment of paternity or the establishment, modification, or enforcement of support obligations, including, but not limited to:
1. Endorsing any draft, check, money order, or other negotiable instrument representing support payments which are received on behalf of the dependent child as reimbursement for the public assistance moneys previously or currently paid;
2. Compromising claims;
3. Pursuing the establishment or modification of support obligations;
4. Pursuing civil and criminal enforcement of support obligations; and
5. Executing verified complaints for the purpose of instituting an action for the determination of paternity of a child born, or to be born, out of wedlock.
(3) The department shall be subrogated to the right of the dependent child or person having the care, custody, and control of the child to prosecute or maintain any support action or action to determine paternity or execute any legal, equitable, or administrative remedy existing under the laws of the state to obtain reimbursement of temporary cash assistance or Title IV-E assistance paid, being paid, or to be paid.
(4) No obligation of support under this section shall be incurred by any person who is the recipient of supplemental security income or temporary cash assistance for the benefit of a dependent child or who is incapacitated and financially unable to pay as determined by the department.
(5) With respect to cases for which there is an assignment in effect:
(a) The IV-D agency shall obtain basic medical support information for Medicaid recipients and applicants for Medicaid and provide this information to the state Medicaid agency for third-party liability purposes.
(b) When health insurance is obtained for the dependent child, the IV-D agency shall provide health insurance policy information, including any information available about the health insurance policy which would permit a claim to be filed or, in the case of a health maintenance or preferred provider organization, service to be provided, to the state Medicaid agency.
(c) The state Medicaid agency, upon receipt of the health insurance information from the IV-D agency, shall notify the insuring entity that the Medicaid agency must be notified within 30 days after the health insurance is discontinued.
(d) Entities providing health insurance as defined in s. 624.603 and health maintenance organizations and prepaid health clinics as defined in chapter 641 shall provide such records and information as is necessary to accomplish the purpose of this subsection, unless such requirement results in an unreasonable burden.
(e) Upon the state Medicaid agency receiving notice from the insuring entity that the health insurance is discontinued due to cancellation or other means, the Medicaid agency shall notify the IV-D agency of such discontinuance and the effective date. When appropriate, the IV-D agency shall then take action to bring the obligor before the court for enforcement.
History.—s. 4, ch. 76-220; s. 1, ch. 77-174; s. 2, ch. 82-140; s. 2, ch. 85-178; s. 142, ch. 86-220; s. 16, ch. 87-95; s. 11, ch. 88-176; s. 7, ch. 89-183; s. 4, ch. 91-71; s. 6, ch. 94-124; s. 5, ch. 94-318; s. 254, ch. 96-406; s. 1020, ch. 97-103; s. 47, ch. 97-170; s. 23, ch. 98-397; s. 11, ch. 99-375; s. 29, ch. 2001-158; s. 11, ch. 2004-334; s. 25, ch. 2005-39; s. 9, ch. 2005-82; s. 5, ch. 2009-90.
409.2563 Administrative establishment of child support obligations.—
(1) DEFINITIONS.—As used in this section, the term:
(a) “Administrative support order” means a final order rendered by or on behalf of the department pursuant to this section establishing or modifying the obligation of a parent to contribute to the support and maintenance of his or her child or children, which may include provisions for monetary support, retroactive support, health care, and other elements of support pursuant to chapter 61.
(b) “Caregiver” means a person, other than the mother, father, or putative father, who has physical custody of the child or with whom the child primarily resides.
(c) “Filed” means a document has been received and accepted for filing at the offices of the department by the clerk or any authorized deputy clerk of the department. The date of filing must be indicated on the face of the document by the clerk or deputy clerk.
(d) “Financial affidavit” means an affidavit or written declaration as provided by s. 92.525(2) which shows an individual’s income, allowable deductions, net income, and other information needed to calculate the child support guideline amount under s. 61.30.
(e) “Rendered” means that a signed written order is filed with the clerk or any deputy clerk of the department and served on the respondent. The date of filing must be indicated on the face of the order at the time of rendition.
(f) “Title IV-D case” means a case or proceeding in which the department is providing child support services within the scope of Title IV-D of the Social Security Act, 42 U.S.C. ss. 651 et seq.
(g) “Retroactive support” means a child support obligation established pursuant to s. 61.30(17).
Other terms used in this section have the meanings ascribed in ss. 61.046 and 409.2554.
(2) PURPOSE AND SCOPE.—
(a) It is not the Legislature’s intent to limit the jurisdiction of the circuit courts to hear and determine issues regarding child support. This section is intended to provide the department with an alternative procedure for establishing child support obligations in Title IV-D cases in a fair and expeditious manner when there is no court order of support. The procedures in this section are effective throughout the state and shall be implemented statewide.
(b) The administrative procedure set forth in this section concerns only the establishment of child support obligations. This section does not grant jurisdiction to the department or the Division of Administrative Hearings to hear or determine issues of dissolution of marriage, separation, alimony or spousal support, termination of parental rights, dependency, disputed paternity, except for a determination of paternity as provided in s. 409.256, or award of or change of time-sharing. This paragraph notwithstanding, the department and the Division of Administrative Hearings may make findings of fact that are necessary for a proper determination of a parent’s support obligation as authorized by this section.
(c) If there is no support order for a child in a Title IV-D case whose paternity has been established or is presumed by law, or whose paternity is the subject of a proceeding under s. 409.256, the department may establish a parent’s child support obligation pursuant to this section, s. 61.30, and other relevant provisions of state law. The parent’s obligation determined by the department may include any obligation to pay retroactive support and any obligation to provide for health care for a child, whether through insurance coverage, reimbursement of expenses, or both. The department may proceed on behalf of:
1. An applicant or recipient of public assistance, as provided by ss. 409.2561 and 409.2567;
2. A former recipient of public assistance, as provided by s. 409.2569;
3. An individual who has applied for services as provided by s. 409.2567;
4. Itself or the child, as provided by s. 409.2561; or
5. A state or local government of another state, as provided by chapter 88.
(d) Either parent, or a caregiver if applicable, may at any time file a civil action in a circuit court having jurisdiction and proper venue to determine parental support obligations, if any. A support order issued by a circuit court prospectively supersedes an administrative support order rendered by the department.
(e) Pursuant to paragraph (b), neither the department nor the Division of Administrative Hearings has jurisdiction to award or change child custody or rights of parental contact. Either parent may at any time file a civil action in a circuit having jurisdiction and proper venue for a determination of child custody and rights of parental contact.
(f) The department shall terminate the administrative proceeding and file an action in circuit court to determine support if within 20 days after receipt of the initial notice the parent from whom support is being sought requests in writing that the department proceed in circuit court or states in writing his or her intention to address issues concerning time-sharing or rights to parental contact in court and if within 10 days after receipt of the department’s petition and waiver of service the parent from whom support is being sought signs and returns the waiver of service form to the department.
(g) The notices and orders issued by the department under this section shall be written clearly and plainly.
(3) JURISDICTION OVER NONRESIDENTS.—The department may use the procedures authorized by this section to establish a child support obligation against a nonresident over whom the state may assert personal jurisdiction under chapter 48 or chapter 88.
(4) NOTICE OF PROCEEDING TO ESTABLISH ADMINISTRATIVE SUPPORT ORDER.—To commence a proceeding under this section, the department shall provide to the parent from whom support is not being sought and serve the parent from whom support is being sought with a notice of proceeding to establish administrative support order and a blank financial affidavit form. The notice must state:
(a) The names of both parents, the name of the caregiver, if any, and the name and date of birth of the child or children;
(b) That the department intends to establish an administrative support order as defined in this section;
(c) That both parents must submit a completed financial affidavit to the department within 20 days after receiving the notice, as provided by paragraph (13)(a);
(d) That both parents, or parent and caregiver if applicable, are required to furnish to the department information regarding their identities and locations, as provided by paragraph (13)(b);
(e) That both parents, or parent and caregiver if applicable, are required to promptly notify the department of any change in their mailing addresses to ensure receipt of all subsequent pleadings, notices, and orders, as provided by paragraph (13)(c);
(f) That the department will calculate support obligations based on the child support guidelines schedule in s. 61.30 and using all available information, as provided by paragraph (5)(a), and will incorporate such obligations into a proposed administrative support order;
(g) That the department will send by regular mail to both parents, or parent and caregiver if applicable, a copy of the proposed administrative support order, the department’s child support worksheet, and any financial affidavits submitted by a parent or prepared by the department;
(h) That the parent from whom support is being sought may file a request for a hearing in writing within 20 days after the date of mailing or other service of the proposed administrative support order or will be deemed to have waived the right to request a hearing;
(i) That if the parent from whom support is being sought does not file a timely request for hearing after service of the proposed administrative support order, the department will issue an administrative support order that incorporates the findings of the proposed administrative support order, and will send by regular mail a copy of the administrative support order to both parents, or parent and caregiver if applicable;
(j) That after an administrative support order is rendered, the department will file a copy of the order with the clerk of the circuit court;
(k) That after an administrative support order is rendered, the department may enforce the administrative support order by any lawful means;
(l) That either parent, or caregiver if applicable, may file at any time a civil action in a circuit court having jurisdiction and proper venue to determine parental support obligations, if any, and that a support order issued by a circuit court supersedes an administrative support order rendered by the department;
(m) That neither the department nor the Division of Administrative Hearings has jurisdiction to award or change child custody or rights of parental contact or time-sharing, and these issues may be addressed only in circuit court.
1. The parent from whom support is being sought may request in writing that the department proceed in circuit court to determine his or her support obligations.
2. The parent from whom support is being sought may state in writing to the department his or her intention to address issues concerning custody or rights to parental contact in circuit court.
3. If the parent from whom support is being sought submits the request authorized in subparagraph 1., or the statement authorized in subparagraph 2. to the department within 20 days after the receipt of the initial notice, the department shall file a petition in circuit court for the determination of the parent’s child support obligations, and shall send to the parent from whom support is being sought a copy of its petition, a notice of commencement of action, and a request for waiver of service of process as provided in the Florida Rules of Civil Procedure.
4. If, within 10 days after receipt of the department’s petition and waiver of service, the parent from whom support is being sought signs and returns the waiver of service form to the department, the department shall terminate the administrative proceeding without prejudice and proceed in circuit court.
5. In any circuit court action filed by the department pursuant to this paragraph or filed by a parent from whom support is being sought or other person pursuant to paragraph (l) or paragraph (n), the department shall be a party only with respect to those issues of support allowed and reimbursable under Title IV-D of the Social Security Act. It is the responsibility of the parent from whom support is being sought or other person to take the necessary steps to present other issues for the court to consider.
(n) That if the parent from whom support is being sought files an action in circuit court and serves the department with a copy of the petition within 20 days after being served notice under this subsection, the administrative process ends without prejudice and the action must proceed in circuit court;
(o) Information provided by the Office of State Courts Administrator concerning the availability and location of self-help programs for those who wish to file an action in circuit court but who cannot afford an attorney.
The department may serve the notice of proceeding to establish administrative support order by certified mail, restricted delivery, return receipt requested. Alternatively, the department may serve the notice by any means permitted for service of process in a civil action. For purposes of this section, an authorized employee of the department may serve the notice and execute an affidavit of service. Service by certified mail is completed when the certified mail is received or refused by the addressee or by an authorized agent as designated by the addressee in writing. If a person other than the addressee signs the return receipt, the department shall attempt to reach the addressee by telephone to confirm whether the notice was received, and the department shall document any telephonic communications. If someone other than the addressee signs the return receipt, the addressee does not respond to the notice, and the department is unable to confirm that the addressee has received the notice, service is not completed and the department shall attempt to have the addressee served personally. The department shall provide the parent from whom support is not being sought or the caregiver with a copy of the notice by regular mail to the last known address of the parent from whom support is not being sought or caregiver.
(5) PROPOSED ADMINISTRATIVE SUPPORT ORDER.—
(a) After serving notice upon a parent in accordance with subsection (4), the department shall calculate that parent’s child support obligation under the child support guidelines schedule as provided by s. 61.30, based on any timely financial affidavits received and other information available to the department. If either parent fails to comply with the requirement to furnish a financial affidavit, the department may proceed on the basis of information available from any source, if such information is sufficiently reliable and detailed to allow calculation of guideline schedule amounts under s. 61.30. If a parent receives public assistance and fails to submit a financial affidavit, the department may submit a financial affidavit or written declaration for that parent pursuant to s. 61.30(15). If there is a lack of sufficient reliable information concerning a parent’s actual earnings for a current or past period, it shall be presumed for the purpose of establishing a support obligation that the parent had an earning capacity equal to the federal minimum wage during the applicable period.
(b) The department shall send by regular mail to both parents, or to a parent and caregiver if applicable, copies of the proposed administrative support order, its completed child support worksheet, and any financial affidavits submitted by a parent or prepared by the department. The proposed administrative support order must contain the same elements as required for an administrative support order under paragraph (7)(e).
(c) The department shall provide a notice of rights with the proposed administrative support order, which notice must inform the parent from whom support is being sought that:
1. The parent from whom support is being sought may, within 20 days after the date of mailing or other service of the proposed administrative support order, request a hearing by filing a written request for hearing in a form and manner specified by the department;
2. If the parent from whom support is being sought files a timely request for a hearing, the case shall be transferred to the Division of Administrative Hearings, which shall conduct further proceedings and may enter an administrative support order;
3. A parent from whom support is being sought who fails to file a timely request for a hearing shall be deemed to have waived the right to a hearing, and the department may render an administrative support order pursuant to paragraph (7)(b);
4. The parent from whom support is being sought may consent in writing to entry of an administrative support order without a hearing;
5. The parent from whom support is being sought may, within 10 days after the date of mailing or other service of the proposed administrative support order, contact a department representative, at the address or telephone number specified in the notice, to informally discuss the proposed administrative support order and, if informal discussions are requested timely, the time for requesting a hearing will be extended until 10 days after the department notifies the parent that the informal discussions have been concluded; and
6. If an administrative support order that establishes a parent’s support obligation is rendered, whether after a hearing or without a hearing, the department may enforce the administrative support order by any lawful means.
(d) If, after serving the proposed administrative support order but before a final administrative support order is rendered, the department receives additional information that makes it necessary to amend the proposed administrative support order, it shall prepare an amended proposed administrative support order, with accompanying amended child support worksheets and other material necessary to explain the changes, and follow the same procedures set forth in paragraphs (b) and (c).
(6) HEARING.—If the parent from whom support is being sought files a timely request for hearing or the department determines that an evidentiary hearing is appropriate, the department shall refer the proceeding to the Division of Administrative Hearings. Unless otherwise provided by this section, chapter 120 and the Uniform Rules of Procedure shall govern the conduct of the proceedings. The administrative law judge shall consider all available and admissible information and any presumptions that apply as provided by paragraph (5)(a).
(7) ADMINISTRATIVE SUPPORT ORDER.—
(a) If a hearing is held, the administrative law judge of the Division of Administrative Hearings shall issue an administrative support order, or a final order denying an administrative support order, which constitutes final agency action by the department. The Division of Administrative Hearings shall transmit any such order to the department for filing and rendering.
(b) If the parent from whom support is being sought does not file a timely request for a hearing, the parent will be deemed to have waived the right to request a hearing.
(c) If the parent from whom support is being sought waives the right to a hearing, or consents in writing to the entry of an order without a hearing, the department may render an administrative support order.
(d) The department shall send by regular mail a copy of the administrative support order, or the final order denying an administrative support order, to both parents, or a parent and caregiver if applicable. The parent from whom support is being sought shall be notified of the right to seek judicial review of the administrative support order in accordance with s. 120.68.
(e) An administrative support order must comply with ss. 61.13(1) and 61.30. The department shall develop a standard form or forms for administrative support orders. An administrative support order must provide and state findings, if applicable, concerning:
1. The full name and date of birth of the child or children;
2. The name of the parent from whom support is being sought and the other parent or caregiver;
3. The parent’s duty and ability to provide support;
4. The amount of the parent’s monthly support obligation;
5. Any obligation to pay retroactive support;
6. The parent’s obligation to provide for the health care needs of each child, whether through health insurance, contribution toward the cost of health insurance, payment or reimbursement of health care expenses for the child, or any combination thereof;
7. The beginning date of any required monthly payments and health insurance;
8. That all support payments ordered must be paid to the Florida State Disbursement Unit as provided by s. 61.1824;
9. That the parents, or caregiver if applicable, must file with the department when the administrative support order is rendered, if they have not already done so, and update as appropriate the information required pursuant to paragraph (13)(b);
10. That both parents, or parent and caregiver if applicable, are required to promptly notify the department of any change in their mailing addresses pursuant to paragraph (13)(c); and
11. That if the parent ordered to pay support receives reemployment assistance or unemployment compensation benefits, the payor shall withhold, and transmit to the department, 40 percent of the benefits for payment of support, not to exceed the amount owed.
An income deduction order as provided by s. 61.1301 must be incorporated into the administrative support order or, if not incorporated into the administrative support order, the department or the Division of Administrative Hearings shall render a separate income deduction order.
(8) FILING WITH THE CLERK OF THE CIRCUIT COURT; OFFICIAL PAYMENT RECORD; JUDGMENT BY OPERATION OF LAW.—The department shall file with the clerk of the circuit court a certified copy of an administrative support order rendered under this section. The depository operated pursuant to s. 61.181 for the county where the administrative support order has been filed shall:
(a) Act as the official recordkeeper for payments required under the administrative support order;
(b) Establish and maintain the necessary payment accounts;
(c) Upon a delinquency, initiate the judgment by operation of law procedure as provided by s. 61.14(6); and
(d) Perform all other duties required of a depository with respect to a support order entered by a court of this state.
When a proceeding to establish an administrative support order is commenced under subsection (4), the department shall file a copy of the initial notice with the depository. The depository shall assign an account number and provide the account number to the department within 4 business days after the initial notice is filed.
(9) COLLECTION ACTION; ENFORCEMENT.—
(a) The department may implement an income deduction notice immediately upon rendition of an income deduction order, whether it is incorporated in the administrative support order or rendered separately.
(b) The department may initiate other collection action 15 days after the date an administrative support order is rendered under this section.
(c) In a subsequent proceeding to enforce an administrative support order, notice of the proceeding that is sent by regular mail to the person’s address of record furnished to the department constitutes adequate notice of the proceeding pursuant to paragraph (13)(c).
(d) An administrative support order rendered under this section has the same force and effect as a court order and, until modified by the department or superseded by a court order, may be enforced:
1. In any manner permitted for enforcement of a support order issued by a court of this state, except for contempt; or
2. Pursuant to s. 120.69.
(10) JUDICIAL REVIEW, ENFORCEMENT, OR COURT ORDER SUPERSEDING ADMINISTRATIVE SUPPORT ORDER.—
(a) The obligor has the right to seek judicial review of an administrative support order or a final order denying an administrative support order in accordance with s. 120.68. The department has the right to seek judicial review, in accordance with s. 120.68, of an administrative support order or a final order denying an administrative support order entered by an administrative law judge of the Division of Administrative Hearings.
(b) An administrative support order rendered under this section has the same force and effect as a court order and may be enforced by any circuit court in the same manner as a support order issued by the court, except for contempt. If the circuit court issues its own order enforcing the administrative support order, the circuit court may enforce its own order by contempt. The presumption of ability to pay and purge contempt established in s. 61.14(5)(a) applies to an administrative support order that includes a finding of present ability to pay. Enforcement by the court, without any change by the court in the support obligations established in the administrative support order, does not supersede the administrative support order or affect the department’s authority to modify the administrative support order as provided by subsection (12). An order by the court that requires a parent to make periodic payments on arrearages does not constitute a change in the support obligations established in the administrative support order and does not supersede the administrative order.
(c) A circuit court of this state, where venue is proper and the court has jurisdiction of the parties, may enter an order prospectively changing the support obligations established in an administrative support order, in which case the administrative support order is superseded and the court’s order shall govern future proceedings in the case. Any unpaid support owed under the superseded administrative support order may not be retroactively modified by the circuit court, except as provided by s. 61.14(1)(a), and remains enforceable by the department, by the obligee, or by the court. In all cases in which an administrative support order is superseded, the court shall determine the amount of any unpaid support owed under the administrative support order and shall include the amount as arrearage in its superseding order.
(11) EFFECTIVENESS OF ADMINISTRATIVE SUPPORT ORDER.—An administrative support order rendered under this section has the same force and effect as a court order and remains in effect until modified by the department, vacated on appeal, or superseded by a subsequent court order. If the department closes a Title IV-D case in which an administrative support order has been rendered:
(a) The department shall take no further action to enforce or modify the administrative support order;
(b) The administrative support order remains effective until superseded by a subsequent court order; and
(c) The administrative support order may be enforced by the obligee by any means provided by law.
(12) MODIFICATION OF ADMINISTRATIVE SUPPORT ORDER.—If it has not been superseded by a subsequent court order, the department may modify, suspend, or terminate an administrative support order in a Title IV-D case prospectively, subject to the requirements for modifications of judicial support orders established in chapters 61 and 409, by following the same procedures set forth in this section for establishing an administrative support order, as applicable.
(13) REQUIRED DISCLOSURES; PRESUMPTIONS; NOTICE SENT TO ADDRESS OF RECORD.—In all proceedings pursuant to this section:
(a) Each parent must execute and furnish to the department, no later than 20 days after receipt of the notice of proceeding to establish administrative support order, a financial affidavit in the form prescribed by the department. An updated financial affidavit must be executed and furnished to the department at the inception of each proceeding to modify an administrative support order. A caregiver is not required to furnish a financial affidavit.
(b) Each parent and caregiver, if applicable, shall disclose to the department, no later than 20 days after receipt of the notice of proceeding to establish administrative support order, and update as appropriate, information regarding his or her identity and location, including names he or she is known by; social security number; residential and mailing addresses; telephone numbers; driver’s license numbers; and names, addresses, and telephone numbers of employers. Pursuant to the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, each person must provide his or her social security number in accordance with this section. Disclosure of social security numbers obtained through this requirement shall be limited to the purpose of administration of the Title IV-D program for child support enforcement.
(c) Each parent and caregiver, if applicable, has a continuing obligation to promptly inform the department in writing of any change in his or her mailing address to ensure receipt of all subsequent pleadings, notices, payments, statements, and orders, and receipt is presumed if sent by regular mail to the most recent address furnished by the person.
(14) JUDICIAL PLEADINGS AND MOTIONS.—A party to any subsequent judicial proceeding concerning the support of the same child or children shall affirmatively plead the existence of, and furnish the court with a correct copy of, an administrative support order rendered under this section, and shall provide the department with a copy of the initial pleading. The department may intervene as a matter of right in any such judicial proceeding involving issues within the scope of the Title IV-D case.
(15) PROVISIONS SUPPLEMENTAL TO EXISTING LAW.—This section does not limit or negate the department’s authority to seek establishment of child support obligations under any other applicable law.
(16) RULEMAKING AUTHORITY.—The department may adopt rules to administer this section.
History.—s. 30, ch. 2001-158; s. 10, ch. 2002-173; s. 3, ch. 2002-239; s. 12, ch. 2004-334; s. 65, ch. 2005-2; s. 26, ch. 2005-39; s. 21, ch. 2008-61; s. 56, ch. 2009-21; s. 6, ch. 2009-90; s. 8, ch. 2010-187; s. 62, ch. 2012-30.
409.25635 Determination and collection of noncovered medical expenses.—
(1) DEFINITION.—As used in this section, “noncovered medical expenses” means uninsured medical, dental, or prescription medication expenses that are ordered to be paid on behalf of a child as provided in s. 61.13(1)(b) or a similar law of another state.
(2) PROCEEDING TO DETERMINE AMOUNT OWED FOR NONCOVERED MEDICAL EXPENSES.—In a Title IV-D case, the Department of Revenue may proceed under this section to determine the amount owed by an obligor for noncovered medical expenses if:
(a) The obligor is subject to a support order that requires the obligor to pay all or part of a child’s noncovered medical expenses.
(b) The obligee provides the department with a written declaration under penalty of perjury that states:
1. Noncovered medical expenses have been incurred on behalf of the dependent child whom the obligor has been ordered to support.
2. The obligee has paid for noncovered medical expenses that have been incurred on behalf of the child.
3. The obligor has not paid all or part of the child’s noncovered medical expenses as ordered.
4. The amount paid by the obligee for noncovered medical expenses and the amount the obligor allegedly owes to the obligee.
(c) The obligee provides documentation in support of the written declaration.
(3) NOTICE OF PROCEEDING.—
(a) To proceed under this section, the Department of Revenue shall serve a notice on the obligor that states:
1. That the department has commenced a proceeding to determine the amount the obligor owes for noncovered medical expenses.
2. The name of the court or other tribunal that issued the support order that requires the obligor to pay noncovered medical expenses and the date of the order.
3. That the proceeding is based on the requirements of the support order, the obligee’s written sworn statement, and the supporting documentation provided to the department by the obligee.
4. The amount of noncovered medical expenses that the obligee alleges the obligor owes.
5. If the support order was entered by a court of this state or a tribunal of another state, that the obligor may file a motion in the circuit court to contest the amount of noncovered medical expenses owed within 25 days after the date of mailing of the notice or, if the support order was entered by the department, that the obligor may file with the department a petition to contest within 25 days after the date of mailing of the notice.
6. If the support order was entered by a court of this state or a tribunal of another state, that the court shall determine the amount owed by the obligor and enter judgment as appropriate if the obligor timely files a motion in the circuit court to contest the amount of noncovered medical expenses owed or, if the support order was entered by the department, the department shall determine the amount owed by the obligor and render a final order as appropriate if the obligor timely files with the department a petition to contest the amount of noncovered medical expenses owed.
7. If the obligor does not timely file a motion or petition to contest the amount alleged to be owed, that the obligor shall owe the amount alleged in the notice.
8. If an amount owed is determined after a hearing or becomes final because the obligor does not file a timely motion or petition to contest, the department shall begin collection action.
(b) The notice shall be served on the obligor by regular mail that is sent to the obligor’s address of record according to the clerk of the court or according to the Department of Revenue if the support order was entered by the department or to a more recent address if known. A copy of the obligee’s written declaration and supporting documentation must be served on the obligor with the notice. The department shall provide the obligee with a copy of the notice and with any subsequent notice of hearing.
(4) RIGHT TO HEARING; DETERMINATION AFTER HEARING; WAIVER OF HEARING.—
(a) Within 25 days after the date the notice required by subsection (3) is mailed, if the support order was entered by a court of this state or a tribunal of another state, the obligor may file a motion in the circuit court to contest the amount of noncovered medical expenses owed. If a timely motion is filed, the court shall determine after a hearing whether the obligor owes the obligee the amount alleged for noncovered medical expenses and enter a judgment, as appropriate.
(b) Within 25 days after the date the notice required by subsection (3) is mailed, if the support order was entered by the Department of Revenue, the obligor may file with the department a petition to contest the amount of noncovered medical expenses owed. If a timely petition is filed, the department shall determine after a hearing pursuant to chapter 120 whether the obligor owes the obligee for the amount alleged for noncovered medical expenses and render a final order, as appropriate.
(c) If the obligor does not timely file a motion or petition to contest, the amount owed as alleged in the notice becomes final and is legally enforceable.
(5) EFFECT OF DETERMINATION BY THE DEPARTMENT OF REVENUE AND UNCONTESTED PROCEEDINGS.—The amount owed for noncovered medical expenses that is determined by the Department of Revenue as provided in paragraph (4)(b) or that becomes final as provided in paragraph (4)(c) has the same effect as a judgment entered by a court.
(6) FILING WITH THE DEPOSITORY; RECORDING; MAINTENANCE OF ACCOUNTS.—When an amount owed for noncovered medical expenses is determined, the department shall file a certified copy of the final order or uncontested notice with the depository. Upon receipt of a final order or uncontested notice, the depository shall record the final order or uncontested notice in the same manner as a final judgment. The depository shall maintain necessary accounts to reflect obligations and payments for noncovered medical expenses.
(7) COLLECTION ACTION; ADMINISTRATIVE REMEDIES.—Any administrative remedy available for collection of support may be used to collect noncovered medical expenses that are determined or established under this section. The department may collect noncovered medical expenses in installments by adding a periodic payment to an income deduction notice issued by the department.
(8) SUPPLEMENTAL REMEDY.—This section provides a supplemental remedy for determining and enforcing noncovered medical expenses. As an alternative, the department or any other party may petition the circuit court for enforcement of noncovered medical expenses.
(9) RULEMAKING AUTHORITY.—The department may adopt rules to implement this section.
History.—s. 27, ch. 2005-39; s. 9, ch. 2010-187.
409.2564 Actions for support.—
(1) In each case in which regular support payments are not being made as provided herein, the department shall institute, within 30 days after determination of the obligor’s reasonable ability to pay, action as is necessary to secure the obligor’s payment of current support and any arrearage which may have accrued under an existing order of support. The department shall notify the program attorney in the judicial circuit in which the recipient resides setting forth the facts in the case, including the obligor’s address, if known, and the public assistance case number. Whenever applicable, the procedures established under the provisions of chapter 88, Uniform Interstate Family Support Act, chapter 61, Dissolution of Marriage; Support; Time-sharing, chapter 39, Proceedings Relating to Children, chapter 984, Children and Families in Need of Services, and chapter 985, Delinquency; Interstate Compact on Juveniles, may govern actions instituted under the provisions of this act, except that actions for support under chapter 39, chapter 984, or chapter 985 brought pursuant to this act shall not require any additional investigation or supervision by the department.
(2) The order for support entered pursuant to an action instituted by the department under the provisions of subsection (1) shall require that the support payments be made periodically to the department through the depository. Upon receipt of a payment made by the obligor pursuant to any order of the court, the depository shall transmit the payment to the department within 2 working days, except those payments made by personal check which shall be disbursed in accordance with s. 61.181. Upon request, the depository shall furnish to the department a certified statement of all payments made by the obligor. Such statement shall be provided by the depository at no cost to the department.
(3) When it is no longer authorized to receive payments for the obligee, the department shall notify the depository to redirect income deduction payments to the obligee.
(4) Whenever the Department of Revenue has undertaken an action for enforcement of support, the Department of Revenue may enter into an agreement with the obligor for the entry of a judgment determining paternity, if applicable, and for periodic child support payments based on the child support guidelines schedule in s. 61.30. Before entering into this agreement, the obligor shall be informed that a judgment will be entered based on the agreement. The clerk of the court shall file the agreement without the payment of any fees or charges, and the court, upon entry of the judgment, shall forward a copy of the judgment to the parties to the action.
(5) Whenever the department has undertaken an action to determine paternity, to establish an obligation of support, or to enforce or modify an obligation of support, the department shall be a party to the action only for those purposes allowed under Title IV-D of the Social Security Act. The program attorney shall be the attorney of record solely for the purposes of support enforcement as authorized under Title IV-D and may prosecute only those activities which are eligible for federal financial participation under Title IV-D. An attorney-client relationship exists only between the department and the legal services providers in all Title IV-D cases. The attorney shall advise the obligee in Title IV-D cases that the attorney represents the agency and not the obligee.
(6) The department and its officers, employees, and agents and all persons and agencies acting pursuant to contract with the department are immune from liability in tort for actions taken to establish, enforce, or modify support obligations if such actions are taken in good faith, with apparent legal authority, without malicious purpose, and in a manner not exhibiting wanton and willful disregard of rights or property of another.
(7) The director of the department, or the director’s designee, is authorized to subpoena from any person financial and other information necessary to establish, modify, or enforce a child support order.
(a) For the purpose of establishing or modifying a child support order, or enforcing a support order, the director of the department or another state’s Title IV-D agency, or any employee designated by the director of the department or authorized under another state’s law, may administer oaths or affirmations, subpoena witnesses and compel their attendance, take evidence and require the production of any matter which is relevant to the support action, including the existence, description, nature, custody, condition, and location of any books, documents, or other tangible things and the identity and location of persons having knowledge of relevant facts or any other matter reasonably calculated to lead to the discovery of material evidence.
(b) Subpoenas issued by the department or another state’s Title IV-D agency may be challenged in accordance with s. 120.569(2)(k)1. While a subpoena is being challenged, the department may not impose a fine as provided for under paragraph (c) until the challenge is complete and the subpoena has been found to be valid.
(c) The department is authorized to impose a fine for failure to comply with a subpoena. Failure to comply with the subpoena, or to challenge the subpoena as provided in paragraph (b), within 15 days after service of the subpoena may result in the agency taking the following actions:
1. Imposition of an administrative fine of not more than $500.
2. Enforcement of the subpoena as provided in s. 120.569(2)(k)2. When the subpoena is enforced pursuant to s. 120.569(2)(k)2., the court may award costs and fees to the prevailing party in accordance with that section.
(d) The department may seek to collect administrative fines imposed pursuant to paragraph (c) by filing a petition in the circuit court of the judicial circuit in which the person against whom the fine was imposed resides. All fines collected pursuant to this subsection shall be deposited into the Child Support Enforcement Application and Program Revenue Trust Fund.
(8) In cases in which support is subject to an assignment as provided under 45 C.F.R. s. 301.1, the department shall, upon providing notice to the obligor and obligee, direct the obligor or other payor to change the payee to the appropriate depository.
(9)(a) For the purpose of securing delinquent support, the department may increase the amount of the monthly support obligation to include amounts for delinquencies, subject to such conditions or limitations as set forth in paragraph (b).
(b) In support obligations not subject to income deduction, the department shall notify the obligor of his or her delinquency and of the department’s intent to require an additional 20 percent of the monthly obligation amount to allow for collection of the delinquency unless, within 20 days, the obligor:
1. Pays the delinquency in full; or
2. Files a petition with the circuit court to contest the delinquency action.
(10) For the purposes of denial, revocation, or limitation of an obligor’s United States passport, consistent with 42 U.S.C. s. 652(k)(1), the department shall have procedures to certify to the Secretary of the United States Department of Health and Human Services that an obligor owes arrearages of support in an amount exceeding $2,500. Said procedures shall provide that the obligor be given notice of the determination and of the consequence thereof and an opportunity to contest the accuracy of the determination.
(11)(a) The Department of Revenue shall review child support orders in IV-D cases at least once every 3 years when requested by either party, or when support rights are assigned to the state under s. 414.095(7), and may seek modification of the order if appropriate under the child support guidelines in s. 61.30. Not less than once every 3 years the department shall provide notice to the parties subject to the order informing them of their right to request a review and, if appropriate, a modification of the child support order. The notice requirement may be met by including appropriate language in the initial support order or any subsequent orders.
(b) If the department’s review of a support order entered by the circuit court indicates that the order should be modified, the department, through counsel, shall file a petition to modify the order with the court. Along with the petition, the department shall file a child support guideline worksheet, any financial affidavits or written declarations, pursuant to s. 61.30(15), received from the parties or completed by the department as part of the support order review, a proposed modified order that includes findings as to the source and amount of income, and a notice that informs the parties of the requirement to file an objection or a request for hearing with the court if the party wants a court hearing on the petition to modify. A copy of the petition, proposed order, and other documents shall be served by regular mail on a party who requested the support order review. A party that did not request the support order review shall be served personally in any manner authorized under chapter 48.
(c) To obtain a court hearing on a petition to modify a support order, a party who is served by regular mail must file an objection to the proposed order or a request for hearing with the court within 30 days after the date on which the petition, proposed order, and other documents were mailed. If a party is served personally, to obtain a court hearing on a petition to modify the party must file an objection to the proposed order or a request for hearing with the court within 30 days after the date of receipt of the petition, proposed order, and other documents.
(d) If a timely objection or request for hearing is not filed with the court, the court may modify the support order without a hearing in accordance with the terms of the proposed order.
(e) If a support order does not provide for payment of noncovered medical expenses or require health insurance for the minor child and health insurance is accessible to the child and available at a reasonable cost, the department shall seek to have the order modified and any modification shall be made without a requirement for proof or showing of a change in circumstances.
(12)(a) When the department files a petition for modification of a child support order and the petition is accompanied with a verified motion signed by the department to redirect payment alleging that:
1. The child is residing with a relative caretaker as defined in s. 414.0252 and the relative caretaker receives temporary cash assistance as defined in s. 414.0252; or
2. The child was formerly residing with a relative caretaker as defined in s. 414.0252, the child support payments were redirected to the relative caretaker, and the child is now residing with the original payee,
then the court shall enter a temporary order, ex parte, within 5 days that redirects the child support payments to the relative caretaker or original payee pending a final hearing and may grant such relief as the court deems proper. Upon the filing of a verified motion by the department to redirect payment, the relative caretaker is deemed a party to the proceedings.
(b) In the event that it is subsequently determined by the court that the child support payments were improperly diverted, the department shall pay the improperly diverted child support payments to the appropriate party and shall attempt to recoup any child support improperly paid.
(13) The department shall have the authority to adopt rules to implement this section.
History.—s. 5, ch. 76-220; s. 143, ch. 86-220; s. 20, ch. 92-138; s. 12, ch. 95-222; s. 89, ch. 96-175; s. 48, ch. 97-170; s. 39, ch. 98-280; s. 24, ch. 98-397; ss. 12, 13, ch. 99-375; s. 54, ch. 2000-153; s. 93, ch. 2000-165; s. 31, ch. 2001-158; ss. 28, 29, ch. 2005-39; s. 1, ch. 2005-61; s. 4, ch. 2007-85; s. 22, ch. 2008-61; s. 10, ch. 2010-187.
409.25641 Procedures for processing interstate enforcement requests.—The department shall use automated administrative enforcement as provided in 42 U.S.C. s. 666(a)(14)(A) to respond to a request from another state to enforce a support order and shall promptly report the results of the enforcement action to the requesting state.
History.—s. 49, ch. 97-170; s. 25, ch. 98-397; s. 14, ch. 99-375; s. 5, ch. 2007-85.
409.2565 Publication of delinquent obligors.—For support orders that are being enforced by the department, the department may compile and make available for publication a listing of cases in which payment of the support obligation is overdue. Each case on the list may be identified only by the name of the support obligor, the support obligor’s court order docket or case number, the county in which the obligor’s support order is filed, the arrearage amount, and a photograph. The department need not give prior notice to the obligor of the publication and listing of cases.
History.—s. 3, ch. 95-222; s. 33, ch. 2001-158.
409.25656 Garnishment.—
(1) If a person has a support obligation which is subject to enforcement by the department as the state Title IV-D program, the executive director or his or her designee may give notice of past due and/or overdue support by registered mail to all persons who have in their possession or under their control any credits or personal property, including wages, belonging to the support obligor, or owing any debts to the support obligor at the time of receipt by them of such notice. Thereafter, any person who has been notified may not transfer or make any other disposition, up to the amount provided for in the notice, of such credits, other personal property, or debts until the executive director or his or her designee consents to a transfer or disposition, or until 60 days after the receipt of such notice. If the obligor contests the intended levy in the circuit court or under chapter 120, the notice under this section shall remain in effect until final disposition of that circuit court or chapter 120 action. Any financial institution receiving such notice will maintain a right of setoff for any transaction involving a debit card occurring on or before the date of receipt of such notice.
(2) Each person who is notified under this section must, within 5 days after receipt of the notice, advise the executive director or his or her designee of the credits, other personal property, or debts in their possession, under their control, or owed by them and must advise the executive director or designee within 5 days of coming into possession or control of any subsequent credits, personal property, or debts owed during the time prescribed by the notice. Any such person coming into possession or control of such subsequent credits, personal property, or debts shall not transfer or dispose of them during the time prescribed by the notice or until the department consents to a transfer.
(3) During the last 30 days of the 60-day period set forth in subsection (1), the executive director or his or her designee may levy upon such credits, personal property, or debts. The levy must be accomplished by delivery of a notice of levy by registered mail, upon receipt of which the person possessing the credits, other personal property, or debts shall transfer them to the department or pay to the department the amount owed by the obligor. If the department levies upon securities and the value of the securities is less than the total amount of past due or overdue support, the person who possesses or controls the securities shall liquidate the securities in a commercially reasonable manner. After liquidation, the person shall transfer to the department the proceeds, less any applicable commissions or fees, or both, which are charged in the normal course of business. If the value of the securities exceeds the total amount of past due or overdue support, the obligor may, within 7 days after receipt of the department’s notice of levy, instruct the person who possesses or controls the securities which securities are to be sold to satisfy the obligation for past due or overdue support. If the obligor does not provide instructions for liquidation, the person who possesses or controls the securities shall liquidate the securities in a commercially reasonable manner in an amount sufficient to cover the obligation for past due or overdue support and any applicable commissions or fees, or both, which are charged in the normal course of business, beginning with the securities purchased most recently. After liquidation, the person who possesses or controls the securities shall transfer to the department the total amount of past due or overdue support.
(4) A notice that is delivered under this section is effective at the time of delivery against all credits, other personal property, or debts of the obligor which are not at the time of such notice subject to an attachment, garnishment, or execution issued through a judicial process.
(5) The department is authorized to bring an action in circuit court for an order compelling compliance with any notice issued under this section.
(6) Any person acting in accordance with the terms of the notice or levy issued by the executive director or his or her designee is expressly discharged from any obligation or liability to the obligor with respect to such credits, other personal property, or debts of the obligor affected by compliance with the notice of freeze or levy.
(7)(a) Levy may be made under subsection (3) upon credits, other personal property, or debt of any person with respect to any past due or overdue support obligation only after the executive director or his or her designee has notified such person in writing of the intention to make such levy.
(b) Not less than 30 days before the day of the levy, the notice of intent to levy required under paragraph (a) must be given in person or sent by certified or registered mail to the person’s last known address.
(c) The notice required in paragraph (a) must include a brief statement that sets forth:
1. The provisions of this section relating to levy and sale of property;
2. The procedures applicable to the levy under this section;
3. The administrative and judicial appeals available to the obligor with respect to such levy and sale, and the procedures relating to such appeals; and
4. The alternatives, if any, available to the obligor which could prevent levy on the property.
(d) The obligor may consent in writing to the levy at any time after receipt of a notice of intent to levy.
(8) An obligor may contest the notice of intent to levy provided for under subsection (7) by filing a petition in the existing circuit court case. Alternatively, the obligor may file a petition under the applicable provisions of chapter 120. After an action has been initiated under chapter 120 to contest the notice of intent to levy, an action relating to the same levy may not be filed by the obligor in circuit court, and judicial review is exclusively limited to appellate review pursuant to s. 120.68. Also, after an action has been initiated in circuit court, an action may not be brought under chapter 120.
(9) An action may not be brought to contest a notice of intent to levy under chapter 120 or in circuit court, later than 21 days after the date of receipt of the notice of intent to levy.
(10) The department shall provide notice to the Chief Financial Officer, in electronic or other form specified by the Chief Financial Officer, listing the obligors for whom warrants are outstanding. Pursuant to subsection (1), the Chief Financial Officer shall, upon notice from the department, withhold all payments to any obligor who provides commodities or services to the state, leases real property to the state, or constructs a public building or public work for the state. The department may levy upon the withheld payments in accordance with subsection (3). Section 215.422 does not apply from the date the notice is filed with the Chief Financial Officer until the date the department notifies the Chief Financial Officer of its consent to make payment to the person or 60 days after receipt of the department’s notice in accordance with subsection (1), whichever occurs earlier.
(11) The Department of Revenue has the authority to adopt rules to implement this section.
History.—s. 90, ch. 96-175; s. 12, ch. 96-189; s. 51, ch. 97-170; s. 15, ch. 99-375; ss. 34, 35, ch. 2001-158; s. 11, ch. 2002-173; s. 443, ch. 2003-261; s. 13, ch. 2004-334.
409.25657 Requirements for financial institutions.—
(1) Definitions.—For purposes of this section, reference is made to 42 U.S.C. s. 669A:
(a) “Financial institution” means:
1. A depository institution, as defined in s. 3(c) of the Federal Deposit Insurance Act, 12 U.S.C. s. 1813(c);
2. An institution-affiliated party, as defined in s. 3(u) of such act, 12 U.S.C. s. 1813(u);
3. Any federal credit union or state credit union, as defined in s. 101 of the Federal Credit Union Act, 12 U.S.C. s. 1752, including an institution-affiliated party of such a credit union, as defined in s. 206(r) of such act, 12 U.S.C. s. 1786(r); and
4. Any benefit association, insurance company, safe deposit company, money-market mutual fund, or similar entity authorized to do business in the state.
(b) An “account” means a demand deposit account, checking or negotiable withdrawal order account, savings account, time deposit account, or money-market mutual fund account.
(2) The department shall develop procedures to enter into agreements with financial institutions doing business in the state, in coordination with such financial institutions and with the Federal Parent Locator Service in the case of financial institutions doing business in two or more states, to develop and operate a data match system, using automated data exchanges to the maximum extent feasible, in which each financial institution is required to provide for each calendar quarter the name, record address, social security number or other taxpayer identification number, average daily account balance, and other identifying information for:
(a) Each parent who maintains an account at such institution and who owes past due support, as identified by the department by name and social security number or other taxpayer identification number; or
(b) At the financial institution’s option, each individual who maintains an account at such institution. Use of this information shall be limited to the purpose of administration of the Title IV-D program for child support enforcement.
(3) The department shall pay a reasonable fee to a financial institution for conducting the data match provided for in subsection (2), not to exceed the actual costs incurred by such financial institution.
(4) A financial institution shall not be liable to any person nor shall it be required to provide notice to its customers:
(a) For disclosure of any information as required under this section;
(b) For encumbering or surrendering any assets held by such financial institution in response to a notice of lien or levy issued by the department;
(c) For disclosing any information in connection with a data match; or
(d) For any other action taken in good faith to comply with the requirements of this section.
(5) Any financial records obtained pursuant to this section may be disclosed only for the purpose of, and to the extent necessary in, establishing, modifying, or enforcing a support obligation of such individual.
(6) The Department of Revenue may adopt rules for establishing the procedures for automated data matches with financial institutions.
History.—s. 52, ch. 97-170; s. 16, ch. 99-375; s. 36, ch. 2001-158; s. 23, ch. 2008-61.
409.25658 Use of unclaimed property for past due support.—
(1) In a joint effort to facilitate the collection and payment of past due support, the Department of Revenue, in cooperation with the Department of Financial Services, shall identify persons owing support collected through a court who are presumed to have unclaimed property held by the Department of Financial Services.
(2) The department shall periodically provide the Department of Financial Services with an electronic file of support obligors who owe past due support. The Department of Financial Services shall conduct a data match of the file against all apparent owners of unclaimed property under chapter 717 and provide the resulting match list to the department.
(3) Upon receipt of the data match list, the department shall provide to the Department of Financial Services the obligor’s last known address. The Department of Financial Services shall follow the notification procedures under s. 717.118.
(4) Prior to paying an obligor’s approved claim, the Department of Financial Services shall notify the department that such claim has been approved. Upon confirmation that the Department of Financial Services has approved the claim, the department shall immediately send a notice by certified mail to the obligor, with a copy to the Department of Financial Services, advising the obligor of the department’s intent to intercept the approved claim up to the amount of the past due support, and informing the obligor of the obligor’s right to request a hearing under chapter 120. The Department of Financial Services shall retain custody of the property until a final order has been entered and any appeals thereon have been concluded. If the obligor fails to request a hearing, the department shall enter a final order instructing the Department of Financial Services to transfer to the department the property in the amount stated in the final order. Upon such transfer, the Department of Financial Services shall be released from further liability related to the transferred property.
(5) The provisions of this section provide a supplemental remedy, and the department may use this remedy in conjunction with any other method of collecting support.
History.—s. 26, ch. 98-397; s. 37, ch. 2001-158; s. 12, ch. 2002-173; s. 444, ch. 2003-261.
409.25659 Insurance claim data exchange.—
(1) As used in this section, the term:
(a) “Insurer” means an entity that is responsible for paying a claim on liability coverage in an insurance contract and is:
1. An insurer, as defined in s. 624.03, authorized to transact insurance in this state;
2. An eligible surplus lines insurer pursuant to part VIII of chapter 626;
3. A joint underwriter or joint reinsurer created by law or otherwise operating pursuant to s. 627.311; or
4. An insurance risk apportionment plan operating pursuant to s. 627.351.
(b) “Claim” means an open, unresolved bodily injury claim on liability coverage in excess of $3,000 in an insurance contract payable to an individual, or to a third party for the benefit of the individual, who is a resident of this state or who had an accident or loss that occurred in this state or who has an outstanding child support obligation in this state.
(2) The department shall develop and operate a data match system after consultation with one or more insurers, using automated data exchanges to the maximum extent feasible, in which an insurer may voluntarily provide the department monthly with the name, address, and, if known, date of birth and social security number or other taxpayer identification number for each parent who has a claim with the insurer and who owes past due support, and the claim number maintained by the insurer for each claim. An insurer may provide such data by:
(a) Authorizing an insurance claim data collection organization, to which the insurer subscribes and to which the insurer submits the required claim data on at least a monthly basis, to:
1. Receive or access a data file from the department and conduct a data match of all parents who have a claim with the insurer and who owe past due support and submit the required data for each such parent to the department; or
2. Submit a data file to the department which contains the required data for each claim being maintained by the insurer for the department to conduct a data match;
(b) Providing the required data for each claim being maintained by the insurer directly to the department in an electronic medium; or
(c) Receiving or accessing a data file from the department and conducting a data match of all parents who have a claim with the insurer and who owe past due support and submitting the required data for each such parent to the department.
(3) The department shall establish by rule a standard fee, not to exceed actual costs, and pay the fee upon request to an insurer or the insurer’s claim data collection organization for conducting a data match as provided by subsection (2).
(4) An insurer and its directors, agents, employees, and insureds, and any insurance claim data collection organization and its agents and employees authorized by an insurer to act on its behalf, which provides or attempts to provide data under this section are immune from any civil liability under any law to any person or entity for any alleged or actual damages that occur as a result of providing or attempting to provide data under this section.
(5) The department and insurers may only use the data obtained pursuant to subsection (2) for the purpose of identifying parents who owe past due support. If the department does not match such data with a parent who owes past due support, such data shall be destroyed immediately and shall not be maintained by the department.
(6) The department may adopt rules to implement and administer this section.
History.—s. 14, ch. 2004-334; s. 24, ch. 2008-61.
409.25661 Public records exemption for insurance claim data exchange information.—Information obtained by the Department of Revenue pursuant to s. 409.25659 is confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution until such time as the department determines whether a match exists. If a match exists, such information becomes available for public disclosure. If a match does not exist, the nonmatch information shall be destroyed as provided in s. 409.25659.
History.—s. 1, ch. 2004-339; s. 114, ch. 2008-4; s. 1, ch. 2009-119; s. 1, ch. 2010-73; s. 1, ch. 2012-200.
409.2567 Services to individuals not otherwise eligible.—
(1) All support services provided by the department shall be made available on behalf of all dependent children. Services shall be provided upon acceptance of public assistance or upon proper application filed with the department. The federally required application fee for individuals who do not receive public assistance is $1, which shall be waived for all applicants and paid by the department. The annual fee required under 42 U.S.C. s. 654(6)(B) for cases involving an individual who has never received temporary cash assistance and for whom the department has collected at least $500 of support shall be paid by the department.
(2) An attorney-client relationship exists only between the department and the legal services providers in Title IV-D cases. The attorney shall advise the obligee in Title IV-D cases that the attorney represents the agency and not the obligee.
(3) All administrative costs shall be assessed only against the nonprevailing obligor after the court makes a determination of the nonprevailing obligor’s ability to pay such costs and fees. In any case where the court does not award all costs, the court shall state in the record its reasons for not awarding the costs. The court shall order payment of costs without requiring the department to have a member of the bar testify or submit an affidavit as to the reasonableness of the costs.
(4) The Department of Revenue shall not be considered a party for purposes of this section; however, fees may be assessed against the department pursuant to s. 57.105(1).
(5) The Department of Revenue may seek a waiver from the Secretary of the United States Department of Health and Human Services to authorize the Department of Revenue to provide services in accordance with Title IV-D of the Social Security Act to individuals who are owed support without need of an application. The department may seek a waiver if it determines that the estimated increase in federal funding to the state derived from the waiver would exceed any additional cost to the state if the waiver is granted. If the waiver is granted, the Department of Revenue shall adopt rules to implement the waiver and begin providing Title IV-D services if support payments are not being paid as ordered, except that the individual first must be given written notice of the right to refuse Title IV-D services and a reasonable opportunity to respond.
History.—s. 6, ch. 76-220; s. 1, ch. 77-174; s. 13, ch. 78-433; s. 3, ch. 82-140; s. 144, ch. 86-220; s. 17, ch. 87-95; s. 12, ch. 88-176; s. 22, ch. 92-138; s. 16, ch. 93-208; s. 7, ch. 94-124; s. 7, ch. 94-318; s. 41, ch. 96-175; s. 47, ch. 96-418; s. 53, ch. 97-170; s. 27, ch. 98-397; s. 38, ch. 2001-158; ss. 31, 32, ch. 2005-39; s. 10, ch. 2005-82; s. 6, ch. 2007-85; s. 11, ch. 2010-187.
409.2569 Continuation of support services for recipients of public assistance when benefits are terminated.—Whenever a recipient of public assistance ceases to receive such public assistance, the department shall continue to provide services after the recipient ceases to receive benefits unless otherwise advised in writing or in person not to do so by the former recipient. These services shall be provided in accordance with the state plan of priorities. After the termination of public assistance, the department shall continue to provide support services and to recover all costs incurred in providing the services pursuant to s. 409.2567 unless the recipient instructs the department to discontinue services.
History.—s. 145, ch. 86-220; s. 13, ch. 88-176; s. 23, ch. 92-138.
409.257 Service of process.—
(1) The service of original process and orders in any paternity or child support action or proceeding filed by the department shall be made in accordance with chapter 48. The sheriff shall be reimbursed at the prevailing rate of federal financial participation for service of process and orders as allowed by law. The sheriff shall bill the department monthly as provided for in s. 30.51(2).
(2) Process and orders may be served or executed by authorized agents of the department at the department’s discretion if the agent of the department does not take any action against personal property, real property, or persons.
(3) Service of process by publication under chapter 49 may be made on the legal father in any action or proceeding to determine paternity, which may result in termination of the legal father’s parental rights, in which another man is alleged to be the biological father. Before service of process by publication may be made, the petitioner shall conduct a diligent search and inquiry to locate the legal father. A diligent search must include the inquiries required by s. 63.088(5). The petitioner shall execute an affidavit of diligent search and file it with the court confirming completion of each aspect of the diligent search enumerated in s. 63.088(5) and specifying the results. If the legal father cannot be located, he shall be served with process by publication in the manner provided in chapter 49. The notice shall be published in the county where the legal father was last known to have resided. The clerk of the circuit court shall mail a copy of the notice to the legal father at his last known address.
(4) Notices and other intermediate process, except witness subpoenas, shall be served by the department as provided for in the Florida Rules of Civil Procedure.
(5) Witness subpoenas shall be served by the department by United States mail as provided for in s. 48.031(3).
History.—s. 2, ch. 84-141; s. 9, ch. 87-405; s. 8, ch. 89-183; s. 8, ch. 2004-273; s. 15, ch. 2004-334; s. 7, ch. 2007-85.
409.2571 Court and witness fees; bond.—
(1) The department or an authorized agent thereof shall be entitled to the necessary services of the clerk, court reporter, and county comptroller in any proceedings under the IV-D program, including contempt proceedings; and no fees for such court reporter, clerk, or comptroller services shall be charged against the department. No bond shall be required of the department for any action taken pursuant to the IV-D program, except by order of the court. Nothing herein shall prevent the depository from charging and collecting fees for services rendered.
(2) No witness fees shall be paid to any party to a petition or complaint or to any parent or legal custodian of a dependent child described in a petition or complaint filed pursuant to this act.
History.—s. 7, ch. 76-220; s. 1, ch. 77-174; s. 1, ch. 84-141; s. 146, ch. 86-220; s. 18, ch. 87-95; s. 24, ch. 92-138.
409.2572 Cooperation.—
(1) An applicant for, or recipient of, public assistance for a dependent child shall cooperate in good faith with the department or a program attorney in:
(a) Identifying and helping to locate the alleged parent or obligor.
(b) Assisting in establishing the paternity of a child born out of wedlock.
(c) Assisting in obtaining support payments from the obligor.
(d) Assisting in obtaining any other payments or property due from the obligor.
(e) Identifying another putative father when an earlier named putative father has been excluded by DNA, Human Leukocyte Antigen, or other scientific test.
(f) Appearing at an office of the department, or another designated office, as necessary to provide verbal or written information, or documentary or physical evidence, known to, possessed by, or reasonably obtainable by the applicant or recipient.
(g) Appearing as a witness at judicial or other hearings or proceedings.
(h) Providing information under oath regarding the identity or location of the alleged father of the child or attesting to the lack of information.
(i) Paying to the department any support received from the obligor after the assignment is effective.
(2) Noncooperation, or failure to cooperate in good faith, is defined to include, but is not limited to, the following conduct:
(a) Refusing to identify the father of the child, or where more than one man could be the father of the child, refusing to identify all such persons.
(b) Failing to appear for two appointments at the department or other designated office without justification and notice.
(c) Providing false information regarding the paternity of the child or the obligation of the obligor.
(d) All actions of the obligee which interfere with the state’s efforts to proceed to establish paternity, the obligation of support, or to enforce or collect support.
(e) Failure to appear to submit a DNA sample or leaving the location prior to submitting a DNA sample without compelling reasons.
(f) Failure to assist in the recovery of third-party payment for medical services.
(3) The Title IV-D staff of the department shall be responsible for determining and reporting to the staff of the Department of Children and Family Services acts of noncooperation by applicants or recipients of public assistance. Any person who applies for or is receiving public assistance for, or who has the care, custody, or control of, a dependent child and who without good cause fails or refuses to cooperate with the department, a program attorney, or a prosecuting attorney in the course of administering this chapter shall be sanctioned by the Department of Children and Family Services pursuant to chapter 414 and is ineligible to receive public assistance until such time as the department determines cooperation has been satisfactory.
(4) Except as provided for in s. 414.32, the Title IV-D agency shall determine whether an applicant for or recipient of public assistance for a dependent child has good cause for failing to cooperate with the Title IV-D agency as required by this section.
(5) As used in this section only, the term “applicant for or recipient of public assistance for a dependent child” refers to such applicants and recipients of public assistance as defined in s. 409.2554(8), with the exception of applicants for or recipients of Medicaid solely for the benefit of a dependent child.
History.—s. 4, ch. 82-140; s. 147, ch. 86-220; s. 19, ch. 87-95; s. 93, ch. 96-175; s. 197, ch. 97-101; s. 41, ch. 97-173; s. 28, ch. 98-397; s. 39, ch. 2001-158; s. 16, ch. 2004-334; s. 7, ch. 2009-90.
409.2574 Income deduction enforcement in Title IV-D cases.—
(1) The department or its designee shall enforce income deduction orders on behalf of obligees who have applied for IV-D services, and the department shall be considered a party in the action.
(2)(a) In a support order being enforced under Title IV-D of the Social Security Act and which order does not specify income deduction, income deduction shall be enforced by the department or its designee without the need for any amendment to the support order or any further action by the court.
(b) The department shall serve a notice on the obligor that the income deduction notice has been served on the employers. Service upon an obligor under this section shall be made in the manner prescribed in chapter 48. The department shall furnish to the obligor a statement of the obligor’s rights, remedies, and duties in regard to the income deduction.
(c) The obligor has 15 days from the serving of the notice to request a hearing with the department to contest enforcement of income deduction.
(d) The department shall adopt rules to ensure that applicable provisions of s. 61.1301 are followed.
History.—s. 8, ch. 76-220; s. 5, ch. 82-140; s. 148, ch. 86-220; s. 45, ch. 97-103; s. 54, ch. 97-170.
409.2575 Liens on motor vehicles and vessels.—
(1) The director of the state IV-D program, or the director’s designee, may cause a lien for unpaid and delinquent support to be placed upon motor vehicles, as defined in chapter 320, and upon vessels, as defined in chapter 327, that are registered in the name of an obligor who is delinquent in support payments, if the title to the property is held by a lienholder, in the manner provided in chapter 319 or chapter 328. Notice of lien shall not be mailed unless the delinquency in support exceeds $600.
(2) If the first lienholder fails, neglects, or refuses to forward the certificate of title to the appropriate department as requested pursuant to s. 319.24 or s. 328.15, the director of the IV-D program, or the director’s designee, may apply to the circuit court for an order to enforce the requirements of s. 319.24 or s. 328.15, whichever applies.
History.—s. 14, ch. 88-176; s. 46, ch. 97-103; s. 29, ch. 98-397.
409.2576 State Directory of New Hires.—
(1) DIRECTORY CREATED.—The State Directory of New Hires is hereby created and shall be administered by the Department of Revenue or its agent. All employers in the state shall furnish a report consistent with subsection (3) for each newly hired or rehired employee unless the employee is employed by a federal or state agency performing intelligence or counterintelligence functions and the head of such agency has determined that reporting pursuant to this section could endanger the safety of the employee or compromise an ongoing investigation or intelligence mission.
(2) DEFINITIONS.—For purposes of this section:
(a) “Employee” is defined as an individual who is an employee within the meaning of chapter 24 of the Internal Revenue Code of 1986.
(b) “Employer” has the meaning given such term in s. 3401(d) of the Internal Revenue Code of 1986 and includes any government entity and labor organization.
(c) “Labor organization” has the meaning given such term in s. 2(5) of the National Labor Relations Act and includes any entity which is used by the organization and an employer to carry out requirements described in s. 8(f)(3) of such act of an agreement between the organization and employer.
(d) “Date of hire” is the first day of work for which the employee is owed income.
(3) EMPLOYERS TO FURNISH REPORTS.—
(a) Each employer subject to the reporting requirements of chapter 443 with 250 or more employees, shall provide to the State Directory of New Hires, a report listing the employer’s legal name, address, and reemployment assistance identification number. The report must also provide the name and social security number of each new employee or rehired employee at the end of the first pay period following employment or reemployment.
(b) All employers shall furnish a report to the State Directory of New Hires of the state in which the newly hired or rehired employee works. The report required in this section shall be made on a W-4 form or, at the option of the employer, an equivalent form, and can be transmitted magnetically, electronically, by first-class mail, or other methods which may be prescribed by the State Directory. Each report shall include the name, address, date of hire, and social security number of every new and rehired employee and the name, address, and federal employer identification number of the reporting employer. If available, the employer may also include the employee’s date of birth in the report. Multistate employers that report new hire information electronically or magnetically may designate a single state to which it will transmit the above noted report, provided the employer has employees in that state and the employer notifies the Secretary of Health and Human Services in writing to which state the information will be provided. Agencies of the United States Government shall report directly to the National Directory of New Hires.
(c) Pursuant to the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, each party is required to provide his or her social security number in accordance with this section. Disclosure of social security numbers obtained through this requirement shall be limited to the purpose of administration of the Title IV-D program for child support enforcement and those programs listed in subsection (9).
(4) TIME FOR REPORTS.—Employers must report new hire information, as described in subsection (3), within 20 days of the hire date of the employee, or, in the case of employers that report new hire information electronically or by magnetic tape, by two monthly transmissions, if necessary, not less than 12 days nor more than 16 days apart.
(5) ENTRY OF DATA.—The State Directory of New Hires shall enter new hire information into an automated database within 5 business days of receipt.
(6) MATCHES TO STATE REGISTRY.—Not later than May 1, 1998, the Department of Revenue or its agent must conduct automated matches of the social security numbers of employees reported to the State Directory of New Hires against the social security numbers of records in the State Case Registry. The Title IV-D agency shall use the new hire information received to locate individuals for the purposes of establishing paternity and establishing, modifying, and enforcing support obligations. Private entities under contract with the Title IV-D agency to provide Title IV-D services may have access to information obtained from the State Directory of New Hires and must comply with privacy safeguards.
(7) WAGE WITHHOLDING NOTICE AND NATIONAL MEDICAL SUPPORT NOTICE.—The department shall transmit a wage withholding notice consistent with s. 61.1301 and, when appropriate, a national medical support notice, as defined in s. 61.046, to the employee’s employer within 2 business days after entry of the new hire information into the State Directory of New Hires’ database, unless the court has determined that the employee’s wages are not subject to withholding or, for purposes of the national medical support notice, the support order does not contain a provision for the employee to provide health insurance. The withholding notice shall direct the employer to withhold income in accordance with the income deduction order, and the national medical support notice shall direct the employer to withhold premiums for health insurance.
(8) PROVIDING INFORMATION TO NATIONAL DIRECTORY.—The State Directory of New Hires must furnish information regarding newly hired or rehired employees to the National Directory of New Hires for matching with the records of other state case registries within 3 business days of entering such information from the employer into the State Directory of New Hires. The State Directory of New Hires shall enter into an agreement with the Department of Economic Opportunity or its tax collection service provider for the quarterly reporting to the National Directory of New Hires information on wages and reemployment assistance taken from the quarterly report to the Secretary of Labor, now required by Title III of the Social Security Act, except that no report shall be filed with respect to an employee of a state or local agency performing intelligence or counterintelligence functions, if the head of such agency has determined that filing such a report could endanger the safety of the employee or compromise an ongoing investigation or intelligence mission.
(9) DISCLOSURE OF INFORMATION.—
(a) New hire information shall be disclosed to the state agency administering the following programs for the purposes of determining eligibility under those programs:
1. Any state program funded under part A of Title IV of the Social Security Act;
2. The Medicaid program under Title XIX of the Social Security Act;
3. The reemployment assistance or unemployment compensation program under s. 3304 of the Internal Revenue Code of 1954;
4. The food assistance program under the Food and Nutrition Act of 2008; and
5. Any state program under a plan approved under Title I (Old-Age Assistance for the Aged), Title X (Aid to the Blind), Title XIV (Aid to the Permanently and Totally Disabled), or Title XVI (Aid to the Aged, Blind, or Disabled; Supplemental Security Income for the Aged, Blind, and Disabled) of the Social Security Act.
(b) New hire information shall be disclosed to the state agencies operating employment security and workers’ compensation programs for the purposes of administering such programs.
History.—s. 55, ch. 97-170; s. 30, ch. 98-397; s. 13, ch. 2002-173; s. 8, ch. 2009-90; s. 10, ch. 2010-209; s. 301, ch. 2011-142; s. 21, ch. 2011-213; s. 63, ch. 2012-30; s. 55, ch. 2013-18.
409.2577 Parent locator service.—The department shall establish a parent locator service to assist in locating parents who have deserted their children and other persons liable for support of dependent children. The department shall use all sources of information available, including the Federal Parent Locator Service, and may request and shall receive information from the records of any person or the state or any of its political subdivisions or any officer thereof. Any agency as defined in s. 120.52, any political subdivision, and any other person shall, upon request, provide the department any information relating to location, salary, insurance, social security, income tax, and employment history necessary to locate parents who owe or potentially owe a duty of support pursuant to Title IV-D of the Social Security Act. This provision shall expressly take precedence over any other statutory nondisclosure provision which limits the ability of an agency to disclose such information, except that law enforcement information as provided in s. 119.071(4)(d) is not required to be disclosed, and except that confidential taxpayer information possessed by the Department of Revenue shall be disclosed only to the extent authorized in s. 213.053(16). Nothing in this section requires the disclosure of information if such disclosure is prohibited by federal law. Information gathered or used by the parent locator service is confidential and exempt from the provisions of s. 119.07(1). Additionally, the department is authorized to collect any additional information directly bearing on the identity and whereabouts of a person owing or asserted to be owing an obligation of support for a dependent child. The department shall, upon request, make information available only to public officials and agencies of this state; political subdivisions of this state, including any agency thereof providing child support enforcement services to non-Title IV-D clients; the parent owed support, legal guardian, attorney, or agent of the child; and other states seeking to locate parents who have deserted their children and other persons liable for support of dependents, for the sole purpose of establishing, modifying, or enforcing their liability for support, and shall make such information available to the Department of Children and Family Services for the purpose of diligent search activities pursuant to chapter 39. If the department has reasonable evidence of domestic violence or child abuse and the disclosure of information could be harmful to the parent owed support or the child of such parent, the child support program director or designee shall notify the Department of Children and Family Services and the Secretary of the United States Department of Health and Human Services of this evidence. Such evidence is sufficient grounds for the department to disapprove an application for location services.
History.—s. 9, ch. 76-220; s. 1, ch. 77-174; s. 20, ch. 87-95; s. 15, ch. 88-176; s. 5, ch. 91-71; s. 25, ch. 92-138; s. 13, ch. 95-398; s. 255, ch. 96-406; s. 56, ch. 97-170; s. 149, ch. 98-403; s. 17, ch. 99-375; s. 43, ch. 2004-335; s. 50, ch. 2005-251; s. 4, ch. 2006-85; s. 2, ch. 2006-180; s. 25, ch. 2008-61.
409.2578 Access to employment information; administrative fine.—
(1) For the purpose of establishing paternity, establishing a child support obligation, or enforcing a support obligation, all persons in this state, including for-profit, not-for-profit, and governmental employers or contractors, shall, upon written request from the IV-D agency for information concerning an individual employee of such person, provide to the IV-D agency of this state or its designee or to the Title IV-D agency of any other state or its designee information on the employment, compensation, and benefits of any employee who has a liability to pay support and is delinquent or who has a potential liability. The IV-D agency may also make such a request for the purpose of modifying a child support obligation after an unsuccessful attempt to obtain the information from either party. The information requested shall be provided within 30 days of receipt of the written request. The Title IV-D agency of this state is authorized to impose a fine for failure to respond to its request.
(2) Prior to imposition of a fine, the department shall issue a written notification of noncompliance. Failure to comply with the request within 15 days of receipt of the written notification without good cause may result in the agency taking the following actions:
(a) Imposition of an administrative fine of not more than $500;
(b) The application by the Title IV-D agency or its designee, to the circuit court for an order compelling compliance. The person who is determined to be in noncompliance with the request shall be liable for reasonable attorney’s fees and costs associated with the department bringing this action upon showing by the department that the person failed to comply with the request without good cause.
(3) All fines collected pursuant to this section shall be made payable to the Child Support Enforcement Application and Program Revenue Trust Fund.
History.—s. 57, ch. 97-170; s. 31, ch. 98-397; s. 40, ch. 2001-158; s. 56, ch. 2013-18.
409.2579 Safeguarding Title IV-D case file information.—
(1) Information concerning applicants for or recipients of Title IV-D child support services is confidential and exempt from the provisions of s. 119.07(1). The use or disclosure of such information by the IV-D program is limited to purposes directly connected with:
(a) The administration of the plan or program approved under part A, part B, part D, part E, or part F of Title IV; under Title II, Title X, Title XIV, Title XVI, Title XIX, or Title XX; or under the supplemental security income program established under Title XVI of the Social Security Act;
(b) Any investigation, prosecution, or criminal or civil proceeding connected with the administration of any such plan or program;
(c) The administration of any other federal or federally assisted program which provides service or assistance, in cash or in kind, directly to individuals on the basis of need;
(d) Reporting to an appropriate agency or official, information on known or suspected instances of physical or mental injury, child abuse, sexual abuse or exploitation, or negligent treatment or maltreatment of a child who is the subject of a support enforcement activity under circumstances which indicate that the child’s health or welfare is threatened thereby; and
(e) Mandatory disclosure of identifying and location information as provided in s. 61.13(7) by the IV-D program when providing Title IV-D services.
(2) The IV-D program may not disclose to any legislative body, whether federal, state, or local, or any committee thereof, any information that identifies by name or address an applicant or recipient of support services.
(3) As required by federal law, 42 U.S.C. s. 654(26), upon notice that such an order exists, the IV-D program shall not disclose information on the whereabouts of one party or the child to the other party against whom a protective order with respect to the former party or the child has been entered.
(4) As required by federal law, 42 U.S.C. s. 654(26), the IV-D program shall not disclose information on the whereabouts of one party or the child to another person if the program has reason to believe that the release of information to that person may result in physical or emotional harm to the party or the child.
(5) The Department of Revenue is authorized to establish, by rule, procedures to implement this section.
(6) Any person who willfully and knowingly violates any of the provisions of this section is guilty of a misdemeanor of the first degree punishable as provided in s. 775.082 or s. 775.083.
History.—s. 16, ch. 88-176; s. 6, ch. 91-71; s. 256, ch. 96-406; s. 58, ch. 97-170; s. 32, ch. 98-397; s. 41, ch. 2001-158; s. 11, ch. 2005-239; s. 26, ch. 2008-61.
409.2581 Use of clearing accounts and revolving funds.—To facilitate the cash flow and administration of child support enforcement under this act, the department may use clearing accounts and revolving funds.
History.—s. 10, ch. 76-220.
409.2584 Interest on obligations due; waiver.—The department may collect interest at the rate established in s. 55.03 on all support obligations due and owing to the department; however, the department is not required to maintain interest balance due accounts, and said interest may be waived by the department if the waiver would facilitate the collection of the obligation.
History.—s. 11, ch. 76-220; s. 149, ch. 86-220; s. 26, ch. 92-138.
409.259 Filing fees in Title IV-D cases; electronic filing of pleadings, returns of service, and other papers.—
(1) Notwithstanding s. 28.241, each clerk of the circuit court shall accept petitions, complaints, and motions filed by the department in Title IV-D cases without billing the department separately for each filing, as long as the clerk is being reimbursed in a different manner for expenses incurred in such filings under the cooperative agreement with the department pursuant to ss. 61.181(1) and 61.1826(2) and (4).
(2) Notwithstanding subsection (1), the department shall continue to be entitled to the other necessary services of the clerk of court in any proceedings under the IV-D program as authorized under s. 409.2571.
(3) The clerks of the circuit court, chief judges through the Office of the State Courts Administrator, sheriffs, Office of the Attorney General, and Department of Revenue shall implement electronic filing of pleadings, returns of service, and other papers in Title IV-D cases upon completion of the Child Support Automated Management System II.
History.—s. 11, ch. 89-183; s. 94, ch. 96-175; s. 94, ch. 2000-165; s. 17, ch. 2004-334; s. 34, ch. 2005-39; s. 12, ch. 2010-187.
409.2594 Record requirements.—The department shall keep the records necessary to evaluate the effectiveness of the program. At a minimum, the records shall include:
(1) The number of parents located.
(2) The amount of money generated through the collection of support of dependent children.
(3) The cost of program management and administration.
History.—s. 14, ch. 76-220; s. 18, ch. 84-254; s. 43, ch. 2001-158.
409.2597 Retention of actions.—All actions pending under the authority of those statutes repealed by this act shall not abate but shall continue pursuant to the provisions of this act.
History.—s. 16, ch. 76-220.
409.2598 License suspension proceeding to enforce support order.—
(1) DEFINITIONS.—As used in this section, the term:
(a) “License” means a license, permit, certificate, registration, franchise, or other form of written permission issued by a licensing agency to an individual which authorizes the individual to engage in an occupation, business, trade, or profession or to engage in a recreational activity, including hunting or fishing. Where the context permits, the term also includes an application for a new or renewal license.
(b) “Licensee” means an individual who has a license.
(c) “Licensing agency” means a department, commission, agency, district, county, municipality, or other subdivision of state or local government which issues licenses.
(2) NOTICE OF NONCOMPLIANCE AND INTENT TO SUSPEND LICENSE.—If a support order has not been complied with for at least 30 days, the Department of Revenue may commence a license suspension proceeding to enforce compliance with the support order by providing written notice to the obligor that states:
(a) That the obligor is not in compliance with the support order and whether the noncompliance is due to the obligor’s nonpayment of current support, delinquencies or arrears, or the failure to provide health care coverage or medical support.
(b) The kind of license that is subject to suspension.
(c) That the obligor may avoid license suspension by complying with the support order or entering into a written agreement with the department within 30 days after the mailing of the notice.
(d) If the obligor timely complies with the support order or a written agreement entered into with the department, the proceeding ends and the obligor’s license is not suspended.
(e) That the obligor may contest license suspension by filing a petition in circuit court within 30 days after the mailing of the notice of noncompliance.
(f) If the obligor timely files a petition in circuit court, that the license suspension proceeding is stayed pending a ruling by the court.
The notice shall be served on the obligor by regular mail sent to the obligor’s last address of record with the local depository or a more recent address if known, which may include the obligor’s mailing address as reflected by the records of the licensing agency.
(3) HEARING; STAY OF PROCEEDING.—The obligor may contest license suspension by filing a petition in circuit court within 30 days after the mailing of the notice of noncompliance and serving a copy of the petition on the Department of Revenue. If the obligor timely files a petition in circuit court, the license suspension proceeding is stayed pending a ruling by the court. The obligor may contest on the basis of a mistake of fact concerning the obligor’s compliance with the support order, the reasonableness of a payment agreement offered by the department, or the identity of the obligor. A timely petition to contest must be heard by the court within 15 days after the petition is filed. The court must enter an order ruling on the matter within 10 days after the hearing, and a copy of the order must be served on the parties.
(4) COMPLIANCE; REINSTATEMENT.—
(a) If the obligor complies with the support order or a written agreement entered into with the department after a proceeding is commenced but before the obligor’s license is suspended, the proceeding shall cease and the obligor’s license may not be suspended. If the obligor subsequently does not comply with the support order, the department may commence a new proceeding or proceed as provided in paragraph (c) if the obligor enters into a written agreement and does not comply with the agreement.
(b) If the obligor complies with the support order or a written agreement entered into with the department after the obligor’s license is suspended, the department shall provide the obligor with a reinstatement notice and the licensing agency shall reinstate the obligor’s license at no additional charge to the obligor.
(c) If the obligor enters into a written agreement with the department and does not comply with the agreement, the department shall notify the licensing agency to suspend the obligor’s license unless the obligor notifies the department that the obligor can no longer comply with the written agreement. If the obligor notifies the department of the inability to comply with the written agreement, the obligor shall provide full disclosure to the department of the obligor’s income, assets, and employment. If after full disclosure the written agreement cannot be renegotiated, the department or the obligor may file a petition in circuit court to determine the matter.
(d) A licensing agency shall promptly reinstate the obligor’s license upon receipt of a court order for reinstatement.
(e) Notwithstanding any other statutory provision, a notice from the court or the department shall reinstate to the obligor all licenses established in chapter 379 that were valid at the time of suspension.
(5) NOTICE TO LICENSING AGENCY; SUSPENSION.—
(a) The Department of Revenue shall notify the licensing agency to suspend the obligor’s license when:
1. Thirty or more days have elapsed after a proceeding has been commenced and the obligor has not complied with the support order or a written agreement entered into with the department or filed a timely petition to contest license suspension in circuit court;
2. The obligor enters into a written agreement with the department and does not comply with the agreement, unless the obligor notifies the department that the obligor can no longer comply with the agreement; or
3. The department is ordered to do so by the circuit court.
(b) Upon notice by the department or the circuit court, the licensing agency shall suspend the obligor’s license and may only reinstate the license upon further notice by the department or the court.
(6) ENFORCEMENT OF SUBPOENAS.—A license may be suspended under this section to enforce compliance with a subpoena, order to appear, order to show cause, or similar order in a child support or paternity proceeding by using the same procedures as those used for enforcing compliance with a support order.
(7) MULTIPLE LICENSES.—The Department of Revenue may combine a proceeding under this section with a proceeding to suspend a driver’s license under s. 61.13016. A proceeding to suspend a license under this section may apply to one or more of the obligor’s licenses.
(8) RULEMAKING AUTHORITY.—The Department of Revenue may adopt rules to implement and enforce the requirements of this section.
History.—s. 9, ch. 93-208; s. 4, ch. 95-222; s. 95, ch. 96-175; s. 1021, ch. 97-103; s. 59, ch. 97-170; s. 29, ch. 98-166; s. 36, ch. 99-289; s. 21, ch. 2000-160; s. 19, ch. 2000-364; s. 44, ch. 2001-158; s. 993, ch. 2002-387; s. 18, ch. 2004-334; s. 33, ch. 2005-39; s. 57, ch. 2009-21.
409.2599 Data processing services; interagency agreement.—The Department of Children and Family Services shall provide to the child support enforcement program in the Department of Revenue data processing services that meet the standards for federal certification pursuant to an interagency agreement.
History.—s. 1(5), ch. 94-124; ss. 12, 26, ch. 95-272; ss. 117, 118, ch. 97-101; s. 12, ch. 97-287.
409.25995 State Title IV-D agency; contracts.—The Department of Revenue, in its capacity as the state Title IV-D agency, may enter into contracts consistent with federal law for the provision of program services by for-profit corporations, governmental entities, not-for-profit corporations, and other entities capable of providing administrative services.
History.—s. 1(6), ch. 94-124.
409.2673 Shared county and state health care program for low-income persons.—
(1) It is the policy of the state that the state and local governments have a joint obligation, as provided in this section, to participate in the provision of health care services to low-income persons who do not meet the criteria for Medicaid or any other state-funded or federally funded program which includes hospital care.
(2) A shared county and state program is established to provide inpatient hospital services and, at the option of the county, outpatient hospital services and physician specialty services for hospital care, including out-of-county inpatient hospital services to single adults under the age of 65, childless couples, and parents in intact families with incomes up to 100 percent of the federal poverty income guidelines who do not meet the criteria for Medicaid or any other state-funded or federally funded inpatient health care program; who have insufficient third-party insurance coverage; who do not live in public institutions, as defined in the medical assistance program for the needy under Title XIX of the Social Security Act, as amended; and who are United States citizens or lawfully admitted aliens. This program is intended to serve as the payor of last resort.
(3)(a) County participation in this program is optional.
(b) Beginning October 1, 1991, county participation in this program shall be mandatory.
(4) The levels of financial participation by counties and the state for this program shall be determined as follows:
(a) If on July 1, 1988, a county funded inpatient hospital services for those who would have been eligible for the program, the county shall fund 35 percent of the cost of this program and the state shall provide the remaining 65 percent of the funding required for this program. A county participating at this level shall use that portion of its budget that previously would have funded these inpatient hospital services and that, under this program, has been offset by state funding for funding other health programs.
(b) If a county has not reached its maximum ad valorem millage rate as authorized by law and certified to the Department of Revenue and the county does not currently fund inpatient hospital services for those who would be eligible for this program, the county:
1. Shall provide 35 percent of the cost for this program from within the county’s existing budget, and the state shall provide the remaining 65 percent of the funding required for this program; however, under no circumstances will county funding which had been used for funding the county health department under chapter 154 be utilized for funding the county’s portion of this program; or
2. Shall levy an additional ad valorem millage to fund the county’s portion of this program. The state shall provide the remaining portion of program funding if:
a. A county levies additional ad valorem millage up to the maximum authorized by law and certified to the Department of Revenue and still does not have sufficient funds to meet its 35 percent of the funding of this program; and
b. A county has exhausted all revenue sources which can statutorily be used as possible funding sources for this program.
(c) A county will be eligible for 100-percent state funding of this program if:
1. On July 1, 1988, the county did not fund inpatient hospital services for those who would have been eligible for this program;
2. The county has reached its maximum ad valorem millage as authorized by law and certified to the Department of Revenue; and
3. The county has exhausted all revenue sources which can statutorily be used as possible funding sources for this program.
Reporting forms specifically designed to capture the information necessary to determine the above levels of participation will be developed as part of the joint rulemaking required for the shared county and state program. For purposes of this program, the counties will be required to report necessary information to the Department of Financial Services.
(5) Under no circumstances shall any county receive more than 15 percent of the total state appropriation during any fiscal year from the state for the state’s share of the funding for the shared county and state program.
(6)(a) If, during the course of any fiscal year the state’s specific appropriation for this program is depleted, the program will cease to operate for the remainder of that fiscal year. When state dollars are depleted, county obligations cease. A county is not liable for funding without appropriate state matching funds.
(b) If, during the course of any fiscal year the county’s specific appropriation for this program is depleted, the program will cease to operate in that county for the remainder of that fiscal year. When county dollars are depleted, state obligations cease. The state is not liable for funding without appropriate county matching funds.
(c) The state’s portion of the funding shall be made available from the Public Medical Assistance Trust Fund.
(7) A county that participates in the program at any level may not reduce its total per capita expenditures being devoted to health care if any of these funds were previously utilized for the provision of inpatient hospital services to those persons made eligible for the shared county and state program. It is the intent of the Legislature that, as a result of the shared county and state program, local funds which were previously used for the provision of inpatient hospital services to persons made eligible by the program be used by counties for funding other health care programs which, for purposes of this section, are health expenditures as reported annually to the Department of Financial Services pursuant to s. 218.32, provided that this subsection does not apply to reductions in county funding resulting from the expiration of special sales taxes levied pursuant to chapter 84-373, Laws of Florida.
(8)(a) For those counties contributing funding to the shared county and state program, the county has the first right of refusal in deciding if it will be responsible for making eligibility determinations required as part of the shared county and state program if the state is contributing 80 percent or less of program funding. If a county declines the eligibility determination function, such determinations shall be made by the department.
(b) In those counties where the shared county and state program is 80 percent or more funded by the state, the department shall be responsible for making eligibility determinations required as part of the program.
(c) When eligibility is determined by the county, the county must determine whether the individual is receiving services under the primary care program operated by the county’s health department. If the individual is receiving such services, the county shall accept any verification of residency or indigency in the primary care case record that meets the criteria described in the administrative rules governing the shared county and state health care program.
(9) Each county shall designate a lead agency under the shared county and state program. The lead agency:
(a) May be any agency of the county, the county health department, or any other public or private nonprofit agency designated by the board of county commissioners.
(b) Shall serve as the overall coordinator of the program and establish a coordinated system to identify clients in this program, other county programs, private programs, and the primary care program established in s. 154.011.
(c) Shall establish working relationships with appropriate hospitals for the acceptance of individuals determined eligible under the program.
(d) Shall negotiate reimbursement rates and, at the option of the county, negotiate with appropriate hospitals the number of days of care provided under the program.
(e) Shall negotiate, at the option of the county, prepaid reimbursement plans with appropriate hospitals.
(f) Shall coordinate and develop, to the extent possible, health care programs for indigent county residents.
(10) Under the shared county and state program, reimbursement to a hospital for services for an eligible person must:
(a) Be at a reimbursement rate which is negotiated by the lead agency but which does not exceed the hospital’s per diem reimbursement rate in effect at the time of service delivery for the hospital under the medical assistance program for the needy under Title XIX of the Social Security Act, as amended;
(b) Be limited to payment for 12 days of service per admission, not to exceed 45 days of service per county fiscal year;
(c) Be conditioned on participation of the eligible person prior to hospitalization in a case-managed program of primary care and health care services which is coordinated by the lead agency or referral of the eligible person immediately subsequent to discharge from the hospital to the lead agency’s case-managed services. For purposes of this program, case-managed programs of primary care and other health care services are those operated by:
1. A state-funded county health department, a county health department primary care program, or a contractor whose primary care program is funded through a county health department;
2. A county-operated primary care program or a contractor whose primary care program is funded by or through a county governing authority;
3. A federally funded community or migrant primary health care center; or
4. A private physician or group of physicians who agree to work with the lead agency and other providers of primary care within the county in providing services to individuals enrolled in a countywide program of primary care;
(d) Be conditioned, for public hospitals and hospital districts that deliver services as part of this program, on a commitment not to reduce the percentage of the hospital’s ad valorem tax dollars being devoted to health care for low-income persons if any of these funds were previously utilized for the provision of health care services to those persons made eligible for the shared county and state program. It is the intent of the Legislature that, as a result of the shared county and state program, funds that were previously utilized for the provision of health care services to persons made eligible by the program be used by public hospitals and hospital districts to expand their health care program capabilities for low-income persons; and
(e) Be conditioned, for tax district hospitals that deliver services as part of this program, on the delivery of charity care, as defined in the rules of the Agency for Health Care Administration, which equals a minimum of 2.5 percent of the tax district hospital’s net revenues; however, those tax district hospitals which by virtue of the population within the geographic boundaries of the tax district cannot feasibly provide this level of charity care shall assure an “open door” policy to those residents of the geographic boundaries of the tax district who would otherwise be considered charity cases.
(11) For each person determined eligible for the shared county and state program, every effort must be made as part of the eligibility determination process to determine if any applicable third-party insurance coverage is available. A requirement for participation by the applicant in the shared county and state program shall be complete cooperation of each applicant in the eligibility review process. Failure of a potential program participant to provide necessary documentation and followup will result in program rejection.
(12) There is created the Shared County and State Program Trust Fund in the Treasury to be used by the Agency for Health Care Administration for the purpose of funding the state’s portion of the shared county and state program created pursuant to this section.
(13) There is created in each county the Shared County and State Program Trust Fund to be used by the county for reimbursing participating hospitals for the provision of services to those eligible for coverage by the shared county and state program created pursuant to this section. There shall be deposited into the trust fund county funds for the shared county and state program and the county’s share of state funds allocated for the shared county and state program. Any balance in the trust fund at the end of any fiscal year shall remain therein and shall be available for carrying out the provisions of this section.
(14) Any dispute among a county, the Agency for Health Care Administration, the department, or a participating hospital shall be resolved by order as provided in chapter 120. Hearings held under this subsection shall be conducted in the same manner as provided in ss. 120.569 and 120.57, except that the administrative law judge’s or hearing officer’s order constitutes final agency action. Cases filed under chapter 120 may combine all relevant disputes between parties.
History.—ss. 26, 28, 29, ch. 88-294; s. 19, ch. 90-295; s. 61, ch. 91-282; s. 193, ch. 96-410; s. 198, ch. 97-101; s. 17, ch. 98-89; s. 55, ch. 2000-153; s. 445, ch. 2003-261.
409.26731 Certification of local funds as state match for federally funded services.—The department is authorized to certify local funds as state match for eligible Title IV-E expenditures in excess of the amount of state general revenue matching funds appropriated for such services by the General Appropriations Act. Title IV-E funds provided to the state as federal financial participation consequent to certified local matching funds shall automatically be passed through to the local entity that provided the certified local match. Notwithstanding the provisions of s. 215.425, all such federal Title IV-E funds earned for the current fiscal year as a result of using certified local match, except for up to 5 percent of such earnings that the department is authorized to retain for administrative purposes, shall be distributed as set forth in this section and this process shall not impact the department’s allocation to any district. All of the provisions of this section are based upon federal approval of the provisions as specifically limited in this section and shall not become effective if any further modifications are required of the state, unless and until federal approval has been obtained. The department shall annually prepare a report to be submitted to the Legislature no later than January 1 documenting the specific activities undertaken during the previous fiscal year pursuant to this section.
History.—s. 6, ch. 97-260; s. 55, ch. 99-193.
409.285 Opportunity for hearing and appeal.—
(1) If an application for public assistance is not acted upon within a reasonable time after the filing of the application, or is denied in whole or in part, or if an assistance payment is modified or canceled, the applicant or recipient may appeal the decision to the Department of Children and Family Services in the manner and form prescribed by the department.
(2) The hearing authority may be the Secretary of Children and Family Services, a panel of department officials, or a hearing officer appointed for that purpose. The hearing authority is responsible for a final administrative decision in the name of the department on all issues that have been the subject of a hearing. With regard to the department, the decision of the hearing authority is final and binding. The department is responsible for seeing that the decision is carried out promptly.
(3) The department may adopt rules to administer this section. Rules for the Temporary Assistance for Needy Families block grant programs must be similar to the federal requirements for Medicaid programs.
History.—s. 1, ch. 69-268; ss. 19, 35, ch. 69-106; s. 1, ch. 70-255; s. 283, ch. 77-147; s. 1, ch. 77-174; s. 19, ch. 78-95; s. 120, ch. 97-101; s. 9, ch. 98-152.
409.352 Licensing requirements for physicians, osteopathic physicians, and chiropractic physicians employed by the department.—
(1) It is the intent of the Legislature that physicians providing services in state institutions meet the professional standards of their respective licensing boards and that such institutions make every reasonable effort to assure that all physicians employed are licensed, or will become licensed, in this state. When state-licensed physicians cannot be obtained in sufficient numbers to provide quality services, the licensing requirements in chapters 458, 459, and 460 to the contrary notwithstanding, persons employed as physicians, osteopathic physicians, or chiropractic physicians in a state institution, except those under the control of the Department of Corrections on June 28, 1977, may be exempted from licensure in accordance with the following provisions:
(a) No more than 10 percent of such persons shall be exempted from licensure during their continued employment in a state institution. Those persons who shall be so exempted shall be selected by the State Surgeon General. In making the selection, the State Surgeon General shall submit his or her recommendations to the appropriate licensing board for a determination by the board, without written examination, of whether or not the person recommended meets the professional standards required of such person in the performance of his or her duties or functions. The criteria to be used by the respective board in making its determination shall include, but not be limited to, the person’s professional educational background, formal specialty training, and professional experience within the 10 years immediately preceding employment by the state institution.
(b) Those persons not exempted pursuant to paragraph (a) shall not be required to obtain a license from the applicable licensing board in accordance with the provisions of chapter 458, chapter 459, or chapter 460 prior to October 1, 1981, as a prerequisite to their continued employment as a physician, osteopathic physician, or chiropractic physician in a state institution. Each such exempted physician shall have been certified to the department by the appropriate licensing board as eligible for admission for examination in this state. A licensing board shall not certify to the department as eligible for admission for examination any person who has been adjudged unqualified or guilty of any of the acts enumerated in the disciplinary provisions of the applicable licensing law.
(c) Each unlicensed physician employed by the department shall work under the direct supervision of a licensed physician.
(2) No person subject to the provisions of this section shall, by virtue of continued employment in accordance with such provisions, be in violation of the unauthorized practice provisions of chapter 458, chapter 459, or chapter 460 during such period of employment.
History.—s. 3, ch. 79-302; ss. 2, 3, ch. 80-352; s. 1, ch. 80-354; s. 47, ch. 97-103; s. 182, ch. 99-8; s. 57, ch. 2008-6.
1409.401 Interstate Compact on the Placement of Children.—The Interstate Compact on the Placement of Children is hereby enacted into law and entered into with all other jurisdictions legally joining therein in form substantially as follows:
INTERSTATE COMPACT ON THE
PLACEMENT OF CHILDREN
ARTICLE I. Purpose and Policy
It is the purpose and policy of the party states to cooperate with each other in the interstate placement of children to the end that:
(a) Each child requiring placement shall receive the maximum opportunity to be placed in a suitable environment and with persons or institutions having appropriate qualifications and facilities to provide a necessary and desirable degree and type of care.
(b) The appropriate authorities in a state where a child is to be placed may have full opportunity to ascertain the circumstances of the proposed placement, thereby promoting full compliance with applicable requirements for the protection of the child.
(c) The proper authorities of the state from which the placement is made may obtain the most complete information on the basis on which to evaluate a projected placement before it is made.
(d) Appropriate jurisdictional arrangements for the care of children will be promoted.
ARTICLE II. Definitions
As used in this compact:
(a) “Child” means a person who, by reason of minority, is legally subject to parental, guardianship or similar control.
(b) “Sending agency” means a party state, officer or employee thereof; a subdivision of a party state, or officer or employee thereof; a court of a party state; a person, corporation, association, charitable agency or other entity which sends, brings, or causes to be sent or brought any child to another party state.
(c) “Receiving state” means the state to which a child is sent, brought, or caused to be sent or brought, whether by public authorities or private persons or agencies, and whether for placement with state or local public authorities or for placement with private agencies or persons.
(d) “Placement” means the arrangement for the care of a child in a family free or boarding home or in a child-caring agency or institution but does not include any institution caring for the mentally ill, mentally defective or epileptic or any institution primarily educational in character, and any hospital or other medical facility.
ARTICLE III. Conditions for Placement
(a) No sending agency shall send, bring, or cause to be sent or brought into any other party state any child for placement in foster care or as a preliminary to a possible adoption unless the sending agency shall comply with each and every requirement set forth in this article and with the applicable laws of the receiving state governing the placement of children therein.
(b) Prior to sending, bringing, or causing any child to be sent or brought into a receiving state for placement in foster care or as a preliminary to a possible adoption, the sending agency shall furnish the appropriate public authorities in the receiving state written notice of the intention to send, bring, or place the child in the receiving state. The notice shall contain:
(1) The name, date and place of birth of the child.
(2) The identity and address or addresses of the parents or legal guardian.
(3) The name and address of the person, agency or institution to or with which the sending agency proposes to send, bring, or place the child.
(4) A full statement of the reasons for such proposed action and evidence of the authority pursuant to which the placement is proposed to be made.
(c) Any public officer or agency in a receiving state which is in receipt of a notice pursuant to paragraph (b) of this article may request of the sending agency, or any other appropriate officer or agency of or in the sending agency’s state, and shall be entitled to receive therefrom, such supporting or additional information as it may deem necessary under the circumstances to carry out the purpose and policy of this compact.
(d) The child shall not be sent, brought, or caused to be sent or brought into the receiving state until the appropriate public authorities in the receiving state shall notify the sending agency, in writing, to the effect that the proposed placement does not appear to be contrary to the interests of the child.
ARTICLE IV. Penalty for Illegal Placement
The sending, bringing, or causing to be sent or brought into any receiving state of a child in violation of the terms of this compact shall constitute a violation of the laws respecting the placement of children of both the state in which the sending agency is located or from which it sends or brings the child and of the receiving state. Such violation may be punished or subjected to penalty in either jurisdiction in accordance with its laws. In addition to liability for any such punishment or penalty, any such violation shall constitute full and sufficient grounds for the suspension or revocation of any license, permit, or other legal authorization held by the sending agency which empowers or allows it to place, or care for children.
ARTICLE V. Retention of Jurisdiction
(a) The sending agency shall retain jurisdiction over the child sufficient to determine all matters in relation to the custody, supervision, care, treatment and disposition of the child which it would have had if the child had remained in the sending agency’s state, until the child is adopted, reaches majority, becomes self-supporting or is discharged with the concurrence of the appropriate authority in the receiving state. Such jurisdiction shall also include the power to effect or cause the return of the child or its transfer to another location and custody pursuant to law. The sending agency shall continue to have financial responsibility for support and maintenance of the child during the period of the placement. Nothing contained herein shall defeat a claim of jurisdiction by a receiving state sufficient to deal with an act of delinquency or crime committed therein.
(b) When the sending agency is a public agency, it may enter into an agreement with an authorized public or private agency in the receiving state providing for the performance of one or more services in respect of such case by the latter as agent for the sending agency.
(c) Nothing in this compact shall be construed to prevent a private charitable agency authorized to place children in the receiving state from performing services or acting as agent in that state for a private charitable agency of the sending state; nor to prevent the agency in the receiving state from discharging financial responsibility for the support and maintenance of a child who has been placed on behalf of the sending agency without relieving the responsibility set forth in paragraph (a) hereof.
ARTICLE VI. Institutional Care of
Delinquent Children
A child adjudicated delinquent may be placed in an institution in another party jurisdiction pursuant to this compact but no such placement shall be made unless the child is given a court hearing on notice to the parent or guardian with opportunity to be heard, prior to being sent to such other party jurisdiction for institutional care and the court finds that:
1. Equivalent facilities for the child are not available in the sending agency’s jurisdiction; and
2. Institutional care in the other jurisdiction is in the best interest of the child and will not produce undue hardship.
ARTICLE VII. Compact Administrator
The executive head of each jurisdiction party to this compact shall designate an officer who shall be general coordinator of activities under this compact in his or her jurisdiction and who, acting jointly with like officers of other party jurisdictions, shall have power to promulgate rules and regulations to carry out more effectively the terms and provisions of this compact.
ARTICLE VIII. Limitations
This compact shall not apply to:
(a) The sending or bringing of a child into a receiving state by a parent, stepparent, grandparent, adult brother or sister, adult uncle or aunt, or a guardian and leaving the child with any such relative or nonagency guardian in the receiving state.
(b) Any placement, sending or bringing of a child into a receiving state pursuant to any other interstate compact to which both the state from which the child is sent or brought and the receiving state are party, or to any other agreement between said states which has the force of law.
ARTICLE IX. Enactment and Withdrawal
This compact shall be open to joinder by any state, territory or possession of the United States, the District of Columbia, the Commonwealth of Puerto Rico, and, with the consent of Congress, the Government of Canada or any province thereof. It shall become effective with respect to any such jurisdiction when such jurisdiction has enacted the same into law. Withdrawal from this compact shall be by the enactment of a statute repealing the same, but shall not take effect until 2 years after the effective date of such statute and until written notice of the withdrawal has been given by the withdrawing state to the Governor of each other party jurisdiction. Withdrawal of a party state shall not affect the rights, duties and obligations under this compact of any sending agency therein with respect to a placement made prior to the effective date of withdrawal.
ARTICLE X. Construction and Severability
The provisions of this compact shall be liberally construed to effectuate the purposes thereof. The provisions of this compact shall be severable and if any phrase, clause, sentence or provision of this compact is declared to be contrary to the constitution of any party state or of the United States or the applicability thereof to any government, agency, person or circumstance is held invalid, the validity of the remainder of this compact and the applicability thereof to any government, agency, person or circumstance shall not be affected thereby. If this compact shall be held contrary to the constitution of any state party thereto, the compact shall remain in full force and effect as to the remaining states and in full force and effect as to the state affected as to all severable matters.
History.—s. 1, ch. 74-317; s. 48, ch. 97-103; s. 2, ch. 2009-148.
1Note.—Section 409.409, created by s. 2, ch. 2009-148, provides that the existing compact in s. 409.401 will remain in effect until entry into the replacement compact created in s. 409.408. Section 409.408 provides for execution of the new compact by the Governor “[e]ffective July 1, 2009, or upon the enactment of the Interstate Compact for the Placement of Children into law by the 35th compacting state, whichever date occurs later.”
409.402 Financial responsibility for child.—Financial responsibility for any child placed pursuant to the provisions of the Interstate Compact on the Placement of Children shall be determined in accordance with the provisions of Article V thereof in the first instance. However, in the event of partial or complete default of performance thereunder, the provisions of state laws fixing responsibility for the support of children also may be invoked.
History.—s. 2, ch. 74-317.
409.403 Definitions; Interstate Compact on the Placement of Children.—
(1) The “appropriate public authorities” as used in Article III of the Interstate Compact on the Placement of Children shall, with reference to this state, mean the Department of Children and Family Services, and said department shall receive and act with reference to notices required by said Article III.
(2) As used in paragraph (a) of Article V of the Interstate Compact on the Placement of Children, the phrase “appropriate authority in the receiving state” with reference to this state shall mean the Department of Children and Family Services.
(3) As used in Article VII of the Interstate Compact on the Placement of Children, the term “executive head” means the Governor. The Governor is hereby authorized to appoint a compact administrator in accordance with the terms of said Article VII.
History.—ss. 3, 4, 8, ch. 74-317; s. 288, ch. 77-147; s. 121, ch. 97-101.
409.404 Agreements between party state officers and agencies.—
(1) The officers and agencies of this state and its subdivisions having authority to place children are hereby empowered to enter into agreements with appropriate officers or agencies of or in other party states pursuant to paragraph (b) of Article V of the Interstate Compact on the Placement of Children, s. 409.401. Any such agreement which contains a financial commitment or imposes a financial obligation on this state or subdivision or agency thereof shall not be binding unless it has the approval in writing of the secretary of Children and Family Services in the case of the state.
(2) Any requirements for visitation, inspection, or supervision of children, homes, institutions, or other agencies in another party state which may apply under the provisions of chapter 63 and this chapter shall be deemed to be met if performed pursuant to an agreement entered into by appropriate agencies of this state or a subdivision thereof as contemplated by paragraph (b) of Article V of the Interstate Compact on the Placement of Children, s. 409.401.
History.—ss. 5, 6, ch. 74-317; s. 122, ch. 97-101.
409.405 Court placement of delinquent children.—Any court having jurisdiction to place delinquent children may place such a child in an institution in another state pursuant to Article VI of the Interstate Compact on the Placement of Children, s. 409.401, and shall retain jurisdiction as provided in Article V thereof.
History.—s. 7, ch. 74-317.
409.406 Interstate Compact on Adoption and Medical Assistance.—The Interstate Compact on Adoption and Medical Assistance is enacted into law and entered into with all other jurisdictions legally joining therein in form substantially as follows:
INTERSTATE COMPACT ON
ADOPTION AND MEDICAL ASSISTANCE
ARTICLE I. Findings
The Legislature finds that:
(a) Special measures are required to find adoptive families for children for whom state assistance is desirable pursuant to s. 409.166 and to assure the protection of the interest of the children affected during the entire assistance period when the adoptive parents move to another state or are residents of another state.
(b) The providers of medical and other necessary services for children who benefit from state assistance encounter special difficulties when the provision of services takes place in other states.
ARTICLE II. Purposes
The purposes of the act are to:
(a) Authorize the Department of Children and Family Services to enter into interstate agreements with agencies of other states to protect children for whom it provides adoption assistance.
(b) Provide procedures for interstate children’s adoption-assistance payments, including medical payments.
ARTICLE III. Definitions
As used in this compact, the term:
(a) “Agency” means the Agency for Health Care Administration.
(b) “Department” means the Florida Department of Children and Family Services.
(c) “State” means a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, the Commonwealth of the Northern Mariana Islands, or a territory or possession of or administered by the United States.
(d) “Adoption-assistance state” means the state that is signatory to an adoption-assistance agreement in a particular case.
(e) “Residence state” means the state where the child resides.
(f) “Medical assistance” means the medical-assistance program authorized by Title XIX of the Social Security Act.
ARTICLE IV. Compacts Authorized
The Department of Children and Family Services, by and through its secretary, may participate in the development of and negotiate and enter into interstate compacts on behalf of this state with other states to implement the purposes of this act. Such a compact has the force and effect of law.
ARTICLE V. Contents of Compacts
A compact entered into under this act must have the following content:
(a) A provision making it available for joinder by all states;
(b) A provision for withdrawal from the compact upon written notice to the parties, but with a period of 1 year between the date of the notice and the effective date of the withdrawal;
(c) A requirement that the protections afforded under the compact continue in force for the duration of the adoption assistance and are applicable to all children and their adoptive parents who, on the effective date of the withdrawal, are receiving adoption assistance from a party state other than the one in which they are residents and have their principal place of abode;
(d) A requirement that each instance of adoption assistance to which the compact applies be covered by an adoption-assistance agreement in writing between the adoptive parents and the state child welfare agency of the state which undertakes to provide the adoption assistance and, further, that any such agreement be expressly for the benefit of the adopted child and enforceable by the adoptive parents and the state agency providing the adoption assistance; and
(e) Such other provisions as are appropriate to the proper administration of the compact.
ARTICLE VI. Optional Contents
of Compacts
A compact entered into under this section may contain provisions in addition to those required by Article V, as follows:
(a) Provisions establishing procedures and entitlement to medical and other necessary social services for the child in accordance with applicable laws, even though the child and the adoptive parents are in a state other than the one responsible for or providing the services, or the funds to defray part or all of the costs thereof; and
(b) Such other provisions as are appropriate or incidental to the proper administration of the compact.
ARTICLE VII. Medical Assistance
(a) A child with special needs who is a resident of this state and who is the subject of an adoption-assistance agreement with another state is entitled to receive a medical-assistance identification from this state upon the filing with the agency of a certified copy of the adoption-assistance agreement obtained from the adoption-assistance state. Pursuant to rules of the agency, the adoptive parents shall at least annually show that the agreement is still in force or has been renewed.
(b) The terms of the compact entered into by the department apply to children who are the subject of federal adoption-assistance agreements. The state will provide the benefits under this section to children who are the subject of a state adoption-assistance agreement, upon the determination by the department and the agency that the adoption-assistance state is a party to the compact and has reciprocity in provision of medical assistance to state adoption-assistance children.
(c) The agency shall consider the holder of a medical-assistance identification pursuant to this section as any other holder of a medical-assistance identification under the laws of this state and shall process and make payment on claims on behalf of such holder in the same manner and under the same conditions and procedures established for other recipients of medical assistance.
(d) The provisions of this article apply only to medical assistance for children under adoption-assistance agreements from a state that has entered into a compact with this state under which the other state provided medical assistance to children with special needs under adoption-assistance agreements made by this state. All other children entitled to medical assistance pursuant to an adoption-assistance agreement entered into by this state are eligible to receive such assistance under the laws and procedures applicable thereto.
(e) The department shall adopt rules necessary for administering this section.
ARTICLE VIII. Federal Participation
Consistent with federal law, the department and the agency, in administering this act and any compact pursuant to this act, must include in any state plan made pursuant to the Adoption Assistance and Child Welfare Act of 1980 (Pub. L. No. 96-272), Titles IV(E) and XIX of the Social Security Act, and any other applicable federal laws, the provision of adoption assistance and medical assistance for which the Federal Government pays some or all of the cost. The department and the agency shall apply for and administer all relevant federal aid in accordance with law.
History.—s. 1, ch. 2002-16.
409.407 Interstate agreements between the Department of Children and Family Services and agencies of other states.—The Department of Children and Family Services, which is authorized to enter into interstate agreements with agencies of other states for the implementation of the purposes of the Interstate Compact on Adoption and Medical Assistance pursuant to s. 409.406, may not expand the financial commitment of the state beyond the financial obligation of the adoption-assistance agreements and Medicaid.
History.—s. 2, ch. 2002-16.
409.408 Interstate Compact for the Placement of Children.—Effective July 1, 2009, or upon the enactment of the Interstate Compact for the Placement of Children into law by the 35th compacting state, whichever date occurs later, the Governor is authorized and directed to execute a compact on behalf of this state with any other state or states legally joining therein in the form substantially as follows:
INTERSTATE COMPACT
FOR THE PLACEMENT OF CHILDREN
ARTICLE I. PURPOSE
The purpose of this Interstate Compact for the Placement of Children is to:
A. Provide a process through which children subject to this compact are placed in safe and suitable homes in a timely manner.
B. Facilitate ongoing supervision of a placement, the delivery of services, and communication between the states.
C. Provide operating procedures that will ensure that children are placed in safe and suitable homes in a timely manner.
D. Provide for the promulgation and enforcement of administrative rules implementing the provisions of this compact and regulating the covered activities of the member states.
E. Provide for uniform data collection and information sharing between member states under this compact.
F. Promote coordination between this compact, the Interstate Compact for Juveniles, the Interstate Compact on Adoption and Medical Assistance, and other compacts affecting the placement of and which provide services to children otherwise subject to this compact.
G. Provide for a state’s continuing legal jurisdiction and responsibility for placement and care of a child that it would have had if the placement were intrastate.
H. Provide for the promulgation of guidelines, in collaboration with Indian tribes, for interstate cases involving Indian children as is or may be permitted by federal law.
ARTICLE II. DEFINITIONS
As used in this compact:
A. “Approved placement” means the public child-placing agency in the receiving state has determined that the placement is both safe and suitable for the child.
B. “Assessment” means an evaluation of a prospective placement by a public child-placing agency in the receiving state to determine if the placement meets the individualized needs of the child, including, but not limited to, the child’s safety and stability, health and well-being, and mental, emotional, and physical development. An assessment is only applicable to a placement by a public child-placing agency.
C. “Child” means an individual who has not attained the age of 18.
D. “Certification” means to attest, declare, or swear to before a judge or notary public.
E. “Default” means the failure of a member state to perform the obligations or responsibilities imposed upon it by this compact or the bylaws or rules of the Interstate Commission.
F. “Home study” means an evaluation of a home environment conducted in accordance with the applicable requirements of the state in which the home is located and that documents the preparation and the suitability of the placement resource for placement of a child in accordance with the laws and requirements of the state in which the home is located.
G. “Indian tribe” means any Indian tribe, band, nation, or other organized group or community of Indians recognized as eligible for services provided to Indians by the Secretary of the Interior because of their status as Indians, including any Alaskan native village as defined in section 3(c) of the Alaska Native Claims Settlement Act, 43 U.S.C. s. 1602(c).
H. “Interstate Commission for the Placement of Children” means the commission that is created under Article VIII of this compact and which is generally referred to as the “Interstate Commission.”
I. “Jurisdiction” means the power and authority of a court to hear and decide matters.
J. “Legal risk placement” or “legal risk adoption” means a placement made preliminary to an adoption where the prospective adoptive parents acknowledge in writing that a child can be ordered returned to the sending state or the birth mother’s state of residence, if different from the sending state, and a final decree of adoption shall not be entered in any jurisdiction until all required consents are obtained or are dispensed with in accordance with applicable law.
K. “Member state” means a state that has enacted this compact.
L. “Noncustodial parent” means a person who, at the time of the commencement of court proceedings in the sending state, does not have sole legal custody of the child or has joint legal custody of a child, and who is not the subject of allegations or findings of child abuse or neglect.
M. “Nonmember state” means a state which has not enacted this compact.
N. “Notice of residential placement” means information regarding a placement into a residential facility provided to the receiving state, including, but not limited to, the name, date, and place of birth of the child, the identity and address of the parent or legal guardian, evidence of authority to make the placement, and the name and address of the facility in which the child will be placed. Notice of residential placement shall also include information regarding a discharge and any unauthorized absence from the facility.
O. “Placement” means the act by a public or private child-placing agency intended to arrange for the care or custody of a child in another state.
P. “Private child-placing agency” means any private corporation, agency, foundation, institution, or charitable organization, or any private person or attorney, that facilitates, causes, or is involved in the placement of a child from one state to another and that is not an instrumentality of the state or acting under color of state law.
Q. “Provisional placement” means a determination made by the public child-placing agency in the receiving state that the proposed placement is safe and suitable, and, to the extent allowable, the receiving state has temporarily waived its standards or requirements otherwise applicable to prospective foster or adoptive parents so as to not delay the placement. Completion of the receiving state requirements regarding training for prospective foster or adoptive parents shall not delay an otherwise safe and suitable placement.
R. “Public child-placing agency” means any government child welfare agency or child protection agency or a private entity under contract with such an agency, regardless of whether the entity acts on behalf of a state, a county, a municipality, or another governmental unit, and which facilitates, causes, or is involved in the placement of a child from one state to another.
S. “Receiving state” means the state to which a child is sent, brought, or caused to be sent or brought.
T. “Relative” means someone who is related to the child as a parent, stepparent, sibling by half or whole blood or by adoption, grandparent, aunt, uncle, or first cousin or a nonrelative with such significant ties to the child that the nonrelative may be regarded as a relative as determined by the court in the sending state.
U. “Residential facility” means a facility providing a level of care that is sufficient to substitute for parental responsibility or foster care and that is beyond what is needed for assessment or treatment of an acute condition. For purposes of the compact, the term “residential facility” does not include institutions primarily educational in character, hospitals, or other medical facilities.
V. “Rule” means a written directive, mandate, standard, or principle issued by the Interstate Commission promulgated pursuant to Article XI of this compact that is of general applicability and that implements, interprets, or prescribes a policy or provision of the compact. A rule has the force and effect of an administrative rule in a member state and includes the amendment, repeal, or suspension of an existing rule.
W. “Sending state” means the state from which the placement of a child is initiated.
X. “Service member’s permanent duty station” means the military installation where an active duty United States Armed Services member is currently assigned and is physically located under competent orders that do not specify the duty as temporary.
Y. “Service member’s state of legal residence” means the state in which the active duty United States Armed Services member is considered a resident for tax and voting purposes.
Z. “State” means a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, and any other territory of the United States.
AA. “State court” means a judicial body of a state that is vested by law with responsibility for adjudicating cases involving abuse, neglect, deprivation, delinquency, or status offenses of individuals who have not attained the age of 18.
BB. “Supervision” means monitoring provided by the receiving state once a child has been placed in a receiving state pursuant to this compact.
ARTICLE III. APPLICABILITY
A. Except as otherwise provided in Article III, Section B, this compact shall apply to:
1. The interstate placement of a child subject to ongoing court jurisdiction in the sending state, due to allegations or findings that the child has been abused, neglected, or deprived as defined by the laws of the sending state; provided, however, that the placement of such a child into a residential facility shall only require notice of residential placement to the receiving state prior to placement.
2. The interstate placement of a child adjudicated delinquent or unmanageable based on the laws of the sending state and subject to ongoing court jurisdiction of the sending state if:
a. The child is being placed in a residential facility in another member state and is not covered under another compact; or
b. The child is being placed in another member state and the determination of safety and suitability of the placement and services required is not provided through another compact.
3. The interstate placement of any child by a public child-placing agency or private child-placing agency as a preliminary step to a possible adoption.
B. The provisions of this compact shall not apply to:
1. The interstate placement of a child in a custody proceeding in which a public child-placing agency is not a party; provided, however, that the placement is not intended to effectuate an adoption.
2. The interstate placement of a child with a nonrelative in a receiving state by a parent with the legal authority to make such a placement; provided, however, that the placement is not intended to effectuate an adoption.
3. The interstate placement of a child by one relative with the lawful authority to make such a placement directly with a relative in a receiving state.
4. The placement of a child, not subject to Article III, Section A, into a residential facility by his or her parent.
5. The placement of a child with a noncustodial parent, provided that:
a. The noncustodial parent proves to the satisfaction of a court in the sending state a substantial relationship with the child;
b. The court in the sending state makes a written finding that placement with the noncustodial parent is in the best interests of the child; and
c. The court in the sending state dismisses its jurisdiction in interstate placements in which the public child-placing agency is a party to the proceeding.
6. A child entering the United States from a foreign country for the purpose of adoption or leaving the United States to go to a foreign country for the purpose of adoption in that country.
7. Cases in which a child who is a United States citizen living overseas with his or her family, at least one of whom is in the United States Armed Services and stationed overseas, is removed and placed in a state.
8. The sending of a child by a public child-placing agency or a private child-placing agency for a visit as defined by the rules of the Interstate Commission.
C. For purposes of determining the applicability of this compact to the placement of a child with a family member in the United States Armed Services, the public child-placing agency or private child-placing agency may choose the state of the service member’s permanent duty station or the service member’s declared legal residence.
D. Nothing in this compact shall be construed to prohibit the concurrent application of the provisions of this compact with other applicable interstate compacts, including the Interstate Compact for Juveniles and the Interstate Compact on Adoption and Medical Assistance. The Interstate Commission may, in cooperation with other interstate compact commissions having responsibility for the interstate movement, placement, or transfer of children, promulgate similar rules to ensure the coordination of services, timely placement of children, and reduction of unnecessary or duplicative administrative or procedural requirements.
ARTICLE IV. JURISDICTION
A. Except as provided in Article IV, Section H, and Article V, Section B, paragraphs 2. and 3., concerning private and independent adoptions, and in interstate placements in which the public child-placing agency is not a party to a custody proceeding, the sending state shall retain jurisdiction over a child with respect to all matters of custody and disposition of the child which it would have had if the child had remained in the sending state. Such jurisdiction shall also include the power to order the return of the child to the sending state.
B. When an issue of child protection or custody is brought before a court in the receiving state, such court shall confer with the court of the sending state to determine the most appropriate forum for adjudication.
C. In cases that are before courts and subject to this compact, the taking of testimony for hearings before any judicial officer may occur in person or by telephone, audio-video conference, or such other means as approved by the rules of the Interstate Commission, and judicial officers may communicate with other judicial officers and persons involved in the interstate process as may be permitted by their Code of Judicial Conduct and any rules promulgated by the Interstate Commission.
D. In accordance with its own laws, the court in the sending state shall have authority to terminate its jurisdiction if:
1. The child is reunified with the parent in the receiving state who is the subject of allegations or findings of abuse or neglect, only with the concurrence of the public child-placing agency in the receiving state;
2. The child is adopted;
3. The child reaches the age of majority under the laws of the sending state;
4. The child achieves legal independence pursuant to the laws of the sending state;
5. A guardianship is created by a court in the receiving state with the concurrence of the court in the sending state;
6. An Indian tribe has petitioned for and received jurisdiction from the court in the sending state; or
7. The public child-placing agency of the sending state requests termination and has obtained the concurrence of the public child-placing agency in the receiving state.
E. When a sending state court terminates its jurisdiction, the receiving state child-placing agency shall be notified.
F. Nothing in this article shall defeat a claim of jurisdiction by a receiving state court sufficient to deal with an act of truancy, delinquency, crime, or behavior involving a child as defined by the laws of the receiving state committed by the child in the receiving state which would be a violation of its laws.
G. Nothing in this article shall limit the receiving state’s ability to take emergency jurisdiction for the protection of the child.
H. The substantive laws of the state in which an adoption will be finalized shall solely govern all issues relating to the adoption of the child, and the court in which the adoption proceeding is filed shall have subject matter jurisdiction regarding all substantive issues relating to the adoption, except:
1. When the child is a ward of another court that established jurisdiction over the child prior to the placement;
2. When the child is in the legal custody of a public agency in the sending state; or
3. When a court in the sending state has otherwise appropriately assumed jurisdiction over the child prior to the submission of the request for approval of placement.
I. A final decree of adoption shall not be entered in any jurisdiction until the placement is authorized as an “approved placement” by the public child-placing agency in the receiving state.
ARTICLE V. PLACEMENT EVALUATION
A. Prior to sending, bringing, or causing a child to be sent or brought into a receiving state, the public child-placing agency shall provide a written request for assessment to the receiving state.
B. For placements by a private child-placing agency, a child may be sent or brought, or caused to be sent or brought, into a receiving state upon receipt and immediate review of the required content in a request for approval of a placement in both the sending and receiving state public child-placing agencies. The required content to accompany a request for approval shall include all of the following:
1. A request for approval identifying the child, the birth parents, the prospective adoptive parents, and the supervising agency, signed by the person requesting approval.
2. The appropriate consents or relinquishments signed by the birth parents in accordance with the laws of the sending state or, where permitted, the laws of the state where the adoption will be finalized.
3. Certification by a licensed attorney or authorized agent of a private adoption agency that the consent or relinquishment is in compliance with the applicable laws of the sending state or, where permitted, the laws of the state where finalization of the adoption will occur.
4. A home study.
5. An acknowledgment of legal risk signed by the prospective adoptive parents.
C. The sending state and the receiving state may request additional information or documents prior to finalization of an approved placement, but they may not delay travel by the prospective adoptive parents with the child if the required content for approval has been submitted, received, and reviewed by the public child-placing agency in both the sending state and the receiving state.
D. Approval from the public child-placing agency in the receiving state for a provisional or approved placement is required as provided for in the rules of the Interstate Commission.
E. The procedures for making the request for an assessment shall contain all information and be in such form as provided for in the rules of the Interstate Commission.
F. Upon receipt of a request from the public child-placing agency of the sending state, the receiving state shall initiate an assessment of the proposed placement to determine its safety and suitability. If the proposed placement is a placement with a relative, the public child-placing agency of the sending state may request a determination for a provisional placement.
G. The public child-placing agency in the receiving state may request from the public child-placing agency or the private child-placing agency in the sending state, and shall be entitled to receive, supporting or additional information necessary to complete the assessment or approve the placement.
H. The public child-placing agency in the receiving state shall approve a provisional placement and complete or arrange for the completion of the assessment within the timeframes established by the rules of the Interstate Commission.
I. For a placement by a private child-placing agency, the sending state shall not impose any additional requirements to complete the home study that are not required by the receiving state, unless the adoption is finalized in the sending state.
J. The Interstate Commission may develop uniform standards for the assessment of the safety and suitability of interstate placements.
ARTICLE VI. PLACEMENT AUTHORITY
A. Except as otherwise provided in this compact, no child subject to this compact shall be placed in a receiving state until approval for such placement is obtained.
B. If the public child-placing agency in the receiving state does not approve the proposed placement, then the child shall not be placed. The receiving state shall provide written documentation of any such determination in accordance with the rules promulgated by the Interstate Commission. Such determination is not subject to judicial review in the sending state.
C. If the proposed placement is not approved, any interested party shall have standing to seek an administrative review of the receiving state’s determination.
1. The administrative review and any further judicial review associated with the determination shall be conducted in the receiving state pursuant to its applicable Administrative Procedures Act.
2. If a determination not to approve the placement of the child in the receiving state is overturned upon review, the placement shall be deemed approved; provided, however, that all administrative or judicial remedies have been exhausted or the time for such remedies has passed.
ARTICLE VII. PLACING AGENCY RESPONSIBILITY
A. For the interstate placement of a child made by a public child-placing agency or state court:
1. The public child-placing agency in the sending state shall have financial responsibility for:
a. The ongoing support and maintenance for the child during the period of the placement, unless otherwise provided for in the receiving state; and
b. As determined by the public child-placing agency in the sending state, services for the child beyond the public services for which the child is eligible in the receiving state.
2. The receiving state shall only have financial responsibility for:
a. Any assessment conducted by the receiving state; and
b. Supervision conducted by the receiving state at the level necessary to support the placement as agreed upon by the public child-placing agencies of the receiving and sending states.
3. Nothing in this section shall prohibit public child-placing agencies in the sending state from entering into agreements with licensed agencies or persons in the receiving state to conduct assessments and provide supervision.
B. For the placement of a child by a private child-placing agency preliminary to a possible adoption, the private child-placing agency shall be:
1. Legally responsible for the child during the period of placement as provided for in the law of the sending state until the finalization of the adoption.
2. Financially responsible for the child absent a contractual agreement to the contrary.
C. The public child-placing agency in the receiving state shall provide timely assessments, as provided for in the rules of the Interstate Commission.
D. The public child-placing agency in the receiving state shall provide, or arrange for the provision of, supervision and services for the child, including timely reports, during the period of the placement.
E. Nothing in this compact shall be construed to limit the authority of the public child-placing agency in the receiving state from contracting with a licensed agency or person in the receiving state for an assessment or the provision of supervision or services for the child or otherwise authorizing the provision of supervision or services by a licensed agency during the period of placement.
F. Each member state shall provide for coordination among its branches of government concerning the state’s participation in and compliance with the compact and Interstate Commission activities through the creation of an advisory council or use of an existing body or board.
G. Each member state shall establish a central state compact office which shall be responsible for state compliance with the compact and the rules of the Interstate Commission.
H. The public child-placing agency in the sending state shall oversee compliance with the provisions of the Indian Child Welfare Act, 25 U.S.C. ss. 1901 et seq., for placements subject to the provisions of this compact, prior to placement.
I. With the consent of the Interstate Commission, states may enter into limited agreements that facilitate the timely assessment and provision of services and supervision of placements under this compact.
ARTICLE VIII. INTERSTATE COMMISSION FOR
THE PLACEMENT OF CHILDREN
The member states hereby establish, by way of this compact, a commission known as the “Interstate Commission for the Placement of Children.” The activities of the Interstate Commission are the formation of public policy and are a discretionary state function. The Interstate Commission shall:
A. Be a joint commission of the member states and shall have the responsibilities, powers, and duties set forth herein and such additional powers as may be conferred upon it by subsequent concurrent action of the respective legislatures of the member states.
B. Consist of one commissioner from each member state who shall be appointed by the executive head of the state human services administration with ultimate responsibility for the child welfare program. The appointed commissioner shall have the legal authority to vote on policy-related matters governed by this compact binding the state.
1. Each member state represented at a meeting of the Interstate Commission is entitled to one vote.
2. A majority of the member states shall constitute a quorum for the transaction of business, unless a larger quorum is required by the bylaws of the Interstate Commission.
3. A representative shall not delegate a vote to another member state.
4. A representative may delegate voting authority to another person from that state for a specified meeting.
C. Include, in addition to the commissioners of each member state, persons who are members of interested organizations as defined in the bylaws or rules of the Interstate Commission. Such members shall be ex officio and shall not be entitled to vote on any matter before the Interstate Commission.
D. Establish an executive committee which shall have the authority to administer the day-to-day operations and administration of the Interstate Commission. The executive committee shall not have the power to engage in rulemaking.
ARTICLE IX. POWERS AND DUTIES OF
THE INTERSTATE COMMISSION
The Interstate Commission shall have the following powers:
A. To promulgate rules and take all necessary actions to effect the goals, purposes, and obligations as enumerated in this compact.
B. To provide for dispute resolution among member states.
C. To issue, upon request of a member state, advisory opinions concerning the meaning or interpretation of the interstate compact, its bylaws, rules, or actions.
D. To enforce compliance with this compact or the bylaws or rules of the Interstate Commission pursuant to Article XII.
E. Collect standardized data concerning the interstate placement of children subject to this compact as directed through its rules, which shall specify the data to be collected, the means of collection and data exchange, and reporting requirements.
F. To establish and maintain offices as may be necessary for the transacting of its business.
G. To purchase and maintain insurance and bonds.
H. To hire or contract for services of personnel or consultants as necessary to carry out its functions under the compact and establish personnel qualification policies and rates of compensation.
I. To establish and appoint committees and officers, including, but not limited to, an executive committee as required by Article X.
J. To accept any and all donations and grants of money, equipment, supplies, materials, and services, and to receive, utilize, and dispose thereof.
K. To lease, purchase, accept contributions or donations of, or otherwise to own, hold, improve, or use any property, real, personal, or mixed.
L. To sell, convey, mortgage, pledge, lease, exchange, abandon, or otherwise dispose of any property, real, personal, or mixed.
M. To establish a budget and make expenditures.
N. To adopt a seal and bylaws governing the management and operation of the Interstate Commission.
O. To report annually to the legislatures, the governors, the judiciary, and the state advisory councils of the member states concerning the activities of the Interstate Commission during the preceding year. Such reports shall also include any recommendations that may have been adopted by the Interstate Commission.
P. To coordinate and provide education, training, and public awareness regarding the interstate movement of children for officials involved in such activity.
Q. To maintain books and records in accordance with the bylaws of the Interstate Commission.
R. To perform such functions as may be necessary or appropriate to achieve the purposes of this compact.
ARTICLE X. ORGANIZATION AND OPERATION
OF THE INTERSTATE COMMISSION
A. Organization.
1. Within 12 months after the first Interstate Commission meeting, the Interstate Commission shall adopt rules to govern its conduct as may be necessary or appropriate to carry out the purposes of the compact.
2. The Interstate Commission’s rules shall establish conditions and procedures under which the Interstate Commission shall make its information and official records available to the public for inspection or copying.
B. Meetings.
1. The Interstate Commission shall meet at least once each calendar year. The chairperson may call additional meetings and, upon the request of a simple majority of the member states, shall call additional meetings.
2. Public notice shall be given by the Interstate Commission of all meetings, and all meetings shall be open to the public.
3. The bylaws may provide for meetings of the Interstate Commission to be conducted by telecommunication or other electronic communication.
C. Officers and staff.
1. The Interstate Commission may, through its executive committee, appoint or retain a staff director for such period, upon such terms and conditions, and for such compensation as the Interstate Commission may deem appropriate. The staff director shall serve as secretary to the Interstate Commission but shall not have a vote. The staff director may hire and supervise such other staff as may be authorized by the Interstate Commission.
2. The Interstate Commission shall elect, from among its members, a chairperson and a vice chairperson of the executive committee, and other necessary officers, each of whom shall have such authority and duties as may be specified in the bylaws.
D. Qualified immunity, defense, and indemnification.
1. The Interstate Commission’s staff director and its employees shall be immune from suit and liability, either personally or in their official capacity, for a claim for damage to or loss of property or personal injury or other civil liability caused or arising out of or relating to an actual or alleged act, error, or omission that occurred or that such person had a reasonable basis for believing occurred within the scope of Interstate Commission employment, duties, or responsibilities; provided, however, that such person shall not be protected from suit or liability for damage, loss, injury, or liability caused by a criminal act or the intentional or willful and wanton misconduct of such person.
a. The liability of the Interstate Commission’s staff director and employees or Interstate Commission representatives, acting within the scope of such person’s employment or duties, for acts, errors, or omissions occurring within such person’s state may not exceed the limits of liability set forth under the Constitution and laws of that state for state officials, employees, and agents. The Interstate Commission is considered to be an instrumentality of the states for the purposes of any such action. Nothing in this subsection shall be construed to protect such person from suit or liability for damage, loss, injury, or liability caused by a criminal act or the intentional or willful and wanton misconduct of such person.
b. The Interstate Commission shall defend the staff director and its employees and, subject to the approval of the Attorney General or other appropriate legal counsel of the member state, shall defend the commissioner of a member state in a civil action seeking to impose liability arising out of an actual or alleged act, error, or omission that occurred within the scope of Interstate Commission employment, duties, or responsibilities, or that the defendant had a reasonable basis for believing occurred within the scope of Interstate Commission employment, duties, or responsibilities; provided, however, that the actual or alleged act, error, or omission did not result from intentional or willful and wanton misconduct on the part of such person.
c. To the extent not covered by the state involved, a member state, or the Interstate Commission, the representatives or employees of the Interstate Commission shall be held harmless in the amount of a settlement or judgment, including attorney’s fees and costs, obtained against such persons arising out of an actual or alleged act, error, or omission that occurred within the scope of Interstate Commission employment, duties, or responsibilities, or that such persons had a reasonable basis for believing occurred within the scope of Interstate Commission employment, duties, or responsibilities; provided, however, that the actual or alleged act, error, or omission did not result from intentional or willful and wanton misconduct on the part of such persons.
ARTICLE XI. RULEMAKING FUNCTIONS
OF THE INTERSTATE COMMISSION
A. The Interstate Commission shall promulgate and publish rules in order to effectively and efficiently achieve the purposes of the compact.
B. Rulemaking shall occur pursuant to the criteria set forth in this article and the bylaws and rules adopted pursuant thereto. Such rulemaking shall substantially conform to the principles of the “Model State Administrative Procedures Act,” 1981 Act, Uniform Laws Annotated, Vol. 15, p. 1 (2000), or such other administrative procedure acts as the Interstate Commission deems appropriate, consistent with due process requirements under the United States Constitution as now or hereafter interpreted by the United States Supreme Court. All rules and amendments shall become binding as of the date specified, as published with the final version of the rule as approved by the Interstate Commission.
C. When promulgating a rule, the Interstate Commission shall, at a minimum:
1. Publish the proposed rule’s entire text stating the reasons for that proposed rule;
2. Allow and invite any and all persons to submit written data, facts, opinions, and arguments, which information shall be added to the record and made publicly available; and
3. Promulgate a final rule and its effective date, if appropriate, based on input from state or local officials or interested parties.
D. Rules promulgated by the Interstate Commission shall have the force and effect of administrative rules and shall be binding in the compacting states to the extent and in the manner provided for in this compact.
E. Not later than 60 days after a rule is promulgated, an interested person may file a petition in the United States District Court for the District of Columbia or in the Federal District Court where the Interstate Commission’s principal office is located for judicial review of such rule. If the court finds that the Interstate Commission’s action is not supported by substantial evidence in the rulemaking record, the court shall hold the rule unlawful and set it aside.
F. If a majority of the legislatures of the member states rejects a rule, those states may by enactment of a statute or resolution in the same manner used to adopt the compact cause that such rule shall have no further force and effect in any member state.
G. The existing rules governing the operation of the Interstate Compact on the Placement of Children superseded by this act shall be null and void no less than 12 months but no more than 24 months after the first meeting of the Interstate Commission created hereunder, as determined by the members during the first meeting.
H. Within the first 12 months of operation, the Interstate Commission shall promulgate rules addressing the following:
1. Transition rules.
2. Forms and procedures.
3. Timelines.
4. Data collection and reporting.
5. Rulemaking.
6. Visitation.
7. Progress reports and supervision.
8. Sharing of information and confidentiality.
9. Financing of the Interstate Commission.
10. Mediation, arbitration, and dispute resolution.
11. Education, training, and technical assistance.
12. Enforcement.
13. Coordination with other interstate compacts.
I. Upon determination by a majority of the members of the Interstate Commission that an emergency exists:
1. The Interstate Commission may promulgate an emergency rule only if it is required to:
a. Protect the children covered by this compact from an imminent threat to their health, safety, and well-being;
b. Prevent loss of federal or state funds; or
c. Meet a deadline for the promulgation of an administrative rule required by federal law.
2. An emergency rule shall become effective immediately upon adoption, provided that the usual rulemaking procedures provided hereunder shall be retroactively applied to the emergency rule as soon as reasonably possible, but no later than 90 days after the effective date of the emergency rule.
3. An emergency rule shall be promulgated as provided for in the rules of the Interstate Commission.
ARTICLE XII. OVERSIGHT, DISPUTE
RESOLUTION, AND ENFORCEMENT
A. Oversight.
1. The Interstate Commission shall oversee the administration and operation of the compact.
2. The executive, legislative, and judicial branches of state government in each member state shall enforce this compact and the rules of the Interstate Commission and shall take all actions necessary and appropriate to effectuate the compact’s purposes and intent. The compact and its rules shall be binding in the compacting states to the extent and in the manner provided for in this compact.
3. All courts shall take judicial notice of the compact and the rules in any judicial or administrative proceeding in a member state pertaining to the subject matter of this compact.
4. The Interstate Commission shall be entitled to receive service of process in any action in which the validity of a compact provision or rule is the issue for which a judicial determination has been sought and shall have standing to intervene in any proceedings. Failure to provide service of process to the Interstate Commission shall render any judgment, order, or other determination, however so captioned or classified, void as to this compact, its bylaws, or rules of the Interstate Commission.
B. Dispute resolution.
1. The Interstate Commission shall attempt, upon the request of a member state, to resolve disputes which are subject to the compact and which may arise among member states and between member and nonmember states.
2. The Interstate Commission shall promulgate a rule providing for both mediation and binding dispute resolution for disputes among compacting states. The costs of such mediation or dispute resolution shall be the responsibility of the parties to the dispute.
C. Enforcement.
1. If the Interstate Commission determines that a member state has defaulted in the performance of its obligations or responsibilities under this compact, its bylaws, or rules of the Interstate Commission, the Interstate Commission may:
a. Provide remedial training and specific technical assistance;
b. Provide written notice to the defaulting state and other member states of the nature of the default and the means of curing the default. The Interstate Commission shall specify the conditions by which the defaulting state must cure its default;
c. By majority vote of the members, initiate against a defaulting member state legal action in the United States District Court for the District of Columbia or, at the discretion of the Interstate Commission, in the federal district where the Interstate Commission has its principal office, to enforce compliance with the provisions of the compact, its bylaws, or rules of the Interstate Commission. The relief sought may include both injunctive relief and damages. In the event judicial enforcement is necessary, the prevailing party shall be awarded all costs of such litigation, including reasonable attorney’s fees; or
d. Avail itself of any other remedies available under state law or the regulation of official or professional conduct.
ARTICLE XIII. FINANCING OF THE COMMISSION
A. The Interstate Commission shall pay, or provide for the payment of, the reasonable expenses of its establishment, organization, and ongoing activities.
B. The Interstate Commission may levy on and collect an annual assessment from each member state to cover the cost of the operations and activities of the Interstate Commission and its staff, which must be in a total amount sufficient to cover the Interstate Commission’s annual budget as approved by its members each year. The aggregate annual assessment amount shall be allocated based upon a formula to be determined by the Interstate Commission, which shall promulgate a rule binding upon all member states.
C. The Interstate Commission shall not incur obligations of any kind prior to securing the funds adequate to meet those obligations, nor shall the Interstate Commission pledge the credit of any of the member states, except by and with the authority of the member state.
D. The Interstate Commission shall keep accurate accounts of all receipts and disbursements. The receipts and disbursements of the Interstate Commission shall be subject to the audit and accounting procedures established under its bylaws. However, all receipts and disbursements of funds handled by the Interstate Commission shall be audited yearly by a certified or licensed public accountant, and the report of the audit shall be included in and become part of the annual report of the Interstate Commission.
ARTICLE XIV. MEMBER STATES, EFFECTIVE
DATE, AND AMENDMENT
A. Any state is eligible to become a member state.
B. The compact shall become effective and binding upon legislative enactment of the compact into law by no less than 35 states. The effective date shall be the later of July 1, 2007, or upon enactment of the compact into law by the 35th state. Thereafter, it shall become effective and binding as to any other member state upon enactment of the compact into law by that state. The executive heads of the state human services administration with ultimate responsibility for the child welfare program of nonmember states or their designees shall be invited to participate in the activities of the Interstate Commission on a nonvoting basis prior to adoption of the compact by all states.
C. The Interstate Commission may propose amendments to the compact for enactment by the member states. No amendment shall become effective and binding on the member states unless and until it is enacted into law by unanimous consent of the member states.
ARTICLE XV. WITHDRAWAL AND DISSOLUTION
A. Withdrawal.
1. Once effective, the compact shall continue in force and remain binding upon each and every member state, provided that a member state may withdraw from the compact by specifically repealing the statute which enacted the compact into law.
2. Withdrawal from this compact shall be by the enactment of a statute repealing the compact. The effective date of withdrawal shall be the effective date of the repeal of the statute.
3. The withdrawing state shall immediately notify the president of the Interstate Commission in writing upon the introduction of legislation repealing this compact in the withdrawing state. The Interstate Commission shall then notify the other member states of the withdrawing state’s intent to withdraw.
4. The withdrawing state is responsible for all assessments, obligations, and liabilities incurred through the effective date of withdrawal.
5. Reinstatement following withdrawal of a member state shall occur upon the withdrawing state reenacting the compact or upon such later date as determined by the members of the Interstate Commission.
B. Dissolution of compact.
1. This compact shall dissolve effective upon the date of the withdrawal or default of the member state which reduces the membership in the compact to one member state.
2. Upon the dissolution of this compact, the compact becomes null and void and shall be of no further force or effect, and the business and affairs of the Interstate Commission shall be concluded and surplus funds shall be distributed in accordance with the bylaws.
ARTICLE XVI. SEVERABILITY
AND CONSTRUCTION
A. The provisions of this compact shall be severable, and, if any phrase, clause, sentence, or provision is deemed unenforceable, the remaining provisions of the compact shall be enforceable.
B. The provisions of this compact shall be liberally construed to effectuate its purposes.
C. Nothing in this compact shall be construed to prohibit the concurrent applicability of other interstate compacts to which the states are members.
ARTICLE XVII. BINDING EFFECT OF COMPACT
AND OTHER LAWS
A. Other laws.
1. Nothing in this compact prevents the enforcement of any other law of a member state that is not inconsistent with this compact.
B. Binding effect of the compact.
1. All lawful actions of the Interstate Commission are binding upon the member states.
2. All agreements between the Interstate Commission and the member states are binding in accordance with their terms.
3. In the event any provision of this compact exceeds the constitutional limits imposed on the legislature or executive branch of any member state, such provision shall be ineffective to the extent of the conflict with the constitutional provision in question in that member state.
ARTICLE XVIII. INDIAN TRIBES
Notwithstanding any other provision in this compact, the Interstate Commission may promulgate guidelines to permit Indian tribes to utilize the compact to achieve any or all of the purposes of the compact as specified in Article I. The Interstate Commission shall make reasonable efforts to consult with Indian tribes in promulgating guidelines to reflect the diverse circumstances of the various Indian tribes.
History.—s. 1, ch. 2009-148.
409.409 Effect of existing compact provisions.—The provisions of the existing Interstate Compact on the Placement of Children, as created under s. 409.401, shall remain in effect until repealed by entry into the new Interstate Compact for the Placement of Children, as created under s. 409.408, by the Governor as authorized by ss. 409.408-409.4101.
History.—s. 2, ch. 2009-148.
409.4101 Rulemaking authority.—Following entry into the new Interstate Compact for the Placement of Children by this state pursuant to ss. 409.408 and 409.409, any rules adopted by the Interstate Commission shall not be binding unless also adopted by this state through the rulemaking process. The Department of Children and Family Services shall have rulemaking authority pursuant to ss. 120.536(1) and 120.54 to implement the provisions of the Interstate Compact for the Placement of Children created under s. 409.408.
History.—s. 3, ch. 2009-148.
409.441 Runaway youth programs and centers.—
(1) LEGISLATIVE INTENT.—The purpose of this act is to assist runaway youths and their families through a program of prevention, early intervention, community outreach, short-term residential care, aftercare, and counseling. The Legislature intends that a continuum of services be required so that runaway youths and their families are assured the least restrictive alternatives suitable to their needs and so that the family unit is strengthened through the development, expansion, and coordination of various community-based services. The development of innovative approaches specifically designed for runaway youths, which approaches have an impact on cost-avoidance, cost-effectiveness, and program efficiency, shall be encouraged.
(2) DEFINITIONS.—
(a) “Department” means the Department of Children and Family Services.
(b) “Runaway youth centers” means those community-based programs providing a range of services to troubled youths and runaway youths and their families, including prevention, community outreach, early intervention and crisis intervention, temporary residential shelter, counseling services, and aftercare followup.
(3) CRITERIA FOR LICENSING OF CENTERS; STANDARD SERVICES.—The department shall establish standard services for runaway youth centers which can be monitored and evaluated, and the establishment of these services shall be a prerequisite to receiving state funds. Such services shall include, but are not limited to:
(a) Programs for outreach and prevention for troubled youths and runaway youths and their families.
(b) Early intervention counseling services for troubled youths and runaway youths and their families, with 24-hour access geared toward crisis or time-of-need intervention.
(c) Temporary or short-term shelter, food, and clothing.
(d) Uniform and confidential intake and records systems.
(e) Provision for aftercare including individual and family counseling services.
(f) Programs for advocacy for client population and community support.
(g) Provisions for case management and referral from service to service.
(4) RECORDS CONFIDENTIAL.—All information about clients which is part of a center’s intake and client records system is confidential and exempt from the provisions of s. 119.07(1).
History.—ss. 2, 3, 5, 6, ch. 83-162; s. 8, ch. 91-71; s. 258, ch. 96-406; s. 199, ch. 97-101; s. 125, ch. 2010-102; s. 58, ch. 2013-18.
409.508 Low-income home energy assistance program.—
(1) As used in this section:
(a) “Eligible household” means a household eligible for funds from the Low-income Home Energy Assistance Act of 1981, 42 U.S.C. ss. 8621 et seq.
(b) “Home energy” means a source of heating or cooling in residential dwellings.
(c) “Utility” means any person, corporation, partnership, municipality, cooperative, association, or other legal entity and its lessees, trustees, or receivers now or hereafter owning, operating, managing, or controlling any plant or other facility supplying electricity or natural gas to or for the public within this state, directly or indirectly, for compensation.
(2) The Department of Economic Opportunity is designated as the state agency to administer the Low-income Home Energy Assistance Act of 1981, 42 U.S.C. ss. 8621 et seq. The Department of Economic Opportunity is authorized to provide home energy assistance benefits to eligible households which may be in the form of cash, vouchers, certificates, or direct payments to electric or natural gas utilities or other energy suppliers and operators of low-rent, subsidized housing in behalf of eligible households. Priority shall be given to eligible households having at least one elderly or handicapped individual and to eligible households with the lowest incomes.
(3) Agreements may be established between electric or natural gas utility companies, other energy suppliers, the Department of Revenue, and the Department of Economic Opportunity for the purpose of providing payments to energy suppliers in the form of a credit against sales and use taxes due or direct payments to energy suppliers for services rendered to low-income, eligible households.
(4) The Department of Economic Opportunity shall adopt rules to carry out the provisions of this act.
History.—ss. 3, 4, 6, ch. 80-167; s. 7, ch. 82-100; s. 70, ch. 83-218; s. 20, ch. 93-181; s. 302, ch. 2011-142.
409.509 Definitions; weatherization of low-income residences.—As used in this act, the term:
(1) “Community action agency” means a private corporation or public agency established pursuant to the Economic Opportunity Act of 1964, Pub. L. No. 88-452, which is authorized to administer funds from federal, state, local, or private funding entities to assess, design, operate, finance, and oversee antipoverty programs.
(2) “Department” means the Department of Economic Opportunity.
(3) “Energy assessment” means an analysis of a dwelling unit to determine the need for cost-effective energy conservation measures as determined by the department.
(4) “Household” means an individual or group of individuals living in a dwelling unit as defined by the department.
(5) “Low income” means household income that is at or below 125 percent of the federally established poverty level.
(6) “Residence” means a dwelling unit as defined by the department.
(7) “Weatherization” means materials or measures and their installation as defined in the federal Energy Conservation and Production Act, Pub. L. No. 94-385, which are used to improve the thermal efficiency of a residence.
(8) “Weatherizing agency” means any approved department grantee that bears the responsibility for ensuring the performance of weatherization of residences under this act and has been approved by the department, that was performing weatherization services as of July 1, 1988, unless such agency has withdrawn or lost its designation as a result of failure to perform under acceptable contract conditions as determined by the department.
History.—s. 2, ch. 91-287; s. 303, ch. 2011-142.
409.5091 Department responsible for weatherizing agencies; energy assessment.—
(1) The department is responsible for ensuring that weatherizing agencies comply with state laws and department rules.
(2) Before a residence is weatherized, the department shall require that an energy assessment be conducted.
History.—s. 3, ch. 91-287.
409.5093 Replacement agency.—If any area of the state has no designated weatherization agency as a result of withdrawal or loss of designation by departmental action, a replacement agency or agencies may be selected following a process delineated by federal and state law, regulations, and rules.
History.—s. 5, ch. 91-287.
PART II
KIDCARE409.810 Short title.
409.811 Definitions relating to Florida Kidcare Act.
409.812 Program created; purpose.
409.813 Health benefits coverage; program components; entitlement and nonentitlement.
409.8132 Medikids program component.
409.8134 Program expenditure ceiling; enrollment.
409.8135 Behavioral health services.
409.814 Eligibility.
409.815 Health benefits coverage; limitations.
409.816 Limitations on premiums and cost sharing.
409.817 Approval of health benefits coverage; financial assistance.
409.8175 Delivery of services in rural counties.
409.8177 Program evaluation.
409.818 Administration.
409.820 Quality assurance and access standards.
409.821 Florida Kidcare program public records exemption.
409.810 Short title.—Sections 409.810-409.821 may be cited as the “Florida Kidcare Act.”
History.—ss. 32, 57, ch. 98-288; s. 22, ch. 2003-405; s. 1, ch. 2009-113.
409.811 Definitions relating to Florida Kidcare Act.—As used in ss. 409.810-409.821, the term:
(1) “Actuarially equivalent” means that:
(a) The aggregate value of the benefits included in health benefits coverage is equal to the value of the benefits in the benchmark benefit plan; and
(b) The benefits included in health benefits coverage are substantially similar to the benefits included in the benchmark benefit plan, except that preventive health services must be the same as in the benchmark benefit plan.
(2) “Agency” means the Agency for Health Care Administration.
(3) “Applicant” means a parent or guardian of a child or a child whose disability of nonage has been removed under chapter 743, who applies for determination of eligibility for health benefits coverage under ss. 409.810-409.821.
(4) “Benchmark benefit plan” means the form and level of health benefits coverage established in s. 409.815.
(5) “Child” means any person under 19 years of age.
(6) “Child with special health care needs” means a child whose serious or chronic physical or developmental condition requires extensive preventive and maintenance care beyond that required by typically healthy children. Health care utilization by such a child exceeds the statistically expected usage of the normal child adjusted for chronological age, and such a child often needs complex care requiring multiple providers, rehabilitation services, and specialized equipment in a number of different settings.
(7) “Children’s Medical Services Network” or “network” means a statewide managed care service system as defined in s. 391.021(1).
(8) “Community rate” means a method used to develop premiums for a health insurance plan that spreads financial risk across a large population and allows adjustments only for age, gender, family composition, and geographic area.
(9) “Department” means the Department of Health.
(10) “Enrollee” means a child who has been determined eligible for and is receiving coverage under ss. 409.810-409.821.
(11) “Family” means the group or the individuals whose income is considered in determining eligibility for the Florida Kidcare program. The family includes a child with a parent or caretaker relative who resides in the same house or living unit or, in the case of a child whose disability of nonage has been removed under chapter 743, the child. The family may also include other individuals whose income and resources are considered in whole or in part in determining eligibility of the child.
(12) “Family income” means cash received at periodic intervals from any source, such as wages, benefits, contributions, or rental property. Income also may include any money that would have been counted as income under the Aid to Families with Dependent Children (AFDC) state plan in effect prior to August 22, 1996.
(13) “Florida Kidcare program,” “Kidcare program,” or “program” means the health benefits program administered through ss. 409.810-409.821.
(14) “Guarantee issue” means that health benefits coverage must be offered to an individual regardless of the individual’s health status, preexisting condition, or claims history.
(15) “Health benefits coverage” means protection that provides payment of benefits for covered health care services or that otherwise provides, either directly or through arrangements with other persons, covered health care services on a prepaid per capita basis or on a prepaid aggregate fixed-sum basis.
(16) “Health insurance plan” means health benefits coverage under the following:
(a) A health plan offered by any certified health maintenance organization or authorized health insurer, except a plan that is limited to the following: a limited benefit, specified disease, or specified accident; hospital indemnity; accident only; limited benefit convalescent care; Medicare supplement; credit disability; dental; vision; long-term care; disability income; coverage issued as a supplement to another health plan; workers’ compensation liability or other insurance; or motor vehicle medical payment only; or
(b) An employee welfare benefit plan that includes health benefits established under the Employee Retirement Income Security Act of 1974, as amended.
(17) “Medicaid” means the medical assistance program authorized by Title XIX of the Social Security Act, and regulations thereunder, and ss. 409.901-409.920, as administered in this state by the agency.
(18) “Medically necessary” means the use of any medical treatment, service, equipment, or supply necessary to palliate the effects of a terminal condition, or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity and which is:
(a) Consistent with the symptom, diagnosis, and treatment of the enrollee’s condition;
(b) Provided in accordance with generally accepted standards of medical practice;
(c) Not primarily intended for the convenience of the enrollee, the enrollee’s family, or the health care provider;
(d) The most appropriate level of supply or service for the diagnosis and treatment of the enrollee’s condition; and
(e) Approved by the appropriate medical body or health care specialty involved as effective, appropriate, and essential for the care and treatment of the enrollee’s condition.
(19) “Medikids” means a component of the Florida Kidcare program of medical assistance authorized by Title XXI of the Social Security Act, and regulations thereunder, and s. 409.8132, as administered in the state by the agency.
(20) “Preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.
(21) “Premium” means the entire cost of a health insurance plan, including the administration fee or the risk assumption charge.
(22) “Premium assistance payment” means the monthly consideration paid by the agency per enrollee in the Florida Kidcare program towards health insurance premiums.
(23) “Qualified alien” means an alien as defined in s. 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
(24) “Resident” means a United States citizen, or qualified alien, who is domiciled in this state.
(25) “Rural county” means a county having a population density of less than 100 persons per square mile, or a county defined by the most recent United States Census as rural, in which there is no prepaid health plan participating in the Medicaid program as of July 1, 1998.
(26) “Substantially similar” means that, with respect to additional services as defined in s. 2103(c)(2) of Title XXI of the Social Security Act, these services must have an actuarial value equal to at least 75 percent of the actuarial value of the coverage for that service in the benchmark benefit plan and, with respect to the basic services as defined in s. 2103(c)(1) of Title XXI of the Social Security Act, these services must be the same as the services in the benchmark benefit plan.
History.—ss. 33, 57, ch. 98-288; s. 22, ch. 2003-405; s. 1, ch. 2004-1; s. 5, ch. 2006-28; s. 27, ch. 2008-61; s. 2, ch. 2009-113.
409.812 Program created; purpose.—The Florida Kidcare program is created to provide a defined set of health benefits to uninsured, low-income children through the establishment of a variety of affordable health benefits coverage options from which families may select coverage and through which families may contribute financially to the health care of their children.
History.—ss. 34, 57, ch. 98-288; s. 22, ch. 2003-405; s. 3, ch. 2009-113.
409.813 Health benefits coverage; program components; entitlement and nonentitlement.—
(1) The Florida Kidcare program includes health benefits coverage provided to children through the following program components, which shall be marketed as the Florida Kidcare program:
(a) Medicaid;
(b) Medikids as created in s. 409.8132;
(c) The Florida Healthy Kids Corporation as created in s. 624.91;
(d) Employer-sponsored group health insurance plans approved under ss. 409.810-409.821; and
(e) The Children’s Medical Services network established in chapter 391.
(2) Except for Title XIX-funded Florida Kidcare program coverage under the Medicaid program, coverage under the Florida Kidcare program is not an entitlement. No cause of action shall arise against the state, the department, the Department of Children and Family Services, or the agency for failure to make health services available to any person under ss. 409.810-409.821.
History.—ss. 35, 57, ch. 98-288; s. 22, ch. 2003-405; s. 4, ch. 2009-113.
409.8132 Medikids program component.—
(1) PROGRAM COMPONENT CREATED; PURPOSE.—The Medikids program component is created in the Agency for Health Care Administration to provide health care services under the Florida Kidcare program to eligible children using the administrative structure and provider network of the Medicaid program.
(2) ADMINISTRATION.—The secretary of the agency shall appoint an administrator of the Medikids program component. The Agency for Health Care Administration is designated as the state agency authorized to make payments for medical assistance and related services for the Medikids program component of the Florida Kidcare program. Payments shall be made, subject to any limitations or directions in the General Appropriations Act, only for covered services provided to eligible children by qualified health care providers under the Florida Kidcare program.
(3) INSURANCE LICENSURE NOT REQUIRED.—The Medikids program component shall not be subject to the licensing requirements of the Florida Insurance Code or rules adopted thereunder.
(4) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908, 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127, 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply to the administration of the Medikids program component of the Florida Kidcare program, except that s. 409.9122 applies to Medikids as modified by the provisions of subsection (7).
(5) BENEFITS.—Benefits provided under the Medikids program component shall be the same benefits provided to children as specified in ss. 409.905 and 409.906.
(6) ELIGIBILITY.—
(a) A child who has attained the age of 1 year but who is under the age of 5 years is eligible to enroll in the Medikids program component of the Florida Kidcare program, if the child is a member of a family that has a family income which exceeds the Medicaid applicable income level as specified in s. 409.903, but which is equal to or below 200 percent of the current federal poverty level. In determining the eligibility of such a child, an assets test is not required. A child who is eligible for Medikids may elect to enroll in Florida Healthy Kids coverage or employer-sponsored group coverage. However, a child who is eligible for Medikids may participate in the Florida Healthy Kids program only if the child has a sibling participating in the Florida Healthy Kids program and the child’s county of residence permits such enrollment.
(b) The provisions of s. 409.814 apply to the Medikids program.
(7) ENROLLMENT.—Enrollment in the Medikids program component may occur at any time throughout the year. A child may not receive services under the Medikids program until the child is enrolled in a managed care plan or MediPass. Once determined eligible, an applicant may receive choice counseling and select a managed care plan or MediPass. The agency may initiate mandatory assignment for a Medikids applicant who has not chosen a managed care plan or MediPass provider after the applicant’s voluntary choice period ends. An applicant may select MediPass under the Medikids program component only in counties that have fewer than two managed care plans available to serve Medicaid recipients and only if the federal Health Care Financing Administration determines that MediPass constitutes “health insurance coverage” as defined in Title XXI of the Social Security Act.
(8) PENALTIES FOR VOLUNTARY CANCELLATION.—The agency shall establish enrollment criteria that include penalties or waiting periods of 30 days for reinstatement of coverage upon voluntary cancellation for nonpayment of premiums.
History.—ss. 36, 57, ch. 98-288; s. 2, ch. 2000-253; s. 18, ch. 2000-305; s. 13, ch. 2002-400; s. 446, ch. 2003-261; s. 22, ch. 2003-405; s. 2, ch. 2004-1; s. 1, ch. 2005-123; s. 5, ch. 2009-113; s. 2, ch. 2012-33.
409.8134 Program expenditure ceiling; enrollment.—
(1) Except for the Medicaid program, a ceiling shall be placed on annual federal and state expenditures for the Florida Kidcare program as provided each year in the General Appropriations Act.
(2) The Florida Kidcare program may conduct enrollment continuously throughout the year. Children eligible for coverage under the Title XXI-funded Florida Kidcare program shall be enrolled on a first-come, first-served basis using the date the enrollment application is received. Enrollment shall immediately cease when the expenditure ceiling is reached. Year-round enrollment shall only be held if the Social Services Estimating Conference determines that sufficient federal and state funds will be available to finance the increased enrollment. The application for the Florida Kidcare program is valid for a period of 120 days after the date it was received. At the end of the 120-day period, if the applicant has not been enrolled in the program, the application is invalid and the applicant shall be notified of the action. The applicant may reactivate the application after notification of the action taken by the program. Except for the Medicaid program, whenever the Social Services Estimating Conference determines that there are presently, or will be by the end of the current fiscal year, insufficient funds to finance the current or projected enrollment in the Florida Kidcare program, all additional enrollment must cease and additional enrollment may not resume until sufficient funds are available to finance such enrollment.
(3) Upon determination by the Social Services Estimating Conference that there are insufficient funds to finance the current enrollment in the Florida Kidcare program within current appropriations, the program shall initiate disenrollment procedures to remove enrollees, except those children enrolled in the Children’s Medical Services Network, on a last-in, first-out basis until the expenditure and appropriation levels are balanced.
(4) The agencies that administer the Florida Kidcare program components shall collect and analyze the data needed to project program enrollment costs, including price level adjustments, participation and attrition rates, current and projected caseloads, utilization, and current and projected expenditures for the next 3 years. The agencies shall report caseload and expenditure trends to the Social Services Estimating Conference in accordance with chapter 216.
History.—ss. 37, 57, ch. 98-288; s. 3, ch. 2000-253; s. 22, ch. 2003-405; s. 3, ch. 2004-1; s. 3, ch. 2004-270; s. 2, ch. 2005-123; s. 6, ch. 2006-28; s. 6, ch. 2009-113.
409.8135 Behavioral health services.—In order to ensure a high level of integration of physical and behavioral health care and to meet the more intensive treatment needs of enrollees with the most serious emotional disturbances or substance abuse problems, the Department of Health shall contract with the Department of Children and Family Services to provide behavioral health services to non-Medicaid-eligible children with special health care needs. The Department of Children and Family Services, in consultation with the Department of Health and the agency, is authorized to establish the following:
(1) The scope of behavioral health services, including duration and frequency.
(2) Clinical guidelines for referral to behavioral health services.
(3) Behavioral health services standards.
(4) Performance-based measures and outcomes for behavioral health services.
(5) Practice guidelines for behavioral health services to ensure cost-effective treatment and to prevent unnecessary expenditures.
(6) Rules to implement this section.
History.—ss. 38, 57, ch. 98-288; s. 22, ch. 2003-405.
409.814 Eligibility.—A child who has not reached 19 years of age whose family income is equal to or below 200 percent of the federal poverty level is eligible for the Florida Kidcare program as provided in this section. If an enrolled individual is determined to be ineligible for coverage, he or she must be immediately disenrolled from the respective Florida Kidcare program component.
(1) A child who is eligible for Medicaid coverage under s. 409.903 or s. 409.904 must be enrolled in Medicaid and is not eligible to receive health benefits under any other health benefits coverage authorized under the Florida Kidcare program.
(2) A child who is not eligible for Medicaid, but who is eligible for the Florida Kidcare program, may obtain health benefits coverage under any of the other components listed in s. 409.813 if such coverage is approved and available in the county in which the child resides.
(3) A Title XXI-funded child who is eligible for the Florida Kidcare program who is a child with special health care needs, as determined through a medical or behavioral screening instrument, is eligible for health benefits coverage from and shall be assigned to and may opt out of the Children’s Medical Services Network.
(4) The following children are not eligible to receive Title XXI-funded premium assistance for health benefits coverage under the Florida Kidcare program, except under Medicaid if the child would have been eligible for Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
(a) A child who is covered under a family member’s group health benefit plan or under other private or employer health insurance coverage, if the cost of the child’s participation is not greater than 5 percent of the family’s income. If a child is otherwise eligible for a subsidy under the Florida Kidcare program and the cost of the child’s participation in the family member’s health insurance benefit plan is greater than 5 percent of the family’s income, the child may enroll in the appropriate subsidized Kidcare program.
(b) A child who is seeking premium assistance for the Florida Kidcare program through employer-sponsored group coverage, if the child has been covered by the same employer’s group coverage during the 60 days before the family submitted an application for determination of eligibility under the program.
(c) A child who is an alien, but who does not meet the definition of qualified alien, in the United States.
(d) A child who is an inmate of a public institution or a patient in an institution for mental diseases.
(e) A child who is otherwise eligible for premium assistance for the Florida Kidcare program and has had his or her coverage in an employer-sponsored or private health benefit plan voluntarily canceled in the last 60 days, except those children whose coverage was voluntarily canceled for good cause, including, but not limited to, the following circumstances:
1. The cost of participation in an employer-sponsored health benefit plan is greater than 5 percent of the family’s income;
2. The parent lost a job that provided an employer-sponsored health benefit plan for children;
3. The parent who had health benefits coverage for the child is deceased;
4. The child has a medical condition that, without medical care, would cause serious disability, loss of function, or death;
5. The employer of the parent canceled health benefits coverage for children;
6. The child’s health benefits coverage ended because the child reached the maximum lifetime coverage amount;
7. The child has exhausted coverage under a COBRA continuation provision;
8. The health benefits coverage does not cover the child’s health care needs; or
9. Domestic violence led to loss of coverage.
(5) A child who is otherwise eligible for the Florida Kidcare program and who has a preexisting condition that prevents coverage under another insurance plan as described in paragraph (4)(a) which would have disqualified the child for the Florida Kidcare program if the child were able to enroll in the plan is eligible for Florida Kidcare coverage when enrollment is possible.
(6) A child whose family income is above 200 percent of the federal poverty level or a child who is excluded under the provisions of subsection (4) may participate in the Florida Kidcare program as provided in s. 409.8132 or, if the child is ineligible for Medikids by reason of age, in the Florida Healthy Kids program, subject to the following:
(a) The family is not eligible for premium assistance payments and must pay the full cost of the premium, including any administrative costs.
(b) The board of directors of the Florida Healthy Kids Corporation may offer a reduced benefit package to these children in order to limit program costs for such families.
(7) Once a child is enrolled in the Florida Kidcare program, the child is eligible for coverage for 12 months without a redetermination or reverification of eligibility, if the family continues to pay the applicable premium. Eligibility for program components funded through Title XXI of the Social Security Act terminates when a child attains the age of 19. A child who has not attained the age of 5 and who has been determined eligible for the Medicaid program is eligible for coverage for 12 months without a redetermination or reverification of eligibility.
(8) When determining or reviewing a child’s eligibility under the Florida Kidcare program, the applicant shall be provided with reasonable notice of changes in eligibility which may affect enrollment in one or more of the program components. If a transition from one program component to another is authorized, there shall be cooperation between the program components and the affected family which promotes continuity of health care coverage. Any authorized transfers must be managed within the program’s overall appropriated or authorized levels of funding. Each component of the program shall establish a reserve to ensure that transfers between components will be accomplished within current year appropriations. These reserves shall be reviewed by each convening of the Social Services Estimating Conference to determine the adequacy of such reserves to meet actual experience.
(9) In determining the eligibility of a child, an assets test is not required. Each applicant shall provide documentation during the application process and the redetermination process, including, but not limited to, the following:
(a) Proof of family income, which must be verified electronically to determine financial eligibility for the Florida Kidcare program. Written documentation, which may include wages and earnings statements or pay stubs, W-2 forms, or a copy of the applicant’s most recent federal income tax return, is required only if the electronic verification is not available or does not substantiate the applicant’s income.
(b) A statement from all applicable, employed family members that:
1. Their employers do not sponsor health benefit plans for employees;
2. The potential enrollee is not covered by an employer-sponsored health benefit plan; or
3. The potential enrollee is covered by an employer-sponsored health benefit plan and the cost of the employer-sponsored health benefit plan is more than 5 percent of the family’s income.
(c) To enroll in the Children’s Medical Services Network, a completed application, including a clinical screening.
(10) Subject to paragraph (4)(a), the Florida Kidcare program shall withhold benefits from an enrollee if the program obtains evidence that the enrollee is no longer eligible, submitted incorrect or fraudulent information in order to establish eligibility, or failed to provide verification of eligibility. The applicant or enrollee shall be notified that because of such evidence program benefits will be withheld unless the applicant or enrollee contacts a designated representative of the program by a specified date, which must be within 10 working days after the date of notice, to discuss and resolve the matter. The program shall make every effort to resolve the matter within a timeframe that will not cause benefits to be withheld from an eligible enrollee.
(11) The following individuals may be subject to prosecution in accordance with s. 414.39:
(a) An applicant obtaining or attempting to obtain benefits for a potential enrollee under the Florida Kidcare program when the applicant knows or should have known the potential enrollee does not qualify for the Florida Kidcare program.
(b) An individual who assists an applicant in obtaining or attempting to obtain benefits for a potential enrollee under the Florida Kidcare program when the individual knows or should have known the potential enrollee does not qualify for the Florida Kidcare program.
History.—ss. 39, 57, ch. 98-288; s. 4, ch. 2000-253; s. 22, ch. 2003-405; s. 4, ch. 2004-1; ss. 4, 5, ch. 2004-270; s. 1, ch. 2004-478; s. 50, ch. 2006-1; s. 7, ch. 2006-28; s. 1, ch. 2006-248; s. 5, ch. 2008-32; s. 7, ch. 2009-113; s. 3, ch. 2012-33.
409.815 Health benefits coverage; limitations.—
(1) MEDICAID BENEFITS.—For purposes of the Florida Kidcare program, benefits available under Medicaid and Medikids include those goods and services provided under the medical assistance program authorized by Title XIX of the Social Security Act, and regulations thereunder, as administered in this state by the agency. This includes those mandatory Medicaid services authorized under s. 409.905 and optional Medicaid services authorized under s. 409.906, rendered on behalf of eligible individuals by qualified providers, in accordance with federal requirements for Title XIX, subject to any limitations or directions provided for in the General Appropriations Act or chapter 216, and according to methodologies and limitations set forth in agency rules and policy manuals and handbooks incorporated by reference thereto.
(2) BENCHMARK BENEFITS.—In order for health benefits coverage to qualify for premium assistance payments for an eligible child under ss. 409.810-409.821, the health benefits coverage, except for coverage under Medicaid and Medikids, must include the following minimum benefits, as medically necessary.
(a) Preventive health services.—Covered services include:
1. Well-child care, including services recommended in the Guidelines for Health Supervision of Children and Youth as developed by the American Academy of Pediatrics;
2. Immunizations and injections;
3. Health education counseling and clinical services;
4. Vision screening; and
5. Hearing screening.
(b) Inpatient hospital services.—All covered services provided for the medical care and treatment of an enrollee who is admitted as an inpatient to a hospital licensed under part I of chapter 395, with the following exceptions:
1. All admissions must be authorized by the enrollee’s health benefits coverage provider.
2. The length of the patient stay shall be determined based on the medical condition of the enrollee in relation to the necessary and appropriate level of care.
3. Room and board may be limited to semiprivate accommodations, unless a private room is considered medically necessary or semiprivate accommodations are not available.
4. Admissions for rehabilitation and physical therapy are limited to 15 days per contract year.
(c) Emergency services.—Covered services include visits to an emergency room or other licensed facility if needed immediately due to an injury or illness and delay means risk of permanent damage to the enrollee’s health. Health maintenance organizations shall comply with the provisions of s. 641.513.
(d) Maternity services.—Covered services include maternity and newborn care, including prenatal and postnatal care, with the following limitations:
1. Coverage may be limited to the fee for vaginal deliveries; and
2. Initial inpatient care for newborn infants of enrolled adolescents shall be covered, including normal newborn care, nursery charges, and the initial pediatric or neonatal examination, and the infant may be covered for up to 3 days following birth.
(e) Organ transplantation services.—Covered services include pretransplant, transplant, and postdischarge services and treatment of complications after transplantation for transplants deemed necessary and appropriate within the guidelines set by the Organ Transplant Advisory Council under s. 765.53 or the Bone Marrow Transplant Advisory Panel under s. 627.4236.
(f) Outpatient services.—Covered services include preventive, diagnostic, therapeutic, palliative care, and other services provided to an enrollee in the outpatient portion of a health facility licensed under chapter 395, except for the following limitations:
1. Services must be authorized by the enrollee’s health benefits coverage provider; and
2. Treatment for temporomandibular joint disease (TMJ) is specifically excluded.
(g) Behavioral health services.—
1. Mental health benefits include:
a. Inpatient services, limited to 30 inpatient days per contract year for psychiatric admissions, or residential services in facilities licensed under s. 394.875(6) or s. 395.003 in lieu of inpatient psychiatric admissions; however, a minimum of 10 of the 30 days shall be available only for inpatient psychiatric services if authorized by a physician; and
b. Outpatient services, including outpatient visits for psychological or psychiatric evaluation, diagnosis, and treatment by a licensed mental health professional, limited to 40 outpatient visits each contract year.
2. Substance abuse services include:
a. Inpatient services, limited to 7 inpatient days per contract year for medical detoxification only and 30 days of residential services; and
b. Outpatient services, including evaluation, diagnosis, and treatment by a licensed practitioner, limited to 40 outpatient visits per contract year.
Effective October 1, 2009, covered services include inpatient and outpatient services for mental and nervous disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Such benefits include psychological or psychiatric evaluation, diagnosis, and treatment by a licensed mental health professional and inpatient, outpatient, and residential treatment of substance abuse disorders. Any benefit limitations, including duration of services, number of visits, or number of days for hospitalization or residential services, shall not be any less favorable than those for physical illnesses generally. The program may also implement appropriate financial incentives, peer review, utilization requirements, and other methods used for the management of benefits provided for other medical conditions in order to reduce service costs and utilization without compromising quality of care.
(h) Durable medical equipment.—Covered services include equipment and devices that are medically indicated to assist in the treatment of a medical condition and specifically prescribed as medically necessary, with the following limitations:
1. Low-vision and telescopic aides are not included.
2. Corrective lenses and frames may be limited to one pair every 2 years, unless the prescription or head size of the enrollee changes.
3. Hearing aids shall be covered only when medically indicated to assist in the treatment of a medical condition.
4. Covered prosthetic devices include artificial eyes and limbs, braces, and other artificial aids.
(i) Health practitioner services.—Covered services include services and procedures rendered to an enrollee when performed to diagnose and treat diseases, injuries, or other conditions, including care rendered by health practitioners acting within the scope of their practice, with the following exceptions:
1. Chiropractic services shall be provided in the same manner as in the Florida Medicaid program.
2. Podiatric services may be limited to one visit per day totaling two visits per month for specific foot disorders.
(j) Home health services.—Covered services include prescribed home visits by both registered and licensed practical nurses to provide skilled nursing services on a part-time intermittent basis, subject to the following limitations:
1. Coverage may be limited to include skilled nursing services only;
2. Meals, housekeeping, and personal comfort items may be excluded; and
3. Private duty nursing is limited to circumstances where such care is medically necessary.
(k) Hospice services.—Covered services include reasonable and necessary services for palliation or management of an enrollee’s terminal illness, with the following exceptions:
1. Once a family elects to receive hospice care for an enrollee, other services that treat the terminal condition will not be covered; and
2. Services required for conditions totally unrelated to the terminal condition are covered to the extent that the services are included in this section.
(l) Laboratory and X-ray services.—Covered services include diagnostic testing, including clinical radiologic, laboratory, and other diagnostic tests.
(m) Nursing facility services.—Covered services include regular nursing services, rehabilitation services, drugs and biologicals, medical supplies, and the use of appliances and equipment furnished by the facility, with the following limitations:
1. All admissions must be authorized by the health benefits coverage provider.
2. The length of the patient stay shall be determined based on the medical condition of the enrollee in relation to the necessary and appropriate level of care, but is limited to not more than 100 days per contract year.
3. Room and board may be limited to semiprivate accommodations, unless a private room is considered medically necessary or semiprivate accommodations are not available.
4. Specialized treatment centers and independent kidney disease treatment centers are excluded.
5. Private duty nurses, television, and custodial care are excluded.
6. Admissions for rehabilitation and physical therapy are limited to 15 days per contract year.
(n) Prescribed drugs.—
1. Coverage shall include drugs prescribed for the treatment of illness or injury when prescribed by a licensed health practitioner acting within the scope of his or her practice.
2. Prescribed drugs may be limited to generics if available and brand name products if a generic substitution is not available, unless the prescribing licensed health practitioner indicates that a brand name is medically necessary.
3. Prescribed drugs covered under this section shall include all prescribed drugs covered under the Florida Medicaid program.
(o) Therapy services.—Covered services include rehabilitative services, including occupational, physical, respiratory, and speech therapies, with the following limitations:
1. Services must be for short-term rehabilitation where significant improvement in the enrollee’s condition will result; and
2. Services shall be limited to not more than 24 treatment sessions within a 60-day period per episode or injury, with the 60-day period beginning with the first treatment.
(p) Transportation services.—Covered services include emergency transportation required in response to an emergency situation.
(q) Dental services.—Effective October 1, 2009, dental services shall be covered as required under federal law and may also include those dental benefits provided to children by the Florida Medicaid program under s. 409.906(6).
(r) Lifetime maximum.—Health benefits coverage obtained under ss. 409.810-409.820 shall pay an enrollee’s covered expenses at a lifetime maximum of $1 million per covered child.
(s) Cost sharing.—Cost-sharing provisions must comply with s. 409.816.
(t) Exclusions.—
1. Experimental or investigational procedures that have not been clinically proven by reliable evidence are excluded;
2. Services performed for cosmetic purposes only or for the convenience of the enrollee are excluded; and
3. Abortion may be covered only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.
(u) Enhancements to minimum requirements.—
1. This section sets the minimum benefits that must be included in any health benefits coverage, other than Medicaid or Medikids coverage, offered under ss. 409.810-409.821. Health benefits coverage may include additional benefits not included under this subsection, but may not include benefits excluded under paragraph (s).
2. Health benefits coverage may extend any limitations beyond the minimum benefits described in this section.
Except for the Children’s Medical Services Network, the agency may not increase the premium assistance payment for either additional benefits provided beyond the minimum benefits described in this section or the imposition of less restrictive service limitations.
(v) Applicability of other state laws.—Health insurers, health maintenance organizations, and their agents are subject to the provisions of the Florida Insurance Code, except for any such provisions waived in this section.
1. Except as expressly provided in this section, a law requiring coverage for a specific health care service or benefit, or a law requiring reimbursement, utilization, or consideration of a specific category of licensed health care practitioner, does not apply to a health insurance plan policy or contract offered or delivered under ss. 409.810-409.821 unless that law is made expressly applicable to such policies or contracts.
2. Notwithstanding chapter 641, a health maintenance organization may issue contracts providing benefits equal to, exceeding, or actuarially equivalent to the benchmark benefit plan authorized by this section and may pay providers located in a rural county negotiated fees or Medicaid reimbursement rates for services provided to enrollees who are residents of the rural county.
(w) Reimbursement of federally qualified health centers and rural health clinics.—Effective October 1, 2009, payments for services provided to enrollees by federally qualified health centers and rural health clinics under this section shall be reimbursed using the Medicaid Prospective Payment System as provided for under s. 2107(e)(1)(D) of the Social Security Act. If such services are paid for by health insurers or health care providers under contract with the Florida Healthy Kids Corporation, such entities are responsible for this payment. The agency may seek any available federal grants to assist with this transition.
History.—ss. 40, 57, ch. 98-288; s. 5, ch. 2000-253; s. 19, ch. 2001-377; s. 45, ch. 2003-1; ss. 6, 22, ch. 2003-405; s. 5, ch. 2004-1; s. 135, ch. 2007-230; s. 2, ch. 2009-55; s. 8, ch. 2009-113.
409.816 Limitations on premiums and cost sharing.—The following limitations on premiums and cost sharing are established for the program.
(1) Enrollees who receive coverage under the Medicaid program may not be required to pay:
(a) Enrollment fees, premiums, or similar charges; or
(b) Copayments, deductibles, coinsurance, or similar charges.
(2) Enrollees in families with a family income equal to or below 150 percent of the federal poverty level, who are not receiving coverage under the Medicaid program, may not be required to pay:
(a) Enrollment fees, premiums, or similar charges that exceed the maximum monthly charge permitted under s. 1916(b)(1) of the Social Security Act; or
(b) Copayments, deductibles, coinsurance, or similar charges that exceed a nominal amount, as determined consistent with regulations referred to in s. 1916(a)(3) of the Social Security Act. However, such charges may not be imposed for preventive services, including well-baby and well-child care, age-appropriate immunizations, and routine hearing and vision screenings.
(3) Enrollees in families with a family income above 150 percent of the federal poverty level who are not receiving coverage under the Medicaid program or who are not eligible under s. 409.814(6) may be required to pay enrollment fees, premiums, copayments, deductibles, coinsurance, or similar charges on a sliding scale related to income, except that the total annual aggregate cost sharing with respect to all children in a family may not exceed 5 percent of the family’s income. However, copayments, deductibles, coinsurance, or similar charges may not be imposed for preventive services, including well-baby and well-child care, age-appropriate immunizations, and routine hearing and vision screenings.
History.—ss. 41, 57, ch. 98-288; s. 22, ch. 2003-405; s. 9, ch. 2009-113; s. 91, ch. 2010-5.
409.817 Approval of health benefits coverage; financial assistance.—In order for health insurance coverage to qualify for premium assistance payments for an eligible child under ss. 409.810-409.821, the health benefits coverage must:
(1) Be certified by the Office of Insurance Regulation of the Financial Services Commission under s. 409.818 as meeting, exceeding, or being actuarially equivalent to the benchmark benefit plan;
(2) Be guarantee issued;
(3) Be community rated;
(4) Not impose any preexisting condition exclusion for covered benefits; however, group health insurance plans may permit the imposition of a preexisting condition exclusion, but only insofar as it is permitted under s. 627.6561;
(5) Comply with the applicable limitations on premiums and cost sharing in s. 409.816;
(6) Comply with the quality assurance and access standards developed under s. 409.820; and
(7) Establish periodic open enrollment periods, which may not occur more frequently than quarterly.
History.—ss. 42, 57, ch. 98-288; s. 447, ch. 2003-261; s. 22, ch. 2003-405; s. 10, ch. 2009-113.
409.8175 Delivery of services in rural counties.—A health maintenance organization or a health insurer may reimburse providers located in a rural county according to the Medicaid fee schedule for services provided to enrollees in rural counties if the provider agrees to accept such fee schedule.
History.—ss. 43, 57, ch. 98-288; s. 22, ch. 2003-405.
409.8177 Program evaluation.—
(1) The agency, in consultation with the Department of Health, the Department of Children and Family Services, and the Florida Healthy Kids Corporation, shall contract for an evaluation of the Florida Kidcare program and shall by January 1 of each year submit to the Governor, the President of the Senate, and the Speaker of the House of Representatives a report of the program. In addition to the items specified under s. 2108 of Title XXI of the Social Security Act, the report shall include an assessment of crowd-out and access to health care, as well as the following:
(a) An assessment of the operation of the program, including the progress made in reducing the number of uncovered low-income children.
(b) An assessment of the effectiveness in increasing the number of children with creditable health coverage, including an assessment of the impact of outreach.
(c) The characteristics of the children and families assisted under the program, including ages of the children, family income, and access to or coverage by other health insurance prior to the program and after disenrollment from the program.
(d) The quality of health coverage provided, including the types of benefits provided.
(e) The amount and level, including payment of part or all of any premium, of assistance provided.
(f) The average length of coverage of a child under the program.
(g) The program’s choice of health benefits coverage and other methods used for providing child health assistance.
(h) The sources of nonfederal funding used in the program.
(i) An assessment of the effectiveness of the Florida Kidcare program, including Medicaid, the Florida Healthy Kids program, Medikids, and the Children’s Medical Services network, and other public and private programs in the state in increasing the availability of affordable quality health insurance and health care for children.
(j) A review and assessment of state activities to coordinate the program with other public and private programs.
(k) An analysis of changes and trends in the state that affect the provision of health insurance and health care to children.
(l) A description of any plans the state has for improving the availability of health insurance and health care for children.
(m) Recommendations for improving the program.
(n) Other studies as necessary.
(2) The agency shall submit each month to the Governor, the President of the Senate, and the Speaker of the House of Representatives a report of enrollment for each program component of the Florida Kidcare program.
History.—ss. 44, 57, ch. 98-288; s. 6, ch. 2000-253; s. 14, ch. 2002-400; s. 22, ch. 2003-405; s. 11, ch. 2009-113.
409.818 Administration.—In order to implement ss. 409.810-409.821, the following agencies shall have the following duties:
(1) The Department of Children and Family Services shall:
(a) Develop a simplified eligibility application mail-in form to be used for determining the eligibility of children for coverage under the Florida Kidcare program, in consultation with the agency, the Department of Health, and the Florida Healthy Kids Corporation. The simplified eligibility application form must include an item that provides an opportunity for the applicant to indicate whether coverage is being sought for a child with special health care needs. Families applying for children’s Medicaid coverage must also be able to use the simplified application form without having to pay a premium.
(b) Establish and maintain the eligibility determination process under the program except as specified in subsection (5). The department shall directly, or through the services of a contracted third-party administrator, establish and maintain a process for determining eligibility of children for coverage under the program. The eligibility determination process must be used solely for determining eligibility of applicants for health benefits coverage under the program. The eligibility determination process must include an initial determination of eligibility for any coverage offered under the program, as well as a redetermination or reverification of eligibility each subsequent 6 months. Effective January 1, 1999, a child who has not attained the age of 5 and who has been determined eligible for the Medicaid program is eligible for coverage for 12 months without a redetermination or reverification of eligibility. In conducting an eligibility determination, the department shall determine if the child has special health care needs. The department, in consultation with the Agency for Health Care Administration and the Florida Healthy Kids Corporation, shall develop procedures for redetermining eligibility which enable a family to easily update any change in circumstances which could affect eligibility. The department may accept changes in a family’s status as reported to the department by the Florida Healthy Kids Corporation without requiring a new application from the family. Redetermination of a child’s eligibility for Medicaid may not be linked to a child’s eligibility determination for other programs.
(c) Inform program applicants about eligibility determinations and provide information about eligibility of applicants to the Florida Kidcare program and to insurers and their agents, through a centralized coordinating office.
(d) Adopt rules necessary for conducting program eligibility functions.
(2) The Department of Health shall:
(a) Design an eligibility intake process for the program, in coordination with the Department of Children and Family Services, the agency, and the Florida Healthy Kids Corporation. The eligibility intake process may include local intake points that are determined by the Department of Health in coordination with the Department of Children and Family Services.
(b) Chair a state-level Florida Kidcare coordinating council to review and make recommendations concerning the implementation and operation of the program. The coordinating council shall include representatives from the department, the Department of Children and Family Services, the agency, the Florida Healthy Kids Corporation, the Office of Insurance Regulation of the Financial Services Commission, local government, health insurers, health maintenance organizations, health care providers, families participating in the program, and organizations representing low-income families.
(c) In consultation with the Florida Healthy Kids Corporation and the Department of Children and Family Services, establish a toll-free telephone line to assist families with questions about the program.
(d) Adopt rules necessary to implement outreach activities.
(3) The Agency for Health Care Administration, under the authority granted in s. 409.914(1), shall:
(a) Calculate the premium assistance payment necessary to comply with the premium and cost-sharing limitations specified in s. 409.816. The premium assistance payment for each enrollee in a health insurance plan participating in the Florida Healthy Kids Corporation shall equal the premium approved by the Florida Healthy Kids Corporation and the Office of Insurance Regulation of the Financial Services Commission pursuant to ss. 627.410 and 641.31, less any enrollee’s share of the premium established within the limitations specified in s. 409.816. The premium assistance payment for each enrollee in an employer-sponsored health insurance plan approved under ss. 409.810-409.821 shall equal the premium for the plan adjusted for any benchmark benefit plan actuarial equivalent benefit rider approved by the Office of Insurance Regulation pursuant to ss. 627.410 and 641.31, less any enrollee’s share of the premium established within the limitations specified in s. 409.816. In calculating the premium assistance payment levels for children with family coverage, the agency shall set the premium assistance payment levels for each child proportionately to the total cost of family coverage.
(b) Make premium assistance payments to health insurance plans on a periodic basis. The agency may use its Medicaid fiscal agent or a contracted third-party administrator in making these payments. The agency may require health insurance plans that participate in the Medikids program or employer-sponsored group health insurance to collect premium payments from an enrollee’s family. Participating health insurance plans shall report premium payments collected on behalf of enrollees in the program to the agency in accordance with a schedule established by the agency.
(c) Monitor compliance with quality assurance and access standards developed under s. 409.820 and in accordance with s. 2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
(d) Establish a mechanism for investigating and resolving complaints and grievances from program applicants, enrollees, and health benefits coverage providers, and maintain a record of complaints and confirmed problems. In the case of a child who is enrolled in a health maintenance organization, the agency must use the provisions of s. 641.511 to address grievance reporting and resolution requirements.
(e) Approve health benefits coverage for participation in the program, following certification by the Office of Insurance Regulation under subsection (4).
(f) Adopt rules necessary for calculating premium assistance payment levels, making premium assistance payments, monitoring access and quality assurance standards, investigating and resolving complaints and grievances, administering the Medikids program, and approving health benefits coverage.
The agency is designated the lead state agency for Title XXI of the Social Security Act for purposes of receipt of federal funds, for reporting purposes, and for ensuring compliance with federal and state regulations and rules.
(4) The Office of Insurance Regulation shall certify that health benefits coverage plans that seek to provide services under the Florida Kidcare program, except those offered through the Florida Healthy Kids Corporation or the Children’s Medical Services Network, meet, exceed, or are actuarially equivalent to the benchmark benefit plan and that health insurance plans will be offered at an approved rate. In determining actuarial equivalence of benefits coverage, the Office of Insurance Regulation and health insurance plans must comply with the requirements of s. 2103 of Title XXI of the Social Security Act. The department shall adopt rules necessary for certifying health benefits coverage plans.
(5) The Florida Healthy Kids Corporation shall retain its functions as authorized in s. 624.91, including eligibility determination for participation in the Healthy Kids program.
(6) The agency, the Department of Health, the Department of Children and Family Services, the Florida Healthy Kids Corporation, and the Office of Insurance Regulation, after consultation with and approval of the Speaker of the House of Representatives and the President of the Senate, are authorized to make program modifications that are necessary to overcome any objections of the United States Department of Health and Human Services to obtain approval of the state’s child health insurance plan under Title XXI of the Social Security Act.
History.—ss. 45, 57, ch. 98-288; s. 7, ch. 2000-253; s. 448, ch. 2003-261; s. 22, ch. 2003-405; s. 11, ch. 2004-1; s. 8, ch. 2006-28; s. 3, ch. 2009-55; s. 12, ch. 2009-113.
409.820 Quality assurance and access standards.—Except for Medicaid, the Department of Health, in consultation with the agency and the Florida Healthy Kids Corporation, shall develop a minimum set of quality assurance and access standards for all program components. The standards must include a process for granting exceptions to specific requirements for quality assurance and access. Compliance with the standards shall be a condition of program participation by health benefits coverage providers. These standards shall comply with the provisions of this chapter and chapter 641 and Title XXI of the Social Security Act.
History.—ss. 47, 57, ch. 98-288; s. 22, ch. 2003-405.
409.821 Florida Kidcare program public records exemption.—
(1) Personal identifying information of a Florida Kidcare program applicant or enrollee, as defined in s. 409.811, held by the Agency for Health Care Administration, the Department of Children and Family Services, the Department of Health, or the Florida Healthy Kids Corporation is confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
(2)(a) Upon request, such information shall be disclosed to:
1. Another governmental entity in the performance of its official duties and responsibilities;
2. The Department of Revenue for purposes of administering the state Title IV-D program;
3. The Florida Health Choices, Inc., for the purpose of administering the program authorized pursuant to s. 408.910; or
4. Any person who has the written consent of the program applicant.
(b) This section does not prohibit an enrollee’s legal guardian from obtaining confirmation of coverage, dates of coverage, the name of the enrollee’s health plan, and the amount of premium being paid.
(3) This exemption applies to any information identifying a Florida Kidcare program applicant or enrollee held by the Agency for Health Care Administration, the Department of Children and Family Services, the Department of Health, or the Florida Healthy Kids Corporation before, on, or after the effective date of this exemption.
(4) A knowing and willful violation of this section is a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.
History.—s. 1, ch. 98-119; s. 56, ch. 2000-153; ss. 1, 2, ch. 2003-104; s. 35, ch. 2005-39; s. 11, ch. 2005-82; ss. 1, 2, ch. 2008-146; s. 5, ch. 2011-195.
PART III
MEDICAID409.901 Definitions; ss. 409.901-409.920.
409.902 Designated single state agency; payment requirements; program title; release of medical records.
409.90201 Recipient address update process.
409.9021 Forfeiture of eligibility agreement.
409.9025 Eligibility while an inmate.
409.903 Mandatory payments for eligible persons.
409.904 Optional payments for eligible persons.
409.905 Mandatory Medicaid services.
409.906 Optional Medicaid services.
409.9062 Lung transplant services for Medicaid recipients.
409.9066 Medicare prescription discount program.
409.907 Medicaid provider agreements.
409.9071 Medicaid provider agreements for school districts certifying state match.
409.908 Reimbursement of Medicaid providers.
409.9081 Copayments.
409.9082 Quality assessment on nursing home facility providers; exemptions; purpose; federal approval required; remedies.
409.9083 Quality assessment on privately operated intermediate care facilities for the developmentally disabled; exemptions; purpose; federal approval required; remedies.
409.909 Statewide Medicaid Residency Program.
409.910 Responsibility for payments on behalf of Medicaid-eligible persons when other parties are liable.
409.9101 Recovery for payments made on behalf of Medicaid-eligible persons.
409.9102 A qualified state Long-Term Care Insurance Partnership Program in Florida.
409.911 Disproportionate share program.
409.9113 Disproportionate share program for teaching hospitals.
409.9115 Disproportionate share program for mental health hospitals.
409.91151 Expenditure of funds generated through mental health disproportionate share program.
409.9116 Disproportionate share/financial assistance program for rural hospitals.
409.9118 Disproportionate share program for specialty hospitals.
409.91188 Specialty prepaid health plans for Medicaid recipients with HIV or AIDS.
409.9119 Disproportionate share program for specialty hospitals for children.
409.91195 Medicaid Pharmaceutical and Therapeutics Committee.
409.91196 Supplemental rebate agreements; public records and public meetings exemption.
409.912 Cost-effective purchasing of health care.
409.91206 Alternatives for health and long-term care reforms.
409.9121 Legislative findings and intent.
409.91211 Medicaid managed care pilot program.
409.91212 Medicaid managed care fraud.
409.91213 Quarterly progress reports and annual reports.
409.9122 Mandatory Medicaid managed care enrollment; programs and procedures.
409.9123 Quality-of-care reporting.
409.9124 Managed care reimbursement.
409.91255 Federally qualified health center access program.
409.9126 Children with special health care needs.
409.9127 Preauthorization and concurrent utilization review; conflict-of-interest standards.
409.9128 Requirements for providing emergency services and care.
409.913 Oversight of the integrity of the Medicaid program.
409.9131 Special provisions relating to integrity of the Medicaid program.
409.9132 Pilot project to monitor home health services.
409.9133 Pilot project for home health care management.
409.914 Assistance for the uninsured.
409.915 County contributions to Medicaid.
409.916 Grants and Donations Trust Fund.
409.918 Public Medical Assistance Trust Fund.
409.919 Rules.
409.920 Medicaid provider fraud.
409.9201 Medicaid fraud.
409.9203 Rewards for reporting Medicaid fraud.
409.9205 Medicaid Fraud Control Unit.
409.901 Definitions; ss. 409.901-409.920.—As used in ss. 409.901-409.920, except as otherwise specifically provided, the term:
(1) “Affiliate” or “affiliated person” means any person who directly or indirectly manages, controls, or oversees the operation of a corporation or other business entity that is a Medicaid provider, regardless of whether such person is a partner, shareholder, owner, officer, director, agent, or employee of the entity.
(2) “Agency” means the Agency for Health Care Administration. The agency is the Medicaid agency for the state, as provided under federal law.
(3) “Applicant” means an individual whose written application for medical assistance provided by Medicaid under ss. 409.903-409.906 has been submitted to the Department of Children and Family Services, or to the Social Security Administration if the application is for Supplemental Security Income, but has not received final action. This term includes an individual, who need not be alive at the time of application, whose application is submitted through a representative or a person acting for the individual.
(4) “Benefit” means any benefit, assistance, aid, obligation, promise, debt, liability, or the like, related to any covered injury, illness, or necessary medical care, goods, or services.
(5) “Change of ownership” means:
(a) An event in which the provider ownership changes to a different individual entity as evidenced by a change in federal employer identification number or taxpayer identification number;
(b) An event in which 51 percent or more of the ownership, shares, membership, or controlling interest of a provider is in any manner transferred or otherwise assigned. This paragraph does not apply to a licensee that is publicly traded on a recognized stock exchange; or
(c) When the provider is licensed or registered by the agency, an event considered a change of ownership for licensure as defined in s. 408.803.
A change solely in the management company or board of directors is not a change of ownership.
(6) “Claim” means any communication, whether written or electronic (electronic impulse or magnetic), which is used by any person to apply for payment from the Medicaid program or its fiscal agent for each item or service purported by any person to have been provided by a person to any Medicaid recipient.
(7) “Collateral” means:
(a) Any and all causes of action, suits, claims, counterclaims, and demands that accrue to the recipient or to the recipient’s legal representative, related to any covered injury, illness, or necessary medical care, goods, or services that necessitated that Medicaid provide medical assistance.
(b) All judgments, settlements, and settlement agreements rendered or entered into and related to such causes of action, suits, claims, counterclaims, demands, or judgments.
(c) Proceeds, as defined in this section.
(8) “Convicted” or “conviction” means a finding of guilt, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere, regardless of whether an appeal from judgment is pending.
(9) “Covered injury or illness” means any sickness, injury, disease, disability, deformity, abnormality disease, necessary medical care, pregnancy, or death for which a third party is, may be, could be, should be, or has been liable, and for which Medicaid is, or may be, obligated to provide, or has provided, medical assistance.
(10) “Emergency medical condition” means:
(a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
1. Serious jeopardy to the health of a patient, including a pregnant woman or a fetus.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
(b) With respect to a pregnant woman:
1. That there is inadequate time to effect safe transfer to another hospital prior to delivery.
2. That a transfer may pose a threat to the health and safety of the patient or fetus.
3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.
(11) “Emergency services and care” means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable laws, by other appropriate personnel under the supervision of a physician, to determine whether an emergency medical condition exists and, if it does, the care, treatment, or surgery for a covered service by a physician which is necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital.
(12) “Legal representative” means a guardian, conservator, survivor, or personal representative of a recipient or applicant, or of the property or estate of a recipient or applicant.
(13) “Managed care plan” means a health maintenance organization authorized pursuant to chapter 641 or a prepaid health plan authorized pursuant to s. 409.912.
(14) “Medicaid” means the medical assistance program authorized by Title XIX of the Social Security Act, 42 U.S.C. s. 1396 et seq., and regulations thereunder, as administered in this state by the agency.
(15) “Medicaid agency” or “agency” means the single state agency that administers or supervises the administration of the state Medicaid plan under federal law.
(16) “Medicaid program” means the program authorized under Title XIX of the federal Social Security Act which provides for payments for medical items or services, or both, on behalf of any person who is determined by the Department of Children and Family Services, or, for Supplemental Security Income, by the Social Security Administration, to be eligible on the date of service for Medicaid assistance.
(17) “Medicaid provider” or “provider” means a person or entity that has a Medicaid provider agreement in effect with the agency and is in good standing with the agency.
(18) “Medicaid provider agreement” or “provider agreement” means a contract between the agency and a provider for the provision of services or goods, or both, to Medicaid recipients pursuant to Medicaid.
(19) “Medicaid recipient” or “recipient” means an individual whom the Department of Children and Family Services, or, for Supplemental Security Income, by the Social Security Administration, determines is eligible, pursuant to federal and state law, to receive medical assistance and related services for which the agency may make payments under the Medicaid program. For the purposes of determining third-party liability, the term includes an individual formerly determined to be eligible for Medicaid, an individual who has received medical assistance under the Medicaid program, or an individual on whose behalf Medicaid has become obligated.
(20) “Medicaid-related records” means records that relate to the provider’s business or profession and to a Medicaid recipient. Medicaid-related records include records related to non-Medicaid customers, clients, or patients but only to the extent that the documentation is shown by the agency to be necessary to determine a provider’s entitlement to payments under the Medicaid program.
(21) “Medical assistance” means any provision of, payment for, or liability for medical services by Medicaid to, or on behalf of, any recipient.
(22) “Medical services” or “medical care” means medical or medically related institutional or noninstitutional care, goods, or services covered by the Medicaid program. The term includes any services authorized and funded in the General Appropriations Act.
(23) “MediPass” means a primary care case management program operated by the agency.
(24) “Minority physician network” means a network of primary care physicians with experience managing Medicaid or Medicare recipients that is predominantly owned by minorities as defined in s. 288.703, which may have a collaborative partnership with a public college or university and a tax-exempt charitable corporation.
(25) “Payment,” as it relates to third-party benefits, means performance of a duty, promise, or obligation, or discharge of a debt or liability, by the delivery, provision, or transfer of third-party benefits for medical services. To “pay” means to do any of the acts set forth in this subsection.
(26) “Proceeds” means whatever is received upon the sale, exchange, collection, or other disposition of the collateral or proceeds thereon and includes insurance payable by reason of loss or damage to the collateral or proceeds. Money, checks, deposit accounts, and the like are “cash proceeds.” All other proceeds are “noncash proceeds.”
(27) “Third party” means an individual, entity, or program, excluding Medicaid, that is, may be, could be, should be, or has been liable for all or part of the cost of medical services related to any medical assistance covered by Medicaid. A third party includes a third-party administrator or a pharmacy benefits manager.
(28) “Third-party benefit” means any benefit that is or may be available at any time through contract, court award, judgment, settlement, agreement, or any arrangement between a third party and any person or entity, including, without limitation, a Medicaid recipient, a provider, another third party, an insurer, or the agency, for any Medicaid-covered injury, illness, goods, or services, including costs of medical services related thereto, for personal injury or for death of the recipient, but specifically excluding policies of life insurance on the recipient, unless available under terms of the policy to pay medical expenses prior to death. The term includes, without limitation, collateral, as defined in this section, health insurance, any benefit under a health maintenance organization, a preferred provider arrangement, a prepaid health clinic, liability insurance, uninsured motorist insurance or personal injury protection coverage, medical benefits under workers’ compensation, and any obligation under law or equity to provide medical support.
History.—s. 30, ch. 91-282; s. 1, ch. 95-393; s. 4, ch. 96-199; s. 1, ch. 96-387; s. 1, ch. 96-417; s. 183, ch. 99-8; s. 11, ch. 2000-163; s. 48, ch. 2000-256; s. 7, ch. 2003-405; s. 2, ch. 2004-365; s. 11, ch. 2008-246; s. 58, ch. 2009-223.
409.902 Designated single state agency; payment requirements; program title; release of medical records.—
(1) The Agency for Health Care Administration is designated as the single state agency authorized to make payments for medical assistance and related services under Title XIX of the Social Security Act. These payments shall be made, subject to any limitations or directions provided for in the General Appropriations Act, only for services included in the program, shall be made only on behalf of eligible individuals, and shall be made only to qualified providers in accordance with federal requirements for Title XIX of the Social Security Act and the provisions of state law. This program of medical assistance is designated the “Medicaid program.” The Department of Children and Family Services is responsible for Medicaid eligibility determinations, including, but not limited to, policy, rules, and the agreement with the Social Security Administration for Medicaid eligibility determinations for Supplemental Security Income recipients, as well as the actual determination of eligibility. As a condition of Medicaid eligibility, subject to federal approval, the Agency for Health Care Administration and the Department of Children and Family Services shall ensure that each recipient of Medicaid consents to the release of her or his medical records to the Agency for Health Care Administration and the Medicaid Fraud Control Unit of the Department of Legal Affairs.
(2) Eligibility is restricted to United States citizens and to lawfully admitted noncitizens who meet the criteria provided in s. 414.095(3).
(a) Citizenship or immigration status must be verified. For noncitizens, this includes verification of the validity of documents with the United States Citizenship and Immigration Services using the federal SAVE verification process.
(b) State funds may not be used to provide medical services to individuals who do not meet the requirements of this subsection unless the services are necessary to treat an emergency medical condition or are for pregnant women. Such services are authorized only to the extent provided under federal law and in accordance with federal regulations as provided in 42 C.F.R. s. 440.255.
(3) To the extent that funds are appropriated, the department shall collaborate with the Agency for Health Care Administration to develop an Internet-based system that is modular, interoperable, and scalable for eligibility determination for Medicaid and the Children’s Health Insurance Program (CHIP) that complies with all applicable federal and state laws and requirements.
(4) The system shall accomplish the following primary business objectives:
(a) Provide individuals and families with a single point of access to information that explains benefits, premiums, and cost sharing available through Medicaid, the Children’s Health Insurance Program, or any other state or federal health insurance exchange.
(b) Enable timely, accurate, and efficient enrollment of eligible persons into available assistance programs.
(c) Prevent eligibility fraud.
(d) Allow for detailed financial analysis of eligibility-based cost drivers.
(5) The system shall include, but is not limited to, the following business and functional requirements:
(a) Allow for the completion and submission of an online application for eligibility determination that accepts the use of electronic signatures.
(b) Include a process that enables automatic enrollment of qualified individuals in Medicaid, the Children’s Health Insurance Program, or any other state or federal exchange that offers cost-sharing benefits for the purchase of health insurance.
(c) Allow for the determination of Medicaid eligibility based on modified adjusted gross income by using information submitted in the application and information accessed and verified through automated and secure interfaces with authorized databases.
(d) Include the ability to determine specific categories of Medicaid eligibility and interfaces with the Florida Medicaid Management Information System to support a determination, using federally approved assessment methodologies, of state and federal financial participation rates for persons in each eligibility category.
(e) Allow for the accurate and timely processing of eligibility claims and adjudications.
(f) Align with and incorporate all applicable state and federal laws, requirements, and standards to include the information technology security requirements established pursuant to s. 282.318 and the accessibility standards established under part II of chapter 282.
(g) Produce transaction data, reports, and performance information that contribute to an evaluation of the program, continuous improvement in business operations, and increased transparency and accountability.
(6) The department shall develop the system, subject to the approval by the Legislative Budget Commission and as required by the General Appropriations Act for the 2012-2013 fiscal year.
(7) The system must be completed by October 1, 2013, and ready for implementation by January 1, 2014.
(8) The department shall implement the following project governance structure until the system is implemented:
(a) The Secretary of Children and Family Services shall have overall responsibility for the project.
(b) The project shall be governed by an executive steering committee composed of three department staff members appointed by the Secretary of Children and Family Services; three agency staff members, including at least two state Medicaid program staff members, appointed by the Secretary of the Agency for Health Care Administration; one staff member from Children’s Medical Services within the Department of Health appointed by the Surgeon General; and a representative from the Florida Healthy Kids Corporation.
(c) The executive steering committee shall have the overall responsibility for ensuring that the project meets its primary business objectives and shall:
1. Provide management direction and support to the project management team.
2. Review and approve any changes to the project’s scope, schedule, and budget.
3. Review, approve, and determine whether to proceed with any major deliverable project.
4. Recommend suspension or termination of the project to the Governor, the President of the Senate, and the Speaker of the House of Representatives if the committee determines that the primary business objectives cannot be achieved.
(d) A project management team shall be appointed by and work under the direction of the executive steering committee. The project management team shall:
1. Provide planning, management, and oversight of the project.
2. Submit an operational work plan and provide quarterly updates to the plan to the executive steering committee. The plan must specify project milestones, deliverables, and expenditures.
3. Submit written monthly project status reports to the executive steering committee.
History.—s. 31, ch. 91-282; s. 2, ch. 95-393; s. 12, ch. 2000-163; s. 49, ch. 2000-256; s. 15, ch. 2002-400; s. 32, ch. 2011-135; s. 4, ch. 2012-33.
409.90201 Recipient address update process.—The Agency for Health Care Administration and the Department of Children and Family Services, in consultation with hospitals and nursing homes that serve Medicaid recipients, shall develop a process to update a recipient’s address in the Medicaid eligibility system at the time a recipient is admitted to a hospital or nursing home. If a recipient’s address information in the Medicaid eligibility system needs to be updated, the update shall be completed within 10 days after the recipient’s admission to a hospital or nursing home.
History.—s. 13, ch. 2012-33
409.9021 Forfeiture of eligibility agreement.—As a condition of Medicaid eligibility, subject to federal approval, a Medicaid applicant shall agree in writing to forfeit all entitlements to any goods or services provided through the Medicaid program for the next 10 years if he or she has been found to have committed Medicaid fraud, through judicial or administrative determination. This provision applies only to the Medicaid recipient found to have committed or participated in Medicaid fraud and does not apply to any family member of the recipient who was not involved in the fraud.
History.—s. 4, ch. 2004-344; s. 8, ch. 2011-135.
409.9025 Eligibility while an inmate.—
(1) Notwithstanding any other provision of law other than s. 409.9021, in the event that a person who is an inmate in the state’s correctional system as defined in s. 944.02, in a county detention facility as defined in s. 951.23, or in a municipal detention facility as defined in s. 951.23 was in receipt of medical assistance under this chapter immediately prior to being admitted as an inmate, such person shall remain eligible for medical assistance while an inmate, except that no medical assistance shall be furnished under this chapter for any care, services, or supplies provided during such time as the person is an inmate; however, nothing in this section shall be deemed as preventing the provision of medical assistance for inpatient hospital services furnished to an inmate at a hospital outside of the premises of the inmate’s facility to the extent that federal financial participation is available for the costs of such services.
(2) Upon release from incarceration, such person shall continue to be eligible for receipt of medical assistance furnished under this chapter until such time as the person is otherwise determined to no longer be eligible for such assistance.
(3) To the extent permitted by federal law, the time during which such person is an inmate shall not be included in any calculation of when the person must recertify his or her eligibility for medical assistance in accordance with this chapter.
History.—s. 1, ch. 2008-217.
409.903 Mandatory payments for eligible persons.—The agency shall make payments for medical assistance and related services on behalf of the following persons who the department, or the Social Security Administration by contract with the Department of Children and Family Services, determines to be eligible, subject to the income, assets, and categorical eligibility tests set forth in federal and state law. Payment on behalf of these Medicaid eligible persons is subject to the availability of moneys and any limitations established by the General Appropriations Act or chapter 216.
(1) Low-income families with children are eligible for Medicaid provided they meet the following requirements:
(a) The family includes a dependent child who is living with a caretaker relative.
(b) The family’s income does not exceed the gross income test limit.
(c) The family’s countable income and resources do not exceed the applicable Aid to Families with Dependent Children (AFDC) income and resource standards under the AFDC state plan in effect in July 1996, except as amended in the Medicaid state plan to conform as closely as possible to the requirements of the welfare transition program, to the extent permitted by federal law.
(2) A person who receives payments from, who is determined eligible for, or who was eligible for but lost cash benefits from the federal program known as the Supplemental Security Income program (SSI). This category includes a low-income person age 65 or over and a low-income person under age 65 considered to be permanently and totally disabled.
(3) A child under age 21 living in a low-income, two-parent family, and a child under age 7 living with a nonrelative, if the income and assets of the family or child, as applicable, do not exceed the resource limits under the Temporary Cash Assistance Program.
(4) A child who is eligible under Title IV-E of the Social Security Act for subsidized board payments, foster care, or adoption subsidies, and a child for whom the state has assumed temporary or permanent responsibility and who does not qualify for Title IV-E assistance but is in foster care, shelter or emergency shelter care, or subsidized adoption. This category includes a young adult who is eligible to receive services under s. 409.1451, until the young adult reaches 21 years of age, without regard to any income, resource, or categorical eligibility test that is otherwise required. This category also includes a person who as a child was eligible under Title IV-E of the Social Security Act for foster care or the state-provided foster care and who is a participant in the Road-to-Independence Program.
(5) A pregnant woman for the duration of her pregnancy and for the postpartum period as defined in federal law and rule, or a child under age 1, if either is living in a family that has an income which is at or below 150 percent of the most current federal poverty level, or, effective January 1, 1992, that has an income which is at or below 185 percent of the most current federal poverty level. Such a person is not subject to an assets test. Further, a pregnant woman who applies for eligibility for the Medicaid program through a qualified Medicaid provider must be offered the opportunity, subject to federal rules, to be made presumptively eligible for the Medicaid program.
(6) A child born after September 30, 1983, living in a family that has an income which is at or below 100 percent of the current federal poverty level, who has attained the age of 6, but has not attained the age of 19. In determining the eligibility of such a child, an assets test is not required. A child who is eligible for Medicaid under this subsection must be offered the opportunity, subject to federal rules, to be made presumptively eligible. A child who has been deemed presumptively eligible for Medicaid shall not be enrolled in a managed care plan until the child’s full eligibility determination for Medicaid has been completed.
(7) A child living in a family that has an income which is at or below 133 percent of the current federal poverty level, who has attained the age of 1, but has not attained the age of 6. In determining the eligibility of such a child, an assets test is not required. A child who is eligible for Medicaid under this subsection must be offered the opportunity, subject to federal rules, to be made presumptively eligible. A child who has been deemed presumptively eligible for Medicaid shall not be enrolled in a managed care plan until the child’s full eligibility determination for Medicaid has been completed.
(8) A person who is age 65 or over or is determined by the agency to be disabled, whose income is at or below 100 percent of the most current federal poverty level and whose assets do not exceed limitations established by the agency. However, the agency may only pay for premiums, coinsurance, and deductibles, as required by federal law, unless additional coverage is provided for any or all members of this group by s. 409.904(1).
History.—s. 32, ch. 91-282; s. 97, ch. 96-175; s. 27, ch. 98-191; s. 13, ch. 2000-163; s. 95, ch. 2000-165; s. 8, ch. 2000-253; s. 50, ch. 2000-256; s. 8, ch. 2002-19; s. 6, ch. 2004-270; s. 4, ch. 2005-60; s. 13, ch. 2006-194; s. 3, ch. 2007-147; s. 11, ch. 2010-209; s. 10, ch. 2013-178.
409.904 Optional payments for eligible persons.—The agency may make payments for medical assistance and related services on behalf of the following persons who are determined to be eligible subject to the income, assets, and categorical eligibility tests set forth in federal and state law. Payment on behalf of these Medicaid eligible persons is subject to the availability of moneys and any limitations established by the General Appropriations Act or chapter 216.
(1) Subject to federal waiver approval, a person who is age 65 or older or is determined to be disabled, whose income is at or below 88 percent of the federal poverty level, whose assets do not exceed established limitations, and who is not eligible for Medicare or, if eligible for Medicare, is also eligible for and receiving Medicaid-covered institutional care services, hospice services, or home and community-based services. The agency shall seek federal authorization through a waiver to provide this coverage.
(2) A family, a pregnant woman, a child under age 21, a person age 65 or over, or a blind or disabled person, who would be eligible under any group listed in s. 409.903(1), (2), or (3), except that the income or assets of such family or person exceed established limitations. For a family or person in one of these coverage groups, medical expenses are deductible from income in accordance with federal requirements in order to make a determination of eligibility. A family or person eligible under the coverage known as the “medically needy,” is eligible to receive the same services as other Medicaid recipients, with the exception of services in skilled nursing facilities and intermediate care facilities for the developmentally disabled.
(3) A person who is in need of the services of a licensed nursing facility, a licensed intermediate care facility for the developmentally disabled, or a state mental hospital, whose income does not exceed 300 percent of the SSI income standard, and who meets the assets standards established under federal and state law. In determining the person’s responsibility for the cost of care, the following amounts must be deducted from the person’s income:
(a) The monthly personal allowance for residents as set based on appropriations.
(b) The reasonable costs of medically necessary services and supplies that are not reimbursable by the Medicaid program.
(c) The cost of premiums, copayments, coinsurance, and deductibles for supplemental health insurance.
(4) A low-income person who meets all other requirements for Medicaid eligibility except citizenship and who is in need of emergency medical services. The eligibility of such a recipient is limited to the period of the emergency, in accordance with federal regulations.
(5) Subject to specific federal authorization, a woman living in a family that has an income that is at or below 185 percent of the most current federal poverty level is eligible for family planning services as specified in s. 409.905(3) for a period of up to 24 months following a loss of Medicaid benefits.
(6) A child who has not attained the age of 19 who has been determined eligible for the Medicaid program is deemed to be eligible for a total of 6 months, regardless of changes in circumstances other than attainment of the maximum age. Effective January 1, 1999, a child who has not attained the age of 5 and who has been determined eligible for the Medicaid program is deemed to be eligible for a total of 12 months regardless of changes in circumstances other than attainment of the maximum age.
(7) A child under 1 year of age who lives in a family that has an income above 185 percent of the most recently published federal poverty level, but which is at or below 200 percent of such poverty level. In determining the eligibility of such child, an assets test is not required. A child who is eligible for Medicaid under this subsection must be offered the opportunity, subject to federal rules, to be made presumptively eligible.
(8) A Medicaid-eligible individual for the individual’s health insurance premiums, if the agency determines that such payments are cost-effective.
(9) Eligible women with incomes at or below 200 percent of the federal poverty level and under age 65, for cancer treatment pursuant to the federal Breast and Cervical Cancer Prevention and Treatment Act of 2000, screened through the Mary Brogan Breast and Cervical Cancer Early Detection Program established under s. 381.93.
History.—s. 33, ch. 91-282; s. 2, ch. 96-417; s. 11, ch. 97-263; s. 51, ch. 98-288; s. 9, ch. 2000-253; s. 2, ch. 2001-52; s. 1, ch. 2001-104; ss. 1, 2, ch. 2001-377; ss. 16, 17, ch. 2002-400; s. 1, ch. 2003-9; s. 8, ch. 2003-405; s. 51, ch. 2004-5; s. 7, ch. 2004-270; s. 5, ch. 2005-60; s. 9, ch. 2006-28; s. 3, ch. 2008-143; s. 4, ch. 2009-55; s. 4, ch. 2010-156; s. 3, ch. 2011-61.
409.905 Mandatory Medicaid services.—The agency may make payments for the following services, which are required of the state by Title XIX of the Social Security Act, furnished by Medicaid providers to recipients who are determined to be eligible on the dates on which the services were provided. Any service under this section shall be provided only when medically necessary and in accordance with state and federal law. Mandatory services rendered by providers in mobile units to Medicaid recipients may be restricted by the agency. Nothing in this section shall be construed to prevent or limit the agency from adjusting fees, reimbursement rates, lengths of stay, number of visits, number of services, or any other adjustments necessary to comply with the availability of moneys and any limitations or directions provided for in the General Appropriations Act or chapter 216.
(1) ADVANCED REGISTERED NURSE PRACTITIONER SERVICES.—The agency shall pay for services provided to a recipient by a licensed advanced registered nurse practitioner who has a valid collaboration agreement with a licensed physician on file with the Department of Health or who provides anesthesia services in accordance with established protocol required by state law and approved by the medical staff of the facility in which the anesthetic service is performed. Reimbursement for such services must be provided in an amount that equals not less than 80 percent of the reimbursement to a physician who provides the same services, unless otherwise provided for in the General Appropriations Act.
(2) EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT SERVICES.—The agency shall pay for early and periodic screening and diagnosis of a recipient under age 21 to ascertain physical and mental problems and conditions and all services determined by the agency to be medically necessary for the treatment, correction, or amelioration of these problems and conditions, including personal care, private duty nursing, durable medical equipment, physical therapy, occupational therapy, speech therapy, respiratory therapy, and immunizations.
(3) FAMILY PLANNING SERVICES.—The agency shall pay for services necessary to enable a recipient voluntarily to plan family size or to space children. These services include information; education; counseling regarding the availability, benefits, and risks of each method of pregnancy prevention; drugs and supplies; and necessary medical care and followup. Each recipient participating in the family planning portion of the Medicaid program must be provided freedom to choose any alternative method of family planning, as required by federal law.
(4) HOME HEALTH CARE SERVICES.—The agency shall pay for nursing and home health aide services, supplies, appliances, and durable medical equipment, necessary to assist a recipient living at home. An entity that provides such services must be licensed under part III of chapter 400. These services, equipment, and supplies, or reimbursement therefor, may be limited as provided in the General Appropriations Act and do not include services, equipment, or supplies provided to a person residing in a hospital or nursing facility.
(a) The agency shall require prior authorization of home health services based on diagnosis, utilization rates, and billing rates. The home health agency must submit the recipient’s plan of care and documentation that supports the recipient’s diagnosis to the agency when requesting prior authorization.
(b) The agency shall implement a comprehensive utilization management program of all private duty nursing services, an individualized treatment plan that includes information about medication and treatment orders, treatment goals, methods of care to be used, and plans for care coordination by nurses and other health professionals. The utilization management program must also include a process for periodically reviewing the ongoing use of private duty nursing services. The assessment of need shall be based on a child’s condition; family support and care supplements; a family’s ability to provide care; a family’s and child’s schedule regarding work, school, sleep, and care for other family dependents; and a determination of the medical necessity for private duty nursing instead of other more cost-effective in-home services. When implemented, the private duty nursing utilization management program shall replace the current authorization program used by the agency and the Children’s Medical Services program of the Department of Health. The agency may competitively bid a contract to select a qualified organization to provide utilization management of private duty nursing services. The agency may seek federal waivers to implement this initiative.
(c) The agency may not pay for home health services unless the services are medically necessary and:
1. The services are ordered by a physician.
2. The written prescription for the services is signed and dated by the recipient’s physician before the development of a plan of care and before any request requiring prior authorization.
3. The physician ordering the services is not employed, under contract with, or otherwise affiliated with the home health agency rendering the services. However, this subparagraph does not apply to a home health agency affiliated with a retirement community, of which the parent corporation or a related legal entity owns a rural health clinic certified under 42 C.F.R. part 491, subpart A, ss. 1-11, a nursing home licensed under part II of chapter 400, or an apartment or single-family home for independent living. For purposes of this subparagraph, the agency may, on a case-by-case basis, provide an exception for medically fragile children who are younger than 21 years of age.
4. The physician ordering the services has examined the recipient within the 30 days preceding the initial request for the services and biannually thereafter.
5. The written prescription for the services includes the recipient’s acute or chronic medical condition or diagnosis, the home health service required, and, for skilled nursing services, the frequency and duration of the services.
6. The national provider identifier, Medicaid identification number, or medical practitioner license number of the physician ordering the services is listed on the written prescription for the services, the claim for home health reimbursement, and the prior authorization request.
(5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for all covered services provided for the medical care and treatment of a recipient who is admitted as an inpatient by a licensed physician or dentist to a hospital licensed under part I of chapter 395. However, the agency shall limit the payment for inpatient hospital services for a Medicaid recipient 21 years of age or older to 45 days or the number of days necessary to comply with the General Appropriations Act. Effective August 1, 2012, the agency shall limit payment for hospital emergency department visits for a nonpregnant Medicaid recipient 21 years of age or older to six visits per fiscal year.
(a) The agency may implement reimbursement and utilization management reforms in order to comply with any limitations or directions in the General Appropriations Act, which may include, but are not limited to: prior authorization for inpatient psychiatric days; prior authorization for nonemergency hospital inpatient admissions for individuals 21 years of age and older; authorization of emergency and urgent-care admissions within 24 hours after admission; enhanced utilization and concurrent review programs for highly utilized services; reduction or elimination of covered days of service; adjusting reimbursement ceilings for variable costs; adjusting reimbursement ceilings for fixed and property costs; and implementing target rates of increase. The agency may limit prior authorization for hospital inpatient services to selected diagnosis-related groups, based on an analysis of the cost and potential for unnecessary hospitalizations represented by certain diagnoses. Admissions for normal delivery and newborns are exempt from requirements for prior authorization. In implementing the provisions of this section related to prior authorization, the agency shall ensure that the process for authorization is accessible 24 hours per day, 7 days per week and authorization is automatically granted when not denied within 4 hours after the request. Authorization procedures must include steps for review of denials. Upon implementing the prior authorization program for hospital inpatient services, the agency shall discontinue its hospital retrospective review program.
(b) A licensed hospital maintained primarily for the care and treatment of patients having mental disorders or mental diseases is not eligible to participate in the hospital inpatient portion of the Medicaid program except as provided in federal law. However, the department shall apply for a waiver, within 9 months after June 5, 1991, designed to provide hospitalization services for mental health reasons to children and adults in the most cost-effective and lowest cost setting possible. Such waiver shall include a request for the opportunity to pay for care in hospitals known under federal law as “institutions for mental disease” or “IMD’s.” The waiver proposal shall propose no additional aggregate cost to the state or Federal Government, and shall be conducted in Hillsborough County, Highlands County, Hardee County, Manatee County, and Polk County. The waiver proposal may incorporate competitive bidding for hospital services, comprehensive brokering, prepaid capitated arrangements, or other mechanisms deemed by the department to show promise in reducing the cost of acute care and increasing the effectiveness of preventive care. When developing the waiver proposal, the department shall take into account price, quality, accessibility, linkages of the hospital to community services and family support programs, plans of the hospital to ensure the earliest discharge possible, and the comprehensiveness of the mental health and other health care services offered by participating providers.
(c) The agency shall implement a prospective payment methodology for establishing reimbursement rates for inpatient hospital services. Rates shall be calculated annually and take effect July 1 of each year. The methodology shall categorize each inpatient admission into a diagnosis-related group and assign a relative payment weight to the base rate according to the average relative amount of hospital resources used to treat a patient in a specific diagnosis-related group category. The agency may adopt the most recent relative weights calculated and made available by the Nationwide Inpatient Sample maintained by the Agency for Healthcare Research and Quality or may adopt alternative weights if the agency finds that Florida-specific weights deviate with statistical significance from national weights for high-volume diagnosis-related groups. The agency shall establish a single, uniform base rate for all hospitals unless specifically exempt pursuant to s. 409.908(1).
1. Adjustments may not be made to the rates after October 31 of the state fiscal year in which the rates take effect, except for cases of insufficient collections of intergovernmental transfers authorized under s. 409.908(1) or the General Appropriations Act. In such cases, the agency shall submit a budget amendment or amendments under chapter 216 requesting approval of rate reductions by amounts necessary for the aggregate reduction to equal the dollar amount of intergovernmental transfers not collected and the corresponding federal match. Notwithstanding the $1 million limitation on increases to an approved operating budget contained in ss. 216.181(11) and 216.292(3), a budget amendment exceeding that dollar amount is subject to notice and objection procedures set forth in s. 216.177.
2. Errors in source data or calculations discovered after October 31 must be reconciled in a subsequent rate period. However, the agency may not make any adjustment to a hospital’s reimbursement more than 5 years after a hospital is notified of an audited rate established by the agency. The prohibition against adjustments more than 5 years after notification is remedial and applies to actions by providers involving Medicaid claims for hospital services. Hospital reimbursement is subject to such limits or ceilings as may be established in law or described in the agency’s hospital reimbursement plan. Specific exemptions to the limits or ceilings may be provided in the General Appropriations Act.
(d) The agency shall implement a comprehensive utilization management program for hospital neonatal intensive care stays in certain high-volume participating hospitals, select counties, or statewide, and replace existing hospital inpatient utilization management programs for neonatal intensive care admissions. The program shall be designed to manage appropriate admissions and discharges for children being treated in neonatal intensive care units and must seek medically appropriate discharge to the child’s home or other less costly treatment setting. The agency may competitively bid a contract for the selection of a qualified organization to provide neonatal intensive care utilization management services. The agency may seek federal waivers to implement this initiative.
(e) The agency may develop and implement a program to reduce the number of hospital readmissions among the non-Medicare population eligible in areas 9, 10, and 11.
(6) HOSPITAL OUTPATIENT SERVICES.—
(a) The agency shall pay for preventive, diagnostic, therapeutic, or palliative care and other services provided to a recipient in the outpatient portion of a hospital licensed under part I of chapter 395, and provided under the direction of a licensed physician or licensed dentist, except that payment for such care and services is limited to $1,500 per state fiscal year per recipient, unless an exception has been made by the agency, and with the exception of a Medicaid recipient under age 21, in which case the only limitation is medical necessity.
(b) The agency shall implement a methodology for establishing base reimbursement rates for outpatient services for each hospital based on allowable costs, as defined by the agency. Rates shall be calculated annually and take effect July 1 of each year based on the most recent complete and accurate cost report submitted by each hospital.
1. Adjustments may not be made to the rates after October 31 of the state fiscal year in which the rates take effect, except for cases of insufficient collections of intergovernmental transfers authorized under s. 409.908(1) or the General Appropriations Act. In such cases, the agency shall submit a budget amendment or amendments under chapter 216 requesting approval of rate reductions by amounts necessary for the aggregate reduction to equal the dollar amount of intergovernmental transfers not collected and the corresponding federal match. Notwithstanding the $1 million limitation on increases to an approved operating budget under ss. 216.181(11) and 216.292(3), a budget amendment exceeding that dollar amount is subject to notice and objection procedures set forth in s. 216.177.
2. Errors in source data or calculations discovered after October 31 must be reconciled in a subsequent rate period. However, the agency may not make any adjustment to a hospital’s reimbursement more than 5 years after a hospital is notified of an audited rate established by the agency. The prohibition against adjustments more than 5 years after notification is remedial and applies to actions by providers involving Medicaid claims for hospital services. Hospital reimbursement is subject to such limits or ceilings as may be established in law or described in the agency’s hospital reimbursement plan. Specific exemptions to the limits or ceilings may be provided in the General Appropriations Act.
(7) INDEPENDENT LABORATORY SERVICES.—The agency shall pay for medically necessary diagnostic laboratory procedures ordered by a licensed physician or other licensed practitioner of the healing arts which are provided for a recipient in a laboratory that meets the requirements for Medicare participation and is licensed under chapter 483, if required.
(8) NURSING FACILITY SERVICES.—The agency shall pay for 24-hour-a-day nursing and rehabilitative services for a recipient in a nursing facility licensed under part II of chapter 400 or in a rural hospital, as defined in s. 395.602, or in a Medicare certified skilled nursing facility operated by a hospital, as defined by s. 395.002(10), that is licensed under part I of chapter 395, and in accordance with provisions set forth in s. 409.908(2)(a), which services are ordered by and provided under the direction of a licensed physician. However, if a nursing facility has been destroyed or otherwise made uninhabitable by natural disaster or other emergency and another nursing facility is not available, the agency must pay for similar services temporarily in a hospital licensed under part I of chapter 395 provided federal funding is approved and available. The agency shall pay only for bed-hold days if the facility has an occupancy rate of 95 percent or greater. The agency is authorized to seek any federal waivers to implement this policy.
(9) PHYSICIAN SERVICES.—The agency shall pay for covered services and procedures rendered to a recipient by, or under the personal supervision of, a person licensed under state law to practice medicine or osteopathic medicine. These services may be furnished in the physician’s office, the Medicaid recipient’s home, a hospital, a nursing facility, or elsewhere, but shall be medically necessary for the treatment of an injury, illness, or disease within the scope of the practice of medicine or osteopathic medicine as defined by state law. The agency shall not pay for services that are clinically unproven, experimental, or for purely cosmetic purposes.
(10) PORTABLE X-RAY SERVICES.—The agency shall pay for professional and technical portable radiological services ordered by a licensed physician or other licensed practitioner of the healing arts which are provided by a licensed professional in a setting other than a hospital, clinic, or office of a physician or practitioner of the healing arts, on behalf of a recipient.
(11) RURAL HEALTH CLINIC SERVICES.—The agency shall pay for outpatient primary health care services for a recipient provided by a clinic certified by and participating in the Medicare program which is located in a federally designated, rural, medically underserved area and has on its staff one or more licensed primary care nurse practitioners or physician assistants, and a licensed staff supervising physician or a consulting supervising physician.
(12) TRANSPORTATION SERVICES.—The agency shall ensure that appropriate transportation services are available for a Medicaid recipient in need of transport to a qualified Medicaid provider for medically necessary and Medicaid-compensable services, provided a client’s ability to choose a specific transportation provider shall be limited to those options resulting from policies established by the agency to meet the fiscal limitations of the General Appropriations Act. The agency may pay for transportation and other related travel expenses as necessary only if these services are not otherwise available.
History.—s. 34, ch. 91-282; s. 32, ch. 93-129; s. 27, ch. 93-211; s. 56, ch. 94-218; s. 3, ch. 94-317; s. 3, ch. 95-393; s. 3, ch. 96-417; s. 64, ch. 97-237; s. 12, ch. 97-263; s. 40, ch. 97-264; s. 35, ch. 98-89; s. 57, ch. 2000-153; ss. 14, 29, ch. 2000-163; s. 22, ch. 2000-171; s. 51, ch. 2000-256; s. 3, ch. 2001-104; s. 1, ch. 2001-223; s. 66, ch. 2001-277; s. 18, ch. 2002-400; s. 8, ch. 2004-270; s. 1, ch. 2005-252; s. 10, ch. 2006-28; s. 80, ch. 2006-197; s. 3, ch. 2006-254; s. 136, ch. 2007-230; s. 5, ch. 2009-55; s. 11, ch. 2009-223; s. 92, ch. 2010-5; s. 5, ch. 2010-156; s. 4, ch. 2011-61; s. 9, ch. 2011-135; s. 5, ch. 2012-33; s. 3, ch. 2013-48.
409.906 Optional Medicaid services.—Subject to specific appropriations, the agency may make payments for services which are optional to the state under Title XIX of the Social Security Act and are furnished by Medicaid providers to recipients who are determined to be eligible on the dates on which the services were provided. Any optional service that is provided shall be provided only when medically necessary and in accordance with state and federal law. Optional services rendered by providers in mobile units to Medicaid recipients may be restricted or prohibited by the agency. Nothing in this section shall be construed to prevent or limit the agency from adjusting fees, reimbursement rates, lengths of stay, number of visits, or number of services, or making any other adjustments necessary to comply with the availability of moneys and any limitations or directions provided for in the General Appropriations Act or chapter 216. If necessary to safeguard the state’s systems of providing services to elderly and disabled persons and subject to the notice and review provisions of s. 216.177, the Governor may direct the Agency for Health Care Administration to amend the Medicaid state plan to delete the optional Medicaid service known as “Intermediate Care Facilities for the Developmentally Disabled.” Optional services may include:
(1) ADULT DENTAL SERVICES.—
(a) The agency may pay for medically necessary, emergency dental procedures to alleviate pain or infection. Emergency dental care shall be limited to emergency oral examinations, necessary radiographs, extractions, and incision and drainage of abscess, for a recipient who is 21 years of age or older.
(b) Beginning July 1, 2006, the agency may pay for full or partial dentures, the procedures required to seat full or partial dentures, and the repair and reline of full or partial dentures, provided by or under the direction of a licensed dentist, for a recipient who is 21 years of age or older.
(c) However, Medicaid will not provide reimbursement for dental services provided in a mobile dental unit, except for a mobile dental unit:
1. Owned by, operated by, or having a contractual agreement with the Department of Health and complying with Medicaid’s county health department clinic services program specifications as a county health department clinic services provider.
2. Owned by, operated by, or having a contractual arrangement with a federally qualified health center and complying with Medicaid’s federally qualified health center specifications as a federally qualified health center provider.
3. Rendering dental services to Medicaid recipients, 21 years of age and older, at nursing facilities.
4. Owned by, operated by, or having a contractual agreement with a state-approved dental educational institution.
(2) ADULT HEALTH SCREENING SERVICES.—The agency may pay for an annual routine physical examination, conducted by or under the direction of a licensed physician, for a recipient age 21 or older, without regard to medical necessity, in order to detect and prevent disease, disability, or other health condition or its progression.
(3) AMBULATORY SURGICAL CENTER SERVICES.—The agency may pay for services provided to a recipient in an ambulatory surgical center licensed under part I of chapter 395, by or under the direction of a licensed physician or dentist.
(4) BIRTH CENTER SERVICES.—The agency may pay for examinations and delivery, recovery, and newborn assessment, and related services, provided in a licensed birth center staffed with licensed physicians, certified nurse midwives, and midwives licensed in accordance with chapter 467, to a recipient expected to experience a low-risk pregnancy and delivery.
(5) CASE MANAGEMENT SERVICES.—The agency may pay for primary care case management services rendered to a recipient pursuant to a federally approved waiver, and targeted case management services for specific groups of targeted recipients, for which funding has been provided and which are rendered pursuant to federal guidelines. The agency is authorized to limit reimbursement for targeted case management services in order to comply with any limitations or directions provided for in the General Appropriations Act.
(6) CHILDREN’S DENTAL SERVICES.—The agency may pay for diagnostic, preventive, or corrective procedures, including orthodontia in severe cases, provided to a recipient under age 21, by or under the supervision of a licensed dentist. Services provided under this program include treatment of the teeth and associated structures of the oral cavity, as well as treatment of disease, injury, or impairment that may affect the oral or general health of the individual. However, Medicaid will not provide reimbursement for dental services provided in a mobile dental unit, except for a mobile dental unit:
(a) Owned by, operated by, or having a contractual agreement with the Department of Health and complying with Medicaid’s county health department clinic services program specifications as a county health department clinic services provider.
(b) Owned by, operated by, or having a contractual arrangement with a federally qualified health center and complying with Medicaid’s federally qualified health center specifications as a federally qualified health center provider.
(c) Rendering dental services to Medicaid recipients, 21 years of age and older, at nursing facilities.
(d) Owned by, operated by, or having a contractual agreement with a state-approved dental educational institution.
(7) CHIROPRACTIC SERVICES.—The agency may pay for manual manipulation of the spine and initial services, screening, and X rays provided to a recipient by a licensed chiropractic physician.
(8) COMMUNITY MENTAL HEALTH SERVICES.—
(a) The agency may pay for rehabilitative services provided to a recipient by a mental health or substance abuse provider under contract with the agency or the Department of Children and Family Services to provide such services. Those services which are psychiatric in nature shall be rendered or recommended by a psychiatrist, and those services which are medical in nature shall be rendered or recommended by a physician or psychiatrist. The agency must develop a provider enrollment process for community mental health providers which bases provider enrollment on an assessment of service need. The provider enrollment process shall be designed to control costs, prevent fraud and abuse, consider provider expertise and capacity, and assess provider success in managing utilization of care and measuring treatment outcomes. Providers will be selected through a competitive procurement or selective contracting process. In addition to other community mental health providers, the agency shall consider for enrollment mental health programs licensed under chapter 395 and group practices licensed under chapter 458, chapter 459, chapter 490, or chapter 491. The agency is also authorized to continue operation of its behavioral health utilization management program and may develop new services if these actions are necessary to ensure savings from the implementation of the utilization management system. The agency shall coordinate the implementation of this enrollment process with the Department of Children and Family Services and the Department of Juvenile Justice. The agency is authorized to utilize diagnostic criteria in setting reimbursement rates, to preauthorize certain high-cost or highly utilized services, to limit or eliminate coverage for certain services, or to make any other adjustments necessary to comply with any limitations or directions provided for in the General Appropriations Act.
(b) The agency is authorized to implement reimbursement and use management reforms in order to comply with any limitations or directions in the General Appropriations Act, which may include, but are not limited to: prior authorization of treatment and service plans; prior authorization of services; enhanced use review programs for highly used services; and limits on services for those determined to be abusing their benefit coverages.
(9) DIALYSIS FACILITY SERVICES.—Subject to specific appropriations being provided for this purpose, the agency may pay a dialysis facility that is approved as a dialysis facility in accordance with Title XVIII of the Social Security Act, for dialysis services that are provided to a Medicaid recipient under the direction of a physician licensed to practice medicine or osteopathic medicine in this state, including dialysis services provided in the recipient’s home by a hospital-based or freestanding dialysis facility.
(10) DURABLE MEDICAL EQUIPMENT.—The agency may authorize and pay for certain durable medical equipment and supplies provided to a Medicaid recipient as medically necessary.
(11) HEALTHY START SERVICES.—The agency may pay for a continuum of risk-appropriate medical and psychosocial services for the Healthy Start program in accordance with a federal waiver. The agency may not implement the federal waiver unless the waiver permits the state to limit enrollment or the amount, duration, and scope of services to ensure that expenditures will not exceed funds appropriated by the Legislature or available from local sources. If the Health Care Financing Administration does not approve a federal waiver for Healthy Start services, the agency, in consultation with the Department of Health and the Florida Association of Healthy Start Coalitions, is authorized to establish a Medicaid certified-match program for Healthy Start services. Participation in the Healthy Start certified-match program shall be voluntary, and reimbursement shall be limited to the federal Medicaid share to Medicaid-enrolled Healthy Start coalitions for services provided to Medicaid recipients. The agency shall take no action to implement a certified-match program without ensuring that the amendment and review requirements of ss. 216.177 and 216.181 have been met.
(12) HEARING SERVICES.—The agency may pay for hearing and related services, including hearing evaluations, hearing aid devices, dispensing of the hearing aid, and related repairs, if provided to a recipient by a licensed hearing aid specialist, otolaryngologist, otologist, audiologist, or physician.
(13) HOME AND COMMUNITY-BASED SERVICES.—
(a) The agency may pay for home-based or community-based services that are rendered to a recipient in accordance with a federally approved waiver program. The agency may limit or eliminate coverage for certain services, preauthorize high-cost or highly utilized services, or make any other adjustments necessary to comply with any limitations or directions provided for in the General Appropriations Act.
(b) The agency may consolidate types of services offered in the Aged and Disabled Waiver, the Channeling Waiver, the Project AIDS Care Waiver, and the Traumatic Brain and Spinal Cord Injury Waiver programs in order to group similar services under a single service, or continue a service upon evidence of the need for including a particular service type in a particular waiver. The agency is authorized to seek a Medicaid state plan amendment or federal waiver approval to implement this policy.
(c) The agency may implement a utilization management program designed to prior-authorize home and community-based service plans and includes, but is not limited to, assessing proposed quantity and duration of services and monitoring ongoing service use by participants in the program. The agency is authorized to competitively procure a qualified organization to provide utilization management of home and community-based services. The agency is authorized to seek any federal waivers to implement this initiative.
(d) The agency shall request federal approval to develop a system to require payment of premiums or other cost sharing by the parents of a child who is being served by a waiver under this subsection if the adjusted household income is greater than 100 percent of the federal poverty level. The amount of the premium or cost sharing shall be calculated using a sliding scale based on the size of the family, the amount of the parent’s adjusted gross income, and the federal poverty guidelines. The premium and cost-sharing system developed by the agency shall not adversely affect federal funding to the state. After the agency receives federal approval, the Department of Children and Family Services may collect income information from parents of children who will be affected by this paragraph. The agency shall prepare a report to include the estimated operational cost of implementing the premium and cost-sharing system and the estimated revenues to be collected from parents of children in the waiver program. The report shall be delivered to the President of the Senate and the Speaker of the House of Representatives by June 30, 2012.
(14) HOSPICE CARE SERVICES.—The agency may pay for all reasonable and necessary services for the palliation or management of a recipient’s terminal illness, if the services are provided by a hospice that is licensed under part IV of chapter 400 and meets Medicare certification requirements.
(15) INTERMEDIATE CARE FACILITY FOR THE DEVELOPMENTALLY DISABLED SERVICES.—The agency may pay for health-related care and services provided on a 24-hour-a-day basis by a facility licensed and certified as a Medicaid Intermediate Care Facility for the Developmentally Disabled, for a recipient who needs such care because of a developmental disability. Payment shall not include bed-hold days except in facilities with occupancy rates of 95 percent or greater. The agency is authorized to seek any federal waiver approvals to implement this policy.
(16) INTERMEDIATE CARE SERVICES.—The agency may pay for 24-hour-a-day intermediate care nursing and rehabilitation services rendered to a recipient in a nursing facility licensed under part II of chapter 400, if the services are ordered by and provided under the direction of a physician.
(17) OPTOMETRIC SERVICES.—The agency may pay for services provided to a recipient, including examination, diagnosis, treatment, and management, related to ocular pathology, if the services are provided by a licensed optometrist or physician.
(18) PHYSICIAN ASSISTANT SERVICES.—The agency may pay for all services provided to a recipient by a physician assistant licensed under s. 458.347 or s. 459.022. Reimbursement for such services must be not less than 80 percent of the reimbursement that would be paid to a physician who provided the same services.
(19) PODIATRIC SERVICES.—The agency may pay for services, including diagnosis and medical, surgical, palliative, and mechanical treatment, related to ailments of the human foot and lower leg, if provided to a recipient by a podiatric physician licensed under state law.
(20) PRESCRIBED DRUG SERVICES.—The agency may pay for medications that are prescribed for a recipient by a physician or other licensed practitioner of the healing arts authorized to prescribe medications and that are dispensed to the recipient by a licensed pharmacist or physician in accordance with applicable state and federal law.
(21) REGISTERED NURSE FIRST ASSISTANT SERVICES.—The agency may pay for all services provided to a recipient by a registered nurse first assistant as described in s. 464.027. Reimbursement for such services may not be less than 80 percent of the reimbursement that would be paid to a physician providing the same services.
(22) STATE HOSPITAL SERVICES.—The agency may pay for all-inclusive psychiatric inpatient hospital care provided to a recipient age 65 or older in a state mental hospital.
(23) VISUAL SERVICES.—The agency may pay for visual examinations, eyeglasses, and eyeglass repairs for a recipient if they are prescribed by a licensed physician specializing in diseases of the eye or by a licensed optometrist. Eyeglass frames for adult recipients shall be limited to one pair per recipient every 2 years, except a second pair may be provided during that period after prior authorization. Eyeglass lenses for adult recipients shall be limited to one pair per year except a second pair may be provided during that period after prior authorization.
(24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.—The Agency for Health Care Administration, in consultation with the Department of Children and Family Services, may establish a targeted case-management project in those counties identified by the Department of Children and Family Services and for all counties with a community-based child welfare project, as authorized under s. 409.1671, which have been specifically approved by the department. The covered group of individuals who are eligible to receive targeted case management include children who are eligible for Medicaid; who are between the ages of birth through 21; and who are under protective supervision or postplacement supervision, under foster-care supervision, or in shelter care or foster care. The number of individuals who are eligible to receive targeted case management is limited to the number for whom the Department of Children and Family Services has matching funds to cover the costs. The general revenue funds required to match the funds for services provided by the community-based child welfare projects are limited to funds available for services described under s. 409.1671. The Department of Children and Family Services may transfer the general revenue matching funds as billed by the Agency for Health Care Administration.
(25) ASSISTIVE-CARE SERVICES.—The agency may pay for assistive-care services provided to recipients with functional or cognitive impairments residing in assisted living facilities, adult family-care homes, or residential treatment facilities. These services may include health support, assistance with the activities of daily living and the instrumental acts of daily living, assistance with medication administration, and arrangements for health care.
(26) HOME AND COMMUNITY-BASED SERVICES FOR AUTISM SPECTRUM DISORDER AND OTHER DEVELOPMENTAL DISABILITIES.—The agency is authorized to seek federal approval through a Medicaid waiver or a state plan amendment for the provision of occupational therapy, speech therapy, physical therapy, behavior analysis, and behavior assistant services to individuals who are 5 years of age and under and have a diagnosed developmental disability as defined in s. 393.063, autism spectrum disorder as defined in s. 627.6686, or Down syndrome, a genetic disorder caused by the presence of extra chromosomal material on chromosome 21. Causes of the syndrome may include Trisomy 21, Mosaicism, Robertsonian Translocation, and other duplications of a portion of chromosome 21. Coverage for such services shall be limited to $36,000 annually and may not exceed $108,000 in total lifetime benefits. The agency shall submit an annual report beginning on January 1, 2009, to the President of the Senate, the Speaker of the House of Representatives, and the relevant committees of the Senate and the House of Representatives regarding progress on obtaining federal approval and recommendations for the implementation of these home and community-based services. The agency may not implement this subsection without prior legislative approval.
(27) ANESTHESIOLOGIST ASSISTANT SERVICES.—The agency may pay for all services provided to a recipient by an anesthesiologist assistant licensed under s. 458.3475 or s. 459.023. Reimbursement for such services must be not less than 80 percent of the reimbursement that would be paid to a physician who provided the same services.
History.—s. 35, ch. 91-282; s. 1, ch. 94-299; s. 1, ch. 95-291; s. 4, ch. 95-393; s. 4, ch. 96-417; s. 42, ch. 97-98; s. 12, ch. 97-260; s. 17, ch. 97-263; s. 185, ch. 98-166; s. 52, ch. 98-288; s. 7, ch. 99-144; s. 3, ch. 99-206; s. 66, ch. 99-397; s. 15, ch. 2000-163; s. 52, ch. 2000-256; s. 4, ch. 2001-104; s. 2, ch. 2001-223; s. 67, ch. 2001-277; ss. 3, 4, ch. 2001-377; s. 68, ch. 2002-1; s. 7, ch. 2002-219; s. 19, ch. 2002-400; s. 9, ch. 2003-405; s. 85, ch. 2004-267; s. 9, ch. 2004-270; s. 6, ch. 2005-60; s. 51, ch. 2005-152; s. 11, ch. 2006-28; s. 81, ch. 2006-197; s. 1, ch. 2008-30; s. 4, ch. 2008-143; s. 6, ch. 2009-55; s. 126, ch. 2010-102; s. 10, ch. 2011-135.
409.9062 Lung transplant services for Medicaid recipients.—Subject to the availability of funds and subject to any limitations or directions provided for in the General Appropriations Act or chapter 216, the Agency for Health Care Administration Medicaid program shall pay for medically necessary lung transplant services for Medicaid recipients. These payments must be used to reimburse approved lung transplant facilities a global fee for providing lung transplant services to Medicaid recipients.
History.—s. 2, ch. 2002-35; s. 4, ch. 2005-133.
409.9066 Medicare prescription discount program.—
(1) As a condition of participation in the Florida Medicaid program or the pharmaceutical expense assistance program, a pharmacy must agree to charge any individual who is a Medicare beneficiary and who is a Florida resident showing a Medicare card when he or she presents a prescription, a price no greater than the cost of ingredients equal to the average wholesale price minus 9 percent, and a dispensing fee of $4.50.
(2) In lieu of the provisions of subsection (1), and as a condition of participation in the Florida Medicaid program or the pharmaceutical expense assistance program, a pharmacy must agree to:
(a) Provide a private voluntary prescription discount program to state residents who are Medicare beneficiaries; or
(b) Accept a private voluntary discount prescription program from state residents who are Medicare beneficiaries.
Discounts under this subsection must be at least as great as discounts under subsection (1).
(3) The Agency for Health Care Administration shall publish, on a free website available to the public, the most recent average wholesale prices for the 200 drugs most frequently dispensed and shall provide a mechanism that consumers may use to calculate the retail price and the price that should be paid after the discount required in subsection (1) is applied. The agency shall provide retail information by geographic area and retail information by provider within geographical areas.
History.—s. 3, ch. 2000-254; s. 1, ch. 2003-61; s. 12, ch. 2004-297.
409.907 Medicaid provider agreements.—The agency may make payments for medical assistance and related services rendered to Medicaid recipients only to an individual or entity who has a provider agreement in effect with the agency, who is performing services or supplying goods in accordance with federal, state, and local law, and who agrees that no person shall, on the grounds of handicap, race, color, or national origin, or for any other reason, be subjected to discrimination under any program or activity for which the provider receives payment from the agency.
(1) Each provider agreement shall require the provider to comply fully with all state and federal laws pertaining to the Medicaid program, as well as all federal, state, and local laws pertaining to licensure, if required, and the practice of any of the healing arts, and shall require the provider to provide services or goods of not less than the scope and quality it provides to the general public.
(2) Each provider agreement shall be a voluntary contract between the agency and the provider, in which the provider agrees to comply with all laws and rules pertaining to the Medicaid program when furnishing a service or goods to a Medicaid recipient and the agency agrees to pay a sum, determined by fee schedule, payment methodology, or other manner, for the service or goods provided to the Medicaid recipient. Each provider agreement shall be effective for a stipulated period of time, shall be terminable by either party after reasonable notice, and shall be renewable by mutual agreement.
(3) The provider agreement developed by the agency, in addition to the requirements specified in subsections (1) and (2), shall require the provider to:
(a) Have in its possession at the time of signing the provider agreement, and maintain in good standing throughout the period of the agreement’s effectiveness, a valid professional or facility license pertinent to the services or goods being provided, as required by the state or locality in which the provider is located, and the Federal Government, if applicable.
(b) Maintain in a systematic and orderly manner all medical and Medicaid-related records that the agency requires and determines are relevant to the services or goods being provided.
(c) Retain all medical and Medicaid-related records for a period of 5 years to satisfy all necessary inquiries by the agency.
(d) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients and comply with all state and federal laws pertaining to confidentiality of patient information.
(e) Permit the agency, the Attorney General, the Federal Government, and the authorized agents of each of these entities access to all Medicaid-related information, which may be in the form of records, logs, documents, or computer files, and other information pertaining to services or goods billed to the Medicaid program, including access to all patient records and other provider information if the provider cannot easily separate records for Medicaid patients from other records.
(f) Bill other insurers and third parties, including the Medicare program, before billing the Medicaid program, if the recipient is eligible for payment for health care or related services from another insurer or person, and comply with all other state and federal requirements in this regard.
(g) Promptly report any moneys received in error or in excess of the amount to which the provider is entitled from the Medicaid program, and promptly refund such moneys to the agency.
(h) Be liable for and indemnify, defend, and hold the agency harmless from all claims, suits, judgments, or damages, including court costs and attorney’s fees, arising out of the negligence or omissions of the provider in the course of providing services to a recipient or a person believed to be a recipient.
(i) At the option of the agency, provide proof of liability insurance and maintain such insurance in effect for any period during which services or goods are furnished to Medicaid recipients.
(j) Accept Medicaid payment as payment in full, and prohibit the provider from billing or collecting from the recipient or the recipient’s responsible party any additional amount except, and only to the extent the agency permits or requires, copayments, coinsurance, or deductibles to be paid by the recipient for the services or goods provided. The Medicaid payment-in-full policy does not apply to services or goods provided to a recipient if the services or goods are not covered by the Medicaid program.
(k) Report a change in any principal of the provider, including any officer, director, agent, managing employee, or affiliated person, or any partner or shareholder who has an ownership interest equal to 5 percent or more in the provider, to the agency in writing within 30 days after the change occurs. For a hospital licensed under chapter 395 or a nursing home licensed under part II of chapter 400, a principal of the provider is one who meets the definition of a controlling interest under s. 408.803.
(4) A provider agreement shall provide that, if the provider sells or transfers a business interest or practice that substantially constitutes the entity named as the provider in the provider agreement, or sells or transfers a facility that is of substantial importance to the entity named as the provider in the provider agreement, the provider is required to maintain and make available to the agency Medicaid-related records that relate to the sale or transfer of the business interest, practice, or facility in the same manner as though the sale or transaction had not taken place, unless the provider enters into an agreement with the purchaser of the business interest, practice, or facility to fulfill this requirement.
(5) The agency:
(a) Is required to make timely payment at the established rate for services or goods furnished to a recipient by the provider upon receipt of a properly completed claim form. The claim form shall require certification that the services or goods have been completely furnished to the recipient and that, with the exception of those services or goods specified by the agency, the amount billed does not exceed the provider’s usual and customary charge for the same services or goods.
(b) Is prohibited from demanding repayment from the provider in any instance in which the Medicaid overpayment is attributable to 1error of the department in the determination of eligibility of a recipient.
(c) May adopt, and include in the provider agreement, such other requirements and stipulations on either party as the agency finds necessary to properly and efficiently administer the Medicaid program.
(d) May enroll entities as Medicare crossover-only providers for payment and claims processing purposes only. The provider agreement shall:
1. Require that the provider be able to demonstrate to the satisfaction of the agency that the provider is an eligible Medicare provider and has a current provider agreement in place with the Centers for Medicare and Medicaid Services.
2. Require the provider to notify the agency immediately in writing upon being suspended or disenrolled as a Medicare provider. If the provider does not provide such notification within 5 business days after suspension or disenrollment, sanctions may be imposed pursuant to this chapter and the provider may be required to return funds paid to the provider during the period of time that the provider was suspended or disenrolled as a Medicare provider.
3. Require the applicant to submit an attestation, as approved by the agency, that the provider meets the requirements of Florida Medicaid provider enrollment criteria.
4. Require the applicant to submit fingerprints as required by the agency.
5. Require that all records pertaining to health care services provided to each of the provider’s recipients be kept for a minimum of 6 years. The agreement shall also require that records and any information relating to payments claimed by the provider for services under the agreement be delivered to the agency or the Office of the Attorney General Medicaid Fraud Control Unit when requested. If a provider does not provide such records and information when requested, sanctions may be imposed pursuant to this chapter.
6. Disclose that the agreement is for the purposes of paying and processing Medicare crossover claims only.
This paragraph pertains solely to Medicare crossover-only providers. In order to become a standard Medicaid provider, the requirements of this section and applicable rules must be met. This paragraph does not create an entitlement or obligation of the agency to enroll all Medicare providers that may be considered Medicare crossover-only providers in the Medicaid program.
(e) Providers that are required to post a surety bond as part of the Medicaid enrollment process are excluded for enrollment under paragraph (d) and must complete a full Medicaid application. The agency may establish additional criteria to promote program integrity.
(6) A Medicaid provider agreement may be revoked, at the option of the agency, due to a change of ownership of any facility, association, partnership, or other entity named as the provider in the provider agreement.
(a) If there is a change of ownership, the transferor remains liable for all outstanding overpayments, administrative fines, and any other moneys owed to the agency before the effective date of the change. The transferee is also liable to the agency for all outstanding overpayments identified by the agency on or before the effective date of the change of ownership. In the event of a change of ownership for a skilled nursing facility or intermediate care facility, the Medicaid provider agreement shall be assigned to the transferee if the transferee meets all other Medicaid provider qualifications. In the event of a change of ownership involving a skilled nursing facility licensed under part II of chapter 400, liability for all outstanding overpayments, administrative fines, and any moneys owed to the agency before the effective date of the change of ownership shall be determined in accordance with s. 400.179.
(b) At least 60 days before the anticipated date of the change of ownership, the transferor must notify the agency of the intended change and the transferee must submit to the agency a Medicaid provider enrollment application. If a change of ownership occurs without compliance with the notice requirements of this subsection, the transferor and transferee are jointly and severally liable for all overpayments, administrative fines, and other moneys due to the agency, regardless of whether the agency identified the overpayments, administrative fines, or other moneys before or after the effective date of the change. The agency may not approve a transferee’s Medicaid provider enrollment application if the transferee or transferor has not paid or agreed in writing to a payment plan for all outstanding overpayments, administrative fines, and other moneys due to the agency. This subsection does not preclude the agency from seeking any other legal or equitable remedies available to the agency for the recovery of moneys owed to the Medicaid program. In the event of a change of ownership involving a skilled nursing facility licensed under part II of chapter 400, liability for all outstanding overpayments, administrative fines, and any moneys owed to the agency before the effective date of the change of ownership shall be determined in accordance with s. 400.179 if the Medicaid provider enrollment application for change of ownership is submitted before the change.
(c) As used in this subsection, the term:
1. “Administrative fines” includes any amount identified in a notice of a monetary penalty or fine which has been issued by the agency or other regulatory or licensing agency that governs the provider.
2. “Outstanding overpayment” includes any amount identified in a preliminary audit report issued to the transferor by the agency on or before the effective date of a change of ownership.
(7) As a condition of participating in the Medicaid program and before entering into the provider agreement, the agency may require the provider to submit information, in an initial and any required renewal applications, concerning the professional, business, and personal background of the provider and permit an onsite inspection of the provider’s service location by agency staff or other personnel designated by the agency to perform this function. Before entering into a provider agreement, the agency may perform an onsite inspection of the provider’s service location to determine the applicant’s ability to provide the services in compliance with the Medicaid program and professional regulations. As a continuing condition of participation in the Medicaid program, a provider must immediately notify the agency of any current or pending bankruptcy filing. Before entering into the provider agreement, or as a condition of continuing participation in the Medicaid program, the agency may also require Medicaid providers reimbursed on a fee-for-services basis or fee schedule basis that is not cost-based to post a surety bond not to exceed $50,000 or the total amount billed by the provider to the program during the current or most recent calendar year, whichever is greater. For new providers, the amount of the surety bond shall be determined by the agency based on the provider’s estimate of its first year’s billing. If the provider’s billing during the first year exceeds the bond amount, the agency may require the provider to acquire an additional bond equal to the actual billing level of the provider. A provider’s bond need not exceed $50,000 if a physician or group of physicians licensed under chapter 458, chapter 459, or chapter 460 has a 50 percent or greater ownership interest in the provider or if the provider is an assisted living facility licensed under chapter 429. The bonds permitted by this section are in addition to the bonds referenced in s. 400.179(2)(d). If the provider is a corporation, partnership, association, or other entity, the agency may require the provider to submit information concerning the background of that entity and of any principal of the entity, including any partner or shareholder having an ownership interest in the entity equal to 5 percent or greater, and any treating provider who participates in or intends to participate in Medicaid through the entity. The information must include:
(a) Proof of holding a valid license or operating certificate, as applicable, if required by the state or local jurisdiction in which the provider is located or if required by the Federal Government.
(b) Information concerning any prior violation, fine, suspension, termination, or other administrative action taken under the Medicaid laws or rules of this state or of any other state or the Federal Government; any prior violation of the laws or rules relating to the Medicare program; any prior violation of the rules of any other public or private insurer; and any prior violation of the laws or rules of any regulatory body of this or any other state.
(c) Full and accurate disclosure of any financial or ownership interest that the provider, or any principal, partner, or major shareholder thereof, may hold in any other Medicaid provider or health care related entity or any other entity that is licensed by the state to provide health or residential care and treatment to persons.
(d) If a group provider, identification of all members of the group and attestation that all members of the group are enrolled in or have applied to enroll in the Medicaid program.
(8) Each provider, or each principal of the provider if the provider is a corporation, partnership, association, or other entity, seeking to participate in the Medicaid program must submit a complete set of his or her fingerprints to the agency for the purpose of conducting a criminal history record check. Principals of the provider include any officer, director, billing agent, managing employee, or affiliated person, or any partner or shareholder who has an ownership interest equal to 5 percent or more in the provider. However, for a hospital licensed under chapter 395 or a nursing home licensed under chapter 400, principals of the provider are those who meet the definition of a controlling interest under s. 408.803. A director of a not-for-profit corporation or organization is not a principal for purposes of a background investigation required by this section if the director: serves solely in a voluntary capacity for the corporation or organization, does not regularly take part in the day-to-day operational decisions of the corporation or organization, receives no remuneration from the not-for-profit corporation or organization for his or her service on the board of directors, has no financial interest in the not-for-profit corporation or organization, and has no family members with a financial interest in the not-for-profit corporation or organization; and if the director submits an affidavit, under penalty of perjury, to this effect to the agency and the not-for-profit corporation or organization submits an affidavit, under penalty of perjury, to this effect to the agency as part of the corporation’s or organization’s Medicaid provider agreement application. Notwithstanding the above, the agency may require a background check for any person reasonably suspected by the agency to have been convicted of a crime.
(a) This subsection does not apply to:
1. A unit of local government, except that requirements of this subsection apply to nongovernmental providers and entities contracting with the local government to provide Medicaid services. The actual cost of the state and national criminal history record checks must be borne by the nongovernmental provider or entity; or
2. Any business that derives more than 50 percent of its revenue from the sale of goods to the final consumer, and the business or its controlling parent is required to file a form 10-K or other similar statement with the Securities and Exchange Commission or has a net worth of $50 million or more.
(b) Background screening shall be conducted in accordance with chapter 435 and s. 408.809. The cost of the state and national criminal record check shall be borne by the provider.
(9) Upon receipt of a completed, signed, and dated application, and completion of any necessary background investigation and criminal history record check, the agency must:
(a) Enroll the applicant as a Medicaid provider upon approval of the provider application. The enrollment effective date is the date the agency receives the provider application. With respect to a provider that requires a Medicare certification survey, the enrollment effective date is the date the certification is awarded. With respect to a provider that completes a change of ownership, the effective date is the date the agency received the application, the date the change of ownership was complete, or the date the applicant became eligible to provide services under Medicaid, whichever date is later. With respect to a provider of emergency medical services transportation or emergency services and care, the effective date is the date the services were rendered. Payment for any claims for services provided to Medicaid recipients between the date of receipt of the application and the date of approval is contingent on applying any and all applicable audits and edits contained in the agency’s claims adjudication and payment processing systems. The agency may enroll a provider located outside this state if:
1. The provider’s location is no more than 50 miles from the state line;
2. The provider is a physician actively licensed in this state and interprets diagnostic testing results through telecommunications and information technology provided from a distance; or
3. The agency determines a need for that provider type to ensure adequate access to care; or
(b) Deny the application if the agency finds that it is in the best interest of the Medicaid program to do so. The agency may consider the factors listed in subsection (10), as well as any other factor that could affect the effective and efficient administration of the program, including, but not limited to, the applicant’s demonstrated ability to provide services, conduct business, and operate a financially viable concern; the current availability of medical care, services, or supplies to recipients, taking into account geographic location and reasonable travel time; the number of providers of the same type already enrolled in the same geographic area; and the credentials, experience, success, and patient outcomes of the provider for the services that it is making application to provide in the Medicaid program. The agency shall deny the application if the agency finds that a provider; any officer, director, agent, managing employee, or affiliated person; or any partner or shareholder having an ownership interest equal to 5 percent or greater in the provider if the provider is a corporation, partnership, or other business entity, has failed to pay all outstanding fines or overpayments assessed by final order of the agency or final order of the Centers for Medicare and Medicaid Services, not subject to further appeal, unless the provider agrees to a repayment plan that includes withholding Medicaid reimbursement until the amount due is paid in full.
(10) The agency may consider whether the provider, or any officer, director, agent, managing employee, or affiliated person, or any partner or shareholder having an ownership interest equal to 5 percent or greater in the provider if the provider is a corporation, partnership, or other business entity, has:
(a) Made a false representation or omission of any material fact in making the application, including the submission of an application that conceals the controlling or ownership interest of any officer, director, agent, managing employee, affiliated person, or partner or shareholder who may not be eligible to participate;
(b) Been or is currently excluded, suspended, terminated from, or has involuntarily withdrawn from participation in, Florida’s Medicaid program or any other state’s Medicaid program, or from participation in any other governmental or private health care or health insurance program;
(c) Been convicted of a criminal offense relating to the delivery of any goods or services under Medicaid or Medicare or any other public or private health care or health insurance program including the performance of management or administrative services relating to the delivery of goods or services under any such program;
(d) Been convicted under federal or state law of a criminal offense related to the neglect or abuse of a patient in connection with the delivery of any health care goods or services;
(e) Been convicted under federal or state law of a criminal offense relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance;
(f) Been convicted of any criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct;
(g) Been convicted under federal or state law of a crime punishable by imprisonment of a year or more which involves moral turpitude;
(h) Been convicted in connection with the interference or obstruction of any investigation into any criminal offense listed in this subsection;
(i) Been found to have violated federal or state laws, rules, or regulations governing Florida’s Medicaid program or any other state’s Medicaid program, the Medicare program, or any other publicly funded federal or state health care or health insurance program, and been sanctioned accordingly;
(j) Been previously found by a licensing, certifying, or professional standards board or agency to have violated the standards or conditions relating to licensure or certification or the quality of services provided; or
(k) Failed to pay any fine or overpayment properly assessed under the Medicaid program in which no appeal is pending or after resolution of the proceeding by stipulation or agreement, unless the agency has issued a specific letter of forgiveness or has approved a repayment schedule to which the provider agrees to adhere.
(11) Before signing a provider agreement and at the discretion of the agency, other provisions of this section notwithstanding, an entity may become eligible to receive payment from the Medicaid program at the time it first furnishes services or goods, if:
(a) The services or goods provided are otherwise compensable;
(b) The entity meets all other requirements of a Medicaid provider at the time the services or goods were provided; and
(c) The entity agrees to abide by the provisions of the provider agreement effective from the date the services or goods were provided.
(12) Licensed, certified, or otherwise qualified providers are not entitled to enrollment in a Medicaid provider network.
History.—s. 36, ch. 91-282; s. 3, ch. 94-251; s. 2, ch. 96-387; s. 5, ch. 96-417; s. 1, ch. 97-290; s. 16, ch. 2000-163; s. 53, ch. 2000-256; s. 6, ch. 2001-377; s. 21, ch. 2002-400; s. 20, ch. 2004-267; s. 11, ch. 2004-270; s. 53, ch. 2004-350; s. 66, ch. 2005-2; s. 8, ch. 2005-60; s. 16, ch. 2005-133; s. 12, ch. 2006-28; s. 82, ch. 2006-197; s. 137, ch. 2007-230; s. 12, ch. 2008-246; s. 12, ch. 2009-223; s. 25, ch. 2010-114; s. 6, ch. 2010-156; s. 11, ch. 2011-135; s. 1, ch. 2013-150.
1Note.—As amended by s. 5, ch. 96-417. The amendment by s. 2, ch. 96-387, uses the words “agency error” instead of the words “error of the department.”
409.9071 Medicaid provider agreements for school districts certifying state match.—
(1) The agency shall reimburse school-based services as provided in former s. 236.0812 pursuant to the rehabilitative services option provided under 42 U.S.C. s. 1396d(a)(13). For purposes of this section, billing agent consulting services shall be considered billing agent services, as that term is used in s. 409.913(10), and, as such, payments to such persons shall not be based on amounts for which they bill nor based on the amount a provider receives from the Medicaid program. This provision shall not restrict privatization of Medicaid school-based services. Subject to any limitations provided for in the General Appropriations Act, the agency, in compliance with appropriate federal authorization, shall develop policies and procedures and shall allow for certification of state and local education funds which have been provided for school-based services as specified in s. 1011.70 and authorized by a physician’s order where required by federal Medicaid law. Any state or local funds certified pursuant to this section shall be for children with specified disabilities who are eligible for both Medicaid and part B or part H of the Individuals with Disabilities Education Act (IDEA), or the exceptional student education program, or who have an individualized educational plan.
(2) School districts that wish to enroll as Medicaid providers and that certify state match in order to receive federal Medicaid reimbursements for services, pursuant to subsection (1), shall agree to:
(a) Verify Medicaid eligibility. The agency and the Department of Education shall work cooperatively to facilitate local school districts’ verification of Medicaid eligibility.
(b) Develop and maintain the financial and individual education plan records needed to document the appropriate use of state and federal Medicaid funds.
(c) Comply with all state and federal Medicaid laws, rules, regulations, and policies, including, but not limited to, those related to the confidentiality of records and freedom of choice of providers.
(d) Be responsible for reimbursing the cost of any state or federal disallowance that results from failure to comply with state or federal Medicaid laws, rules, or regulations.
(3) State and local education dollars certified as state Medicaid match may be capped based on the maximum amount of federal participation budgeted for this purpose. Unless otherwise specifically provided for in the General Appropriations Act, certification of such funds shall be reduced proportionately to other voluntary Medicaid programs if a cap is established by the federal Medicaid agency that reduces federal Medicaid funding.
(4) Within 90 days after a school district applies to enroll as a Medicaid provider under the certified match program, the agency may conduct a review to ensure that the school district has the capability to comply with the requirements in subsection (2). A finding by the agency that a school district has the capability to comply with the requirements in subsection (2) shall not relieve a school district of its responsibility for correcting any deficiencies or for reimbursing the cost of the state or federal disallowances identified pursuant to any subsequent state or federal audits.
(5) The agency shall develop a reimbursement schedule specific to school-based services which is based on the federal rehabilitative services option.
(6) Retroactive reimbursements for services as specified in former s. 236.0812 as of July 1, 1996, including reimbursement for the 1995-1996 and 1996-1997 school years, are subject to federal approval.
(7) The agency’s and school districts’ confidentiality is waived. They shall provide any information or documents relating to this section to the Medicaid Fraud Control Unit in the Department of Legal Affairs, upon request pursuant to its authority under s. 409.920.
History.—s. 2, ch. 95-336; s. 5, ch. 96-199; s. 3, ch. 96-294; s. 2, ch. 97-168; ss. 13, 18, ch. 97-263; s. 5, ch. 2000-163; ss. 994, 995, ch. 2002-387; s. 20, ch. 2004-344; s. 67, ch. 2005-2.
409.908 Reimbursement of Medicaid providers.—Subject to specific appropriations, the agency shall reimburse Medicaid providers, in accordance with state and federal law, according to methodologies set forth in the rules of the agency and in policy manuals and handbooks incorporated by reference therein. These methodologies may include fee schedules, reimbursement methods based on cost reporting, negotiated fees, competitive bidding pursuant to s. 287.057, and other mechanisms the agency considers efficient and effective for purchasing services or goods on behalf of recipients. If a provider is reimbursed based on cost reporting and submits a cost report late and that cost report would have been used to set a lower reimbursement rate for a rate semester, then the provider’s rate for that semester shall be retroactively calculated using the new cost report, and full payment at the recalculated rate shall be effected retroactively. Medicare-granted extensions for filing cost reports, if applicable, shall also apply to Medicaid cost reports. Payment for Medicaid compensable services made on behalf of Medicaid eligible persons is subject to the availability of moneys and any limitations or directions provided for in the General Appropriations Act or chapter 216. Further, nothing in this section shall be construed to prevent or limit the agency from adjusting fees, reimbursement rates, lengths of stay, number of visits, or number of services, or making any other adjustments necessary to comply with the availability of moneys and any limitations or directions provided for in the General Appropriations Act, provided the adjustment is consistent with legislative intent.
(1) Reimbursement to hospitals licensed under part I of chapter 395 must be made prospectively or on the basis of negotiation.
(a) Reimbursement for inpatient care is limited as provided in s. 409.905(5), except as otherwise provided in this subsection.
1. If authorized by the General Appropriations Act, the agency may modify reimbursement for specific types of services or diagnoses, recipient ages, and hospital provider types.
2. The agency may establish an alternative methodology to the DRG-based prospective payment system to set reimbursement rates for:
a. State-owned psychiatric hospitals.
b. Newborn hearing screening services.
c. Transplant services for which the agency has established a global fee.
d. Recipients who have tuberculosis that is resistant to therapy who are in need of long-term, hospital-based treatment pursuant to s. 392.62.
3. The agency shall modify reimbursement according to other methodologies recognized in the General Appropriations Act.
The agency may receive funds from state entities, including, but not limited to, the Department of Health, local governments, and other local political subdivisions, for the purpose of making special exception payments, including federal matching funds, through the Medicaid inpatient reimbursement methodologies. Funds received for this purpose shall be separately accounted for and may not be commingled with other state or local funds in any manner. The agency may certify all local governmental funds used as state match under Title XIX of the Social Security Act, to the extent and in the manner authorized under the General Appropriations Act and pursuant to an agreement between the agency and the local governmental entity. In order for the agency to certify such local governmental funds, a local governmental entity must submit a final, executed letter of agreement to the agency, which must be received by October 1 of each fiscal year and provide the total amount of local governmental funds authorized by the entity for that fiscal year under this paragraph, paragraph (b), or the General Appropriations Act. The local governmental entity shall use a certification form prescribed by the agency. At a minimum, the certification form must identify the amount being certified and describe the relationship between the certifying local governmental entity and the local health care provider. The agency shall prepare an annual statement of impact which documents the specific activities undertaken during the previous fiscal year pursuant to this paragraph, to be submitted to the Legislature annually by January 1.
(b) Reimbursement for hospital outpatient care is limited to $1,500 per state fiscal year per recipient, except for:
1. Such care provided to a Medicaid recipient under age 21, in which case the only limitation is medical necessity.
2. Renal dialysis services.
3. Other exceptions made by the agency.
The agency is authorized to receive funds from state entities, including, but not limited to, the Department of Health, the Board of Governors of the State University System, local governments, and other local political subdivisions, for the purpose of making payments, including federal matching funds, through the Medicaid outpatient reimbursement methodologies. Funds received from state entities and local governments for this purpose shall be separately accounted for and shall not be commingled with other state or local funds in any manner.
(c) Hospitals that provide services to a disproportionate share of low-income Medicaid recipients, or that participate in the regional perinatal intensive care center program under chapter 383, or that participate in the statutory teaching hospital disproportionate share program may receive additional reimbursement. The total amount of payment for disproportionate share hospitals shall be fixed by the General Appropriations Act. The computation of these payments must be made in compliance with all federal regulations and the methodologies described in ss. 409.911 and 409.9113.
(d) The agency is authorized to limit inflationary increases for outpatient hospital services as directed by the General Appropriations Act.
(2)(a)1. Reimbursement to nursing homes licensed under part II of chapter 400 and state-owned-and-operated intermediate care facilities for the developmentally disabled licensed under part VIII of chapter 400 must be made prospectively.
2. Unless otherwise limited or directed in the General Appropriations Act, reimbursement to hospitals licensed under part I of chapter 395 for the provision of swing-bed nursing home services must be made on the basis of the average statewide nursing home payment, and reimbursement to a hospital licensed under part I of chapter 395 for the provision of skilled nursing services must be made on the basis of the average nursing home payment for those services in the county in which the hospital is located. When a hospital is located in a county that does not have any community nursing homes, reimbursement shall be determined by averaging the nursing home payments in counties that surround the county in which the hospital is located. Reimbursement to hospitals, including Medicaid payment of Medicare copayments, for skilled nursing services shall be limited to 30 days, unless a prior authorization has been obtained from the agency. Medicaid reimbursement may be extended by the agency beyond 30 days, and approval must be based upon verification by the patient’s physician that the patient requires short-term rehabilitative and recuperative services only, in which case an extension of no more than 15 days may be approved. Reimbursement to a hospital licensed under part I of chapter 395 for the temporary provision of skilled nursing services to nursing home residents who have been displaced as the result of a natural disaster or other emergency may not exceed the average county nursing home payment for those services in the county in which the hospital is located and is limited to the period of time which the agency considers necessary for continued placement of the nursing home residents in the hospital.
(b) Subject to any limitations or directions in the General Appropriations Act, the agency shall establish and implement a state Title XIX Long-Term Care Reimbursement Plan for nursing home care in order to provide care and services in conformance with the applicable state and federal laws, rules, regulations, and quality and safety standards and to ensure that individuals eligible for medical assistance have reasonable geographic access to such care.
1. The agency shall amend the long-term care reimbursement plan and cost reporting system to create direct care and indirect care subcomponents of the patient care component of the per diem rate. These two subcomponents together shall equal the patient care component of the per diem rate. Separate cost-based ceilings shall be calculated for each patient care subcomponent. The direct care subcomponent of the per diem rate shall be limited by the cost-based class ceiling, and the indirect care subcomponent may be limited by the lower of the cost-based class ceiling, the target rate class ceiling, or the individual provider target.
2. The direct care subcomponent shall include salaries and benefits of direct care staff providing nursing services including registered nurses, licensed practical nurses, and certified nursing assistants who deliver care directly to residents in the nursing home facility. This excludes nursing administration, staff development, the staffing coordinator, and the administrative portion of the minimum data set and care plan coordinators. The direct care subcomponent also includes medically necessary dental care, vision care, hearing care, and podiatric care.
3. All other patient care costs shall be included in the indirect care cost subcomponent of the patient care per diem rate. Costs may not be allocated directly or indirectly to the direct care subcomponent from a home office or management company.
4. On July 1 of each year, the agency shall report to the Legislature direct and indirect care costs, including average direct and indirect care costs per resident per facility and direct care and indirect care salaries and benefits per category of staff member per facility.
5. In order to offset the cost of general and professional liability insurance, the agency shall amend the plan to allow for interim rate adjustments to reflect increases in the cost of general or professional liability insurance for nursing homes. This provision shall be implemented to the extent existing appropriations are available.
It is the intent of the Legislature that the reimbursement plan achieve the goal of providing access to health care for nursing home residents who require large amounts of care while encouraging diversion services as an alternative to nursing home care for residents who can be served within the community. The agency shall base the establishment of any maximum rate of payment, whether overall or component, on the available moneys as provided for in the General Appropriations Act. The agency may base the maximum rate of payment on the results of scientifically valid analysis and conclusions derived from objective statistical data pertinent to the particular maximum rate of payment.
(3) Subject to any limitations or directions provided for in the General Appropriations Act, the following Medicaid services and goods may be reimbursed on a fee-for-service basis. For each allowable service or goods furnished in accordance with Medicaid rules, policy manuals, handbooks, and state and federal law, the payment shall be the amount billed by the provider, the provider’s usual and customary charge, or the maximum allowable fee established by the agency, whichever amount is less, with the exception of those services or goods for which the agency makes payment using a methodology based on capitation rates, average costs, or negotiated fees.
(a) Advanced registered nurse practitioner services.
(b) Birth center services.
(c) Chiropractic services.
(d) Community mental health services.
(e) Dental services, including oral and maxillofacial surgery.
(f) Durable medical equipment.
(g) Hearing services.
(h) Occupational therapy for Medicaid recipients under age 21.
(i) Optometric services.
(j) Orthodontic services.
(k) Personal care for Medicaid recipients under age 21.
(l) Physical therapy for Medicaid recipients under age 21.
(m) Physician assistant services.
(n) Podiatric services.
(o) Portable X-ray services.
(p) Private-duty nursing for Medicaid recipients under age 21.
(q) Registered nurse first assistant services.
(r) Respiratory therapy for Medicaid recipients under age 21.
(s) Speech therapy for Medicaid recipients under age 21.
(t) Visual services.
(4) Subject to any limitations or directions provided for in the General Appropriations Act, alternative health plans, health maintenance organizations, and prepaid health plans shall be reimbursed a fixed, prepaid amount negotiated, or competitively bid pursuant to s. 287.057, by the agency and prospectively paid to the provider monthly for each Medicaid recipient enrolled. The amount may not exceed the average amount the agency determines it would have paid, based on claims experience, for recipients in the same or similar category of eligibility. The agency shall calculate capitation rates on a regional basis and, beginning September 1, 1995, shall include age-band differentials in such calculations.
(5) An ambulatory surgical center shall be reimbursed the lesser of the amount billed by the provider or the Medicare-established allowable amount for the facility.
(6) A provider of early and periodic screening, diagnosis, and treatment services to Medicaid recipients who are children under age 21 shall be reimbursed using an all-inclusive rate stipulated in a fee schedule established by the agency. A provider of the visual, dental, and hearing components of such services shall be reimbursed the lesser of the amount billed by the provider or the Medicaid maximum allowable fee established by the agency.
(7) A provider of family planning services shall be reimbursed the lesser of the amount billed by the provider or an all-inclusive amount per type of visit for physicians and advanced registered nurse practitioners, as established by the agency in a fee schedule.
(8) A provider of home-based or community-based services rendered pursuant to a federally approved waiver shall be reimbursed based on an established or negotiated rate for each service. These rates shall be established according to an analysis of the expenditure history and prospective budget developed by each contract provider participating in the waiver program, or under any other methodology adopted by the agency and approved by the Federal Government in accordance with the waiver. Privately owned and operated community-based residential facilities which meet agency requirements and which formerly received Medicaid reimbursement for the optional intermediate care facility for the intellectually disabled service may participate in the developmental services waiver as part of a home-and-community-based continuum of care for Medicaid recipients who receive waiver services.
(9) A provider of home health care services or of medical supplies and appliances shall be reimbursed on the basis of competitive bidding or for the lesser of the amount billed by the provider or the agency’s established maximum allowable amount, except that, in the case of the rental of durable medical equipment, the total rental payments may not exceed the purchase price of the equipment over its expected useful life or the agency’s established maximum allowable amount, whichever amount is less.
(10) A hospice shall be reimbursed through a prospective system for each Medicaid hospice patient at Medicaid rates using the methodology established for hospice reimbursement pursuant to Title XVIII of the federal Social Security Act.
(11) A provider of independent laboratory services shall be reimbursed on the basis of competitive bidding or for the least of the amount billed by the provider, the provider’s usual and customary charge, or the Medicaid maximum allowable fee established by the agency.
(12)(a) A physician shall be reimbursed the lesser of the amount billed by the provider or the Medicaid maximum allowable fee established by the agency.
(b) The agency shall adopt a fee schedule, subject to any limitations or directions provided for in the General Appropriations Act, based on a resource-based relative value scale for pricing Medicaid physician services. Under this fee schedule, physicians shall be paid a dollar amount for each service based on the average resources required to provide the service, including, but not limited to, estimates of average physician time and effort, practice expense, and the costs of professional liability insurance. The fee schedule shall provide increased reimbursement for preventive and primary care services and lowered reimbursement for specialty services by using at least two conversion factors, one for cognitive services and another for procedural services. The fee schedule shall not increase total Medicaid physician expenditures unless moneys are available. The Agency for Health Care Administration shall seek the advice of a 16-member advisory panel in formulating and adopting the fee schedule. The panel shall consist of Medicaid physicians licensed under chapters 458 and 459 and shall be composed of 50 percent primary care physicians and 50 percent specialty care physicians.
(c) Notwithstanding paragraph (b), reimbursement fees to physicians for providing total obstetrical services to Medicaid recipients, which include prenatal, delivery, and postpartum care, shall be at least $1,500 per delivery for a pregnant woman with low medical risk and at least $2,000 per delivery for a pregnant woman with high medical risk. However, reimbursement to physicians working in Regional Perinatal Intensive Care Centers designated pursuant to chapter 383, for services to certain pregnant Medicaid recipients with a high medical risk, may be made according to obstetrical care and neonatal care groupings and rates established by the agency. Nurse midwives licensed under part I of chapter 464 or midwives licensed under chapter 467 shall be reimbursed at no less than 80 percent of the low medical risk fee. The agency shall by rule determine, for the purpose of this paragraph, what constitutes a high or low medical risk pregnant woman and shall not pay more based solely on the fact that a caesarean section was performed, rather than a vaginal delivery. The agency shall by rule determine a prorated payment for obstetrical services in cases where only part of the total prenatal, delivery, or postpartum care was performed. The Department of Health shall adopt rules for appropriate insurance coverage for midwives licensed under chapter 467. Prior to the issuance and renewal of an active license, or reactivation of an inactive license for midwives licensed under chapter 467, such licensees shall submit proof of coverage with each application.
(13) Medicare premiums for persons eligible for both Medicare and Medicaid coverage shall be paid at the rates established by Title XVIII of the Social Security Act. For Medicare services rendered to Medicaid-eligible persons, Medicaid shall pay Medicare deductibles and coinsurance as follows:
(a) Medicaid’s financial obligation for deductibles and coinsurance payments shall be based on Medicare allowable fees, not on a provider’s billed charges.
(b) Medicaid will pay no portion of Medicare deductibles and coinsurance when payment that Medicare has made for the service equals or exceeds what Medicaid would have paid if it had been the sole payor. The combined payment of Medicare and Medicaid shall not exceed the amount Medicaid would have paid had it been the sole payor. The Legislature finds that there has been confusion regarding the reimbursement for services rendered to dually eligible Medicare beneficiaries. Accordingly, the Legislature clarifies that it has always been the intent of the Legislature before and after 1991 that, in reimbursing in accordance with fees established by Title XVIII for premiums, deductibles, and coinsurance for Medicare services rendered by physicians to Medicaid eligible persons, physicians be reimbursed at the lesser of the amount billed by the physician or the Medicaid maximum allowable fee established by the Agency for Health Care Administration, as is permitted by federal law. It has never been the intent of the Legislature with regard to such services rendered by physicians that Medicaid be required to provide any payment for deductibles, coinsurance, or copayments for Medicare cost sharing, or any expenses incurred relating thereto, in excess of the payment amount provided for under the State Medicaid plan for such service. This payment methodology is applicable even in those situations in which the payment for Medicare cost sharing for a qualified Medicare beneficiary with respect to an item or service is reduced or eliminated. This expression of the Legislature is in clarification of existing law and shall apply to payment for, and with respect to provider agreements with respect to, items or services furnished on or after the effective date of this act. This paragraph applies to payment by Medicaid for items and services furnished before the effective date of this act if such payment is the subject of a lawsuit that is based on the provisions of this section, and that is pending as of, or is initiated after, the effective date of this act.
(c) Notwithstanding paragraphs (a) and (b):
1. Medicaid payments for Nursing Home Medicare part A coinsurance are limited to the Medicaid nursing home per diem rate less any amounts paid by Medicare, but only up to the amount of Medicare coinsurance. The Medicaid per diem rate shall be the rate in effect for the dates of service of the crossover claims and may not be subsequently adjusted due to subsequent per diem rate adjustments.
2. Medicaid shall pay all deductibles and coinsurance for Medicare-eligible recipients receiving freestanding end stage renal dialysis center services.
3. Medicaid payments for general and specialty hospital inpatient services are limited to the Medicare deductible and coinsurance per spell of illness. Medicaid payments for hospital Medicare Part A coinsurance shall be limited to the Medicaid hospital per diem rate less any amounts paid by Medicare, but only up to the amount of Medicare coinsurance. Medicaid payments for coinsurance shall be limited to the Medicaid per diem rate in effect for the dates of service of the crossover claims and may not be subsequently adjusted due to subsequent per diem adjustments.
4. Medicaid shall pay all deductibles and coinsurance for Medicare emergency transportation services provided by ambulances licensed pursuant to chapter 401.
5. Medicaid shall pay all deductibles and coinsurance for portable X-ray Medicare Part B services provided in a nursing home.
(14) A provider of prescribed drugs shall be reimbursed the least of the amount billed by the provider, the provider’s usual and customary charge, or the Medicaid maximum allowable fee established by the agency, plus a dispensing fee. The Medicaid maximum allowable fee for ingredient cost must be based on the lowest of: the average wholesale price (AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC) plus 1.5 percent, the federal upper limit (FUL), the state maximum allowable cost (SMAC), or the usual and customary (UAC) charge billed by the provider.
(a) Medicaid providers must dispense generic drugs if available at lower cost and the agency has not determined that the branded product is more cost-effective, unless the prescriber has requested and received approval to require the branded product.
(b) The agency shall implement a variable dispensing fee for prescribed medicines while ensuring continued access for Medicaid recipients. The variable dispensing fee may be based upon, but not limited to, either or both the volume of prescriptions dispensed by a specific pharmacy provider, the volume of prescriptions dispensed to an individual recipient, and dispensing of preferred-drug-list products.
(c) The agency may increase the pharmacy dispensing fee authorized by statute and in the General Appropriations Act by $0.50 for the dispensing of a Medicaid preferred-drug-list product and reduce the pharmacy dispensing fee by $0.50 for the dispensing of a Medicaid product that is not included on the preferred drug list.
(d) The agency may establish a supplemental pharmaceutical dispensing fee to be paid to providers returning unused unit-dose packaged medications to stock and crediting the Medicaid program for the ingredient cost of those medications if the ingredient costs to be credited exceed the value of the supplemental dispensing fee.
(e) The agency may limit reimbursement for prescribed medicine in order to comply with any limitations or directions provided in the General Appropriations Act, which may include implementing a prospective or concurrent utilization review program.
(15) A provider of primary care case management services rendered pursuant to a federally approved waiver shall be reimbursed by payment of a fixed, prepaid monthly sum for each Medicaid recipient enrolled with the provider.
(16) A provider of rural health clinic services and federally qualified health center services shall be reimbursed a rate per visit based on total reasonable costs of the clinic, as determined by the agency in accordance with federal regulations.
(17) A provider of targeted case management services shall be reimbursed pursuant to an established fee, except where the Federal Government requires a public provider be reimbursed on the basis of average actual costs.
(18) Unless otherwise provided for in the General Appropriations Act, a provider of transportation services shall be reimbursed the lesser of the amount billed by the provider or the Medicaid maximum allowable fee established by the agency, except when the agency has entered into a direct contract with the provider, or with a community transportation coordinator, for the provision of an all-inclusive service, or when services are provided pursuant to an agreement negotiated between the agency and the provider. The agency, as provided for in s. 427.0135, shall purchase transportation services through the community coordinated transportation system, if available, unless the agency, after consultation with the commission, determines that it cannot reach mutually acceptable contract terms with the commission. The agency may then contract for the same transportation services provided in a more cost-effective manner and of comparable or higher quality and standards. Nothing in this subsection shall be construed to limit or preclude the agency from contracting for services using a prepaid capitation rate or from establishing maximum fee schedules, individualized reimbursement policies by provider type, negotiated fees, prior authorization, competitive bidding, increased use of mass transit, or any other mechanism that the agency considers efficient and effective for the purchase of services on behalf of Medicaid clients, including implementing a transportation eligibility process. The agency shall not be required to contract with any community transportation coordinator or transportation operator that has been determined by the agency, the Department of Legal Affairs Medicaid Fraud Control Unit, or any other state or federal agency to have engaged in any abusive or fraudulent billing activities. The agency is authorized to competitively procure transportation services or make other changes necessary to secure approval of federal waivers needed to permit federal financing of Medicaid transportation services at the service matching rate rather than the administrative matching rate. Notwithstanding chapter 427, the agency is authorized to continue contracting for Medicaid nonemergency transportation services in agency service area 11 with managed care plans that were under contract for those services before July 1, 2004.
(19) County health department services shall be reimbursed a rate per visit based on total reasonable costs of the clinic, as determined by the agency in accordance with federal regulations under the authority of 42 C.F.R. s. 431.615.
(20) A renal dialysis facility that provides dialysis services under s. 409.906(9) must be reimbursed the lesser of the amount billed by the provider, the provider’s usual and customary charge, or the maximum allowable fee established by the agency, whichever amount is less.
(21) The agency shall reimburse school districts which certify the state match pursuant to ss. 409.9071 and 1011.70 for the federal portion of the school district’s allowable costs to deliver the services, based on the reimbursement schedule. The school district shall determine the costs for delivering services as authorized in ss. 409.9071 and 1011.70 for which the state match will be certified. Reimbursement of school-based providers is contingent on such providers being enrolled as Medicaid providers and meeting the qualifications contained in 42 C.F.R. s. 440.110, unless otherwise waived by the federal Health Care Financing Administration. Speech therapy providers who are certified through the Department of Education pursuant to rule 6A-4.0176, Florida Administrative Code, are eligible for reimbursement for services that are provided on school premises. Any employee of the school district who has been fingerprinted and has received a criminal background check in accordance with Department of Education rules and guidelines shall be exempt from any agency requirements relating to criminal background checks.
(22) The agency shall request and implement Medicaid waivers from the federal Health Care Financing Administration to advance and treat a portion of the Medicaid nursing home per diem as capital for creating and operating a risk-retention group for self-insurance purposes, consistent with federal and state laws and rules.
(23)(a) The agency shall establish rates at a level that ensures no increase in statewide expenditures resulting from a change in unit costs effective July 1, 2011. Reimbursement rates shall be as provided in the General Appropriations Act.
(b) Base rate reimbursement under a diagnosis-related group payment methodology shall be provided in the General Appropriations Act.
(c) This subsection applies to the following provider types:
1. Inpatient hospitals.
2. Outpatient hospitals.
3. Nursing homes.
4. County health departments.
5. Community intermediate care facilities for the developmentally disabled.
6. Prepaid health plans.
(d) The agency shall apply the effect of this subsection to the reimbursement rates for nursing home diversion programs.
(24) If a provider fails to notify the agency within 5 business days after suspension or disenrollment from Medicare, sanctions may be imposed pursuant to this chapter, and the provider may be required to return funds paid to the provider during the period of time that the provider was suspended or disenrolled as a Medicare provider.
History.—s. 37, ch. 91-282; s. 17, ch. 92-179; s. 1, ch. 92-311; s. 47, ch. 93-129; s. 28, ch. 93-211; s. 2, ch. 94-299; s. 4, ch. 94-317; s. 2, ch. 95-291; s. 3, ch. 95-336; s. 5, ch. 95-393; s. 6, ch. 96-417; s. 3, ch. 97-168; s. 65, ch. 97-237; s. 1, ch. 97-243; s. 11, ch. 97-260; ss. 14, 19, ch. 97-263; s. 4, ch. 97-309; ss. 13, 38, ch. 98-46; s. 236, ch. 98-166; s. 28, ch. 98-191; ss. 17, 30, ch. 2000-163; s. 19, ch. 2000-209; s. 54, ch. 2000-256; s. 110, ch. 2000-318; s. 49, ch. 2001-45; s. 51, ch. 2001-62; s. 5, ch. 2001-104; s. 4, ch. 2001-222; s. 7, ch. 2001-377; s. 16, ch. 2002-223; s. 996, ch. 2002-387; s. 22, ch. 2002-400; s. 11, ch. 2003-405; s. 53, ch. 2004-5; s. 12, ch. 2004-270; s. 21, ch. 2004-344; s. 68, ch. 2005-2; s. 9, ch. 2005-60; s. 17, ch. 2005-133; s. 13, ch. 2006-28; s. 53, ch. 2006-227; s. 96, ch. 2007-5; s. 50, ch. 2007-217; s. 3, ch. 2007-331; s. 5, ch. 2008-143; s. 1, ch. 2008-203; s. 93, ch. 2010-5; s. 7, ch. 2010-156; s. 5, ch. 2011-61; s. 12, ch. 2011-135; s. 6, ch. 2012-33; s. 4, ch. 2013-48; s. 14, ch. 2013-162.
409.9081 Copayments.—
(1) The agency shall require, subject to federal regulations and limitations, each Medicaid recipient to pay at the time of service a nominal copayment for the following Medicaid services:
(a) Hospital outpatient services: up to $3 for each hospital outpatient visit.
(b) Physician services: up to $2 copayment for each visit with a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 463.
(c) Hospital emergency department visits for nonemergency care: 5 percent of up to the first $300 of the Medicaid payment for emergency room services, not to exceed $15. The agency shall seek federal approval to require Medicaid recipients to pay a $100 copayment for nonemergency services and care furnished in a hospital emergency department. Upon waiver approval, a Medicaid recipient who requests such services and care must pay a $100 copayment to the hospital for the nonemergency services and care provided in the hospital emergency department.
(d) Prescription drugs: a coinsurance equal to 2.5 percent of the Medicaid cost of the prescription drug at the time of purchase. The maximum coinsurance shall be $7.50 per prescription drug purchased.
(2) The agency shall, subject to federal regulations and any directions or limitations provided for in the General Appropriations Act, require copayments for the following additional services: hospital inpatient, laboratory and X-ray services, transportation services, home health care services, community mental health services, rural health services, federally qualified health clinic services, and nurse practitioner services. The agency may only establish copayments for prescribed drugs or for any other federally authorized service if such copayment is specifically provided for in the General Appropriations Act or other law.
(3) In accordance with federal regulations, the agency shall not require copayments of the following Medicaid recipients:
(a) Children under age 21.
(b) Pregnant women when the services relate to the pregnancy or to any other medical condition which may complicate the pregnancy up to 6 weeks after delivery.
(c) Any individual who is an inpatient in a hospital, long-term care facility, or other medical institution if, as a condition of receiving services in the institution, that individual is required to spend all but a minimal amount of her or his income required for personal needs for medical care costs.
(d) Any individual who requires emergency services after the sudden onset of a medical condition which, left untreated, would place the individual’s health in serious jeopardy.
(e) Any individual when the services or supplies relate to family planning.
(f) Any individual who is enrolled in a Medicaid prepaid health plan or health maintenance organization.
(4) No provider shall impose more than one copayment for any encounter upon a Medicaid recipient.
(5) The agency shall develop a mechanism by which participating providers are able to identify those Medicaid recipients from whom they shall not collect copayments.
(6) This section does not require a provider to bill or collect a copayment required or authorized under 1this section from the Medicaid recipient. If the provider chooses not to bill or collect a copayment from a Medicaid recipient, the agency must still deduct the amount of the copayment from the Medicaid reimbursement made to the provider.
History.—s. 48, ch. 93-129; s. 6, ch. 95-393; s. 5, ch. 96-280; s. 5, ch. 96-387; s. 1022, ch. 97-103; s. 12, ch. 2003-405; s. 14, ch. 2006-28; s. 13, ch. 2011-135.
1Note.—As created by s. 5, ch. 96-280. Subsection (6) was also created by s. 5, ch. 96-387, and that version used the words “subsection (1)” instead of “this section.”
409.9082 Quality assessment on nursing home facility providers; exemptions; purpose; federal approval required; remedies.—
(1) As used in this section, the term:
(a) “Net patient service revenue” means gross revenues from services provided to nursing home facility patients, less reductions from gross revenue resulting from an inability to collect payment of charges. Such reductions include bad debts; contractual adjustments; uncompensated care; administrative, courtesy, and policy discounts and adjustments; and other such revenue deductions.
(b) “Nursing home facility” means a facility licensed under part II of chapter 400.
(c) “Resident day” means a calendar day of care provided to a nursing home facility resident, including the day of admission and excluding the day of discharge, except that, when admission and discharge occur on the same day, 1 day of care is deemed to exist.
(d) “Medicare Part A resident days” means those patient days funded by the Medicare program or by a Medicare Advantage or special needs plan.
(e) “Skilled nursing facility units of acute care hospitals” means the Medicare-certified skilled nursing beds located in hospitals licensed under chapter 395.
(2) Effective April 1, 2009, a quality assessment is imposed upon each nursing home facility. The aggregated amount of assessments for all nursing home facilities in a given year shall be an amount not exceeding the maximum percentage allowed under federal law of the total aggregate net patient service revenue of assessed facilities. The agency shall calculate the quality assessment rate annually on a per-resident-day basis, exclusive of those resident days funded by the Medicare program, as reported by the facilities. The per-resident-day assessment rate must be uniform except as prescribed in subsection (3). Each facility shall report monthly to the agency its total number of resident days, exclusive of Medicare Part A resident days, and remit an amount equal to the assessment rate times the reported number of days. The agency shall collect, and each facility shall pay, the quality assessment each month. The agency shall collect the assessment from nursing home facility providers by the 15th day of the next succeeding calendar month. The agency shall notify providers of the quality assessment and provide a standardized form to complete and submit with payments. The collection of the nursing home facility quality assessment shall commence no sooner than 5 days after the agency’s initial payment of the Medicaid rates containing the elements prescribed in subsection (4). Nursing home facilities may not create a separate line-item charge for the purpose of passing the assessment through to residents.
(3)(a) The following nursing home facility providers are exempt from the quality assessment:
1. Nursing home facilities that are licensed under part II of chapter 400 and located on the campus of continuing care retirement communities operating pursuant to a certificate of authority under chapter 651;
2. Nursing home facilities that have 45 or fewer beds; and
3. The skilled nursing facility units of acute care hospitals licensed by the agency under chapter 395.
(b) The agency may apply a lower quality assessment rate to high-volume Medicaid nursing facilities. The agency shall apply the lower rate to the fewest number of such facilities necessary to meet federal Medicaid waiver requirements.
(c) The agency may apply a lower quality assessment rate to high-patient-volume nursing facilities. The agency shall apply the lower rate to the fewest number of such facilities necessary to meet federal Medicaid waiver requirements.
(d) Effective July 1, 2011, the agency may exempt from the quality assessment or apply a lower quality assessment rate to a qualified public, nonstate-owned or operated nursing home facility whose total annual indigent census days are greater than 20 percent of the facility’s total annual census days.
(4) The purpose of the nursing home facility quality assessment is to ensure continued quality of care. Collected assessment funds shall be used to obtain federal financial participation through the Medicaid program to make Medicaid payments for nursing home facility services up to the amount of nursing home facility Medicaid rates as calculated in accordance with the approved state Medicaid plan in effect on December 31, 2007. The quality assessment and federal matching funds shall be used exclusively for the following purposes and in the following order of priority:
(a) To reimburse the Medicaid share of the quality assessment as a pass-through, Medicaid-allowable cost;
(b) To increase to each nursing home facility’s Medicaid rate, as needed, an amount that restores rate reductions effective on or after January 1, 2008, as provided in the General Appropriations Act; and
(c) To increase each nursing home facility’s Medicaid rate that accounts for the portion of the total assessment not included in paragraphs (a) and (b) which begins a phase-in to a pricing model for the operating cost component.
(5) The agency shall seek necessary federal approval in the form of waivers and state plan amendments in order to implement the provisions of this section.
(6) The quality assessment shall terminate and the agency shall discontinue the imposition, assessment, and collection of the nursing facility quality assessment if the agency does not obtain necessary federal approval for the nursing home facility quality assessment or the payment rates required by subsection (4). Upon termination, all collected assessment revenues, less any amounts expended by the agency, shall be returned on a pro rata basis to the nursing facilities that paid them.
(7) The agency may seek any of the following remedies for failure of any nursing home facility provider to pay its assessment timely:
(a) Withholding any medical assistance reimbursement payments until such time as the assessment amount is recovered;
(b) Suspension or revocation of the nursing home facility license; and
(c) Imposition of a fine of up to $1,000 per day for each delinquent payment, not to exceed the amount of the assessment.
(8) The agency shall adopt rules necessary to administer this section.
History.—s. 1, ch. 2009-4; s. 7, ch. 2009-55; s. 8, ch. 2010-156; s. 6, ch. 2011-61.
409.9083 Quality assessment on privately operated intermediate care facilities for the developmentally disabled; exemptions; purpose; federal approval required; remedies.—
(1) As used in this section, the term:
(a) “Intermediate care facility for the developmentally disabled” or “ICF/DD” means a privately operated intermediate care facility for the developmentally disabled licensed under part VIII of chapter 400.
(b) “Net patient service revenue” means gross revenues from services provided to ICF/DD facility residents, less reductions from gross revenue resulting from an inability to collect payment of charges. Net patient service revenue excludes nonresident care revenues such as gain or loss on asset disposal, prior year revenue, donations, and physician billings, and all outpatient revenues. Reductions from gross revenue include bad debts; contractual adjustments; uncompensated care; administrative, courtesy, and policy discounts and adjustments; and other such revenue deductions.
(c) “Resident day” means a calendar day of care provided to an ICF/DD facility resident, including the day of admission and excluding the day of discharge, except that, when admission and discharge occur on the same day, 1 day of care exists.
(2) Effective October 1, 2009, there is imposed upon each intermediate care facility for the developmentally disabled a quality assessment. The aggregated amount of assessments for all ICF/DDs in a given year shall be an amount not exceeding the maximum percentage allowed under federal law of the total aggregate net patient service revenue of assessed facilities. The agency shall calculate the quality assessment rate annually on a per-resident-day basis as reported by the facilities. The per-resident-day assessment rate shall be uniform. Each facility shall report monthly to the agency its total number of resident days and shall remit an amount equal to the assessment rate times the reported number of days. The agency shall collect, and each facility shall pay, the quality assessment each month. The agency shall collect the assessment from facility providers no later than the 15th of the next succeeding calendar month. The agency shall notify providers of the quality assessment rate and provide a standardized form to complete and submit with payments. The collection of the quality assessment shall commence no sooner than 15 days after the agency’s initial payment to the facilities that implement the increased Medicaid rates containing the elements prescribed in subsection (3) and monthly thereafter. Intermediate care facilities for the developmentally disabled may increase their rates to incorporate the assessment but may not create a separate line-item charge for the purpose of passing through the assessment to residents.
(3) The purpose of the facility quality assessment is to ensure continued quality of care. Collected assessment funds shall be used to obtain federal financial participation through the Medicaid program to make Medicaid payments for ICF/DD services up to the amount of the Medicaid rates for such facilities as calculated in accordance with the approved state Medicaid plan in effect on April 1, 2008. The quality assessment and federal matching funds shall be used exclusively for the following purposes and in the following order of priority to:
(a) Reimburse the Medicaid share of the quality assessment as a pass-through, Medicaid-allowable cost.
(b) Increase each privately operated ICF/DD Medicaid rate, as needed, by an amount that restores rate reductions effective on or after October 1, 2008, as provided in the General Appropriations Act.
(c) Increase payments to such facilities to fund covered services to Medicaid beneficiaries.
(4) The agency shall seek necessary federal approval in the form of state plan amendments in order to implement the provisions of this section.
(5)(a) The quality assessment shall terminate and the agency shall discontinue the imposition, assessment, and collection of the quality assessment if the agency does not obtain necessary federal approval for the facility quality assessment or the payment rates required by subsection (3).
(b) Upon termination of the quality assessment, all collected assessment revenues, less any amounts expended by the agency, shall be returned on a pro rata basis to the facilities that paid such assessments.
(6) The agency may seek any of the following remedies for failure of any ICF/DD provider to timely pay its assessment:
(a) Withholding any medical assistance reimbursement payments until the assessment amount is recovered.
(b) Suspending or revoking the facility’s license.
(c) Imposing a fine of up to $1,000 per day for each delinquent payment, not to exceed the amount of the assessment.
(7) The agency shall adopt rules necessary to administer this section.
History.—s. 8, ch. 2009-55; s. 9, ch. 2010-156; s. 7, ch. 2011-61.
409.909 Statewide Medicaid Residency Program.—
(1) The Statewide Medicaid Residency Program is established to improve the quality of care and access to care for Medicaid recipients, expand graduate medical education on an equitable basis, and increase the supply of highly trained physicians statewide. The agency shall make payments to hospitals licensed under part I of chapter 395 for graduate medical education associated with the Medicaid program. This system of payments is designed to generate federal matching funds under Medicaid and distribute the resulting funds to participating hospitals on a quarterly basis in each fiscal year for which an appropriation is made.
(2) On or before September 15 of each year, the agency shall calculate an allocation fraction to be used for distributing funds to participating hospitals. On or before the final business day of each quarter of a state fiscal year, the agency shall distribute to each participating hospital one-fourth of that hospital’s annual allocation calculated under subsection (4). The allocation fraction for each participating hospital is based on the hospital’s number of full-time equivalent residents and the amount of its Medicaid payments. As used in this section, the term:
(a) “Full-time equivalent,” or “FTE,” means a resident who is in his or her initial residency period, which is defined as the minimum number of years of training required before the resident may become eligible for board certification by the American Osteopathic Association Bureau of Osteopathic Specialists or the American Board of Medical Specialties in the specialty in which he or she first began training, not to exceed 5 years. A resident training beyond the initial residency period is counted as 0.5 FTE, unless his or her chosen specialty is in general surgery or primary care, in which case the resident is counted as 1.0 FTE. For the purposes of this section, primary care specialties include:
1. Family medicine;
2. General internal medicine;
3. General pediatrics;
4. Preventive medicine;
5. Geriatric medicine;
6. Osteopathic general practice;
7. Obstetrics and gynecology; and
8. Emergency medicine.
(b) “Medicaid payments” means the estimated total payments for reimbursing a hospital for direct inpatient services for the fiscal year in which the allocation fraction is calculated based on the hospital inpatient appropriation and the parameters for the inpatient diagnosis-related group base rate, including applicable intergovernmental transfers, specified in the General Appropriations Act, as determined by the agency.
(c) “Resident” means a medical intern, fellow, or resident enrolled in a program accredited by the Accreditation Council for Graduate Medical Education, the American Association of Colleges of Osteopathic Medicine, or the American Osteopathic Association at the beginning of the state fiscal year during which the allocation fraction is calculated, as reported by the hospital to the agency.
(3) The agency shall use the following formula to calculate a participating hospital’s allocation fraction:
HAF=[0.9 x (HFTE/TFTE)] + [0.1 x (HMP/TMP)]
Where:
HAF=A hospital’s allocation fraction.
HFTE=A hospital’s total number of FTE residents.
TFTE=The total FTE residents for all participating hospitals.
HMP=A hospital’s Medicaid payments.
TMP=The total Medicaid payments for all participating hospitals.
(4) A hospital’s annual allocation shall be calculated by multiplying the funds appropriated for the Statewide Medicaid Residency Program in the General Appropriations Act by that hospital’s allocation fraction. If the calculation results in an annual allocation that exceeds $50,000 per FTE resident, the hospital’s annual allocation shall be reduced to a sum equaling no more than $50,000 per FTE resident. The funds calculated for that hospital in excess of $50,000 per FTE resident shall be redistributed to participating hospitals whose annual allocation does not exceed $50,000 per FTE resident, using the same methodology and payment schedule specified in this section.
(5) The agency may adopt rules to administer this section.
History.—s. 5, ch. 2013-48.
409.910 Responsibility for payments on behalf of Medicaid-eligible persons when other parties are liable.—
(1) It is the intent of the Legislature that Medicaid be the payor of last resort for medically necessary goods and services furnished to Medicaid recipients. All other sources of payment for medical care are primary to medical assistance provided by Medicaid. If benefits of a liable third party are discovered or become available after medical assistance has been provided by Medicaid, it is the intent of the Legislature that Medicaid be repaid in full and prior to any other person, program, or entity. Medicaid is to be repaid in full from, and to the extent of, any third-party benefits, regardless of whether a recipient is made whole or other creditors paid. Principles of common law and equity as to assignment, lien, and subrogation are abrogated to the extent necessary to ensure full recovery by Medicaid from third-party resources. It is intended that if the resources of a liable third party become available at any time, the public treasury should not bear the burden of medical assistance to the extent of such resources.
(2) This section may be cited as the “Medicaid Third-Party Liability Act.”
(3) Third-party benefits for medical services shall be primary to medical assistance provided by Medicaid.
(4) After the agency has provided medical assistance under the Medicaid program, it shall seek recovery of reimbursement from third-party benefits to the limit of legal liability and for the full amount of third-party benefits, but not in excess of the amount of medical assistance paid by Medicaid, as to:
(a) Claims for which the agency has a waiver pursuant to federal law; or
(b) Situations in which the agency learns of the existence of a liable third party or in which third-party benefits are discovered or become available after medical assistance has been provided by Medicaid.
(5) An applicant, recipient, or legal representative shall inform the agency of any rights the applicant or recipient has to third-party benefits and shall inform the agency of the name and address of any person that is or may be liable to provide third-party benefits. When the agency provides, pays for, or becomes liable for medical services provided by a hospital, the recipient receiving such medical services or his or her legal representative shall also provide the information as to third-party benefits, as defined in this section, to the hospital, which shall provide notice thereof to the agency in a manner specified by the agency.
(6) When the agency provides, pays for, or becomes liable for medical care under the Medicaid program, it has the following rights, as to which the agency may assert independent principles of law, which shall nevertheless be construed together to provide the greatest recovery from third-party benefits:
(a) The agency is automatically subrogated to any rights that an applicant, recipient, or legal representative has to any third-party benefit for the full amount of medical assistance provided by Medicaid. Recovery pursuant to the subrogation rights created hereby shall not be reduced, prorated, or applied to only a portion of a judgment, award, or settlement, but is to provide full recovery by the agency from any and all third-party benefits. Equities of a recipient, his or her legal representative, a recipient’s creditors, or health care providers shall not defeat, reduce, or prorate recovery by the agency as to its subrogation rights granted under this paragraph.
(b) By applying for or accepting medical assistance, an applicant, recipient, or legal representative automatically assigns to the agency any right, title, and interest such person has to any third-party benefit, excluding any Medicare benefit to the extent required to be excluded by federal law.
1. The assignment granted under this paragraph is absolute, and vests legal and equitable title to any such right in the agency, but not in excess of the amount of medical assistance provided by the agency.
2. The agency is a bona fide assignee for value in the assigned right, title, or interest, and takes vested legal and equitable title free and clear of latent equities in a third person. Equities of a recipient, the recipient’s legal representative, his or her creditors, or health care providers shall not defeat or reduce recovery by the agency as to the assignment granted under this paragraph.
3. By accepting medical assistance, the recipient grants to the agency the limited power of attorney to act in his or her name, place, and stead to perform specific acts with regard to third-party benefits, the recipient’s assent being deemed to have been given, including:
a. Endorsing any draft, check, money order, or other negotiable instrument representing third-party benefits that are received on behalf of the recipient as a third-party benefit.
b. Compromising claims to the extent of the rights assigned, provided that the recipient is not otherwise represented by an attorney as to the claim.
(c) The agency is entitled to, and has, an automatic lien for the full amount of medical assistance provided by Medicaid to or on behalf of the recipient for medical care furnished as a result of any covered injury or illness for which a third party is or may be liable, upon the collateral, as defined in s. 409.901.
1. The lien attaches automatically when a recipient first receives treatment for which the agency may be obligated to provide medical assistance under the Medicaid program. The lien is perfected automatically at the time of attachment.
2. The agency is authorized to file a verified claim of lien. The claim of lien shall be signed by an authorized employee of the agency, and shall be verified as to the employee’s knowledge and belief. The claim of lien may be filed and recorded with the clerk of the circuit court in the recipient’s last known county of residence or in any county deemed appropriate by the agency. The claim of lien, to the extent known by the agency, shall contain:
a. The name and last known address of the person to whom medical care was furnished.
b. The date of injury.
c. The period for which medical assistance was provided.
d. The amount of medical assistance provided or paid, or for which Medicaid is otherwise liable.
e. The names and addresses of all persons claimed by the recipient to be liable for the covered injuries or illness.
3. The filing of the claim of lien pursuant to this section shall be notice thereof to all persons.
4. If the claim of lien is filed within 1 year after the later of the date when the last item of medical care relative to a specific covered injury or illness was paid, or the date of discovery by the agency of the liability of any third party, or the date of discovery of a cause of action against a third party brought by a recipient or his or her legal representative, record notice shall relate back to the time of attachment of the lien.
5. If the claim of lien is filed after 1 year after the later of the events specified in subparagraph 4., notice shall be effective as of the date of filing.
6. Only one claim of lien need be filed to provide notice as set forth in this paragraph and shall provide sufficient notice as to any additional or after-paid amount of medical assistance provided by Medicaid for any specific covered injury or illness. The agency may, in its discretion, file additional, amended, or substitute claims of lien at any time after the initial filing, until the agency has been repaid the full amount of medical assistance provided by Medicaid or otherwise has released the liable parties and recipient.
7. No release or satisfaction of any cause of action, suit, claim, counterclaim, demand, judgment, settlement, or settlement agreement shall be valid or effectual as against a lien created under this paragraph, unless the agency joins in the release or satisfaction or executes a release of the lien. An acceptance of a release or satisfaction of any cause of action, suit, claim, counterclaim, demand, or judgment and any settlement of any of the foregoing in the absence of a release or satisfaction of a lien created under this paragraph shall prima facie constitute an impairment of the lien, and the agency is entitled to recover damages on account of such impairment. In an action on account of impairment of a lien, the agency may recover from the person accepting the release or satisfaction or making the settlement the full amount of medical assistance provided by Medicaid. Nothing in this section shall be construed as creating a lien or other obligation on the part of an insurer which in good faith has paid a claim pursuant to its contract without knowledge or actual notice that the agency has provided medical assistance for the recipient related to a particular covered injury or illness. However, notice or knowledge that an insured is, or has been a Medicaid recipient within 1 year from the date of service for which a claim is being paid creates a duty to inquire on the part of the insurer as to any injury or illness for which the insurer intends or is otherwise required to pay benefits.
8. The lack of a properly filed claim of lien shall not affect the agency’s assignment or subrogation rights provided in this subsection, nor shall it affect the existence of the lien, but only the effective date of notice as provided in subparagraph 5.
9. The lien created by this paragraph is a first lien and superior to the liens and charges of any provider, and shall exist for a period of 7 years, if recorded, after the date of recording; and shall exist for a period of 7 years after the date of attachment, if not recorded. If recorded, the lien may be extended for one additional period of 7 years by rerecording the claim of lien within the 90-day period preceding the expiration of the lien.
10. The clerk of the circuit court for each county in the state shall endorse on a claim of lien filed under this paragraph the date and hour of filing and shall record the claim of lien in the official records of the county as for other records received for filing. The clerk shall receive as his or her fee for filing and recording any claim of lien or release of lien under this paragraph the total sum of $2. Any fee required to be paid by the agency shall not be required to be paid in advance of filing and recording, but may be billed to the agency after filing and recording of the claim of lien or release of lien.
11. After satisfaction of any lien recorded under this paragraph, the agency shall, within 60 days after satisfaction, either file with the appropriate clerk of the circuit court or mail to any appropriate party, or counsel representing such party, if represented, a satisfaction of lien in a form acceptable for filing in Florida.
(7) The agency shall recover the full amount of all medical assistance provided by Medicaid on behalf of the recipient to the full extent of third-party benefits.
(a) Recovery of such benefits shall be collected directly from:
1. Any third party;
2. The recipient or legal representative, if he or she has received third-party benefits;
3. The provider of a recipient’s medical services if third-party benefits have been recovered by the provider; notwithstanding any provision of this section, to the contrary, however, no provider shall be required to refund or pay to the agency any amount in excess of the actual third-party benefits received by the provider from a third-party payor for medical services provided to the recipient; or
4. Any person who has received the third-party benefits.
(b) Upon receipt of any recovery or other collection pursuant to this section, the agency shall distribute the amount collected as follows:
1. To itself, an amount equal to the state Medicaid expenditures for the recipient plus any incentive payment made in accordance with paragraph (14)(a).
2. To the Federal Government, the federal share of the state Medicaid expenditures minus any incentive payment made in accordance with paragraph (14)(a) and federal law, and minus any other amount permitted by federal law to be deducted.
3. To the recipient, after deducting any known amounts owed to the agency for any related medical assistance or to health care providers, any remaining amount. This amount shall be treated as income or resources in determining eligibility for Medicaid.
The provisions of this subsection do not apply to any proceeds received by the state, or any agency thereof, pursuant to a final order, judgment, or settlement agreement, in any matter in which the state asserts claims brought on its own behalf, and not as a subrogee of a recipient, or under other theories of liability. The provisions of this subsection do not apply to any proceeds received by the state, or an agency thereof, pursuant to a final order, judgment, or settlement agreement, in any matter in which the state asserted both claims as a subrogee and additional claims, except as to those sums specifically identified in the final order, judgment, or settlement agreement as reimbursements to the recipient as expenditures for the named recipient on the subrogation claim.
(8) The agency shall require an applicant or recipient, or the legal representative thereof, to cooperate in the recovery by the agency of third-party benefits of a recipient and in establishing paternity and support of a recipient child born out of wedlock. As a minimal standard of cooperation, the recipient or person able to legally assign a recipient’s rights shall:
(a) Appear at an office designated by the agency to provide relevant information or evidence.
(b) Appear as a witness at a court or other proceeding.
(c) Provide information, or attest to lack of information, under penalty of perjury.
(d) Pay to the agency any third-party benefit received.
(e) Take any additional steps to assist in establishing paternity or securing third-party benefits, or both.
(f) Paragraphs (a)-(e) notwithstanding, the agency shall have the discretion to waive, in writing, the requirement of cooperation for good cause shown and as required by federal law.
(9) The department shall deny or terminate eligibility for any applicant or recipient who refuses to cooperate as required in subsection (8), unless cooperation has been waived in writing by the department as provided in paragraph (8)(f). However, any denial or termination of eligibility shall not reduce medical assistance otherwise payable by the department to a provider for medical care provided to a recipient prior to denial or termination of eligibility.
(10) An applicant or recipient shall be deemed to have provided to the agency the authority to obtain and release medical information and other records with respect to such medical care, for the sole purpose of obtaining reimbursement for medical assistance provided by Medicaid.
(11) The agency may, as a matter of right, in order to enforce its rights under this section, institute, intervene in, or join any legal or administrative proceeding in its own name in one or more of the following capacities: individually, as subrogee of the recipient, as assignee of the recipient, or as lienholder of the collateral.
(a) If either the recipient, or his or her legal representative, or the agency brings an action against a third party, the recipient, or the recipient’s legal representative, or the agency, or their attorneys, shall, within 30 days after filing the action, provide to the other written notice, by personal delivery or registered mail, of the action, the name of the court in which the case is brought, the case number of such action, and a copy of the pleadings. If an action is brought by either the agency, or the recipient or the recipient’s legal representative, the other may, at any time before trial on the merits, become a party to, or shall consolidate his or her action with the other if brought independently. Unless waived by the other, the recipient, or his or her legal representative, or the agency shall provide notice to the other of the intent to dismiss at least 21 days prior to voluntary dismissal of an action against a third party. Notice to the agency shall be sent to an address set forth by rule. Notice to the recipient or his or her legal representative, if represented by an attorney, shall be sent to the attorney, and, if not represented, then to the last known address of the recipient or his or her legal representative.
(b) An action by the agency to recover damages in tort under this subsection, which action is derivative of the rights of the recipient or his or her legal representative, shall not constitute a waiver of sovereign immunity pursuant to s. 768.14.
(c) In the event of judgment, award, or settlement in a claim or action against a third party, the court shall order the segregation of an amount sufficient to repay the agency’s expenditures for medical assistance, plus any other amounts permitted under this section, and shall order such amounts paid directly to the agency.
(d) No judgment, award, or settlement in any action by a recipient or his or her legal representative to recover damages for injuries or other third-party benefits, when the agency has an interest, shall be satisfied without first giving the agency notice and a reasonable opportunity to file and satisfy its lien, and satisfy its assignment and subrogation rights or proceed with any action as permitted in this section.
(e) Except as otherwise provided in this section, notwithstanding any other provision of law, the entire amount of any settlement of the recipient’s action or claim involving third-party benefits, with or without suit, is subject to the agency’s claims for reimbursement of the amount of medical assistance provided and any lien pursuant thereto.
(f) Notwithstanding any provision in this section to the contrary, in the event of an action in tort against a third party in which the recipient or his or her legal representative is a party which results in a judgment, award, or settlement from a third party, the amount recovered shall be distributed as follows:
1. After attorney’s fees and taxable costs as defined by the Florida Rules of Civil Procedure, one-half of the remaining recovery shall be paid to the agency up to the total amount of medical assistance provided by Medicaid.
2. The remaining amount of the recovery shall be paid to the recipient.
3. For purposes of calculating the agency’s recovery of medical assistance benefits paid, the fee for services of an attorney retained by the recipient or his or her legal representative shall be calculated at 25 percent of the judgment, award, or settlement.
4. Notwithstanding any provision of this section to the contrary, the agency shall be entitled to all medical coverage benefits up to the total amount of medical assistance provided by Medicaid. For purposes of this paragraph, “medical coverage” means any benefits under health insurance, a health maintenance organization, a preferred provider arrangement, or a prepaid health clinic, and the portion of benefits designated for medical payments under coverage for workers’ compensation, personal injury protection, and casualty.
(g) In the event that the recipient, his or her legal representative, or the recipient’s estate brings an action against a third party, notice of institution of legal proceedings, notice of settlement, and all other notices required by this section or by rule shall be given to the agency, in Tallahassee, in a manner set forth by rule. All such notices shall be given by the attorney retained to assert the recipient’s or legal representative’s claim, or, if no attorney is retained, by the recipient, the recipient’s legal representative, or his or her estate.
(h) Except as otherwise provided in this section, actions to enforce the rights of the agency under this section shall be commenced within 5 years after the date a cause of action accrues, with the period running from the later of the date of discovery by the agency of a case filed by a recipient or his or her legal representative, or of discovery of any judgment, award, or settlement contemplated in this section, or of discovery of facts giving rise to a cause of action under this section. Nothing in this paragraph affects or prevents a proceeding to enforce a lien during the existence of the lien as set forth in subparagraph (6)(c)9.
(i) Upon the death of a recipient, and within the time prescribed by ss. 733.702 and 733.710, the agency, in addition to any other available remedy, may file a claim against the estate of the recipient for the total amount of medical assistance provided by Medicaid for the benefit of the recipient. Claims so filed shall take priority as class 3 claims as provided by s. 733.707(1)(c). The filing of a claim pursuant to this paragraph shall neither reduce nor diminish the general claims of the agency under s. 414.28, except that the agency may not receive double recovery for the same expenditure. Claims under this paragraph shall be superior to those under s. 414.28. The death of the recipient shall neither extinguish nor diminish any right of the agency to recover third-party benefits from a third party or provider. Nothing in this paragraph affects or prevents a proceeding to enforce a lien created pursuant to this section or a proceeding to set aside a fraudulent conveyance as defined in subsection (16).
(12) No action taken by the agency shall operate to deny the recipient’s recovery of that portion of benefits not assigned or subrogated to the agency, or not secured by the agency’s lien. The agency’s rights of recovery created by this section, however, shall not be limited to some portion of recovery from a judgment, award, or settlement. Only the following benefits are not subject to the rights of the agency: benefits not related in any way to a covered injury or illness; proceeds of life insurance coverage on the recipient; proceeds of insurance coverage, such as coverage for property damage, which by its terms and provisions cannot be construed to cover personal injury, death, or a covered injury or illness; proceeds of disability coverage for lost income; and recovery in excess of the amount of medical benefits provided by Medicaid after repayment in full to the agency.
(13) No action of the recipient shall prejudice the rights of the agency under this section. No settlement, agreement, consent decree, trust agreement, annuity contract, pledge, security arrangement, or any other device, hereafter collectively referred to in this subsection as a “settlement agreement,” entered into or consented to by the recipient or his or her legal representative shall impair the agency’s rights. However, in a structured settlement, no settlement agreement by the parties shall be effective or binding against the agency for benefits accrued without the express written consent of the agency or an appropriate order of a court having personal jurisdiction over the agency.
(14) The agency is authorized to enter into agreements to enforce or collect medical support and other third-party benefits.
(a) If a cooperative agreement is entered into with any agency, program, or subdivision of the state, or any agency, program, or legal entity of or operated by a subdivision of the state, or with any other state, the agency is authorized to make an incentive payment of up to 15 percent of the amount actually collected and reimbursed to the agency, to the extent of medical assistance paid by Medicaid. Such incentive payment is to be deducted from the federal share of that amount, to the extent authorized by federal law. The agency may pay such person an additional percentage of the amount actually collected and reimbursed to the agency as a result of the efforts of the person, but no more than a maximum percentage established by the agency. In no case shall the percentage exceed the lesser of a percentage determined to be commercially reasonable or 15 percent, in addition to the 15-percent incentive payment, of the amount actually collected and reimbursed to the agency as a result of the efforts of the person under contract.
(b) If an agreement to enforce or collect third-party benefits is entered into by the agency with any person other than those described in paragraph (a), including any attorney retained by the agency who is not an employee or agent of any person named in paragraph (a), then the agency may pay such person a percentage of the amount actually collected and reimbursed to the agency as a result of the efforts of the person, to the extent of medical assistance paid by Medicaid. In no case shall the percentage exceed a maximum established by the agency, which shall not exceed the lesser of a percentage determined to be commercially reasonable or 30 percent of the amount actually collected and reimbursed to the agency as a result of the efforts of the person under contract.
(c) An agreement pursuant to this subsection may permit reasonable litigation costs or expenses to be paid from the agency’s recovery to a person under contract with the agency.
(d) Contingency fees and costs incurred in recovery pursuant to an agreement under this subsection may, for purposes of determining state and federal share, be deemed to be administrative expenses of the state. To the extent permitted by federal law, such administrative expenses shall be shared with, or fully paid by, the Federal Government.
(15) Insurance and other third-party benefits may not contain any term or provision which purports to limit or exclude payment or provisions of benefits for an individual if the individual is eligible for, or a recipient of, medical assistance from Medicaid, and any such term or provision shall be void as against public policy.
(16) Any transfer or encumbrance of any right, title, or interest to which the agency has a right pursuant to this section, with the intent, likelihood, or practical effect of defeating, hindering, or reducing recovery by the agency for reimbursement of medical assistance provided by Medicaid, shall be deemed to be a fraudulent conveyance, and such transfer or encumbrance shall be void and of no effect against the claim of the agency, unless the transfer was for adequate consideration and the proceeds of the transfer are reimbursed in full to the agency, but not in excess of the amount of medical assistance provided by Medicaid.
(17)(a) A recipient or his or her legal representative or any person representing, or acting as agent for, a recipient or the recipient’s legal representative, who has notice, excluding notice charged solely by reason of the recording of the lien pursuant to paragraph (6)(c), or who has actual knowledge of the agency’s rights to third-party benefits under this section, who receives any third-party benefit or proceeds for a covered illness or injury, must, within 60 days after receipt of settlement proceeds, pay the agency the full amount of the third-party benefits, but not more than the total medical assistance provided by Medicaid, or place the full amount of the third-party benefits in an interest-bearing trust account for the benefit of the agency pending an administrative determination of the agency’s right to the benefits under this subsection. Proof that such person had notice or knowledge that the recipient had received medical assistance from Medicaid, and that third-party benefits or proceeds were in any way related to a covered illness or injury for which Medicaid had provided medical assistance, and that such person knowingly obtained possession or control of, or used, third-party benefits or proceeds and failed to pay the agency the full amount required by this section or to hold the full amount of third-party benefits or proceeds in an interest-bearing trust account pending an administrative determination, unless adequately explained, gives rise to an inference that such person knowingly failed to credit the state or its agent for payments received from social security, insurance, or other sources, pursuant to s. 414.39(4)(b), and acted with the intent set forth in s. 812.014(1).
(b) A recipient may contest the amount designated as recovered medical expense damages payable to the agency pursuant to the formula specified in paragraph (11)(f) by filing a petition under chapter 120 within 21 days after the date of payment of funds to the agency or after the date of placing the full amount of the third-party benefits in the trust account for the benefit of the agency pursuant to paragraph (a). The petition shall be filed with the Division of Administrative Hearings. For purposes of chapter 120, the payment of funds to the agency or the placement of the full amount of the third-party benefits in the trust account for the benefit of the agency constitutes final agency action and notice thereof. Final order authority for the proceedings specified in 1this subsection rests with the Division of Administrative Hearings. This procedure is the exclusive method for challenging the amount of third-party benefits payable to the agency. In order to successfully challenge the amount payable to the agency, the recipient must prove, by clear and convincing evidence, that a lesser portion of the total recovery should be allocated as reimbursement for past and future medical expenses than the amount calculated by the agency pursuant to the formula set forth in paragraph (11)(f) or that Medicaid provided a lesser amount of medical assistance than that 2asserted by the agency.
(c) The agency’s provider processing system reports are admissible as prima facie evidence in substantiating the agency’s claim.
(d) Venue for all administrative proceedings pursuant to 3this subsection lies in Leon County, at the discretion of the agency. Venue for all appellate proceedings arising from the administrative proceeding outlined in 3this subsection lies at the First District Court of Appeal in Leon County, at the discretion of the agency.
(e) Each party shall bear its own attorney fees and costs for any administrative proceeding conducted pursuant to 4paragraphs (b)-(e).
(f) In cases of suspected criminal violations or fraudulent activity, the agency may take any civil action permitted at law or equity to recover the greatest possible amount, including, without limitation, treble damages under ss. 772.11 and 812.035(7).
(g) The agency may investigate and request appropriate officers or agencies of the state to investigate suspected criminal violations or fraudulent activity related to third-party benefits, including, without limitation, ss. 414.39 and 812.014. Such requests may be directed, without limitation, to the Medicaid Fraud Control Unit of the Office of the Attorney General or to any state attorney. Pursuant to s. 409.913, the Attorney General has primary responsibility to investigate and control Medicaid fraud.
(h) In carrying out duties and responsibilities related to Medicaid fraud control, the agency may subpoena witnesses or materials within or outside the state and, through any duly designated employee, administer oaths and affirmations and collect evidence for possible use in either civil or criminal judicial proceedings.
(i) All information obtained and documents prepared pursuant to an investigation of a Medicaid recipient, the recipient’s legal representative, or any other person relating to an allegation of recipient fraud or theft is confidential and exempt from s. 119.07(1):
1. Until such time as the agency takes final agency action;
2. Until such time as the Department of Legal Affairs refers the case for criminal prosecution;
3. Until such time as an indictment or criminal information is filed by a state attorney in a criminal case; or
4. At all times if otherwise protected by law.
(18) In recovering any payments in accordance with this section, the agency is authorized to make appropriate settlements.
(19) Notwithstanding any provision in this section to the contrary, the agency shall not be required to seek reimbursement from a liable third party on claims for which the agency determines that the amount it reasonably expects to recover will be less than the cost of recovery, or that recovery efforts will otherwise not be cost-effective.
(20) Entities providing health insurance as defined in s. 624.603, health maintenance organizations and prepaid health clinics as defined in chapter 641, and, on behalf of their clients, third-party administrators and pharmacy benefits managers as defined in s. 409.901(27) shall provide such records and information as are necessary to accomplish the purpose of this section, unless such requirement results in an unreasonable burden.
(a) The director of the agency and the Director of the Office of Insurance Regulation of the Financial Services Commission shall enter into a cooperative agreement for requesting and obtaining information necessary to effect the purpose and objective of this section.
1. The agency shall request only that information necessary to determine whether health insurance as defined pursuant to s. 624.603, or those health services provided pursuant to chapter 641, could be, should be, or have been claimed and paid with respect to items of medical care and services furnished to any person eligible for services under this section.
2. All information obtained pursuant to subparagraph 1. is confidential and exempt from s. 119.07(1). The agency shall provide the information obtained pursuant to subparagraph 1. to the Department of Revenue for purposes of administering the state Title IV-D program. The agency and the Department of Revenue shall enter into a cooperative agreement for purposes of implementing this requirement.
3. The cooperative agreement or rules adopted under this subsection may include financial arrangements to reimburse the reporting entities for reasonable costs or a portion thereof incurred in furnishing the requested information. Neither the cooperative agreement nor the rules shall require the automation of manual processes to provide the requested information.
(b) The agency and the Financial Services Commission jointly shall adopt rules for the development and administration of the cooperative agreement. The rules shall include the following:
1. A method for identifying those entities subject to furnishing information under the cooperative agreement.
2. A method for furnishing requested information.
3. Procedures for requesting exemption from the cooperative agreement based on an unreasonable burden to the reporting entity.
(21) Entities providing health insurance as defined in s. 624.603, and health maintenance organizations as defined in chapter 641, requiring tape or electronic billing formats from the agency shall accept Medicaid billings that are prepared using the current Medicare standard billing format. If the insurance entity or health maintenance organization is unable to use the agency format, the entity shall accept paper claims from the agency in lieu of tape or electronic billing, provided that these claims are prepared using current Medicare standard billing formats.
(22) The agency is authorized to adopt rules to implement the provisions of this section and federal requirements.
History.—s. 4, ch. 90-232; s. 33, ch. 90-295; s. 38, ch. 91-282; s. 4, ch. 92-79; s. 4, ch. 94-251; s. 98, ch. 96-175; s. 3, ch. 96-331; s. 259, ch. 96-406; s. 1023, ch. 97-103; s. 32, ch. 98-191; s. 1, ch. 98-411; s. 184, ch. 99-8; s. 1, ch. 99-231; s. 1, ch. 99-323; s. 8, ch. 99-356; s. 9, ch. 99-393; s. 67, ch. 99-397; s. 58, ch. 2000-153; s. 449, ch. 2003-261; s. 3, ch. 2005-140; s. 13, ch. 2008-246; s. 13, ch. 2010-187; s. 6, ch. 2013-48; s. 2, ch. 2013-150.
1Note.—As amended by s. 6, ch. 2013-48. The amendment by s. 2, ch. 2013-150, used “this section” instead of “this subsection.”
2Note.—As amended by s. 6, ch. 2013-48. The amendment by s. 2, ch. 2013-150, used the word “determined” instead of the word “asserted.”
3Note.—As amended by s. 6, ch. 2013-48. The amendment by s. 2, ch. 2013-150, referenced “paragraph (a)” instead of “this subsection.”
4Note.—Substituted by the editors for a reference to “this paragraph,” as referenced in the amendment by s. 6, ch. 2013-48, and which language became paragraphs (b)-(e) in the compilation of the text pursuant to renumbering by s. 2, ch. 2013-150. Section 2, ch. 2013-150, referenced “paragraph (a) or paragraph (b).”
409.9101 Recovery for payments made on behalf of Medicaid-eligible persons.—
(1) This section may be cited as the “Medicaid Estate Recovery Act.”
(2) It is the intent of the Legislature by this section to supplement Medicaid funds that are used to provide medical services to eligible persons. Medicaid estate recovery shall be accomplished by the agency filing a statement of claim against the estate of a deceased Medicaid recipient as provided in part VII of chapter 733. Recovery shall be made pursuant to federal authority in s. 13612 of the Omnibus Budget Reconciliation Act of 1993, which amends s. 1917(b)(1) of the Social Security Act, 42 U.S.C. s. 1396p(b)(1).
(3) The acceptance of public medical assistance, as defined by Title XIX (Medicaid) of the Social Security Act, including mandatory and optional supplemental payments under the Social Security Act, shall create a debt to the agency in the total amount paid to or for the benefit of the recipient for medical assistance after the recipient reached 55 years of age. Payment of benefits to a person under the age of 55 years does not create a debt. Upon filing of a statement of claim in the probate proceeding, the agency shall be an interested person as defined in s. 731.201 to the same extent as other estate claimants.
(4) The agency may amend the claim as a matter of right up to 1 year after the last date medical services were rendered to the decedent.
(5) The agency’s provider processing system reports shall be admissible as prima facie evidence in substantiating the agency’s claim.
(6) The debt created under this section shall not be enforced if the recipient is survived by:
(a) A spouse;
(b) A child or children under 21 years of age; or
(c) A child or children who are blind or permanently and totally disabled pursuant to the eligibility requirements of Title XIX of the Social Security Act.
(7) No debt under this section shall be enforced against any property that is determined to be exempt from the claims of creditors under the constitution or laws of this state.
(8) The agency shall not recover from an estate if doing so would cause undue hardship for the qualified heirs, as defined in s. 731.201. The personal representative of an estate and any heir may request that the agency waive recovery of any or all of the debt when recovery would create a hardship. A hardship does not exist solely because recovery will prevent any heirs from receiving an anticipated inheritance. The following criteria shall be considered by the agency in reviewing a hardship request:
(a) The heir:
1. Currently resides in the residence of the decedent;
2. Resided there at the time of the death of the decedent;
3. Has made the residence his or her primary residence for the 12 months immediately preceding the death of the decedent; and
4. Owns no other residence;
(b) The heir would be deprived of food, clothing, shelter, or medical care necessary for the maintenance of life or health;
(c) The heir can document that he or she provided full-time care to the recipient which delayed the recipient’s entry into a nursing home. The heir must be either the decedent’s sibling or the son or daughter of the decedent and must have resided with the recipient for at least 1 year prior to the recipient’s death; or
(d) The cost involved in the sale of the property would be equal to or greater than the value of the property.
(9) Instances arise in Medicaid estate-recovery cases where the assets include a settlement of a claim against a liable third party. The agency’s claim under s. 409.910 must be satisfied prior to including the settlement proceeds as estate assets. The remaining settlement proceeds shall be included in the estate and be available to satisfy the Medicaid estate-recovery claim. The Medicaid estate-recovery share shall be one-half of the settlement proceeds included in the estate. Nothing in this subsection is intended to limit the agency’s rights against other assets in the estate not related to the settlement. However, in no circumstances shall the agency’s recovery exceed the total amount of Medicaid medical assistance provided to the recipient.
(10) In instances where there are no liquid assets to satisfy the Medicaid estate-recovery claim, if there is nonexempt personal property or real property which is not protected homestead and the costs of sale will not exceed the proceeds, the property shall be sold to satisfy the Medicaid estate-recovery claim. Real property shall not be transferred to the agency in any instance.
History.—s. 68, ch. 99-397; s. 2, ch. 2001-226; s. 59, ch. 2013-18.
409.9102 A qualified state Long-Term Care Insurance Partnership Program in Florida.—The Agency for Health Care Administration, in consultation with the Office of Insurance Regulation and the Department of Children and Family Services, is directed to establish a qualified state Long-Term Care Insurance Partnership Program in Florida, in compliance with the requirements of s. 1917(b) of the Social Security Act, as amended.
(1) The program shall:
(a) Provide incentives for an individual to obtain or maintain insurance to cover the cost of long-term care.
(b) Provide a mechanism to qualify for coverage of the costs of long-term care needs under Medicaid without first being required to substantially exhaust his or her assets, including a provision for the disregard of any assets in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under the program.
(c) Alleviate the financial burden on the state’s medical assistance program by encouraging the pursuit of private initiatives.
(2) The Agency for Health Care Administration, in consultation with the Office of Insurance Regulation and the Department of Children and Family Services, and in accordance with federal guidelines, shall create standards for long-term care partnership program information distributed to individuals through insurance companies offering approved long-term care partnership program policies.
(3) The Agency for Health Care Administration is authorized to amend the Medicaid state plan and adopt rules pursuant to ss. 120.536(1) and 120.54 to implement this section.
(4) The Department of Children and Family Services, when determining eligibility for Medicaid long-term care services for an individual who is the beneficiary of an approved long-term care partnership program policy, shall reduce the total countable assets of the individual by an amount equal to the insurance benefit payments that are made to or on behalf of the individual. The department is authorized to adopt rules pursuant to ss. 120.536(1) and 120.54 to implement this subsection.
History.—s. 2, ch. 2005-252; ss. 1, 3, ch. 2006-254.
409.911 Disproportionate share program.—Subject to specific allocations established within the General Appropriations Act and any limitations established pursuant to chapter 216, the agency shall distribute, pursuant to this section, moneys to hospitals providing a disproportionate share of Medicaid or charity care services by making quarterly Medicaid payments as required. Notwithstanding the provisions of s. 409.915, counties are exempt from contributing toward the cost of this special reimbursement for hospitals serving a disproportionate share of low-income patients.
(1) DEFINITIONS.—As used in this section and the Florida Hospital Uniform Reporting System manual:
(a) “Adjusted patient days” means the sum of acute care patient days and intensive care patient days as reported to the Agency for Health Care Administration, divided by the ratio of inpatient revenues generated from acute, intensive, ambulatory, and ancillary patient services to gross revenues.
(b) “Actual audited data” or “actual audited experience” means data reported to the Agency for Health Care Administration which has been audited in accordance with generally accepted auditing standards by the agency or representatives under contract with the agency.
(c) “Charity care” or “uncompensated charity care” means that portion of hospital charges reported to the Agency for Health Care Administration for which there is no compensation, other than restricted or unrestricted revenues provided to a hospital by local governments or tax districts regardless of the method of payment, for care provided to a patient whose family income for the 12 months preceding the determination is less than or equal to 200 percent of the federal poverty level, unless the amount of hospital charges due from the patient exceeds 25 percent of the annual family income. However, in no case shall the hospital charges for a patient whose family income exceeds four times the federal poverty level for a family of four be considered charity.
(d) “Charity care days” means the sum of the deductions from revenues for charity care minus 50 percent of restricted and unrestricted revenues provided to a hospital by local governments or tax districts, divided by gross revenues per adjusted patient day.
(e) “Hospital” means a health care institution licensed as a hospital pursuant to chapter 395, but does not include ambulatory surgical centers.
(f) “Medicaid days” means the number of actual days attributable to Medicaid patients as determined by the Agency for Health Care Administration.
(2) The Agency for Health Care Administration shall use the following actual audited data to determine the Medicaid days and charity care to be used in calculating the disproportionate share payment:
(a) The average of the 2005, 2006, and 2007 audited disproportionate share data to determine each hospital’s Medicaid days and charity care for the 2013-2014 state fiscal year.
(b) If the Agency for Health Care Administration does not have the prescribed 3 years of audited disproportionate share data as noted in paragraph (a) for a hospital, the agency shall use the average of the years of the audited disproportionate share data as noted in paragraph (a) which is available.
(c) In accordance with s. 1923(b) of the Social Security Act, a hospital with a Medicaid inpatient utilization rate greater than one standard deviation above the statewide mean or a hospital with a low-income utilization rate of 25 percent or greater shall qualify for reimbursement.
(3) Hospitals that qualify for a disproportionate share payment solely under paragraph (2)(c) shall have their payment calculated in accordance with the following formulas:
DSHP = (HMD/TMSD) x $1 million
Where:
DSHP = disproportionate share hospital payment.
HMD = hospital Medicaid days.
TSD = total state Medicaid days.
Any funds not allocated to hospitals qualifying under this section shall be redistributed to the non-state government owned or operated hospitals with greater than 3,100 Medicaid days.
(4) The following formulas shall be used to pay disproportionate share dollars to public hospitals:
(a) For state mental health hospitals:
DSHP = (HMD/TMDMH) x TAAMH
shall be the difference between the federal cap for Institutions for Mental Diseases and the amounts paid under the mental health disproportionate share program.
Where:
DSHP = disproportionate share hospital payment.
HMD = hospital Medicaid days.
TMDHH = total Medicaid days for state mental health hospitals.
TAAMH = total amount available for mental health hospitals.
(b) For non-state government owned or operated hospitals with 3,100 or more Medicaid days:
DSHP = [(.82 x HCCD/TCCD) + (.18 x HMD/TMD)]
x TAAPH
TAAPH = TAA - TAAMH
Where:
TAA = total available appropriation.
TAAPH = total amount available for public hospitals.
DSHP = disproportionate share hospital payments.
HMD = hospital Medicaid days.
TMD = total state Medicaid days for public hospitals.
HCCD = hospital charity care dollars.
TCCD = total state charity care dollars for public non-state hospitals.
The TAAPH shall be reduced by $6,365,257 before computing the DSHP for each public hospital. The $6,365,257 shall be distributed equally between the public hospitals that are also designated statutory teaching hospitals.
(c) For non-state government owned or operated hospitals with less than 3,100 Medicaid days, a total of $750,000 shall be distributed equally among these hospitals.
(d) Any nonstate government owned or operated hospital eligible for payments under this section on July 1, 2011, remains eligible for payments during the 2013-2014 state fiscal year.
(5) The following formula shall be used to pay disproportionate share dollars to provider service network (PSN) hospitals:
DSHP = TAAPSNH x (IHPSND/THPSND)
Where:
DSHP = Disproportionate share hospital payments.
TAAPSNH = Total amount available for PSN hospitals.
IHPSND = Individual hospital PSN days.
THPSND = Total of all hospital PSN days.
For purposes of this subsection, the PSN inpatient days shall be provided in the General Appropriations Act.
(6) In no case shall total payments to a hospital under this section, with the exception of public non-state facilities or state facilities, exceed the total amount of uncompensated charity care of the hospital, as determined by the agency according to the most recent calendar year audited data available at the beginning of each state fiscal year.
(7) The agency is authorized to receive funds from local governments and other local political subdivisions for the purpose of making payments, including federal matching funds, through the Medicaid disproportionate share program. Funds received from local governments for this purpose shall be separately accounted for and shall not be commingled with other state or local funds in any manner.
(8) Payments made by the agency to hospitals eligible to participate in this program shall be made in accordance with federal rules and regulations.
(a) If the Federal Government prohibits, restricts, or changes in any manner the methods by which funds are distributed for this program, the agency shall not distribute any additional funds and shall return all funds to the local government from which the funds were received, except as provided in paragraph (b).
(b) If the Federal Government imposes a restriction that still permits a partial or different distribution, the agency may continue to disburse funds to hospitals participating in the disproportionate share program in a federally approved manner, provided:
1. Each local government which contributes to the disproportionate share program agrees to the new manner of distribution as shown by a written document signed by the governing authority of each local government; and
2. The Executive Office of the Governor, the Office of Planning and Budgeting, the House of Representatives, and the Senate are provided at least 7 days’ prior notice of the proposed change in the distribution, and do not disapprove such change.
(c) No distribution shall be made under the alternative method specified in paragraph (b) unless all parties agree or unless all funds of those parties that disagree which are not yet disbursed have been returned to those parties.
(9) Notwithstanding the provisions of chapter 216, the Executive Office of the Governor is hereby authorized to establish sufficient trust fund authority to implement the disproportionate share program.
(10) The Agency for Health Care Administration shall create a Medicaid Low-Income Pool Council by July 1, 2006. The Low-Income Pool Council shall consist of 24 members, including 2 members appointed by the President of the Senate, 2 members appointed by the Speaker of the House of Representatives, 3 representatives of statutory teaching hospitals, 3 representatives of public hospitals, 3 representatives of nonprofit hospitals, 3 representatives of for-profit hospitals, 2 representatives of rural hospitals, 2 representatives of units of local government which contribute funding, 1 representative of family practice teaching hospitals, 1 representative of federally qualified health centers, 1 representative from the Department of Health, and 1 nonvoting representative of the Agency for Health Care Administration who shall serve as chair of the council. Except for a full-time employee of a public entity, an individual who qualifies as a lobbyist under s. 11.045 or s. 112.3215 may not serve as a member of the council. Of the members appointed by the Senate President, only one shall be a physician. Of the members appointed by the Speaker of the House of Representatives, only one shall be a physician. The physician member appointed by the Senate President and the physician member appointed by the Speaker of the House of Representatives must be physicians who routinely take calls in a trauma center, as defined in s. 395.4001, or a hospital emergency department. The council shall:
(a) Make recommendations on the financing of the low-income pool and the disproportionate share hospital program and the distribution of their funds.
(b) Advise the Agency for Health Care Administration on the development of the low-income pool plan required by the federal Centers for Medicare and Medicaid Services pursuant to the Medicaid reform waiver.
(c) Advise the Agency for Health Care Administration on the distribution of hospital funds used to adjust inpatient hospital rates, rebase rates, or otherwise exempt hospitals from reimbursement limits as financed by intergovernmental transfers.
(d) Submit its findings and recommendations to the Governor and the Legislature no later than February 1 of each year.
This subsection expires October 1, 2014.
History.—s. 39, ch. 91-282; s. 78, ch. 92-289; s. 24, ch. 95-146; s. 185, ch. 99-8; s. 6, ch. 2001-104; s. 5, ch. 2001-222; s. 23, ch. 2002-400; s. 13, ch. 2003-405; s. 13, ch. 2004-270; s. 11, ch. 2005-60; s. 1, ch. 2005-358; s. 15, ch. 2006-28; s. 6, ch. 2008-143; s. 1, ch. 2009-42; s. 9, ch. 2009-55; s. 94, ch. 2010-5; s. 10, ch. 2010-156; s. 8, ch. 2011-61; s. 14, ch. 2011-135; s. 7, ch. 2012-33; s. 7, ch. 2013-48.
409.9113 Disproportionate share program for teaching hospitals.—In addition to the payments made under s. 409.911, the agency shall make disproportionate share payments to teaching hospitals, as defined in s. 408.07, for their increased costs associated with medical education programs and for tertiary health care services provided to the indigent. This system of payments must conform to federal requirements and distribute funds in each fiscal year for which an appropriation is made by making quarterly Medicaid payments. Notwithstanding s. 409.915, counties are exempt from contributing toward the cost of this special reimbursement for hospitals serving a disproportionate share of low-income patients. The agency shall distribute the moneys provided in the General Appropriations Act to statutorily defined teaching hospitals and family practice teaching hospitals, as defined in s. 395.805, pursuant to this section. The funds provided for statutorily defined teaching hospitals shall be distributed as provided in the General Appropriations Act. The funds provided for family practice teaching hospitals shall be distributed equally among family practice teaching hospitals.
(1) On or before September 15 of each year, the agency shall calculate an allocation fraction to be used for distributing funds to statutory teaching hospitals. Subsequent to the end of each quarter of the state fiscal year, the agency shall distribute to each statutory teaching hospital an amount determined by multiplying one-fourth of the funds appropriated for this purpose by the Legislature times such hospital’s allocation fraction. The allocation fraction for each such hospital shall be determined by the sum of the following three primary factors, divided by three:
(a) The number of nationally accredited graduate medical education programs offered by the hospital, including programs accredited by the Accreditation Council for Graduate Medical Education or programs accredited by the Council on Postdoctoral Training of the American Osteopathic Association and the combined Internal Medicine and Pediatrics programs acceptable to both the American Board of Internal Medicine and the American Board of Pediatrics at the beginning of the state fiscal year preceding the date on which the allocation fraction is calculated. The numerical value of this factor is the fraction that the hospital represents of the total number of programs, where the total is computed for all statutory teaching hospitals.
(b) The number of full-time equivalent trainees in the hospital, which comprises two components:
1. The number of trainees enrolled in nationally accredited graduate medical education programs, as defined in paragraph (a). Full-time equivalents are computed using the fraction of the year during which each trainee is primarily assigned to the given institution, over the state fiscal year preceding the date on which the allocation fraction is calculated. The numerical value of this factor is the fraction that the hospital represents of the total number of full-time equivalent trainees enrolled in accredited graduate programs, where the total is computed for all statutory teaching hospitals.
2. The number of medical students enrolled in accredited colleges of medicine and engaged in clinical activities, including required clinical clerkships and clinical electives. Full-time equivalents are computed using the fraction of the year during which each trainee is primarily assigned to the given institution, over the course of the state fiscal year preceding the date on which the allocation fraction is calculated. The numerical value of this factor is the fraction that the given hospital represents of the total number of full-time equivalent students enrolled in accredited colleges of medicine, where the total is computed for all statutory teaching hospitals.
The primary factor for full-time equivalent trainees is computed as the sum of these two components, divided by two.
(c) A service index that comprises three components:
1. The Agency for Health Care Administration Service Index, computed by applying the standard Service Inventory Scores established by the agency to services offered by the given hospital, as reported on Worksheet A-2 for the last fiscal year reported to the agency before the date on which the allocation fraction is calculated. The numerical value of this factor is the fraction that the given hospital represents of the total index values, where the total is computed for all statutory teaching hospitals.
2. A volume-weighted service index, computed by applying the standard Service Inventory Scores established by the agency to the volume of each service, expressed in terms of the standard units of measure reported on Worksheet A-2 for the last fiscal year reported to the agency before the date on which the allocation factor is calculated. The numerical value of this factor is the fraction that the given hospital represents of the total volume-weighted service index values, where the total is computed for all statutory teaching hospitals.
3. Total Medicaid payments to each hospital for direct inpatient and outpatient services during the fiscal year preceding the date on which the allocation factor is calculated. This includes payments made to each hospital for such services by Medicaid prepaid health plans, whether the plan was administered by the hospital or not. The numerical value of this factor is the fraction that each hospital represents of the total of such Medicaid payments, where the total is computed for all statutory teaching hospitals.
The primary factor for the service index is computed as the sum of these three components, divided by three.
(2) By October 1 of each year, the agency shall use the following formula to calculate the maximum additional disproportionate share payment for statutory teaching hospitals:
TAP = THAF x A
Where:
TAP = total additional payment.
THAF = teaching hospital allocation factor.
A = amount appropriated for a teaching hospital disproportionate share program.
History.—s. 41, ch. 91-282; s. 99, ch. 92-33; s. 18, ch. 98-89; s. 15, ch. 2004-270; s. 13, ch. 2005-60; s. 16, ch. 2006-28; s. 8, ch. 2008-143; s. 11, ch. 2009-55; s. 12, ch. 2010-156; s. 10, ch. 2011-61; s. 9, ch. 2012-33.
409.9115 Disproportionate share program for mental health hospitals.—The Agency for Health Care Administration shall design and implement a system of making mental health disproportionate share payments to hospitals that qualify for disproportionate share payments under s. 409.911. This system of payments shall conform with federal requirements and shall distribute funds in each fiscal year for which an appropriation is made by making quarterly Medicaid payments. Notwithstanding s. 409.915, counties are exempt from contributing toward the cost of this special reimbursement for patients.
(1) The following formula shall be used by the agency to calculate the total amount earned for hospitals that participate in the mental health disproportionate share program:
TAP = (DSH/TDSH) x TA
Where:
TAP = total additional payment for a mental health hospital.
DSH = total amount earned by a mental health hospital under s. 409.911.
TDSH = sum of total amount earned by each hospital that participates in the mental health hospital disproportionate share program.
TA = total appropriation for the mental health hospital disproportionate share program.
(2) In order to receive payments under this section, a hospital must participate in the Florida Title XIX program and must:
(a) Agree to serve all individuals referred by the agency who require inpatient psychiatric services, regardless of ability to pay.
(b) Be certified or certifiable to be a provider of Title XVIII services.
(c) Receive all of its inpatient clients from admissions governed by the Baker Act as specified in chapter 394.
History.—s. 1, ch. 92-322; s. 5, ch. 95-430; s. 4, ch. 96-420; s. 3, ch. 97-153; ss. 4, 38, ch. 98-46; ss. 3, 53, ch. 99-228; s. 13, ch. 2000-171; s. 9, ch. 2002-2.
409.91151 Expenditure of funds generated through mental health disproportionate share program.—Funding generated through the mental health disproportionate share program shall be expended in accordance with legislatively authorized appropriations. If such funding is not addressed in legislatively authorized appropriations, the Agency for Health Care Administration shall prepare a plan and submit a request for spending authority in accordance with the applicable provisions of chapter 216.
History.—s. 2, ch. 92-322; s. 187, ch. 99-8.
409.9116 Disproportionate share/financial assistance program for rural hospitals.—In addition to the payments made under s. 409.911, the Agency for Health Care Administration shall administer a federally matched disproportionate share program and a state-funded financial assistance program for statutory rural hospitals. The agency shall make disproportionate share payments to statutory rural hospitals that qualify for such payments and financial assistance payments to statutory rural hospitals that do not qualify for disproportionate share payments. The disproportionate share program payments shall be limited by and conform with federal requirements. Funds shall be distributed quarterly in each fiscal year for which an appropriation is made. Notwithstanding the provisions of s. 409.915, counties are exempt from contributing toward the cost of this special reimbursement for hospitals serving a disproportionate share of low-income patients.
(1) The following formula shall be used by the agency to calculate the total amount earned for hospitals that participate in the rural hospital disproportionate share program or the financial assistance program:
TAERH = (CCD + MDD)/TPD
Where:
CCD = total charity care-other, plus charity care-Hill-Burton, minus 50 percent of unrestricted tax revenue from local governments, and restricted funds for indigent care, divided by gross revenue per adjusted patient day; however, if CCD is less than zero, then zero shall be used for CCD.
MDD = Medicaid inpatient days plus Medicaid HMO inpatient days.
TPD = total inpatient days.
TAERH = total amount earned by each rural hospital.
In computing the total amount earned by each rural hospital, the agency must use the average of the 3 most recent years of actual data reported in accordance with s. 408.061(4). The agency shall provide a preliminary estimate of the payments under the rural disproportionate share and financial assistance programs to the rural hospitals by August 31 of each state fiscal year for review. Each rural hospital shall have 30 days to review the preliminary estimates of payments and report any errors to the agency. The agency shall make any corrections deemed necessary and compute the rural disproportionate share and financial assistance program payments.
(2) The agency shall use the following formula for distribution of funds for the disproportionate share/financial assistance program for rural hospitals.
(a) The agency shall first determine a preliminary payment amount for each rural hospital by allocating all available state funds using the following formula:
PDAER = (TAERH x TARH)/STAERH
Where:
PDAER = preliminary distribution amount for each rural hospital.
TAERH = total amount earned by each rural hospital.
TARH = total amount appropriated or distributed under this section.
STAERH = sum of total amount earned by each rural hospital.
(b) Federal matching funds for the disproportionate share program shall then be calculated for those hospitals that qualify for disproportionate share in paragraph (a).
(c) The state-funds-only payment amount shall then be calculated for each hospital using the formula:
SFOER = Maximum value of (1) SFOL - PDAER or (2) 0
Where:
SFOER = state-funds-only payment amount for each rural hospital.
SFOL = state-funds-only payment level, which is set at 4 percent of TARH.
In calculating the SFOER, PDAER includes federal matching funds from paragraph (b).
(d) The adjusted total amount allocated to the rural disproportionate share program shall then be calculated using the following formula:
ATARH = (TARH - SSFOER)
Where:
ATARH = adjusted total amount appropriated or distributed under this section.
SSFOER = sum of the state-funds-only payment amount calculated under paragraph (c) for all rural hospitals.
(e) The distribution of the adjusted total amount of rural disproportionate share hospital funds shall then be calculated using the following formula:
DAERH = [(TAERH x ATARH)/STAERH]
Where:
DAERH = distribution amount for each rural hospital.
(f) Federal matching funds for the disproportionate share program shall then be calculated for those hospitals that qualify for disproportionate share in paragraph (e).
(g) State-funds-only payment amounts calculated under paragraph (c) and corresponding federal matching funds are then added to the results of paragraph (f) to determine the total distribution amount for each rural hospital.
(3) The Agency for Health Care Administration may recommend to the Legislature a formula to be used in subsequent fiscal years to distribute funds appropriated for this section that includes charity care, uncompensated care to medically indigent patients, and Medicaid inpatient days.
(4) In the event that federal matching funds for the rural hospital disproportionate share program are not available, state matching funds appropriated for the program may be utilized for the Rural Hospital Financial Assistance Program and shall be allocated to rural hospitals based on the formulas in subsections (1) and (2).
(5) In order to receive payments under this section, a hospital must be a rural hospital as defined in s. 395.602 and must meet the following additional requirements:
(a) Agree to conform to all agency requirements to ensure high quality in the provision of services, including criteria adopted by agency rule concerning staffing ratios, medical records, standards of care, equipment, space, and such other standards and criteria as the agency deems appropriate as specified by rule.
(b) Agree to accept all patients, regardless of ability to pay, on a functional space-available basis.
(c) Agree to provide backup and referral services to the county public health departments and other low-income providers within the hospital’s service area, including the development of written agreements between these organizations and the hospital.
(d) For any hospital owned by a county government which is leased to a management company, agree to submit on a quarterly basis a report to the agency, in a format specified by the agency, which provides a specific accounting of how all funds dispersed under this act are spent.
(6) This section applies only to hospitals that were defined as statutory rural hospitals, or their successor-in-interest hospital, prior to January 1, 2001. Any additional hospital that is defined as a statutory rural hospital, or its successor-in-interest hospital, on or after January 1, 2001, is not eligible for programs under this section unless additional funds are appropriated each fiscal year specifically to the rural hospital disproportionate share and financial assistance programs in an amount necessary to prevent any hospital, or its successor-in-interest hospital, eligible for the programs prior to January 1, 2001, from incurring a reduction in payments because of the eligibility of an additional hospital to participate in the programs. A hospital, or its successor-in-interest hospital, which received funds pursuant to this section before January 1, 2001, and which qualifies under s. 395.602(2)(e), shall be included in the programs under this section and is not required to seek additional appropriations under this subsection.
History.—s. 33, ch. 93-129; s. 1, ch. 94-120; s. 6, ch. 96-420; s. 201, ch. 97-101; s. 5, ch. 97-153; s. 4, ch. 98-14; ss. 6, 38, ch. 98-46; ss. 5, 53, ch. 99-228; s. 59, ch. 2000-153; s. 15, ch. 2000-171; s. 3, ch. 2000-227; s. 7, ch. 2001-104; s. 10, ch. 2002-2; s. 24, ch. 2002-400; s. 33, ch. 2003-57; s. 15, ch. 2003-405.
409.9118 Disproportionate share program for specialty hospitals.—The Agency for Health Care Administration shall design and implement a system of making disproportionate share payments to those hospitals licensed in accordance with part I of chapter 395 as a specialty hospital which meet all requirements listed in subsection (2). Notwithstanding s. 409.915, counties are exempt from contributing toward the cost of this special reimbursement for patients.
(1) The following formula shall be used by the agency to calculate the total amount earned for hospitals that participate under this section:
TAE=(MD/TMD) x TA
Where:
TAE=total amount earned by a specialty hospital.
TA=total appropriation for payments to hospitals that qualify under this program.
MD=total Medicaid days for each qualifying hospital.
TMD=total Medicaid days for all hospitals that qualify under this program.
(2) In order to receive payments under this section, a hospital must be licensed in accordance with part I of chapter 395, to participate in the Florida Title XIX program, and meet the following requirements:
(a) Be certified or certifiable to be a provider of Title XVIII services.
(b) Receive inpatient clients through referrals or admissions from county public health departments, as defined in chapter 154.
(c) Require a diagnosis for the control of active tuberculosis or a history of noncompliance with prescribed drug regimens for the treatment of tuberculosis for admissions for inpatient treatment.
(d) Retain a contract with the Department of Health to accept clients for admission and inpatient treatment pursuant to s. 392.62.
History.—s. 13, ch. 97-260; s. 8, ch. 2013-48.
409.91188 Specialty prepaid health plans for Medicaid recipients with HIV or AIDS.—The Agency for Health Care Administration is authorized to contract with specialty prepaid health plans and pay them on a prepaid capitated basis to provide Medicaid benefits to Medicaid-eligible recipients who have human immunodeficiency syndrome (HIV) or acquired immunodeficiency syndrome (AIDS). The agency shall apply for and is authorized to implement federal waivers or other necessary federal authorization to implement the prepaid health plans authorized by this section. The agency shall procure the specialty prepaid health plans through a competitive procurement. In awarding a contract to a managed care plan, the agency shall take into account price, quality, accessibility, linkages to community-based organizations, and the comprehensiveness of the benefit package offered by the plan. The agency may bid the HIV/AIDS specialty plans on a county, regional, or statewide basis. Qualified plans must be licensed under chapter 641. The agency shall monitor and evaluate the implementation of this waiver program if it is approved by the Federal Government. To improve coordination of medical care delivery and to increase cost efficiency for the Medicaid program in treating HIV disease, the Agency for Health Care Administration shall seek all necessary federal waivers to allow participation in the Medipass HIV disease management program for Medicare beneficiaries who test positive for HIV infection and who also qualify for Medicaid benefits such as prescription medications not covered by Medicare.
History.—s. 169, ch. 2000-318; s. 147, ch. 2001-277; s. 69, ch. 2005-2.
409.9119 Disproportionate share program for specialty hospitals for children.—In addition to the payments made under s. 409.911, the Agency for Health Care Administration shall develop and implement a system under which disproportionate share payments are made to those hospitals that are licensed by the state as specialty hospitals for children and were licensed on January 1, 2000, as specialty hospitals for children. This system of payments must conform to federal requirements and must distribute funds in each fiscal year for which an appropriation is made by making quarterly Medicaid payments. Notwithstanding s. 409.915, counties are exempt from contributing toward the cost of this special reimbursement for hospitals that serve a disproportionate share of low-income patients. The agency may make disproportionate share payments to specialty hospitals for children as provided for in the General Appropriations Act.
(1) Unless specified in the General Appropriations Act, the agency shall use the following formula to calculate the total amount earned for hospitals that participate in the specialty hospital for children disproportionate share program:
TAE = DSR x BMPD x MD
Where:
TAE = total amount earned by a specialty hospital for children.
DSR = disproportionate share rate.
BMPD = base Medicaid per diem.
MD = Medicaid days.
(2) The agency shall calculate the total additional payment for hospitals that participate in the specialty hospital for children disproportionate share program as follows:
TAP = (TAE x TA) ÷ STAE
Where:
TAP = total additional payment for a specialty hospital for children.
TAE = total amount earned by a specialty hospital for children.
TA = total appropriation for the specialty hospital for children disproportionate share program.
STAE = sum of total amount earned by each hospital that participates in the specialty hospital for children disproportionate share program.
(3) A hospital may not receive any payments under this section until it achieves full compliance with the applicable rules of the agency. A hospital that is not in compliance for two or more consecutive quarters may not receive its share of the funds. Any forfeited funds must be distributed to the remaining participating specialty hospitals for children that are in compliance.
History.—s. 18, ch. 2000-163; ss. 16, 66, ch. 2000-171; s. 55, ch. 2000-256; s. 17, ch. 2003-405; s. 13, ch. 2009-55.
409.91195 Medicaid Pharmaceutical and Therapeutics Committee.—There is created a Medicaid Pharmaceutical and Therapeutics Committee within the agency for the purpose of developing a Medicaid preferred drug list.
(1) The committee shall be composed of 11 members appointed by the Governor. Four members shall be physicians, licensed under chapter 458; one member licensed under chapter 459; five members shall be pharmacists licensed under chapter 465; and one member shall be a consumer representative. The members shall be appointed to serve for terms of 2 years from the date of their appointment. Members may be appointed to more than one term. The agency shall serve as staff for the committee and assist them with all ministerial duties. The Governor shall ensure that at least some of the members of the committee represent Medicaid participating physicians and pharmacies serving all segments and diversity of the Medicaid population, and have experience in either developing or practicing under a preferred drug list. At least one of the members shall represent the interests of pharmaceutical manufacturers.
(2) Committee members shall select a chairperson and a vice chairperson each year from the committee membership.
(3) The committee shall meet at least quarterly and may meet at other times at the discretion of the chairperson and members. The committee shall comply with rules adopted by the agency, including notice of any meeting of the committee pursuant to the requirements of the Administrative Procedure Act.
(4) Upon recommendation of the committee, the agency shall adopt a preferred drug list as described in s. 409.912(37). To the extent feasible, the committee shall review all drug classes included on the preferred drug list every 12 months, and may recommend additions to and deletions from the preferred drug list, such that the preferred drug list provides for medically appropriate drug therapies for Medicaid patients which achieve cost savings contained in the General Appropriations Act.
(5) Except for antiretroviral drugs, reimbursement of drugs not included on the preferred drug list is subject to prior authorization.
(6) The agency shall publish and disseminate the preferred drug list to all Medicaid providers in the state by Internet posting on the agency’s website or in other media.
(7) The committee shall ensure that interested parties, including pharmaceutical manufacturers agreeing to provide a supplemental rebate as outlined in this chapter, have an opportunity to present public testimony to the committee with information or evidence supporting inclusion of a product on the preferred drug list. Such public testimony shall occur prior to any recommendations made by the committee for inclusion or exclusion from the preferred drug list. Upon timely notice, the agency shall ensure that any drug that has been approved or had any of its particular uses approved by the United States Food and Drug Administration under a priority review classification will be reviewed by the committee at the next regularly scheduled meeting following 3 months of distribution of the drug to the general public.
(8) The committee shall develop its preferred drug list recommendations by considering the clinical efficacy, safety, and cost-effectiveness of a product.
(9) Upon timely notice, the agency shall ensure that any therapeutic class of drugs which includes a drug that has been removed from distribution to the public by its manufacturer or the United States Food and Drug Administration or has been required to carry a black box warning label by the United States Food and Drug Administration because of safety concerns is reviewed by the committee at the next regularly scheduled meeting. After such review, the committee must recommend whether to retain the therapeutic class of drugs or subcategories of drugs within a therapeutic class on the preferred drug list and whether to institute prior authorization requirements necessary to ensure patient safety.
(10) The Medicaid Pharmaceutical and Therapeutics Committee may also make recommendations to the agency regarding the prior authorization of any prescribed drug covered by Medicaid.
(11) Medicaid recipients may appeal agency preferred drug formulary decisions using the Medicaid fair hearing process administered by the Department of Children and Family Services.
History.—s. 72, ch. 2000-367; s. 8, ch. 2001-104; s. 25, ch. 2002-400; s. 15, ch. 2005-60; s. 15, ch. 2011-135.
409.91196 Supplemental rebate agreements; public records and public meetings exemption.—
(1) The rebate amount, percent of rebate, manufacturer’s pricing, and supplemental rebate, and other trade secrets as defined in s. 688.002 that the agency has identified for use in negotiations, held by the Agency for Health Care Administration under s. 409.912(37)(a)7. are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
(2) That portion of a meeting of the Medicaid Pharmaceutical and Therapeutics Committee at which the rebate amount, percent of rebate, manufacturer’s pricing, or supplemental rebate, or other trade secrets as defined in s. 688.002 that the agency has identified for use in negotiations, are discussed is exempt from s. 286.011 and s. 24(b), Art. I of the State Constitution. A record shall be made of each exempt portion of a meeting. Such record must include the times of commencement and termination, all discussions and proceedings, the names of all persons present at any time, and the names of all persons speaking. No exempt portion of a meeting may be held off the record.
History.—ss. 1, 3, ch. 2001-216; s. 70, ch. 2002-1; s. 46, ch. 2003-1; s. 54, ch. 2004-5; s. 22, ch. 2004-344; s. 51, ch. 2006-1; s. 1, ch. 2006-159; s. 16, ch. 2011-135.
409.912 Cost-effective purchasing of health care.—The agency shall purchase goods and services for Medicaid recipients in the most cost-effective manner consistent with the delivery of quality medical care. To ensure that medical services are effectively utilized, the agency may, in any case, require a confirmation or second physician’s opinion of the correct diagnosis for purposes of authorizing future services under the Medicaid program. This section does not restrict access to emergency services or poststabilization care services as defined in 42 C.F.R. part 438.114. Such confirmation or second opinion shall be rendered in a manner approved by the agency. The agency shall maximize the use of prepaid per capita and prepaid aggregate fixed-sum basis services when appropriate and other alternative service delivery and reimbursement methodologies, including competitive bidding pursuant to s. 287.057, designed to facilitate the cost-effective purchase of a case-managed continuum of care. The agency shall also require providers to minimize the exposure of recipients to the need for acute inpatient, custodial, and other institutional care and the inappropriate or unnecessary use of high-cost services. The agency shall contract with a vendor to monitor and evaluate the clinical practice patterns of providers in order to identify trends that are outside the normal practice patterns of a provider’s professional peers or the national guidelines of a provider’s professional association. The vendor must be able to provide information and counseling to a provider whose practice patterns are outside the norms, in consultation with the agency, to improve patient care and reduce inappropriate utilization. The agency may mandate prior authorization, drug therapy management, or disease management participation for certain populations of Medicaid beneficiaries, certain drug classes, or particular drugs to prevent fraud, abuse, overuse, and possible dangerous drug interactions. The Pharmaceutical and Therapeutics Committee shall make recommendations to the agency on drugs for which prior authorization is required. The agency shall inform the Pharmaceutical and Therapeutics Committee of its decisions regarding drugs subject to prior authorization. The agency is authorized to limit the entities it contracts with or enrolls as Medicaid providers by developing a provider network through provider credentialing. The agency may competitively bid single-source-provider contracts if procurement of goods or services results in demonstrated cost savings to the state without limiting access to care. The agency may limit its network based on the assessment of beneficiary access to care, provider availability, provider quality standards, time and distance standards for access to care, the cultural competence of the provider network, demographic characteristics of Medicaid beneficiaries, practice and provider-to-beneficiary standards, appointment wait times, beneficiary use of services, provider turnover, provider profiling, provider licensure history, previous program integrity investigations and findings, peer review, provider Medicaid policy and billing compliance records, clinical and medical record audits, and other factors. Providers are not entitled to enrollment in the Medicaid provider network. The agency shall determine instances in which allowing Medicaid beneficiaries to purchase durable medical equipment and other goods is less expensive to the Medicaid program than long-term rental of the equipment or goods. The agency may establish rules to facilitate purchases in lieu of long-term rentals in order to protect against fraud and abuse in the Medicaid program as defined in s. 409.913. The agency may seek federal waivers necessary to administer these policies.
(1) The agency shall work with the Department of Children and Family Services to ensure access of children and families in the child protection system to needed and appropriate mental health and substance abuse services. This subsection expires October 1, 2014.
(2) The agency may enter into agreements with appropriate agents of other state agencies or of any agency of the Federal Government and accept such duties in respect to social welfare or public aid as may be necessary to implement the provisions of Title XIX of the Social Security Act and ss. 409.901-409.920. This subsection expires October 1, 2016.
(3) The agency may contract with health maintenance organizations certified pursuant to part I of chapter 641 for the provision of services to recipients. This subsection expires October 1, 2014.
(4) The agency may contract with:
(a) An entity that provides no prepaid health care services other than Medicaid services under contract with the agency and which is owned and operated by a county, county health department, or county-owned and operated hospital to provide health care services on a prepaid or fixed-sum basis to recipients, which entity may provide such prepaid services either directly or through arrangements with other providers. Such prepaid health care services entities must be licensed under parts I and III of chapter 641. An entity recognized under this paragraph which demonstrates to the satisfaction of the Office of Insurance Regulation of the Financial Services Commission that it is backed by the full faith and credit of the county in which it is located may be exempted from s. 641.225. This paragraph expires October 1, 2014.
(b) An entity that is providing comprehensive behavioral health care services to certain Medicaid recipients through a capitated, prepaid arrangement pursuant to the federal waiver provided for by s. 409.905(5). Such entity must be licensed under chapter 624, chapter 636, or chapter 641, or authorized under paragraph (c) or paragraph (d), and must possess the clinical systems and operational competence to manage risk and provide comprehensive behavioral health care to Medicaid recipients. As used in this paragraph, the term “comprehensive behavioral health care services” means covered mental health and substance abuse treatment services that are available to Medicaid recipients. The secretary of the Department of Children and Family Services shall approve provisions of procurements related to children in the department’s care or custody before enrolling such children in a prepaid behavioral health plan. Any contract awarded under this paragraph must be competitively procured. In developing the behavioral health care prepaid plan procurement document, the agency shall ensure that the procurement document requires the contractor to develop and implement a plan to ensure compliance with s. 394.4574 related to services provided to residents of licensed assisted living facilities that hold a limited mental health license. Except as provided in subparagraph 5., and except in counties where the Medicaid managed care pilot program is authorized pursuant to s. 409.91211, the agency shall seek federal approval to contract with a single entity meeting these requirements to provide comprehensive behavioral health care services to all Medicaid recipients not enrolled in a Medicaid managed care plan authorized under s. 409.91211, a provider service network authorized under paragraph (d), or a Medicaid health maintenance organization in an AHCA area. In an AHCA area where the Medicaid managed care pilot program is authorized pursuant to s. 409.91211 in one or more counties, the agency may procure a contract with a single entity to serve the remaining counties as an AHCA area or the remaining counties may be included with an adjacent AHCA area and are subject to this paragraph. Each entity must offer a sufficient choice of providers in its network to ensure recipient access to care and the opportunity to select a provider with whom they are satisfied. The network shall include all public mental health hospitals. To ensure unimpaired access to behavioral health care services by Medicaid recipients, all contracts issued pursuant to this paragraph must require 80 percent of the capitation paid to the managed care plan, including health maintenance organizations and capitated provider service networks, to be expended for the provision of behavioral health care services. If the managed care plan expends less than 80 percent of the capitation paid for the provision of behavioral health care services, the difference shall be returned to the agency. The agency shall provide the plan with a certification letter indicating the amount of capitation paid during each calendar year for behavioral health care services pursuant to this section. The agency may reimburse for substance abuse treatment services on a fee-for-service basis until the agency finds that adequate funds are available for capitated, prepaid arrangements.
1. The agency shall modify the contracts with the entities providing comprehensive inpatient and outpatient mental health care services to Medicaid recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk Counties, to include substance abuse treatment services.
2. Except as provided in subparagraph 5., the agency and the Department of Children and Family Services shall contract with managed care entities in each AHCA area except area 6 or arrange to provide comprehensive inpatient and outpatient mental health and substance abuse services through capitated prepaid arrangements to all Medicaid recipients who are eligible to participate in such plans under federal law and regulation. In AHCA areas where eligible individuals number less than 150,000, the agency shall contract with a single managed care plan to provide comprehensive behavioral health services to all recipients who are not enrolled in a Medicaid health maintenance organization, a provider service network authorized under paragraph (d), or a Medicaid capitated managed care plan authorized under s. 409.91211. The agency may contract with more than one comprehensive behavioral health provider to provide care to recipients who are not enrolled in a Medicaid capitated managed care plan authorized under s. 409.91211, a provider service network authorized under paragraph (d), or a Medicaid health maintenance organization in AHCA areas where the eligible population exceeds 150,000. In an AHCA area where the Medicaid managed care pilot program is authorized pursuant to s. 409.91211 in one or more counties, the agency may procure a contract with a single entity to serve the remaining counties as an AHCA area or the remaining counties may be included with an adjacent AHCA area and shall be subject to this paragraph. Contracts for comprehensive behavioral health providers awarded pursuant to this section shall be competitively procured. Both for-profit and not-for-profit corporations are eligible to compete. Managed care plans contracting with the agency under subsection (3) or paragraph (d) shall provide and receive payment for the same comprehensive behavioral health benefits as provided in AHCA rules, including handbooks incorporated by reference. In AHCA area 11, the agency shall contract with at least two comprehensive behavioral health care providers to provide behavioral health care to recipients in that area who are enrolled in, or assigned to, the MediPass program. One of the behavioral health care contracts must be with the existing provider service network pilot project, as described in paragraph (d), for the purpose of demonstrating the cost-effectiveness of the provision of quality mental health services through a public hospital-operated managed care model. Payment shall be at an agreed-upon capitated rate to ensure cost savings. Of the recipients in area 11 who are assigned to MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those MediPass-enrolled recipients shall be assigned to the existing provider service network in area 11 for their behavioral care.
3. Children residing in a statewide inpatient psychiatric program, or in a Department of Juvenile Justice or a Department of Children and Family Services residential program approved as a Medicaid behavioral health overlay services provider may not be included in a behavioral health care prepaid health plan or any other Medicaid managed care plan pursuant to this paragraph.
4. Traditional community mental health providers under contract with the Department of Children and Family Services pursuant to part IV of chapter 394, child welfare providers under contract with the Department of Children and Family Services in areas 1 and 6, and inpatient mental health providers licensed pursuant to chapter 395 must be offered an opportunity to accept or decline a contract to participate in any provider network for prepaid behavioral health services.
5. All Medicaid-eligible children, except children in area 1 and children in Highlands County, Hardee County, Polk County, or Manatee County of area 6, that are open for child welfare services in the statewide automated child welfare information system, shall receive their behavioral health care services through a specialty prepaid plan operated by community-based lead agencies through a single agency or formal agreements among several agencies. The agency shall work with the specialty plan to develop clinically effective, evidence-based alternatives as a downward substitution for the statewide inpatient psychiatric program and similar residential care and institutional services. The specialty prepaid plan must result in savings to the state comparable to savings achieved in other Medicaid managed care and prepaid programs. Such plan must provide mechanisms to maximize state and local revenues. The specialty prepaid plan shall be developed by the agency and the Department of Children and Family Services. The agency may seek federal waivers to implement this initiative. Medicaid-eligible children whose cases are open for child welfare services in the statewide automated child welfare information system and who reside in AHCA area 10 shall be enrolled in a capitated provider service network or other capitated managed care plan, which, in coordination with available community-based care providers specified in s. 409.1671, shall provide sufficient medical, developmental, and behavioral health services to meet the needs of these children.
Effective July 1, 2012, in order to ensure continuity of care, the agency is authorized to extend or modify current contracts based on current service areas or on a regional basis, as determined appropriate by the agency, with comprehensive behavioral health care providers as described in this paragraph during the period prior to its expiration. This paragraph expires October 1, 2014.
(c) A federally qualified health center or an entity owned by one or more federally qualified health centers or an entity owned by other migrant and community health centers receiving non-Medicaid financial support from the Federal Government to provide health care services on a prepaid or fixed-sum basis to recipients. A federally qualified health center or an entity that is owned by one or more federally qualified health centers and is reimbursed by the agency on a prepaid basis is exempt from parts I and III of chapter 641, but must comply with the solvency requirements in s. 641.2261(2) and meet the appropriate requirements governing financial reserve, quality assurance, and patients’ rights established by the agency. This paragraph expires October 1, 2014.
(d)1. A provider service network, which may be reimbursed on a fee-for-service or prepaid basis. Prepaid provider service networks shall receive per-member, per-month payments. A provider service network that does not choose to be a prepaid plan shall receive fee-for-service rates with a shared savings settlement. The fee-for-service option shall be available to a provider service network only for the first 2 years of the plan’s operation or until the contract year beginning September 1, 2014, whichever is later. The agency shall annually conduct cost reconciliations to determine the amount of cost savings achieved by fee-for-service provider service networks for the dates of service in the period being reconciled. Only payments for covered services for dates of service within the reconciliation period and paid within 6 months after the last date of service in the reconciliation period shall be included. The agency shall perform the necessary adjustments for the inclusion of claims incurred but not reported within the reconciliation for claims that could be received and paid by the agency after the 6-month claims processing time lag. The agency shall provide the results of the reconciliations to the fee-for-service provider service networks within 45 days after the end of the reconciliation period. The fee-for-service provider service networks shall review and provide written comments or a letter of concurrence to the agency within 45 days after receipt of the reconciliation results. This reconciliation shall be considered final.
2. A provider service network which is reimbursed by the agency on a prepaid basis shall be exempt from parts I and III of chapter 641, but must comply with the solvency requirements in s. 641.2261(2) and meet appropriate financial reserve, quality assurance, and patient rights requirements as established by the agency.
3. Medicaid recipients assigned to a provider service network shall be chosen equally from those who would otherwise have been assigned to prepaid plans and MediPass. The agency is authorized to seek federal Medicaid waivers as necessary to implement the provisions of this section. This subparagraph expires October 1, 2014.
4. A provider service network is a network established or organized and operated by a health care provider, or group of affiliated health care providers, including minority physician networks and emergency room diversion programs that meet the requirements of s. 409.91211, which provides a substantial proportion of the health care items and services under a contract directly through the provider or affiliated group of providers and may make arrangements with physicians or other health care professionals, health care institutions, or any combination of such individuals or institutions to assume all or part of the financial risk on a prospective basis for the provision of basic health services by the physicians, by other health professionals, or through the institutions. The health care providers must have a controlling interest in the governing body of the provider service network organization.
(e) An entity that provides only comprehensive behavioral health care services to certain Medicaid recipients through an administrative services organization agreement. Such an entity must possess the clinical systems and operational competence to provide comprehensive health care to Medicaid recipients. As used in this paragraph, the term “comprehensive behavioral health care services” means covered mental health and substance abuse treatment services that are available to Medicaid recipients. Any contract awarded under this paragraph must be competitively procured. The agency must ensure that Medicaid recipients have available the choice of at least two managed care plans for their behavioral health care services. This paragraph expires October 1, 2014.
(f) An entity authorized in s. 430.205 to contract with the agency and the Department of Elderly Affairs to provide health care and social services on a prepaid or fixed-sum basis to elderly recipients. Such prepaid health care services entities are exempt from the provisions of part I of chapter 641 for the first 3 years of operation. An entity recognized under this paragraph that demonstrates to the satisfaction of the Office of Insurance Regulation that it is backed by the full faith and credit of one or more counties in which it operates may be exempted from s. 641.225. This paragraph expires October 1, 2013.
(g) A Children’s Medical Services Network, as defined in s. 391.021. This paragraph expires October 1, 2014.
(5) The agency may contract with any public or private entity otherwise authorized by this section on a prepaid or fixed-sum basis for the provision of health care services to recipients. An entity may provide prepaid services to recipients, either directly or through arrangements with other entities, if each entity involved in providing services:
(a) Is organized primarily for the purpose of providing health care or other services of the type regularly offered to Medicaid recipients;
(b) Ensures that services meet the standards set by the agency for quality, appropriateness, and timeliness;
(c) Makes provisions satisfactory to the agency for insolvency protection and ensures that neither enrolled Medicaid recipients nor the agency will be liable for the debts of the entity;
(d) Submits to the agency, if a private entity, a financial plan that the agency finds to be fiscally sound and that provides for working capital in the form of cash or equivalent liquid assets excluding revenues from Medicaid premium payments equal to at least the first 3 months of operating expenses or $200,000, whichever is greater;
(e) Furnishes evidence satisfactory to the agency of adequate liability insurance coverage or an adequate plan of self-insurance to respond to claims for injuries arising out of the furnishing of health care;
(f) Provides, through contract or otherwise, for periodic review of its medical facilities and services, as required by the agency; and
(g) Provides organizational, operational, financial, and other information required by the agency.
This subsection expires October 1, 2014.
(6) The agency may contract on a prepaid or fixed-sum basis with any health insurer that:
(a) Pays for health care services provided to enrolled Medicaid recipients in exchange for a premium payment paid by the agency;
(b) Assumes the underwriting risk; and
(c) Is organized and licensed under applicable provisions of the Florida Insurance Code and is currently in good standing with the Office of Insurance Regulation.
This subsection expires October 1, 2014.
(7) The agency may contract on a prepaid or fixed-sum basis with an exclusive provider organization to provide health care services to Medicaid recipients provided that the exclusive provider organization meets applicable managed care plan requirements in this section, ss. 409.9122, 409.9123, 409.9128, and 627.6472, and other applicable provisions of law. This subsection expires October 1, 2014.
(8) The Agency for Health Care Administration may provide cost-effective purchasing of chiropractic services on a fee-for-service basis to Medicaid recipients through arrangements with a statewide chiropractic preferred provider organization incorporated in this state as a not-for-profit corporation. The agency shall ensure that the benefit limits and prior authorization requirements in the current Medicaid program shall apply to the services provided by the chiropractic preferred provider organization. This subsection expires October 1, 2014.
(9) The agency shall not contract on a prepaid or fixed-sum basis for Medicaid services with an entity which knows or reasonably should know that any officer, director, agent, managing employee, or owner of stock or beneficial interest in excess of 5 percent common or preferred stock, or the entity itself, has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty, to:
(a) Fraud;
(b) Violation of federal or state antitrust statutes, including those proscribing price fixing between competitors and the allocation of customers among competitors;
(c) Commission of a felony involving embezzlement, theft, forgery, income tax evasion, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims, or obstruction of justice; or
(d) Any crime in any jurisdiction which directly relates to the provision of health services on a prepaid or fixed-sum basis.
This subsection expires October 1, 2014.
(10) The agency, after notifying the Legislature, may apply for waivers of applicable federal laws and regulations as necessary to implement more appropriate systems of health care for Medicaid recipients and reduce the cost of the Medicaid program to the state and federal governments and shall implement such programs, after legislative approval, within a reasonable period of time after federal approval. These programs must be designed primarily to reduce the need for inpatient care, custodial care and other long-term or institutional care, and other high-cost services. Prior to seeking legislative approval of such a waiver as authorized by this subsection, the agency shall provide notice and an opportunity for public comment. Notice shall be provided to all persons who have made requests of the agency for advance notice and shall be published in the Florida Administrative Register not less than 28 days prior to the intended action. This subsection expires October 1, 2016.
(11) The agency shall establish a postpayment utilization control program designed to identify recipients who may inappropriately overuse or underuse Medicaid services and shall provide methods to correct such misuse. This subsection expires October 1, 2014.
(12) The agency shall develop and provide coordinated systems of care for Medicaid recipients and may contract with public or private entities to develop and administer such systems of care among public and private health care providers in a given geographic area. This subsection expires October 1, 2014.
(13) The agency shall operate or contract for the operation of utilization management and incentive systems designed to encourage cost-effective use of services and to eliminate services that are medically unnecessary. The agency shall track Medicaid provider prescription and billing patterns and evaluate them against Medicaid medical necessity criteria and coverage and limitation guidelines adopted by rule. Medical necessity determination requires that service be consistent with symptoms or confirmed diagnosis of illness or injury under treatment and not in excess of the patient’s needs. The agency shall conduct reviews of provider exceptions to peer group norms and shall, using statistical methodologies, provider profiling, and analysis of billing patterns, detect and investigate abnormal or unusual increases in billing or payment of claims for Medicaid services and medically unnecessary provision of services. Providers that demonstrate a pattern of submitting claims for medically unnecessary services shall be referred to the Medicaid program integrity unit for investigation. In its annual report, required in s. 409.913, the agency shall report on its efforts to control overutilization as described in this subsection. This subsection expires October 1, 2014.
(14)(a) The agency shall operate the Comprehensive Assessment and Review for Long-Term Care Services (CARES) nursing facility preadmission screening program to ensure that Medicaid payment for nursing facility care is made only for individuals whose conditions require such care and to ensure that long-term care services are provided in the setting most appropriate to the needs of the person and in the most economical manner possible. The CARES program shall also ensure that individuals participating in Medicaid home and community-based waiver programs meet criteria for those programs, consistent with approved federal waivers.
(b) The agency shall operate the CARES program through an interagency agreement with the Department of Elderly Affairs. The agency, in consultation with the Department of Elderly Affairs, may contract for any function or activity of the CARES program, including any function or activity required by 42 C.F.R. part 483.20, relating to preadmission screening and resident review.
(c) Prior to making payment for nursing facility services for a Medicaid recipient, the agency must verify that the nursing facility preadmission screening program has determined that the individual requires nursing facility care and that the individual cannot be safely served in community-based programs. The nursing facility preadmission screening program shall refer a Medicaid recipient to a community-based program if the individual could be safely served at a lower cost and the recipient chooses to participate in such program. For individuals whose nursing home stay is initially funded by Medicare and Medicare coverage is being terminated for lack of progress towards rehabilitation, CARES staff shall consult with the person making the determination of progress toward rehabilitation to ensure that the recipient is not being inappropriately disqualified from Medicare coverage. If, in their professional judgment, CARES staff believes that a Medicare beneficiary is still making progress toward rehabilitation, they may assist the Medicare beneficiary with an appeal of the disqualification from Medicare coverage. The use of CARES teams to review Medicare denials for coverage under this section is authorized only if it is determined that such reviews qualify for federal matching funds through Medicaid. The agency shall seek or amend federal waivers as necessary to implement this section.
(d) For the purpose of initiating immediate prescreening and diversion assistance for individuals residing in nursing homes and in order to make families aware of alternative long-term care resources so that they may choose a more cost-effective setting for long-term placement, CARES staff shall conduct an assessment and review of a sample of individuals whose nursing home stay is expected to exceed 20 days, regardless of the initial funding source for the nursing home placement. CARES staff shall provide counseling and referral services to these individuals regarding choosing appropriate long-term care alternatives. This paragraph does not apply to continuing care facilities licensed under chapter 651 or to retirement communities that provide a combination of nursing home, independent living, and other long-term care services.
(e) By January 15 of each year, the agency shall submit a report to the Legislature describing the operations of the CARES program. The report must describe:
1. Rate of diversion to community alternative programs;
2. CARES program staffing needs to achieve additional diversions;
3. Reasons the program is unable to place individuals in less restrictive settings when such individuals desired such services and could have been served in such settings;
4. Barriers to appropriate placement, including barriers due to policies or operations of other agencies or state-funded programs; and
5. Statutory changes necessary to ensure that individuals in need of long-term care services receive care in the least restrictive environment.
(f) The Department of Elderly Affairs shall track individuals over time who are assessed under the CARES program and who are diverted from nursing home placement. By January 15 of each year, the department shall submit to the Legislature a longitudinal study of the individuals who are diverted from nursing home placement. The study must include:
1. The demographic characteristics of the individuals assessed and diverted from nursing home placement, including, but not limited to, age, race, gender, frailty, caregiver status, living arrangements, and geographic location;
2. A summary of community services provided to individuals for 1 year after assessment and diversion;
3. A summary of inpatient hospital admissions for individuals who have been diverted; and
4. A summary of the length of time between diversion and subsequent entry into a nursing home or death.
This subsection expires October 1, 2013.
(15)(a) The agency shall identify health care utilization and price patterns within the Medicaid program which are not cost-effective or medically appropriate and assess the effectiveness of new or alternate methods of providing and monitoring service, and may implement such methods as it considers appropriate. Such methods may include disease management initiatives, an integrated and systematic approach for managing the health care needs of recipients who are at risk of or diagnosed with a specific disease by using best practices, prevention strategies, clinical-practice improvement, clinical interventions and protocols, outcomes research, information technology, and other tools and resources to reduce overall costs and improve measurable outcomes.
(b) The responsibility of the agency under this subsection includes the development of capabilities to identify actual and optimal practice patterns; patient and provider educational initiatives; methods for determining patient compliance with prescribed treatments; fraud, waste, and abuse prevention and detection programs; and beneficiary case management programs.
1. The practice pattern identification program shall evaluate practitioner prescribing patterns based on national and regional practice guidelines, comparing practitioners to their peer groups. The agency and its Drug Utilization Review Board shall consult with the Department of Health and a panel of practicing health care professionals consisting of the following: the Speaker of the House of Representatives and the President of the Senate shall each appoint three physicians licensed under chapter 458 or chapter 459, and the Governor shall appoint two pharmacists licensed under chapter 465 and one dentist licensed under chapter 466 who is an oral surgeon. Terms of the panel members shall expire at the discretion of the appointing official. The advisory panel shall be responsible for evaluating treatment guidelines and recommending ways to incorporate their use in the practice pattern identification program. Practitioners who are prescribing inappropriately or inefficiently, as determined by the agency, may have their prescribing of certain drugs subject to prior authorization or may be terminated from all participation in the Medicaid program.
2. The agency shall also develop educational interventions designed to promote the proper use of medications by providers and beneficiaries.
3. The agency shall implement a pharmacy fraud, waste, and abuse initiative that may include a surety bond or letter of credit requirement for participating pharmacies, enhanced provider auditing practices, the use of additional fraud and abuse software, recipient management programs for beneficiaries inappropriately using their benefits, and other steps that eliminate provider and recipient fraud, waste, and abuse. The initiative shall address enforcement efforts to reduce the number and use of counterfeit prescriptions.
4. The agency may contract with an entity in the state to provide Medicaid providers with electronic access to Medicaid prescription refill data and information relating to the Medicaid preferred drug list. The initiative shall be designed to enhance the agency’s efforts to reduce fraud, abuse, and errors in the prescription drug benefit program and to otherwise further the intent of this paragraph.
5. The agency shall contract with an entity to design a database of clinical utilization information or electronic medical records for Medicaid providers. The database must be web-based and allow providers to review on a real-time basis the utilization of Medicaid services, including, but not limited to, physician office visits, inpatient and outpatient hospitalizations, laboratory and pathology services, radiological and other imaging services, dental care, and patterns of dispensing prescription drugs in order to coordinate care and identify potential fraud and abuse.
6. The agency may apply for any federal waivers needed to administer this paragraph.
This subsection expires October 1, 2014.
(16) An entity contracting on a prepaid or fixed-sum basis shall meet the surplus requirements of s. 641.225. If an entity’s surplus falls below an amount equal to the surplus requirements of s. 641.225, the agency shall prohibit the entity from engaging in marketing and preenrollment activities, shall cease to process new enrollments, and may not renew the entity’s contract until the required balance is achieved. The requirements of this subsection do not apply:
(a) Where a public entity agrees to fund any deficit incurred by the contracting entity; or
(b) Where the entity’s performance and obligations are guaranteed in writing by a guaranteeing organization which:
1. Has been in operation for at least 5 years and has assets in excess of $50 million; or
2. Submits a written guarantee acceptable to the agency which is irrevocable during the term of the contracting entity’s contract with the agency and, upon termination of the contract, until the agency receives proof of satisfaction of all outstanding obligations incurred under the contract.
This subsection expires October 1, 2014.
(17)(a) The agency may require an entity contracting on a prepaid or fixed-sum basis to establish a restricted insolvency protection account with a federally guaranteed financial institution licensed to do business in this state. The entity shall deposit into that account 5 percent of the capitation payments made by the agency each month until a maximum total of 2 percent of the total current contract amount is reached. The restricted insolvency protection account may be drawn upon with the authorized signatures of two persons designated by the entity and two representatives of the agency. If the agency finds that the entity is insolvent, the agency may draw upon the account solely with the two authorized signatures of representatives of the agency, and the funds may be disbursed to meet financial obligations incurred by the entity under the prepaid contract. If the contract is terminated, expired, or not continued, the account balance must be released by the agency to the entity upon receipt of proof of satisfaction of all outstanding obligations incurred under this contract.
(b) The agency may waive the insolvency protection account requirement in writing when evidence is on file with the agency of adequate insolvency insurance and reinsurance that will protect enrollees if the entity becomes unable to meet its obligations.
(18) An entity that contracts with the agency on a prepaid or fixed-sum basis for the provision of Medicaid services shall reimburse any hospital or physician that is outside the entity’s authorized geographic service area as specified in its contract with the agency, and that provides services authorized by the entity to its members, at a rate negotiated with the hospital or physician for the provision of services or according to the lesser of the following:
(a) The usual and customary charges made to the general public by the hospital or physician; or
(b) The Florida Medicaid reimbursement rate established for the hospital or physician.
This subsection expires October 1, 2014.
(19) When a merger or acquisition of a Medicaid prepaid contractor has been approved by the Office of Insurance Regulation pursuant to s. 628.4615, the agency shall approve the assignment or transfer of the appropriate Medicaid prepaid contract upon request of the surviving entity of the merger or acquisition if the contractor and the other entity have been in good standing with the agency for the most recent 12-month period, unless the agency determines that the assignment or transfer would be detrimental to the Medicaid recipients or the Medicaid program. To be in good standing, an entity must not have failed accreditation or committed any material violation of the requirements of s. 641.52 and must meet the Medicaid contract requirements. For purposes of this section, a merger or acquisition means a change in controlling interest of an entity, including an asset or stock purchase. This subsection expires October 1, 2014.
(20) Any entity contracting with the agency pursuant to this section to provide health care services to Medicaid recipients is prohibited from engaging in any of the following practices or activities:
(a) Practices that are discriminatory, including, but not limited to, attempts to discourage participation on the basis of actual or perceived health status.
(b) Activities that could mislead or confuse recipients, or misrepresent the organization, its marketing representatives, or the agency. Violations of this paragraph include, but are not limited to:
1. False or misleading claims that marketing representatives are employees or representatives of the state or county, or of anyone other than the entity or the organization by whom they are reimbursed.
2. False or misleading claims that the entity is recommended or endorsed by any state or county agency, or by any other organization which has not certified its endorsement in writing to the entity.
3. False or misleading claims that the state or county recommends that a Medicaid recipient enroll with an entity.
4. Claims that a Medicaid recipient will lose benefits under the Medicaid program, or any other health or welfare benefits to which the recipient is legally entitled, if the recipient does not enroll with the entity.
(c) Granting or offering of any monetary or other valuable consideration for enrollment, except as authorized by subsection (23).
(d) Door-to-door solicitation of recipients who have not contacted the entity or who have not invited the entity to make a presentation.
(e) Solicitation of Medicaid recipients by marketing representatives stationed in state offices unless approved and supervised by the agency or its agent and approved by the affected state agency when solicitation occurs in an office of the state agency. The agency shall ensure that marketing representatives stationed in state offices shall market their managed care plans to Medicaid recipients only in designated areas and in such a way as to not interfere with the recipients’ activities in the state office.
(f) Enrollment of Medicaid recipients.
(21) The agency may impose a fine for a violation of this section or the contract with the agency by a person or entity that is under contract with the agency. With respect to any nonwillful violation, such fine shall not exceed $2,500 per violation. In no event shall such fine exceed an aggregate amount of $10,000 for all nonwillful violations arising out of the same action. With respect to any knowing and willful violation of this section or the contract with the agency, the agency may impose a fine upon the entity in an amount not to exceed $20,000 for each such violation. In no event shall such fine exceed an aggregate amount of $100,000 for all knowing and willful violations arising out of the same action.
(22) A health maintenance organization or a person or entity exempt from chapter 641 that is under contract with the agency for the provision of health care services to Medicaid recipients may not use or distribute marketing materials used to solicit Medicaid recipients, unless such materials have been approved by the agency. The provisions of this subsection do not apply to general advertising and marketing materials used by a health maintenance organization to solicit both non-Medicaid subscribers and Medicaid recipients. This subsection expires October 1, 2014.
(23) Upon approval by the agency, health maintenance organizations and persons or entities exempt from chapter 641 that are under contract with the agency for the provision of health care services to Medicaid recipients may be permitted within the capitation rate to provide additional health benefits that the agency has found are of high quality, are practicably available, provide reasonable value to the recipient, and are provided at no additional cost to the state. This subsection expires October 1, 2014.
(24) The agency shall utilize the statewide health maintenance organization complaint hotline for the purpose of investigating and resolving Medicaid and prepaid health plan complaints, maintaining a record of complaints and confirmed problems, and receiving disenrollment requests made by recipients. This subsection expires October 1, 2014.
(25) The agency shall require the publication of the health maintenance organization’s and the prepaid health plan’s consumer services telephone numbers and the “800” telephone number of the statewide health maintenance organization complaint hotline on each Medicaid identification card issued by a health maintenance organization or prepaid health plan contracting with the agency to serve Medicaid recipients and on each subscriber handbook issued to a Medicaid recipient. This subsection expires October 1, 2014.
(26) The agency shall establish a health care quality improvement system for those entities contracting with the agency pursuant to this section, incorporating all the standards and guidelines developed by the Medicaid Bureau of the Health Care Financing Administration as a part of the quality assurance reform initiative. The system shall include, but need not be limited to, the following:
(a) Guidelines for internal quality assurance programs, including standards for:
1. Written quality assurance program descriptions.
2. Responsibilities of the governing body for monitoring, evaluating, and making improvements to care.
3. An active quality assurance committee.
4. Quality assurance program supervision.
5. Requiring the program to have adequate resources to effectively carry out its specified activities.
6. Provider participation in the quality assurance program.
7. Delegation of quality assurance program activities.
8. Credentialing and recredentialing.
9. Enrollee rights and responsibilities.
10. Availability and accessibility to services and care.
11. Ambulatory care facilities.
12. Accessibility and availability of medical records, as well as proper recordkeeping and process for record review.
13. Utilization review.
14. A continuity of care system.
15. Quality assurance program documentation.
16. Coordination of quality assurance activity with other management activity.
17. Delivering care to pregnant women and infants; to elderly and disabled recipients, especially those who are at risk of institutional placement; to persons with developmental disabilities; and to adults who have chronic, high-cost medical conditions.
(b) Guidelines which require the entities to conduct quality-of-care studies which:
1. Target specific conditions and specific health service delivery issues for focused monitoring and evaluation.
2. Use clinical care standards or practice guidelines to objectively evaluate the care the entity delivers or fails to deliver for the targeted clinical conditions and health services delivery issues.
3. Use quality indicators derived from the clinical care standards or practice guidelines to screen and monitor care and services delivered.
(c) Guidelines for external quality review of each contractor which require: focused studies of patterns of care; individual care review in specific situations; and followup activities on previous pattern-of-care study findings and individual-care-review findings. In designing the external quality review function and determining how it is to operate as part of the state’s overall quality improvement system, the agency shall construct its external quality review organization and entity contracts to address each of the following:
1. Delineating the role of the external quality review organization.
2. Length of the external quality review organization contract with the state.
3. Participation of the contracting entities in designing external quality review organization review activities.
4. Potential variation in the type of clinical conditions and health services delivery issues to be studied at each plan.
5. Determining the number of focused pattern-of-care studies to be conducted for each plan.
6. Methods for implementing focused studies.
7. Individual care review.
8. Followup activities.
This subsection expires October 1, 2016.
(27) In order to ensure that children receive health care services for which an entity has already been compensated, an entity contracting with the agency pursuant to this section shall achieve an annual Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Service screening rate of at least 60 percent for those recipients continuously enrolled for at least 8 months. The agency shall develop a method by which the EPSDT screening rate shall be calculated. For any entity which does not achieve the annual 60 percent rate, the entity must submit a corrective action plan for the agency’s approval. If the entity does not meet the standard established in the corrective action plan during the specified timeframe, the agency is authorized to impose appropriate contract sanctions. At least annually, the agency shall publicly release the EPSDT Services screening rates of each entity it has contracted with on a prepaid basis to serve Medicaid recipients. This subsection expires October 1, 2014.
(28) The agency shall perform enrollments and disenrollments for Medicaid recipients who are eligible for MediPass or managed care plans. Notwithstanding the prohibition contained in paragraph (20)(f), managed care plans may perform preenrollments of Medicaid recipients under the supervision of the agency or its agents. For the purposes of this section, the term “preenrollment” means the provision of marketing and educational materials to a Medicaid recipient and assistance in completing the application forms, but does not include actual enrollment into a managed care plan. An application for enrollment may not be deemed complete until the agency or its agent verifies that the recipient made an informed, voluntary choice. The agency, in cooperation with the Department of Children and Family Services, may test new marketing initiatives to inform Medicaid recipients about their managed care options at selected sites. The agency may contract with a third party to perform managed care plan and MediPass enrollment and disenrollment services for Medicaid recipients and may adopt rules to administer such services. The agency may adjust the capitation rate only to cover the costs of a third-party enrollment and disenrollment contract, and for agency supervision and management of the managed care plan enrollment and disenrollment contract. This subsection expires October 1, 2014.
(29) Any lists of providers made available to Medicaid recipients, MediPass enrollees, or managed care plan enrollees shall be arranged alphabetically showing the provider’s name and specialty and, separately, by specialty in alphabetical order. This subsection expires October 1, 2014.
(30) The agency shall establish an enhanced managed care quality assurance oversight function, to include at least the following components:
(a) At least quarterly analysis and followup, including sanctions as appropriate, of managed care participant utilization of services.
(b) At least quarterly analysis and followup, including sanctions as appropriate, of quality findings of the Medicaid peer review organization and other external quality assurance programs.
(c) At least quarterly analysis and followup, including sanctions as appropriate, of the fiscal viability of managed care plans.
(d) At least quarterly analysis and followup, including sanctions as appropriate, of managed care participant satisfaction and disenrollment surveys.
(e) The agency shall conduct regular and ongoing Medicaid recipient satisfaction surveys.
The analyses and followup activities conducted by the agency under its enhanced managed care quality assurance oversight function shall not duplicate the activities of accreditation reviewers for entities regulated under part III of chapter 641, but may include a review of the finding of such reviewers. This subsection expires October 1, 2014.
(31) Each managed care plan that is under contract with the agency to provide health care services to Medicaid recipients shall annually conduct a background check with the Department of Law Enforcement of all persons with ownership interest of 5 percent or more or executive management responsibility for the managed care plan and shall submit to the agency information concerning any such person who has been found guilty of, regardless of adjudication, or has entered a plea of nolo contendere or guilty to, any of the offenses listed in s. 435.04. This subsection expires October 1, 2014.
(32) The agency shall, by rule, develop a process whereby a Medicaid managed care plan enrollee who wishes to enter hospice care may be disenrolled from the managed care plan within 24 hours after contacting the agency regarding such request. The agency rule shall include a methodology for the agency to recoup managed care plan payments on a pro rata basis if payment has been made for the enrollment month when disenrollment occurs. This subsection expires October 1, 2014.
(33) The agency and entities that contract with the agency to provide health care services to Medicaid recipients under this section or ss. 409.91211 and 409.9122 must comply with the provisions of s. 641.513 in providing emergency services and care to Medicaid recipients and MediPass recipients. Where feasible, safe, and cost-effective, the agency shall encourage hospitals, emergency medical services providers, and other public and private health care providers to work together in their local communities to enter into agreements or arrangements to ensure access to alternatives to emergency services and care for those Medicaid recipients who need nonemergent care. The agency shall coordinate with hospitals, emergency medical services providers, private health plans, capitated managed care networks as established in s. 409.91211, and other public and private health care providers to implement the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to develop and implement emergency department diversion programs for Medicaid recipients. This subsection expires October 1, 2014.
(34) All entities providing health care services to Medicaid recipients shall make available, and encourage all pregnant women and mothers with infants to receive, and provide documentation in the medical records to reflect, the following:
(a) Healthy Start prenatal or infant screening.
(b) Healthy Start care coordination, when screening or other factors indicate need.
(c) Healthy Start enhanced services in accordance with the prenatal or infant screening results.
(d) Immunizations in accordance with recommendations of the Advisory Committee on Immunization Practices of the United States Public Health Service and the American Academy of Pediatrics, as appropriate.
(e) Counseling and services for family planning to all women and their partners.
(f) A scheduled postpartum visit for the purpose of voluntary family planning, to include discussion of all methods of contraception, as appropriate.
(g) Referral to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
This subsection expires October 1, 2014.
(35) Any entity that provides Medicaid prepaid health plan services shall ensure the appropriate coordination of health care services with an assisted living facility in cases where a Medicaid recipient is both a member of the entity’s prepaid health plan and a resident of the assisted living facility. If the entity is at risk for Medicaid targeted case management and behavioral health services, the entity shall inform the assisted living facility of the procedures to follow should an emergent condition arise. This subsection expires October 1, 2014.
(36) The agency shall enter into agreements with not-for-profit organizations based in this state for the purpose of providing vision screening. This subsection expires October 1, 2014.
(37)(a) The agency shall implement a Medicaid prescribed-drug spending-control program that includes the following components:
1. A Medicaid preferred drug list, which shall be a listing of cost-effective therapeutic options recommended by the Medicaid Pharmacy and Therapeutics Committee established pursuant to s. 409.91195 and adopted by the agency for each therapeutic class on the preferred drug list. At the discretion of the committee, and when feasible, the preferred drug list should include at least two products in a therapeutic class. The agency may post the preferred drug list and updates to the list on an Internet website without following the rulemaking procedures of chapter 120. Antiretroviral agents are excluded from the preferred drug list. The agency shall also limit the amount of a prescribed drug dispensed to no more than a 34-day supply unless the drug products’ smallest marketed package is greater than a 34-day supply, or the drug is determined by the agency to be a maintenance drug in which case a 100-day maximum supply may be authorized. The agency may seek any federal waivers necessary to implement these cost-control programs and to continue participation in the federal Medicaid rebate program, or alternatively to negotiate state-only manufacturer rebates. The agency may adopt rules to administer this subparagraph. The agency shall continue to provide unlimited contraceptive drugs and items. The agency must establish procedures to ensure that:
a. There is a response to a request for prior consultation by telephone or other telecommunication device within 24 hours after receipt of a request for prior consultation; and
b. A 72-hour supply of the drug prescribed is provided in an emergency or when the agency does not provide a response within 24 hours as required by sub-subparagraph a.
2. Reimbursement to pharmacies for Medicaid prescribed drugs shall be set at the lowest of: the average wholesale price (AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC) plus 1.5 percent, the federal upper limit (FUL), the state maximum allowable cost (SMAC), or the usual and customary (UAC) charge billed by the provider.
3. The agency shall develop and implement a process for managing the drug therapies of Medicaid recipients who are using significant numbers of prescribed drugs each month. The management process may include, but is not limited to, comprehensive, physician-directed medical-record reviews, claims analyses, and case evaluations to determine the medical necessity and appropriateness of a patient’s treatment plan and drug therapies. The agency may contract with a private organization to provide drug-program-management services. The Medicaid drug benefit management program shall include initiatives to manage drug therapies for HIV/AIDS patients, patients using 20 or more unique prescriptions in a 180-day period, and the top 1,000 patients in annual spending. The agency shall enroll any Medicaid recipient in the drug benefit management program if he or she meets the specifications of this provision and is not enrolled in a Medicaid health maintenance organization.
4. The agency may limit the size of its pharmacy network based on need, competitive bidding, price negotiations, credentialing, or similar criteria. The agency shall give special consideration to rural areas in determining the size and location of pharmacies included in the Medicaid pharmacy network. A pharmacy credentialing process may include criteria such as a pharmacy’s full-service status, location, size, patient educational programs, patient consultation, disease management services, and other characteristics. The agency may impose a moratorium on Medicaid pharmacy enrollment if it is determined that it has a sufficient number of Medicaid-participating providers. The agency must allow dispensing practitioners to participate as a part of the Medicaid pharmacy network regardless of the practitioner’s proximity to any other entity that is dispensing prescription drugs under the Medicaid program. A dispensing practitioner must meet all credentialing requirements applicable to his or her practice, as determined by the agency.
5. The agency shall develop and implement a program that requires Medicaid practitioners who prescribe drugs to use a counterfeit-proof prescription pad for Medicaid prescriptions. The agency shall require the use of standardized counterfeit-proof prescription pads by Medicaid-participating prescribers or prescribers who write prescriptions for Medicaid recipients. The agency may implement the program in targeted geographic areas or statewide.
6. The agency may enter into arrangements that require manufacturers of generic drugs prescribed to Medicaid recipients to provide rebates of at least 15.1 percent of the average manufacturer price for the manufacturer’s generic products. These arrangements shall require that if a generic-drug manufacturer pays federal rebates for Medicaid-reimbursed drugs at a level below 15.1 percent, the manufacturer must provide a supplemental rebate to the state in an amount necessary to achieve a 15.1-percent rebate level.
7. The agency may establish a preferred drug list as described in this subsection, and, pursuant to the establishment of such preferred drug list, negotiate supplemental rebates from manufacturers that are in addition to those required by Title XIX of the Social Security Act and at no less than 14 percent of the average manufacturer price as defined in 42 U.S.C. s. 1936 on the last day of a quarter unless the federal or supplemental rebate, or both, equals or exceeds 29 percent. There is no upper limit on the supplemental rebates the agency may negotiate. The agency may determine that specific products, brand-name or generic, are competitive at lower rebate percentages. Agreement to pay the minimum supplemental rebate percentage guarantees a manufacturer that the Medicaid Pharmaceutical and Therapeutics Committee will consider a product for inclusion on the preferred drug list. However, a pharmaceutical manufacturer is not guaranteed placement on the preferred drug list by simply paying the minimum supplemental rebate. Agency decisions will be made on the clinical efficacy of a drug and recommendations of the Medicaid Pharmaceutical and Therapeutics Committee, as well as the price of competing products minus federal and state rebates. The agency may contract with an outside agency or contractor to conduct negotiations for supplemental rebates. For the purposes of this section, the term “supplemental rebates” means cash rebates. Value-added programs as a substitution for supplemental rebates are prohibited. The agency may seek any federal waivers to implement this initiative.
8. The agency shall expand home delivery of pharmacy products. The agency may amend the state plan and issue a procurement, as necessary, in order to implement this program. The procurements must include agreements with a pharmacy or pharmacies located in the state to provide mail order delivery services at no cost to the recipients who elect to receive home delivery of pharmacy products. The procurement must focus on serving recipients with chronic diseases for which pharmacy expenditures represent a significant portion of Medicaid pharmacy expenditures or which impact a significant portion of the Medicaid population. The agency may seek and implement any federal waivers necessary to implement this subparagraph.
9. The agency shall limit to one dose per month any drug prescribed to treat erectile dysfunction.
10.a. The agency may implement a Medicaid behavioral drug management system. The agency may contract with a vendor that has experience in operating behavioral drug management systems to implement this program. The agency may seek federal waivers to implement this program.
b. The agency, in conjunction with the Department of Children and Family Services, may implement the Medicaid behavioral drug management system that is designed to improve the quality of care and behavioral health prescribing practices based on best practice guidelines, improve patient adherence to medication plans, reduce clinical risk, and lower prescribed drug costs and the rate of inappropriate spending on Medicaid behavioral drugs. The program may include the following elements:
(I) Provide for the development and adoption of best practice guidelines for behavioral health-related drugs such as antipsychotics, antidepressants, and medications for treating bipolar disorders and other behavioral conditions; translate them into practice; review behavioral health prescribers and compare their prescribing patterns to a number of indicators that are based on national standards; and determine deviations from best practice guidelines.
(II) Implement processes for providing feedback to and educating prescribers using best practice educational materials and peer-to-peer consultation.
(III) Assess Medicaid beneficiaries who are outliers in their use of behavioral health drugs with regard to the numbers and types of drugs taken, drug dosages, combination drug therapies, and other indicators of improper use of behavioral health drugs.
(IV) Alert prescribers to patients who fail to refill prescriptions in a timely fashion, are prescribed multiple same-class behavioral health drugs, and may have other potential medication problems.
(V) Track spending trends for behavioral health drugs and deviation from best practice guidelines.
(VI) Use educational and technological approaches to promote best practices, educate consumers, and train prescribers in the use of practice guidelines.
(VII) Disseminate electronic and published materials.
(VIII) Hold statewide and regional conferences.
(IX) Implement a disease management program with a model quality-based medication component for severely mentally ill individuals and emotionally disturbed children who are high users of care.
11. The agency shall implement a Medicaid prescription drug management system.
a. The agency may contract with a vendor that has experience in operating prescription drug management systems in order to implement this system. Any management system that is implemented in accordance with this subparagraph must rely on cooperation between physicians and pharmacists to determine appropriate practice patterns and clinical guidelines to improve the prescribing, dispensing, and use of drugs in the Medicaid program. The agency may seek federal waivers to implement this program.
b. The drug management system must be designed to improve the quality of care and prescribing practices based on best practice guidelines, improve patient adherence to medication plans, reduce clinical risk, and lower prescribed drug costs and the rate of inappropriate spending on Medicaid prescription drugs. The program must:
(I) Provide for the adoption of best practice guidelines for the prescribing and use of drugs in the Medicaid program, including translating best practice guidelines into practice; reviewing prescriber patterns and comparing them to indicators that are based on national standards and practice patterns of clinical peers in their community, statewide, and nationally; and determine deviations from best practice guidelines.
(II) Implement processes for providing feedback to and educating prescribers using best practice educational materials and peer-to-peer consultation.
(III) Assess Medicaid recipients who are outliers in their use of a single or multiple prescription drugs with regard to the numbers and types of drugs taken, drug dosages, combination drug therapies, and other indicators of improper use of prescription drugs.
(IV) Alert prescribers to recipients who fail to refill prescriptions in a timely fashion, are prescribed multiple drugs that may be redundant or contraindicated, or may have other potential medication problems.
12. The agency may contract for drug rebate administration, including, but not limited to, calculating rebate amounts, invoicing manufacturers, negotiating disputes with manufacturers, and maintaining a database of rebate collections.
13. The agency may specify the preferred daily dosing form or strength for the purpose of promoting best practices with regard to the prescribing of certain drugs as specified in the General Appropriations Act and ensuring cost-effective prescribing practices.
14. The agency may require prior authorization for Medicaid-covered prescribed drugs. The agency may prior-authorize the use of a product:
a. For an indication not approved in labeling;
b. To comply with certain clinical guidelines; or
c. If the product has the potential for overuse, misuse, or abuse.
The agency may require the prescribing professional to provide information about the rationale and supporting medical evidence for the use of a drug. The agency shall post prior authorization, step-edit criteria and protocol, and updates to the list of drugs that are subject to prior authorization on the agency’s Internet website within 21 days after the prior authorization and step-edit criteria and protocol and updates are approved by the agency. For purposes of this subparagraph, the term “step-edit” means an automatic electronic review of certain medications subject to prior authorization.
15. The agency, in conjunction with the Pharmaceutical and Therapeutics Committee, may require age-related prior authorizations for certain prescribed drugs. The agency may preauthorize the use of a drug for a recipient who may not meet the age requirement or may exceed the length of therapy for use of this product as recommended by the manufacturer and approved by the Food and Drug Administration. Prior authorization may require the prescribing professional to provide information about the rationale and supporting medical evidence for the use of a drug.
16. The agency shall implement a step-therapy prior authorization approval process for medications excluded from the preferred drug list. Medications listed on the preferred drug list must be used within the previous 12 months before the alternative medications that are not listed. The step-therapy prior authorization may require the prescriber to use the medications of a similar drug class or for a similar medical indication unless contraindicated in the Food and Drug Administration labeling. The trial period between the specified steps may vary according to the medical indication. The step-therapy approval process shall be developed in accordance with the committee as stated in s. 409.91195(7) and (8). A drug product may be approved without meeting the step-therapy prior authorization criteria if the prescribing physician provides the agency with additional written medical or clinical documentation that the product is medically necessary because:
a. There is not a drug on the preferred drug list to treat the disease or medical condition which is an acceptable clinical alternative;
b. The alternatives have been ineffective in the treatment of the beneficiary’s disease; or
c. Based on historic evidence and known characteristics of the patient and the drug, the drug is likely to be ineffective, or the number of doses have been ineffective.
The agency shall work with the physician to determine the best alternative for the patient. The agency may adopt rules waiving the requirements for written clinical documentation for specific drugs in limited clinical situations.
17. The agency shall implement a return and reuse program for drugs dispensed by pharmacies to institutional recipients, which includes payment of a $5 restocking fee for the implementation and operation of the program. The return and reuse program shall be implemented electronically and in a manner that promotes efficiency. The program must permit a pharmacy to exclude drugs from the program if it is not practical or cost-effective for the drug to be included and must provide for the return to inventory of drugs that cannot be credited or returned in a cost-effective manner. The agency shall determine if the program has reduced the amount of Medicaid prescription drugs which are destroyed on an annual basis and if there are additional ways to ensure more prescription drugs are not destroyed which could safely be reused.
(b) The agency shall implement this subsection to the extent that funds are appropriated to administer the Medicaid prescribed-drug spending-control program. The agency may contract all or any part of this program to private organizations.
(c) The agency shall submit quarterly reports to the Governor, the President of the Senate, and the Speaker of the House of Representatives which must include, but need not be limited to, the progress made in implementing this subsection and its effect on Medicaid prescribed-drug expenditures.
(38) Notwithstanding the provisions of chapter 287, the agency may, at its discretion, renew a contract or contracts for fiscal intermediary services one or more times for such periods as the agency may decide; however, all such renewals may not combine to exceed a total period longer than the term of the original contract.
(39) The agency shall establish a demonstration project in Miami-Dade County of a long-term-care facility and a psychiatric facility licensed pursuant to chapter 395 to improve access to health care for a predominantly minority, medically underserved, and medically complex population and to evaluate alternatives to nursing home care and general acute care for such population. Such project is to be located in a health care condominium and collocated with licensed facilities providing a continuum of care. These projects are not subject to the provisions of s. 408.036 or s. 408.039. This subsection expires October 1, 2013.
(40) The agency shall develop and implement a utilization management program for Medicaid-eligible recipients for the management of occupational, physical, respiratory, and speech therapies. The agency shall establish a utilization program that may require prior authorization in order to ensure medically necessary and cost-effective treatments. The program shall be operated in accordance with a federally approved waiver program or state plan amendment. The agency may seek a federal waiver or state plan amendment to implement this program. The agency may also competitively procure these services from an outside vendor on a regional or statewide basis. This subsection expires October 1, 2014.
(41)(a) The agency shall contract on a prepaid or fixed-sum basis with appropriately licensed prepaid dental health plans to provide dental services. This paragraph expires October 1, 2014.
(b) Notwithstanding paragraph (a) and for the 2012-2013 fiscal year only, the agency is authorized to provide a Medicaid prepaid dental health program in Miami-Dade County. For all other counties, the agency may not limit dental services to prepaid plans and must allow qualified dental providers to provide dental services under Medicaid on a fee-for-service reimbursement methodology. The agency may seek any necessary revisions or amendments to the state plan or federal waivers in order to implement this paragraph. The agency shall terminate existing contracts as needed to implement this paragraph. This paragraph expires July 1, 2013.
(42) The Agency for Health Care Administration shall ensure that any Medicaid managed care plan as defined in s. 409.9122(2)(f), whether paid on a capitated basis or a shared savings basis, is cost-effective. For purposes of this subsection, the term “cost-effective” means that a network’s per-member, per-month costs to the state, including, but not limited to, fee-for-service costs, administrative costs, and case-management fees, if any, must be no greater than the state’s costs associated with contracts for Medicaid services established under subsection (3), which may be adjusted for health status. The agency shall conduct actuarially sound adjustments for health status in order to ensure such cost-effectiveness and shall annually publish the results on its Internet website. Contracts established pursuant to this subsection which are not cost-effective may not be renewed. This subsection expires October 1, 2014.
(43) Subject to the availability of funds, the agency shall mandate a recipient’s participation in a provider lock-in program, when appropriate, if a recipient is found by the agency to have used Medicaid goods or services at a frequency or amount not medically necessary, limiting the receipt of goods or services to medically necessary providers after the 21-day appeal process has ended, for a period of not less than 1 year. The lock-in programs shall include, but are not limited to, pharmacies, medical doctors, and infusion clinics. The limitation does not apply to emergency services and care provided to the recipient in a hospital emergency department. The agency shall seek any federal waivers necessary to implement this subsection. The agency shall adopt any rules necessary to comply with or administer this subsection. This subsection expires October 1, 2014.
(44) The agency shall seek a federal waiver for permission to terminate the eligibility of a Medicaid recipient who has been found to have committed fraud, through judicial or administrative determination, two times in a period of 5 years.
(45)(a) A provider is not entitled to enrollment in the Medicaid provider network. The agency may implement a Medicaid fee-for-service provider network controls, including, but not limited to, competitive procurement and provider credentialing. If a credentialing process is used, the agency may limit its provider network based upon the following considerations: beneficiary access to care, provider availability, provider quality standards and quality assurance processes, cultural competency, demographic characteristics of beneficiaries, practice standards, service wait times, provider turnover, provider licensure and accreditation history, program integrity history, peer review, Medicaid policy and billing compliance records, clinical and medical record audit findings, and such other areas that are considered necessary by the agency to ensure the integrity of the program.
(b) The agency shall limit its network of durable medical equipment and medical supply providers. For dates of service after January 1, 2009, the agency shall limit payment for durable medical equipment and supplies to providers that meet all the requirements of this paragraph.
1. Providers must be accredited by a Centers for Medicare and Medicaid Services deemed accreditation organization for suppliers of durable medical equipment, prosthetics, orthotics, and supplies. The provider must maintain accreditation and is subject to unannounced reviews by the accrediting organization.
2. Providers must provide the services or supplies directly to the Medicaid recipient or caregiver at the provider location or recipient’s residence or send the supplies directly to the recipient’s residence with receipt of mailed delivery. Subcontracting or consignment of the service or supply to a third party is prohibited.
3. Notwithstanding subparagraph 2., a durable medical equipment provider may store nebulizers at a physician’s office for the purpose of having the physician’s staff issue the equipment if it meets all of the following conditions:
a. The physician must document the medical necessity and need to prevent further deterioration of the patient’s respiratory status by the timely delivery of the nebulizer in the physician’s office.
b. The durable medical equipment provider must have written documentation of the competency and training by a Florida-licensed registered respiratory therapist of any durable medical equipment staff who participate in the training of physician office staff for the use of nebulizers, including cleaning, warranty, and special needs of patients.
c. The physician’s office must have documented the training and competency of any staff member who initiates the delivery of nebulizers to patients. The durable medical equipment provider must maintain copies of all physician office training.
d. The physician’s office must maintain inventory records of stored nebulizers, including documentation of the durable medical equipment provider source.
e. A physician contracted with a Medicaid durable medical equipment provider may not have a financial relationship with that provider or receive any financial gain from the delivery of nebulizers to patients.
4. Providers must have a physical business location and a functional landline business phone. The location must be within the state or not more than 50 miles from the Florida state line. The agency may make exceptions for providers of durable medical equipment or supplies not otherwise available from other enrolled providers located within the state.
5. Physical business locations must be clearly identified as a business that furnishes durable medical equipment or medical supplies by signage that can be read from 20 feet away. The location must be readily accessible to the public during normal, posted business hours and must operate at least 5 hours per day and at least 5 days per week, with the exception of scheduled and posted holidays. The location may not be located within or at the same numbered street address as another enrolled Medicaid durable medical equipment or medical supply provider or as an enrolled Medicaid pharmacy that is also enrolled as a durable medical equipment provider. A licensed orthotist or prosthetist that provides only orthotic or prosthetic devices as a Medicaid durable medical equipment provider is exempt from this paragraph.
6. Providers must maintain a stock of durable medical equipment and medical supplies on site that is readily available to meet the needs of the durable medical equipment business location’s customers.
7. Providers must provide a surety bond of $50,000 for each provider location, up to a maximum of 5 bonds statewide or an aggregate bond of $250,000 statewide, as identified by Federal Employer Identification Number. Providers who post a statewide or an aggregate bond must identify all of their locations in any Medicaid durable medical equipment and medical supply provider enrollment application or bond renewal. Each provider location’s surety bond must be renewed annually and the provider must submit proof of renewal even if the original bond is a continuous bond. A licensed orthotist or prosthetist that provides only orthotic or prosthetic devices as a Medicaid durable medical equipment provider is exempt from the provisions in this paragraph.
8. Providers must obtain a level 2 background screening, in accordance with chapter 435 and s. 408.809, for each provider employee in direct contact with or providing direct services to recipients of durable medical equipment and medical supplies in their homes. This requirement includes, but is not limited to, repair and service technicians, fitters, and delivery staff. The provider shall pay for the cost of the background screening.
9. The following providers are exempt from subparagraphs 1. and 7.:
a. Durable medical equipment providers owned and operated by a government entity.
b. Durable medical equipment providers that are operating within a pharmacy that is currently enrolled as a Medicaid pharmacy provider.
c. Active, Medicaid-enrolled orthopedic physician groups, primarily owned by physicians, which provide only orthotic and prosthetic devices.
(46) The agency shall contract with established minority physician networks that provide services to historically underserved minority patients. The networks must provide cost-effective Medicaid services, comply with the requirements to be a MediPass provider, and provide their primary care physicians with access to data and other management tools necessary to assist them in ensuring the appropriate use of services, including inpatient hospital services and pharmaceuticals.
(a) The agency shall provide for the development and expansion of minority physician networks in each service area to provide services to Medicaid recipients who are eligible to participate under federal law and rules.
(b) The agency shall reimburse each minority physician network as a fee-for-service provider, including the case management fee for primary care, if any, or as a capitated rate provider for Medicaid services. Any savings shall be shared with the minority physician networks pursuant to the contract.
(c) For purposes of this subsection, the term “cost-effective” means that a network’s per-member, per-month costs to the state, including, but not limited to, fee-for-service costs, administrative costs, and case-management fees, if any, must be no greater than the state’s costs associated with contracts for Medicaid services established under subsection (3), which shall be actuarially adjusted for case mix, model, and service area. The agency shall conduct actuarially sound audits adjusted for case mix and model in order to ensure such cost-effectiveness and shall annually publish the audit results on its Internet website. Contracts established pursuant to this subsection which are not cost-effective may not be renewed.
(d) The agency may apply for any federal waivers needed to implement this subsection.
This subsection expires October 1, 2014.
(47) To the extent permitted by federal law and as allowed under s. 409.906, the agency shall provide reimbursement for emergency mental health care services for Medicaid recipients in crisis stabilization facilities licensed under s. 394.875 as long as those services are less expensive than the same services provided in a hospital setting.
(48) The agency shall work with the Agency for Persons with Disabilities to develop a home and community-based waiver to serve children and adults who are diagnosed with familial dysautonomia or Riley-Day syndrome caused by a mutation of the IKBKAP gene on chromosome 9. The agency shall seek federal waiver approval and implement the approved waiver subject to the availability of funds and any limitations provided in the General Appropriations Act. The agency may adopt rules to implement this waiver program.
(49) The agency shall implement a program of all-inclusive care for children. The program of all-inclusive care for children shall be established to provide in-home hospice-like support services to children diagnosed with a life-threatening illness and enrolled in the Children’s Medical Services network to reduce hospitalizations as appropriate. The agency, in consultation with the Department of Health, may implement the program of all-inclusive care for children after obtaining approval from the Centers for Medicare and Medicaid Services.
(50) Before seeking an amendment to the state plan for purposes of implementing programs authorized by the Deficit Reduction Act of 2005, the agency shall notify the Legislature.
(51) The agency may not pay for psychotropic medication prescribed for a child in the Medicaid program without the express and informed consent of the child’s parent or legal guardian. The physician shall document the consent in the child’s medical record and provide the pharmacy with a signed attestation of this documentation with the prescription. The express and informed consent or court authorization for a prescription of psychotropic medication for a child in the custody of the Department of Children and Family Services shall be obtained pursuant to s. 39.407.
History.—s. 43, ch. 91-282; s. 3, ch. 94-299; s. 5, ch. 94-317; s. 59, ch. 95-144; s. 6, ch. 96-199; s. 11, ch. 96-223; s. 3, ch. 96-387; s. 7, ch. 96-417; s. 11, ch. 97-82; s. 43, ch. 97-98; s. 202, ch. 97-101; s. 66, ch. 97-237; s. 10, ch. 97-260; s. 15, ch. 97-263; s. 5, ch. 97-290; ss. 29, 30, ch. 98-191; s. 150, ch. 98-403; s. 188, ch. 99-8; ss. 14, 15, 53, ch. 99-228; s. 16, ch. 99-393; ss. 69, 207, ch. 99-397; s. 60, ch. 2000-153; s. 20, ch. 2000-157; s. 61, ch. 2000-158; ss. 19, 26, ch. 2000-163; s. 5, ch. 2000-209; ss. 19, 59, ch. 2000-256; s. 1, ch. 2000-277; s. 98, ch. 2000-349; s. 71, ch. 2000-367; s. 52, ch. 2001-62; s. 9, ch. 2001-104; s. 7, ch. 2001-222; ss. 8, 9, ch. 2001-377; ss. 8, 14, ch. 2002-223; ss. 26, 27, ch. 2002-400; s. 47, ch. 2003-1; s. 450, ch. 2003-261; s. 9, ch. 2003-279; s. 18, ch. 2003-405; s. 55, ch. 2004-5; s. 28, ch. 2004-267; s. 17, ch. 2004-270; s. 5, ch. 2004-344; s. 3, ch. 2004-365; s. 3, ch. 2004-386; s. 70, ch. 2005-2; s. 16, ch. 2005-60; s. 1, ch. 2005-115; s. 1, ch. 2005-133; s. 52, ch. 2005-152; s. 2, ch. 2005-358; s. 18, ch. 2006-28; s. 83, ch. 2006-197; s. 1, ch. 2006-257; s. 97, ch. 2007-5; s. 1, ch. 2007-82; s. 4, ch. 2007-331; s. 10, ch. 2008-143; s. 14, ch. 2008-246; s. 14, ch. 2009-55; s. 16, ch. 2009-223; s. 95, ch. 2010-5; s. 127, ch. 2010-102; ss. 26, 50, ch. 2010-114; s. 15, ch. 2010-144; s. 12, ch. 2011-61; s. 17, ch. 2011-135; s. 6, ch. 2011-195; s. 2, ch. 2012-44; s. 9, ch. 2012-119; s. 39, ch. 2012-160; s. 47, ch. 2013-14.
409.91206 Alternatives for health and long-term care reforms.—The Governor, the President of the Senate, and the Speaker of the House of Representatives may convene workgroups to propose alternatives for cost-effective health and long-term care reforms, including, but not limited to, reforms for Medicaid.
History.—s. 11, ch. 2008-143.
409.9121 Legislative findings and intent.—The Legislature hereby finds that the Medicaid program has experienced an annual growth rate of approximately 28 percent per year for the past 5 years, and is consuming more than half of all new general revenue growth. The present Medicaid system must be reoriented to emphasize, to the maximum extent possible, the delivery of health care through entities and mechanisms which are designed to contain costs, to emphasize preventive and primary care, and to promote access and continuity of care. The Legislature further finds that the concept of “managed care” best encompasses these multiple goals. The Legislature also finds that, with the cooperation of the physician community, MediPass, the Medicaid primary care case management program, is responsible for ensuring that there is a sufficient supply of primary care to provide access to preventive and primary care services to Medicaid recipients. Therefore, the Legislature declares its intent that the Medicaid program require, to the maximum extent practicable and permitted by federal law, that all Medicaid recipients be enrolled in a managed care program.
History.—s. 50, ch. 93-129.
1409.91211 Medicaid managed care pilot program.—
(1)(a) The agency is authorized to seek and implement experimental, pilot, or demonstration project waivers, pursuant to s. 1115 of the Social Security Act, to create a statewide initiative to provide for a more efficient and effective service delivery system that enhances quality of care and client outcomes in the Florida Medicaid program pursuant to this section. Phase one of the demonstration shall be implemented in two geographic areas. One demonstration site shall include only Broward County. A second demonstration site shall initially include Duval County and shall be expanded to include Baker, Clay, and Nassau Counties within 1 year after the Duval County program becomes operational. The agency shall implement expansion of the program to include the remaining counties of the state and remaining eligibility groups in accordance with the process specified in the federally approved special terms and conditions numbered 11-W-00206/4, as approved by the federal Centers for Medicare and Medicaid Services on October 19, 2005, with a goal of full statewide implementation by June 30, 2011.
(b) This waiver authority is contingent upon federal approval to preserve the upper-payment-limit funding mechanism for hospitals, including a guarantee of a reasonable growth factor, a methodology to allow the use of a portion of these funds to serve as a risk pool for demonstration sites, provisions to preserve the state’s ability to use intergovernmental transfers, and provisions to protect the disproportionate share program authorized pursuant to this chapter. Upon completion of the evaluation conducted under s. 3, ch. 2005-133, Laws of Florida, the agency may request statewide expansion of the demonstration projects. Statewide phase-in to additional counties shall be contingent upon review and approval by the Legislature. Under the upper-payment-limit program, or the low-income pool as implemented by the Agency for Health Care Administration pursuant to federal waiver, the state matching funds required for the program shall be provided by local governmental entities through intergovernmental transfers in accordance with published federal statutes and regulations. The Agency for Health Care Administration shall distribute upper-payment-limit, disproportionate share hospital, and low-income pool funds according to published federal statutes, regulations, and waivers and the low-income pool methodology approved by the federal Centers for Medicare and Medicaid Services.
(c) It is the intent of the Legislature that the low-income pool plan required by the terms and conditions of the Medicaid reform waiver and submitted to the federal Centers for Medicare and Medicaid Services propose the distribution of the above-mentioned program funds based on the following objectives:
1. Assure a broad and fair distribution of available funds based on the access provided by Medicaid participating hospitals, regardless of their ownership status, through their delivery of inpatient or outpatient care for Medicaid beneficiaries and uninsured and underinsured individuals;
2. Assure accessible emergency inpatient and outpatient care for Medicaid beneficiaries and uninsured and underinsured individuals;
3. Enhance primary, preventive, and other ambulatory care coverages for uninsured individuals;
4. Promote teaching and specialty hospital programs;
5. Promote the stability and viability of statutorily defined rural hospitals and hospitals that serve as sole community hospitals;
6. Recognize the extent of hospital uncompensated care costs;
7. Maintain and enhance essential community hospital care;
8. Maintain incentives for local governmental entities to contribute to the cost of uncompensated care;
9. Promote measures to avoid preventable hospitalizations;
10. Account for hospital efficiency; and
11. Contribute to a community’s overall health system.
(2) The Legislature intends for the capitated managed care pilot program to:
(a) Provide recipients in Medicaid fee-for-service or the MediPass program a comprehensive and coordinated capitated managed care system for all health care services specified in ss. 409.905 and 409.906.
(b) Stabilize Medicaid expenditures under the pilot program compared to Medicaid expenditures in the pilot area for the 3 years before implementation of the pilot program, while ensuring:
1. Consumer education and choice.
2. Access to medically necessary services.
3. Coordination of preventative, acute, and long-term care.
4. Reductions in unnecessary service utilization.
(c) Provide an opportunity to evaluate the feasibility of statewide implementation of capitated managed care networks as a replacement for the current Medicaid fee-for-service and MediPass systems.
(3) The agency shall have the following powers, duties, and responsibilities with respect to the pilot program:
(a) To implement a system to deliver all mandatory services specified in s. 409.905 and optional services specified in s. 409.906, as approved by the Centers for Medicare and Medicaid Services and the Legislature in the waiver pursuant to this section. Services to recipients under plan benefits shall include emergency services provided under s. 409.9128.
(b) To implement a pilot program, including Medicaid eligibility categories specified in ss. 409.903 and 409.904, as authorized in an approved federal waiver.
(c) To implement the managed care pilot program that maximizes all available state and federal funds, including those obtained through intergovernmental transfers, the low-income pool, supplemental Medicaid payments, and the disproportionate share program. Within the parameters allowed by federal statute and rule, the agency may seek options for making direct payments to hospitals and physicians employed by or under contract with the state’s medical schools for the costs associated with graduate medical education under Medicaid reform.
(d) To implement actuarially sound, risk-adjusted capitation rates for Medicaid recipients in the pilot program which cover comprehensive care, enhanced services, and catastrophic care.
(e) To implement policies and guidelines for phasing in financial risk for approved provider service networks that, for purposes of this paragraph, include the Children’s Medical Services Network, over the period of the waiver and the extension thereof. These policies and guidelines must include an option for a provider service network to be paid fee-for-service rates. For any provider service network established in a managed care pilot area, the option to be paid fee-for-service rates must include a savings-settlement mechanism that is consistent with s. 409.912(42). This model must be converted to a risk-adjusted capitated rate by the beginning of the final year of operation under the waiver extension, and may be converted earlier at the option of the provider service network. Federally qualified health centers may be offered an opportunity to accept or decline a contract to participate in any provider network for prepaid primary care services.
(f) To implement stop-loss requirements and the transfer of excess cost to catastrophic coverage that accommodates the risks associated with the development of the pilot program.
(g) To recommend a process to be used by the Social Services Estimating Conference to determine and validate the rate of growth of the per-member costs of providing Medicaid services under the managed care pilot program.
(h) To implement program standards and credentialing requirements for capitated managed care networks to participate in the pilot program, including those related to fiscal solvency, quality of care, and adequacy of access to health care providers. It is the intent of the Legislature that, to the extent possible, any pilot program authorized by the state under this section include any federally qualified health center, federally qualified rural health clinic, county health department, the Children’s Medical Services Network within the Department of Health, or other federally, state, or locally funded entity that serves the geographic areas within the boundaries of the pilot program that requests to participate. This paragraph does not relieve an entity that qualifies as a capitated managed care network under this section from any other licensure or regulatory requirements contained in state or federal law which would otherwise apply to the entity. The standards and credentialing requirements shall be based upon, but are not limited to:
1. Compliance with the accreditation requirements as provided in s. 641.512.
2. Compliance with early and periodic screening, diagnosis, and treatment screening requirements under federal law.
3. The percentage of voluntary disenrollments.
4. Immunization rates.
5. Standards of the National Committee for Quality Assurance and other approved accrediting bodies.
6. Recommendations of other authoritative bodies.
7. Specific requirements of the Medicaid program, or standards designed to specifically meet the unique needs of Medicaid recipients.
8. Compliance with the health quality improvement system as established by the agency, which incorporates standards and guidelines developed by the Centers for Medicare and Medicaid Services as part of the quality assurance reform initiative.
9. The network’s infrastructure capacity to manage financial transactions, recordkeeping, data collection, and other administrative functions.
10. The network’s ability to submit any financial, programmatic, or patient-encounter data or other information required by the agency to determine the actual services provided and the cost of administering the plan.
(i) To implement a mechanism for providing information to Medicaid recipients for the purpose of selecting a capitated managed care plan. For each plan available to a recipient, the agency, at a minimum, shall ensure that the recipient is provided with:
1. A list and description of the benefits provided.
2. Information about cost sharing.
3. Plan performance data, if available.
4. An explanation of benefit limitations.
5. Contact information, including identification of providers participating in the network, geographic locations, and transportation limitations.
6. Any other information the agency determines would facilitate a recipient’s understanding of the plan or insurance that would best meet his or her needs.
(j) To implement a system to ensure that there is a record of recipient acknowledgment that choice counseling has been provided.
(k) To implement a choice counseling system to ensure that the choice counseling process and related material are designed to provide counseling through face-to-face interaction, by telephone, and in writing and through other forms of relevant media. Materials shall be written at the fourth-grade reading level and available in a language other than English when 5 percent of the county speaks a language other than English. Choice counseling shall also use language lines and other services for impaired recipients, such as TTD/TTY.
(l) To implement a system that prohibits capitated managed care plans, their representatives, and providers employed by or contracted with the capitated managed care plans from recruiting persons eligible for or enrolled in Medicaid, from providing inducements to Medicaid recipients to select a particular capitated managed care plan, and from prejudicing Medicaid recipients against other capitated managed care plans. The system shall require the entity performing choice counseling to determine if the recipient has made a choice of a plan or has opted out because of duress, threats, payment to the recipient, or incentives promised to the recipient by a third party. If the choice counseling entity determines that the decision to choose a plan was unlawfully influenced or a plan violated any of the provisions of s. 409.912(20), the choice counseling entity shall immediately report the violation to the agency’s program integrity section for investigation. Verification of choice counseling by the recipient shall include a stipulation that the recipient acknowledges the provisions of this subsection.
(m) To implement a choice counseling system that promotes health literacy and provides information aimed to reduce minority health disparities through outreach activities for Medicaid recipients.
(n) To contract with entities to perform choice counseling. The agency may establish standards and performance contracts, including standards requiring the contractor to hire choice counselors who are representative of the state’s diverse population and to train choice counselors in working with culturally diverse populations.
(o) To implement eligibility assignment processes to facilitate client choice while ensuring pilot programs of adequate enrollment levels. These processes shall ensure that pilot sites have sufficient levels of enrollment to conduct a valid test of the managed care pilot program within a 2-year timeframe.
(p) To implement standards for plan compliance, including, but not limited to, standards for quality assurance and performance improvement, standards for peer or professional reviews, grievance policies, and policies for maintaining program integrity. The agency shall develop a data-reporting system, seek input from managed care plans in order to establish requirements for patient-encounter reporting, and ensure that the data reported is accurate and complete.
1. In performing the duties required under this section, the agency shall work with managed care plans to establish a uniform system to measure and monitor outcomes for a recipient of Medicaid services.
2. The system shall use financial, clinical, and other criteria based on pharmacy, medical services, and other data that is related to the provision of Medicaid services, including, but not limited to:
a. The Health Plan Employer Data and Information Set (HEDIS) or measures that are similar to HEDIS.
b. Member satisfaction.
c. Provider satisfaction.
d. Report cards on plan performance and best practices.
e. Compliance with the requirements for prompt payment of claims under ss. 627.613, 641.3155, and 641.513.
f. Utilization and quality data for the purpose of ensuring access to medically necessary services, including underutilization or inappropriate denial of services.
3. The agency shall require the managed care plans that have contracted with the agency to establish a quality assurance system that incorporates the provisions of s. 409.912(26) and any standards, rules, and guidelines developed by the agency.
4. The agency shall establish an encounter database in order to compile data on health services rendered by health care practitioners who provide services to patients enrolled in managed care plans in the demonstration sites. The encounter database shall:
a. Collect the following for each type of patient encounter with a health care practitioner or facility, including:
(I) The demographic characteristics of the patient.
(II) The principal, secondary, and tertiary diagnosis.
(III) The procedure performed.
(IV) The date and location where the procedure was performed.
(V) The payment for the procedure, if any.
(VI) If applicable, the health care practitioner’s universal identification number.
(VII) If the health care practitioner rendering the service is a dependent practitioner, the modifiers appropriate to indicate that the service was delivered by the dependent practitioner.
b. Collect appropriate information relating to prescription drugs for each type of patient encounter.
c. Collect appropriate information related to health care costs and utilization from managed care plans participating in the demonstration sites.
5. To the extent practicable, when collecting the data the agency shall use a standardized claim form or electronic transfer system that is used by health care practitioners, facilities, and payors.
6. Health care practitioners and facilities in the demonstration sites shall electronically submit, and managed care plans participating in the demonstration sites shall electronically receive, information concerning claims payments and any other information reasonably related to the encounter database using a standard format as required by the agency.
7. The agency shall establish reasonable deadlines for phasing in the electronic transmittal of full encounter data.
8. The system must ensure that the data reported is accurate and complete.
(q) To implement a grievance resolution process for Medicaid recipients enrolled in a capitated managed care network under the pilot program modeled after the subscriber assistance panel, as created in s. 408.7056. This process shall include a mechanism for an expedited review of no greater than 24 hours after notification of a grievance if the life of a Medicaid recipient is in imminent and emergent jeopardy.
(r) To implement a grievance resolution process for health care providers employed by or contracted with a capitated managed care network under the pilot program in order to settle disputes among the provider and the managed care network or the provider and the agency.
(s) To implement criteria in an approved federal waiver to designate health care providers as eligible to participate in the pilot program. These criteria must include at a minimum those criteria specified in s. 409.907.
(t) To use health care provider agreements for participation in the pilot program.
(u) To require that all health care providers under contract with the pilot program be duly licensed in the state, if such licensure is available, and meet other criteria as may be established by the agency. These criteria shall include at a minimum those criteria specified in s. 409.907.
(v) To ensure that managed care organizations work collaboratively with other state or local governmental programs or institutions for the coordination of health care to eligible individuals receiving services from such programs or institutions.
(w) To implement procedures to minimize the risk of Medicaid fraud and abuse in all plans operating in the Medicaid managed care pilot program authorized in this section.
1. The agency shall ensure that applicable provisions of this chapter and chapters 414, 626, 641, and 932 which relate to Medicaid fraud and abuse are applied and enforced at the demonstration project sites.
2. Providers must have the certification, license, and credentials that are required by law and waiver requirements.
3. The agency shall ensure that the plan is in compliance with s. 409.912(20) and (21).
4. The agency shall require that each plan establish functions and activities governing program integrity in order to reduce the incidence of fraud and abuse. Plans must report instances of fraud and abuse pursuant to chapter 641.
5. The plan shall have written administrative and management arrangements or procedures, including a mandatory compliance plan, which are designed to guard against fraud and abuse. The plan shall designate a compliance officer who has sufficient experience in health care.
6.a. The agency shall require all managed care plan contractors in the pilot program to report all instances of suspected fraud and abuse. A failure to report instances of suspected fraud and abuse is a violation of law and subject to the penalties provided by law.
b. An instance of fraud and abuse in the managed care plan, including, but not limited to, defrauding the state health care benefit program by misrepresentation of fact in reports, claims, certifications, enrollment claims, demographic statistics, or patient-encounter data; misrepresentation of the qualifications of persons rendering health care and ancillary services; bribery and false statements relating to the delivery of health care; unfair and deceptive marketing practices; and false claims actions in the provision of managed care, is a violation of law and subject to the penalties provided by law.
c. The agency shall require that all contractors make all files and relevant billing and claims data accessible to state regulators and investigators and that all such data is linked into a unified system to ensure consistent reviews and investigations.
(x) To develop and provide actuarial and benefit design analyses that indicate the effect on capitation rates and benefits offered in the pilot program over a prospective 5-year period based on the following assumptions:
1. Growth in capitation rates which is limited to the estimated growth rate in general revenue.
2. Growth in capitation rates which is limited to the average growth rate over the last 3 years in per-recipient Medicaid expenditures.
3. Growth in capitation rates which is limited to the growth rate of aggregate Medicaid expenditures between the 2003-2004 fiscal year and the 2004-2005 fiscal year.
(y) To develop a mechanism to require capitated managed care plans to reimburse qualified emergency service providers, including, but not limited to, ambulance services, in accordance with ss. 409.908 and 409.9128. The pilot program must include a provision for continuing fee-for-service payments for emergency services, including, but not limited to, individuals who access ambulance services or emergency departments and who are subsequently determined to be eligible for Medicaid services.
(z) To ensure that school districts participating in the certified school match program pursuant to ss. 409.908(21) and 1011.70 shall be reimbursed by Medicaid, subject to the limitations of s. 1011.70(1), for a Medicaid-eligible child participating in the services as authorized in s. 1011.70, as provided for in s. 409.9071, regardless of whether the child is enrolled in a capitated managed care network. Capitated managed care networks must make a good faith effort to execute agreements with school districts regarding the coordinated provision of services authorized under s. 1011.70. County health departments and federally qualified health centers delivering school-based services pursuant to ss. 381.0056 and 381.0057 must be reimbursed by Medicaid for the federal share for a Medicaid-eligible child who receives Medicaid-covered services in a school setting, regardless of whether the child is enrolled in a capitated managed care network. Capitated managed care networks must make a good faith effort to execute agreements with county health departments and federally qualified health centers regarding the coordinated provision of services to a Medicaid-eligible child. To ensure continuity of care for Medicaid patients, the agency, the Department of Health, and the Department of Education shall develop procedures for ensuring that a student’s capitated managed care network provider receives information relating to services provided in accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
(aa) To implement a mechanism whereby Medicaid recipients who are already enrolled in a managed care plan or the MediPass program in the pilot areas shall be offered the opportunity to change to capitated managed care plans on a staggered basis, as defined by the agency. All Medicaid recipients shall have 30 days in which to make a choice of capitated managed care plans. Those Medicaid recipients who do not make a choice shall be assigned to a capitated managed care plan in accordance with paragraph (4)(a) and shall be exempt from s. 409.9122. To facilitate continuity of care for a Medicaid recipient who is also a recipient of Supplemental Security Income (SSI), prior to assigning the SSI recipient to a capitated managed care plan, the agency shall determine whether the SSI recipient has an ongoing relationship with a provider or capitated managed care plan, and, if so, the agency shall assign the SSI recipient to that provider or capitated managed care plan where feasible. Those SSI recipients who do not have such a provider relationship shall be assigned to a capitated managed care plan provider in accordance with paragraph (4)(a) and shall be exempt from s. 409.9122.
(bb) To develop and recommend a service delivery alternative for children having chronic medical conditions which establishes a medical home project to provide primary care services to this population. The project shall provide community-based primary care services that are integrated with other subspecialties to meet the medical, developmental, and emotional needs for children and their families. This project shall include an evaluation component to determine impacts on hospitalizations, length of stays, emergency room visits, costs, and access to care, including specialty care and patient and family satisfaction.
(cc) To develop and recommend service delivery mechanisms within capitated managed care plans to provide Medicaid services as specified in ss. 409.905 and 409.906 to persons with developmental disabilities sufficient to meet the medical, developmental, and emotional needs of these persons.
(dd) To implement service delivery mechanisms within a specialty plan in area 10 to provide behavioral health care services to Medicaid-eligible children whose cases are open for child welfare services in the HomeSafeNet system. These services must be coordinated with community-based care providers as specified in s. 409.1671, where available, and be sufficient to meet the developmental, behavioral, and emotional needs of these children. Children in area 10 who have an open case in the HomeSafeNet system shall be enrolled into the specialty plan. These service delivery mechanisms must be implemented no later than July 1, 2011, in AHCA area 10 in order for the children in AHCA area 10 to remain exempt from the statewide plan under s. 409.912(4)(b)5. An administrative fee may be paid to the specialty plan for the coordination of services based on the receipt of the state share of that fee being provided through intergovernmental transfers.
(4)(a) A Medicaid recipient in the pilot area who is not currently enrolled in a capitated managed care plan upon implementation is not eligible for services as specified in ss. 409.905 and 409.906, for the amount of time that the recipient does not enroll in a capitated managed care network. If a Medicaid recipient has not enrolled in a capitated managed care plan within 30 days after eligibility, the agency shall assign the Medicaid recipient to a capitated managed care plan based on the assessed needs of the recipient as determined by the agency and the recipient shall be exempt from s. 409.9122. When making assignments, the agency shall take into account the following criteria:
1. A capitated managed care network has sufficient network capacity to meet the needs of members.
2. The capitated managed care network has previously enrolled the recipient as a member, or one of the capitated managed care network’s primary care providers has previously provided health care to the recipient.
3. The agency has knowledge that the member has previously expressed a preference for a particular capitated managed care network as indicated by Medicaid fee-for-service claims data, but has failed to make a choice.
4. The capitated managed care network’s primary care providers are geographically accessible to the recipient’s residence.
(b) When more than one capitated managed care network provider meets the criteria specified in paragraph (3)(h), the agency shall make recipient assignments consecutively by family unit.
(c) If a recipient is currently enrolled with a Medicaid managed care organization that also operates an approved reform plan within a demonstration area and the recipient fails to choose a plan during the reform enrollment process or during redetermination of eligibility, the recipient shall be automatically assigned by the agency into the most appropriate reform plan operated by the recipient’s current Medicaid managed care plan. If the recipient’s current managed care plan does not operate a reform plan in the demonstration area which adequately meets the needs of the Medicaid recipient, the agency shall use the automatic assignment process as prescribed in the special terms and conditions numbered 11-W-00206/4. All enrollment and choice counseling materials provided by the agency must contain an explanation of the provisions of this paragraph for current managed care recipients.
(d) The agency may not engage in practices that are designed to favor one capitated managed care plan over another or that are designed to influence Medicaid recipients to enroll in a particular capitated managed care network in order to strengthen its particular fiscal viability.
(e) After a recipient has made a selection or has been enrolled in a capitated managed care network, the recipient shall have 90 days in which to voluntarily disenroll and select another capitated managed care network. After 90 days, no further changes may be made except for cause. Cause shall include, but not be limited to, poor quality of care, lack of access to necessary specialty services, an unreasonable delay or denial of service, inordinate or inappropriate changes of primary care providers, service access impairments due to significant changes in the geographic location of services, or fraudulent enrollment. The agency may require a recipient to use the capitated managed care network’s grievance process as specified in paragraph (3)(q) prior to the agency’s determination of cause, except in cases in which immediate risk of permanent damage to the recipient’s health is alleged. The grievance process, when used, must be completed in time to permit the recipient to disenroll no later than the first day of the second month after the month the disenrollment request was made. If the capitated managed care network, as a result of the grievance process, approves an enrollee’s request to disenroll, the agency is not required to make a determination in the case. The agency must make a determination and take final action on a recipient’s request so that disenrollment occurs no later than the first day of the second month after the month the request was made. If the agency fails to act within the specified timeframe, the recipient’s request to disenroll is deemed to be approved as of the date agency action was required. Recipients who disagree with the agency’s finding that cause does not exist for disenrollment shall be advised of their right to pursue a Medicaid fair hearing to dispute the agency’s finding.
(f) The agency shall apply for federal waivers from the Centers for Medicare and Medicaid Services to lock eligible Medicaid recipients into a capitated managed care network for 12 months after an open enrollment period. After 12 months of enrollment, a recipient may select another capitated managed care network. However, nothing shall prevent a Medicaid recipient from changing primary care providers within the capitated managed care network during the 12-month period.
(g) The agency shall apply for federal waivers from the Centers for Medicare and Medicaid Services to allow recipients to purchase health care coverage through an employer-sponsored health insurance plan instead of through a Medicaid-certified plan. This provision shall be known as the opt-out option.
1. A recipient who chooses the Medicaid opt-out option shall have an opportunity for a specified period of time, as authorized under a waiver granted by the Centers for Medicare and Medicaid Services, to select and enroll in a Medicaid-certified plan. If the recipient remains in the employer-sponsored plan after the specified period, the recipient shall remain in the opt-out program for at least 1 year or until the recipient no longer has access to employer-sponsored coverage, until the employer’s open enrollment period for a person who opts out in order to participate in employer-sponsored coverage, or until the person is no longer eligible for Medicaid, whichever time period is shorter.
2. Notwithstanding any other provision of this section, coverage, cost sharing, and any other component of employer-sponsored health insurance shall be governed by applicable state and federal laws.
(5) This section does not authorize the agency to implement any provision of s. 1115 of the Social Security Act experimental, pilot, or demonstration project waiver to reform the state Medicaid program in any part of the state other than the two geographic areas specified in this section unless approved by the Legislature.
(6) The agency shall develop and submit for approval applications for waivers of applicable federal laws and regulations as necessary to implement the managed care pilot project as defined in this section. The agency shall post all waiver applications under this section on its Internet website 30 days before submitting the applications to the United States Centers for Medicare and Medicaid Services. All waiver applications shall be provided for review and comment to the appropriate committees of the Senate and House of Representatives for at least 10 working days prior to submission. All waivers submitted to and approved by the United States Centers for Medicare and Medicaid Services under this section must be approved by the Legislature. Federally approved waivers must be submitted to the President of the Senate and the Speaker of the House of Representatives for referral to the appropriate legislative committees. The appropriate committees shall recommend whether to approve the implementation of any waivers to the Legislature as a whole. The agency shall submit a plan containing a recommended timeline for implementation of any waivers and budgetary projections of the effect of the pilot program under this section on the total Medicaid budget for the 2006-2007 through 2009-2010 state fiscal years. This implementation plan shall be submitted to the President of the Senate and the Speaker of the House of Representatives at the same time any waivers are submitted for consideration by the Legislature. The agency may implement the waiver and special terms and conditions numbered 11-W-00206/4, as approved by the federal Centers for Medicare and Medicaid Services. If the agency seeks approval by the Federal Government of any modifications to these special terms and conditions, the agency must provide written notification of its intent to modify these terms and conditions to the President of the Senate and the Speaker of the House of Representatives at least 15 days before submitting the modifications to the Federal Government for consideration. The notification must identify all modifications being pursued and the reason the modifications are needed. Upon receiving federal approval of any modifications to the special terms and conditions, the agency shall provide a report to the Legislature describing the federally approved modifications to the special terms and conditions within 7 days after approval by the Federal Government.
(7)(a) The Secretary of Health Care Administration shall convene a technical advisory panel to advise the agency in the areas of risk-adjusted-rate setting, benefit design, and choice counseling. The panel shall include representatives from the Florida Association of Health Plans, representatives from provider-sponsored networks, a Medicaid consumer representative, and a representative from the Office of Insurance Regulation.
(b) The technical advisory panel shall advise the agency concerning:
1. The risk-adjusted rate methodology to be used by the agency, including recommendations on mechanisms to recognize the risk of all Medicaid enrollees and for the transition to a risk-adjustment system, including recommendations for phasing in risk adjustment and the use of risk corridors.
2. Implementation of an encounter data system to be used for risk-adjusted rates.
3. Administrative and implementation issues regarding the use of risk-adjusted rates, including, but not limited to, cost, simplicity, client privacy, data accuracy, and data exchange.
4. Issues of benefit design, including the actuarial equivalence and sufficiency standards to be used.
5. The implementation plan for the proposed choice-counseling system, including the information and materials to be provided to recipients, the methodologies by which recipients will be counseled regarding choice, criteria to be used to assess plan quality, the methodology to be used to assign recipients into plans if they fail to choose a managed care plan, and the standards to be used for responsiveness to recipient inquiries.
(c) The technical advisory panel shall continue in existence and advise the agency on matters outlined in this subsection.
(8) The agency must ensure, in the first two state fiscal years in which a risk-adjusted methodology is a component of rate setting, that no managed care plan providing comprehensive benefits to TANF and SSI recipients has an aggregate risk score that varies by more than 10 percent from the aggregate weighted mean of all managed care plans providing comprehensive benefits to TANF and SSI recipients in a reform area. The agency’s payment to a managed care plan shall be based on such revised aggregate risk score.
(9) After any calculations of aggregate risk scores or revised aggregate risk scores in subsection (8), the capitation rates for plans participating under this section shall be phased in as follows:
(a) In the first year, the capitation rates shall be weighted so that 75 percent of each capitation rate is based on the current methodology and 25 percent is based on a new risk-adjusted capitation rate methodology.
(b) In the second year, the capitation rates shall be weighted so that 50 percent of each capitation rate is based on the current methodology and 50 percent is based on a new risk-adjusted rate methodology.
(c) In the following fiscal year, the risk-adjusted capitation methodology may be fully implemented.
(10) Subsections (8) and (9) do not apply to managed care plans offering benefits exclusively to high-risk, specialty populations. The agency may set risk-adjusted rates immediately for such plans.
(11) Before the implementation of risk-adjusted rates, the rates shall be certified by an actuary and approved by the federal Centers for Medicare and Medicaid Services.
(12) For purposes of this section, the term “capitated managed care plan” includes health insurers authorized under chapter 624, exclusive provider organizations authorized under chapter 627, health maintenance organizations authorized under chapter 641, the Children’s Medical Services Network under chapter 391, and provider service networks that elect to be paid fee-for-service for up to 5 years as authorized under this section.
(13) Upon review and approval of the applications for waivers of applicable federal laws and regulations to implement the managed care pilot program by the Legislature, the agency may initiate adoption of rules pursuant to ss. 120.536(1) and 120.54 to implement and administer the managed care pilot program as provided in this section.
(14) It is the intent of the Legislature that if any conflict exists between the provisions contained in this section and other provisions of this chapter which relate to the implementation of the Medicaid managed care pilot program, the provisions contained in this section shall control. The agency shall provide a written report to the Legislature immediately upon identifying any provisions of this chapter which conflict with the implementation of the Medicaid managed care pilot program created in this section.
History.—s. 2, ch. 2005-133; s. 3, ch. 2005-358; s. 98, ch. 2007-5; s. 7, ch. 2007-331; s. 15, ch. 2009-55; s. 96, ch. 2010-5; s. 16, ch. 2010-144; ss. 19, 20, ch. 2011-135.
409.91212 Medicaid managed care fraud.—
(1) Each managed care plan, as defined in s. 409.920(1)(e), shall adopt an anti-fraud plan addressing the detection and prevention of overpayments, abuse, and fraud relating to the provision of and payment for Medicaid services and submit the plan to the Office of Medicaid Program Integrity within the agency for approval. At a minimum, the anti-fraud plan must include:
(a) A written description or chart outlining the organizational arrangement of the plan’s personnel who are responsible for the investigation and reporting of possible overpayment, abuse, or fraud;
(b) A description of the plan’s procedures for detecting and investigating possible acts of fraud, abuse, and overpayment;
(c) A description of the plan’s procedures for the mandatory reporting of possible overpayment, abuse, or fraud to the Office of Medicaid Program Integrity within the agency;
(d) A description of the plan’s program and procedures for educating and training personnel on how to detect and prevent fraud, abuse, and overpayment;
(e) The name, address, telephone number, e-mail address, and fax number of the individual responsible for carrying out the anti-fraud plan; and
(f) A summary of the results of the investigations of fraud, abuse, or overpayment which were conducted during the previous year by the managed care organization’s fraud investigative unit.
(2) A managed care plan that provides Medicaid services shall:
(a) Establish and maintain a fraud investigative unit to investigate possible acts of fraud, abuse, and overpayment; or
(b) Contract for the investigation of possible fraudulent or abusive acts by Medicaid recipients, persons providing services to Medicaid recipients, or any other persons.
(3) If a managed care plan contracts for the investigation of fraudulent claims and other types of program abuse by recipients or service providers, the managed care plan shall file the following with the Office of Medicaid Program Integrity within the agency for approval before the plan executes any contracts for fraud and abuse prevention and detection:
(a) A copy of the written contract between the plan and the contracting entity;
(b) The names, addresses, telephone numbers, e-mail addresses, and fax numbers of the principals of the entity with which the managed care plan has contracted; and
(c) A description of the qualifications of the principals of the entity with which the managed care plan has contracted.
(4) On or before September 1 of each year, each managed care plan shall report to the Office of Medicaid Program Integrity within the agency on its experience in implementing an anti-fraud plan, as provided under subsection (1), and, if applicable, conducting or contracting for investigations of possible fraudulent or abusive acts as provided under this section for the prior state fiscal year. The report must include, at a minimum:
(a) The dollar amount of losses and recoveries attributable to overpayment, abuse, and fraud.
(b) The number of referrals to the Office of Medicaid Program Integrity during the prior year.
(5) If a managed care plan fails to timely submit a final acceptable anti-fraud plan, fails to timely submit its annual report, fails to implement its anti-fraud plan or investigative unit, if applicable, or otherwise refuses to comply with this section, the agency shall impose:
(a) An administrative fine of $2,000 per calendar day for failure to submit an acceptable anti-fraud plan or report until the agency deems the managed care plan or report to be in compliance;
(b) An administrative fine of not more than $10,000 for failure by a managed care plan to implement an anti-fraud plan or investigative unit, as applicable; or
(c) The administrative fines pursuant to paragraphs (a) and (b).
(6) Each managed care plan shall report all suspected or confirmed instances of provider or recipient fraud or abuse within 15 calendar days after detection to the Office of Medicaid Program Integrity within the agency. At a minimum the report must contain the name of the provider or recipient, the Medicaid billing number or tax identification number, and a description of the fraudulent or abusive act. The Office of Medicaid Program Integrity in the agency shall forward the report of suspected overpayment, abuse, or fraud to the appropriate investigative unit, including, but not limited to, the Bureau of Medicaid program integrity, the Medicaid fraud control unit, the Division of Public Assistance Fraud, the Division of Insurance Fraud, or the Department of Law Enforcement.
(a) Failure to timely report shall result in an administrative fine of $1,000 per calendar day after the 15th day of detection.
(b) Failure to timely report may result in additional administrative, civil, or criminal penalties.
(7) The agency may adopt rules to administer this section.
History.—s. 12, ch. 2010-144.
409.91213 Quarterly progress reports and annual reports.—
(1) The agency shall submit to the Governor, the President of the Senate, the Speaker of the House of Representatives, the Minority Leader of the Senate, the Minority Leader of the House of Representatives, and the Office of Program Policy Analysis and Government Accountability the following reports:
(a) The quarterly progress report submitted to the United States Centers for Medicare and Medicaid Services no later than 60 days following the end of each quarter. The intent of this report is to present the agency’s analysis and the status of various operational areas. The quarterly progress report must include, but need not be limited to:
1. Events occurring during the quarter or anticipated to occur in the near future which affect health care delivery, including, but not limited to, the approval of and contracts for new plans, which report must specify the coverage area, phase-in period, populations served, and benefits; the enrollment; grievances; and other operational issues.
2. Action plans for addressing any policy and administrative issues.
3. Agency efforts related to collecting and verifying encounter data and utilization data.
4. Enrollment data disaggregated by plan and by eligibility category, such as Temporary Assistance for Needy Families or Supplemental Security Income; the total number of enrollees; market share; and the percentage change in enrollment by plan. In addition, the agency shall provide a summary of voluntary and mandatory selection rates and disenrollment data.
5. For purposes of monitoring budget neutrality, enrollment data, member-month data, and expenditures in the format for monitoring budget neutrality which is provided by the federal Centers for Medicare and Medicaid Services.
6. Activities and associated expenditures of the low-income pool.
7. Activities related to the implementation of choice counseling, including efforts to improve health literacy and the methods used to obtain public input, such as recipient focus groups.
8. Participation rates in the enhanced benefit accounts program, including participation levels; a summary of activities and associated expenditures; the number of accounts established, including active participants and individuals who continue to retain access to funds in an account but who no longer actively participate; an estimate of quarterly deposits in the accounts; and expenditures from the accounts.
9. Enrollment data concerning employer-sponsored insurance which document the number of individuals selecting to opt out when employer-sponsored insurance is available. The agency shall include data that identify enrollee characteristics, including the eligibility category, type of employer-sponsored insurance, and type of coverage, such as individual or family coverage. The agency shall develop and maintain disenrollment reports specifying the reason for disenrollment in an employer-sponsored insurance program. The agency shall also track and report on those enrollees who elect the option to reenroll in the Medicaid reform demonstration.
10. Progress toward meeting the demonstration goals.
11. Evaluation activities.
(b) An annual report documenting accomplishments, project status, quantitative and case-study findings, utilization data, and policy and administrative difficulties in the operation of the Medicaid waiver demonstration program. The agency shall submit the draft annual report no later than October 1 after the end of each fiscal year.
(2) Beginning with the annual report for demonstration year two, the agency shall include a section concerning the administration of enhanced benefit accounts, the participation rates, an assessment of expenditures, and an assessment of potential cost savings.
(3) Beginning with the annual report for demonstration year four, the agency shall include a section that provides qualitative and quantitative data describing the impact the low-income pool has had on the rate of uninsured people in this state, beginning with the implementation of the demonstration program.
History.—s. 4, ch. 2005-358.
409.9122 Mandatory Medicaid managed care enrollment; programs and procedures.—
(1) It is the intent of the Legislature that the MediPass program be cost-effective, provide quality health care, and improve access to health services, and that the program be statewide. This subsection expires October 1, 2014.
(2)(a) The agency shall enroll in a managed care plan or MediPass all Medicaid recipients, except those Medicaid recipients who are: in an institution; enrolled in the Medicaid medically needy program; or eligible for both Medicaid and Medicare. Upon enrollment, individuals will be able to change their managed care option during the 90-day opt out period required by federal Medicaid regulations. The agency is authorized to seek the necessary Medicaid state plan amendment to implement this policy. However, to the extent permitted by federal law, the agency may enroll in a managed care plan or MediPass a Medicaid recipient who is exempt from mandatory managed care enrollment, provided that:
1. The recipient’s decision to enroll in a managed care plan or MediPass is voluntary;
2. If the recipient chooses to enroll in a managed care plan, the agency has determined that the managed care plan provides specific programs and services which address the special health needs of the recipient; and
3. The agency receives any necessary waivers from the federal Centers for Medicare and Medicaid Services.
School districts participating in the certified school match program pursuant to ss. 409.908(21) and 1011.70 shall be reimbursed by Medicaid, subject to the limitations of s. 1011.70(1), for a Medicaid-eligible child participating in the services as authorized in s. 1011.70, as provided for in s. 409.9071, regardless of whether the child is enrolled in MediPass or a managed care plan. Managed care plans shall make a good faith effort to execute agreements with school districts regarding the coordinated provision of services authorized under s. 1011.70. County health departments delivering school-based services pursuant to ss. 381.0056 and 381.0057 shall be reimbursed by Medicaid for the federal share for a Medicaid-eligible child who receives Medicaid-covered services in a school setting, regardless of whether the child is enrolled in MediPass or a managed care plan. Managed care plans shall make a good faith effort to execute agreements with county health departments regarding the coordinated provision of services to a Medicaid-eligible child. To ensure continuity of care for Medicaid patients, the agency, the Department of Health, and the Department of Education shall develop procedures for ensuring that a student’s managed care plan or MediPass provider receives information relating to services provided in accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
(b) A Medicaid recipient may not be enrolled in or assigned to a managed care plan or MediPass unless the managed care plan or MediPass has complied with the quality-of-care standards specified in paragraphs (4)(a) and (b), respectively.
(c) Medicaid recipients shall have a choice of managed care plans or MediPass. The Agency for Health Care Administration, the Department of Health, the Department of Children and Family Services, and the Department of Elderly Affairs shall cooperate to ensure that each Medicaid recipient receives clear and easily understandable information that meets the following requirements:
1. Explains the concept of managed care, including MediPass.
2. Provides information on the comparative performance of managed care plans and MediPass in the areas of quality, credentialing, preventive health programs, network size and availability, and patient satisfaction.
3. Explains where additional information on each managed care plan and MediPass in the recipient’s area can be obtained.
4. Explains that recipients have the right to choose their managed care coverage at the time they first enroll in Medicaid and again at regular intervals set by the agency. However, if a recipient does not choose a managed care plan or MediPass, the agency will assign the recipient to a managed care plan or MediPass according to the criteria specified in this section.
5. Explains the recipient’s right to complain, file a grievance, or change managed care plans or MediPass providers if the recipient is not satisfied with the managed care plan or MediPass.
(d) The agency shall develop a mechanism for providing information to Medicaid recipients for the purpose of making a managed care plan or MediPass selection. Examples of such mechanisms may include, but not be limited to, interactive information systems, mailings, and mass marketing materials. Managed care plans and MediPass providers are prohibited from providing inducements to Medicaid recipients to select their plans or from prejudicing Medicaid recipients against other managed care plans or MediPass providers.
(e) Medicaid recipients who are already enrolled in a managed care plan or MediPass shall be offered the opportunity to change managed care plans or MediPass providers on a staggered basis, as defined by the agency. All Medicaid recipients shall have 30 days in which to make a choice of managed care plans or MediPass providers. Those Medicaid recipients who do not make a choice shall be assigned in accordance with paragraph (f). To facilitate continuity of care, for a Medicaid recipient who is also a recipient of Supplemental Security Income (SSI), prior to assigning the SSI recipient to a managed care plan or MediPass, the agency shall determine whether the SSI recipient has an ongoing relationship with a MediPass provider or managed care plan, and if so, the agency shall assign the SSI recipient to that MediPass provider or managed care plan. Those SSI recipients who do not have such a provider relationship shall be assigned to a managed care plan or MediPass provider in accordance with paragraph (f).
(f) If a Medicaid recipient does not choose a managed care plan or MediPass provider, the agency shall assign the Medicaid recipient to a managed care plan or MediPass provider. Medicaid recipients eligible for managed care plan enrollment who are subject to mandatory assignment but who fail to make a choice shall be assigned to managed care plans until an enrollment of 35 percent in MediPass and 65 percent in managed care plans, of all those eligible to choose managed care, is achieved. Once this enrollment is achieved, the assignments shall be divided in order to maintain an enrollment in MediPass and managed care plans which is in a 35 percent and 65 percent proportion, respectively. Thereafter, assignment of Medicaid recipients who fail to make a choice shall be based proportionally on the preferences of recipients who have made a choice in the previous period. Such proportions shall be revised at least quarterly to reflect an update of the preferences of Medicaid recipients. The agency shall disproportionately assign Medicaid-eligible recipients who are required to but have failed to make a choice of managed care plan or MediPass to the Children’s Medical Services Network as defined in s. 391.021, exclusive provider organizations, provider service networks, minority physician networks, and pediatric emergency department diversion programs authorized by this chapter or the General Appropriations Act, in such manner as the agency deems appropriate, until the agency has determined that the networks and programs have sufficient numbers to be operated economically. For purposes of this paragraph, when referring to assignment, the term “managed care plans” includes health maintenance organizations, exclusive provider organizations, provider service networks, minority physician networks, Children’s Medical Services Network, and pediatric emergency department diversion programs authorized by this chapter or the General Appropriations Act. When making assignments, the agency shall take into account the following criteria:
1. A managed care plan has sufficient network capacity to meet the need of members.
2. The managed care plan or MediPass has previously enrolled the recipient as a member, or one of the managed care plan’s primary care providers or MediPass providers has previously provided health care to the recipient.
3. The agency has knowledge that the member has previously expressed a preference for a particular managed care plan or MediPass provider as indicated by Medicaid fee-for-service claims data, but has failed to make a choice.
4. The managed care plan’s or MediPass primary care providers are geographically accessible to the recipient’s residence.
(g) When more than one managed care plan or MediPass provider meets the criteria specified in paragraph (f), the agency shall make recipient assignments consecutively by family unit.
(h) The agency may not engage in practices that are designed to favor one managed care plan over another or that are designed to influence Medicaid recipients to enroll in MediPass rather than in a managed care plan or to enroll in a managed care plan rather than in MediPass. This subsection does not prohibit the agency from reporting on the performance of MediPass or any managed care plan, as measured by performance criteria developed by the agency.
(i) After a recipient has made his or her selection or has been enrolled in a managed care plan or MediPass, the recipient shall have 90 days to exercise the opportunity to voluntarily disenroll and select another managed care plan or MediPass. After 90 days, no further changes may be made except for good cause. Good cause includes, but is not limited to, poor quality of care, lack of access to necessary specialty services, an unreasonable delay or denial of service, or fraudulent enrollment. The agency shall develop criteria for good cause disenrollment for chronically ill and disabled populations who are assigned to managed care plans if more appropriate care is available through the MediPass program. The agency must make a determination as to whether cause exists. However, the agency may require a recipient to use the managed care plan’s or MediPass grievance process prior to the agency’s determination of cause, except in cases in which immediate risk of permanent damage to the recipient’s health is alleged. The grievance process, when utilized, must be completed in time to permit the recipient to disenroll by the first day of the second month after the month the disenrollment request was made. If the managed care plan or MediPass, as a result of the grievance process, approves an enrollee’s request to disenroll, the agency is not required to make a determination in the case. The agency must make a determination and take final action on a recipient’s request so that disenrollment occurs no later than the first day of the second month after the month the request was made. If the agency fails to act within the specified timeframe, the recipient’s request to disenroll is deemed to be approved as of the date agency action was required. Recipients who disagree with the agency’s finding that cause does not exist for disenrollment shall be advised of their right to pursue a Medicaid fair hearing to dispute the agency’s finding.
(j) The agency shall apply for a federal waiver from the Centers for Medicare and Medicaid Services to lock eligible Medicaid recipients into a managed care plan or MediPass for 12 months after an open enrollment period. After 12 months’ enrollment, a recipient may select another managed care plan or MediPass provider. However, nothing shall prevent a Medicaid recipient from changing primary care providers within the managed care plan or MediPass program during the 12-month period.
(k) When a Medicaid recipient does not choose a managed care plan or MediPass provider, the agency shall assign the Medicaid recipient to a managed care plan, except in those counties in which there are fewer than two managed care plans accepting Medicaid enrollees, in which case assignment shall be to a managed care plan or a MediPass provider. Medicaid recipients in counties with fewer than two managed care plans accepting Medicaid enrollees who are subject to mandatory assignment but who fail to make a choice shall be assigned to managed care plans until an enrollment of 35 percent in MediPass and 65 percent in managed care plans, of all those eligible to choose managed care, is achieved. Once that enrollment is achieved, the assignments shall be divided in order to maintain an enrollment in MediPass and managed care plans which is in a 35 percent and 65 percent proportion, respectively. For purposes of this paragraph, when referring to assignment, the term “managed care plans” includes exclusive provider organizations, provider service networks, Children’s Medical Services Network, minority physician networks, and pediatric emergency department diversion programs authorized by this chapter or the General Appropriations Act. When making assignments, the agency shall take into account the following criteria:
1. A managed care plan has sufficient network capacity to meet the need of members.
2. The managed care plan or MediPass has previously enrolled the recipient as a member, or one of the managed care plan’s primary care providers or MediPass providers has previously provided health care to the recipient.
3. The agency has knowledge that the member has previously expressed a preference for a particular managed care plan or MediPass provider as indicated by Medicaid fee-for-service claims data, but has failed to make a choice.
4. The managed care plan’s or MediPass primary care providers are geographically accessible to the recipient’s residence.
5. The agency has authority to make mandatory assignments based on quality of service and performance of managed care plans.
(l) Notwithstanding chapter 287, the agency may renew cost-effective contracts for choice counseling services once or more for such periods as the agency may decide. However, all such renewals may not combine to exceed a total period longer than the term of the original contract.
This subsection expires October 1, 2014.
(3) Notwithstanding s. 409.961, if a Medicaid recipient is diagnosed with HIV/AIDS, the agency shall assign the recipient to a managed care plan that is a health maintenance organization authorized under chapter 641, that is under contract with the agency as an HIV/AIDS specialty plan as of January 1, 2013, and that offers a delivery system through a university-based teaching and research-oriented organization that specializes in providing health care services and treatment for individuals diagnosed with HIV/AIDS. This subsection applies to recipients who are subject to mandatory managed care enrollment and have failed to choose a managed care option.
(4)(a) The agency shall establish quality-of-care standards for managed care plans. These standards shall be based upon, but are not limited to:
1. Compliance with the accreditation requirements as provided in s. 641.512.
2. Compliance with Early and Periodic Screening, Diagnosis, and Treatment screening requirements.
3. The percentage of voluntary disenrollments.
4. Immunization rates.
5. Standards of the National Committee for Quality Assurance and other approved accrediting bodies.
6. Recommendations of other authoritative bodies.
7. Specific requirements of the Medicaid program, or standards designed to specifically assist the unique needs of Medicaid recipients.
8. Compliance with the health quality improvement system as established by the agency, which incorporates standards and guidelines developed by the Medicaid Bureau of the Health Care Financing Administration as part of the quality assurance reform initiative.
(b) For the MediPass program, the agency shall establish standards which are based upon, but are not limited to:
1. Quality-of-care standards which are comparable to those required of managed care plans.
2. Credentialing standards for MediPass providers.
3. Compliance with Early and Periodic Screening, Diagnosis, and Treatment screening requirements.
4. Immunization rates.
5. Specific requirements of the Medicaid program, or standards designed to specifically assist the unique needs of Medicaid recipients.
This subsection expires October 1, 2014.
(5)(a) Each female recipient may select as her primary care provider an obstetrician/gynecologist who has agreed to participate as a MediPass primary care case manager.
(b) The agency shall establish a complaints and grievance process to assist Medicaid recipients enrolled in the MediPass program to resolve complaints and grievances. The agency shall investigate reports of quality-of-care grievances which remain unresolved to the satisfaction of the enrollee.
This subsection expires October 1, 2014.
(6)(a) The agency shall work cooperatively with the Social Security Administration to identify beneficiaries who are jointly eligible for Medicare and Medicaid and shall develop cooperative programs to encourage these beneficiaries to enroll in a Medicare participating health maintenance organization or prepaid health plans.
(b) The agency shall work cooperatively with the Department of Elderly Affairs to assess the potential cost-effectiveness of providing MediPass to beneficiaries who are jointly eligible for Medicare and Medicaid on a voluntary choice basis. If the agency determines that enrollment of these beneficiaries in MediPass has the potential for being cost-effective for the state, the agency shall offer MediPass to these beneficiaries on a voluntary choice basis in the counties where MediPass operates.
This subsection expires October 1, 2014.
(7) MediPass enrolled recipients may receive up to 10 visits of reimbursable services by participating Medicaid physicians licensed under chapter 460 and up to four visits of reimbursable services by participating Medicaid physicians licensed under chapter 461. Any further visits must be by prior authorization by the MediPass primary care provider. However, nothing in this subsection may be construed to increase the total number of visits or the total amount of dollars per year per person under current Medicaid rules, unless otherwise provided for in the General Appropriations Act. This subsection expires October 1, 2014.
(8)(a) The agency shall develop and implement a comprehensive plan to ensure that recipients are adequately informed of their choices and rights under all Medicaid managed care programs and that Medicaid managed care programs meet acceptable standards of quality in patient care, patient satisfaction, and financial solvency.
(b) The agency shall provide adequate means for informing patients of their choice and rights under a managed care plan at the time of eligibility determination.
(c) The agency shall require managed care plans and MediPass providers to demonstrate and document plans and activities, as defined by rule, including outreach and followup, undertaken to ensure that Medicaid recipients receive the health care service to which they are entitled.
This subsection expires October 1, 2014.
(9) The agency shall consult with Medicaid consumers and their representatives on an ongoing basis regarding measurements of patient satisfaction, procedures for resolving patient grievances, standards for ensuring quality of care, mechanisms for providing patient access to services, and policies affecting patient care. This subsection expires October 1, 2014.
(10) The agency may extend eligibility for Medicaid recipients enrolled in licensed and accredited health maintenance organizations for the duration of the enrollment period or for 6 months, whichever is earlier, provided the agency certifies that such an offer will not increase state expenditures. This subsection expires October 1, 2013.
(11) A managed care plan that has a Medicaid contract shall at least annually review each primary care physician’s active patient load and shall ensure that additional Medicaid recipients are not assigned to physicians who have a total active patient load of more than 3,000 patients. As used in this subsection, the term “active patient” means a patient who is seen by the same primary care physician, or by a physician assistant or advanced registered nurse practitioner under the supervision of the primary care physician, at least three times within a calendar year. Each primary care physician shall annually certify to the managed care plan whether or not his or her patient load exceeds the limits established under this subsection and the managed care plan shall accept such certification on face value as compliance with this subsection. The agency shall accept the managed care plan’s representations that it is in compliance with this subsection based on the certification of its primary care physicians, unless the agency has an objective indication that access to primary care is being compromised, such as receiving complaints or grievances relating to access to care. If the agency determines that an objective indication exists that access to primary care is being compromised, it may verify the patient load certifications submitted by the managed care plan’s primary care physicians and that the managed care plan is not assigning Medicaid recipients to primary care physicians who have an active patient load of more than 3,000 patients. This subsection expires October 1, 2014.
(12) Effective July 1, 2003, the agency shall adjust the enrollee assignment process of Medicaid managed prepaid health plans for those Medicaid managed prepaid plans operating in Miami-Dade County which have executed a contract with the agency for a minimum of 8 consecutive years in order for the Medicaid managed prepaid plan to maintain a minimum enrollment level of 15,000 members per month. When assigning enrollees pursuant to this subsection, the agency shall give priority to providers that initially qualified under this subsection until such providers reach and maintain an enrollment level of 15,000 members per month. A prepaid health plan that has a statewide Medicaid enrollment of 25,000 or more members is not eligible for enrollee assignments under this subsection. This subsection expires October 1, 2014.
(13) The agency shall include in its calculation of the hospital inpatient component of a Medicaid health maintenance organization’s capitation rate any special payments, including, but not limited to, upper payment limit or disproportionate share hospital payments, made to qualifying hospitals through the fee-for-service program. The agency may seek federal waiver approval or state plan amendment as needed to implement this adjustment.
(14) The agency shall develop a process to enable any recipient with access to employer-sponsored health care coverage to opt out of all eligible plans in the Medicaid program and to use Medicaid financial assistance to pay for the recipient’s share of cost in any such employer-sponsored coverage. Contingent on federal approval, the agency shall also enable recipients with access to other insurance or related products that provide access to health care services created pursuant to state law, including any plan or product available pursuant to the Florida Health Choices Program or any health exchange, to opt out. The amount of financial assistance provided for each recipient may not exceed the amount of the Medicaid premium that would have been paid to a plan for that recipient.
(15) The agency shall maintain and operate the Medicaid Encounter Data System to collect, process, store, and report on covered services provided to all Florida Medicaid recipients enrolled in prepaid managed care plans.
(a) Prepaid managed care plans shall submit encounter data electronically in a format that complies with the Health Insurance Portability and Accountability Act provisions for electronic claims and in accordance with deadlines established by the agency. Prepaid managed care plans must certify that the data reported is accurate and complete.
(b) The agency is responsible for validating the data submitted by the plans. The agency shall develop methods and protocols for ongoing analysis of the encounter data that adjusts for differences in characteristics of prepaid plan enrollees to allow comparison of service utilization among plans and against expected levels of use. The analysis shall be used to identify possible cases of systemic underutilization or denials of claims and inappropriate service utilization such as higher-than-expected emergency department encounters. The analysis shall provide periodic feedback to the plans and enable the agency to establish corrective action plans when necessary. One of the focus areas for the analysis shall be the use of prescription drugs.
(16) The agency may establish a per-member, per-month payment for Medicare Advantage Special Needs members that are also eligible for Medicaid as a mechanism for meeting the state’s cost-sharing obligation. The agency may also develop a per-member, per-month payment only for Medicaid-covered services for which the state is responsible. The agency shall develop a mechanism to ensure that such per-member, per-month payment enhances the value to the state and enrolled members by limiting cost sharing, enhances the scope of Medicare supplemental benefits that are equal to or greater than Medicaid coverage for select services, and improves care coordination.
(17) The agency shall establish, and managed care plans shall use, a uniform method of accounting for and reporting medical and nonmedical costs.
(a) Managed care plans shall submit financial data electronically in a format that complies with the uniform accounting procedures established by the agency. Managed care plans must certify that the data reported is accurate and complete.
(b) The agency is responsible for validating the financial data submitted by the plans. The agency shall develop methods and protocols for ongoing analysis of data that adjusts for differences in characteristics of plan enrollees to allow comparison among plans and against expected levels of expenditures. The analysis shall be used to identify possible cases of overspending on administrative costs or underspending on medical services.
(18) The agency shall establish and maintain an information system to make encounter data, financial data, and other measures of plan performance available to the public and any interested party.
(a) Information submitted by the managed care plans shall be available online as well as in other formats.
(b) Periodic agency reports shall be published that include summary as well as plan specific measures of financial performance and service utilization.
(c) Any release of the financial and encounter data submitted by managed care plans shall ensure the confidentiality of personal health information.
(19) The agency may, on a case-by-case basis, exempt a recipient from mandatory enrollment in a managed care plan when the recipient has a unique, time-limited disease or condition-related circumstance and managed care enrollment will interfere with ongoing care because the recipient’s provider does not participate in the managed care plans available in the recipient’s area.
(20) The agency shall contract with a single provider service network to function as a managing entity for the MediPass program in all counties with fewer than two prepaid plans. The contractor shall be responsible for implementing preauthorization procedures, case management programs, and utilization management initiatives in order to improve care coordination and patient outcomes while reducing costs. The contractor may earn an administrative fee if the fee is less than any savings as determined by the reconciliation process under s. 409.912(4)(d)1. This subsection expires October 1, 2014, or upon full implementation of the managed medical assistance program, whichever is sooner.
(21) Subject to federal approval, the agency shall contract with a single provider service network to function as a third-party administrator and managing entity for the Medically Needy program in all counties. The contractor shall provide care coordination and utilization management in order to achieve more cost-effective services for Medically Needy enrollees. To facilitate the care management functions of the provider service network, enrollment in the network shall be for a continuous 6-month period or until the end of the contract between the provider service network and the agency, whichever is sooner. Beginning the second month after the determination of eligibility, the contractor may collect a monthly premium from each Medically Needy recipient provided the premium does not exceed the enrollee’s share of cost as determined by the Department of Children and Family Services. The contractor must provide a 90-day grace period before disenrolling a Medically Needy recipient for failure to pay premiums. The contractor may earn an administrative fee, if the fee is less than any savings determined by the reconciliation process pursuant to s. 409.912(4)(d)1. Premium revenue collected from the recipients shall be deducted from the contractor’s earned savings. This subsection expires October 1, 2014, or upon full implementation of the managed medical assistance program, whichever is sooner.
(22) If required as a condition of a waiver, the agency may calculate a medical loss ratio for managed care plans. The calculation shall utilize uniform financial data collected from all plans and shall be computed for each plan on a statewide basis. The method for calculating the medical loss ratio shall meet the following criteria:
(a) Except as provided in paragraphs (b) and (c), expenditures shall be classified in a manner consistent with 45 C.F.R. part 158.
(b) Funds provided by plans to graduate medical education institutions to underwrite the costs of residency positions shall be classified as medical expenditures, provided the funding is sufficient to sustain the positions for the number of years necessary to complete the residency requirements and the residency positions funded by the plans are active providers of care to Medicaid and uninsured patients.
(c) Prior to final determination of the medical loss ratio for any period, a plan may contribute to a designated state trust fund for the purpose of supporting Medicaid and indigent care and have the contribution counted as a medical expenditure for the period.
History.—s. 51, ch. 93-129; s. 1, ch. 95-281; s. 7, ch. 96-199; s. 203, ch. 97-101; s. 4, ch. 97-168; s. 190, ch. 97-264; s. 3, ch. 97-290; s. 31, ch. 98-191; s. 29, ch. 2000-171; s. 53, ch. 2001-62; s. 10, ch. 2001-104; ss. 10, 11, ch. 2001-377; s. 997, ch. 2002-387; ss. 28, 29, ch. 2002-400; s. 19, ch. 2003-405; s. 56, ch. 2004-5; s. 18, ch. 2004-270; s. 23, ch. 2004-344; s. 17, ch. 2005-60; s. 6, ch. 2005-133; s. 19, ch. 2006-28; ss. 5, 6, ch. 2007-331; s. 12, ch. 2008-143; s. 16, ch. 2009-55; s. 13, ch. 2011-61; s. 21, ch. 2011-135; s. 49, ch. 2012-5; s. 11, ch. 2012-33; s. 3, ch. 2012-44; s. 9, ch. 2013-48.
409.9123 Quality-of-care reporting.—In order to promote competition between Medicaid managed care plans and MediPass based on quality-of-care indicators, the agency shall annually develop and publish a set of measures of managed care plan performance. This information shall be made available to each Medicaid recipient who makes a choice of a managed care plan in her or his area. This information shall be easily understandable to the Medicaid recipient and shall use nationally recognized standards wherever possible. In formulating this information, the agency shall take into account at least the following:
(1) The recommendations of the National Committee for Quality Assurance Medicaid HEDIS Task Force.
(2) Requirements and recommendations of the Health Care Financing Administration.
(3) Recommendations of the managed care industry.
History.—s. 8, ch. 96-199; s. 1024, ch. 97-103.
409.9124 Managed care reimbursement.—The agency shall develop and adopt by rule a methodology for reimbursing managed care plans.
(1) Final managed care rates shall be published annually prior to September 1 of each year, based on methodology that:
(a) Uses Medicaid’s fee-for-service expenditures.
(b) Is certified as an actuarially sound computation of Medicaid fee-for-service expenditures for comparable groups of Medicaid recipients and includes all fee-for-service expenditures, including those fee-for-service expenditures attributable to recipients who are enrolled for a portion of a year in a managed care plan or waiver program.
(c) Is compliant with applicable federal laws and regulations, including, but not limited to, the requirements to include an allowance for administrative expenses and to account for all fee-for-service expenditures, including fee-for-service expenditures for those groups enrolled for part of a year.
(2) Each year prior to establishing new managed care rates, the agency shall review all prior year adjustments for changes in trend, and shall reduce or eliminate those adjustments which are not reasonable and which reflect policies or programs which are not in effect. In addition, the agency shall apply only those policy reductions applicable to the fiscal year for which the rates are being set, which can be accurately estimated and verified by an independent actuary, and which have been implemented prior to or will be implemented during the fiscal year.
(3) The agency shall by rule prescribe those items of financial information which each managed care plan shall report to the agency, in the time periods prescribed by rule. In prescribing items for reporting and definitions of terms, the agency shall consult with the Office of Insurance Regulation of the Financial Services Commission wherever possible.
(4) The agency shall quarterly examine the financial condition of each managed care plan, and its performance in serving Medicaid patients, and shall utilize examinations performed by the Office of Insurance Regulation wherever possible.
(5) The agency shall develop two rates for children under 1 year of age. One set of rates shall cover the month of birth through the second complete month subsequent to the month of birth, and a separate set of rates shall cover the third complete month subsequent to the month of birth through the eleventh complete month subsequent to the month of birth. The agency shall amend the payment methodology for participating Medicaid-managed health care plans to comply with this subsection.
(6) For the 2005-2006 fiscal year only, the agency shall make an additional adjustment in calculating the capitation payments to prepaid health plans, excluding prepaid mental health plans. This adjustment must result in an increase of 2.8 percent in the average per-member, per-month rate paid to prepaid health plans, excluding prepaid mental health plans, which are funded from Specific Appropriations 225 and 226 in the 2005-2006 General Appropriations Act.
History.—s. 9, ch. 96-199; s. 451, ch. 2003-261; s. 19, ch. 2004-270; s. 18, ch. 2005-60; s. 20, ch. 2005-133; s. 13, ch. 2008-143.
409.91255 Federally qualified health center access program.—
(1) SHORT TITLE.—This section may be cited as the “Community Health Center Access Program Act.”
(2) LEGISLATIVE FINDINGS AND INTENT.—
(a) The Legislature finds that, despite significant investments in health care programs, more than 2 million low-income Floridians, primarily the working poor and minority populations, continue to lack access to basic health care services. Further, the Legislature recognizes that federally qualified health centers have a proven record of providing cost-effective, comprehensive primary and preventive health care and are uniquely qualified to address the lack of adequate health care services for the uninsured.
(b) It is the intent of the Legislature to recognize the significance of increased federal investments in federally qualified health centers and to leverage that investment through the creation of a program to provide for the expansion of the primary and preventive health care services offered by federally qualified health centers. Further, such a program will support the coordination of federal, state, and local resources to assist such health centers in developing an expanded community-based primary care delivery system.
(3) ASSISTANCE TO FEDERALLY QUALIFIED HEALTH CENTERS.—The Department of Health shall develop a program for the expansion of federally qualified health centers for the purpose of providing comprehensive primary and preventive health care and urgent care services that may reduce the morbidity, mortality, and cost of care among the uninsured population of the state. The program shall provide for distribution of financial assistance to federally qualified health centers that apply and demonstrate a need for such assistance in order to sustain or expand the delivery of primary and preventive health care services. In selecting centers to receive this financial assistance, the program:
(a) Shall give preference to communities that have few or no community-based primary care services or in which the current services are unable to meet the community’s needs.
(b) Shall require that primary care services be provided to the medically indigent using a sliding fee schedule based on income.
(c) Shall allow innovative and creative uses of federal, state, and local health care resources.
(d) Shall require that the funds provided be used to pay for operating costs of a projected expansion in patient caseloads or services or for capital improvement projects. Capital improvement projects may include renovations to existing facilities or construction of new facilities, provided that an expansion in patient caseloads or services to a new patient population will occur as a result of the capital expenditures. The department shall include in its standard contract document a requirement that any state funds provided for the purchase of or improvements to real property are contingent upon the contractor granting to the state a security interest in the property at least to the amount of the state funds provided for at least 5 years from the date of purchase or the completion of the improvements or as further required by law. The contract must include a provision that, as a condition of receipt of state funding for this purpose, the contractor agrees that, if it disposes of the property before the department’s interest is vacated, the contractor will refund the proportionate share of the state’s initial investment, as adjusted by depreciation.
(e) May require in-kind support from other sources.
(f) May encourage coordination among federally qualified health centers, other private sector providers, and publicly supported programs.
(g) Shall allow the development of community emergency room diversion programs in conjunction with local resources, providing extended hours of operation to urgent care patients. Diversion programs shall include case management for emergency room followup care.
(4) EVALUATION OF APPLICATIONS.—A review panel shall be established, consisting of four persons appointed by the State Surgeon General and three persons appointed by the chief executive officer of the Florida Association of Community Health Centers, Inc., to review all applications for financial assistance under the program. Applicants shall specify in the application whether the program funds will be used for the expansion of patient caseloads or services or for capital improvement projects to expand and improve patient facilities. The panel shall use the following elements in reviewing application proposals and shall determine the relative weight for scoring and evaluating these elements:
(a) The target population to be served.
(b) The health benefits to be provided.
(c) The methods that will be used to measure cost-effectiveness.
(d) How patient satisfaction will be measured.
(e) The proposed internal quality assurance process.
(f) Projected health status outcomes.
(g) How data will be collected to measure cost-effectiveness, health status outcomes, and overall achievement of the goals of the proposal.
(h) All resources, including cash, in-kind, voluntary, or other resources that will be dedicated to the proposal.
(5) ADMINISTRATION AND TECHNICAL ASSISTANCE.—The Department of Health may contract with the Florida Association of Community Health Centers, Inc., to administer the program and provide technical assistance to the federally qualified health centers selected to receive financial assistance.
History.—s. 1, ch. 2002-289; s. 19, ch. 2004-297; s. 58, ch. 2008-6.
409.9126 Children with special health care needs.—
(1) Except as provided in subsection (4), children eligible for Children’s Medical Services who receive Medicaid benefits, and other Medicaid-eligible children with special health care needs, shall be exempt from the provisions of s. 409.9122 and shall be served through the Children’s Medical Services network established in chapter 391.
(2) The Legislature directs the agency to apply to the federal Health Care Financing Administration for a waiver to assign to the Children’s Medical Services network all Medicaid-eligible children who meet the criteria for participation in the Children’s Medical Services program and other Medicaid-eligible children with special health care needs.
(3) Services provided through the Children’s Medical Services network shall be reimbursed on a fee-for-service basis and shall utilize a primary care case management process. Beginning July 1, 1999, the Florida Medicaid program shall phase in by geographical area, capitation payments to Children’s Medical Services for services provided to Medicaid children with special health care needs. By January 1, 2001, the Agency for Health Care Administration shall make capitation payments for Children’s Medical Services enrollees statewide, to the extent provided by federal law.
(4) The agency may approve requests to provide services to Medicaid-eligible children with special health care needs from managed care plans that meet access, quality-of-care, network, and service integration standards and are in good standing with the agency. The agency shall monitor on a quarterly basis managed care plans which have been approved to provide services to Medicaid-eligible children with special health care needs. The agency may determine the number of enrollment slots approved for a managed care plan based on the managed care plan’s network capacity to serve children with special health care needs.
(5) The agency, in consultation with the Department of Health, shall adopt rules that address Medicaid requirements for referral, enrollment, and disenrollment of children with special health care needs who are enrolled in Medicaid managed care plans and who may benefit from the Children’s Medical Services network.
History.—s. 11, ch. 96-199; s. 5, ch. 97-168; s. 53, ch. 98-288; s. 151, ch. 98-403; s. 35, ch. 99-397.
409.9127 Preauthorization and concurrent utilization review; conflict-of-interest standards.—
(1) The Agency for Health Care Administration shall be solely responsible for developing and enforcing standards to prohibit financial and other conflicts of interest among vendors selected to provide preauthorization and concurrent utilization review management with direct-service organizations providing substance abuse, mental health, or related services to clients or services to disabled persons who have services authorized through the preauthorization and concurrent utilization review management system established to achieve cost savings in the provision of substance abuse, mental health, or related services or services to disabled persons. The agency may require the posting of a surety bond to guarantee that no financial or other conflicts of interest exist or will exist among vendors selected to provide preauthorization and concurrent utilization review management services.
(2) Vendors selected to conduct preauthorization or concurrent utilization review management, or both, may be peer-review organizations, qualified licensed clinical practitioners, or public or private organizations that demonstrate the ability to conduct such reviews according to criteria developed by the agency and that have no financial or other conflict of interest with any direct-service organization providing substance abuse, mental health, or related services or services to disabled persons. Selection of vendors shall be accomplished through a competitive process.
(3) The agency shall help the Agency for Persons with Disabilities meet the requirements of s. 393.065(4). Only admissions approved pursuant to such assessments are eligible for reimbursement under this chapter.
History.—s. 5, ch. 97-260; s. 8, ch. 99-144; s. 54, ch. 2006-227.
409.9128 Requirements for providing emergency services and care.—
(1) In providing for emergency services and care as a covered service, neither a managed care plan nor the MediPass program may:
(a) Require prior authorization for the receipt of prehospital transport or treatment or for emergency services and care.
(b) Indicate that emergencies are covered only if care is secured within a certain period of time.
(c) Use terms such as “life threatening” or “bona fide” to qualify the kind of emergency that is covered.
(d) Deny payment based on the enrollee’s or the hospital’s failure to notify the managed care plan or MediPass primary care provider in advance or within a certain period of time after the care is given.
(2) Prehospital and hospital-based trauma services and emergency services and care must be provided to an enrollee of a managed care plan or the MediPass program as required under ss. 395.1041, 395.4045, and 401.45.
(3)(a) When an enrollee is present at a hospital seeking emergency services and care, the determination as to whether an emergency medical condition, as defined in s. 409.901, exists shall be made, for the purposes of treatment, by a physician of the hospital or, to the extent permitted by applicable law, by other appropriate licensed professional hospital personnel under the supervision of the hospital physician. The physician or the appropriate personnel shall indicate in the patient’s chart the results of the screening, examination, and evaluation. The managed care plan or the Medicaid program on behalf of MediPass patients shall compensate the provider for the screening, evaluation, and examination that is reasonably calculated to assist the health care provider in arriving at a determination as to whether the patient’s condition is an emergency medical condition. The managed care plan or the Medicaid program on behalf of MediPass patients shall compensate the provider for emergency services and care. If a determination is made that an emergency medical condition does not exist, payment for services rendered subsequent to that determination is governed by the managed care plan’s contract with the agency.
(b) If a determination has been made that an emergency medical condition exists and the enrollee has notified the hospital, or the hospital emergency personnel otherwise has knowledge that the patient is an enrollee of the managed care plan or the MediPass program, the hospital must make a reasonable attempt to notify the enrollee’s primary care physician, if known, or the managed care plan, if the managed care plan had previously requested in writing that the notification be made directly to the managed care plan, of the existence of the emergency medical condition. If the primary care physician is not known, or has not been contacted, the hospital must:
1. Notify the managed care plan or the MediPass provider as soon as possible prior to discharge of the enrollee from the emergency care area; or
2. Notify the managed care plan or the MediPass provider within 24 hours or on the next business day after admission of the enrollee as an inpatient to the hospital.
If notification required by this paragraph is not accomplished, the hospital must document its attempts to notify the managed care plan or the MediPass provider or the circumstances that precluded attempts to notify the managed care plan or the MediPass provider. Neither a managed care plan nor the Medicaid program on behalf of MediPass patients may deny payment for emergency services and care based on a hospital’s failure to comply with the notification requirements of this paragraph.
(c) If the enrollee’s primary care physician responds to the notification, the hospital physician and the primary care physician may discuss the appropriate care and treatment of the enrollee. The managed care plan may have a member of the hospital staff with whom it has a contract participate in the treatment of the enrollee within the scope of the physician’s hospital staff privileges. The enrollee may be transferred, in accordance with state and federal law, to a hospital that has a contract with the managed care plan and has the service capability to treat the enrollee’s emergency medical condition. Notwithstanding any other state law, a hospital may request and collect insurance or financial information from a patient in accordance with federal law, which is necessary to determine if the patient is an enrollee of a managed care plan or the MediPass program, if emergency services and care are not delayed.
(4) Nothing in this section is intended to prohibit or limit application of a nominal copayment as provided in s. 409.9081 for the use of an emergency room for services other than emergency services and care.
(5) Reimbursement for services provided to an enrollee of a managed care plan under this section by a provider who does not have a contract with the managed care plan shall be the lesser of:
(a) The provider’s charges;
(b) The usual and customary provider charges for similar services in the community where the services were provided;
(c) The charge mutually agreed to by the entity and the provider within 60 days after submittal of the claim; or
(d) The Medicaid rate.
History.—s. 12, ch. 96-199.
409.913 Oversight of the integrity of the Medicaid program.—The agency shall operate a program to oversee the activities of Florida Medicaid recipients, and providers and their representatives, to ensure that fraudulent and abusive behavior and neglect of recipients occur to the minimum extent possible, and to recover overpayments and impose sanctions as appropriate. Beginning January 1, 2003, and each year thereafter, the agency and the Medicaid Fraud Control Unit of the Department of Legal Affairs shall submit a joint report to the Legislature documenting the effectiveness of the state’s efforts to control Medicaid fraud and abuse and to recover Medicaid overpayments during the previous fiscal year. The report must describe the number of cases opened and investigated each year; the sources of the cases opened; the disposition of the cases closed each year; the amount of overpayments alleged in preliminary and final audit letters; the number and amount of fines or penalties imposed; any reductions in overpayment amounts negotiated in settlement agreements or by other means; the amount of final agency determinations of overpayments; the amount deducted from federal claiming as a result of overpayments; the amount of overpayments recovered each year; the amount of cost of investigation recovered each year; the average length of time to collect from the time the case was opened until the overpayment is paid in full; the amount determined as uncollectible and the portion of the uncollectible amount subsequently reclaimed from the Federal Government; the number of providers, by type, that are terminated from participation in the Medicaid program as a result of fraud and abuse; and all costs associated with discovering and prosecuting cases of Medicaid overpayments and making recoveries in such cases. The report must also document actions taken to prevent overpayments and the number of providers prevented from enrolling in or reenrolling in the Medicaid program as a result of documented Medicaid fraud and abuse and must include policy recommendations necessary to prevent or recover overpayments and changes necessary to prevent and detect Medicaid fraud. All policy recommendations in the report must include a detailed fiscal analysis, including, but not limited to, implementation costs, estimated savings to the Medicaid program, and the return on investment. The agency must submit the policy recommendations and fiscal analyses in the report to the appropriate estimating conference, pursuant to s. 216.137, by February 15 of each year. The agency and the Medicaid Fraud Control Unit of the Department of Legal Affairs each must include detailed unit-specific performance standards, benchmarks, and metrics in the report, including projected cost savings to the state Medicaid program during the following fiscal year.
(1) For the purposes of this section, the term:
(a) “Abuse” means:
1. Provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care.
2. Recipient practices that result in unnecessary cost to the Medicaid program.
(b) “Complaint” means an allegation that fraud, abuse, or an overpayment has occurred.
(c) “Fraud” means an intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to herself or himself or another person. The term includes any act that constitutes fraud under applicable federal or state law.
(d) “Medical necessity” or “medically necessary” means any goods or services necessary to palliate the effects of a terminal condition, or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity, which goods or services are provided in accordance with generally accepted standards of medical practice. For purposes of determining Medicaid reimbursement, the agency is the final arbiter of medical necessity. Determinations of medical necessity must be made by a licensed physician employed by or under contract with the agency and must be based upon information available at the time the goods or services are provided.
(e) “Overpayment” includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.
(f) “Person” means any natural person, corporation, partnership, association, clinic, group, or other entity, whether or not such person is enrolled in the Medicaid program or is a provider of health care.
(2) The agency shall conduct, or cause to be conducted by contract or otherwise, reviews, investigations, analyses, audits, or any combination thereof, to determine possible fraud, abuse, overpayment, or recipient neglect in the Medicaid program and shall report the findings of any overpayments in audit reports as appropriate. At least 5 percent of all audits shall be conducted on a random basis. As part of its ongoing fraud detection activities, the agency shall identify and monitor, by contract or otherwise, patterns of overutilization of Medicaid services based on state averages. The agency shall track Medicaid provider prescription and billing patterns and evaluate them against Medicaid medical necessity criteria and coverage and limitation guidelines adopted by rule. Medical necessity determination requires that service be consistent with symptoms or confirmed diagnosis of illness or injury under treatment and not in excess of the patient’s needs. The agency shall conduct reviews of provider exceptions to peer group norms and shall, using statistical methodologies, provider profiling, and analysis of billing patterns, detect and investigate abnormal or unusual increases in billing or payment of claims for Medicaid services and medically unnecessary provision of services.
(3) The agency may conduct, or may contract for, prepayment review of provider claims to ensure cost-effective purchasing; to ensure that billing by a provider to the agency is in accordance with applicable provisions of all Medicaid rules, regulations, handbooks, and policies and in accordance with federal, state, and local law; and to ensure that appropriate care is rendered to Medicaid recipients. Such prepayment reviews may be conducted as determined appropriate by the agency, without any suspicion or allegation of fraud, abuse, or neglect, and may last for up to 1 year. Unless the agency has reliable evidence of fraud, misrepresentation, abuse, or neglect, claims shall be adjudicated for denial or payment within 90 days after receipt of complete documentation by the agency for review. If there is reliable evidence of fraud, misrepresentation, abuse, or neglect, claims shall be adjudicated for denial of payment within 180 days after receipt of complete documentation by the agency for review.
(4) Any suspected criminal violation identified by the agency must be referred to the Medicaid Fraud Control Unit of the Office of the Attorney General for investigation. The agency and the Attorney General shall enter into a memorandum of understanding, which must include, but need not be limited to, a protocol for regularly sharing information and coordinating casework. The protocol must establish a procedure for the referral by the agency of cases involving suspected Medicaid fraud to the Medicaid Fraud Control Unit for investigation, and the return to the agency of those cases where investigation determines that administrative action by the agency is appropriate. Offices of the Medicaid program integrity program and the Medicaid Fraud Control Unit of the Department of Legal Affairs, shall, to the extent possible, be collocated. The agency and the Department of Legal Affairs shall periodically conduct joint training and other joint activities designed to increase communication and coordination in recovering overpayments.
(5) A Medicaid provider is subject to having goods and services that are paid for by the Medicaid program reviewed by an appropriate peer-review organization designated by the agency. The written findings of the applicable peer-review organization are admissible in any court or administrative proceeding as evidence of medical necessity or the lack thereof.
(6) Any notice required to be given to a provider under this section is presumed to be sufficient notice if sent to the address last shown on the provider enrollment file. It is the responsibility of the provider to furnish and keep the agency informed of the provider’s current address. United States Postal Service proof of mailing or certified or registered mailing of such notice to the provider at the address shown on the provider enrollment file constitutes sufficient proof of notice. Any notice required to be given to the agency by this section must be sent to the agency at an address designated by rule.
(7) When presenting a claim for payment under the Medicaid program, a provider has an affirmative duty to supervise the provision of, and be responsible for, goods and services claimed to have been provided, to supervise and be responsible for preparation and submission of the claim, and to present a claim that is true and accurate and that is for goods and services that:
(a) Have actually been furnished to the recipient by the provider prior to submitting the claim.
(b) Are Medicaid-covered goods or services that are medically necessary.
(c) Are of a quality comparable to those furnished to the general public by the provider’s peers.
(d) Have not been billed in whole or in part to a recipient or a recipient’s responsible party, except for such copayments, coinsurance, or deductibles as are authorized by the agency.
(e) Are provided in accord with applicable provisions of all Medicaid rules, regulations, handbooks, and policies and in accordance with federal, state, and local law.
(f) Are documented by records made at the time the goods or services were provided, demonstrating the medical necessity for the goods or services rendered. Medicaid goods or services are excessive or not medically necessary unless both the medical basis and the specific need for them are fully and properly documented in the recipient’s medical record.
The agency shall deny payment or require repayment for goods or services that are not presented as required in this subsection.
(8) The agency shall not reimburse any person or entity for any prescription for medications, medical supplies, or medical services if the prescription was written by a physician or other prescribing practitioner who is not enrolled in the Medicaid program. This section does not apply:
(a) In instances involving bona fide emergency medical conditions as determined by the agency;
(b) To a provider of medical services to a patient in a hospital emergency department, hospital inpatient or outpatient setting, or nursing home;
(c) To bona fide pro bono services by preapproved non-Medicaid providers as determined by the agency;
(d) To prescribing physicians who are board-certified specialists treating Medicaid recipients referred for treatment by a treating physician who is enrolled in the Medicaid program;
(e) To prescriptions written for dually eligible Medicare beneficiaries by an authorized Medicare provider who is not enrolled in the Medicaid program;
(f) To other physicians who are not enrolled in the Medicaid program but who provide a medically necessary service or prescription not otherwise reasonably available from a Medicaid-enrolled physician; or
(9) A Medicaid provider shall retain medical, professional, financial, and business records pertaining to services and goods furnished to a Medicaid recipient and billed to Medicaid for a period of 5 years after the date of furnishing such services or goods. The agency may investigate, review, or analyze such records, which must be made available during normal business hours. However, 24-hour notice must be provided if patient treatment would be disrupted. The provider must keep the agency informed of the location of the provider’s Medicaid-related records. The authority of the agency to obtain Medicaid-related records from a provider is neither curtailed nor limited during a period of litigation between the agency and the provider.
(10) Payments for the services of billing agents or persons participating in the preparation of a Medicaid claim shall not be based on amounts for which they bill nor based on the amount a provider receives from the Medicaid program.
(11) The agency shall deny payment or require repayment for inappropriate, medically unnecessary, or excessive goods or services from the person furnishing them, the person under whose supervision they were furnished, or the person causing them to be furnished.
(12) The complaint and all information obtained pursuant to an investigation of a Medicaid provider, or the authorized representative or agent of a provider, relating to an allegation of fraud, abuse, or neglect are confidential and exempt from the provisions of s. 119.07(1):
(a) Until the agency takes final agency action with respect to the provider and requires repayment of any overpayment, or imposes an administrative sanction;
(b) Until the Attorney General refers the case for criminal prosecution;
(c) Until 10 days after the complaint is determined without merit; or
(d) At all times if the complaint or information is otherwise protected by law.
(13) The agency shall terminate participation of a Medicaid provider in the Medicaid program and may seek civil remedies or impose other administrative sanctions against a Medicaid provider, if the provider or any principal, officer, director, agent, managing employee, or affiliated person of the provider, or any partner or shareholder having an ownership interest in the provider equal to 5 percent or greater, has been convicted of a criminal offense under federal law or the law of any state relating to the practice of the provider’s profession, or a criminal offense listed under s. 408.809(4), s. 409.907(10), or s. 435.04(2). If the agency determines that the provider did not participate or acquiesce in the offense, termination will not be imposed. If the agency effects a termination under this subsection, the agency shall take final agency action.
(14) If the provider has been suspended or terminated from participation in the Medicaid program or the Medicare program by the Federal Government or any state, the agency must immediately suspend or terminate, as appropriate, the provider’s participation in this state’s Medicaid program for a period no less than that imposed by the Federal Government or any other state, and may not enroll such provider in this state’s Medicaid program while such foreign suspension or termination remains in effect. The agency shall also immediately suspend or terminate, as appropriate, a provider’s participation in this state’s Medicaid program if the provider participated or acquiesced in any action for which any principal, officer, director, agent, managing employee, or affiliated person of the provider, or any partner or shareholder having an ownership interest in the provider equal to 5 percent or greater, was suspended or terminated from participating in the Medicaid program or the Medicare program by the Federal Government or any state. This sanction is in addition to all other remedies provided by law.
(15) The agency shall seek a remedy provided by law, including, but not limited to, any remedy provided in subsections (13) and (16) and s. 812.035, if:
(a) The provider’s license has not been renewed, or has been revoked, suspended, or terminated, for cause, by the licensing agency of any state;
(b) The provider has failed to make available or has refused access to Medicaid-related records to an auditor, investigator, or other authorized employee or agent of the agency, the Attorney General, a state attorney, or the Federal Government;
(c) The provider has not furnished or has failed to make available such Medicaid-related records as the agency has found necessary to determine whether Medicaid payments are or were due and the amounts thereof;
(d) The provider has failed to maintain medical records made at the time of service, or prior to service if prior authorization is required, demonstrating the necessity and appropriateness of the goods or services rendered;
(e) The provider is not in compliance with provisions of Medicaid provider publications that have been adopted by reference as rules in the Florida Administrative Code; with provisions of state or federal laws, rules, or regulations; with provisions of the provider agreement between the agency and the provider; or with certifications found on claim forms or on transmittal forms for electronically submitted claims that are submitted by the provider or authorized representative, as such provisions apply to the Medicaid program;
(f) The provider or person who ordered, authorized, or prescribed the care, services, or supplies has furnished, or ordered or authorized the furnishing of, goods or services to a recipient which are inappropriate, unnecessary, excessive, or harmful to the recipient or are of inferior quality;
(g) The provider has demonstrated a pattern of failure to provide goods or services that are medically necessary;
(h) The provider or an authorized representative of the provider, or a person who ordered, authorized, or prescribed the goods or services, has submitted or caused to be submitted false or a pattern of erroneous Medicaid claims;
(i) The provider or an authorized representative of the provider, or a person who has ordered, authorized, or prescribed the goods or services, has submitted or caused to be submitted a Medicaid provider enrollment application, a request for prior authorization for Medicaid services, a drug exception request, or a Medicaid cost report that contains materially false or incorrect information;
(j) The provider or an authorized representative of the provider has collected from or billed a recipient or a recipient’s responsible party improperly for amounts that should not have been so collected or billed by reason of the provider’s billing the Medicaid program for the same service;
(k) The provider or an authorized representative of the provider has included in a cost report costs that are not allowable under a Florida Title XIX reimbursement plan after the provider or authorized representative had been advised in an audit exit conference or audit report that the costs were not allowable;
(l) The provider is charged by information or indictment with fraudulent billing practices or an offense referenced in subsection (13). The sanction applied for this reason is limited to suspension of the provider’s participation in the Medicaid program for the duration of the indictment unless the provider is found guilty pursuant to the information or indictment;
(m) The provider or a person who ordered, authorized, or prescribed the goods or services is found liable for negligent practice resulting in death or injury to the provider’s patient;
(n) The provider fails to demonstrate that it had available during a specific audit or review period sufficient quantities of goods, or sufficient time in the case of services, to support the provider’s billings to the Medicaid program;
(o) The provider has failed to comply with the notice and reporting requirements of s. 409.907;
(p) The agency has received reliable information of patient abuse or neglect or of any act prohibited by s. 409.920; or
(q) The provider has failed to comply with an agreed-upon repayment schedule.
A provider is subject to sanctions for violations of this subsection as the result of actions or inactions of the provider, or actions or inactions of any principal, officer, director, agent, managing employee, or affiliated person of the provider, or any partner or shareholder having an ownership interest in the provider equal to 5 percent or greater, in which the provider participated or acquiesced.
(16) The agency shall impose any of the following sanctions or disincentives on a provider or a person for any of the acts described in subsection (15):
(a) Suspension for a specific period of time of not more than 1 year. Suspension precludes participation in the Medicaid program, which includes any action that results in a claim for payment to the Medicaid program for furnishing, supervising a person who is furnishing, or causing a person to furnish goods or services.
(b) Termination for a specific period of time ranging from more than 1 year to 20 years. Termination precludes participation in the Medicaid program, which includes any action that results in a claim for payment to the Medicaid program for furnishing, supervising a person who is furnishing, or causing a person to furnish goods or services.
(c) Imposition of a fine of up to $5,000 for each violation. Each day that an ongoing violation continues, such as refusing to furnish Medicaid-related records or refusing access to records, is considered a separate violation. Each instance of improper billing of a Medicaid recipient; each instance of including an unallowable cost on a hospital or nursing home Medicaid cost report after the provider or authorized representative has been advised in an audit exit conference or previous audit report of the cost unallowability; each instance of furnishing a Medicaid recipient goods or professional services that are inappropriate or of inferior quality as determined by competent peer judgment; each instance of knowingly submitting a materially false or erroneous Medicaid provider enrollment application, request for prior authorization for Medicaid services, drug exception request, or cost report; each instance of inappropriate prescribing of drugs for a Medicaid recipient as determined by competent peer judgment; and each false or erroneous Medicaid claim leading to an overpayment to a provider is considered a separate violation.
(d) Immediate suspension, if the agency has received information of patient abuse or neglect or of any act prohibited by s. 409.920. Upon suspension, the agency must issue an immediate final order under s. 120.569(2)(n).
(e) A fine, not to exceed $10,000, for a violation of paragraph (15)(i).
(f) Imposition of liens against provider assets, including, but not limited to, financial assets and real property, not to exceed the amount of fines or recoveries sought, upon entry of an order determining that such moneys are due or recoverable.
(g) Prepayment reviews of claims for a specified period of time.
(h) Comprehensive followup reviews of providers every 6 months to ensure that they are billing Medicaid correctly.
(i) Corrective-action plans that remain in effect for up to 3 years and that are monitored by the agency every 6 months while in effect.
(j) Other remedies as permitted by law to effect the recovery of a fine or overpayment.
If a provider voluntarily relinquishes its Medicaid provider number or an associated license, or allows the associated licensure to expire after receiving written notice that the agency is conducting, or has conducted, an audit, survey, inspection, or investigation and that a sanction of suspension or termination will or would be imposed for noncompliance discovered as a result of the audit, survey, inspection, or investigation, the agency shall impose the sanction of termination for cause against the provider. The agency’s termination with cause is subject to hearing rights as may be provided under chapter 120. The Secretary of Health Care Administration may make a determination that imposition of a sanction or disincentive is not in the best interest of the Medicaid program, in which case a sanction or disincentive may not be imposed.
(17) In determining the appropriate administrative sanction to be applied, or the duration of any suspension or termination, the agency shall consider:
(a) The seriousness and extent of the violation or violations.
(b) Any prior history of violations by the provider relating to the delivery of health care programs which resulted in either a criminal conviction or in administrative sanction or penalty.
(c) Evidence of continued violation within the provider’s management control of Medicaid statutes, rules, regulations, or policies after written notification to the provider of improper practice or instance of violation.
(d) The effect, if any, on the quality of medical care provided to Medicaid recipients as a result of the acts of the provider.
(e) Any action by a licensing agency respecting the provider in any state in which the provider operates or has operated.
(f) The apparent impact on access by recipients to Medicaid services if the provider is suspended or terminated, in the best judgment of the agency.
The agency shall document the basis for all sanctioning actions and recommendations.
(18) The agency may take action to sanction, suspend, or terminate a particular provider working for a group provider, and may suspend or terminate Medicaid participation at a specific location, rather than or in addition to taking action against an entire group.
(19) The agency shall establish a process for conducting followup reviews of a sampling of providers who have a history of overpayment under the Medicaid program. This process must consider the magnitude of previous fraud or abuse and the potential effect of continued fraud or abuse on Medicaid costs.
(20) In making a determination of overpayment to a provider, the agency must use accepted and valid auditing, accounting, analytical, statistical, or peer-review methods, or combinations thereof. Appropriate statistical methods may include, but are not limited to, sampling and extension to the population, parametric and nonparametric statistics, tests of hypotheses, and other generally accepted statistical methods. Appropriate analytical methods may include, but are not limited to, reviews to determine variances between the quantities of products that a provider had on hand and available to be purveyed to Medicaid recipients during the review period and the quantities of the same products paid for by the Medicaid program for the same period, taking into appropriate consideration sales of the same products to non-Medicaid customers during the same period. In meeting its burden of proof in any administrative or court proceeding, the agency may introduce the results of such statistical methods as evidence of overpayment.
(21) When making a determination that an overpayment has occurred, the agency shall prepare and issue an audit report to the provider showing the calculation of overpayments. The agency’s determination must be based solely upon information available to it before issuance of the audit report and, in the case of documentation obtained to substantiate claims for Medicaid reimbursement, based solely upon contemporaneous records. The agency may consider addenda or modifications to a note that was made contemporaneously with the patient care episode if the addenda or modifications are germane to the note.
(22) The audit report, supported by agency work papers, showing an overpayment to a provider constitutes evidence of the overpayment. A provider may not present or elicit testimony on direct examination or cross-examination in any court or administrative proceeding, regarding the purchase or acquisition by any means of drugs, goods, or supplies; sales or divestment by any means of drugs, goods, or supplies; or inventory of drugs, goods, or supplies, unless such acquisition, sales, divestment, or inventory is documented by written invoices, written inventory records, or other competent written documentary evidence maintained in the normal course of the provider’s business. A provider may not present records to contest an overpayment or sanction unless such records are contemporaneous and, if requested during the audit process, were furnished to the agency or its agent upon request. This limitation does not apply to Medicaid cost report audits. This limitation does not preclude consideration by the agency of addenda or modifications to a note if the addenda or modifications are made before notification of the audit, the addenda or modifications are germane to the note, and the note was made contemporaneously with a patient care episode. Notwithstanding the applicable rules of discovery, all documentation to be offered as evidence at an administrative hearing on a Medicaid overpayment or an administrative sanction must be exchanged by all parties at least 14 days before the administrative hearing or be excluded from consideration.
(23)(a) In an audit or investigation of a violation committed by a provider which is conducted pursuant to this section, the agency is entitled to recover all investigative, legal, and expert witness costs if the agency’s findings were not contested by the provider or, if contested, the agency ultimately prevailed.
(b) The agency has the burden of documenting the costs, which include salaries and employee benefits and out-of-pocket expenses. The amount of costs that may be recovered must be reasonable in relation to the seriousness of the violation and must be set taking into consideration the financial resources, earning ability, and needs of the provider, who has the burden of demonstrating such factors.
(c) The provider may pay the costs over a period to be determined by the agency if the agency determines that an extreme hardship would result to the provider from immediate full payment. Any default in payment of costs may be collected by any means authorized by law.
(24) If the agency imposes an administrative sanction pursuant to subsection (13), subsection (14), or subsection (15), except paragraphs (15)(e) and (o), upon any provider or any principal, officer, director, agent, managing employee, or affiliated person of the provider who is regulated by another state entity, the agency shall notify that other entity of the imposition of the sanction within 5 business days. Such notification must include the provider’s or person’s name and license number and the specific reasons for sanction.
(25)(a) The agency shall withhold Medicaid payments, in whole or in part, to a provider upon receipt of reliable evidence that the circumstances giving rise to the need for a withholding of payments involve fraud, willful misrepresentation, or abuse under the Medicaid program, or a crime committed while rendering goods or services to Medicaid recipients. If it is determined that fraud, willful misrepresentation, abuse, or a crime did not occur, the payments withheld must be paid to the provider within 14 days after such determination. Amounts not paid within 14 days accrue interest at the rate of 10 percent per year, beginning after the 14th day.
(b) The agency shall deny payment, or require repayment, if the goods or services were furnished, supervised, or caused to be furnished by a person who has been suspended or terminated from the Medicaid program or Medicare program by the Federal Government or any state.
(c) Overpayments owed to the agency bear interest at the rate of 10 percent per year from the date of final determination of the overpayment by the agency, and payment arrangements must be made within 30 days after the date of the final order, which is not subject to further appeal.
(d) The agency, upon entry of a final agency order, a judgment or order of a court of competent jurisdiction, or a stipulation or settlement, may collect the moneys owed by all means allowable by law, including, but not limited to, notifying any fiscal intermediary of Medicare benefits that the state has a superior right of payment. Upon receipt of such written notification, the Medicare fiscal intermediary shall remit to the state the sum claimed.
(e) The agency may institute amnesty programs to allow Medicaid providers the opportunity to voluntarily repay overpayments. The agency may adopt rules to administer such programs.
(26) The agency may impose administrative sanctions against a Medicaid recipient, or the agency may seek any other remedy provided by law, including, but not limited to, the remedies provided in s. 812.035, if the agency finds that a recipient has engaged in solicitation in violation of s. 409.920 or that the recipient has otherwise abused the Medicaid program.
(27) When the Agency for Health Care Administration has made a probable cause determination and alleged that an overpayment to a Medicaid provider has occurred, the agency, after notice to the provider, shall:
(a) Withhold, and continue to withhold during the pendency of an administrative hearing pursuant to chapter 120, any medical assistance reimbursement payments until such time as the overpayment is recovered, unless within 30 days after receiving notice thereof the provider:
1. Makes repayment in full; or
2. Establishes a repayment plan that is satisfactory to the Agency for Health Care Administration.
(b) Withhold, and continue to withhold during the pendency of an administrative hearing pursuant to chapter 120, medical assistance reimbursement payments if the terms of a repayment plan are not adhered to by the provider.
(28) Venue for all Medicaid program integrity cases lies in Leon County, at the discretion of the agency.
(29) Notwithstanding other provisions of law, the agency and the Medicaid Fraud Control Unit of the Department of Legal Affairs may review a provider’s Medicaid-related and non-Medicaid-related records in order to determine the total output of a provider’s practice to reconcile quantities of goods or services billed to Medicaid with quantities of goods or services used in the provider’s total practice.
(30) The agency shall terminate a provider’s participation in the Medicaid program if the provider fails to reimburse an overpayment or pay an agency-imposed fine that has been determined by final order, not subject to further appeal, within 30 days after the date of the final order, unless the provider and the agency have entered into a repayment agreement.
(31) If a provider requests an administrative hearing pursuant to chapter 120, such hearing must be conducted within 90 days following assignment of an administrative law judge, absent exceptionally good cause shown as determined by the administrative law judge or hearing officer. Upon issuance of a final order, the outstanding balance of the amount determined to constitute the overpayment and fines is due. If a provider fails to make payments in full, fails to enter into a satisfactory repayment plan, or fails to comply with the terms of a repayment plan or settlement agreement, the agency shall withhold reimbursement payments for Medicaid services until the amount due is paid in full.
(32) Duly authorized agents and employees of the agency shall have the power to inspect, during normal business hours, the records of any pharmacy, wholesale establishment, or manufacturer, or any other place in which drugs and medical supplies are manufactured, packed, packaged, made, stored, sold, or kept for sale, for the purpose of verifying the amount of drugs and medical supplies ordered, delivered, or purchased by a provider. The agency shall provide at least 2 business days’ prior notice of any such inspection. The notice must identify the provider whose records will be inspected, and the inspection shall include only records specifically related to that provider.
(33) In accordance with federal law, Medicaid recipients convicted of a crime pursuant to 42 U.S.C. s. 1320a-7b may be limited, restricted, or suspended from Medicaid eligibility for a period not to exceed 1 year, as determined by the agency head or designee.
(34) To deter fraud and abuse in the Medicaid program, the agency may limit the number of Schedule II and Schedule III refill prescription claims submitted from a pharmacy provider. The agency shall limit the allowable amount of reimbursement of prescription refill claims for Schedule II and Schedule III pharmaceuticals if the agency or the Medicaid Fraud Control Unit determines that the specific prescription refill was not requested by the Medicaid recipient or authorized representative for whom the refill claim is submitted or was not prescribed by the recipient’s medical provider or physician. Any such refill request must be consistent with the original prescription.
(35) The Office of Program Policy Analysis and Government Accountability shall provide a report to the President of the Senate and the Speaker of the House of Representatives on a biennial basis, beginning January 31, 2006, on the agency’s efforts to prevent, detect, and deter, as well as recover funds lost to, fraud and abuse in the Medicaid program.
(36) At least three times a year, the agency shall provide to each Medicaid recipient or his or her representative an explanation of benefits in the form of a letter that is mailed to the most recent address of the recipient on the record with the Department of Children and Family Services. The explanation of benefits must include the patient’s name, the name of the health care provider and the address of the location where the service was provided, a description of all services billed to Medicaid in terminology that should be understood by a reasonable person, and information on how to report inappropriate or incorrect billing to the agency or other law enforcement entities for review or investigation. At least once a year, the letter also must include information on how to report criminal Medicaid fraud, the Medicaid Fraud Control Unit’s toll-free hotline number, and information about the rewards available under s. 409.9203. The explanation of benefits may not be mailed for Medicaid independent laboratory services as described in s. 409.905(7) or for Medicaid certified match services as described in ss. 409.9071 and 1011.70.
(37) The agency shall post on its website a current list of each Medicaid provider, including any principal, officer, director, agent, managing employee, or affiliated person of the provider, or any partner or shareholder having an ownership interest in the provider equal to 5 percent or greater, who has been terminated for cause from the Medicaid program or sanctioned under this section. The list must be searchable by a variety of search parameters and provide for the creation of formatted lists that may be printed or imported into other applications, including spreadsheets. The agency shall update the list at least monthly.
(38) In order to improve the detection of health care fraud, use technology to prevent and detect fraud, and maximize the electronic exchange of health care fraud information, the agency shall:
(a) Compile, maintain, and publish on its website a detailed list of all state and federal databases that contain health care fraud information and update the list at least biannually;
(b) Develop a strategic plan to connect all databases that contain health care fraud information to facilitate the electronic exchange of health information between the agency, the Department of Health, the Department of Law Enforcement, and the Attorney General’s Office. The plan must include recommended standard data formats, fraud identification strategies, and specifications for the technical interface between state and federal health care fraud databases;
(c) Monitor innovations in health information technology, specifically as it pertains to Medicaid fraud prevention and detection; and
(d) Periodically publish policy briefs that highlight available new technology to prevent or detect health care fraud and projects implemented by other states, the private sector, or the Federal Government which use technology to prevent or detect health care fraud.
History.—s. 44, ch. 91-282; s. 5, ch. 94-251; s. 4, ch. 96-331; s. 4, ch. 96-387; s. 260, ch. 96-406; s. 195, ch. 96-410; s. 1025, ch. 97-103; s. 70, ch. 99-397; s. 61, ch. 2000-153; s. 12, ch. 2001-377; s. 30, ch. 2002-400; s. 6, ch. 2004-344; s. 7, ch. 2005-133; s. 13, ch. 2006-2; s. 14, ch. 2008-143; s. 18, ch. 2009-223; s. 3, ch. 2013-150.
409.9131 Special provisions relating to integrity of the Medicaid program.—
(1) LEGISLATIVE FINDINGS AND INTENT.—It is the intent of the Legislature that physicians, as defined in this section, be subject to Medicaid fraud and abuse investigations in accordance with the provisions set forth in this section as a supplement to the provisions contained in s. 409.913. If a conflict exists between the provisions of this section and s. 409.913, it is the intent of the Legislature that the provisions of this section shall control.
(2) DEFINITIONS.—For purposes of this section, the term:
(a) “Active practice” means a physician must have regularly provided medical care and treatment to patients within the past 2 years.
(b) “Medical necessity” or “medically necessary” means any goods or services necessary to palliate the effects of a terminal condition or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity, which goods or services are provided in accordance with generally accepted standards of medical practice. For purposes of determining Medicaid reimbursement, the agency is the final arbiter of medical necessity. In making determinations of medical necessity, the agency must, to the maximum extent possible, use a physician in active practice, either employed by or under contract with the agency, of the same specialty or subspecialty as the physician under review. Such determination must be based upon the information available at the time the goods or services were provided.
(c) “Peer” means a Florida licensed physician who is, to the maximum extent possible, of the same specialty or subspecialty, licensed under the same chapter, and in active practice.
(d) “Peer review” means an evaluation of the professional practices of a Medicaid physician provider by a peer or peers in order to assess the medical necessity, appropriateness, and quality of care provided, as such care is compared to that customarily furnished by the physician’s peers and to recognized health care standards, and, in cases involving determination of medical necessity, to determine whether the documentation in the physician’s records is adequate.
(e) “Physician” means a person licensed to practice medicine under chapter 458 or a person licensed to practice osteopathic medicine under chapter 459.
(f) “Professional services” means procedures provided to a Medicaid recipient, either directly by or under the supervision of a physician who is a registered provider for the Medicaid program.
(3) ONSITE RECORDS REVIEW.—As specified in s. 409.913(9), the agency may investigate, review, or analyze a physician’s medical records concerning Medicaid patients. The physician must make such records available to the agency during normal business hours. The agency must provide notice to the physician at least 24 hours before such visit. The agency and physician shall make every effort to set a mutually agreeable time for the agency’s visit during normal business hours and within the 24-hour period. If such a time cannot be agreed upon, the agency may set the time.
(4) NOTICE OF DUE PROCESS RIGHTS REQUIRED.—Whenever the agency seeks an administrative remedy against a physician pursuant to this section or s. 409.913, the physician must be advised of his or her rights to due process under chapter 120. This provision shall not limit or hinder the agency’s ability to pursue any remedy available to it under s. 409.913 or other applicable law.
(5) DETERMINATIONS OF OVERPAYMENT.—In making a determination of overpayment to a physician, the agency must:
(a) Use accepted and valid auditing, accounting, analytical, statistical, or peer-review methods, or combinations thereof. Appropriate statistical methods may include, but are not limited to, sampling and extension to the population, parametric and nonparametric statistics, tests of hypotheses, other generally accepted statistical methods, review of medical records, and a consideration of the physician’s client case mix. Before performing a review of the physician’s Medicaid records, however, the agency shall make every effort to consider the physician’s patient case mix, including, but not limited to, patient age and whether individual patients are clients of the Children’s Medical Services Network established in chapter 391. In meeting its burden of proof in any administrative or court proceeding, the agency may introduce the results of such statistical methods and its other audit findings as evidence of overpayment.
(b) Refer all physician service claims for peer review when the agency’s preliminary analysis indicates that an evaluation of the medical necessity, appropriateness, and quality of care needs to be undertaken to determine a potential overpayment, and before any formal proceedings are initiated against the physician, except as required by s. 409.913.
(6) COST REPORTS.—For any Medicaid provider submitting a cost report to the agency by any method, and in addition to any other certification, the following statement must immediately precede the dated signature of the provider’s administrator or chief financial officer on such cost report:
“I certify that I am familiar with the laws and regulations regarding the provision of health care services under the Florida Medicaid program, including the laws and regulations relating to claims for Medicaid reimbursements and payments, and that the services identified in this cost report were provided in compliance with such laws and regulations.”
History.—s. 71, ch. 99-397; s. 62, ch. 2000-158; ss. 7, 24, ch. 2004-344.
409.9132 Pilot project to monitor home health services.—The Agency for Health Care Administration shall expand the home health agency monitoring pilot project in Miami-Dade County on a statewide basis effective July 1, 2012, except in counties in which the program is not cost-effective, as determined by the agency. The agency shall contract with a vendor to verify the utilization and delivery of home health services and provide an electronic billing interface for home health services. The contract must require the creation of a program to submit claims electronically for the delivery of home health services. The program must verify telephonically visits for the delivery of home health services using voice biometrics. The agency may seek amendments to the Medicaid state plan and waivers of federal laws, as necessary, to implement or expand the pilot project. Notwithstanding s. 287.057(3)(e), the agency must award the contract through the competitive solicitation process and may use the current contract to expand the home health agency monitoring pilot project to include additional counties as authorized under this section.
History.—s. 21, ch. 2009-55; s. 31, ch. 2009-223; s. 44, ch. 2010-151; s. 16, ch. 2012-33; s. 15, ch. 2013-154.
409.9133 Pilot project for home health care management.—The Agency for Health Care Administration shall expand the comprehensive care management pilot project for home health services statewide and include private duty nursing and personal care services effective July 1, 2012, except in counties in which the program will not be cost-effective, as determined by the agency. The program must include face-to-face assessments by a nurse licensed pursuant to chapter 464, consultation with physicians ordering services to substantiate the medical necessity for services, and on-site or desk reviews of recipients’ medical records. The agency may contract with a qualified organization to implement or expand the pilot project. The agency shall use the current contract to expand the comprehensive care management pilot project to include the additional services and counties as authorized under this section. The agency may seek amendments to the Medicaid state plan and waivers of federal laws, as necessary, to implement or expand the pilot project.
History.—s. 22, ch. 2009-55; s. 32, ch. 2009-223; s. 17, ch. 2012-33.
409.914 Assistance for the uninsured.—
(1) The agency shall use the claims payment systems, utilization control systems, cost control systems, case management systems, and other systems and controls that it has developed for the management and control of the Medicaid program to assist other agencies and entities, if appropriate, in paying claims and performing other activities necessary for the conduct of programs of state government, or for working with other public and private agencies to solve problems of lack of insurance, underinsurance, or uninsurability. When conducting these services, the agency shall ensure:
(a) That full payment is received for services provided.
(b) That costs of providing these services are clearly segregated from costs necessary for the conduct of the Medicaid program.
(c) That the program conducted serves the interests of the state in ensuring that effective and quality health care at a reasonable cost is provided to the citizens of the state.
(2)(a) The agency shall seek federal statutory or regulatory reforms to establish a Medicaid buy-in program to provide medical assistance to persons ineligible for Medicaid because of current income and categorical restrictions. The agency shall use funds provided by the Robert Wood Johnson Foundation to assist in developing the buy-in program, including, but not limited to, the determination of eligibility and service coverages; cost-sharing requirements; managed care provisions; changes needed to the Medicaid program’s claims processing, utilization control, cost control, case management, and provider enrollment systems to operate a buy-in program.
(b) The agency shall seek federal authorization and financial support for a buy-in program that provides federally supported medical assistance coverage for persons with incomes up to 250 percent of the federal poverty level. The agency shall not implement the Medicaid buy-in program until it has received necessary federal authorization and financial participation and state appropriations.
History.—s. 45, ch. 91-282; s. 52, ch. 93-129; s. 189, ch. 99-8.
409.915 County contributions to Medicaid.—Although the state is responsible for the full portion of the state share of the matching funds required for the Medicaid program, the state shall charge the counties an annual contribution in order to acquire a certain portion of these funds.
(1) As used in this section, the term “state Medicaid expenditures” means those expenditures used as matching funds for the federal Medicaid program.
(2)(a) For the 2013-2014 state fiscal year, the total amount of the counties’ annual contribution is $269.6 million.
(b) For the 2014-2015 state fiscal year, the total amount of the counties’ annual contribution is $277 million.
(c) By March 15, 2015, and each year thereafter, the Social Services Estimating Conference shall determine the percentage change in state Medicaid expenditures by comparing expenditures for the 2 most recent completed state fiscal years.
(d) For the 2015-2016 state fiscal year through the 2019-2020 state fiscal year, the total amount of the counties’ annual contribution shall be the total contribution for the prior fiscal year adjusted by 50 percent of the percentage change in the state Medicaid expenditures as determined by the Social Services Estimating Conference.
(e) For each fiscal year after the 2019-2020 state fiscal year, the total amount of the counties’ annual contribution shall be the total contribution for the prior fiscal year adjusted by the percentage change in the state Medicaid expenditures as determined by the Social Services Estimating Conference.
1(3)(a)1. The amount of each county’s annual contribution is equal to the product of the amount determined under subsection (2) multiplied by the sum of the percentages calculated in sub-subparagraphs a. and b.:
a. The enrollment weight provided in subparagraph 2. is multiplied by a fraction, the numerator of which is the number of the county’s Medicaid enrollees as of March 1 of each year, and the denominator of which is the number of all counties’ Medicaid enrollees as of March 1 of each year. The agency shall calculate this amount for each county and provide the information to the Department of Revenue by May 15 of each year.
b. The payment weight provided in subparagraph 2. is multiplied by the percentage share of payments provided in subparagraph 3. for each county.
2. The weights for each fiscal year are equal to:
WEIGHTS | ||
FISCAL YEAR | ENROLLMENT | PAYMENT |
2013-14 | 0% | 100% |
2014-15 | 0% | 100% |
2015-16 | 20% | 80% |
2016-17 | 40% | 60% |
2017-18 | 60% | 40% |
2018-19 | 80% | 20% |
2019-20+ | 100% | 0% |
3. The percentage share of payments for each county is:
COUNTY | SHARE OF |
Alachua | 1.278% |
Baker | 0.116% |
Bay | 0.607% |
Bradford | 0.179% |
Brevard | 2.471% |
Broward | 9.228% |
Calhoun | 0.084% |
Charlotte | 0.578% |
Citrus | 0.663% |
Clay | 0.635% |
Collier | 1.161% |
Columbia | 0.557% |
Dade | 18.853% |
Desoto | 0.167% |
Dixie | 0.098% |
Duval | 5.337% |
Escambia | 1.615% |
Flagler | 0.397% |
Franklin | 0.091% |
Gadsden | 0.239% |
Gilchrist | 0.078% |
Glades | 0.055% |
Gulf | 0.076% |
Hamilton | 0.075% |
Hardee | 0.110% |
Hendry | 0.163% |
Hernando | 0.862% |
Highlands | 0.468% |
Hillsborough | 6.953% |
Holmes | 0.101% |
Indian River | 0.397% |
Jackson | 0.219% |
Jefferson | 0.083% |
Lafayette | 0.014% |
Lake | 1.525% |
Lee | 2.512% |
Leon | 0.929% |
Levy | 0.256% |
Liberty | 0.050% |
Madison | 0.086% |
Manatee | 1.623% |
Marion | 1.630% |
Martin | 0.353% |
Monroe | 0.262% |
Nassau | 0.240% |
Okaloosa | 0.567% |
Okeechobee | 0.235% |
Orange | 6.682% |
Osceola | 1.613% |
Palm Beach | 5.899% |
Pasco | 2.392% |
Pinellas | 6.645% |
Polk | 3.643% |
Putnam | 0.417% |
Saint Johns | 0.459% |
Saint Lucie | 1.155% |
Santa Rosa | 0.462% |
Sarasota | 1.230% |
Seminole | 1.740% |
Sumter | 0.218% |
Suwannee | 0.252% |
Taylor | 0.103% |
Union | 0.075% |
Volusia | 2.298% |
Wakulla | 0.103% |
Walton | 0.229% |
Washington | 0.114% |
(b)1. The Legislature intends to replace the county percentage share provided in subparagraph (a)3. with percentage shares based upon each county’s proportion of the total statewide amount of county billings made under this section from April 1, 2012, through March 31, 2013, for which the state ultimately receives payment.
2. By February 1 of each year and continuing until a certification is made under sub-subparagraph b., the agency shall report to the President of the Senate and the Speaker of the House of Representatives the status of the county billings made under this section from April 1, 2012, through March 31, 2013, by county, including:
a. The amounts billed to each county which remain unpaid, if any; and
b. A certification from the agency of a final accounting of the amount of funds received by the state from such billings, by county, upon the expiration of all appeal rights that counties may have to contest such billings.
3. By March 15 of the state fiscal year in which the state receives the certification provided for in sub-subparagraph 2.b., the Social Services Estimating Conference shall calculate each county’s percentage share of the total statewide amount of county billings made under this section from April 1, 2012, through March 31, 2013, for which the state ultimately receives payment.
4. Beginning in the state fiscal year following the receipt by the state of the certification provided in sub-subparagraph 2.b., each county’s percentage share under subparagraph (a)3. shall be replaced by the percentage calculated under subparagraph 3.
5. If the court invalidates the replacement of each county’s share as provided in this paragraph, the county share set forth in subparagraph (a)3. shall continue to apply.
1(4) By June 1 of each year, the Department of Revenue shall notify each county of its required annual contribution. Each county shall pay its contribution, by check or electronic transfer, in equal monthly installments to the department by the 5th day of each month. If a county fails to remit the payment by the 5th day of the month, the department shall reduce the monthly distribution of that county pursuant to s. 218.61 and, if necessary, by the amount of the monthly installment pursuant to s. 218.26. The payments and the amounts by which the distributions are reduced shall be transferred to the General Revenue Fund.
(5) In any county in which a special taxing district or authority is located which benefits from the Medicaid program, the board of county commissioners may divide the county’s financial responsibility for this purpose proportionately, and each such district or authority must furnish its share to the board of county commissioners in time for the board to comply with subsection (4). Any appeal of the proration made by the board of county commissioners must be made to the Department of Financial Services, which shall set the proportionate share for each party.
(6)(a) By August 1, 2012, the agency shall certify to each county the amount of such county’s billings from November 1, 2001, through April 30, 2012, which remain unpaid. A county may contest the amount certified by filing a petition under the applicable provisions of chapter 120 on or before September 1, 2012. This procedure is the exclusive method to challenge the amount certified. In order to successfully challenge the amount certified, a county must show, by a preponderance of the evidence, that a recipient was not an eligible recipient of that county or that the amount certified was otherwise in error.
(b) By September 15, 2012, the agency shall certify to the Department of Revenue:
1. For each county that files a petition on or before September 1, 2012, the amount certified under paragraph (a); and
2. For each county that does not file a petition on or before September 1, 2012, an amount equal to 85 percent of the amount certified under paragraph (a).
(c) The filing of a petition under paragraph (a) does not stay or stop the Department of Revenue from reducing distributions in accordance with paragraph (b) and subsection (7). If a county that files a petition under paragraph (a) is able to demonstrate that the amount certified should be reduced, the agency shall notify the Department of Revenue of the amount of the reduction. The Department of Revenue shall adjust all future monthly distribution reductions under subsection (7) in a manner that results in the remaining total distribution reduction being applied in equal monthly amounts.
(7)(a) Beginning with the October 2012 distribution, the Department of Revenue shall reduce each county’s distributions pursuant to s. 218.26 by one thirty-sixth of the amount certified by the agency under subsection (6) for that county, minus any amount required under paragraph (b). Beginning with the October 2013 distribution, the Department of Revenue shall reduce each county’s distributions pursuant to s. 218.26 by one forty-eighth of two-thirds of the amount certified by the agency under subsection (6) for that county, minus any amount required under paragraph (b). However, the amount of the reduction may not exceed 50 percent of each county’s distribution. If, after 60 months, the reductions for any county do not equal the total amount initially certified by the agency, the Department of Revenue shall continue to reduce such county’s distribution by up to 50 percent until the total amount certified is reached. The amounts by which the distributions are reduced shall be transferred to the General Revenue Fund.
(b) As an assurance to holders of bonds issued before the effective date of this act to which distributions made pursuant to s. 218.26 are pledged, or bonds issued to refund such bonds which mature no later than the bonds they refunded and which result in a reduction of debt service payable in each fiscal year, the amount available for distribution to a county shall remain as provided by law and continue to be subject to any lien or claim on behalf of the bondholders. The Department of Revenue must ensure, based on information provided by an affected county, that any reduction in amounts distributed pursuant to paragraph (a) does not reduce the amount of distribution to a county below the amount necessary for the timely payment of principal and interest when due on the bonds and the amount necessary to comply with any covenant under the bond resolution or other documents relating to the issuance of the bonds. If a reduction to a county’s monthly distribution must be decreased in order to comply with this paragraph, the Department of Revenue must notify the agency of the amount of the decrease and the agency must send a bill for payment of such amount to the affected county.
(8) Beginning in the 2013-2014 fiscal year and each year thereafter through the 2020-2021 fiscal year, the Chief Financial Officer shall transfer from the General Revenue Fund to the Lawton Chiles Endowment Fund an amount equal to the amounts transferred to the General Revenue Fund in the previous fiscal year pursuant to subsections (4) and (7) which are in excess of the official estimate for medical hospital fees for such previous fiscal year adopted by the Revenue Estimating Conference on January 12, 2012, as reflected in the conference’s workpapers. By July 20 of each year, the Office of Economic and Demographic Research shall certify the amount to be transferred to the Chief Financial Officer. Such transfers must be made before July 31 of each year until the total transfers for all years equal $350 million. If such transfers do not total $350 million by July 1, 2021, the Legislature shall provide for the transfer of amounts necessary to total $350 million. The Office of Economic and Demographic Research shall publish the official estimates reflected in the conference’s workpapers on its website.
(9) The agency may adopt rules to administer this section.
History.—s. 46, ch. 91-282; s. 8, ch. 96-417; s. 190, ch. 99-8; s. 26, ch. 2000-171; s. 11, ch. 2001-104; s. 3, ch. 2002-35; s. 452, ch. 2003-261; s. 3, ch. 2007-82; s. 12, ch. 2012-33; s. 10, ch. 2013-48.
1Note.—Section 11, ch. 2013-48, provides that “[n]otwithstanding s. 409.915(3) and (4), Florida Statutes, as amended by this act, the amount of each county’s contribution during the 2013-2014 state fiscal year shall be determined and provided to the Department of Revenue by the Agency for Health Care Administration by June 15, 2013. The Department of Revenue shall notify each county of its annual contribution by June 20, 2013.”
409.916 Grants and Donations Trust Fund.—
(1) The agency shall deposit any funds received from pharmaceutical manufacturers and all other funds received by the agency from any other person as the result of a Medicaid cost containment strategy, in the nature of a rebate, grant, or other similar mechanism into the Grants and Donations Trust Fund. The agency shall deposit any funds received from private donations for the purpose of funding a certified electronic health record technology loan fund into the Grants and Donations Trust Fund.
(2) Funds received from pharmaceutical manufacturers shall be used as the state portion for funding Medicaid prescribed drug services. However, at least $75,000 may be appropriated from the Grants and Donations Trust Fund for Medicaid research and development activities as specified in the General Appropriations Act.
(3) Receipts from the agency’s share of Medicaid fraud and abuse recoupments and fines shall be deposited into the Grants and Donations Trust Fund for purposes established by law and the General Appropriations Act.
1(4) Quality assessment fees received from Medicaid providers shall be deposited into the Grants and Donations Trust Fund and used for purposes established by law and the General Appropriations Act.
(5) Funds received through grants and donations from the state and from counties, local governments, public entities, and taxing districts shall be deposited into the Grants and Donations Trust Fund and used for purposes established by law and the General Appropriations Act.
(6) Funds received from the leasehold licensee fee pursuant to s. 400.179(2)(d)2. shall be deposited into the Grants and Donations Trust Fund and used for purposes established by law and the General Appropriations Act.
History.—s. 47, ch. 91-282; s. 37, ch. 96-418; s. 191, ch. 99-8; s. 4, ch. 2009-47; s. 17, ch. 2009-55; s. 4, ch. 2009-172.
1Note.—As created by s. 17, ch. 2009-55. For a description of multiple acts in the same session affecting a statutory provision, see preface to the Florida Statutes, “Statutory Construction.” Subsection (4) was also created by s. 4, ch. 2009-47, and that version reads:
(4) Funds received from Medicaid providers as nursing home quality assessment fees shall be deposited into the Grants and Donations Trust Fund and used for purposes established by law and the General Appropriations Act.
409.918 Public Medical Assistance Trust Fund.—It is declared that access to adequate health care is a right which should be available to all Floridians. However, rapidly increasing health care costs threaten to make such care unaffordable for many citizens. The Legislature finds that unreimbursed health care services provided to persons who are unable to pay for such services cause the cost of services to paying patients to increase in a manner unrelated to the actual cost of services delivered. Further, the Legislature finds that inequities between hospitals in the provision of unreimbursed services prevent hospitals that provide the bulk of such services from competing on an equitable economic basis with hospitals that provide relatively little care to indigent persons. Therefore, it is the intent of the Legislature to provide a method for funding the provision of health care services to indigent persons, the cost of which shall be borne by the state and by hospitals that are granted the privilege of operating in this state.
(1) All moneys collected pursuant to s. 395.701 shall be deposited into the Public Medical Assistance Trust Fund, which is hereby created.
(2) Moneys deposited into the Public Medical Assistance Trust Fund shall be used solely for the purposes specified by law.
History.—ss. 5, 7, ch. 84-35; s. 11, ch. 87-92; s. 25, ch. 88-294; s. 6, ch. 89-355; s. 48, ch. 91-282; s. 79, ch. 92-289; s. 9, ch. 96-417.
Note.—Former s. 409.2662.
409.919 Rules.—The agency shall adopt any rules necessary to comply with or administer ss. 409.901-409.920 and all rules necessary to comply with federal requirements. In addition, the Department of Children and Family Services shall adopt and accept transfer of any rules necessary to carry out its responsibilities for receiving and processing Medicaid applications and determining Medicaid eligibility, and for assuring compliance with and administering ss. 409.901-409.906, as they relate to these responsibilities, and any other provisions related to responsibility for the determination of Medicaid eligibility.
History.—s. 49, ch. 91-282; s. 192, ch. 99-8; s. 20, ch. 2000-163; s. 56, ch. 2000-256; s. 1, ch. 2000-300.
409.920 Medicaid provider fraud.—
(1) For the purposes of this section, the term:
(a) “Agency” means the Agency for Health Care Administration.
(b) “Fiscal agent” means any individual, firm, corporation, partnership, organization, or other legal entity that has contracted with the agency to receive, process, and adjudicate claims under the Medicaid program.
(c) “Item or service” includes:
1. Any particular item, device, medical supply, or service claimed to have been provided to a recipient and listed in an itemized claim for payment; or
2. In the case of a claim based on costs, any entry in the cost report, books of account, or other documents supporting such claim.
(d) “Knowingly” means that the act was done voluntarily and intentionally and not because of mistake or accident. As used in this section, the term “knowingly” also includes the word “willfully” or “willful” which, as used in this section, means that an act was committed voluntarily and purposely, with the specific intent to do something that the law forbids, and that the act was committed with bad purpose, either to disobey or disregard the law.
(e) “Managed care plans” means a health insurer authorized under chapter 624, an exclusive provider organization authorized under chapter 627, a health maintenance organization authorized under chapter 641, the Children’s Medical Services Network authorized under chapter 391, a prepaid health plan authorized under this chapter, a provider service network authorized under this chapter, a minority physician network authorized under this chapter, and an emergency department diversion program authorized under this chapter or the General Appropriations Act, providing health care services pursuant to a contract with the Medicaid program.
(2)(a) A person may not:
1. Knowingly make, cause to be made, or aid and abet in the making of any false statement or false representation of a material fact, by commission or omission, in any claim submitted to the agency or its fiscal agent or a managed care plan for payment.
2. Knowingly make, cause to be made, or aid and abet in the making of a claim for items or services that are not authorized to be reimbursed by the Medicaid program.
3. Knowingly charge, solicit, accept, or receive anything of value, other than an authorized copayment from a Medicaid recipient, from any source in addition to the amount legally payable for an item or service provided to a Medicaid recipient under the Medicaid program or knowingly fail to credit the agency or its fiscal agent for any payment received from a third-party source.
4. Knowingly make or in any way cause to be made any false statement or false representation of a material fact, by commission or omission, in any document containing items of income and expense that is or may be used by the agency to determine a general or specific rate of payment for an item or service provided by a provider.
5. Knowingly solicit, offer, pay, or receive any remuneration, including any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind, in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made, in whole or in part, under the Medicaid program, or in return for obtaining, purchasing, leasing, ordering, or arranging for or recommending, obtaining, purchasing, leasing, or ordering any goods, facility, item, or service, for which payment may be made, in whole or in part, under the Medicaid program.
6. Knowingly submit false or misleading information or statements to the Medicaid program for the purpose of being accepted as a Medicaid provider.
7. Knowingly use or endeavor to use a Medicaid provider’s identification number or a Medicaid recipient’s identification number to make, cause to be made, or aid and abet in the making of a claim for items or services that are not authorized to be reimbursed by the Medicaid program.
(b)1. A person who violates this subsection and receives or endeavors to receive anything of value of:
a. Ten thousand dollars or less commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
b. More than $10,000, but less than $50,000, commits a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
c. Fifty thousand dollars or more commits a felony of the first degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
2. The value of separate funds, goods, or services that a person received or attempted to receive pursuant to a scheme or course of conduct may be aggregated in determining the degree of the offense.
3. In addition to the sentence authorized by law, a person who is convicted of a violation of this subsection shall pay a fine in an amount equal to five times the pecuniary gain unlawfully received or the loss incurred by the Medicaid program or managed care organization, whichever is greater.
(3) The repayment of Medicaid payments wrongfully obtained, or the offer or endeavor to repay Medicaid funds wrongfully obtained, does not constitute a defense to, or a ground for dismissal of, criminal charges brought under this section.
(4) Property “paid for” includes all property furnished to or intended to be furnished to any recipient of benefits under the Medicaid program, regardless of whether reimbursement is ever actually made by the program.
(5) All records in the custody of the agency or its fiscal agent which relate to Medicaid provider fraud are business records within the meaning of s. 90.803(6).
(6) Proof that a claim was submitted to the agency or its fiscal agent which contained a false statement or a false representation of a material fact, by commission or omission, unless satisfactorily explained, gives rise to an inference that the person whose signature appears as the provider’s authorizing signature on the claim form, or whose signature appears on an agency electronic claim submission agreement submitted for claims made to the fiscal agent by electronic means, had knowledge of the false statement or false representation. This subsection applies whether the signature appears on the claim form or the electronic claim submission agreement by means of handwriting, typewriting, facsimile signature stamp, computer impulse, initials, or otherwise.
(7) Proof of submission to the agency or its fiscal agent of a document containing items of income and expense, which document is used or that may be used by the agency or its fiscal agent to determine a general or specific rate of payment and which document contains a false statement or a false representation of a material fact, by commission or omission, unless satisfactorily explained, gives rise to the inference that the person who signed the certification of the document had knowledge of the false statement or representation. This subsection applies whether the signature appears on the document by means of handwriting, typewriting, facsimile signature stamp, electronic transmission, initials, or otherwise.
(8) A person who provides the state, any state agency, any of the state’s political subdivisions, or any agency of the state’s political subdivisions with information about fraud or suspected fraudulent acts by a Medicaid provider, including a managed care organization, is immune from civil liability for libel, slander, or any other relevant tort for providing information about fraud or suspected fraudulent acts unless the person acted with knowledge that the information was false or with reckless disregard for the truth or falsity of the information. Such immunity extends to reports of fraudulent acts or suspected fraudulent acts conveyed to or from the agency in any manner, including any forum and with any audience as directed by the agency, and includes all discussions subsequent to the report and subsequent inquiries from the agency, unless the person acted with knowledge that the information was false or with reckless disregard for the truth or falsity of the information. For purposes of this subsection, the term “fraudulent acts” includes actual or suspected fraud and abuse, insurance fraud, licensure fraud, or public assistance fraud, including any fraud-related matters that a provider or health plan is required to report to the agency or a law enforcement agency.
(9) The Attorney General shall conduct a statewide program of Medicaid fraud control. To accomplish this purpose, the Attorney General shall:
(a) Investigate the possible criminal violation of any applicable state law pertaining to fraud in the administration of the Medicaid program, in the provision of medical assistance, or in the activities of providers of health care under the Medicaid program.
(b) Investigate the alleged abuse or neglect of patients in health care facilities receiving payments under the Medicaid program, in coordination with the agency.
(c) Investigate the alleged misappropriation of patients’ private funds in health care facilities receiving payments under the Medicaid program.
(d) Refer to the Office of Statewide Prosecution or the appropriate state attorney all violations indicating a substantial potential for criminal prosecution.
(e) Refer to the agency all suspected abusive activities not of a criminal or fraudulent nature.
(f) Safeguard the privacy rights of all individuals and provide safeguards to prevent the use of patient medical records for any reason beyond the scope of a specific investigation for fraud or abuse, or both, without the patient’s written consent.
(g) Publicize to state employees and the public the ability of persons to bring suit under the provisions of the Florida False Claims Act and the potential for the persons bringing a civil action under the Florida False Claims Act to obtain a monetary award.
(10) In carrying out the duties and responsibilities under this section, the Attorney General may:
(a) Enter upon the premises of any health care provider, excluding a physician, participating in the Medicaid program to examine all accounts and records that may, in any manner, be relevant in determining the existence of fraud in the Medicaid program, to investigate alleged abuse or neglect of patients, or to investigate alleged misappropriation of patients’ private funds. A participating physician is required to make available any accounts or records that may, in any manner, be relevant in determining the existence of fraud in the Medicaid program, alleged abuse or neglect of patients, or alleged misappropriation of patients’ private funds. The accounts or records of a non-Medicaid patient may not be reviewed by, or turned over to, the Attorney General without the patient’s written consent.
(b) Subpoena witnesses or materials, including medical records relating to Medicaid recipients, within or outside the state and, through any duly designated employee, administer oaths and affirmations and collect evidence for possible use in either civil or criminal judicial proceedings.
(c) Request and receive the assistance of any state attorney or law enforcement agency in the investigation and prosecution of any violation of this section.
(d) Seek any civil remedy provided by law, including, but not limited to, the remedies provided in ss. 68.081-68.092 and 812.035 and this chapter.
(e) Refer to the agency for collection each instance of overpayment to a provider of health care under the Medicaid program which is discovered during the course of an investigation.
History.—s. 50, ch. 91-282; s. 6, ch. 94-251; s. 2, ch. 96-280; s. 6, ch. 96-387; s. 2, ch. 97-290; s. 6, ch. 2000-163; s. 31, ch. 2002-400; s. 8, ch. 2004-344; s. 19, ch. 2009-223; s. 4, ch. 2013-150.
409.9201 Medicaid fraud.—
(1) As used in this section, the term:
(a) “Prescription drug” means any drug, including, but not limited to, finished dosage forms or active ingredients that are subject to, defined by, or described by s. 503(b) of the Federal Food, Drug, and Cosmetic Act or by s. 465.003(8), s. 499.003(46) or (53) or s. 499.007(13).
(b) “Value” means the amount billed to the Medicaid program for the property dispensed or the market value of a legend drug or goods or services at the time and place of the offense. If the market value cannot be determined, the term means the replacement cost of the legend drug or goods or services within a reasonable time after the offense.
(2) Any person who knowingly sells, who knowingly attempts or conspires to sell, or who knowingly causes any other person to sell or attempt or conspire to sell a legend drug that was paid for by the Medicaid program commits a felony.
(a) If the value of the legend drug involved is less than $20,000, the crime is a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(b) If the value of the legend drug involved is $20,000 or more but less than $100,000, the crime is a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(c) If the value of the legend drug involved is $100,000 or more, the crime is a felony of the first degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(3) Any person who knowingly purchases, or who knowingly attempts or conspires to purchase, a legend drug that was paid for by the Medicaid program and intended for use by another person commits a felony.
(a) If the value of the legend drug is less than $20,000, the crime is a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(b) If the value of the legend drug is $20,000 or more but less than $100,000, the crime is a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(c) If the value of the legend drug is $100,000 or more, the crime is a felony of the first degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(4) Any person who knowingly makes or knowingly causes to be made, or who attempts or conspires to make, any false statement or representation to any person for the purpose of obtaining goods or services from the Medicaid program commits a felony.
(a) If the value of the goods or services is less than $20,000, the crime is a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(b) If the value of the goods or services is $20,000 or more but less than $100,000, the crime is a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
(c) If the value of the goods or services involved is $100,000 or more, the crime is a felony of the first degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
The value of individual items of the legend drugs or goods or services involved in distinct transactions committed during a single scheme or course of conduct, whether involving a single person or several persons, may be aggregated when determining the punishment for the offense.
History.—s. 9, ch. 2004-344; s. 38, ch. 2008-207; s. 37, ch. 2010-161.
409.9203 Rewards for reporting Medicaid fraud.—
(1) The Department of Law Enforcement or director of the Medicaid Fraud Control Unit shall, subject to availability of funds, pay a reward to a person who furnishes original information relating to and reports a violation of the state’s Medicaid fraud laws, unless the person declines the reward, if the information and report:
(a) Is made to the Office of the Attorney General, the Agency for Health Care Administration, the Department of Health, or the Department of Law Enforcement;
(b) Relates to criminal fraud upon Medicaid funds or a criminal violation of Medicaid laws by another person; and
(c) Leads to a recovery of a fine, penalty, or forfeiture of property.
(2) The reward may not exceed the lesser of 25 percent of the amount recovered or $500,000 in a single case.
(3) The reward shall be paid from the Operating Trust Fund from moneys collected pursuant to s. 68.085.
(4) A person who receives a reward pursuant to this section is not eligible to receive any funds pursuant to the Florida False Claims Act for Medicaid fraud for which a reward is received pursuant to this section.
History.—s. 20, ch. 2009-223; s. 2, ch. 2013-207.
409.9205 Medicaid Fraud Control Unit.—
(1) Except as provided in s. 110.205, all positions in the Medicaid Fraud Control Unit of the Department of Legal Affairs are hereby transferred to the Career Service System.
(2) All investigators employed by the Medicaid Fraud Control Unit who have been certified under s. 943.1395 are law enforcement officers of the state. Such investigators have the authority to conduct criminal investigations, bear arms, make arrests, and apply for, serve, and execute search warrants, arrest warrants, capias, and other process throughout the state pertaining to Medicaid fraud as described in this chapter. The Attorney General shall provide reasonable notice of criminal investigations conducted by the Medicaid Fraud Control Unit to, and coordinate those investigations with, the sheriffs of the respective counties.
History.—s. 6, ch. 96-331; s. 7, ch. 2000-163; s. 1, ch. 2001-276; s. 59, ch. 2001-277.
PART IV
MEDICAID MANAGED CARE409.961 Statutory construction; applicability; rules.
409.962 Definitions.
409.963 Single state agency.
409.964 Managed care program; state plan; waivers.
409.965 Mandatory enrollment.
409.966 Eligible plans; selection.
409.967 Managed care plan accountability.
409.968 Managed care plan payments.
409.969 Enrollment; disenrollment.
409.97 State and local Medicaid partnerships.
409.971 Managed medical assistance program.
409.972 Mandatory and voluntary enrollment.
409.973 Benefits.
409.974 Eligible plans.
409.975 Managed care plan accountability.
409.976 Managed care plan payment.
409.977 Enrollment.
409.978 Long-term care managed care program.
409.979 Eligibility.
409.98 Long-term care plan benefits.
409.981 Eligible long-term care plans.
409.982 Long-term care managed care plan accountability.
409.983 Long-term care managed care plan payment.
409.984 Enrollment in a long-term care managed care plan.
409.9841 Long-term care managed care technical advisory workgroup.
409.985 Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program.
409.961 Statutory construction; applicability; rules.—It is the intent of the Legislature that if any conflict exists between the provisions contained in this part and in other parts of this chapter, the provisions in this part control. Sections 409.961–409.985 apply only to the Medicaid managed medical assistance program and long-term care managed care program, as provided in this part. The agency shall adopt any rules necessary to comply with or administer this part and all rules necessary to comply with federal requirements. In addition, the department shall adopt and accept the transfer of any rules necessary to carry out the department’s responsibilities for receiving and processing Medicaid applications and determining Medicaid eligibility and for ensuring compliance with and administering this part, as those rules relate to the department’s responsibilities, and any other provisions related to the department’s responsibility for the determination of Medicaid eligibility. Contracts with the agency and a person or entity, including Medicaid providers and managed care plans, necessary to administer the Medicaid program are not rules and are not subject to chapter 120.
History.—s. 2, ch. 2011-134; s. 4, ch. 2012-44.
409.962 Definitions.—As used in this part, except as otherwise specifically provided, the term:
(1) “Accountable care organization” means an entity qualified as an accountable care organization in accordance with federal regulations, and which meets the requirements of a provider service network as described in s. 409.912(4)(d).
(2) “Agency” means the Agency for Health Care Administration.
(3) “Aging network service provider” means a provider that participated in a home and community-based waiver administered by the Department of Elderly Affairs or the community care service system pursuant to s. 430.205 as of October 1, 2013.
(4) “Comprehensive long-term care plan” means a managed care plan, including a Medicare Advantage Special Needs Plan organized as a preferred provider organization, provider-sponsored organization, health maintenance organization, or coordinated care plan, that provides services described in s. 409.973 and also provides the services described in s. 409.98.
(5) “Department” means the Department of Children and Family Services.
(6) “Eligible plan” means a health insurer authorized under chapter 624, an exclusive provider organization authorized under chapter 627, a health maintenance organization authorized under chapter 641, or a provider service network authorized under s. 409.912(4)(d) or an accountable care organization authorized under federal law. For purposes of the managed medical assistance program, the term also includes the Children’s Medical Services Network authorized under chapter 391 and entities qualified under 42 C.F.R. part 422 as Medicare Advantage Preferred Provider Organizations, Medicare Advantage Provider-sponsored Organizations, Medicare Advantage Health Maintenance Organizations, Medicare Advantage Coordinated Care Plans, and Medicare Advantage Special Needs Plans, and the Program of All-inclusive Care for the Elderly.
(7) “Long-term care plan” means a managed care plan that provides the services described in s. 409.98 for the long-term care managed care program.
(8) “Long-term care provider service network” means a provider service network a controlling interest of which is owned by one or more licensed nursing homes, assisted living facilities with 17 or more beds, home health agencies, community care for the elderly lead agencies, or hospices.
(9) “Managed care plan” means an eligible plan under contract with the agency to provide services in the Medicaid program.
(10) “Medicaid” means the medical assistance program authorized by Title XIX of the Social Security Act, 42 U.S.C. ss. 1396 et seq., and regulations thereunder, as administered in this state by the agency.
(11) “Medicaid recipient” or “recipient” means an individual who the department or, for Supplemental Security Income, the Social Security Administration determines is eligible pursuant to federal and state law to receive medical assistance and related services for which the agency may make payments under the Medicaid program. For the purposes of determining third-party liability, the term includes an individual formerly determined to be eligible for Medicaid, an individual who has received medical assistance under the Medicaid program, or an individual on whose behalf Medicaid has become obligated.
(12) “Prepaid plan” means a managed care plan that is licensed or certified as a risk-bearing entity, or qualified pursuant to s. 409.912(4)(d), in the state and is paid a prospective per-member, per-month payment by the agency.
(13) “Provider service network” means an entity qualified pursuant to s. 409.912(4)(d) of which a controlling interest is owned by a health care provider, or group of affiliated providers, or a public agency or entity that delivers health services. Health care providers include Florida-licensed health care professionals or licensed health care facilities, federally qualified health care centers, and home health care agencies.
(14) “Specialty plan” means a managed care plan that serves Medicaid recipients who meet specified criteria based on age, medical condition, or diagnosis.
History.—s. 3, ch. 2011-134; s. 5, ch. 2012-44.
409.963 Single state agency.—The agency is designated as the single state agency authorized to manage, operate, and make payments for medical assistance and related services under Title XIX of the Social Security Act. Subject to any limitations or directions provided in the General Appropriations Act, these payments may be made only for services included in the program, only on behalf of eligible individuals, and only to qualified providers in accordance with federal requirements for Title XIX of the Social Security Act and state law. This program of medical assistance is designated as the “Medicaid program.” The department is responsible for Medicaid eligibility determinations, including, but not limited to, policy, rules, and the agreement with the Social Security Administration for Medicaid eligibility determinations for Supplemental Security Income recipients, as well as the actual determination of eligibility. As a condition of Medicaid eligibility, subject to federal approval, the agency and the department shall ensure that each Medicaid recipient consents to the release of her or his medical records to the agency and the Medicaid Fraud Control Unit of the Department of Legal Affairs.
History.—s. 4, ch. 2011-134.
409.964 Managed care program; state plan; waivers.—The Medicaid program is established as a statewide, integrated managed care program for all covered services, including long-term care services. The agency shall apply for and implement state plan amendments or waivers of applicable federal laws and regulations necessary to implement the program. Before seeking a waiver, the agency shall provide public notice and the opportunity for public comment and include public feedback in the waiver application. The agency shall hold one public meeting in each of the regions described in s. 409.966(2), and the time period for public comment for each region shall end no sooner than 30 days after the completion of the public meeting in that region. The agency shall submit any state plan amendments, new waiver requests, or requests for extensions or expansions for existing waivers, needed to implement the managed care program by August 1, 2011.
History.—s. 5, ch. 2011-134.
409.965 Mandatory enrollment.—All Medicaid recipients shall receive covered services through the statewide managed care program, except as provided by this part pursuant to an approved federal waiver. The following Medicaid recipients are exempt from participation in the statewide managed care program:
(1) Women who are eligible only for family planning services.
(2) Women who are eligible only for breast and cervical cancer services.
(3) Persons who are eligible for emergency Medicaid for aliens.
(4) Children receiving services in a prescribed pediatric extended care center.
History.—s. 6, ch. 2011-134.
409.966 Eligible plans; selection.—
(1) ELIGIBLE PLANS.—Services in the Medicaid managed care program shall be provided by eligible plans. A provider service network must be capable of providing all covered services to a mandatory Medicaid managed care enrollee or may limit the provision of services to a specific target population based on the age, chronic disease state, or medical condition of the enrollee to whom the network will provide services. A specialty provider service network must be capable of coordinating care and delivering or arranging for the delivery of all covered services to the target population. A provider service network may partner with an insurer licensed under chapter 627 or a health maintenance organization licensed under chapter 641 to meet the requirements of a Medicaid contract.
(2) ELIGIBLE PLAN SELECTION.—The agency shall select a limited number of eligible plans to participate in the Medicaid program using invitations to negotiate in accordance with s. 287.057(3)(a). At least 90 days before issuing an invitation to negotiate, the agency shall compile and publish a databook consisting of a comprehensive set of utilization and spending data for the 3 most recent contract years consistent with the rate-setting periods for all Medicaid recipients by region or county. The source of the data in the report must include both historic fee-for-service claims and validated data from the Medicaid Encounter Data System. The report must be available in electronic form and delineate utilization use by age, gender, eligibility group, geographic area, and aggregate clinical risk score. Separate and simultaneous procurements shall be conducted in each of the following regions:
(a) Region 1, which consists of Escambia, Okaloosa, Santa Rosa, and Walton Counties.
(b) Region 2, which consists of Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington Counties.
(c) Region 3, which consists of Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union Counties.
(d) Region 4, which consists of Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia Counties.
(e) Region 5, which consists of Pasco and Pinellas Counties.
(f) Region 6, which consists of Hardee, Highlands, Hillsborough, Manatee, and Polk Counties.
(g) Region 7, which consists of Brevard, Orange, Osceola, and Seminole Counties.
(h) Region 8, which consists of Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Counties.
(i) Region 9, which consists of Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie Counties.
(j) Region 10, which consists of Broward County.
(k) Region 11, which consists of Miami-Dade and Monroe Counties.
(3) QUALITY SELECTION CRITERIA.—
(a) The invitation to negotiate must specify the criteria and the relative weight of the criteria that will be used for determining the acceptability of the reply and guiding the selection of the organizations with which the agency negotiates. In addition to criteria established by the agency, the agency shall consider the following factors in the selection of eligible plans:
1. Accreditation by the National Committee for Quality Assurance, the Joint Commission, or another nationally recognized accrediting body.
2. Experience serving similar populations, including the organization’s record in achieving specific quality standards with similar populations.
3. Availability and accessibility of primary care and specialty physicians in the provider network.
4. Establishment of community partnerships with providers that create opportunities for reinvestment in community-based services.
5. Organization commitment to quality improvement and documentation of achievements in specific quality improvement projects, including active involvement by organization leadership.
6. Provision of additional benefits, particularly dental care and disease management, and other initiatives that improve health outcomes.
7. Evidence that an eligible plan has written agreements or signed contracts or has made substantial progress in establishing relationships with providers before the plan submitting a response.
8. Comments submitted in writing by any enrolled Medicaid provider relating to a specifically identified plan participating in the procurement in the same region as the submitting provider.
9. Documentation of policies and procedures for preventing fraud and abuse.
10. The business relationship an eligible plan has with any other eligible plan that responds to the invitation to negotiate.
(b) An eligible plan must disclose any business relationship it has with any other eligible plan that responds to the invitation to negotiate. The agency may not select plans in the same region for the same managed care program that have a business relationship with each other. Failure to disclose any business relationship shall result in disqualification from participation in any region for the first full contract period after the discovery of the business relationship by the agency. For the purpose of this section, “business relationship” means an ownership or controlling interest, an affiliate or subsidiary relationship, a common parent, or any mutual interest in any limited partnership, limited liability partnership, limited liability company, or other entity or business association, including all wholly or partially owned subsidiaries, majority-owned subsidiaries, parent companies, or affiliates of such entities, business associations, or other enterprises, that exists for the purpose of making a profit.
(c) After negotiations are conducted, the agency shall select the eligible plans that are determined to be responsive and provide the best value to the state. Preference shall be given to plans that:
1. Have signed contracts with primary and specialty physicians in sufficient numbers to meet the specific standards established pursuant to s. 409.967(2)(c).
2. Have well-defined programs for recognizing patient-centered medical homes and providing for increased compensation for recognized medical homes, as defined by the plan.
3. Are organizations that are based in and perform operational functions in this state, in-house or through contractual arrangements, by staff located in this state. Using a tiered approach, the highest number of points shall be awarded to a plan that has all or substantially all of its operational functions performed in the state. The second highest number of points shall be awarded to a plan that has a majority of its operational functions performed in the state. The agency may establish a third tier; however, preference points may not be awarded to plans that perform only community outreach, medical director functions, and state administrative functions in the state. For purposes of this subparagraph, operational functions include corporate headquarters, claims processing, member services, provider relations, utilization and prior authorization, case management, disease and quality functions, and finance and administration. For purposes of this subparagraph, the term “corporate headquarters” means the principal office of the organization, which may not be a subsidiary, directly or indirectly through one or more subsidiaries of, or a joint venture with, any other entity whose principal office is not located in the state.
4. Have contracts or other arrangements for cancer disease management programs that have a proven record of clinical efficiencies and cost savings.
5. Have contracts or other arrangements for diabetes disease management programs that have a proven record of clinical efficiencies and cost savings.
6. Have a claims payment process that ensures that claims that are not contested or denied will be promptly paid pursuant to s. 641.3155.
(d) For the first year of the first contract term, the agency shall negotiate capitation rates or fee for service payments with each plan in order to guarantee aggregate savings of at least 5 percent.
1. For prepaid plans, determination of the amount of savings shall be calculated by comparison to the Medicaid rates that the agency paid managed care plans for similar populations in the same areas in the prior year. In regions containing no prepaid plans in the prior year, determination of the amount of savings shall be calculated by comparison to the Medicaid rates established and certified for those regions in the prior year.
2. For provider service networks operating on a fee-for-service basis, determination of the amount of savings shall be calculated by comparison to the Medicaid rates that the agency paid on a fee-for-service basis for the same services in the prior year.
(e) To ensure managed care plan participation in Regions 1 and 2, the agency shall award an additional contract to each plan with a contract award in Region 1 or Region 2. Such contract shall be in any other region in which the plan submitted a responsive bid and negotiates a rate acceptable to the agency. If a plan that is awarded an additional contract pursuant to this paragraph is subject to penalties pursuant to s. 409.967(2)(h) for activities in Region 1 or Region 2, the additional contract is automatically terminated 180 days after the imposition of the penalties. The plan must reimburse the agency for the cost of enrollment changes and other transition activities.
(f) The agency may not execute contracts with managed care plans at payment rates not supported by the General Appropriations Act.
(4) ADMINISTRATIVE CHALLENGE.—Any eligible plan that participates in an invitation to negotiate in more than one region and is selected in at least one region may not begin serving Medicaid recipients in any region for which it was selected until all administrative challenges to procurements required by this section to which the eligible plan is a party have been finalized. If the number of plans selected is less than the maximum amount of plans permitted in the region, the agency may contract with other selected plans in the region not participating in the administrative challenge before resolution of the administrative challenge. For purposes of this subsection, an administrative challenge is finalized if an order granting voluntary dismissal with prejudice has been entered by any court established under Article V of the State Constitution or by the Division of Administrative Hearings, a final order has been entered into by the agency and the deadline for appeal has expired, a final order has been entered by the First District Court of Appeal and the time to seek any available review by the Florida Supreme Court has expired, or a final order has been entered by the Florida Supreme Court and a warrant has been issued.
History.—s. 7, ch. 2011-134; s. 50, ch. 2012-5; s. 6, ch. 2012-44.
409.967 Managed care plan accountability.—
(1) The agency shall establish a 5-year contract with each managed care plan selected through the procurement process described in s. 409.966. A plan contract may not be renewed; however, the agency may extend the term of a plan contract to cover any delays during the transition to a new plan.
(2) The agency shall establish such contract requirements as are necessary for the operation of the statewide managed care program. In addition to any other provisions the agency may deem necessary, the contract must require:
(a) Physician compensation.—Managed care plans are expected to coordinate care, manage chronic disease, and prevent the need for more costly services. Effective care management should enable plans to redirect available resources and increase compensation for physicians. Plans achieve this performance standard when physician payment rates equal or exceed Medicare rates for similar services. The agency may impose fines or other sanctions on a plan that fails to meet this performance standard after 2 years of continuous operation.
(b) Emergency services.—Managed care plans shall pay for services required by ss. 395.1041 and 401.45 and rendered by a noncontracted provider. The plans must comply with s. 641.3155. Reimbursement for services under this paragraph is the lesser of:
1. The provider’s charges;
2. The usual and customary provider charges for similar services in the community where the services were provided;
3. The charge mutually agreed to by the entity and the provider within 60 days after submittal of the claim; or
4. The rate the agency would have paid on the most recent October 1st.
(c) Access.—
1. The agency shall establish specific standards for the number, type, and regional distribution of providers in managed care plan networks to ensure access to care for both adults and children. Each plan must maintain a regionwide network of providers in sufficient numbers to meet the access standards for specific medical services for all recipients enrolled in the plan. The exclusive use of mail-order pharmacies may not be sufficient to meet network access standards. Consistent with the standards established by the agency, provider networks may include providers located outside the region. A plan may contract with a new hospital facility before the date the hospital becomes operational if the hospital has commenced construction, will be licensed and operational by January 1, 2013, and a final order has issued in any civil or administrative challenge. Each plan shall establish and maintain an accurate and complete electronic database of contracted providers, including information about licensure or registration, locations and hours of operation, specialty credentials and other certifications, specific performance indicators, and such other information as the agency deems necessary. The database must be available online to both the agency and the public and have the capability to compare the availability of providers to network adequacy standards and to accept and display feedback from each provider’s patients. Each plan shall submit quarterly reports to the agency identifying the number of enrollees assigned to each primary care provider.
2. Each managed care plan must publish any prescribed drug formulary or preferred drug list on the plan’s website in a manner that is accessible to and searchable by enrollees and providers. The plan must update the list within 24 hours after making a change. Each plan must ensure that the prior authorization process for prescribed drugs is readily accessible to health care providers, including posting appropriate contact information on its website and providing timely responses to providers. For Medicaid recipients diagnosed with hemophilia who have been prescribed anti-hemophilic-factor replacement products, the agency shall provide for those products and hemophilia overlay services through the agency’s hemophilia disease management program.
3. Managed care plans, and their fiscal agents or intermediaries, must accept prior authorization requests for any service electronically.
(d) Encounter data.—The agency shall maintain and operate a Medicaid Encounter Data System to collect, process, store, and report on covered services provided to all Medicaid recipients enrolled in prepaid plans.
1. Each prepaid plan must comply with the agency’s reporting requirements for the Medicaid Encounter Data System. Prepaid plans must submit encounter data electronically in a format that complies with the Health Insurance Portability and Accountability Act provisions for electronic claims and in accordance with deadlines established by the agency. Prepaid plans must certify that the data reported is accurate and complete.
2. The agency is responsible for validating the data submitted by the plans. The agency shall develop methods and protocols for ongoing analysis of the encounter data that adjusts for differences in characteristics of prepaid plan enrollees to allow comparison of service utilization among plans and against expected levels of use. The analysis shall be used to identify possible cases of systemic underutilization or denials of claims and inappropriate service utilization such as higher-than-expected emergency department encounters. The analysis shall provide periodic feedback to the plans and enable the agency to establish corrective action plans when necessary. One of the focus areas for the analysis shall be the use of prescription drugs.
3. The agency shall make encounter data available to those plans accepting enrollees who are assigned to them from other plans leaving a region.
(e) Continuous improvement.—The agency shall establish specific performance standards and expected milestones or timelines for improving performance over the term of the contract.
1. Each managed care plan shall establish an internal health care quality improvement system, including enrollee satisfaction and disenrollment surveys. The quality improvement system must include incentives and disincentives for network providers.
2. Each plan must collect and report the Health Plan Employer Data and Information Set (HEDIS) measures, as specified by the agency. These measures must be published on the plan’s website in a manner that allows recipients to reliably compare the performance of plans. The agency shall use the HEDIS measures as a tool to monitor plan performance.
3. Each managed care plan must be accredited by the National Committee for Quality Assurance, the Joint Commission, or another nationally recognized accrediting body, or have initiated the accreditation process, within 1 year after the contract is executed. For any plan not accredited within 18 months after executing the contract, the agency shall suspend automatic assignment under s. 409.977 and 409.984.
4. By the end of the fourth year of the first contract term, the agency shall issue a request for information to determine whether cost savings could be achieved by contracting for plan oversight and monitoring, including analysis of encounter data, assessment of performance measures, and compliance with other contractual requirements.
(f) Program integrity.—Each managed care plan shall establish program integrity functions and activities to reduce the incidence of fraud and abuse, including, at a minimum:
1. A provider credentialing system and ongoing provider monitoring, including maintenance of written provider credentialing policies and procedures which comply with federal and agency guidelines;
2. An effective prepayment and postpayment review process including, but not limited to, data analysis, system editing, and auditing of network providers;
3. Procedures for reporting instances of fraud and abuse pursuant to chapter 641;
4. Administrative and management arrangements or procedures, including a mandatory compliance plan, designed to prevent fraud and abuse; and
5. Designation of a program integrity compliance officer.
(g) Grievance resolution.—Consistent with federal law, each managed care plan shall establish and the agency shall approve an internal process for reviewing and responding to grievances from enrollees. Each plan shall submit quarterly reports on the number, description, and outcome of grievances filed by enrollees.
(h) Penalties.—
1. Withdrawal and enrollment reduction.—Managed care plans that reduce enrollment levels or leave a region before the end of the contract term must reimburse the agency for the cost of enrollment changes and other transition activities. If more than one plan leaves a region at the same time, costs must be shared by the departing plans proportionate to their enrollments. In addition to the payment of costs, departing provider services networks must pay a per-enrollee penalty of up to 3 months’ payment and continue to provide services to the enrollee for 90 days or until the enrollee is enrolled in another plan, whichever occurs first. In addition to payment of costs, all other departing plans must pay a penalty of 25 percent of that portion of the minimum surplus maintained pursuant to s. 641.225(1) which is attributable to the provision of coverage to Medicaid enrollees. Plans shall provide at least 180 days’ notice to the agency before withdrawing from a region. If a managed care plan leaves a region before the end of the contract term, the agency shall terminate all contracts with that plan in other regions pursuant to the termination procedures in subparagraph 3.
2. Encounter data.—If a plan fails to comply with the encounter data reporting requirements of this section for 30 days, the agency must assess a fine of $5,000 per day for each day of noncompliance beginning on the 31st day. On the 31st day, the agency must notify the plan that the agency will initiate contract termination procedures on the 90th day unless the plan comes into compliance before that date.
3. Termination.—If the agency terminates more than one regional contract with the same managed care plan due to noncompliance with the requirements of this section, the agency shall terminate all the regional contracts held by that plan. When terminating multiple contracts, the agency must develop a plan to provide for the transition of enrollees to other plans, and phase in the terminations over a time period sufficient to ensure a smooth transition.
(i) Prompt payment.—Managed care plans shall comply with ss. 641.315, 641.3155, and 641.513.
(j) Electronic claims.—Managed care plans, and their fiscal agents or intermediaries, shall accept electronic claims in compliance with federal standards.
(k) Fair payment.—Provider service networks must ensure that no entity licensed under chapter 395 with a controlling interest in the network charges a Medicaid managed care plan more than the amount paid to that provider by the provider service network for the same service.
(l) Itemized payment.—Any claims payment to a provider by a managed care plan, or by a fiscal agent or intermediary of the plan, must be accompanied by an itemized accounting of the individual claims included in the payment including, but not limited to, the enrollee’s name, the date of service, the procedure code, the amount of reimbursement, and the identification of the plan on whose behalf the payment is made.
(m) Provider dispute resolution.—Disputes between a plan and a provider may be resolved as described in s. 408.7057.
(3) ACHIEVED SAVINGS REBATE.—
(a) The agency is responsible for verifying the achieved savings rebate for all Medicaid prepaid plans. To assist the agency, a prepaid plan shall:
1. Submit an annual financial audit conducted by an independent certified public accountant in accordance with generally accepted auditing standards to the agency on or before June 1 for the preceding year; and
2. Submit an annual statement prepared in accordance with statutory accounting principles on or before March 1 pursuant to s. 624.424 if the plan is regulated by the Office of Insurance Regulation.
(b) The agency shall contract with independent certified public accountants to conduct compliance audits for the purpose of auditing financial information, including but not limited to: annual premium revenue, medical and administrative costs, and income or losses reported by each prepaid plan, in order to determine and validate the achieved savings rebate.
(c) Any audit required under this subsection must be conducted by an independent certified public accountant who meets criteria specified by rule. The rules must also provide that:
1. The entity selected by the agency to conduct the audit may not have a conflict of interest that might affect its ability to perform its responsibilities with respect to an examination.
2. The rates charged to the prepaid plan being audited are consistent with rates charged by other certified public accountants and are comparable with the rates charged for comparable examinations.
3. Each prepaid plan audited shall pay to the agency the expenses of the audit at the rates established by the agency by rule. Such expenses include actual travel expenses, reasonable living expense allowances, compensation of the certified public accountant, and necessary attendant administrative costs of the agency directly related to the examination. Travel expense and living expense allowances are limited to those expenses incurred on account of the audit and must be paid by the examined prepaid plan together with compensation upon presentation by the agency to the prepaid plan of a detailed account of the charges and expenses after a detailed statement has been filed by the auditor and approved by the agency.
4. All moneys collected from prepaid plans for such audits shall be deposited into the Grants and Donations Trust Fund, and the agency may make deposits into such fund from moneys appropriated for the operation of the agency.
(d) At a location in this state, the prepaid plan shall make available to the agency and the agency’s contracted certified public accountant all books, accounts, documents, files, and information that relate to the prepaid plan’s Medicaid transactions. Records not in the prepaid plan’s immediate possession must be made available to the agency or the certified public accountant in this state within 3 days after a request is made by the agency or certified public accountant engaged by the agency. A prepaid plan has an obligation to cooperate in good faith with the agency and the certified public accountant. Failure to comply to such record requests shall be deemed a breach of contract.
(e) Once the certified public accountant completes the audit, the certified public accountant shall submit an audit report to the agency attesting to the achieved savings of the plan. The results of the audit report are dispositive.
(f) Achieved savings rebates validated by the certified public accountant are due within 30 days after the report is submitted. Except as provided in paragraph (h), the achieved savings rebate is established by determining pretax income as a percentage of revenues and applying the following income sharing ratios:
1. One hundred percent of income up to and including 5 percent of revenue shall be retained by the plan.
2. Fifty percent of income above 5 percent and up to 10 percent shall be retained by the plan, and the other 50 percent refunded to the state.
3. One hundred percent of income above 10 percent of revenue shall be refunded to the state.
(g) A plan that exceeds agency-defined quality measures in the reporting period may retain an additional 1 percent of revenue. For the purpose of this paragraph, the quality measures must include plan performance for preventing or managing complex, chronic conditions that are associated with an elevated likelihood of requiring high-cost medical treatments.
(h) The following may not be included as allowable expenses in calculating income for determining the achieved savings rebate:
1. Payment of achieved savings rebates.
2. Any financial incentive payments made to the plan outside of the capitation rate.
3. Any financial disincentive payments levied by the state or federal government.
4. Expenses associated with any lobbying or political activities.
5. The cash value or equivalent cash value of bonuses of any type paid or awarded to the plan’s executive staff, other than base salary.
6. Reserves and reserve accounts.
7. Administrative costs, including, but not limited to, reinsurance expenses, interest payments, depreciation expenses, bad debt expenses, and outstanding claims expenses in excess of actuarially sound maximum amounts set by the agency.
The agency shall consider these and other factors in developing contracts that establish shared savings arrangements.
(i) Prepaid plans that incur a loss in the first contract year may apply the full amount of the loss as an offset to income in the second contract year.
(j) If, after an audit, the agency determines that a prepaid plan owes an additional rebate, the plan has 30 days after notification to make the payment. Upon failure to timely pay the rebate, the agency shall withhold future payments to the plan until the entire amount is recouped. If the agency determines that a prepaid plan has made an overpayment, the agency shall return the overpayment within 30 days.
(4) MEDICAL LOSS RATIO.—If required as a condition of a waiver, the agency may calculate a medical loss ratio for managed care plans. The calculation shall use uniform financial data collected from all plans and shall be computed for each plan on a statewide basis. The method for calculating the medical loss ratio shall meet the following criteria:
(a) Except as provided in paragraphs (b) and (c), expenditures shall be classified in a manner consistent with 45 C.F.R. part 158.
(b) Funds provided by plans to graduate medical education institutions to underwrite the costs of residency positions shall be classified as medical expenditures, provided the funding is sufficient to sustain the positions for the number of years necessary to complete the residency requirements and the residency positions funded by the plans are active providers of care to Medicaid and uninsured patients.
(c) Prior to final determination of the medical loss ratio for any period, a plan may contribute to a designated state trust fund for the purpose of supporting Medicaid and indigent care and have the contribution counted as a medical expenditure for the period.
History.—s. 8, ch. 2011-134; s. 7, ch. 2012-44.
409.968 Managed care plan payments.—
(1) Prepaid plans shall receive per-member, per-month payments negotiated pursuant to the procurements described in s. 409.966. Payments shall be risk-adjusted rates based on historical utilization and spending data, projected forward, and adjusted to reflect the eligibility category, geographic area, and clinical risk profile of the recipients. In negotiating rates with the plans, the agency shall consider any adjustments necessary to encourage plans to use the most cost-effective modalities for treatment of chronic disease such as peritoneal dialysis.
(2) Provider service networks may be prepaid plans and receive per-member, per-month payments negotiated pursuant to the procurement process described in s. 409.966. Provider service networks that choose not to be prepaid plans shall receive fee-for-service rates with a shared savings settlement. The fee-for-service option shall be available to a provider service network only for the first 2 years of its operation. The agency shall annually conduct cost reconciliations to determine the amount of cost savings achieved by fee-for-service provider service networks for the dates of service within the period being reconciled. Only payments for covered services for dates of service within the reconciliation period and paid within 6 months after the last date of service in the reconciliation period must be included. The agency shall perform the necessary adjustments for the inclusion of claims incurred but not reported within the reconciliation period for claims that could be received and paid by the agency after the 6-month claims processing time lag. The agency shall provide the results of the reconciliations to the fee-for-service provider service networks within 45 days after the end of the reconciliation period. The fee-for-service provider service networks shall review and provide written comments or a letter of concurrence to the agency within 45 days after receipt of the reconciliation results. This reconciliation is considered final.
(3) The agency may not approve any plan request for a rate increase unless sufficient funds to support the increase have been authorized in the General Appropriations Act.
History.—s. 9, ch. 2011-134.
409.969 Enrollment; disenrollment.—
(1) ENROLLMENT.—All Medicaid recipients shall be enrolled in a managed care plan unless specifically exempted under this part. Each recipient shall have a choice of plans and may select any available plan unless that plan is restricted by contract to a specific population that does not include the recipient. Medicaid recipients shall have 30 days in which to make a choice of plans.
(2) DISENROLLMENT; GRIEVANCES.—After a recipient has enrolled in a managed care plan, the recipient shall have 90 days to voluntarily disenroll and select another plan. After 90 days, no further changes may be made except for good cause. For purposes of this section, the term “good cause” includes, but is not limited to, poor quality of care, lack of access to necessary specialty services, an unreasonable delay or denial of service, or fraudulent enrollment. The agency must make a determination as to whether good cause exists. The agency may require a recipient to use the plan’s grievance process before the agency’s determination of good cause, except in cases in which immediate risk of permanent damage to the recipient’s health is alleged.
(a) The managed care plan internal grievance process, when used, must be completed in time to permit the recipient to disenroll by the first day of the second month after the month the disenrollment request was made. If the result of the grievance process is approval of an enrollee’s request to disenroll, the agency is not required to make a determination in the case.
(b) The agency must make a determination and take final action on a recipient’s request so that disenrollment occurs no later than the first day of the second month after the month the request was made. If the agency fails to act within the specified timeframe, the recipient’s request to disenroll is deemed to be approved as of the date agency action was required. Recipients who disagree with the agency’s finding that good cause does not exist for disenrollment shall be advised of their right to pursue a Medicaid fair hearing to dispute the agency’s finding.
(c) Medicaid recipients enrolled in a managed care plan after the 90-day period shall remain in the plan for the remainder of the 12-month period. After 12 months, the recipient may select another plan. However, nothing shall prevent a Medicaid recipient from changing providers within the plan during that period.
(d) On the first day of the month after receiving notice from a recipient that the recipient has moved to another region, the agency shall automatically disenroll the recipient from the managed care plan the recipient is currently enrolled in and treat the recipient as if the recipient is a new Medicaid enrollee. At that time, the recipient may choose another plan pursuant to the enrollment process established in this section.
(e) The agency must monitor plan disenrollment throughout the contract term to identify any discriminatory practices.
History.—s. 10, ch. 2011-134.
409.97 State and local Medicaid partnerships.—
(1) INTERGOVERNMENTAL TRANSFERS.—In addition to the contributions required pursuant to s. 409.915, beginning in the 2014-2015 fiscal year, the agency may accept voluntary transfers of local taxes and other qualified revenue from counties, municipalities, and special taxing districts. Such transfers must be contributed to advance the general goals of the Florida Medicaid program without restriction and must be executed pursuant to a contract between the agency and the local funding source. Contracts executed before October 31 shall result in contributions to Medicaid for that same state fiscal year. Contracts executed between November 1 and June 30 shall result in contributions for the following state fiscal year. Based on the date of the signed contracts, the agency shall allocate to the low-income pool the first contributions received up to the limit established by subsection (2). No more than 40 percent of the low-income pool funding shall come from any single funding source. Contributions in excess of the low-income pool shall be allocated to the disproportionate share programs defined in ss. 409.911(3) and 409.9113 and to hospital rates pursuant to subsection (4). The local funding source shall designate in the contract which Medicaid providers ensure access to care for low-income and uninsured people within the applicable jurisdiction and are eligible for low-income pool funding. Eligible providers may include hospitals, primary care providers, and primary care access systems.
(2) LOW-INCOME POOL.—The agency shall establish and maintain a low-income pool in a manner authorized by federal waiver. The low-income pool is created to compensate a network of providers designated pursuant to subsection (1). Funding of the low-income pool shall be limited to the maximum amount permitted by federal waiver minus a percentage specified in the General Appropriations Act. The low-income pool must be used to support enhanced access to services by offsetting shortfalls in Medicaid reimbursement, paying for otherwise uncompensated care, and financing coverage for the uninsured. The low-income pool shall be distributed in periodic payments to the Access to Care Partnership throughout the fiscal year. Distribution of low-income pool funds by the Access to Care Partnership to participating providers may be made through capitated payments, fees for services, or contracts for specific deliverables. The agency shall include the distribution amount for each provider in the contract with the Access to Care Partnership pursuant to subsection (3). Regardless of the method of distribution, providers participating in the Access to Care Partnership shall receive payments such that the aggregate benefit in the jurisdiction of each local funding source, as defined in subsection (1), equals the amount of the contribution plus a factor specified in the General Appropriations Act.
(3) ACCESS TO CARE PARTNERSHIP.—The agency shall contract with an administrative services organization that has operating agreements with all health care facilities, programs, and providers supported with local taxes or certified public expenditures and designated pursuant to subsection (1). The contract shall provide for enhanced access to care for Medicaid, low-income, and uninsured Floridians. The partnership shall be responsible for an ongoing program of activities that provides needed, but uncovered or undercompensated, health services to Medicaid enrollees and persons receiving charity care, as defined in s. 409.911. Accountability for services rendered under this contract must be based on the number of services provided to unduplicated qualified beneficiaries, the total units of service provided to these persons, and the effectiveness of services provided as measured by specific standards of care. The agency shall seek such plan amendments or waivers as may be necessary to authorize the implementation of the low-income pool as the Access to Care Partnership pursuant to this section.
(4) HOSPITAL RATE DISTRIBUTION.—
(a) The agency is authorized to implement a tiered hospital rate system to enhance Medicaid payments to all hospitals when resources for the tiered rates are available from general revenue and such contributions pursuant to subsection (1) as are authorized under the General Appropriations Act.
1. Tier 1 hospitals are statutory rural hospitals as defined in s. 395.602, statutory teaching hospitals as defined in s. 408.07(45), and specialty children’s hospitals as defined in s. 395.002(28).
2. Tier 2 hospitals are community hospitals not included in Tier 1 that provided more than 9 percent of the hospital’s total inpatient days to Medicaid patients and charity patients, as defined in s. 409.911, and are located in the jurisdiction of a local funding source pursuant to subsection (1).
3. Tier 3 hospitals include all community hospitals.
(b) When rates are increased pursuant to this section, the Total Tier Allocation (TTA) shall be distributed as follows:
1. Tier 1 (T1A) = 0.35 x TTA.
2. Tier 2 (T2A) = 0.35 x TTA.
3. Tier 3 (T3A) = 0.30 x TTA.
(c) The tier allocation shall be distributed as a percentage increase to the hospital specific base rate (HSBR) established pursuant to s. 409.905(5)(c). The increase in each tier shall be calculated according to the proportion of tier-specific allocation to the total estimated inpatient spending (TEIS) for all hospitals in each tier:
1. Tier 1 percent increase (T1PI) = T1A/Tier 1 total estimated inpatient spending (T1TEIS).
2. Tier 2 percent increase (T2PI) = T2A /Tier 2 total estimated inpatient spending (T2TEIS).
3. Tier 3 percent increase (T3PI) = T3A/ Tier 3 total estimated inpatient spending (T3TEIS).
(d) The hospital-specific tiered rate (HSTR) shall be calculated as follows:
1. For hospitals in Tier 3: HSTR = (1 + T3PI) x HSBR.
2. For hospitals in Tier 2: HSTR = (1 + T2PI) x HSBR.
3. For hospitals in Tier 1: HSTR = (1 + T1PI) x HSBR.
History.—s. 11, ch. 2011-134.
409.971 Managed medical assistance program.—The agency shall make payments for primary and acute medical assistance and related services using a managed care model. By January 1, 2013, the agency shall begin implementation of the statewide managed medical assistance program, with full implementation in all regions by October 1, 2014.
History.—s. 12, ch. 2011-134.
409.972 Mandatory and voluntary enrollment.—
(1) Persons eligible for the program known as “medically needy” pursuant to s. 409.904(2) shall enroll in managed care plans. Medically needy recipients shall meet the share of the cost by paying the plan premium, up to the share of the cost amount, contingent upon federal approval.
(2) The following Medicaid-eligible persons are exempt from mandatory managed care enrollment required by s. 409.965, and may voluntarily choose to participate in the managed medical assistance program:
(a) Medicaid recipients who have other creditable health care coverage, excluding Medicare.
(b) Medicaid recipients residing in residential commitment facilities operated through the Department of Juvenile Justice or mental health treatment facilities as defined by s. 394.455(32).
(c) Persons eligible for refugee assistance.
(d) Medicaid recipients who are residents of a developmental disability center, including Sunland Center in Marianna and Tacachale in Gainesville.
(e) Medicaid recipients enrolled in the home and community based services waiver pursuant to chapter 393, and Medicaid recipients waiting for waiver services.
(3) Persons eligible for Medicaid but exempt from mandatory participation who do not choose to enroll in managed care shall be served in the Medicaid fee-for-service program as provided in part III of this chapter.
(4) The agency shall seek federal approval to require Medicaid recipients enrolled in managed care plans, as a condition of Medicaid eligibility, to pay the Medicaid program a share of the premium of $10 per month.
History.—s. 13, ch. 2011-134; s. 51, ch. 2012-5.
409.973 Benefits.—
(1) MINIMUM BENEFITS.—Managed care plans shall cover, at a minimum, the following services:
(a) Advanced registered nurse practitioner services.
(b) Ambulatory surgical treatment center services.
(c) Birthing center services.
(d) Chiropractic services.
(e) Dental services.
(f) Early periodic screening diagnosis and treatment services for recipients under age 21.
(g) Emergency services.
(h) Family planning services and supplies. Pursuant to 42 C.F.R. s. 438.102, plans may elect to not provide these services due to an objection on moral or religious grounds, and must notify the agency of that election when submitting a reply to an invitation to negotiate.
(i) Healthy start services, except as provided in s. 409.975(4).
(j) Hearing services.
(k) Home health agency services.
(l) Hospice services.
(m) Hospital inpatient services.
(n) Hospital outpatient services.
(o) Laboratory and imaging services.
(p) Medical supplies, equipment, prostheses, and orthoses.
(q) Mental health services.
(r) Nursing care.
(s) Optical services and supplies.
(t) Optometrist services.
(u) Physical, occupational, respiratory, and speech therapy services.
(v) Physician services, including physician assistant services.
(w) Podiatric services.
(x) Prescription drugs.
(y) Renal dialysis services.
(z) Respiratory equipment and supplies.
(aa) Rural health clinic services.
(bb) Substance abuse treatment services.
(cc) Transportation to access covered services.
(2) CUSTOMIZED BENEFITS.—Managed care plans may customize benefit packages for nonpregnant adults, vary cost-sharing provisions, and provide coverage for additional services. The agency shall evaluate the proposed benefit packages to ensure services are sufficient to meet the needs of the plan’s enrollees and to verify actuarial equivalence.
(3) HEALTHY BEHAVIORS.—Each plan operating in the managed medical assistance program shall establish a program to encourage and reward healthy behaviors. At a minimum, each plan must establish a medically approved smoking cessation program, a medically directed weight loss program, and a medically approved alcohol or substance abuse recovery program. Each plan must identify enrollees who smoke, are morbidly obese, or are diagnosed with alcohol or substance abuse in order to establish written agreements to secure the enrollees’ commitment to participation in these programs.
(4) PRIMARY CARE INITIATIVE.—Each plan operating in the managed medical assistance program shall establish a program to encourage enrollees to establish a relationship with their primary care provider. Each plan shall:
(a) Provide information to each enrollee on the importance of and procedure for selecting a primary care provider, and thereafter automatically assign to a primary care provider any enrollee who fails to choose a primary care provider.
(b) If the enrollee was not a Medicaid recipient before enrollment in the plan, assist the enrollee in scheduling an appointment with the primary care provider. If possible the appointment should be made within 30 days after enrollment in the plan. For enrollees who become eligible for Medicaid between January 1, 2014, and December 31, 2015, the appointment should be scheduled within 6 months after enrollment in the plan.
(c) Report to the agency the number of enrollees assigned to each primary care provider within the plan’s network.
(d) Report to the agency the number of enrollees who have not had an appointment with their primary care provider within their first year of enrollment.
(e) Report to the agency the number of emergency room visits by enrollees who have not had at least one appointment with their primary care provider.
History.—s. 14, ch. 2011-134; s. 52, ch. 2012-5; s. 8, ch. 2012-44.
409.974 Eligible plans.—
(1) ELIGIBLE PLAN SELECTION.—The agency shall select eligible plans through the procurement process described in s. 409.966. The agency shall notice invitations to negotiate no later than January 1, 2013.
(a) The agency shall procure two plans for Region 1. At least one plan shall be a provider service network if any provider service networks submit a responsive bid.
(b) The agency shall procure two plans for Region 2. At least one plan shall be a provider service network if any provider service networks submit a responsive bid.
(c) The agency shall procure at least three plans and up to five plans for Region 3. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(d) The agency shall procure at least three plans and up to five plans for Region 4. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(e) The agency shall procure at least two plans and up to four plans for Region 5. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(f) The agency shall procure at least four plans and up to seven plans for Region 6. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(g) The agency shall procure at least three plans and up to six plans for Region 7. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(h) The agency shall procure at least two plans and up to four plans for Region 8. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(i) The agency shall procure at least two plans and up to four plans for Region 9. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(j) The agency shall procure at least two plans and up to four plans for Region 10. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(k) The agency shall procure at least five plans and up to 10 plans for Region 11. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
If no provider service network submits a responsive bid, the agency shall procure no more than one less than the maximum number of eligible plans permitted in that region. Within 12 months after the initial invitation to negotiate, the agency shall attempt to procure a provider service network. The agency shall notice another invitation to negotiate only with provider service networks in those regions where no provider service network has been selected.
(2) QUALITY SELECTION CRITERIA.—In addition to the criteria established in s. 409.966, the agency shall consider evidence that an eligible plan has written agreements or signed contracts or has made substantial progress in establishing relationships with providers before the plan submitting a response. The agency shall evaluate and give special weight to evidence of signed contracts with essential providers as defined by the agency pursuant to s. 409.975(1). The agency shall exercise a preference for plans with a provider network in which over 10 percent of the providers use electronic health records, as defined in s. 408.051. When all other factors are equal, the agency shall consider whether the organization has a contract to provide managed long-term care services in the same region and shall exercise a preference for such plans.
(3) SPECIALTY PLANS.—Participation by specialty plans shall be subject to the procurement requirements of this section. The aggregate enrollment of all specialty plans in a region may not exceed 10 percent of the total enrollees of that region.
(4) CHILDREN’S MEDICAL SERVICES NETWORK.—Participation by the Children’s Medical Services Network shall be pursuant to a single, statewide contract with the agency that is not subject to the procurement requirements or regional plan number limits of this section. The Children’s Medical Services Network must meet all other plan requirements for the managed medical assistance program.
(5) MEDICARE PLANS.—Participation by a Medicare Advantage Preferred Provider Organization, Medicare Advantage Provider-sponsored Organization, Medicare Advantage Health Maintenance Organization, Medicare Advantage Coordinated Care Plan, or Medicare Advantage Special Needs Plan shall be pursuant to a contract with the agency that is consistent with the Medicare Improvement for Patients and Providers Act of 2008, Pub. L. No. 110-275. Such plans are not subject to the procurement requirements if the plan’s Medicaid enrollees consist exclusively of dually eligible recipients who are enrolled in the plan in order to receive Medicare benefits as of the date that the invitation to negotiate is issued. Otherwise, such plans are subject to all procurement requirements.
History.—s. 15, ch. 2011-134; s. 53, ch. 2012-5; s. 9, ch. 2012-44.
409.975 Managed care plan accountability.—In addition to the requirements of s. 409.967, plans and providers participating in the managed medical assistance program shall comply with the requirements of this section.
(1) PROVIDER NETWORKS.—Managed care plans must develop and maintain provider networks that meet the medical needs of their enrollees in accordance with standards established pursuant to s. 409.967(2)(c). Except as provided in this section, managed care plans may limit the providers in their networks based on credentials, quality indicators, and price.
(a) Plans must include all providers in the region that are classified by the agency as essential Medicaid providers, unless the agency approves, in writing, an alternative arrangement for securing the types of services offered by the essential providers. Providers are essential for serving Medicaid enrollees if they offer services that are not available from any other provider within a reasonable access standard, or if they provided a substantial share of the total units of a particular service used by Medicaid patients within the region during the last 3 years and the combined capacity of other service providers in the region is insufficient to meet the total needs of the Medicaid patients. The agency may not classify physicians and other practitioners as essential providers. The agency, at a minimum, shall determine which providers in the following categories are essential Medicaid providers:
1. Federally qualified health centers.
2. Statutory teaching hospitals as defined in s. 408.07(45).
3. Hospitals that are trauma centers as defined in s. 395.4001(14).
4. Hospitals located at least 25 miles from any other hospital with similar services.
Managed care plans that have not contracted with all essential providers in the region as of the first date of recipient enrollment, or with whom an essential provider has terminated its contract, must negotiate in good faith with such essential providers for 1 year or until an agreement is reached, whichever is first. Payments for services rendered by a nonparticipating essential provider shall be made at the applicable Medicaid rate as of the first day of the contract between the agency and the plan. A rate schedule for all essential providers shall be attached to the contract between the agency and the plan. After 1 year, managed care plans that are unable to contract with essential providers shall notify the agency and propose an alternative arrangement for securing the essential services for Medicaid enrollees. The arrangement must rely on contracts with other participating providers, regardless of whether those providers are located within the same region as the nonparticipating essential service provider. If the alternative arrangement is approved by the agency, payments to nonparticipating essential providers after the date of the agency’s approval shall equal 90 percent of the applicable Medicaid rate. If the alternative arrangement is not approved by the agency, payment to nonparticipating essential providers shall equal 110 percent of the applicable Medicaid rate.
(b) Certain providers are statewide resources and essential providers for all managed care plans in all regions. All managed care plans must include these essential providers in their networks. Statewide essential providers include:
1. Faculty plans of Florida medical schools.
2. Regional perinatal intensive care centers as defined in s. 383.16(2).
3. Hospitals licensed as specialty children’s hospitals as defined in s. 395.002(28).
4. Accredited and integrated systems serving medically complex children that are comprised of separately licensed, but commonly owned, health care providers delivering at least the following services: medical group home, in-home and outpatient nursing care and therapies, pharmacy services, durable medical equipment, and Prescribed Pediatric Extended Care.
Managed care plans that have not contracted with all statewide essential providers in all regions as of the first date of recipient enrollment must continue to negotiate in good faith. Payments to physicians on the faculty of nonparticipating Florida medical schools shall be made at the applicable Medicaid rate. Payments for services rendered by regional perinatal intensive care centers shall be made at the applicable Medicaid rate as of the first day of the contract between the agency and the plan. Payments to nonparticipating specialty children’s hospitals shall equal the highest rate established by contract between that provider and any other Medicaid managed care plan.
(c) After 12 months of active participation in a plan’s network, the plan may exclude any essential provider from the network for failure to meet quality or performance criteria. If the plan excludes an essential provider from the plan, the plan must provide written notice to all recipients who have chosen that provider for care. The notice shall be provided at least 30 days before the effective date of the exclusion.
(d) Each managed care plan must offer a network contract to each home medical equipment and supplies provider in the region which meets quality and fraud prevention and detection standards established by the plan and which agrees to accept the lowest price previously negotiated between the plan and another such provider.
(2) FLORIDA MEDICAL SCHOOLS QUALITY NETWORK.—The agency shall contract with a single organization representing medical schools and graduate medical education programs in the state for the purpose of establishing an active and ongoing program to improve clinical outcomes in all managed care plans. Contracted activities must support greater clinical integration for Medicaid enrollees through interdependent and cooperative efforts of all providers participating in managed care plans. The agency shall support these activities with certified public expenditures and any earned federal matching funds and shall seek any plan amendments or waivers necessary to comply with this subsection. To be eligible to participate in the quality network, a medical school must contract with each managed care plan in its region.
(3) PERFORMANCE MEASUREMENT.—Each managed care plan shall monitor the quality and performance of each participating provider. At the beginning of the contract period, each plan shall notify all its network providers of the metrics used by the plan for evaluating the provider’s performance and determining continued participation in the network.
(4) MOMCARE NETWORK.—
(a) The agency shall contract with an administrative services organization representing all Healthy Start Coalitions providing risk appropriate care coordination and other services in accordance with a federal waiver and pursuant to s. 409.906. The contract shall require the network of coalitions to provide counseling, education, risk-reduction and case management services, and quality assurance for all enrollees of the waiver. The agency shall evaluate the impact of the MomCare network by monitoring each plan’s performance on specific measures to determine the adequacy, timeliness, and quality of services for pregnant women and infants. The agency shall support this contract with certified public expenditures of general revenue appropriated for Healthy Start services and any earned federal matching funds.
(b) Each managed care plan shall establish specific programs and procedures to improve pregnancy outcomes and infant health, including, but not limited to, coordination with the Healthy Start program, immunization programs, and referral to the Special Supplemental Nutrition Program for Women, Infants, and Children, and the Children’s Medical Services program for children with special health care needs. Each plan’s programs and procedures shall include agreements with each local Healthy Start Coalition in the region to provide risk-appropriate care coordination for pregnant women and infants, consistent with agency policies and the MomCare network. Each managed care plan must notify the agency of the impending birth of a child to an enrollee, or notify the agency as soon as practicable after the child’s birth.
(5) SCREENING RATE.—After the end of the second contract year, each managed care plan shall achieve an annual Early and Periodic Screening, Diagnosis, and Treatment Service screening rate of at least 80 percent of those recipients continuously enrolled for at least 8 months.
(6) PROVIDER PAYMENT.—Managed care plans and hospitals shall negotiate mutually acceptable rates, methods, and terms of payment. For rates, methods, and terms of payment negotiated after the contract between the agency and the plan is executed, plans shall pay hospitals, at a minimum, the rate the agency would have paid on the first day of the contract between the provider and the plan. Such payments to hospitals may not exceed 120 percent of the rate the agency would have paid on the first day of the contract between the provider and the plan, unless specifically approved by the agency. Payment rates may be updated periodically.
1(7) MEDICALLY NEEDY ENROLLEES.—Each managed care plan must accept any medically needy recipient who selects or is assigned to the plan and provide that recipient with continuous enrollment for 12 months. After the first month of qualifying as a medically needy recipient and enrolling in a plan, and contingent upon federal approval, the enrollee shall pay the plan a portion of the monthly premium equal to the enrollee’s share of the cost as determined by the department. The agency shall pay any remaining portion of the monthly premium. Plans are not obligated to pay claims for medically needy patients for services provided before enrollment in the plan. Medically needy patients are responsible for payment of incurred claims that are used to determine eligibility. Plans must provide a grace period of at least 90 days before disenrolling recipients who fail to pay their shares of the premium.
History.—s. 16, ch. 2011-134; s. 54, ch. 2012-5.
1Note.—Section 29, ch. 2011-135, provides that “[t]he Agency for Health Care Administration shall develop a plan for implementing a plan for medically needy Medicaid enrollees pursuant to s. 409.975(8), Florida Statutes, as created in HB 7107 or similar legislation that is adopted in the same legislative session or an extension thereof and becomes law, and shall immediately seek federal approval to implement that subsection. The plan shall include a preliminary calculation of actuarially sound rates and estimated fiscal impact.” Section 409.975(8), which appeared in early versions of HB 7107, appears as s. 409.975(7) in the enrolled version of the bill; the cross-reference was not updated to conform.
409.976 Managed care plan payment.—In addition to the payment provisions of s. 409.968, the agency shall provide payment to plans in the managed medical assistance program pursuant to this section.
(1) Prepaid payment rates shall be negotiated between the agency and the eligible plans as part of the procurement process described in s. 409.966.
(2) The agency shall establish payment rates for statewide inpatient psychiatric programs. Payments to managed care plans shall be reconciled to reimburse actual payments to statewide inpatient psychiatric programs.
History.—s. 17, ch. 2011-134.
409.977 Enrollment.—
(1) The agency shall automatically enroll into a managed care plan those Medicaid recipients who do not voluntarily choose a plan pursuant to s. 409.969. The agency shall automatically enroll recipients in plans that meet or exceed the performance or quality standards established pursuant to s. 409.967 and may not automatically enroll recipients in a plan that is deficient in those performance or quality standards. When a specialty plan is available to accommodate a specific condition or diagnosis of a recipient, the agency shall assign the recipient to that plan. In the first year of the first contract term only, if a recipient was previously enrolled in a plan that is still available in the region, the agency shall automatically enroll the recipient in that plan unless an applicable specialty plan is available. Except as otherwise provided in this part, the agency may not engage in practices that are designed to favor one managed care plan over another.
(2) When automatically enrolling recipients in managed care plans, the agency shall automatically enroll based on the following criteria:
(a) Whether the plan has sufficient network capacity to meet the needs of the recipients.
(b) Whether the recipient has previously received services from one of the plan’s primary care providers.
(c) Whether primary care providers in one plan are more geographically accessible to the recipient’s residence than those in other plans.
(3) A newborn of a mother enrolled in a plan at the time of the child’s birth shall be enrolled in the mother’s plan. Upon birth, such a newborn is deemed enrolled in the managed care plan, regardless of the administrative enrollment procedures, and the managed care plan is responsible for providing Medicaid services to the newborn. The mother may choose another plan for the newborn within 90 days after the child’s birth.
(4) The agency shall develop a process to enable a recipient with access to employer-sponsored health care coverage to opt out of all managed care plans and to use Medicaid financial assistance to pay for the recipient’s share of the cost in such employer-sponsored coverage. Contingent upon federal approval, the agency shall also enable recipients with access to other insurance or related products providing access to health care services created pursuant to state law, including any product available under the Florida Health Choices Program, or any health exchange, to opt out. The amount of financial assistance provided for each recipient may not exceed the amount of the Medicaid premium that would have been paid to a managed care plan for that recipient. The agency shall seek federal approval to require Medicaid recipients with access to employer-sponsored health care coverage to enroll in that coverage and use Medicaid financial assistance to pay for the recipient’s share of the cost for such coverage. The amount of financial assistance provided for each recipient may not exceed the amount of the Medicaid premium that would have been paid to a managed care plan for that recipient.
History.—s. 18, ch. 2011-134.
409.978 Long-term care managed care program.—
(1) Pursuant to s. 409.963, the agency shall administer the long-term care managed care program described in ss. 409.978-409.985, but may delegate specific duties and responsibilities for the program to the Department of Elderly Affairs and other state agencies. By July 1, 2012, the agency shall begin implementation of the statewide long-term care managed care program, with full implementation in all regions by October 1, 2013.
(2) The agency shall make payments for long-term care, including home and community-based services, using a managed care model. Unless otherwise specified, ss. 409.961-409.97 apply to the long-term care managed care program.
(3) The Department of Elderly Affairs shall assist the agency to develop specifications for use in the invitation to negotiate and the model contract, determine clinical eligibility for enrollment in managed long-term care plans, monitor plan performance and measure quality of service delivery, assist clients and families to address complaints with the plans, facilitate working relationships between plans and providers serving elders and disabled adults, and perform other functions specified in a memorandum of agreement.
History.—s. 19, ch. 2011-134.
409.979 Eligibility.—
(1) Medicaid recipients who meet all of the following criteria are eligible to receive long-term care services and must receive long-term care services by participating in the long-term care managed care program. The recipient must be:
(a) Sixty-five years of age or older, or age 18 or older and eligible for Medicaid by reason of a disability.
(b) Determined by the Comprehensive Assessment Review and Evaluation for Long-Term Care Services (CARES) Program to require nursing facility care as defined in s. 409.985(3).
(2) Medicaid recipients who, on the date long-term care managed care plans become available in their region, reside in a nursing home facility or are enrolled in one of the following long-term care Medicaid waiver programs are eligible to participate in the long-term care managed care program for up to 12 months without being reevaluated for their need for nursing facility care as defined in s. 409.985(3):
(a) The Assisted Living for the Frail Elderly Waiver.
(b) The Aged and Disabled Adult Waiver.
(c) The Consumer-Directed Care Plus Program as described in s. 409.221.
(d) The Program of All-inclusive Care for the Elderly.
(e) The long-term care community-based diversion pilot project as described in s. 430.705.
(f) The Channeling Services Waiver for Frail Elders.
(3) The Department of Elderly Affairs shall make offers for enrollment to eligible individuals based on a wait-list prioritization and subject to availability of funds. Before enrollment offers, the department shall determine that sufficient funds exist to support additional enrollment into plans.
History.—s. 20, ch. 2011-134; s. 14, ch. 2012-33.
409.98 Long-term care plan benefits.—Long-term care plans shall, at a minimum, cover the following:
(1) Nursing facility care.
(2) Services provided in assisted living facilities.
(3) Hospice.
(4) Adult day care.
(5) Medical equipment and supplies, including incontinence supplies.
(6) Personal care.
(7) Home accessibility adaptation.
(8) Behavior management.
(9) Home-delivered meals.
(10) Case management.
(11) Therapies:
(a) Occupational therapy.
(b) Speech therapy.
(c) Respiratory therapy.
(d) Physical therapy.
(12) Intermittent and skilled nursing.
(13) Medication administration.
(14) Medication management.
(15) Nutritional assessment and risk reduction.
(16) Caregiver training.
(17) Respite care.
(18) Transportation.
(19) Personal emergency response system.
History.—s. 21, ch. 2011-134.
409.981 Eligible long-term care plans.—
(1) ELIGIBLE PLANS.—Provider service networks must be long-term care provider service networks. Other eligible plans may be long-term care plans or comprehensive long-term care plans.
(2) ELIGIBLE PLAN SELECTION.—The agency shall select eligible plans through the procurement process described in s. 409.966. The agency shall provide notice of invitations to negotiate by July 1, 2012. The agency shall procure:
(a) Two plans for Region 1. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(b) Two plans for Region 2. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(c) At least three plans and up to five plans for Region 3. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(d) At least three plans and up to five plans for Region 4. At least one plan must be a provider service network if any provider service network submits a responsive bid.
(e) At least two plans and up to four plans for Region 5. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(f) At least four plans and up to seven plans for Region 6. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(g) At least three plans and up to six plans for Region 7. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(h) At least two plans and up to four plans for Region 8. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(i) At least two plans and up to four plans for Region 9. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(j) At least two plans and up to four plans for Region 10. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
(k) At least five plans and up to 10 plans for Region 11. At least one plan must be a provider service network if any provider service networks submit a responsive bid.
If no provider service network submits a responsive bid in a region other than Region 1 or Region 2, the agency shall procure no more than one less than the maximum number of eligible plans permitted in that region. Within 12 months after the initial invitation to negotiate, the agency shall attempt to procure a provider service network. The agency shall notice another invitation to negotiate only with provider service networks in regions where no provider service network has been selected.
(3) QUALITY SELECTION CRITERIA.—In addition to the criteria established in s. 409.966, the agency shall consider the following factors in the selection of eligible plans:
(a) Evidence of the employment of executive managers with expertise and experience in serving aged and disabled persons who require long-term care.
(b) Whether a plan has established a network of service providers dispersed throughout the region and in sufficient numbers to meet specific service standards established by the agency for specialty services for persons receiving home and community-based care.
(c) Whether a plan is proposing to establish a comprehensive long-term care plan and whether the eligible plan has a contract to provide managed medical assistance services in the same region.
(d) Whether a plan offers consumer-directed care services to enrollees pursuant to s. 409.221.
(e) Whether a plan is proposing to provide home and community-based services in addition to the minimum benefits required by s. 409.98.
(4) PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY.—Participation by the Program of All-inclusive Care for the Elderly (PACE) shall be pursuant to a contract with the agency and not subject to the procurement requirements or regional plan number limits of this section. PACE plans may continue to provide services to individuals at such levels and enrollment caps as authorized by the General Appropriations Act.
(5) MEDICARE ADVANTAGE SPECIAL NEEDS PLANS.—Participation by a Medicare Advantage Special Needs Plan shall be pursuant to a contract with the agency that is consistent with the Medicare Improvement for Patients and Providers Act of 2008, Pub. L. No. 110-275. Such plans are not subject to the procurement requirements if the plan’s Medicaid enrollees consist exclusively of dually eligible recipients who are enrolled in the plan in order to receive Medicare benefits as of the date the invitation to negotiate is issued. Otherwise, Medicare Advantage Special Needs Plans are subject to all procurement requirements.
History.—s. 22, ch. 2011-134; s. 10, ch. 2012-44.
409.982 Long-term care managed care plan accountability.—In addition to the requirements of s. 409.967, plans and providers participating in the long-term care managed care program must comply with the requirements of this section.
(1) PROVIDER NETWORKS.—Managed care plans may limit the providers in their networks based on credentials, quality indicators, and price. For the period between October 1, 2013, and September 30, 2014, each selected plan must offer a network contract to all the following providers in the region:
(a) Nursing homes.
(b) Hospices.
(c) Aging network service providers that have previously participated in home and community-based waivers serving elders or community-service programs administered by the Department of Elderly Affairs.
After 12 months of active participation in a managed care plan’s network, the plan may exclude any of the providers named in this subsection from the network for failure to meet quality or performance criteria. If the plan excludes a provider from the plan, the plan must provide written notice to all recipients who have chosen that provider for care. The notice must be provided at least 30 days before the effective date of the exclusion. The agency shall establish contract provisions governing the transfer of recipients from excluded residential providers.
(2) SELECT PROVIDER PARTICIPATION.—Except as provided in this subsection, providers may limit the managed care plans they join. Nursing homes and hospices that are enrolled Medicaid providers must participate in all eligible plans selected by the agency in the region in which the provider is located.
(3) PERFORMANCE MEASUREMENT.—Each managed care plan shall monitor the quality and performance of each participating provider using measures adopted by and collected by the agency and any additional measures mutually agreed upon by the provider and the plan.
(4) PROVIDER NETWORK STANDARDS.—The agency shall establish and each managed care plan must comply with specific standards for the number, type, and regional distribution of providers in the plan’s network, which must include:
(a) Adult day care centers.
(b) Adult family-care homes.
(c) Assisted living facilities.
(d) Health care services pools.
(e) Home health agencies.
(f) Homemaker and companion services.
(g) Hospices.
(h) Community care for the elderly lead agencies.
(i) Nurse registries.
(j) Nursing homes.
(5) PROVIDER PAYMENT.—Managed care plans and providers shall negotiate mutually acceptable rates, methods, and terms of payment. Plans shall pay nursing homes an amount equal to the nursing facility-specific payment rates set by the agency; however, mutually acceptable higher rates may be negotiated for medically complex care. Plans shall pay hospice providers through a prospective system for each enrollee an amount equal to the per diem rate set by the agency. For recipients residing in a nursing facility and receiving hospice services, the plan shall pay the hospice provider the per diem rate set by the agency minus the nursing facility component and shall pay the nursing facility the applicable state rate. Plans must ensure that electronic nursing home and hospice claims that contain sufficient information for processing are paid within 10 business days after receipt.
History.—s. 23, ch. 2011-134.
409.983 Long-term care managed care plan payment.—In addition to the payment provisions of s. 409.968, the agency shall provide payment to plans in the long-term care managed care program pursuant to this section.
(1) Prepaid payment rates for long-term care managed care plans shall be negotiated between the agency and the eligible plans as part of the procurement process described in s. 409.966.
(2) Payment rates for comprehensive long-term care plans covering services described in s. 409.973 shall be blended with rates for long-term care plans for services specified in s. 409.98.
(3) Payment rates for plans must reflect historic utilization and spending for covered services projected forward and adjusted to reflect the level of care profile for enrollees in each plan. The payment shall be adjusted to provide an incentive for reducing institutional placements and increasing the utilization of home and community-based services.
(4) The initial assessment of an enrollee’s level of care shall be made by the Comprehensive Assessment and Review for Long-Term-Care Services (CARES) program, which shall assign the recipient into one of the following levels of care:
(a) Level of care 1 consists of recipients residing in or who must be placed in a nursing home.
(b) Level of care 2 consists of recipients at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, and who require extensive health-related care and services because of mental or physical incapacitation.
(c) Level of care 3 consists of recipients at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, who have a limited need for health-related care and services and are mildly medically or physically incapacitated.
The agency shall periodically adjust payment rates to account for changes in the level of care profile for each managed care plan based on encounter data.
(5) The agency shall make an incentive adjustment in payment rates to encourage the increased utilization of home and community-based services and a commensurate reduction of institutional placement. The incentive adjustment shall be modified in each successive rate period during the first contract period, as follows:
(a) A 2-percentage point shift in the first rate-setting period;
(b) A 2-percentage point shift in the second rate-setting period, as compared to the utilization mix at the end of the first rate-setting period; or
(c) A 3-percentage point shift in the third rate-setting period, and in each subsequent rate-setting period during the first contract period, as compared to the utilization mix at the end of the immediately preceding rate-setting period.
The incentive adjustment shall continue in subsequent contract periods, at a rate of 3 percentage points per year as compared to the utilization mix at the end of the immediately preceding rate-setting period, until no more than 35 percent of the plan’s enrollees are placed in institutional settings. The agency shall annually report to the Legislature the actual change in the utilization mix of home and community-based services compared to institutional placements and provide a recommendation for utilization mix requirements for future contracts.
(6) The agency shall establish nursing-facility-specific payment rates for each licensed nursing home based on facility costs adjusted for inflation and other factors as authorized in the General Appropriations Act. Payments to long-term care managed care plans shall be reconciled to reimburse actual payments to nursing facilities.
(7) The agency shall establish hospice payment rates pursuant to Title XVIII of the Social Security Act. Payments to long-term care managed care plans shall be reconciled to reimburse actual payments to hospices.
History.—s. 24, ch. 2011-134; s. 55, ch. 2012-5.
409.984 Enrollment in a long-term care managed care plan.—
(1) The agency shall automatically enroll into a long-term care managed care plan those Medicaid recipients who do not voluntarily choose a plan pursuant to s. 409.969. The agency shall automatically enroll recipients in plans that meet or exceed the performance or quality standards established pursuant to s. 409.967 and may not automatically enroll recipients in a plan that is deficient in those performance or quality standards. If a recipient is deemed dually eligible for Medicaid and Medicare services and is currently receiving Medicare services from an entity qualified under 42 C.F.R. part 422 as a Medicare Advantage Preferred Provider Organization, Medicare Advantage Provider-sponsored Organization, or Medicare Advantage Special Needs Plan, the agency shall automatically enroll the recipient in such plan for Medicaid services if the plan is currently participating in the long-term care managed care program. Except as otherwise provided in this part, the agency may not engage in practices that are designed to favor one managed care plan over another.
(2) When automatically enrolling recipients in plans, the agency shall take into account the following criteria:
(a) Whether the plan has sufficient network capacity to meet the needs of the recipients.
(b) Whether the recipient has previously received services from one of the plan’s home and community-based service providers.
(c) Whether the home and community-based providers in one plan are more geographically accessible to the recipient’s residence than those in other plans.
(3) Notwithstanding s. 409.969(2), if a recipient is referred for hospice services, the recipient has 30 days during which the recipient may select to enroll in another managed care plan to access the hospice provider of the recipient’s choice.
(4) If a recipient is referred for placement in a nursing home or assisted living facility, the plan must inform the recipient of any facilities within the plan that have specific cultural or religious affiliations and, if requested by the recipient, make a reasonable effort to place the recipient in the facility of the recipient’s choice.
History.—s. 25, ch. 2011-134; s. 56, ch. 2012-5.
409.9841 Long-term care managed care technical advisory workgroup.—
(1) Before August 1, 2011, the agency shall establish a technical advisory workgroup to assist in developing:
(a) The method of determining Medicaid eligibility pursuant to s. 409.985(3).
(b) The requirements for provider payments to nursing homes under s. 409.983(6).
(c) The method for managing Medicare coinsurance crossover claims.
(d) Uniform requirements for claims submissions and payments, including electronic funds transfers and claims processing.
(e) The process for enrollment of and payment for individuals pending determination of Medicaid eligibility.
(2) The advisory workgroup must include, but is not limited to, representatives of providers and plans who could potentially participate in long-term care managed care. Members of the workgroup shall serve without compensation but may be reimbursed for per diem and travel expenses as provided in s. 112.061.
(3) This section is repealed on June 30, 2013.
History.—s. 26, ch. 2011-134.
409.985 Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program.—
(1) The agency shall operate the Comprehensive Assessment and Review for Long-Term Care Services (CARES) preadmission screening program to ensure that only individuals whose conditions require long-term care services are enrolled in the long-term care managed care program.
(2) The agency shall operate the CARES program through an interagency agreement with the Department of Elderly Affairs. The agency, in consultation with the Department of Elderly Affairs, may contract for any function or activity of the CARES program, including any function or activity required by 42 C.F.R. part 483.20, relating to preadmission screening and review.
(3) The CARES program shall determine if an individual requires nursing facility care and, if the individual requires such care, assign the individual to a level of care as described in s. 409.983(4). When determining the need for nursing facility care, consideration shall be given to the nature of the services prescribed and which level of nursing or other health care personnel meets the qualifications necessary to provide such services and the availability to and access by the individual of community or alternative resources. For the purposes of the long-term care managed care program, the term “nursing facility care” means the individual:
(a) Requires nursing home placement as evidenced by the need for medical observation throughout a 24-hour period and care required to be performed on a daily basis by, or under the direct supervision of, a registered nurse or other health care professional and requires services that are sufficiently medically complex to require supervision, assessment, planning, or intervention by a registered nurse because of a mental or physical incapacitation by the individual;
(b) Requires or is at imminent risk of nursing home placement as evidenced by the need for observation throughout a 24-hour period and care and the constant availability of medical and nursing treatment and requires services on a daily or intermittent basis that are to be performed under the supervision of licensed nursing or other health professionals because the individual is incapacitated mentally or physically; or
(c) Requires or is at imminent risk of nursing home placement as evidenced by the need for observation throughout a 24-hour period and care and the constant availability of medical and nursing treatment and requires limited services that are to be performed under the supervision of licensed nursing or other health professionals because the individual is mildly incapacitated mentally or physically.
(4) For individuals whose nursing home stay is initially funded by Medicare, and Medicare coverage is being terminated for lack of progress towards rehabilitation, CARES staff shall consult with the person making the determination of progress toward rehabilitation to ensure that the recipient is not being inappropriately disqualified from Medicare coverage. If, in their professional judgment, CARES staff believe that a Medicare beneficiary is still making progress toward rehabilitation, they may assist the Medicare beneficiary with an appeal of the disqualification from Medicare coverage. The use of CARES teams to review Medicare denials for coverage under this section is authorized only if it is determined that such reviews qualify for federal matching funds through Medicaid. The agency shall seek or amend federal waivers as necessary to implement this section.
History.—s. 27, ch. 2011-134; s. 57, ch. 2012-5.