CODING: Words stricken are deletions; words underlined are additions.
SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
CHAMBER ACTION
Senate House
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11 Senator Saunders moved the following amendment:
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13 Senate Amendment (with title amendment)
14 On page 69, between lines 9 and 10,
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16 insert:
17 Section 56. Subsection (11) of section 409.906,
18 Florida Statutes, 1998 Supplement, is amended to read:
19 409.906 Optional Medicaid services.--Subject to
20 specific appropriations, the agency may make payments for
21 services which are optional to the state under Title XIX of
22 the Social Security Act and are furnished by Medicaid
23 providers to recipients who are determined to be eligible on
24 the dates on which the services were provided. Any optional
25 service that is provided shall be provided only when medically
26 necessary and in accordance with state and federal law.
27 Nothing in this section shall be construed to prevent or limit
28 the agency from adjusting fees, reimbursement rates, lengths
29 of stay, number of visits, or number of services, or making
30 any other adjustments necessary to comply with the
31 availability of moneys and any limitations or directions
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 provided for in the General Appropriations Act or chapter 216.
2 Optional services may include:
3 (11) HEALTHY START SERVICES.--The agency may pay for a
4 continuum of risk-appropriate medical and psychosocial
5 services for the Healthy Start program in accordance with a
6 federal waiver. The agency may not implement the federal
7 waiver unless the waiver permits the state to limit enrollment
8 or the amount, duration, and scope of services to ensure that
9 expenditures will not exceed funds appropriated by the
10 Legislature or available from local sources. If the Health
11 Care Financing Administration does not approve a federal
12 waiver for Healthy Start services, the agency, in consultation
13 with the Department of Health and the Florida Association of
14 Healthy Start Coalitions, is authorized to establish a
15 Medicaid certified-match program for Healthy Start services.
16 Participation in the Healthy Start certified-match program
17 shall be voluntary and reimbursement shall be limited to the
18 federal Medicaid share to Medicaid-enrolled Healthy Start
19 coalitions for services provided to Medicaid recipients. The
20 agency shall take no action to implement a certified-match
21 program without ensuring that the amendment and review
22 requirements of ss. 216.177 and 216.181 have been met.
23 Section 57. Subsection (21) of section 409.910,
24 Florida Statutes, 1998 Supplement, is renumbered as subsection
25 (22), and a new subsection (21) is added to that section to
26 read:
27 409.910 Responsibility for payments on behalf of
28 Medicaid-eligible persons when other parties are liable.--
29 (21) Entities providing health insurance as defined in
30 s. 624.603, and health maintenance organizations as defined in
31 chapter 641, requiring tape or electronic billing formats from
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 the agency shall accept Medicaid billings that are prepared
2 using the current Medicare standard billing format. If the
3 insurance entity or health maintenance organization is unable
4 to use the agency format, the entity shall accept paper claims
5 from the agency in lieu of tape or electronic billing,
6 provided that these claims are prepared using current Medicare
7 standard billing formats.
8 Section 58. Section 409.9101, Florida Statutes, is
9 created to read:
10 409.9101 Recovery for payments made on behalf of
11 Medicaid-eligible persons.--
12 (1) This section may be cited as the "Medicaid Estate
13 Recovery Act."
14 (2) It is the intent of the Legislature by this
15 section to supplement Medicaid funds that are used to provide
16 medical services to eligible persons. Medicaid estate recovery
17 shall generally be accomplished through the filing of claims
18 against the estates of deceased Medicaid recipients. The
19 recoveries shall be made pursuant to federal authority in s.
20 13612 of the Omnibus Budget Reconciliation Act of 1993, which
21 amends s. 1917(b)(1) of the Social Security Act (42 U.S.C. s.
22 1396p(b)(1)).
23 (3) Pursuant to s. 733.212(4)(a), the personal
24 representative of the estate of the decedent shall serve the
25 agency with a copy of the notice of administration of the
26 estate within 3 months after the first publication of the
27 notice, unless the agency has already filed a claim pursuant
28 to this section.
29 (4) The acceptance of public medical assistance, as
30 defined by Title XIX (Medicaid) of the Social Security Act,
31 including mandatory and optional supplemental payments under
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 the Social Security Act, shall create a claim, as defined in
2 s. 731.201, in favor of the agency as an interested person as
3 defined in s. 731.201. The claim amount is calculated as the
4 total amount paid to or for the benefit of the recipient for
5 medical assistance on behalf of the recipient after he or she
6 reached 55 years of age. There is no claim under this section
7 against estates of recipients who had not yet reached 55 years
8 of age.
9 (5) At the time of filing the claim, the agency may
10 reserve the right to amend the claim amounts based on medical
11 claims submitted by providers subsequent to the agency's
12 initial claim calculation.
13 (6) The claim of the agency shall be the current total
14 allowable amount of Medicaid payments as denoted in the
15 agency's provider payment processing system at the time the
16 agency's claim or amendment is filed. The agency's provider
17 processing system reports shall be admissible as prima facie
18 evidence in substantiating the agency's claim.
19 (7) The claim of the agency under this section shall
20 constitute a Class 3 claim under s. 733.707(1)(c), as provided
21 in s. 414.28(1).
22 (8) The claim created under this section shall not be
23 enforced if the recipient is survived by:
24 (a) A spouse;
25 (b) A child or children under 21 years of age; or
26 (c) A child or children who are blind or permanently
27 and totally disabled pursuant to the eligibility requirements
28 of Title XIX of the Social Security Act.
29 (9) In accordance with s. 4, Art. X of the State
30 Constitution, no claim under this section shall be enforced
31 against any property that is determined to be the homestead of
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 the deceased Medicaid recipient and is determined to be exempt
2 from the claims of creditors of the deceased Medicaid
3 recipient.
4 (10) The agency shall not recover from an estate if
5 doing so would cause undue hardship for the qualified heirs,
6 as defined in s. 731.201. The personal representative of an
7 estate and any heir may request that the agency waive recovery
8 of any or all of the debt when recovery would create a
9 hardship. A hardship does not exist solely because recovery
10 will prevent any heirs from receiving an anticipated
11 inheritance. The following criteria shall be considered by the
12 agency in reviewing a hardship request:
13 (a) The heir:
14 1. Currently resides in the residence of the decedent;
15 2. Resided there at the time of the death of the
16 decedent;
17 3. Has made the residence his or her primary residence
18 for the 12 months immediately preceding the death of the
19 decedent; and
20 4. Owns no other residence;
21 (b) The heir would be deprived of food, clothing,
22 shelter, or medical care necessary for the maintenance of life
23 or health;
24 (c) The heir can document that he or she provided
25 full-time care to the recipient which delayed the recipient's
26 entry into a nursing home. The heir must be either the
27 decedent's sibling or the son or daughter of the decedent and
28 must have resided with the recipient for at least 1 year prior
29 to the recipient's death; or
30 (d) The cost involved in the sale of the property
31 would be equal to or greater than the value of the property.
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 (11) Instances arise in Medicaid estate-recovery cases
2 where the assets include a settlement of a claim against a
3 liable third party. The agency's claim under s. 409.910 must
4 be satisfied prior to including the settlement proceeds as
5 estate assets. The remaining settlement proceeds shall be
6 included in the estate and be available to satisfy the
7 Medicaid estate-recovery claim. The Medicaid estate-recovery
8 share shall be one-half of the settlement proceeds included in
9 the estate. Nothing in this subsection is intended to limit
10 the agency's rights against other assets in the estate not
11 related to the settlement. However, in no circumstances shall
12 the agency's recovery exceed the total amount of Medicaid
13 medical assistance provided to the recipient.
14 (12) In instances where there are no liquid assets to
15 satisfy the Medicaid estate-recovery claim, if there is
16 nonhomestead real property and the costs of sale will not
17 exceed the proceeds, the property shall be sold to satisfy the
18 Medicaid estate-recovery claim. Real property shall not be
19 transferred to the agency in any instance.
20 (13) The agency is authorized to adopt rules to
21 implement the provisions of this section.
22 Section 59. Paragraph (d) of subsection (3) of section
23 409.912, Florida Statutes, 1998 Supplement, is amended to
24 read:
25 409.912 Cost-effective purchasing of health care.--The
26 agency shall purchase goods and services for Medicaid
27 recipients in the most cost-effective manner consistent with
28 the delivery of quality medical care. The agency shall
29 maximize the use of prepaid per capita and prepaid aggregate
30 fixed-sum basis services when appropriate and other
31 alternative service delivery and reimbursement methodologies,
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 including competitive bidding pursuant to s. 287.057, designed
2 to facilitate the cost-effective purchase of a case-managed
3 continuum of care. The agency shall also require providers to
4 minimize the exposure of recipients to the need for acute
5 inpatient, custodial, and other institutional care and the
6 inappropriate or unnecessary use of high-cost services.
7 (3) The agency may contract with:
8 (d) No more than four provider service networks for
9 demonstration projects to test Medicaid direct contracting.
10 One demonstration project must be located in Orange County.
11 The demonstration projects may be reimbursed on a
12 fee-for-service or prepaid basis. A provider service network
13 which is reimbursed by the agency on a prepaid basis shall be
14 exempt from parts I and III of chapter 641, but must meet
15 appropriate financial reserve, quality assurance, and patient
16 rights requirements as established by the agency. The agency
17 shall award contracts on a competitive bid basis and shall
18 select bidders based upon price and quality of care. Medicaid
19 recipients assigned to a demonstration project shall be chosen
20 equally from those who would otherwise have been assigned to
21 prepaid plans and MediPass. The agency is authorized to seek
22 federal Medicaid waivers as necessary to implement the
23 provisions of this section. A demonstration project awarded
24 pursuant to this paragraph shall be for 2 years from the date
25 of implementation.
26 Section 60. Paragraph (a) of subsection (24) of
27 section 409.913, Florida Statutes, is amended to read:
28 409.913 Oversight of the integrity of the Medicaid
29 program.--The agency shall operate a program to oversee the
30 activities of Florida Medicaid recipients, and providers and
31 their representatives, to ensure that fraudulent and abusive
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 behavior and neglect of recipients occur to the minimum extent
2 possible, and to recover overpayments and impose sanctions as
3 appropriate.
4 (24)(a) The agency may withhold Medicaid payments, in
5 whole or in part, to a provider upon receipt of reliable
6 evidence that the circumstances giving rise to the need for a
7 withholding of payments involve fraud or willful
8 misrepresentation under the Medicaid program, or a crime
9 committed while rendering goods or services to Medicaid
10 recipients, up to the amount of the overpayment as determined
11 by final agency audit report, pending completion of legal
12 proceedings under this section. If the agency withholds
13 payments under this section, the Medicaid payment may not be
14 reduced by more than 10 percent. If it is has been determined
15 that fraud, willful misrepresentation, or a crime did not
16 occur an overpayment has not occurred, the payments withheld
17 must be paid to the provider within 14 60 days after such
18 determination with interest at the rate of 10 percent a year.
19 Any money withheld in accordance with this paragraph shall be
20 placed in a suspended account, readily accessible to the
21 agency, so that any payment ultimately due the provider shall
22 be made within 14 days. Furthermore, the authority to withhold
23 payments under this paragraph shall not apply to physicians
24 whose alleged overpayments are being determined by
25 administrative proceedings pursuant to chapter 120. If the
26 amount of the alleged overpayment exceeds $75,000, the agency
27 may reduce the Medicaid payments by up to $25,000 per month.
28 Section 61. Section 409.9131, Florida Statutes, is
29 created to read:
30 409.9131 Special provisions relating to integrity of
31 the Medicaid program.--
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 (1) LEGISLATIVE FINDINGS AND INTENT.--It is the intent
2 of the Legislature that physicians, as defined in this
3 section, be subject to Medicaid fraud and abuse investigations
4 in accordance with the provisions set forth in this section as
5 a supplement to the provisions contained in s. 409.913. If a
6 conflict exists between the provisions of this section and s.
7 409.913, it is the intent of the Legislature that the
8 provisions of this section shall control.
9 (2) DEFINITIONS.--For purposes of this section, the
10 term:
11 (a) "Active practice" means a physician must have
12 regularly provided medical care and treatment to patients
13 within the past 2 years.
14 (b) "Medical necessity" or "medically necessary" means
15 any goods or services necessary to palliate the effects of a
16 terminal condition or to prevent, diagnose, correct, cure,
17 alleviate, or preclude deterioration of a condition that
18 threatens life, causes pain or suffering, or results in
19 illness or infirmity, which goods or services are provided in
20 accordance with generally accepted standards of medical
21 practice. For purposes of determining Medicaid reimbursement,
22 the agency is the final arbiter of medical necessity. In
23 making determinations of medical necessity, the agency must,
24 to the maximum extent possible, use a physician in active
25 practice, either employed by or under contract with the
26 agency, of the same specialty or subspecialty as the physician
27 under review. Such determination must be based upon the
28 information available at the time the goods or services were
29 provided.
30 (c) "Peer" means a Florida licensed physician who is,
31 to the maximum extent possible, of the same specialty or
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 subspecialty, licensed under the same chapter, and in active
2 practice.
3 (d) "Peer review" means an evaluation of the
4 professional practices of a Medicaid physician provider by a
5 peer or peers in order to assess the medical necessity,
6 appropriateness, and quality of care provided, as such care is
7 compared to that customarily furnished by the physician's
8 peers and to recognized health care standards, and to
9 determine whether the documentation in the physician's records
10 is adequate.
11 (e) "Physician" means a person licensed to practice
12 medicine under chapter 458 or a person licensed to practice
13 osteopathic medicine under chapter 459.
14 (f) "Professional services" means procedures provided
15 to a Medicaid recipient, either directly by or under the
16 supervision of a physician who is a registered provider for
17 the Medicaid program.
18 (3) ONSITE RECORDS REVIEW.--As specified in s.
19 409.913(8), the agency may investigate, review, or analyze a
20 physician's medical records concerning Medicaid patients. The
21 physician must make such records available to the agency
22 during normal business hours. The agency must provide notice
23 to the physician at least 24 hours before such visit. The
24 agency and physician shall make every effort to set a mutually
25 agreeable time for the agency's visit during normal business
26 hours and within the 24-hour period. If such a time cannot be
27 agreed upon, the agency may set the time.
28 (4) NOTICE OF DUE PROCESS RIGHTS REQUIRED.--Whenever
29 the agency seeks an administrative remedy against a physician
30 pursuant to this section or s. 409.913, the physician must be
31 advised of his or her rights to due process under chapter 120.
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 This provision shall not limit or hinder the agency's ability
2 to pursue any remedy available to it under s. 409.913 or other
3 applicable law.
4 (5) DETERMINATIONS OF OVERPAYMENT.--In making a
5 determination of overpayment to a physician, the agency must:
6 (a) Use accepted and valid auditing, accounting,
7 analytical, statistical, or peer-review methods, or
8 combinations thereof. Appropriate statistical methods may
9 include, but are not limited to, sampling and extension to the
10 population, parametric and nonparametric statistics, tests of
11 hypotheses, other generally accepted statistical methods,
12 review of medical records, and a consideration of the
13 physician's client case mix. Before performing a review of the
14 physician's Medicaid records, however, the agency shall make
15 every effort to consider the physician's patient case mix,
16 including, but not limited to, patient age and whether
17 individual patients are clients of the Children's Medical
18 Services network established in chapter 391. In meeting its
19 burden of proof in any administrative or court proceeding, the
20 agency may introduce the results of such statistical methods
21 and its other audit findings as evidence of overpayment.
22 (b) Refer all physician service claims for peer review
23 when the agency's preliminary analysis indicates a potential
24 overpayment, and before any formal proceedings are initiated
25 against the physician, except as required by s. 409.913.
26 (c) By March 1, 2000, the agency shall study and
27 report to the Legislature on its current statistical model
28 used to calculate overpayments and advise the Legislature
29 what, if any, changes, improvements, or other modifications
30 should be made to the statistical model. Such review shall
31 include, but not be limited to, a review of the
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 appropriateness of including physician specialty and case-mix
2 parameters within the statistical model.
3 Section 62. Section 641.261, Florida Statutes, is
4 amended to read:
5 641.261 Other reporting requirements.--
6 (1) Each authorized health maintenance organization
7 shall provide records and information to the Agency for Health
8 Care Administration Department of Health and Rehabilitative
9 Services pursuant to s. 409.910(20) and (21) (22) for the sole
10 purpose of identifying potential coverage for claims filed
11 with the agency Department of Health and Rehabilitative
12 Services and its fiscal agents for payment of medical services
13 under the Medicaid program.
14 (2) Any information provided by a health maintenance
15 organization under this section to the agency Department of
16 Health and Rehabilitative Services shall not be considered a
17 violation of any right of confidentiality or contract that the
18 health maintenance organization may have with covered persons.
19 The health maintenance organization is immune from any
20 liability that it may otherwise incur through its release of
21 information to the agency Department of Health and
22 Rehabilitative Services under this section.
23 Section 63. Section 641.411, Florida Statutes, is
24 amended to read:
25 641.411 Other reporting requirements.--
26 (1) Each prepaid health clinic shall provide records
27 and information to the Agency for Health Care Administration
28 Department of Health and Rehabilitative Services pursuant to
29 s. 409.910(20) and (21) (22) for the sole purpose of
30 identifying potential coverage for claims filed with the
31 agency Department of Health and Rehabilitative Services and
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 its fiscal agents for payment of medical services under the
2 Medicaid program.
3 (2) Any information provided by a prepaid health
4 clinic under this section to the agency Department of Health
5 and Rehabilitative Services shall not be considered a
6 violation of any right of confidentiality or contract that the
7 prepaid health clinic may have with covered persons. The
8 prepaid health clinic is immune from any liability that it may
9 otherwise incur through its release of information to the
10 agency Department of Health and Rehabilitative Services under
11 this section.
12 Section 64. Paragraph (a) of subsection (4) of section
13 733.212, Florida Statutes, is amended to read:
14 733.212 Notice of administration; filing of objections
15 and claims.--
16 (4)(a) The personal representative shall promptly make
17 a diligent search to determine the names and addresses of
18 creditors of the decedent who are reasonably ascertainable and
19 shall serve on those creditors a copy of the notice within 3
20 months after the first publication of the notice. Under s.
21 409.9101, the Agency for Health Care Administration is
22 considered a reasonably ascertainable creditor in instances
23 where the decedent had received Medicaid assistance for
24 medical care after reaching 55 years of age. Impracticable and
25 extended searches are not required. Service is not required
26 on any creditor who has filed a claim as provided in this
27 part; a creditor whose claim has been paid in full; or a
28 creditor whose claim is listed in a personal representative's
29 timely proof of claim if the personal representative notified
30 the creditor of that listing.
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Bill No. CS for SB 2220
Amendment No.
1 (Redesignate subsequent sections.)insert:
2
3
4 ================ T I T L E A M E N D M E N T ===============
5 And the title is amended as follows:
6 On page 1, line 2, delete that line
7
8 and insert:
9 An act relating to health care; amending s.
10 409.906, F.S.; authorizing the Agency for
11 Health Care Administration to develop a
12 certified-match program for Healthy Start
13 services under certain circumstances; amending
14 s. 409.910, F.S.; providing for use of Medicare
15 standard billing formats for certain
16 data-exchange purposes; creating s. 409.9101,
17 F.S.; providing a short title; providing
18 legislative intent relating to Medicaid estate
19 recovery; requiring certain notice of
20 administration of the estate of a deceased
21 Medicaid recipient; providing that receipt of
22 Medicaid benefits creates a claim and interest
23 by the agency against an estate; specifying the
24 right of the agency to amend the amount of its
25 claim based on medical claims submitted by
26 providers subsequent to the agency's initial
27 claim calculation; providing the basis of
28 calculation of the amount of the agency's
29 claim; specifying a claim's class standing;
30 providing circumstances for nonenforcement of
31 claims; providing criteria for use in
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SENATE AMENDMENT
Bill No. CS for SB 2220
Amendment No.
1 considering hardship requests; providing for
2 recovery when estate assets result from a claim
3 against a third party; providing for estate
4 recovery in instances involving real property;
5 providing agency rulemaking authority; amending
6 s. 409.912, F.S.; eliminating a requirement
7 that a Medicaid provider service network
8 demonstration project be located in Orange
9 County; amending s. 409.913, F.S.; revising
10 provisions relating to the agency's authority
11 to withhold Medicaid payments pending
12 completion of certain legal proceedings;
13 providing for disbursement of withheld Medicaid
14 provider payments; creating s. 409.9131, F.S.;
15 providing legislative findings and intent
16 relating to integrity of the Medicaid program;
17 providing definitions; authorizing onsite
18 reviews of physician records by the agency;
19 requiring notice for such reviews; requiring
20 notice of due process rights in certain
21 circumstances; specifying procedures for
22 determinations of overpayment; requiring a
23 study of certain statistical models used by the
24 agency; requiring a report; amending ss.
25 641.261 and 641.411, F.S.; conforming
26 references and cross-references; amending s.
27 733.212, F.S.; establishing the agency as a
28 reasonably ascertainable creditor with respect
29 to administration of certain estates;
30
31
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