House Bill hb1753
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
By the Fiscal Responsibility Council and Representative
Maygarden
1 A bill to be entitled
2 An act relating to the Agency for Health Care
3 Administration; amending s. 409.8132, F.S.;
4 deleting the requirement to provide choice
5 counseling to eligible applicants under the
6 Medikids program component; amending s.
7 409.815, F.S.; correcting a cross reference;
8 amending s. 409.903, F.S.; revising Medicaid
9 eligibility requirements for pregnant women and
10 children under age 1; amending s. 409.904,
11 F.S.; revising Medicaid eligibility
12 requirements for certain elderly or disabled
13 persons; revising Medicaid eligibility
14 requirements of postpartum women for family
15 planning services; authorizing payment for
16 health insurance premiums of Medicaid-eligible
17 individuals under certain circumstances;
18 amending s. 409.905, F.S.; updating and
19 revising provisions relating to hospital
20 inpatient behavioral health services provided
21 pursuant to a federally approved waiver;
22 expanding provision of such services statewide;
23 amending s. 409.906, F.S.; deleting adult
24 denture services as optional Medicaid services
25 and restricting authorized hearing and visual
26 services to children; providing additional
27 requirements for authorized intermediate care
28 services; adding assistive care services as an
29 optional Medicaid service for certain
30 recipients; amending s. 409.9065, F.S.;
31 correcting a cross reference; amending s.
1
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 409.908, F.S.; providing for reimbursement of
2 hospital inpatient and outpatient services at
3 certain rates; permitting reimbursement for
4 certain Medicaid services based on competitive
5 bidding; deleting redundant provisions;
6 prohibiting increases in reimbursement rates to
7 nursing homes associated with changes in
8 ownership; precluding premium adjustments to
9 managed care organizations under certain
10 circumstances; revising provisions relating to
11 physician reimbursement and the reimbursement
12 fee schedule; deleting certain preferential
13 Medicaid payments for dually eligible
14 recipients; authorizing competitive procurement
15 of transportation services or the securing
16 through waivers of federal financing of
17 transportation services at certain rates;
18 correcting a cross reference; authorizing
19 public schools affiliated with Florida
20 universities to separately enroll in the
21 Medicaid certified school match program and
22 certify local expenditures; amending s.
23 409.911, F.S.; updating data requirements and
24 share rates for disproportionate share
25 distributions; amending s. 409.91195, F.S.;
26 revising provisions relating to the membership
27 of the Medicaid Pharmaceutical and Therapeutics
28 Committee; providing for development and
29 distribution of a restricted drug formulary for
30 Medicaid providers; amending s. 409.9116, F.S.;
31 modifying the formula for disproportionate
2
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 share/financial assistance distributions to
2 rural hospitals; amending s. 409.912, F.S.;
3 authorizing continued reimbursement of
4 substance abuse treatment services on a
5 fee-for-service basis under certain conditions;
6 expanding Medicaid managed care behavioral
7 health services statewide; deleting requirement
8 for choice counseling; deleting authorization
9 to test new marketing initiatives relating to
10 managed care options; deleting a restriction on
11 adjustment of capitation rates; permitting
12 competitive bidding for certain services;
13 modifying reimbursement to pharmacies;
14 permitting use of a restricted drug formulary,
15 authorizing exemptions therefrom, and
16 authorizing negotiation of supplemental rebates
17 from manufacturers pursuant thereto; requiring
18 prescriptions for Medicaid recipients to be on
19 certain standardized forms; amending s.
20 409.915, F.S.; increasing county contributions
21 to Medicaid for inpatient hospitalization;
22 exempting counties from contributing toward the
23 cost of inpatient services provided by certain
24 hospitals and for special Medicaid payments
25 under certain conditions; repealing s.
26 636.0145, F.S., relating to requirement for
27 licensure of certain entities contracting with
28 Medicaid to provide mental health care services
29 in certain counties pursuant to federal waiver,
30 to conform to changes made in this act;
31
3
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 providing a finding of important state
2 interest; providing an effective date.
3
4 Be It Enacted by the Legislature of the State of Florida:
5
6 Section 1. Subsection (7) of section 409.8132, Florida
7 Statutes, is amended to read:
8 409.8132 Medikids program component.--
9 (7) ENROLLMENT.--Enrollment in the Medikids program
10 component may only occur during periodic open enrollment
11 periods as specified by the agency. An applicant may apply for
12 enrollment in the Medikids program component and proceed
13 through the eligibility determination process at any time
14 throughout the year. However, enrollment in Medikids shall not
15 begin until the next open enrollment period; and a child may
16 not receive services under the Medikids program until the
17 child is enrolled in a managed care plan or MediPass. In
18 addition, Once determined eligible, an applicant may choose
19 receive choice counseling and select a managed care plan or
20 MediPass. The agency may initiate mandatory assignment for a
21 Medikids applicant who has not chosen a managed care plan or
22 MediPass provider after the applicant's voluntary choice
23 period ends. An applicant may select MediPass under the
24 Medikids program component only in counties that have fewer
25 than two managed care plans available to serve Medicaid
26 recipients and only if the federal Health Care Financing
27 Administration determines that MediPass constitutes "health
28 insurance coverage" as defined in Title XXI of the Social
29 Security Act.
30 Section 2. Paragraph (q) of subsection (2) of section
31 409.815, Florida Statutes, is amended to read:
4
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 409.815 Health benefits coverage; limitations.--
2 (2) BENCHMARK BENEFITS.--In order for health benefits
3 coverage to qualify for premium assistance payments for an
4 eligible child under ss. 409.810-409.820, the health benefits
5 coverage, except for coverage under Medicaid and Medikids,
6 must include the following minimum benefits, as medically
7 necessary.
8 (q) Dental services.--Subject to a specific
9 appropriation for this benefit, covered services include those
10 dental services provided to children by the Florida Medicaid
11 program under s. 409.906(5)(6).
12 Section 3. Subsection (5) of section 409.903, Florida
13 Statutes, is amended to read:
14 409.903 Mandatory payments for eligible persons.--The
15 agency shall make payments for medical assistance and related
16 services on behalf of the following persons who the
17 department, or the Social Security Administration by contract
18 with the Department of Children and Family Services,
19 determines to be eligible, subject to the income, assets, and
20 categorical eligibility tests set forth in federal and state
21 law. Payment on behalf of these Medicaid eligible persons is
22 subject to the availability of moneys and any limitations
23 established by the General Appropriations Act or chapter 216.
24 (5) A pregnant woman for the duration of her pregnancy
25 and for the postpartum period as defined in federal law and
26 rule, or a child under age 1, if either is living in a family
27 that has an income which is at or below 150 percent of the
28 most current federal poverty level, or, effective January 1,
29 1992, that has an income which is at or below 185 percent of
30 the most current federal poverty level. Such a person is not
31 subject to an assets test. Further, a pregnant woman who
5
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 applies for eligibility for the Medicaid program through a
2 qualified Medicaid provider must be offered the opportunity,
3 subject to federal rules, to be made presumptively eligible
4 for the Medicaid program.
5 Section 4. Subsections (1) and (5) of section 409.904,
6 Florida Statutes, are amended, and subsection (9) is added to
7 said section, to read:
8 409.904 Optional payments for eligible persons.--The
9 agency may make payments for medical assistance and related
10 services on behalf of the following persons who are determined
11 to be eligible subject to the income, assets, and categorical
12 eligibility tests set forth in federal and state law. Payment
13 on behalf of these Medicaid-eligible persons is subject to the
14 availability of moneys and any limitations established by the
15 General Appropriations Act or chapter 216.
16 (1) A person who is age 65 or older or is determined
17 to be disabled, whose income is at or below 85 100 percent of
18 federal poverty level, and whose assets do not exceed
19 established limitations.
20 (5) Subject to specific federal authorization, a
21 postpartum woman living in a family that has an income that is
22 at or below 150 185 percent of the most current federal
23 poverty level is eligible for family planning services as
24 specified in s. 409.905(3) for a period of up to 24 months
25 following a pregnancy for which Medicaid paid for
26 pregnancy-related services.
27 (9) A Medicaid-eligible individual for the
28 individual's health insurance premiums, if the agency
29 determines that such payments are cost-effective.
30 Section 5. Subsection (5) of section 409.905, Florida
31 Statutes, is amended to read:
6
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 409.905 Mandatory Medicaid services.--The agency may
2 make payments for the following services, which are required
3 of the state by Title XIX of the Social Security Act,
4 furnished by Medicaid providers to recipients who are
5 determined to be eligible on the dates on which the services
6 were provided. Any service under this section shall be
7 provided only when medically necessary and in accordance with
8 state and federal law. Nothing in this section shall be
9 construed to prevent or limit the agency from adjusting fees,
10 reimbursement rates, lengths of stay, number of visits, number
11 of services, or any other adjustments necessary to comply with
12 the availability of moneys and any limitations or directions
13 provided for in the General Appropriations Act or chapter 216.
14 (5) HOSPITAL INPATIENT SERVICES.--The agency shall pay
15 for all covered services provided for the medical care and
16 treatment of a recipient who is admitted as an inpatient by a
17 licensed physician or dentist to a hospital licensed under
18 part I of chapter 395. However, the agency shall limit the
19 payment for inpatient hospital services for a Medicaid
20 recipient 21 years of age or older to 45 days or the number of
21 days necessary to comply with the General Appropriations Act.
22 (a) The agency is authorized to implement
23 reimbursement and utilization management reforms in order to
24 comply with any limitations or directions in the General
25 Appropriations Act, which may include, but are not limited to:
26 prior authorization for inpatient psychiatric days; prior
27 authorization for nonemergency hospital inpatient admissions;
28 enhanced utilization and concurrent review programs for highly
29 utilized services; reduction or elimination of covered days of
30 service; adjusting reimbursement ceilings for variable costs;
31
7
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 adjusting reimbursement ceilings for fixed and property costs;
2 and implementing target rates of increase.
3 (b) A licensed hospital maintained primarily for the
4 care and treatment of patients having mental disorders or
5 mental diseases is not eligible to participate in the hospital
6 inpatient portion of the Medicaid program except as provided
7 under in federal law or pursuant to a federally approved
8 waiver. However, the department shall apply for a waiver,
9 within 9 months after June 5, 1991, designed to provide
10 behavioral health hospitalization services for mental health
11 reasons to children and adults in the most cost-effective and
12 lowest cost setting possible. Such waiver shall include a
13 request for the opportunity to pay for care in hospitals known
14 under federal law as "institutions for mental disease" or
15 "IMD's." The behavioral health waiver proposal shall propose
16 no additional aggregate cost to the state or Federal
17 Government, and shall be conducted in Hillsborough County,
18 Highlands County, Hardee County, Manatee County, and Polk
19 County. Implementation of the behavioral health waiver
20 proposal shall not be the basis for adjusting a hospital's
21 Medicaid inpatient or outpatient rate. The waiver proposal may
22 incorporate competitive bidding for hospital services,
23 comprehensive brokering, prepaid capitated arrangements, or
24 other mechanisms deemed by the department to show promise in
25 reducing the cost of acute care and increasing the
26 effectiveness of preventive care. When developing The waiver
27 proposal, the department shall take into account price,
28 quality, accessibility, linkages of the hospital to community
29 services and family support programs, plans of the hospital to
30 ensure the earliest discharge possible, and the
31
8
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 comprehensiveness of the mental health and other health care
2 services offered by participating providers.
3 (c) Agency for Health Care Administration shall adjust
4 a hospital's current inpatient per diem rate to reflect the
5 cost of serving the Medicaid population at that institution
6 if:
7 1. The hospital experiences an increase in Medicaid
8 caseload by more than 25 percent in any year, primarily
9 resulting from the closure of a hospital in the same service
10 area occurring after July 1, 1995; or
11 2. The hospital's Medicaid per diem rate is at least
12 25 percent below the Medicaid per patient cost for that year.
13
14 No later than November 1, 2000, the agency must provide
15 estimated costs for any adjustment in a hospital inpatient per
16 diem pursuant to this paragraph to the Executive Office of the
17 Governor, the House of Representatives General Appropriations
18 Committee, and the Senate Budget Committee. Before the agency
19 implements a change in a hospital's inpatient per diem rate
20 pursuant to this paragraph, the Legislature must have
21 specifically appropriated sufficient funds in the 2001-2002
22 General Appropriations Act to support the increase in cost as
23 estimated by the agency. This paragraph is repealed on July 1,
24 2001.
25 Section 6. Section 409.906, Florida Statutes, is
26 amended to read:
27 409.906 Optional Medicaid services.--Subject to
28 specific appropriations, the agency may make payments for
29 services which are optional to the state under Title XIX of
30 the Social Security Act and are furnished by Medicaid
31 providers to recipients who are determined to be eligible on
9
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 the dates on which the services were provided. Any optional
2 service that is provided shall be provided only when medically
3 necessary and in accordance with state and federal law.
4 Nothing in this section shall be construed to prevent or limit
5 the agency from adjusting fees, reimbursement rates, lengths
6 of stay, number of visits, or number of services, or making
7 any other adjustments necessary to comply with the
8 availability of moneys and any limitations or directions
9 provided for in the General Appropriations Act or chapter 216.
10 If necessary to safeguard the state's systems of providing
11 services to elderly and disabled persons and subject to the
12 notice and review provisions of s. 216.177, the Governor may
13 direct the Agency for Health Care Administration to amend the
14 Medicaid state plan to delete the optional Medicaid service
15 known as "Intermediate Care Facilities for the Developmentally
16 Disabled." Optional services may include:
17 (1) ADULT DENTURE SERVICES.--The agency may pay for
18 dentures, the procedures required to seat dentures, and the
19 repair and reline of dentures, provided by or under the
20 direction of a licensed dentist, for a recipient who is age 21
21 or older.
22 (1)(2) ADULT HEALTH SCREENING SERVICES.--The agency
23 may pay for an annual routine physical examination, conducted
24 by or under the direction of a licensed physician, for a
25 recipient age 21 or older, without regard to medical
26 necessity, in order to detect and prevent disease, disability,
27 or other health condition or its progression.
28 (2)(3) AMBULATORY SURGICAL CENTER SERVICES.--The
29 agency may pay for services provided to a recipient in an
30 ambulatory surgical center licensed under part I of chapter
31
10
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 395, by or under the direction of a licensed physician or
2 dentist.
3 (3)(4) BIRTH CENTER SERVICES.--The agency may pay for
4 examinations and delivery, recovery, and newborn assessment,
5 and related services, provided in a licensed birth center
6 staffed with licensed physicians, certified nurse midwives,
7 and midwives licensed in accordance with chapter 467, to a
8 recipient expected to experience a low-risk pregnancy and
9 delivery.
10 (4)(5) CASE MANAGEMENT SERVICES.--The agency may pay
11 for primary care case management services rendered to a
12 recipient pursuant to a federally approved waiver, and
13 targeted case management services for specific groups of
14 targeted recipients, for which funding has been provided and
15 which are rendered pursuant to federal guidelines. The agency
16 is authorized to limit reimbursement for targeted case
17 management services in order to comply with any limitations or
18 directions provided for in the General Appropriations Act.
19 Notwithstanding s. 216.292, the Department of Children and
20 Family Services may transfer general funds to the Agency for
21 Health Care Administration to fund state match requirements
22 exceeding the amount specified in the General Appropriations
23 Act for targeted case management services.
24 (5)(6) CHILDREN'S DENTAL SERVICES.--The agency may pay
25 for diagnostic, preventive, or corrective procedures,
26 including orthodontia in severe cases, provided to a recipient
27 under age 21, by or under the supervision of a licensed
28 dentist. Services provided under this program include
29 treatment of the teeth and associated structures of the oral
30 cavity, as well as treatment of disease, injury, or impairment
31 that may affect the oral or general health of the individual.
11
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (6)(7) CHIROPRACTIC SERVICES.--The agency may pay for
2 manual manipulation of the spine and initial services,
3 screening, and X rays provided to a recipient by a licensed
4 chiropractic physician.
5 (7)(8) COMMUNITY MENTAL HEALTH SERVICES.--The agency
6 may pay for rehabilitative services provided to a recipient by
7 a mental health or substance abuse provider licensed by the
8 agency and under contract with the agency or the Department of
9 Children and Family Services to provide such services. Those
10 services which are psychiatric in nature shall be rendered or
11 recommended by a psychiatrist, and those services which are
12 medical in nature shall be rendered or recommended by a
13 physician or psychiatrist. The agency must develop a provider
14 enrollment process for community mental health providers which
15 bases provider enrollment on an assessment of service need.
16 The provider enrollment process shall be designed to control
17 costs, prevent fraud and abuse, consider provider expertise
18 and capacity, and assess provider success in managing
19 utilization of care and measuring treatment outcomes.
20 Providers will be selected through a competitive procurement
21 or selective contracting process. In addition to other
22 community mental health providers, the agency shall consider
23 for enrollment mental health programs licensed under chapter
24 395 and group practices licensed under chapter 458, chapter
25 459, chapter 490, or chapter 491. The agency is also
26 authorized to continue operation of its behavioral health
27 utilization management program and may develop new services if
28 these actions are necessary to ensure savings from the
29 implementation of the utilization management system. The
30 agency shall coordinate the implementation of this enrollment
31 process with the Department of Children and Family Services
12
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 and the Department of Juvenile Justice. The agency is
2 authorized to utilize diagnostic criteria in setting
3 reimbursement rates, to preauthorize certain high-cost or
4 highly utilized services, to limit or eliminate coverage for
5 certain services, or to make any other adjustments necessary
6 to comply with any limitations or directions provided for in
7 the General Appropriations Act.
8 (8)(9) DIALYSIS FACILITY SERVICES.--Subject to
9 specific appropriations being provided for this purpose, the
10 agency may pay a dialysis facility that is approved as a
11 dialysis facility in accordance with Title XVIII of the Social
12 Security Act, for dialysis services that are provided to a
13 Medicaid recipient under the direction of a physician licensed
14 to practice medicine or osteopathic medicine in this state,
15 including dialysis services provided in the recipient's home
16 by a hospital-based or freestanding dialysis facility.
17 (9)(10) DURABLE MEDICAL EQUIPMENT.--The agency may
18 authorize and pay for certain durable medical equipment and
19 supplies provided to a Medicaid recipient as medically
20 necessary.
21 (10)(11) HEALTHY START SERVICES.--The agency may pay
22 for a continuum of risk-appropriate medical and psychosocial
23 services for the Healthy Start program in accordance with a
24 federal waiver. The agency may not implement the federal
25 waiver unless the waiver permits the state to limit enrollment
26 or the amount, duration, and scope of services to ensure that
27 expenditures will not exceed funds appropriated by the
28 Legislature or available from local sources. If the Health
29 Care Financing Administration does not approve a federal
30 waiver for Healthy Start services, the agency, in consultation
31 with the Department of Health and the Florida Association of
13
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 Healthy Start Coalitions, is authorized to establish a
2 Medicaid certified-match program for Healthy Start services.
3 Participation in the Healthy Start certified-match program
4 shall be voluntary, and reimbursement shall be limited to the
5 federal Medicaid share to Medicaid-enrolled Healthy Start
6 coalitions for services provided to Medicaid recipients. The
7 agency shall take no action to implement a certified-match
8 program without ensuring that the amendment and review
9 requirements of ss. 216.177 and 216.181 have been met.
10 (11)(12) HEARING SERVICES.--Except for individuals 21
11 years of age or older, the agency may pay for hearing and
12 related services, including hearing evaluations, hearing aid
13 devices, dispensing of the hearing aid, and related repairs,
14 if provided to a recipient by a licensed hearing aid
15 specialist, otolaryngologist, otologist, audiologist, or
16 physician.
17 (12)(13) HOME AND COMMUNITY-BASED SERVICES.--The
18 agency may pay for home-based or community-based services that
19 are rendered to a recipient in accordance with a federally
20 approved waiver program.
21 (13)(14) HOSPICE CARE SERVICES.--The agency may pay
22 for all reasonable and necessary services for the palliation
23 or management of a recipient's terminal illness, if the
24 services are provided by a hospice that is licensed under part
25 VI of chapter 400 and meets Medicare certification
26 requirements.
27 (14)(15) INTERMEDIATE CARE FACILITY FOR THE
28 DEVELOPMENTALLY DISABLED SERVICES.--The agency may pay for
29 health-related care and services provided on a 24-hour-a-day
30 basis by a facility licensed and certified as a Medicaid
31 Intermediate Care Facility for the Developmentally Disabled,
14
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 for a recipient who needs such care because of a developmental
2 disability.
3 (15)(16) INTERMEDIATE CARE SERVICES.--The agency may
4 pay for 24-hour-a-day intermediate care nursing and
5 rehabilitation services rendered to a recipient in a nursing
6 facility licensed under part II of chapter 400, if the
7 services are ordered by and provided under the direction of a
8 physician, meet nursing home level of care criteria as
9 determined by the Comprehensive Assessment and Review
10 Long-Term Care (CARE) Program of the Department of Elderly
11 Affairs, and do not meet the definition of "general care" as
12 used in the Medicaid budget estimating process.
13 (16)(17) OPTOMETRIC SERVICES.--The agency may pay for
14 services provided to a recipient, including examination,
15 diagnosis, treatment, and management, related to ocular
16 pathology, if the services are provided by a licensed
17 optometrist or physician.
18 (17)(18) PHYSICIAN ASSISTANT SERVICES.--The agency may
19 pay for all services provided to a recipient by a physician
20 assistant licensed under s. 458.347 or s. 459.022.
21 Reimbursement for such services must be not less than 80
22 percent of the reimbursement that would be paid to a physician
23 who provided the same services.
24 (18)(19) PODIATRIC SERVICES.--The agency may pay for
25 services, including diagnosis and medical, surgical,
26 palliative, and mechanical treatment, related to ailments of
27 the human foot and lower leg, if provided to a recipient by a
28 podiatric physician licensed under state law.
29 (19)(20) PRESCRIBED DRUG SERVICES.--The agency may pay
30 for medications that are prescribed for a recipient by a
31 physician or other licensed practitioner of the healing arts
15
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 authorized to prescribe medications and that are dispensed to
2 the recipient by a licensed pharmacist or physician in
3 accordance with applicable state and federal law.
4 (20)(21) REGISTERED NURSE FIRST ASSISTANT
5 SERVICES.--The agency may pay for all services provided to a
6 recipient by a registered nurse first assistant as described
7 in s. 464.027. Reimbursement for such services may not be
8 less than 80 percent of the reimbursement that would be paid
9 to a physician providing the same services.
10 (21)(22) STATE HOSPITAL SERVICES.--The agency may pay
11 for all-inclusive psychiatric inpatient hospital care provided
12 to a recipient age 65 or older in a state mental hospital.
13 (22)(23) VISUAL SERVICES.--Except for individuals 21
14 years of age or older, the agency may pay for visual
15 examinations, eyeglasses, and eyeglass repairs for a
16 recipient, if they are prescribed by a licensed physician
17 specializing in diseases of the eye or by a licensed
18 optometrist.
19 (23)(24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.--The
20 Agency for Health Care Administration, in consultation with
21 the Department of Children and Family Services, may establish
22 a targeted case-management pilot project in those counties
23 identified by the Department of Children and Family Services
24 and for the community-based child welfare project in Sarasota
25 and Manatee counties, as authorized under s. 409.1671. These
26 projects shall be established for the purpose of determining
27 the impact of targeted case management on the child welfare
28 program and the earnings from the child welfare program.
29 Results of the pilot projects shall be reported to the Child
30 Welfare Estimating Conference and the Social Services
31 Estimating Conference established under s. 216.136. The number
16
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 of projects may not be increased until requested by the
2 Department of Children and Family Services, recommended by the
3 Child Welfare Estimating Conference and the Social Services
4 Estimating Conference, and approved by the Legislature. The
5 covered group of individuals who are eligible to receive
6 targeted case management include children who are eligible for
7 Medicaid; who are between the ages of birth through 21; and
8 who are under protective supervision or postplacement
9 supervision, under foster-care supervision, or in shelter care
10 or foster care. The number of individuals who are eligible to
11 receive targeted case management shall be limited to the
12 number for whom the Department of Children and Family Services
13 has available matching funds to cover the costs. The general
14 revenue funds required to match the funds for services
15 provided by the community-based child welfare projects are
16 limited to funds available for services described under s.
17 409.1671. The Department of Children and Family Services may
18 transfer the general revenue matching funds as billed by the
19 Agency for Health Care Administration.
20 (24) ASSISTIVE CARE SERVICES.--The agency may pay for
21 assistive care services provided to recipients with functional
22 or cognitive impairments residing in assisted living
23 facilities, adult family-care homes, or residential treatment
24 facilities with 16 or fewer beds. These services may include
25 health support, assistance with the activities of daily living
26 and the instrumental acts of daily living, assistance with
27 medication administration, and arrangements for health care.
28 Section 7. Subsection (3) of section 409.9065, Florida
29 Statutes, is amended to read:
30 409.9065 Pharmaceutical expense assistance.--
31
17
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (3) BENEFITS.--Medications covered under the
2 pharmaceutical expense assistance program are those covered
3 under the Medicaid program in s. 409.906(19)(20). Monthly
4 benefit payments shall be limited to $80 per program
5 participant. Participants are required to make a 10-percent
6 coinsurance payment for each prescription purchased through
7 this program.
8 Section 8. Section 409.908, Florida Statutes, is
9 amended to read:
10 409.908 Reimbursement of Medicaid providers.--Subject
11 to specific appropriations, the agency shall reimburse
12 Medicaid providers, in accordance with state and federal law,
13 according to methodologies set forth in the rules of the
14 agency and in policy manuals and handbooks incorporated by
15 reference therein. These methodologies may include fee
16 schedules, reimbursement methods based on cost reporting,
17 negotiated fees, competitive bidding pursuant to s. 287.057,
18 and other mechanisms the agency considers efficient and
19 effective for purchasing services or goods on behalf of
20 recipients. Payment for Medicaid compensable services made on
21 behalf of Medicaid eligible persons is subject to the
22 availability of moneys and any limitations or directions
23 provided for in the General Appropriations Act or chapter 216.
24 Further, nothing in this section shall be construed to prevent
25 or limit the agency from adjusting fees, reimbursement rates,
26 lengths of stay, number of visits, or number of services, or
27 making any other adjustments necessary to comply with the
28 availability of moneys and any limitations or directions
29 provided for in the General Appropriations Act, provided the
30 adjustment is consistent with legislative intent.
31
18
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (1) Reimbursement to hospitals licensed under part I
2 of chapter 395 must be made prospectively or on the basis of
3 negotiation or competitive bidding. The agency shall reimburse
4 for hospital inpatient and outpatient services under this
5 subsection at rates no greater than 95 percent of the
6 reimbursement rates in effect for the 2000-2001 state fiscal
7 year.
8 (a) Reimbursement for inpatient care is limited as
9 provided for in s. 409.905(5), except for:
10 1. The raising of rate reimbursement caps, excluding
11 rural hospitals.
12 2. Recognition of the costs of graduate medical
13 education.
14 3. Other methodologies recognized in the General
15 Appropriations Act.
16
17 During the years funds are transferred from the Board of
18 Regents, any reimbursement supported by such funds shall be
19 subject to certification by the Board of Regents that the
20 hospital has complied with s. 381.0403. The agency is
21 authorized to receive funds from state entities, including,
22 but not limited to, the Board of Regents, local governments,
23 and other local political subdivisions, for the purpose of
24 making special exception payments, including federal matching
25 funds, through the Medicaid inpatient reimbursement
26 methodologies. Funds received from state entities or local
27 governments for this purpose shall be separately accounted for
28 and shall not be commingled with other state or local funds in
29 any manner. Notwithstanding this section and s. 409.915,
30 counties are exempt from contributing toward the cost of the
31 special exception reimbursement for hospitals serving a
19
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 disproportionate share of low-income persons and providing
2 graduate medical education.
3 (b) Reimbursement for hospital outpatient care is
4 limited to $1,500 per state fiscal year per recipient, except
5 for:
6 1. Such care provided to a Medicaid recipient under
7 age 21, in which case the only limitation is medical
8 necessity.
9 2. Renal dialysis services.
10 3. Other exceptions made by the agency.
11
12 The agency is authorized to receive funds from state entities,
13 including, but not limited to, the Board of Regents, local
14 governments, and other local political subdivisions, for the
15 purpose of making payments, including federal matching funds,
16 through the Medicaid outpatient reimbursement methodologies.
17 Funds received from state entities and local governments for
18 this purpose shall be separately accounted for and shall not
19 be commingled with other state or local funds in any manner.
20 (c) Hospitals that provide services to a
21 disproportionate share of low-income Medicaid recipients, or
22 that participate in the regional perinatal intensive care
23 center program under chapter 383, or that participate in the
24 statutory teaching hospital disproportionate share program may
25 receive additional reimbursement. The total amount of payment
26 for disproportionate share hospitals shall be fixed by the
27 General Appropriations Act. The computation of these payments
28 must be made in compliance with all federal regulations and
29 the methodologies described in ss. 409.911, 409.9112, and
30 409.9113.
31
20
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (d) The agency is authorized to limit inflationary
2 increases for outpatient hospital services as directed by the
3 General Appropriations Act.
4 (2)(a)1. Reimbursement to nursing homes licensed under
5 part II of chapter 400 and state-owned-and-operated
6 intermediate care facilities for the developmentally disabled
7 licensed under chapter 393 must be made prospectively or on
8 the basis of competitive bidding.
9 2. Unless otherwise limited or directed in the General
10 Appropriations Act, reimbursement to hospitals licensed under
11 part I of chapter 395 for the provision of swing-bed nursing
12 home services must be made on the basis of the average
13 statewide nursing home payment, and reimbursement to a
14 hospital licensed under part I of chapter 395 for the
15 provision of skilled nursing services must be made on the
16 basis of the average nursing home payment for those services
17 in the county in which the hospital is located. When a
18 hospital is located in a county that does not have any
19 community nursing homes, reimbursement must be determined by
20 averaging the nursing home payments, in counties that surround
21 the county in which the hospital is located. Reimbursement to
22 hospitals, including Medicaid payment of Medicare copayments,
23 for skilled nursing services shall be limited to 30 days,
24 unless a prior authorization has been obtained from the
25 agency. Medicaid reimbursement may be extended by the agency
26 beyond 30 days, and approval must be based upon verification
27 by the patient's physician that the patient requires
28 short-term rehabilitative and recuperative services only, in
29 which case an extension of no more than 15 days may be
30 approved. Reimbursement to a hospital licensed under part I of
31 chapter 395 for the temporary provision of skilled nursing
21
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 services to nursing home residents who have been displaced as
2 the result of a natural disaster or other emergency may not
3 exceed the average county nursing home payment for those
4 services in the county in which the hospital is located and is
5 limited to the period of time which the agency considers
6 necessary for continued placement of the nursing home
7 residents in the hospital.
8 (b) Subject to any limitations or directions provided
9 for in the General Appropriations Act, the agency shall
10 establish and implement a Florida Title XIX Long-Term Care
11 Reimbursement Plan (Medicaid) for nursing home care in order
12 to provide care and services in conformance with the
13 applicable state and federal laws, rules, regulations, and
14 quality and safety standards and to ensure that individuals
15 eligible for medical assistance have reasonable geographic
16 access to such care. The agency shall not provide for any
17 increases in reimbursement rates to nursing homes associated
18 with changes in ownership. Under the plan, interim rate
19 adjustments shall not be granted to reflect increases in the
20 cost of general or professional liability insurance for
21 nursing homes unless the following criteria are met: have at
22 least a 65 percent Medicaid utilization in the most recent
23 cost report submitted to the agency, and the increase in
24 general or professional liability costs to the facility for
25 the most recent policy period affects the total Medicaid per
26 diem by at least 5 percent. This rate adjustment shall not
27 result in the per diem exceeding the class ceiling. This
28 provision shall apply only to fiscal year 2000-2001 and shall
29 be implemented to the extent existing appropriations are
30 available. The agency shall report to the Governor, the
31 Speaker of the House of Representatives, and the President of
22
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 the Senate by December 31, 2000, on the cost of liability
2 insurance for Florida nursing homes for fiscal years 1999 and
3 2000 and the extent to which these costs are not being
4 compensated by the Medicaid program. Medicaid-participating
5 nursing homes shall be required to report to the agency
6 information necessary to compile this report. Effective no
7 earlier than the rate-setting period beginning April 1, 1999,
8 the agency shall establish a case-mix reimbursement
9 methodology for the rate of payment for long-term care
10 services for nursing home residents. The agency shall compute
11 a per diem rate for Medicaid residents, adjusted for case mix,
12 which is based on a resident classification system that
13 accounts for the relative resource utilization by different
14 types of residents and which is based on level-of-care data
15 and other appropriate data. The case-mix methodology developed
16 by the agency shall take into account the medical, behavioral,
17 and cognitive deficits of residents. In developing the
18 reimbursement methodology, the agency shall evaluate and
19 modify other aspects of the reimbursement plan as necessary to
20 improve the overall effectiveness of the plan with respect to
21 the costs of patient care, operating costs, and property
22 costs. In the event adequate data are not available, the
23 agency is authorized to adjust the patient's care component or
24 the per diem rate to more adequately cover the cost of
25 services provided in the patient's care component. The agency
26 shall work with the Department of Elderly Affairs, the Florida
27 Health Care Association, and the Florida Association of Homes
28 for the Aging in developing the methodology. It is the intent
29 of the Legislature that the reimbursement plan achieve the
30 goal of providing access to health care for nursing home
31 residents who require large amounts of care while encouraging
23
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 diversion services as an alternative to nursing home care for
2 residents who can be served within the community. The agency
3 shall base the establishment of any maximum rate of payment,
4 whether overall or component, on the available moneys as
5 provided for in the General Appropriations Act. The agency may
6 base the maximum rate of payment on the results of
7 scientifically valid analysis and conclusions derived from
8 objective statistical data pertinent to the particular maximum
9 rate of payment.
10 (3) Subject to any limitations or directions provided
11 for in the General Appropriations Act, the following Medicaid
12 services and goods may be reimbursed on a fee-for-service
13 basis. For each allowable service or goods furnished in
14 accordance with Medicaid rules, policy manuals, handbooks, and
15 state and federal law, the payment shall be the amount billed
16 by the provider, the provider's usual and customary charge, or
17 the maximum allowable fee established by the agency, whichever
18 amount is less, with the exception of those services or goods
19 for which the agency makes payment using a methodology based
20 on capitation rates, average costs, or negotiated fees, or
21 competitive bidding.
22 (a) Advanced registered nurse practitioner services.
23 (b) Birth center services.
24 (c) Chiropractic services.
25 (d) Community mental health services.
26 (e) Dental services, including oral and maxillofacial
27 surgery.
28 (f) Durable medical equipment.
29 (g) Hearing services for Medicaid recipients under age
30 21.
31
24
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (h) Occupational therapy for Medicaid recipients under
2 age 21.
3 (i) Optometric services.
4 (j) Orthodontic services.
5 (k) Personal care for Medicaid recipients under age
6 21.
7 (l) Physical therapy for Medicaid recipients under age
8 21.
9 (m) Physician assistant services.
10 (n) Podiatric services.
11 (o) Portable X-ray services.
12 (p) Private-duty nursing for Medicaid recipients under
13 age 21.
14 (q) Registered nurse first assistant services.
15 (r) Respiratory therapy for Medicaid recipients under
16 age 21.
17 (s) Speech therapy for Medicaid recipients under age
18 21.
19 (t) Visual services for Medicaid recipients under age
20 21.
21 (4) Subject to any limitations or directions provided
22 for in the General Appropriations Act, alternative health
23 plans, health maintenance organizations, and prepaid health
24 plans shall be reimbursed a fixed, prepaid amount negotiated,
25 or competitively bid pursuant to s. 287.057, by the agency and
26 prospectively paid to the provider monthly for each Medicaid
27 recipient enrolled. The amount may not exceed the average
28 amount the agency determines it would have paid, based on
29 claims experience, for recipients in the same or similar
30 category of eligibility. The agency shall calculate
31 capitation rates on a regional basis and, beginning September
25
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 1, 1995, shall include age-band differentials in such
2 calculations. Effective July 1, 2001, the cost of exempting
3 statutory teaching hospitals, specialty hospitals, and
4 community hospital education program hospitals from
5 reimbursement ceilings and the cost of special Medicaid
6 payments shall not be included in premiums paid to health
7 maintenance organizations or prepaid health care plans.
8 (5) An ambulatory surgical center shall be reimbursed
9 the lesser of the amount billed by the provider or the
10 Medicare-established allowable amount for the facility.
11 (6) A provider of early and periodic screening,
12 diagnosis, and treatment services to Medicaid recipients who
13 are children under age 21 shall be reimbursed using an
14 all-inclusive rate stipulated in a fee schedule established by
15 the agency. A provider of the visual, dental, and hearing
16 components of such services shall be reimbursed the lesser of
17 the amount billed by the provider or the Medicaid maximum
18 allowable fee established by the agency.
19 (7) A provider of family planning services shall be
20 reimbursed the lesser of the amount billed by the provider or
21 an all-inclusive amount per type of visit for physicians and
22 advanced registered nurse practitioners, as established by the
23 agency in a fee schedule.
24 (8) A provider of home-based or community-based
25 services rendered pursuant to a federally approved waiver
26 shall be reimbursed based on an established or negotiated rate
27 for each service. These rates shall be established according
28 to an analysis of the expenditure history and prospective
29 budget developed by each contract provider participating in
30 the waiver program, or under any other methodology adopted by
31 the agency and approved by the Federal Government in
26
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 accordance with the waiver. Effective July 1, 1996, privately
2 owned and operated community-based residential facilities
3 which meet agency requirements and which formerly received
4 Medicaid reimbursement for the optional intermediate care
5 facility for the mentally retarded service may participate in
6 the developmental services waiver as part of a
7 home-and-community-based continuum of care for Medicaid
8 recipients who receive waiver services.
9 (9) A provider of home health care services or of
10 medical supplies and appliances shall be reimbursed on the
11 basis of competitive bidding or for the lesser of the amount
12 billed by the provider or the agency's established maximum
13 allowable amount, except that, in the case of the rental of
14 durable medical equipment, the total rental payments may not
15 exceed the purchase price of the equipment over its expected
16 useful life or the agency's established maximum allowable
17 amount, whichever amount is less.
18 (10) A hospice shall be reimbursed through a
19 prospective system for each Medicaid hospice patient at
20 Medicaid rates using the methodology established for hospice
21 reimbursement pursuant to Title XVIII of the federal Social
22 Security Act.
23 (11) A provider of independent laboratory services
24 shall be reimbursed on the basis of competitive bidding or for
25 the least of the amount billed by the provider, the provider's
26 usual and customary charge, or the Medicaid maximum allowable
27 fee established by the agency.
28 (12)(a) A physician shall be reimbursed the lesser of
29 the amount billed by the provider or the Medicaid maximum
30 allowable fee established by the agency.
31
27
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (b) The agency shall adopt a fee schedule, subject to
2 any limitations or directions provided for in the General
3 Appropriations Act, based on a resource-based relative value
4 scale for pricing Medicaid physician services. Under this fee
5 schedule, physicians shall be paid a dollar amount for each
6 service based on the average resources required to provide the
7 service, including, but not limited to, estimates of average
8 physician time and effort, practice expense, and the costs of
9 professional liability insurance. The fee schedule shall
10 provide increased reimbursement for preventive and primary
11 care services and lowered reimbursement for specialty services
12 by using at least two conversion factors, one for cognitive
13 services and another for procedural services. The fee
14 schedule shall not increase total Medicaid physician
15 expenditures unless funds are specifically provided for such
16 increase. However, in no case may any increase result in
17 physicians being paid more than the Medicare fee moneys are
18 available, and shall be phased in over a 2-year period
19 beginning on July 1, 1994. The Agency for Health Care
20 Administration shall seek the advice of a 16-member advisory
21 panel in formulating and adopting the fee schedule. The panel
22 shall consist of Medicaid physicians licensed under chapters
23 458 and 459 and shall be composed of 50 percent primary care
24 physicians and 50 percent specialty care physicians.
25 (c) Notwithstanding paragraph (b), reimbursement fees
26 to physicians for providing total obstetrical services to
27 Medicaid recipients, which include prenatal, delivery, and
28 postpartum care, shall be at least $1,500 per delivery for a
29 pregnant woman with low medical risk and at least $2,000 per
30 delivery for a pregnant woman with high medical risk. However,
31 reimbursement to physicians working in Regional Perinatal
28
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 Intensive Care Centers designated pursuant to chapter 383, for
2 services to certain pregnant Medicaid recipients with a high
3 medical risk, may be made according to obstetrical care and
4 neonatal care groupings and rates established by the agency.
5 Nurse midwives licensed under part I of chapter 464 or
6 midwives licensed under chapter 467 shall be reimbursed at no
7 less than 80 percent of the low medical risk fee. The agency
8 shall by rule determine, for the purpose of this paragraph,
9 what constitutes a high or low medical risk pregnant woman and
10 shall not pay more based solely on the fact that a caesarean
11 section was performed, rather than a vaginal delivery. The
12 agency shall by rule determine a prorated payment for
13 obstetrical services in cases where only part of the total
14 prenatal, delivery, or postpartum care was performed. The
15 Department of Health shall adopt rules for appropriate
16 insurance coverage for midwives licensed under chapter 467.
17 Prior to the issuance and renewal of an active license, or
18 reactivation of an inactive license for midwives licensed
19 under chapter 467, such licensees shall submit proof of
20 coverage with each application.
21 (13) Medicare premiums for persons eligible for both
22 Medicare and Medicaid coverage shall be paid at the rates
23 established by Title XVIII of the Social Security Act. For
24 Medicare services rendered to Medicaid-eligible persons,
25 Medicaid shall pay Medicare deductibles and coinsurance as
26 follows:
27 (a) Medicaid shall make no payment toward deductibles
28 and coinsurance for any service that is not covered by
29 Medicaid.
30
31
29
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (b) Medicaid's financial obligation for deductibles
2 and coinsurance payments shall be based on Medicare allowable
3 fees, not on a provider's billed charges.
4 (c) Medicaid will pay no portion of Medicare
5 deductibles and coinsurance when payment that Medicare has
6 made for the service equals or exceeds what Medicaid would
7 have paid if it had been the sole payor. The combined payment
8 of Medicare and Medicaid shall not exceed the amount Medicaid
9 would have paid had it been the sole payor. The Legislature
10 finds that there has been confusion regarding the
11 reimbursement for services rendered to dually eligible
12 Medicare beneficiaries. Accordingly, the Legislature clarifies
13 that it has always been the intent of the Legislature before
14 and after 1991 that, in reimbursing in accordance with fees
15 established by Title XVIII for premiums, deductibles, and
16 coinsurance for Medicare services rendered by physicians to
17 Medicaid eligible persons, physicians be reimbursed at the
18 lesser of the amount billed by the physician or the Medicaid
19 maximum allowable fee established by the Agency for Health
20 Care Administration, as is permitted by federal law. It has
21 never been the intent of the Legislature with regard to such
22 services rendered by physicians that Medicaid be required to
23 provide any payment for deductibles, coinsurance, or
24 copayments for Medicare cost sharing, or any expenses incurred
25 relating thereto, in excess of the payment amount provided for
26 under the State Medicaid plan for such service. This payment
27 methodology is applicable even in those situations in which
28 the payment for Medicare cost sharing for a qualified Medicare
29 beneficiary with respect to an item or service is reduced or
30 eliminated. This expression of the Legislature is in
31 clarification of existing law and shall apply to payment for,
30
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 and with respect to provider agreements with respect to, items
2 or services furnished on or after the effective date of this
3 act. This paragraph applies to payment by Medicaid for items
4 and services furnished before the effective date of this act
5 if such payment is the subject of a lawsuit that is based on
6 the provisions of this section, and that is pending as of, or
7 is initiated after, the effective date of this act.
8 (d) Notwithstanding The following provisions are
9 exceptions to paragraphs (a)-(c):
10 1. Medicaid payments for Nursing Home Medicare part A
11 coinsurance shall be the lesser of the Medicare coinsurance
12 amount or the Medicaid nursing home per diem rate.
13 2. Medicaid shall pay all deductibles and coinsurance
14 for Nursing Home Medicare part B services.
15 2.3. Medicaid shall pay all deductibles and
16 coinsurance for Medicare-eligible recipients receiving
17 freestanding end stage renal dialysis center services.
18 4. Medicaid shall pay all deductibles and coinsurance
19 for hospital outpatient Medicare part B services.
20 3.5. Medicaid payments for general hospital inpatient
21 services shall be limited to the Medicare deductible per spell
22 of illness. Medicaid shall make no payment toward coinsurance
23 for Medicare general hospital inpatient services.
24 4.6. Medicaid shall pay all deductibles and
25 coinsurance for Medicare emergency transportation services
26 provided by ambulances licensed pursuant to chapter 401.
27 (14) A provider of prescribed drugs shall be
28 reimbursed on the basis of competitive bidding or for the
29 least of the amount billed by the provider, the provider's
30 usual and customary charge, or the Medicaid maximum allowable
31 fee established by the agency, plus a dispensing fee. The
31
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 agency is directed to implement a variable dispensing fee for
2 payments for prescribed medicines while ensuring continued
3 access for Medicaid recipients. The variable dispensing fee
4 may be based upon, but not limited to, either or both the
5 volume of prescriptions dispensed by a specific pharmacy
6 provider and the volume of prescriptions dispensed to an
7 individual recipient. The agency is authorized to limit
8 reimbursement for prescribed medicine in order to comply with
9 any limitations or directions provided for in the General
10 Appropriations Act, which may include implementing a
11 prospective or concurrent utilization review program.
12 (15) A provider of primary care case management
13 services rendered pursuant to a federally approved waiver
14 shall be reimbursed by payment of a fixed, prepaid monthly sum
15 for each Medicaid recipient enrolled with the provider.
16 (16) A provider of rural health clinic services and
17 federally qualified health center services shall be reimbursed
18 a rate per visit based on total reasonable costs of the
19 clinic, as determined by the agency in accordance with federal
20 regulations.
21 (17) A provider of targeted case management services
22 shall be reimbursed pursuant to an established fee, except
23 where the Federal Government requires a public provider be
24 reimbursed on the basis of average actual costs.
25 (18) Unless otherwise provided for in the General
26 Appropriations Act, a provider of transportation services
27 shall be reimbursed the lesser of the amount billed by the
28 provider or the Medicaid maximum allowable fee established by
29 the agency, except when the agency has entered into a direct
30 contract with the provider, or with a community transportation
31 coordinator, for the provision of an all-inclusive service, or
32
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 when services are provided pursuant to an agreement negotiated
2 between the agency and the provider. The agency, as provided
3 for in s. 427.0135, shall purchase transportation services
4 through the community coordinated transportation system, if
5 available, unless the agency determines a more cost-effective
6 method for Medicaid clients. Nothing in this subsection shall
7 be construed to limit or preclude the agency from contracting
8 for services using a prepaid capitation rate or from
9 establishing maximum fee schedules, individualized
10 reimbursement policies by provider type, negotiated fees,
11 prior authorization, competitive bidding, increased use of
12 mass transit, or any other mechanism that the agency considers
13 efficient and effective for the purchase of services on behalf
14 of Medicaid clients, including implementing a transportation
15 eligibility process. The agency shall not be required to
16 contract with any community transportation coordinator or
17 transportation operator that has been determined by the
18 agency, the Department of Legal Affairs Medicaid Fraud Control
19 Unit, or any other state or federal agency to have engaged in
20 any abusive or fraudulent billing activities. The agency is
21 authorized to competitively procure transportation services or
22 make other changes necessary to secure approval of federal
23 waivers needed to permit federal financing of Medicaid
24 transportation services at the service matching rate rather
25 than the administrative matching rate.
26 (19) County health department services may be
27 reimbursed a rate per visit based on total reasonable costs of
28 the clinic, as determined by the agency in accordance with
29 federal regulations under the authority of 42 C.F.R. s.
30 431.615.
31
33
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (20) A renal dialysis facility that provides dialysis
2 services under s. 409.906(8)(9) must be reimbursed the lesser
3 of the amount billed by the provider, the provider's usual and
4 customary charge, or the maximum allowable fee established by
5 the agency, whichever amount is less.
6 (21) The agency shall reimburse school districts which
7 certify the state match pursuant to ss. 236.0812 and 409.9071
8 for the federal portion of the school district's allowable
9 costs to deliver the services, based on the reimbursement
10 schedule. The school district shall determine the costs for
11 delivering services as authorized in ss. 236.0812 and 409.9071
12 for which the state match will be certified. Reimbursement of
13 school-based providers is contingent on such providers being
14 enrolled as Medicaid providers and meeting the qualifications
15 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
16 the federal Health Care Financing Administration. Speech
17 therapy providers who are certified through the Department of
18 Education pursuant to rule 6A-4.0176, Florida Administrative
19 Code, are eligible for reimbursement for services that are
20 provided on school premises. Any employee of the school
21 district who has been fingerprinted and has received a
22 criminal background check in accordance with Department of
23 Education rules and guidelines shall be exempt from any agency
24 requirements relating to criminal background checks.
25 Elementary, middle, and secondary schools affiliated with
26 Florida universities may separately enroll in the Medicaid
27 certified school match program and may certify local
28 expenditures for Medicaid school health services and the
29 administrative claiming program.
30
31
34
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (22) Reimbursement to state-owned-and-operated
2 intermediate care facilities for the developmentally disabled
3 licensed under chapter 393 must be made prospectively.
4 Section 9. Paragraph (c) of subsection (1), paragraph
5 (b) of subsection (3), and subsection (7) of section 409.911,
6 Florida Statutes, are amended to read:
7 409.911 Disproportionate share program.--Subject to
8 specific allocations established within the General
9 Appropriations Act and any limitations established pursuant to
10 chapter 216, the agency shall distribute, pursuant to this
11 section, moneys to hospitals providing a disproportionate
12 share of Medicaid or charity care services by making quarterly
13 Medicaid payments as required. Notwithstanding the provisions
14 of s. 409.915, counties are exempt from contributing toward
15 the cost of this special reimbursement for hospitals serving a
16 disproportionate share of low-income patients.
17 (1) Definitions.--As used in this section and s.
18 409.9112:
19 (c) "Base Medicaid per diem" means the hospital's
20 Medicaid per diem rate initially established by the Agency for
21 Health Care Administration on January 1, 1999 prior to the
22 beginning of each state fiscal year. The base Medicaid per
23 diem rate shall not include any additional per diem increases
24 received as a result of the disproportionate share
25 distribution.
26 (3) In computing the disproportionate share rate:
27 (b) The agency shall use 1994 the most recent calendar
28 year audited financial data available at the beginning of each
29 state fiscal year for the calculation of disproportionate
30 share payments under this section.
31
35
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (7) For fiscal year 1991-1992 and all years other than
2 1992-1993, The following criteria shall be used in determining
3 the disproportionate share percentage:
4 (a) If the disproportionate share rate is less than 10
5 percent, the disproportionate share percentage is zero and
6 there is no additional payment.
7 (b) If the disproportionate share rate is greater than
8 or equal to 10 percent, but less than 20 percent, then the
9 disproportionate share percentage is 1.8478498 2.1544347.
10 (c) If the disproportionate share rate is greater than
11 or equal to 20 percent, but less than 30 percent, then the
12 disproportionate share percentage is 3.4145488 4.6415888766.
13 (d) If the disproportionate share rate is greater than
14 or equal to 30 percent, but less than 40 percent, then the
15 disproportionate share percentage is 6.3095734 10.0000001388.
16 (e) If the disproportionate share rate is greater than
17 or equal to 40 percent, but less than 50 percent, then the
18 disproportionate share percentage is 11.6591440 21.544347299.
19 (f) If the disproportionate share rate is greater than
20 or equal to 50 percent, but less than 60 percent, then the
21 disproportionate share percentage is 73.5642254 46.41588941.
22 (g) If the disproportionate share rate is greater than
23 or equal to 60 percent but less than 72.5 percent, then the
24 disproportionate share percentage is 135.9356391 100.
25 (h) If the disproportionate share rate is greater than
26 or equal to 72.5 percent, then the disproportionate share
27 percentage is 170.
28 Section 10. Section 409.91195, Florida Statutes, is
29 amended to read:
30 409.91195 Medicaid Pharmaceutical and Therapeutics
31 Committee; restricted drug formulary.--There is created a
36
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 Medicaid Pharmaceutical and Therapeutics Committee for the
2 purpose of developing a restricted drug formulary. The
3 committee shall develop and implement a voluntary Medicaid
4 preferred prescribed drug designation program. The program
5 established under this section shall provide information to
6 Medicaid providers on medically appropriate and cost-efficient
7 prescription drug therapies through the development and
8 publication of a restricted drug formulary voluntary Medicaid
9 preferred prescribed-drug list.
10 (1) The Medicaid Pharmaceutical and Therapeutics
11 Committee shall be comprised of nine members as specified in
12 42 U.S.C. s. 1396 appointed as follows: one practicing
13 physician licensed under chapter 458, appointed by the Speaker
14 of the House of Representatives from a list of recommendations
15 from the Florida Medical Association; one practicing physician
16 licensed under chapter 459, appointed by the Speaker of the
17 House of Representatives from a list of recommendations from
18 the Florida Osteopathic Medical Association; one practicing
19 physician licensed under chapter 458, appointed by the
20 President of the Senate from a list of recommendations from
21 the Florida Academy of Family Physicians; one practicing
22 podiatric physician licensed under chapter 461, appointed by
23 the President of the Senate from a list of recommendations
24 from the Florida Podiatric Medical Association; one trauma
25 surgeon licensed under chapter 458, appointed by the Speaker
26 of the House of Representatives from a list of recommendations
27 from the American College of Surgeons; one practicing dentist
28 licensed under chapter 466, appointed by the President of the
29 Senate from a list of recommendations from the Florida Dental
30 Association; one practicing pharmacist licensed under chapter
31 465, appointed by the Governor from a list of recommendations
37
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 from the Florida Pharmacy Association; one practicing
2 pharmacist licensed under chapter 465, appointed by the
3 Governor from a list of recommendations from the Florida
4 Society of Health System Pharmacists; and one health care
5 professional with expertise in clinical pharmacology appointed
6 by the Governor from a list of recommendations from the
7 Pharmaceutical Research and Manufacturers Association. The
8 members shall be appointed to serve for terms of 2 years from
9 the date of their appointment. Members may be appointed to
10 more than one term. The Agency for Health Care Administration
11 shall serve as staff for the committee and assist them with
12 all ministerial duties.
13 (2) With the advice of Upon recommendation by the
14 committee, the Agency for Health Care Administration shall
15 establish a restricted drug formulary the voluntary Medicaid
16 preferred prescribed-drug list. Upon further recommendation by
17 the committee, the agency shall add to, delete from, or modify
18 the list. The committee shall also review requests for
19 additions to, deletions from, or modifications of the
20 formulary as presented to it by the agency; and, upon further
21 recommendation by the committee, the agency shall add to,
22 delete from, or modify the formulary as appropriate list. The
23 list shall be adopted by the committee in consultation with
24 medical specialists, when appropriate, using the following
25 criteria: use of the list shall be voluntary by providers and
26 the list must provide for medically appropriate drug therapies
27 for Medicaid patients which achieve cost savings in the
28 Medicaid program.
29 (3) The Agency for Health Care Administration shall
30 publish and disseminate the restricted drug formulary
31
38
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 voluntary Medicaid preferred prescribed drug list to all
2 Medicaid prescribing providers in the state.
3 Section 11. Subsection (2) of section 409.9116,
4 Florida Statutes, is amended to read:
5 409.9116 Disproportionate share/financial assistance
6 program for rural hospitals.--In addition to the payments made
7 under s. 409.911, the Agency for Health Care Administration
8 shall administer a federally matched disproportionate share
9 program and a state-funded financial assistance program for
10 statutory rural hospitals. The agency shall make
11 disproportionate share payments to statutory rural hospitals
12 that qualify for such payments and financial assistance
13 payments to statutory rural hospitals that do not qualify for
14 disproportionate share payments. The disproportionate share
15 program payments shall be limited by and conform with federal
16 requirements. Funds shall be distributed quarterly in each
17 fiscal year for which an appropriation is made.
18 Notwithstanding the provisions of s. 409.915, counties are
19 exempt from contributing toward the cost of this special
20 reimbursement for hospitals serving a disproportionate share
21 of low-income patients.
22 (2) The agency shall use the following formula for
23 distribution of funds for the disproportionate share/financial
24 assistance program for rural hospitals:
25 (a) The agency shall first determine a preliminary
26 payment amount for each rural hospital by allocating all
27 available state funds using the following formula:
28
29 PDAER = (TAERH x TARH)/STAERH
30
31 Where:
39
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 PDAER = preliminary distribution amount for each rural
2 hospital.
3 TAERH = total amount earned by each rural hospital.
4 TARH = total amount appropriated or distributed under
5 this section.
6 STAERH = sum of total amount earned by each rural
7 hospital.
8 (b) Federal matching funds for the disproportionate
9 share program shall then be calculated for those hospitals
10 that qualify for disproportionate share in paragraph (a).
11 (c) The state-funds-only payment amount shall then be
12 calculated for each hospital using the following formula:
13
14 SFOER = Maximum value of (1) SFOL - PDAER or (2) 0
15
16 Where:
17 SFOER = state-funds-only payment amount for each rural
18 hospital.
19 SFOL = state-funds-only payment level, which is set at
20 4 percent of TARH.
21
22 In calculating the SFOER, PDAER includes federal matching
23 funds from paragraph (b).
24 (d) The adjusted total amount allocated to the rural
25 disproportionate share program shall then be calculated using
26 the following formula:
27
28 ATARH = (TARH - SSFOER)
29
30 Where:
31
40
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 ATARH = adjusted total amount appropriated or
2 distributed under this section.
3 SSFOER = sum of the state-funds-only payment amount
4 calculated under paragraph (c) for all rural hospitals.
5 (e) The distribution of the adjusted total amount of
6 rural disproportionate share hospital funds shall then be
7 calculated using the following formula:
8
9 DAERH = [(TAERH x ATARH)/STAERH]
10
11 Where:
12 DAERH = distribution amount for each rural hospital.
13 (f) Federal matching funds for the disproportionate
14 share program shall then be calculated for those hospitals
15 that qualify for disproportionate share in paragraph (e).
16 (g) State-funds-only payment amounts calculated under
17 paragraph (c) and corresponding federal matching funds are
18 then added to the results of paragraph (f) to determine the
19 total distribution amount for each rural hospital. In
20 determining the payment amount for each rural hospital under
21 this section, the agency shall first allocate all available
22 state funds by the following formula:
23
24 DAER = (TAERH x TARH)/STAERH
25
26 Where:
27 DAER = distribution amount for each rural hospital.
28 STAERH = sum of total amount earned by each rural
29 hospital.
30 TAERH = total amount earned by each rural hospital.
31
41
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 TARH = total amount appropriated or distributed under
2 this section.
3
4 Federal matching funds for the disproportionate share program
5 shall then be calculated for those hospitals that qualify for
6 disproportionate share payments under this section.
7 Section 12. Paragraph (b) of subsection (3),
8 subsections (26) and (34), and paragraph (a) of subsection
9 (37) of section 409.912, Florida Statutes, are amended to
10 read:
11 409.912 Cost-effective purchasing of health care.--The
12 agency shall purchase goods and services for Medicaid
13 recipients in the most cost-effective manner consistent with
14 the delivery of quality medical care. The agency shall
15 maximize the use of prepaid per capita and prepaid aggregate
16 fixed-sum basis services when appropriate and other
17 alternative service delivery and reimbursement methodologies,
18 including competitive bidding pursuant to s. 287.057, designed
19 to facilitate the cost-effective purchase of a case-managed
20 continuum of care. The agency shall also require providers to
21 minimize the exposure of recipients to the need for acute
22 inpatient, custodial, and other institutional care and the
23 inappropriate or unnecessary use of high-cost services.
24 (3) The agency may contract with:
25 (b) An entity that provides is providing comprehensive
26 behavioral health care services to certain Medicaid recipients
27 through a capitated, prepaid arrangement pursuant to the
28 federal waiver provided for by s. 409.905(5). Such an entity
29 must be licensed under chapter 624, chapter 636, or chapter
30 641 and must possess the clinical systems and operational
31 competence to manage risk and provide comprehensive behavioral
42
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 health care to Medicaid recipients. As used in this paragraph,
2 the term "comprehensive behavioral health care services" means
3 covered mental health and substance abuse treatment services
4 that are available to Medicaid recipients. The secretary of
5 the Department of Children and Family Services shall approve
6 provisions of procurements related to children in the
7 department's care or custody prior to enrolling such children
8 in a prepaid behavioral health plan. Any contract awarded
9 under this paragraph must be competitively procured. In
10 developing the behavioral health care prepaid plan procurement
11 document, the agency shall ensure that the procurement
12 document requires the contractor to develop and implement a
13 plan to ensure compliance with s. 394.4574 related to services
14 provided to residents of licensed assisted living facilities
15 that hold a limited mental health license. The agency must
16 ensure that Medicaid recipients have available the choice of
17 at least two managed care plans for their behavioral health
18 care services. The agency may continue to reimburse for
19 substance abuse treatment services on a fee-for-service basis
20 until the agency finds that adequate funds are available for
21 capitated, prepaid arrangements or until the agency determines
22 that a capitated arrangement will not adversely affect the
23 availability of substance abuse treatment services.
24 1. By January 1, 2001, the agency shall modify the
25 contracts with the entities providing comprehensive inpatient
26 and outpatient mental health care services to Medicaid
27 recipients in Hillsborough, Highlands, Hardee, Manatee, and
28 Polk Counties, to include substance-abuse-treatment services.
29 2. By December 31, 2001, the agency shall contract
30 with entities providing comprehensive behavioral health care
31 services to Medicaid recipients through capitated, prepaid
43
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
2 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
3 and Walton Counties. The agency may contract with entities
4 providing comprehensive behavioral health care services to
5 Medicaid recipients through capitated, prepaid arrangements in
6 Alachua County. The agency may determine if Sarasota County
7 shall be included as a separate catchment area or included in
8 any other agency geographic area.
9 1.3. Children residing in a Department of Juvenile
10 Justice residential program approved as a Medicaid behavioral
11 health overlay services provider shall not be included in a
12 behavioral health care prepaid health plan pursuant to this
13 paragraph.
14 2.4. In converting to a prepaid system of delivery,
15 the agency shall in its procurement document require an entity
16 providing comprehensive behavioral health care services to
17 prevent the displacement of indigent care patients by
18 enrollees in the Medicaid prepaid health plan providing
19 behavioral health care services from facilities receiving
20 state funding to provide indigent behavioral health care, to
21 facilities licensed under chapter 395 which do not receive
22 state funding for indigent behavioral health care, or
23 reimburse the unsubsidized facility for the cost of behavioral
24 health care provided to the displaced indigent care patient.
25 3.5. Traditional community mental health providers
26 under contract with the Department of Children and Family
27 Services pursuant to part IV of chapter 394 and inpatient
28 mental health providers licensed pursuant to chapter 395 must
29 be offered an opportunity to accept or decline a contract to
30 participate in any provider network for prepaid behavioral
31 health services.
44
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 (26) The agency shall conduct perform choice
2 counseling, enrollments, and disenrollments for Medicaid
3 recipients who are eligible for MediPass or managed care
4 plans. Notwithstanding the prohibition contained in paragraph
5 (18)(f), managed care plans may perform preenrollments of
6 Medicaid recipients under the supervision of the agency or its
7 agents. For the purposes of this section, "preenrollment"
8 means the provision of marketing and educational materials to
9 a Medicaid recipient and assistance in completing the
10 application forms, but shall not include actual enrollment
11 into a managed care plan. An application for enrollment shall
12 not be deemed complete until the agency or its agent verifies
13 that the recipient made an informed, voluntary choice. The
14 agency, in cooperation with the Department of Children and
15 Family Services, may test new marketing initiatives to inform
16 Medicaid recipients about their managed care options at
17 selected sites. The agency shall report to the Legislature on
18 the effectiveness of such initiatives. The agency may
19 contract with a third party to perform managed care plan and
20 MediPass choice-counseling, enrollment, and disenrollment
21 services for Medicaid recipients and is authorized to adopt
22 rules to implement such services. The agency may adjust the
23 capitation rate only to cover the costs of a third-party
24 choice-counseling, enrollment, and disenrollment contract, and
25 for agency supervision and management of the managed care plan
26 choice-counseling, enrollment, and disenrollment contract.
27 (34) The agency may provide for cost-effective
28 purchasing of home health services, hospital inpatient and
29 outpatient services, private duty nursing services,
30 independent laboratory services, durable medical equipment and
31 supplies, nursing home services, other long-term care
45
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 services, and prescribed drug services through competitive
2 bidding negotiation pursuant to s. 287.057. The agency may
3 request appropriate waivers from the federal Health Care
4 Financing Administration in order to competitively bid such
5 home health services. The agency may exclude providers not
6 selected through the bidding process from the Medicaid
7 provider network.
8 (37)(a) The agency shall implement a Medicaid
9 prescribed-drug spending-control program that includes the
10 following components:
11 1. Medicaid prescribed-drug coverage for brand-name
12 drugs for adult Medicaid recipients not residing in nursing
13 homes or other institutions is limited to the dispensing of
14 four brand-name drugs per month per recipient. Children and
15 institutionalized adults are exempt from this restriction.
16 Antiretroviral agents are excluded from this limitation. No
17 requirements for prior authorization or other restrictions on
18 medications used to treat mental illnesses such as
19 schizophrenia, severe depression, or bipolar disorder may be
20 imposed on Medicaid recipients. Medications that will be
21 available without restriction for persons with mental
22 illnesses include atypical antipsychotic medications,
23 conventional antipsychotic medications, selective serotonin
24 reuptake inhibitors, and other medications used for the
25 treatment of serious mental illnesses. The agency shall also
26 limit the amount of a prescribed drug dispensed to no more
27 than a 34-day supply. The agency shall continue to provide
28 unlimited generic drugs, contraceptive drugs and items, and
29 diabetic supplies. The agency may authorize exceptions to the
30 brand-name-drug restriction or to the restricted drug
31 formulary, based upon the treatment needs of the patients,
46
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 only when such exceptions are based on prior consultation
2 provided by the agency or an agency contractor, but the agency
3 must establish procedures to ensure that:
4 a. There will be a response to a request for prior
5 consultation by telephone or other telecommunication device
6 within 24 hours after receipt of a request for prior
7 consultation; and
8 b. A 72-hour supply of the drug prescribed will be
9 provided in an emergency or when the agency does not provide a
10 response within 24 hours as required by sub-subparagraph a.
11 2. Reimbursement to pharmacies for Medicaid prescribed
12 drugs shall be set at the lowest of the average wholesale
13 price less 13.25 percent, the wholesaler acquisition cost plus
14 7 percent, the federal or state pricing limit, or the
15 provider's usual and customary charge.
16 3. The agency shall develop and implement a process
17 for managing the drug therapies of Medicaid recipients who are
18 using significant numbers of prescribed drugs each month. The
19 management process may include, but is not limited to,
20 comprehensive, physician-directed medical-record reviews,
21 claims analyses, and case evaluations to determine the medical
22 necessity and appropriateness of a patient's treatment plan
23 and drug therapies. The agency may contract with a private
24 organization to provide drug-program-management services.
25 4. The agency may limit the size of its pharmacy
26 network based on need, competitive bidding, price
27 negotiations, credentialing, or similar criteria. The agency
28 shall give special consideration to rural areas in determining
29 the size and location of pharmacies included in the Medicaid
30 pharmacy network. A pharmacy credentialing process may include
31 criteria such as a pharmacy's full-service status, location,
47
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 size, patient educational programs, patient consultation,
2 disease-management services, and other characteristics. The
3 agency may impose a moratorium on Medicaid pharmacy enrollment
4 when it is determined that it has a sufficient number of
5 Medicaid-participating providers.
6 5. The agency shall develop and implement a program
7 that requires Medicaid practitioners who prescribe drugs to
8 use a counterfeit-proof prescription pad for Medicaid
9 prescriptions. The agency shall require the use of
10 standardized counterfeit-proof prescription pads by
11 Medicaid-participating prescribers or prescribers who write
12 prescriptions for Medicaid recipients. The agency may
13 implement the program in targeted geographic areas or
14 statewide.
15 6. The agency may enter into arrangements that require
16 manufacturers of generic drugs prescribed to Medicaid
17 recipients to provide rebates of at least 15.1 percent of the
18 average manufacturer price for the manufacturer's generic
19 products. These arrangements shall require that if a
20 generic-drug manufacturer pays federal rebates for
21 Medicaid-reimbursed drugs at a level below 15.1 percent, the
22 manufacturer must provide a supplemental rebate to the state
23 in an amount necessary to achieve a 15.1-percent rebate level.
24 If a generic-drug manufacturer raises its price in excess of
25 the Consumer Price Index (Urban), the excess amount shall be
26 included in the supplemental rebate to the state.
27 7. The agency may establish a restricted drug
28 formulary in accordance with 42 U.S.C. s. 1396r and, pursuant
29 to the establishment of such formulary, is authorized to
30 negotiate supplemental rebates from manufacturers at no less
31 than 10 percent of the average wholesale price on the last day
48
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 of each quarter. State supplemental manufacturer rebates shall
2 be invoiced concurrently with federal rebates.
3 Section 13. Paragraph (a) of subsection (1) and
4 subsection (7) of section 409.915, Florida Statutes, are
5 amended to read:
6 409.915 County contributions to Medicaid.--Although
7 the state is responsible for the full portion of the state
8 share of the matching funds required for the Medicaid program,
9 in order to acquire a certain portion of these funds, the
10 state shall charge the counties for certain items of care and
11 service as provided in this section.
12 (1) Each county shall participate in the following
13 items of care and service:
14 (a) Payments for inpatient hospitalization in excess
15 of 10 12 days, but not in excess of 45 days, with the
16 exception of pregnant women and children whose income is in
17 excess of the federal poverty level and who do not participate
18 in the Medicaid medically needy program.
19 (7) Counties are exempt from contributing toward the
20 cost of new exemptions on inpatient ceilings for statutory
21 teaching hospitals, specialty hospitals, and community
22 hospital education program hospitals that came into effect
23 July 1, 2000, and for special Medicaid payments that came into
24 effect on or after July 1, 2000. Notwithstanding any
25 provision of this section to the contrary, counties are exempt
26 from contributing toward the increased cost of hospital
27 inpatient services due to the elimination of ceilings on
28 Medicaid inpatient reimbursement rates paid to teaching
29 hospitals, specialty hospitals, and community health education
30 program hospitals and for special Medicaid reimbursements to
31 hospitals for which the Legislature has specifically
49
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 appropriated funds. This subsection is repealed on July 1,
2 2001.
3 Section 14. Section 636.0145, Florida Statutes, is
4 repealed:
5 636.0145 Certain entities contracting with
6 Medicaid.--Notwithstanding the requirements of s.
7 409.912(3)(b), an entity that is providing comprehensive
8 inpatient and outpatient mental health care services to
9 certain Medicaid recipients in Hillsborough, Highlands,
10 Hardee, Manatee, and Polk Counties through a capitated,
11 prepaid arrangement pursuant to the federal waiver provided
12 for in s. 409.905(5) must become licensed under chapter 636 by
13 December 31, 1998. Any entity licensed under this chapter
14 which provides services solely to Medicaid recipients under a
15 contract with Medicaid shall be exempt from ss. 636.017,
16 636.018, 636.022, 636.028, and 636.034.
17 Section 15. The Legislature determines and declares
18 that this act fulfills an important state interest.
19 Section 16. This act shall take effect July 1, 2001.
20
21
22
23
24
25
26
27
28
29
30
31
50
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 *****************************************
2 HOUSE SUMMARY
3
Revises various provisions relating to duties of the
4 Agency for Health Care Administration with respect to
Medicaid. Deletes the requirement to provide recipients
5 counseling regarding choice among health care provider
options. Revises Medicaid eligibility requirements for
6 pregnant women and children under age 1. Revises
Medicaid eligibility requirements for certain elderly or
7 disabled persons. Revises Medicaid eligibility
requirements of postpartum women for family planning
8 services. Authorizes payment for health insurance
premiums of eligible individuals if cost-effective.
9 Updates provisions relating to hospital inpatient
behavioral health services provided pursuant to a
10 federally approved waiver and expands provision of such
services statewide. Deletes adult denture services as
11 optional Medicaid services and restricts authorized
hearing and visual services to children. Provides
12 additional requirements for authorized intermediate care
services. Adds assistive care services as an optional
13 Medicaid service for recipients in certain residential
living settings. Provides for reimbursement of hospital
14 inpatient and outpatient services at certain rates.
Prohibits increases in reimbursement rates to nursing
15 homes associated with changes in ownership. Precludes
premium adjustments to managed care organizations under
16 certain circumstances. Revises provisions relating to
physician reimbursement and the reimbursement fee
17 schedule. Deletes certain preferential Medicaid payments
for dually eligible recipients. Authorizes competitive
18 procurement of transportation services or the securing
through waivers of federal financing of transportation
19 services at certain rates. Authorizes public schools
affiliated with Florida universities to separately enroll
20 in the Medicaid certified school match program and
certify local expenditures therefor. Updates data
21 requirements and share rates for disproportionate share
distributions and modifies the formula for
22 disproportionate share/financial assistance distributions
to rural hospitals. Revises provisions relating to the
23 membership of the Medicaid Pharmaceutical and
Therapeutics Committee. Provides for establishment of a
24 restricted drug formulary for Medicaid providers,
authorizes exemptions therefrom, and authorizes
25 negotiation of supplemental rebates from drug
manufacturers pursuant thereto. Authorizes continued
26 reimbursement of substance abuse treatment services on a
fee-for-service basis under certain conditions. Deletes
27 authorization to test new marketing initiatives relating
to managed care options. Deletes a restriction on
28 adjustment of capitation rates. Permits competitive
bidding for certain services. Modifies reimbursement to
29 pharmacies. Requires prescriptions for Medicaid
recipients to be on certain standardized forms.
30 Increases county contributions to Medicaid for inpatient
hospitalization. Exempts counties from contributing
31 toward the cost of inpatient services provided by certain
hospitals and for special Medicaid payments under certain
51
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1753
187-883A-01
1 conditions. Provides a finding of important state
interest. See bill for details.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
52
CODING: Words stricken are deletions; words underlined are additions.