Senate Bill sb0026B
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Florida Senate - 2001 SB 26-B
By Senator Silver
309-502A-02
1 A bill to be entitled
2 An act relating to the Agency for Health Care
3 Administration; amending s. 400.23, F.S.;
4 revising the date by which certain rules
5 relating to care for nursing home residents
6 must be adopted; amending s. 409.903, F.S.;
7 revising standards for eligibility for certain
8 mandatory medical assistance; repealing s.
9 409.904(11), F.S., which provides eligibility
10 of specified persons for certain optional
11 medical assistance; amending s. 409.904, F.S.;
12 revising standards for eligibility for certain
13 optional medical assistance; amending s.
14 409.906, F.S.; eliminating adult denture
15 services as an optional Medicaid service;
16 limiting provision of certain hearing and
17 visual services to recipients under age 21;
18 revising prescribed drug services and methods
19 of delivering those services; amending s.
20 409.9065, F.S.; prescribing additional
21 eligibility standards with respect to
22 pharmaceutical expense assistance; amending s.
23 409.907, F.S.; authorizing withholding of
24 Medicaid payments in certain circumstances;
25 prescribing additional requirements with
26 respect to providers' submission of
27 information; prescribing additional duties for
28 the agency with respect to provider
29 applications; amending s. 409.9116, F.S.;
30 revising the disproportionate share programs
31 for rural hospitals; eliminating financial
1
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1 assistance program for certain rural hospitals;
2 amending s. 409.912, F.S.; revising the
3 reimbursement rate to pharmacies for Medicaid
4 prescribed drugs; amending s. 409.913, F.S.;
5 prescribing additional sanctions that may be
6 imposed upon a Medicaid provider; eliminating a
7 limit on costs that may be recovered against a
8 provider; amending s. 409.915, F.S.; revising
9 the limit on a county's payment for certain
10 Medicaid costs; amending s. 409.908, F.S.;
11 revising pharmacy dispensing fees for Medicaid
12 drugs; repealing s. 400.0225, F.S., relating to
13 consumer-satisfaction surveys; amending s.
14 400.191, F.S.; eliminating a provision relating
15 to consumer-satisfaction and
16 family-satisfaction surveys; amending s.
17 400.235, F.S.; eliminating a provision relating
18 to participation in the consumer-satisfaction
19 process; repealing s. 400.148, F.S., relating
20 to the Medicaid "Up-or-Out" Quality of Care
21 Contract Management Program; amending s.
22 400.071, F.S.; eliminating a provision relating
23 to participation in a
24 consumer-satisfaction-measurement process;
25 amending s. 409.815, F.S.; conforming a
26 cross-reference; providing effective dates.
27
28 Be It Enacted by the Legislature of the State of Florida:
29
30 Section 1. Paragraph (a) of subsection (3) of section
31 400.23, Florida Statutes, is amended to read:
2
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1 400.23 Rules; evaluation and deficiencies; licensure
2 status.--
3 (3)(a) The agency shall adopt rules providing for the
4 minimum staffing requirements for nursing homes. These
5 requirements shall include, for each nursing home facility, a
6 minimum certified nursing assistant staffing of 2.3 hours of
7 direct care per resident per day beginning May January 1,
8 2002, increasing to 2.6 hours of direct care per resident per
9 day beginning May January 1, 2003, and increasing to 2.9 hours
10 of direct care per resident per day beginning January 1, 2004.
11 Beginning May January 1, 2002, no facility shall staff below
12 one certified nursing assistant per 20 residents, and a
13 minimum licensed nursing staffing of 1.0 hour of direct
14 resident care per resident per day but never below one
15 licensed nurse per 40 residents. Nursing assistants employed
16 under s. 400.211(2) may be included in computing the staffing
17 ratio for certified nursing assistants only if they provide
18 nursing assistance services to residents on a full-time basis.
19 Each nursing home must document compliance with staffing
20 standards as required under this paragraph and post daily the
21 with staffing standards as required under this paragraph and
22 post daily the names of staff on duty for the benefit of
23 facility residents and the public. The agency shall recognize
24 the use of licensed nurses for compliance with minimum
25 staffing requirements for certified nursing assistants,
26 provided that the facility otherwise meets the minimum
27 staffing requirements for licensed nurses and that the
28 licensed nurses so recognized are performing the duties of a
29 certified nursing assistant. Unless otherwise approved by the
30 agency, licensed nurses counted towards the minimum staffing
31 requirements for certified nursing assistants must exclusively
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1 perform the duties of a certified nursing assistant for the
2 entire shift and shall not also be counted towards the minimum
3 staffing requirements for licensed nurses. If the agency
4 approved a facility's request to use a licensed nurse to
5 perform both licensed nursing and certified nursing assistant
6 duties, the facility must allocate the amount of staff time
7 specifically spent on certified nursing assistant duties for
8 the purpose of documenting compliance with minimum staffing
9 requirements for certified and licensed nursing staff. In no
10 event may the hours of a licensed nurse with dual job
11 responsibilities be counted twice.
12 Section 2. Effective July 1, 2002, subsection (5) of
13 section 409.903, Florida 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
4
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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 3. Subsection (11) of section 409.904, Florida
6 Statutes, is repealed.
7 Section 4. Effective July 1, 2002, subsections (2) and
8 (5) of section 409.904, Florida Statutes, are amended to read:
9 409.904 Optional payments for eligible persons.--The
10 agency may make payments for medical assistance and related
11 services on behalf of the following persons who are determined
12 to be eligible subject to the income, assets, and categorical
13 eligibility tests set forth in federal and state law. Payment
14 on behalf of these Medicaid eligible persons is subject to the
15 availability of moneys and any limitations established by the
16 General Appropriations Act or chapter 216.
17 (2) Pregnant women and children under age 1 who would
18 otherwise qualify for Medicaid under s. 409.903(5) and
19 children under age 18 who would otherwise qualify for Medicaid
20 under subsection (8) and s. 409.903(6) and (7) except for
21 their level of income and whose assets fall within the limits
22 established by the Department of Children and Family Services
23 for the medically needy. Coverage for the medically needy is
24 not available to presumptively eligible pregnant women. A
25 family, a pregnant woman, a child under age 18, a person age
26 65 or over, or a blind or disabled person who would be
27 eligible under any group listed in s. 409.903(1), (2), or (3),
28 except that the income or assets of such family or person
29 exceed established limitations. For a family or person in this
30 group, medical expenses are deductible from income in
31 accordance with federal requirements in order to make a
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1 determination of eligibility. A family or person in this
2 group, which group is known as the "medically needy," is
3 eligible to receive the same services as other Medicaid
4 recipients, with the exception of services in skilled nursing
5 facilities and intermediate care facilities for the
6 developmentally disabled.
7 (5) Subject to specific federal authorization, a
8 postpartum woman living in a family that has an income that is
9 at or below 150 185 percent of the most current federal
10 poverty level is eligible for family planning services as
11 specified in s. 409.905(3) for a period of up to 24 months
12 following a pregnancy for which Medicaid paid for
13 pregnancy-related services.
14 Section 5. Section 409.906, Florida Statutes, is
15 amended to read:
16 409.906 Optional Medicaid services.--Subject to
17 specific appropriations, the agency may make payments for
18 services which are optional to the state under Title XIX of
19 the Social Security Act and are furnished by Medicaid
20 providers to recipients who are determined to be eligible on
21 the dates on which the services were provided. Any optional
22 service that is provided shall be provided only when medically
23 necessary and in accordance with state and federal law.
24 Optional services rendered by providers in mobile units to
25 Medicaid recipients may be restricted or prohibited by the
26 agency. Nothing in this section shall be construed to prevent
27 or limit the agency from adjusting fees, reimbursement rates,
28 lengths of stay, number of visits, or number of services, or
29 making any other adjustments necessary to comply with the
30 availability of moneys and any limitations or directions
31 provided for in the General Appropriations Act or chapter 216.
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1 If necessary to safeguard the state's systems of providing
2 services to elderly and disabled persons and subject to the
3 notice and review provisions of s. 216.177, the Governor may
4 direct the Agency for Health Care Administration to amend the
5 Medicaid state plan to delete the optional Medicaid service
6 known as "Intermediate Care Facilities for the Developmentally
7 Disabled." Optional services may include:
8 (1) ADULT DENTURE SERVICES.--The agency may pay for
9 dentures, the procedures required to seat dentures, and the
10 repair and reline of dentures, provided by or under the
11 direction of a licensed dentist, for a recipient who is age 21
12 or older. However, Medicaid will not provide reimbursement for
13 dental services provided in a mobile dental unit, except for a
14 mobile dental unit:
15 (a) Owned by, operated by, or having a contractual
16 agreement with the Department of Health and complying with
17 Medicaid's county health department clinic services program
18 specifications as a county health department clinic services
19 provider.
20 (b) Owned by, operated by, or having a contractual
21 arrangement with a federally qualified health center and
22 complying with Medicaid's federally qualified health center
23 specifications as a federally qualified health center
24 provider.
25 (c) Rendering dental services to Medicaid recipients,
26 21 years of age and older, at nursing facilities.
27 (d) Owned by, operated by, or having a contractual
28 agreement with a state-approved dental educational
29 institution.
30 (1)(2) ADULT HEALTH SCREENING SERVICES.--The agency
31 may pay for an annual routine physical examination, conducted
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1 by or under the direction of a licensed physician, for a
2 recipient age 21 or older, without regard to medical
3 necessity, in order to detect and prevent disease, disability,
4 or other health condition or its progression.
5 (2)(3) AMBULATORY SURGICAL CENTER SERVICES.--The
6 agency may pay for services provided to a recipient in an
7 ambulatory surgical center licensed under part I of chapter
8 395, by or under the direction of a licensed physician or
9 dentist.
10 (3)(4) BIRTH CENTER SERVICES.--The agency may pay for
11 examinations and delivery, recovery, and newborn assessment,
12 and related services, provided in a licensed birth center
13 staffed with licensed physicians, certified nurse midwives,
14 and midwives licensed in accordance with chapter 467, to a
15 recipient expected to experience a low-risk pregnancy and
16 delivery.
17 (4)(5) CASE MANAGEMENT SERVICES.--The agency may pay
18 for primary care case management services rendered to a
19 recipient pursuant to a federally approved waiver, and
20 targeted case management services for specific groups of
21 targeted recipients, for which funding has been provided and
22 which are rendered pursuant to federal guidelines. The agency
23 is authorized to limit reimbursement for targeted case
24 management services in order to comply with any limitations or
25 directions provided for in the General Appropriations Act.
26 Notwithstanding s. 216.292, the Department of Children and
27 Family Services may transfer general funds to the Agency for
28 Health Care Administration to fund state match requirements
29 exceeding the amount specified in the General Appropriations
30 Act for targeted case management services.
31
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1 (5)(6) CHILDREN'S DENTAL SERVICES.--The agency may pay
2 for diagnostic, preventive, or corrective procedures,
3 including orthodontia in severe cases, provided to a recipient
4 under age 21, by or under the supervision of a licensed
5 dentist. Services provided under this program include
6 treatment of the teeth and associated structures of the oral
7 cavity, as well as treatment of disease, injury, or impairment
8 that may affect the oral or general health of the individual.
9 However, Medicaid will not provide reimbursement for dental
10 services provided in a mobile dental unit, except for a mobile
11 dental unit:
12 (a) Owned by, operated by, or having a contractual
13 agreement with the Department of Health and complying with
14 Medicaid's county health department clinic services program
15 specifications as a county health department clinic services
16 provider.
17 (b) Owned by, operated by, or having a contractual
18 arrangement with a federally qualified health center and
19 complying with Medicaid's federally qualified health center
20 specifications as a federally qualified health center
21 provider.
22 (c) Rendering dental services to Medicaid recipients,
23 21 years of age and older, at nursing facilities.
24 (d) Owned by, operated by, or having a contractual
25 agreement with a state-approved dental educational
26 institution.
27 (6)(7) CHIROPRACTIC SERVICES.--The agency may pay for
28 manual manipulation of the spine and initial services,
29 screening, and X rays provided to a recipient by a licensed
30 chiropractic physician.
31 (7)(8) COMMUNITY MENTAL HEALTH SERVICES.--
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1 (a) The agency may pay for rehabilitative services
2 provided to a recipient by a mental health or substance abuse
3 provider under contract with the agency or the Department of
4 Children and Family Services to provide such services. Those
5 services which are psychiatric in nature shall be rendered or
6 recommended by a psychiatrist, and those services which are
7 medical in nature shall be rendered or recommended by a
8 physician or psychiatrist. The agency must develop a provider
9 enrollment process for community mental health providers which
10 bases provider enrollment on an assessment of service need.
11 The provider enrollment process shall be designed to control
12 costs, prevent fraud and abuse, consider provider expertise
13 and capacity, and assess provider success in managing
14 utilization of care and measuring treatment outcomes.
15 Providers will be selected through a competitive procurement
16 or selective contracting process. In addition to other
17 community mental health providers, the agency shall consider
18 for enrollment mental health programs licensed under chapter
19 395 and group practices licensed under chapter 458, chapter
20 459, chapter 490, or chapter 491. The agency is also
21 authorized to continue operation of its behavioral health
22 utilization management program and may develop new services if
23 these actions are necessary to ensure savings from the
24 implementation of the utilization management system. The
25 agency shall coordinate the implementation of this enrollment
26 process with the Department of Children and Family Services
27 and the Department of Juvenile Justice. The agency is
28 authorized to utilize diagnostic criteria in setting
29 reimbursement rates, to preauthorize certain high-cost or
30 highly utilized services, to limit or eliminate coverage for
31 certain services, or to make any other adjustments necessary
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1 to comply with any limitations or directions provided for in
2 the General Appropriations Act.
3 (b) The agency is authorized to implement
4 reimbursement and use management reforms in order to comply
5 with any limitations or directions in the General
6 Appropriations Act, which may include, but are not limited to:
7 prior authorization of treatment and service plans; prior
8 authorization of services; enhanced use review programs for
9 highly used services; and limits on services for those
10 determined to be abusing their benefit coverages.
11 (8)(9) DIALYSIS FACILITY SERVICES.--Subject to
12 specific appropriations being provided for this purpose, the
13 agency may pay a dialysis facility that is approved as a
14 dialysis facility in accordance with Title XVIII of the Social
15 Security Act, for dialysis services that are provided to a
16 Medicaid recipient under the direction of a physician licensed
17 to practice medicine or osteopathic medicine in this state,
18 including dialysis services provided in the recipient's home
19 by a hospital-based or freestanding dialysis facility.
20 (9)(10) DURABLE MEDICAL EQUIPMENT.--The agency may
21 authorize and pay for certain durable medical equipment and
22 supplies provided to a Medicaid recipient as medically
23 necessary.
24 (10)(11) HEALTHY START SERVICES.--The agency may pay
25 for a continuum of risk-appropriate medical and psychosocial
26 services for the Healthy Start program in accordance with a
27 federal waiver. The agency may not implement the federal
28 waiver unless the waiver permits the state to limit enrollment
29 or the amount, duration, and scope of services to ensure that
30 expenditures will not exceed funds appropriated by the
31 Legislature or available from local sources. If the Health
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1 Care Financing Administration does not approve a federal
2 waiver for Healthy Start services, the agency, in consultation
3 with the Department of Health and the Florida Association of
4 Healthy Start Coalitions, is authorized to establish a
5 Medicaid certified-match program for Healthy Start services.
6 Participation in the Healthy Start certified-match program
7 shall be voluntary, and reimbursement shall be limited to the
8 federal Medicaid share to Medicaid-enrolled Healthy Start
9 coalitions for services provided to Medicaid recipients. The
10 agency shall take no action to implement a certified-match
11 program without ensuring that the amendment and review
12 requirements of ss. 216.177 and 216.181 have been met.
13 (11)(12) CHILDREN'S HEARING SERVICES.--The agency may
14 pay for hearing and related services, including hearing
15 evaluations, hearing aid devices, dispensing of the hearing
16 aid, and related repairs, if provided to a recipient under age
17 21 by a licensed hearing aid specialist, otolaryngologist,
18 otologist, audiologist, or physician.
19 (12)(13) HOME AND COMMUNITY-BASED SERVICES.--The
20 agency may pay for home-based or community-based services that
21 are rendered to a recipient in accordance with a federally
22 approved waiver program.
23 (13)(14) HOSPICE CARE SERVICES.--The agency may pay
24 for all reasonable and necessary services for the palliation
25 or management of a recipient's terminal illness, if the
26 services are provided by a hospice that is licensed under part
27 VI of chapter 400 and meets Medicare certification
28 requirements.
29 (14)(15) INTERMEDIATE CARE FACILITY FOR THE
30 DEVELOPMENTALLY DISABLED SERVICES.--The agency may pay for
31 health-related care and services provided on a 24-hour-a-day
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1 basis by a facility licensed and certified as a Medicaid
2 Intermediate Care Facility for the Developmentally Disabled,
3 for a recipient who needs such care because of a developmental
4 disability.
5 (15)(16) INTERMEDIATE CARE SERVICES.--The agency may
6 pay for 24-hour-a-day intermediate care nursing and
7 rehabilitation services rendered to a recipient in a nursing
8 facility licensed under part II of chapter 400, if the
9 services are ordered by and provided under the direction of a
10 physician.
11 (16)(17) OPTOMETRIC SERVICES.--The agency may pay for
12 services provided to a recipient, including examination,
13 diagnosis, treatment, and management, related to ocular
14 pathology, if the services are provided by a licensed
15 optometrist or physician.
16 (17)(18) PHYSICIAN ASSISTANT SERVICES.--The agency may
17 pay for all services provided to a recipient by a physician
18 assistant licensed under s. 458.347 or s. 459.022.
19 Reimbursement for such services must be not less than 80
20 percent of the reimbursement that would be paid to a physician
21 who provided the same services.
22 (18)(19) PODIATRIC SERVICES.--The agency may pay for
23 services, including diagnosis and medical, surgical,
24 palliative, and mechanical treatment, related to ailments of
25 the human foot and lower leg, if provided to a recipient by a
26 podiatric physician licensed under state law.
27 (19)(20) PRESCRIBED DRUG SERVICES.--The agency may pay
28 for medications that are prescribed for a recipient by a
29 physician or other licensed practitioner of the healing arts
30 authorized to prescribe medications and that are dispensed to
31 the recipient by a licensed pharmacist or physician in
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1 accordance with applicable state and federal law. For adults
2 eligible through the medically needy program, pharmacies must
3 dispense a generic drug for a product prescribed for a
4 beneficiary if a generic product exists for the product
5 prescribed.
6 (20)(21) REGISTERED NURSE FIRST ASSISTANT
7 SERVICES.--The agency may pay for all services provided to a
8 recipient by a registered nurse first assistant as described
9 in s. 464.027. Reimbursement for such services may not be
10 less than 80 percent of the reimbursement that would be paid
11 to a physician providing the same services.
12 (21)(22) STATE HOSPITAL SERVICES.--The agency may pay
13 for all-inclusive psychiatric inpatient hospital care provided
14 to a recipient age 65 or older in a state mental hospital.
15 (22)(23) CHILDREN'S VISUAL SERVICES.--The agency may
16 pay for visual examinations, eyeglasses, and eyeglass repairs
17 for a recipient under age 21, if they are prescribed by a
18 licensed physician specializing in diseases of the eye or by a
19 licensed optometrist.
20 (23)(24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.--The
21 Agency for Health Care Administration, in consultation with
22 the Department of Children and Family Services, may establish
23 a targeted case-management pilot project in those counties
24 identified by the Department of Children and Family Services
25 and for the community-based child welfare project in Sarasota
26 and Manatee counties, as authorized under s. 409.1671. These
27 projects shall be established for the purpose of determining
28 the impact of targeted case management on the child welfare
29 program and the earnings from the child welfare program.
30 Results of the pilot projects shall be reported to the Child
31 Welfare Estimating Conference and the Social Services
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1 Estimating Conference established under s. 216.136. The number
2 of projects may not be increased until requested by the
3 Department of Children and Family Services, recommended by the
4 Child Welfare Estimating Conference and the Social Services
5 Estimating Conference, and approved by the Legislature. The
6 covered group of individuals who are eligible to receive
7 targeted case management include children who are eligible for
8 Medicaid; who are between the ages of birth through 21; and
9 who are under protective supervision or postplacement
10 supervision, under foster-care supervision, or in shelter care
11 or foster care. The number of individuals who are eligible to
12 receive targeted case management shall be limited to the
13 number for whom the Department of Children and Family Services
14 has available matching funds to cover the costs. The general
15 revenue funds required to match the funds for services
16 provided by the community-based child welfare projects are
17 limited to funds available for services described under s.
18 409.1671. The Department of Children and Family Services may
19 transfer the general revenue matching funds as billed by the
20 Agency for Health Care Administration.
21 (24)(25) ASSISTIVE-CARE SERVICES.--The agency may pay
22 for assistive-care services provided to recipients with
23 functional or cognitive impairments residing in assisted
24 living facilities, adult family-care homes, or residential
25 treatment facilities. These services may include health
26 support, assistance with the activities of daily living and
27 the instrumental acts of daily living, assistance with
28 medication administration, and arrangements for health care.
29 Section 6. Effective April 1, 2002, subsection (19) of
30 section 409.906, Florida Statutes, as amended by this act, is
31 amended to read:
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1 409.906 Optional Medicaid services.--Subject to
2 specific appropriations, the agency may make payments for
3 services which are optional to the state under Title XIX of
4 the Social Security Act and are furnished by Medicaid
5 providers to recipients who are determined to be eligible on
6 the dates on which the services were provided. Any optional
7 service that is provided shall be provided only when medically
8 necessary and in accordance with state and federal law.
9 Optional services rendered by providers in mobile units to
10 Medicaid recipients may be restricted or prohibited by the
11 agency. Nothing in this section shall be construed to prevent
12 or limit the agency from adjusting fees, reimbursement rates,
13 lengths of stay, number of visits, or number of services, or
14 making any other adjustments necessary to comply with the
15 availability of moneys and any limitations or directions
16 provided for in the General Appropriations Act or chapter 216.
17 If necessary to safeguard the state's systems of providing
18 services to elderly and disabled persons and subject to the
19 notice and review provisions of s. 216.177, the Governor may
20 direct the Agency for Health Care Administration to amend the
21 Medicaid state plan to delete the optional Medicaid service
22 known as "Intermediate Care Facilities for the Developmentally
23 Disabled." Optional services may include:
24 (19) PRESCRIBED DRUG SERVICES.--The agency may pay for
25 medications that are prescribed for a recipient by a physician
26 or other licensed practitioner of the healing arts authorized
27 to prescribe medications and that are dispensed to the
28 recipient by a licensed pharmacist or physician in accordance
29 with applicable state and federal law. The agency may use
30 mail-order pharmacy services for dispensing drugs. For adults
31 eligible through the medically needy program, pharmacies must
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1 dispense a generic drug for a product prescribed for a
2 beneficiary if a generic product exists for the product
3 prescribed.
4 Section 7. Subsections (3) and (5) of section
5 409.9065, Florida Statutes, are amended to read:
6 409.9065 Pharmaceutical expense assistance.--
7 (3) BENEFITS.--Medications covered under the
8 pharmaceutical expense assistance program are those covered
9 under the Medicaid program in s. 409.906(19) s. 409.906(20).
10 Monthly benefit payments shall be limited to $80 per program
11 participant. Participants are required to make a 10-percent
12 coinsurance payment for each prescription purchased through
13 this program.
14 (5) NONENTITLEMENT.--The pharmaceutical expense
15 assistance program established by this section is not an
16 entitlement. Enrollment levels are limited to those authorized
17 by the Legislature in the annual General Appropriations Act.
18 If funds are insufficient to serve all individuals eligible
19 under subsection (2) and seeking coverage, the agency may
20 develop a waiting list based on application dates to use in
21 enrolling individuals in unfilled enrollment slots.
22 Section 8. Effective upon this act becoming a law,
23 paragraph (a) of subsection (5) and subsections (7) and (9) of
24 section 409.907, Florida Statutes, are amended to read:
25 409.907 Medicaid provider agreements.--The agency may
26 make payments for medical assistance and related services
27 rendered to Medicaid recipients only to an individual or
28 entity who has a provider agreement in effect with the agency,
29 who is performing services or supplying goods in accordance
30 with federal, state, and local law, and who agrees that no
31 person shall, on the grounds of handicap, race, color, or
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1 national origin, or for any other reason, be subjected to
2 discrimination under any program or activity for which the
3 provider receives payment from the agency.
4 (5) The agency:
5 (a) Is required to make timely payment at the
6 established rate for services or goods furnished to a
7 recipient by the provider upon receipt of a properly completed
8 claim form. The claim form shall require certification that
9 the services or goods have been completely furnished to the
10 recipient and that, with the exception of those services or
11 goods specified by the agency, the amount billed does not
12 exceed the provider's usual and customary charge for the same
13 services or goods. When a provider is under an active fraud or
14 abuse investigation by the agency, the agency may withhold
15 payment to that provider for any pending claim until the
16 conclusion of the investigation. When exercising the
17 provisions of this paragraph, the agency must timely complete
18 its investigation.
19 (7) The agency may require, as a condition of
20 participating in the Medicaid program and before entering into
21 the provider agreement, that the provider submit information,
22 in an initial and any required renewal applications,
23 concerning the professional, business, and personal background
24 of the provider and permit an onsite inspection of the
25 provider's service location by agency staff or other personnel
26 designated by the agency to perform this function. Before
27 entering into the provider agreement, or as a condition of
28 continuing participation in the Medicaid program, the agency
29 may also require that Medicaid providers reimbursed on a
30 fee-for-services basis or fee schedule basis which is not
31 cost-based, post a surety bond not to exceed $50,000 or the
18
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1 total amount billed by the provider to the program during the
2 current or most recent calendar year, whichever is greater.
3 For new providers, the amount of the surety bond shall be
4 determined by the agency based on the provider's estimate of
5 its first year's billing. If the provider's billing during the
6 first year exceeds the bond amount, the agency may require the
7 provider to acquire an additional bond equal to the actual
8 billing level of the provider. A provider's bond shall not
9 exceed $50,000 if a physician or group of physicians licensed
10 under chapter 458, chapter 459, or chapter 460 has a 50
11 percent or greater ownership interest in the provider or if
12 the provider is an assisted living facility licensed under
13 part III of chapter 400. The bonds permitted by this section
14 are in addition to the bonds referenced in s. 400.179(4)(d).
15 If the provider is a corporation, partnership, association, or
16 other entity, the agency may require the provider to submit
17 information concerning the background of that entity and of
18 any principal of the entity, including any partner or
19 shareholder having an ownership interest in the entity equal
20 to 5 percent or greater, and any treating provider who
21 participates in or intends to participate in Medicaid through
22 the entity. The information must include:
23 (a) Proof of holding a valid license or operating
24 certificate, as applicable, if required by the state or local
25 jurisdiction in which the provider is located or if required
26 by the Federal Government.
27 (b) Information concerning any prior violation, fine,
28 suspension, termination, or other administrative action taken
29 under the Medicaid laws, rules, or regulations of this state
30 or of any other state or the Federal Government; any prior
31 violation of the laws, rules, or regulations relating to the
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1 Medicare program; any prior violation of the rules or
2 regulations of any other public or private insurer; and any
3 prior violation of the laws, rules, or regulations of any
4 regulatory body of this or any other state.
5 (c) Full and accurate disclosure of any financial or
6 ownership interest that the provider, or any principal,
7 partner, or major shareholder thereof, may hold in any other
8 Medicaid provider or health care related entity or any other
9 entity that is licensed by the state to provide health or
10 residential care and treatment to persons.
11 (d) If a group provider, identification of all members
12 of the group and attestation that all members of the group are
13 enrolled in or have applied to enroll in the Medicaid program.
14 (9) Upon receipt of a completed, signed, and dated
15 application, and completion of any necessary background
16 investigation and criminal history record check, the agency
17 must either:
18 (a) Enroll the applicant as a Medicaid provider no
19 earlier than the effective date of the approval of the
20 provider application; or
21 (b) Deny the application if the agency finds that it
22 is in the best interest of the Medicaid program to do so. The
23 agency may consider the factors listed in subsection (10), as
24 well as any other factor that could affect the effective and
25 efficient administration of the program, including, but not
26 limited to, the current availability of medical care,
27 services, or supplies to recipients, taking into account
28 geographic location and reasonable travel time; the number of
29 providers of the same type already enrolled in the same
30 geographic area; and the credentials, experience, success, and
31
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1 patient outcomes of the provider for the services that it is
2 making application to provide in the Medicaid program.
3 Section 9. Section 409.9116, Florida Statutes, is
4 amended to read:
5 409.9116 Disproportionate share share/financial
6 assistance program for rural hospitals.--In addition to the
7 payments made under s. 409.911, the Agency for Health Care
8 Administration shall administer a federally matched
9 disproportionate share program and a state-funded financial
10 assistance program for statutory rural hospitals. The agency
11 shall make disproportionate share payments to statutory rural
12 hospitals that qualify for such payments and financial
13 assistance payments to statutory rural hospitals that do not
14 qualify for disproportionate share payments. The
15 disproportionate share program payments shall be limited by
16 and conform with federal requirements. Funds shall be
17 distributed quarterly in each fiscal year for which an
18 appropriation is made. Notwithstanding the provisions of s.
19 409.915, counties are exempt from contributing toward the cost
20 of this special reimbursement for hospitals serving a
21 disproportionate share of low-income patients.
22 (1) The following formula shall be used by the agency
23 to calculate the total amount earned for hospitals that
24 participate in the rural hospital disproportionate share
25 program or the financial assistance program:
26
27 TAERH = (CCD + MDD)/TPD
28
29 Where:
30 CCD = total charity care-other, plus charity
31 care-Hill-Burton, minus 50 percent of unrestricted tax revenue
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1 from local governments, and restricted funds for indigent
2 care, divided by gross revenue per adjusted patient day;
3 however, if CCD is less than zero, then zero shall be used for
4 CCD.
5 MDD = Medicaid inpatient days plus Medicaid HMO
6 inpatient days.
7 TPD = total inpatient days.
8 TAERH = total amount earned by each rural hospital.
9
10 In computing the total amount earned by each rural hospital,
11 the agency must use the most recent actual data reported in
12 accordance with s. 408.061(4)(a).
13 (2) The agency shall use the following formula for
14 distribution of funds for the disproportionate share
15 share/financial assistance program for rural hospitals.
16 (a) The agency shall first determine a preliminary
17 payment amount for each rural hospital by allocating all
18 available state funds using the following formula:
19
20 PDAER = (TAERH x TARH)/STAERH
21
22 Where:
23 PDAER = preliminary distribution amount for each rural
24 hospital.
25 TAERH = total amount earned by each rural hospital.
26 TARH = total amount appropriated or distributed under
27 this section.
28 STAERH = sum of total amount earned by each rural
29 hospital.
30
31
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1 (b) Federal matching funds for the disproportionate
2 share program shall then be calculated for those hospitals
3 that qualify for disproportionate share in paragraph (a).
4 (c) Any state funds not spent due to an individual
5 hospital's disproportionate-share limit will be redistributed
6 proportionately to those hospitals with an available
7 disproportionate-share limit to maximize available federal
8 funds.
9 (c) The state-funds-only payment amount shall then be
10 calculated for each hospital using the formula:
11
12 SFOER = Maximum value of (1) SFOL - PDAER or (2) 0
13
14 Where:
15 SFOER = state-funds-only payment amount for each rural
16 hospital.
17 SFOL = state-funds-only payment level, which is set at
18 4 percent of TARH.
19
20 In calculating the SFOER, PDAER includes federal matching
21 funds from paragraph (b).
22 (d) The adjusted total amount allocated to the rural
23 disproportionate share program shall then be calculated using
24 the following formula:
25
26 ATARH = (TARH - SSFOER)
27
28 Where:
29 ATARH = adjusted total amount appropriated or
30 distributed under this section.
31
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1 SSFOER = sum of the state-funds-only payment amount
2 calculated under paragraph (c) for all rural hospitals.
3 (e) The distribution of the adjusted total amount of
4 rural disproportionate share hospital funds shall then be
5 calculated using the following formula:
6
7 DAERH = [(TAERH x ATARH)/STAERH]
8
9 Where:
10 DAERH = distribution amount for each rural hospital.
11 (d)(f) Federal matching funds for the disproportionate
12 share program shall then be calculated for those hospitals
13 that qualify for disproportionate share in paragraph (a) (e).
14 (g) State-funds-only payment amounts calculated under
15 paragraph (c) and corresponding federal matching funds are
16 then added to the results of paragraph (f) to determine the
17 total distribution amount for each rural hospital.
18 (3) The Agency for Health Care Administration may
19 recommend to the Legislature a formula to be used in
20 subsequent fiscal years to distribute funds appropriated for
21 this section that includes charity care, uncompensated care to
22 medically indigent patients, and Medicaid inpatient days.
23 (4) In the event that federal matching funds for the
24 rural hospital disproportionate share program are not
25 available, state matching funds appropriated for the program
26 may be utilized for the Rural Hospital Financial Assistance
27 Program and shall be allocated to rural hospitals based on the
28 formulas in subsections (1) and (2).
29 (5) In order to receive payments under this section, a
30 hospital must be a rural hospital as defined in s. 395.602 and
31 must meet the following additional requirements:
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1 (a) Agree to conform to all agency requirements to
2 ensure high quality in the provision of services, including
3 criteria adopted by agency rule concerning staffing ratios,
4 medical records, standards of care, equipment, space, and such
5 other standards and criteria as the agency deems appropriate
6 as specified by rule.
7 (b) Agree to accept all patients, regardless of
8 ability to pay, on a functional space-available basis.
9 (c) Agree to provide backup and referral services to
10 the county public health departments and other low-income
11 providers within the hospital's service area, including the
12 development of written agreements between these organizations
13 and the hospital.
14 (d) For any hospital owned by a county government
15 which is leased to a management company, agree to submit on a
16 quarterly basis a report to the agency, in a format specified
17 by the agency, which provides a specific accounting of how all
18 funds dispersed under this act are spent.
19 (6) For the 2000-2001 fiscal year only, the Agency for
20 Health Care Administration shall use the following formula for
21 distribution of the funds in Specific Appropriation 212 of the
22 2000-2001 General Appropriations Act for the disproportionate
23 share/financial assistance program for rural hospitals.
24 (a) The agency shall first determine a preliminary
25 payment amount for each rural hospital by allocating all
26 available state funds using the following formula:
27
28 PDAER = (TAERH x TARH)/STAERH
29
30 Where:
31
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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 is then
12 calculated for each hospital using the 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 (d) The adjusted total amount allocated to the rural
22 disproportionate share program shall then be calculated using
23 the following formula:
24
25 ATARH = (TARH - SSFOER)
26
27 Where:
28 ATARH = adjusted total amount appropriated or
29 distributed under this section.
30 SSFOER = sum of the state-funds-only payment amount
31 calculated under paragraph (c) for all rural hospitals.
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1 (e) The determination of the amount of rural
2 disproportionate share hospital funds is calculated by the
3 following formula:
4
5 TDAERH = [(TAERH x ATARH)/STAERH]
6
7 Where:
8 TDAERH = total distribution amount for each rural
9 hospital.
10 (f) Federal matching funds for the disproportionate
11 share program shall then be calculated for those hospitals
12 that qualify for disproportionate share in paragraph (e).
13 (g) State-funds-only payment amounts calculated under
14 paragraph (c) are then added to the results of paragraph (f)
15 to determine the total distribution amount for each rural
16 hospital.
17 (h) This subsection is repealed on July 1, 2001.
18 (6)(7) This section applies only to hospitals that
19 were defined as statutory rural hospitals, or their
20 successor-in-interest hospital, prior to July 1, 1998. Any
21 additional hospital that is defined as a statutory rural
22 hospital, or its successor-in-interest hospital, on or after
23 July 1, 1998, is not eligible for programs under this section
24 unless additional funds are appropriated each fiscal year
25 specifically to the rural hospital disproportionate share
26 programs and financial assistance programs in an amount
27 necessary to prevent any hospital, or its
28 successor-in-interest hospital, eligible for the programs
29 prior to July 1, 1998, from incurring a reduction in payments
30 because of the eligibility of an additional hospital to
31 participate in the programs. A hospital, or its
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1 successor-in-interest hospital, which received funds pursuant
2 to this section before July 1, 1998, and which qualifies under
3 s. 395.602(2)(e), shall be included in the programs under this
4 section and is not required to seek additional appropriations
5 under this subsection.
6 Section 10. Paragraph (a) of subsection (37) of
7 section 409.912, Florida Statutes, is amended to read:
8 409.912 Cost-effective purchasing of health care.--The
9 agency shall purchase goods and services for Medicaid
10 recipients in the most cost-effective manner consistent with
11 the delivery of quality medical care. The agency shall
12 maximize the use of prepaid per capita and prepaid aggregate
13 fixed-sum basis services when appropriate and other
14 alternative service delivery and reimbursement methodologies,
15 including competitive bidding pursuant to s. 287.057, designed
16 to facilitate the cost-effective purchase of a case-managed
17 continuum of care. The agency shall also require providers to
18 minimize the exposure of recipients to the need for acute
19 inpatient, custodial, and other institutional care and the
20 inappropriate or unnecessary use of high-cost services. The
21 agency may establish prior authorization requirements for
22 certain populations of Medicaid beneficiaries, certain drug
23 classes, or particular drugs to prevent fraud, abuse, overuse,
24 and possible dangerous drug interactions. The Pharmaceutical
25 and Therapeutics Committee shall make recommendations to the
26 agency on drugs for which prior authorization is required. The
27 agency shall inform the Pharmaceutical and Therapeutics
28 Committee of its decisions regarding drugs subject to prior
29 authorization.
30
31
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1 (37)(a) The agency shall implement a Medicaid
2 prescribed-drug spending-control program that includes the
3 following components:
4 1. Medicaid prescribed-drug coverage for brand-name
5 drugs for adult Medicaid recipients is limited to the
6 dispensing of four brand-name drugs per month per recipient.
7 Children are exempt from this restriction. Antiretroviral
8 agents are excluded from this limitation. No requirements for
9 prior authorization or other restrictions on medications used
10 to treat mental illnesses such as schizophrenia, severe
11 depression, or bipolar disorder may be imposed on Medicaid
12 recipients. Medications that will be available without
13 restriction for persons with mental illnesses include atypical
14 antipsychotic medications, conventional antipsychotic
15 medications, selective serotonin reuptake inhibitors, and
16 other medications used for the treatment of serious mental
17 illnesses. The agency shall also limit the amount of a
18 prescribed drug dispensed to no more than a 34-day supply. The
19 agency shall continue to provide unlimited generic drugs,
20 contraceptive drugs and items, and diabetic supplies. Although
21 a drug may be included on the preferred drug formulary, it
22 would not be exempt from the four-brand limit. The agency may
23 authorize exceptions to the brand-name-drug restriction based
24 upon the treatment needs of the patients, only when such
25 exceptions are based on prior consultation provided by the
26 agency or an agency contractor, but the agency must establish
27 procedures to ensure that:
28 a. There will be a response to a request for prior
29 consultation by telephone or other telecommunication device
30 within 24 hours after receipt of a request for prior
31 consultation;
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1 b. A 72-hour supply of the drug prescribed will be
2 provided in an emergency or when the agency does not provide a
3 response within 24 hours as required by sub-subparagraph a.;
4 and
5 c. Except for the exception for nursing home residents
6 and other institutionalized adults and except for drugs on the
7 restricted formulary for which prior authorization may be
8 sought by an institutional or community pharmacy, prior
9 authorization for an exception to the brand-name-drug
10 restriction is sought by the prescriber and not by the
11 pharmacy. When prior authorization is granted for a patient in
12 an institutional setting beyond the brand-name-drug
13 restriction, such approval is authorized for 12 months and
14 monthly prior authorization is not required for that patient.
15 2. Reimbursement to pharmacies for Medicaid prescribed
16 drugs shall be set at the average wholesale price less 15
17 13.25 percent.
18 3. The agency shall develop and implement a process
19 for managing the drug therapies of Medicaid recipients who are
20 using significant numbers of prescribed drugs each month. The
21 management process may include, but is not limited to,
22 comprehensive, physician-directed medical-record reviews,
23 claims analyses, and case evaluations to determine the medical
24 necessity and appropriateness of a patient's treatment plan
25 and drug therapies. The agency may contract with a private
26 organization to provide drug-program-management services. The
27 Medicaid drug benefit management program shall include
28 initiatives to manage drug therapies for HIV/AIDS patients,
29 patients using 20 or more unique prescriptions in a 180-day
30 period, and the top 1,000 patients in annual spending.
31
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1 4. The agency may limit the size of its pharmacy
2 network based on need, competitive bidding, price
3 negotiations, credentialing, or similar criteria. The agency
4 shall give special consideration to rural areas in determining
5 the size and location of pharmacies included in the Medicaid
6 pharmacy network. A pharmacy credentialing process may include
7 criteria such as a pharmacy's full-service status, location,
8 size, patient educational programs, patient consultation,
9 disease-management services, and other characteristics. The
10 agency may impose a moratorium on Medicaid pharmacy enrollment
11 when it is determined that it has a sufficient number of
12 Medicaid-participating providers.
13 5. The agency shall develop and implement a program
14 that requires Medicaid practitioners who prescribe drugs to
15 use a counterfeit-proof prescription pad for Medicaid
16 prescriptions. The agency shall require the use of
17 standardized counterfeit-proof prescription pads by
18 Medicaid-participating prescribers or prescribers who write
19 prescriptions for Medicaid recipients. The agency may
20 implement the program in targeted geographic areas or
21 statewide.
22 6. The agency may enter into arrangements that require
23 manufacturers of generic drugs prescribed to Medicaid
24 recipients to provide rebates of at least 15.1 percent of the
25 average manufacturer price for the manufacturer's generic
26 products. These arrangements shall require that if a
27 generic-drug manufacturer pays federal rebates for
28 Medicaid-reimbursed drugs at a level below 15.1 percent, the
29 manufacturer must provide a supplemental rebate to the state
30 in an amount necessary to achieve a 15.1-percent rebate level.
31
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1 7. The agency may establish a preferred drug formulary
2 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
3 establishment of such formulary, it is authorized to negotiate
4 supplemental rebates from manufacturers that are in addition
5 to those required by Title XIX of the Social Security Act and
6 at no less than 10 percent of the average manufacturer price
7 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
8 unless the federal or supplemental rebate, or both, equals or
9 exceeds 25 percent. There is no upper limit on the
10 supplemental rebates the agency may negotiate. The agency may
11 determine that specific products, brand-name or generic, are
12 competitive at lower rebate percentages. Agreement to pay the
13 minimum supplemental rebate percentage will guarantee a
14 manufacturer that the Medicaid Pharmaceutical and Therapeutics
15 Committee will consider a product for inclusion on the
16 preferred drug formulary. However, a pharmaceutical
17 manufacturer is not guaranteed placement on the formulary by
18 simply paying the minimum supplemental rebate. Agency
19 decisions will be made on the clinical efficacy of a drug and
20 recommendations of the Medicaid Pharmaceutical and
21 Therapeutics Committee, as well as the price of competing
22 products minus federal and state rebates. The agency is
23 authorized to contract with an outside agency or contractor to
24 conduct negotiations for supplemental rebates. For the
25 purposes of this section, the term "supplemental rebates" may
26 include, at the agency's discretion, cash rebates and other
27 program benefits that offset a Medicaid expenditure. Such
28 other program benefits may include, but are not limited to,
29 disease management programs, drug product donation programs,
30 drug utilization control programs, prescriber and beneficiary
31 counseling and education, fraud and abuse initiatives, and
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1 other services or administrative investments with guaranteed
2 savings to the Medicaid program in the same year the rebate
3 reduction is included in the General Appropriations Act. The
4 agency is authorized to seek any federal waivers to implement
5 this initiative.
6 8. The agency shall establish an advisory committee
7 for the purposes of studying the feasibility of using a
8 restricted drug formulary for nursing home residents and other
9 institutionalized adults. The committee shall be comprised of
10 seven members appointed by the Secretary of Health Care
11 Administration. The committee members shall include two
12 physicians licensed under chapter 458 or chapter 459; three
13 pharmacists licensed under chapter 465 and appointed from a
14 list of recommendations provided by the Florida Long-Term Care
15 Pharmacy Alliance; and two pharmacists licensed under chapter
16 465.
17 Section 11. Effective upon this act becoming a law,
18 subsection (15) and paragraph (a) of subsection (22) of
19 section 409.913, Florida Statutes, are amended to read:
20 409.913 Oversight of the integrity of the Medicaid
21 program.--The agency shall operate a program to oversee the
22 activities of Florida Medicaid recipients, and providers and
23 their representatives, to ensure that fraudulent and abusive
24 behavior and neglect of recipients occur to the minimum extent
25 possible, and to recover overpayments and impose sanctions as
26 appropriate.
27 (15) The agency may impose any of the following
28 sanctions on a provider or a person for any of the acts
29 described in subsection (14):
30 (a) Suspension for a specific period of time of not
31 more than 1 year.
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1 (b) Termination for a specific period of time of from
2 more than 1 year to 20 years.
3 (c) Imposition of a fine of up to $5,000 for each
4 violation. Each day that an ongoing violation continues, such
5 as refusing to furnish Medicaid-related records or refusing
6 access to records, is considered, for the purposes of this
7 section, to be a separate violation. Each instance of
8 improper billing of a Medicaid recipient; each instance of
9 including an unallowable cost on a hospital or nursing home
10 Medicaid cost report after the provider or authorized
11 representative has been advised in an audit exit conference or
12 previous audit report of the cost unallowability; each
13 instance of furnishing a Medicaid recipient goods or
14 professional services that are inappropriate or of inferior
15 quality as determined by competent peer judgment; each
16 instance of knowingly submitting a materially false or
17 erroneous Medicaid provider enrollment application, request
18 for prior authorization for Medicaid services, drug exception
19 request, or cost report; each instance of inappropriate
20 prescribing of drugs for a Medicaid recipient as determined by
21 competent peer judgment; and each false or erroneous Medicaid
22 claim leading to an overpayment to a provider is considered,
23 for the purposes of this section, to be a separate violation.
24 (d) Immediate suspension, if the agency has received
25 information of patient abuse or neglect or of any act
26 prohibited by s. 409.920. Upon suspension, the agency must
27 issue an immediate final order under s. 120.569(2)(n).
28 (e) A fine, not to exceed $10,000, for a violation of
29 paragraph (14)(i).
30 (f) Imposition of liens against provider assets,
31 including, but not limited to, financial assets and real
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1 property, not to exceed the amount of the fine or recovery
2 sought.
3 (g) Other remedies as permitted by law to effect the
4 recovery of a fine or overpayment.
5 (22)(a) In an audit or investigation of a violation
6 committed by a provider which is conducted pursuant to this
7 section, the agency is entitled to recover all up to $15,000
8 in investigative, legal, and expert witness costs if the
9 agency's findings were not contested by the provider or, if
10 contested, the agency ultimately prevailed.
11 Section 12. Subsection (2) of section 409.915, Florida
12 Statutes, is amended to read:
13 409.915 County contributions to Medicaid.--Although
14 the state is responsible for the full portion of the state
15 share of the matching funds required for the Medicaid program,
16 in order to acquire a certain portion of these funds, the
17 state shall charge the counties for certain items of care and
18 service as provided in this section.
19 (2) A county's participation must be 35 percent of the
20 total cost, or the applicable discounted cost paid by the
21 state for Medicaid recipients enrolled in health maintenance
22 organizations or prepaid health plans, of providing the items
23 listed in subsection (1), except that the payments for items
24 listed in paragraph (1)(b) may not exceed $90 $55 per month
25 per person.
26 Section 13. Subsection (14) of section 409.908,
27 Florida Statutes, is amended to read:
28 409.908 Reimbursement of Medicaid providers.--Subject
29 to specific appropriations, the agency shall reimburse
30 Medicaid providers, in accordance with state and federal law,
31 according to methodologies set forth in the rules of the
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1 agency and in policy manuals and handbooks incorporated by
2 reference therein. These methodologies may include fee
3 schedules, reimbursement methods based on cost reporting,
4 negotiated fees, competitive bidding pursuant to s. 287.057,
5 and other mechanisms the agency considers efficient and
6 effective for purchasing services or goods on behalf of
7 recipients. Payment for Medicaid compensable services made on
8 behalf of Medicaid eligible persons is subject to the
9 availability of moneys and any limitations or directions
10 provided for in the General Appropriations Act or chapter 216.
11 Further, nothing in this section shall be construed to prevent
12 or limit the agency from adjusting fees, reimbursement rates,
13 lengths of stay, number of visits, or number of services, or
14 making any other adjustments necessary to comply with the
15 availability of moneys and any limitations or directions
16 provided for in the General Appropriations Act, provided the
17 adjustment is consistent with legislative intent.
18 (14) A provider of prescribed drugs shall be
19 reimbursed the least of the amount billed by the provider, the
20 provider's usual and customary charge, or the Medicaid maximum
21 allowable fee established by the agency, plus a dispensing
22 fee. The agency is directed to implement a variable dispensing
23 fee for payments for prescribed medicines while ensuring
24 continued access for Medicaid recipients. The variable
25 dispensing fee may be based upon, but not limited to, either
26 or both the volume of prescriptions dispensed by a specific
27 pharmacy provider, and the volume of prescriptions dispensed
28 to an individual recipient, and dispensing of
29 preferred-drug-list products. The agency shall increase the
30 pharmacy dispensing fee authorized by statute and in the
31 annual General Appropriations Act by $0.50 for the dispensing
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1 of a Medicaid preferred-drug-list product and reduce the
2 pharmacy dispensing fee by $0.50 for the dispensing of a
3 Medicaid product that is not included on the preferred-drug
4 list. The agency is authorized to limit reimbursement for
5 prescribed medicine in order to comply with any limitations or
6 directions provided for in the General Appropriations Act,
7 which may include implementing a prospective or concurrent
8 utilization review program.
9 Section 14. Section 400.0225, Florida Statutes, is
10 repealed.
11 Section 15. Paragraph (a) of subsection (2) of section
12 400.191, Florida Statutes, is amended to read:
13 400.191 Availability, distribution, and posting of
14 reports and records.--
15 (2) The agency shall provide additional information in
16 consumer-friendly printed and electronic formats to assist
17 consumers and their families in comparing and evaluating
18 nursing home facilities.
19 (a) The agency shall provide an Internet site which
20 shall include at least the following information either
21 directly or indirectly through a link to another established
22 site or sites of the agency's choosing:
23 1. A list by name and address of all nursing home
24 facilities in this state.
25 2. Whether such nursing home facilities are
26 proprietary or nonproprietary.
27 3. The current owner of the facility's license and the
28 year that that entity became the owner of the license.
29 4. The name of the owner or owners of each facility
30 and whether the facility is affiliated with a company or other
31
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1 organization owning or managing more than one nursing facility
2 in this state.
3 5. The total number of beds in each facility.
4 6. The number of private and semiprivate rooms in each
5 facility.
6 7. The religious affiliation, if any, of each
7 facility.
8 8. The languages spoken by the administrator and staff
9 of each facility.
10 9. Whether or not each facility accepts Medicare or
11 Medicaid recipients or insurance, health maintenance
12 organization, Veterans Administration, CHAMPUS program, or
13 workers' compensation coverage.
14 10. Recreational and other programs available at each
15 facility.
16 11. Special care units or programs offered at each
17 facility.
18 12. Whether the facility is a part of a retirement
19 community that offers other services pursuant to part III,
20 part IV, or part V.
21 13. The results of consumer and family satisfaction
22 surveys for each facility, as described in s. 400.0225. The
23 results may be converted to a score or scores, which may be
24 presented in either numeric or symbolic form for the intended
25 consumer audience.
26 13.14. Survey and deficiency information contained on
27 the Online Survey Certification and Reporting (OSCAR) system
28 of the federal Health Care Financing Administration, including
29 annual survey, revisit, and complaint survey information, for
30 each facility for the past 45 months. For noncertified
31 nursing homes, state survey and deficiency information,
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1 including annual survey, revisit, and complaint survey
2 information for the past 45 months shall be provided.
3 14.15. A summary of the Online Survey Certification
4 and Reporting (OSCAR) data for each facility over the past 45
5 months. Such summary may include a score, rating, or
6 comparison ranking with respect to other facilities based on
7 the number of citations received by the facility of annual,
8 revisit, and complaint surveys; the severity and scope of the
9 citations; and the number of annual recertification surveys
10 the facility has had during the past 45 months. The score,
11 rating, or comparison ranking may be presented in either
12 numeric or symbolic form for the intended consumer audience.
13 Section 16. Paragraph (c) of subsection (5) of section
14 400.235, Florida Statutes, is amended to read:
15 400.235 Nursing home quality and licensure status;
16 Gold Seal Program.--
17 (5) Facilities must meet the following additional
18 criteria for recognition as a Gold Seal Program facility:
19 (c) Participate consistently in a the required
20 consumer satisfaction process as prescribed by the agency, and
21 demonstrate that information is elicited from residents,
22 family members, and guardians about satisfaction with the
23 nursing facility, its environment, the services and care
24 provided, the staff's skills and interactions with residents,
25 attention to resident's needs, and the facility's efforts to
26 act on information gathered from the consumer satisfaction
27 measures.
28
29 A facility assigned a conditional licensure status may not
30 qualify for consideration for the Gold Seal Program until
31 after it has operated for 30 months with no class I or class
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1 II deficiencies and has completed a regularly scheduled
2 relicensure survey.
3 Section 17. Section 400.148, Florida Statutes, is
4 repealed.
5 Section 18. Section 400.071, Florida Statutes, is
6 amended to read:
7 400.071 Application for license.--
8 (1) An application for a license as required by s.
9 400.062 shall be made to the agency on forms furnished by it
10 and shall be accompanied by the appropriate license fee.
11 (2) The application shall be under oath and shall
12 contain the following:
13 (a) The name, address, and social security number of
14 the applicant if an individual; if the applicant is a firm,
15 partnership, or association, its name, address, and employer
16 identification number (EIN), and the name and address of any
17 controlling interest; and the name by which the facility is to
18 be known.
19 (b) The name of any person whose name is required on
20 the application under the provisions of paragraph (a) and who
21 owns at least a 10-percent interest in any professional
22 service, firm, association, partnership, or corporation
23 providing goods, leases, or services to the facility for which
24 the application is made, and the name and address of the
25 professional service, firm, association, partnership, or
26 corporation in which such interest is held.
27 (c) The location of the facility for which a license
28 is sought and an indication, as in the original application,
29 that such location conforms to the local zoning ordinances.
30
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1 (d) The name of the person or persons under whose
2 management or supervision the facility will be conducted and
3 the name of the administrator.
4 (e) A signed affidavit disclosing any financial or
5 ownership interest that a person or entity described in
6 paragraph (a) or paragraph (d) has held in the last 5 years in
7 any entity licensed by this state or any other state to
8 provide health or residential care which has closed
9 voluntarily or involuntarily; has filed for bankruptcy; has
10 had a receiver appointed; has had a license denied, suspended,
11 or revoked; or has had an injunction issued against it which
12 was initiated by a regulatory agency. The affidavit must
13 disclose the reason any such entity was closed, whether
14 voluntarily or involuntarily.
15 (f) The total number of beds and the total number of
16 Medicare and Medicaid certified beds.
17 (g) Information relating to the number, experience,
18 and training of the employees of the facility and of the moral
19 character of the applicant and employees which the agency
20 requires by rule, including the name and address of any
21 nursing home with which the applicant or employees have been
22 affiliated through ownership or employment within 5 years of
23 the date of the application for a license and the record of
24 any criminal convictions involving the applicant and any
25 criminal convictions involving an employee if known by the
26 applicant after inquiring of the employee. The applicant must
27 demonstrate that sufficient numbers of qualified staff, by
28 training or experience, will be employed to properly care for
29 the type and number of residents who will reside in the
30 facility.
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1 (h) Copies of any civil verdict or judgment involving
2 the applicant rendered within the 10 years preceding the
3 application, relating to medical negligence, violation of
4 residents' rights, or wrongful death. As a condition of
5 licensure, the licensee agrees to provide to the agency copies
6 of any new verdict or judgment involving the applicant,
7 relating to such matters, within 30 days after filing with the
8 clerk of the court. The information required in this
9 paragraph shall be maintained in the facility's licensure file
10 and in an agency database which is available as a public
11 record.
12 (3) The applicant shall submit evidence which
13 establishes the good moral character of the applicant,
14 manager, supervisor, and administrator. No applicant, if the
15 applicant is an individual; no member of a board of directors
16 or officer of an applicant, if the applicant is a firm,
17 partnership, association, or corporation; and no licensed
18 nursing home administrator shall have been convicted, or found
19 guilty, regardless of adjudication, of a crime in any
20 jurisdiction which affects or may potentially affect residents
21 in the facility.
22 (4) Each applicant for licensure must comply with the
23 following requirements:
24 (a) Upon receipt of a completed, signed, and dated
25 application, the agency shall require background screening of
26 the applicant, in accordance with the level 2 standards for
27 screening set forth in chapter 435. As used in this
28 subsection, the term "applicant" means the facility
29 administrator, or similarly titled individual who is
30 responsible for the day-to-day operation of the licensed
31 facility, and the facility financial officer, or similarly
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1 titled individual who is responsible for the financial
2 operation of the licensed facility.
3 (b) The agency may require background screening for a
4 member of the board of directors of the licensee or an officer
5 or an individual owning 5 percent or more of the licensee if
6 the agency has probable cause to believe that such individual
7 has been convicted of an offense prohibited under the level 2
8 standards for screening set forth in chapter 435.
9 (c) Proof of compliance with the level 2 background
10 screening requirements of chapter 435 which has been submitted
11 within the previous 5 years in compliance with any other
12 health care or assisted living licensure requirements of this
13 state is acceptable in fulfillment of paragraph (a). Proof of
14 compliance with background screening which has been submitted
15 within the previous 5 years to fulfill the requirements of the
16 Department of Insurance pursuant to chapter 651 as part of an
17 application for a certificate of authority to operate a
18 continuing care retirement community is acceptable in
19 fulfillment of the Department of Law Enforcement and Federal
20 Bureau of Investigation background check.
21 (d) A provisional license may be granted to an
22 applicant when each individual required by this section to
23 undergo background screening has met the standards for the
24 Department of Law Enforcement background check, but the agency
25 has not yet received background screening results from the
26 Federal Bureau of Investigation, or a request for a
27 disqualification exemption has been submitted to the agency as
28 set forth in chapter 435, but a response has not yet been
29 issued. A license may be granted to the applicant upon the
30 agency's receipt of a report of the results of the Federal
31 Bureau of Investigation background screening for each
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1 individual required by this section to undergo background
2 screening which confirms that all standards have been met, or
3 upon the granting of a disqualification exemption by the
4 agency as set forth in chapter 435. Any other person who is
5 required to undergo level 2 background screening may serve in
6 his or her capacity pending the agency's receipt of the report
7 from the Federal Bureau of Investigation; however, the person
8 may not continue to serve if the report indicates any
9 violation of background screening standards and a
10 disqualification exemption has not been requested of and
11 granted by the agency as set forth in chapter 435.
12 (e) Each applicant must submit to the agency, with its
13 application, a description and explanation of any exclusions,
14 permanent suspensions, or terminations of the applicant from
15 the Medicare or Medicaid programs. Proof of compliance with
16 disclosure of ownership and control interest requirements of
17 the Medicaid or Medicare programs shall be accepted in lieu of
18 this submission.
19 (f) Each applicant must submit to the agency a
20 description and explanation of any conviction of an offense
21 prohibited under the level 2 standards of chapter 435 by a
22 member of the board of directors of the applicant, its
23 officers, or any individual owning 5 percent or more of the
24 applicant. This requirement shall not apply to a director of a
25 not-for-profit corporation or organization if the director
26 serves solely in a voluntary capacity for the corporation or
27 organization, does not regularly take part in the day-to-day
28 operational decisions of the corporation or organization,
29 receives no remuneration for his or her services on the
30 corporation or organization's board of directors, and has no
31 financial interest and has no family members with a financial
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1 interest in the corporation or organization, provided that the
2 director and the not-for-profit corporation or organization
3 include in the application a statement affirming that the
4 director's relationship to the corporation satisfies the
5 requirements of this paragraph.
6 (g) An application for license renewal must contain
7 the information required under paragraphs (e) and (f).
8 (5) The applicant shall furnish satisfactory proof of
9 financial ability to operate and conduct the nursing home in
10 accordance with the requirements of this part and all rules
11 adopted under this part, and the agency shall establish
12 standards for this purpose, including information reported
13 under paragraph (2)(e). The agency also shall establish
14 documentation requirements, to be completed by each applicant,
15 that show anticipated facility revenues and expenditures, the
16 basis for financing the anticipated cash-flow requirements of
17 the facility, and an applicant's access to contingency
18 financing.
19 (6) If the applicant offers continuing care agreements
20 as defined in chapter 651, proof shall be furnished that such
21 applicant has obtained a certificate of authority as required
22 for operation under that chapter.
23 (7) As a condition of licensure, each licensee, except
24 one offering continuing care agreements as defined in chapter
25 651, must agree to accept recipients of Title XIX of the
26 Social Security Act on a temporary, emergency basis. The
27 persons whom the agency may require such licensees to accept
28 are those recipients of Title XIX of the Social Security Act
29 who are residing in a facility in which existing conditions
30 constitute an immediate danger to the health, safety, or
31 security of the residents of the facility.
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1 (8) As a condition of licensure, each facility must
2 agree to participate in a consumer satisfaction measurement
3 process as prescribed by the agency.
4 (8)(9) The agency may not issue a license to a nursing
5 home that fails to receive a certificate of need under the
6 provisions of ss. 408.031-408.045. It is the intent of the
7 Legislature that, in reviewing a certificate-of-need
8 application to add beds to an existing nursing home facility,
9 preference be given to the application of a licensee who has
10 been awarded a Gold Seal as provided for in s. 400.235, if the
11 applicant otherwise meets the review criteria specified in s.
12 408.035.
13 (9)(10) The agency may develop an abbreviated survey
14 for licensure renewal applicable to a licensee that has
15 continuously operated as a nursing facility since 1991 or
16 earlier, has operated under the same management for at least
17 the preceding 30 months, and has had during the preceding 30
18 months no class I or class II deficiencies.
19 (10)(11) The agency may issue an inactive license to a
20 nursing home that will be temporarily unable to provide
21 services but that is reasonably expected to resume services.
22 Such designation may be made for a period not to exceed 12
23 months but may be renewed by the agency for up to 6 additional
24 months. Any request by a licensee that a nursing home become
25 inactive must be submitted to the agency and approved by the
26 agency prior to initiating any suspension of service or
27 notifying residents. Upon agency approval, the nursing home
28 shall notify residents of any necessary discharge or transfer
29 as provided in s. 400.0255.
30
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1 (11)(12) As a condition of licensure, each facility
2 must establish and submit with its application a plan for
3 quality assurance and for conducting risk management.
4 Section 19. Paragraph (q) of subsection (2) of section
5 409.815, Florida Statutes, is amended to read:
6 409.815 Health benefits coverage; limitations.--
7 (2) BENCHMARK BENEFITS.--In order for health benefits
8 coverage to qualify for premium assistance payments for an
9 eligible child under ss. 409.810-409.820, the health benefits
10 coverage, except for coverage under Medicaid and Medikids,
11 must include the following minimum benefits, as medically
12 necessary.
13 (q) Dental services.--Subject to a specific
14 appropriation for this benefit, covered services include those
15 dental services provided to children by the Florida Medicaid
16 program under s. 409.906(5) s. 409.906(6).
17 Section 20. Except as otherwise specifically provided
18 in this act, this act shall take effect January 1, 2002.
19
20 *****************************************
21 SENATE SUMMARY
22 Revises and repeals various provisions of law relating to
programs administered by the Agency for Health Care
23 Administration. (See bill for details.)
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