Senate Bill sb1108c1
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Florida Senate - 2002 CS for SB 1108
By the Committee on Appropriations; and Senator Silver
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1 A bill to be entitled
2 An act relating to the Agency for Health Care
3 Administration; amending s. 409.8177, F.S.;
4 requiring the agency to contract for an
5 evaluation of the Florida Kidcare program;
6 amending s. 409.904, F.S.; revising provisions
7 governing optional payments for medical
8 assistance and related services; amending s.
9 409.905, F.S.; providing additional criteria
10 for the agency to adjust a hospital's inpatient
11 per diem rate for Medicaid; amending s.
12 409.906, F.S.; authorizing the agency to make
13 payments for specified services which are
14 optional under Title XIX of the Social Security
15 Act; amending s. 409.912, F.S.; revising
16 provisions governing the purchase of goods and
17 services for Medicaid recipients; providing for
18 quarterly reports to the Governor and presiding
19 officers of the Legislature; amending s.
20 409.9116, F.S.; revising the disproportionate
21 share/financial assistance program for rural
22 hospitals; amending s. 409.9122, F.S.; revising
23 provisions governing mandatory Medicaid managed
24 care enrollment; providing an effective date.
25
26 Be It Enacted by the Legislature of the State of Florida:
27
28 Section 1. Section 409.8177, Florida Statutes, is
29 amended to read:
30 409.8177 Program evaluation.--
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1 (1) The agency, in consultation with the Department of
2 Health, the Department of Children and Family Services, and
3 the Florida Healthy Kids Corporation, shall contract for an
4 evaluation of the Florida Kidcare program and shall by January
5 1 of each year submit to the Governor, the President of the
6 Senate, and the Speaker of the House of Representatives a
7 report of the Florida Kidcare program. In addition to the
8 items specified under s. 2108 of Title XXI of the Social
9 Security Act, the report shall include an assessment of
10 crowd-out and access to health care, as well as the following:
11 (a)(1) An assessment of the operation of the program,
12 including the progress made in reducing the number of
13 uncovered low-income children.
14 (b)(2) An assessment of the effectiveness in
15 increasing the number of children with creditable health
16 coverage, including an assessment of the impact of outreach.
17 (c)(3) The characteristics of the children and
18 families assisted under the program, including ages of the
19 children, family income, and access to or coverage by other
20 health insurance prior to the program and after disenrollment
21 from the program.
22 (d)(4) The quality of health coverage provided,
23 including the types of benefits provided.
24 (e)(5) The amount and level, including payment of part
25 or all of any premium, of assistance provided.
26 (f)(6) The average length of coverage of a child under
27 the program.
28 (g)(7) The program's choice of health benefits
29 coverage and other methods used for providing child health
30 assistance.
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1 (h)(8) The sources of nonfederal funding used in the
2 program.
3 (i)(9) An assessment of the effectiveness of Medikids,
4 Children's Medical Services network, and other public and
5 private programs in the state in increasing the availability
6 of affordable quality health insurance and health care for
7 children.
8 (j)(10) A review and assessment of state activities to
9 coordinate the program with other public and private programs.
10 (k)(11) An analysis of changes and trends in the state
11 that affect the provision of health insurance and health care
12 to children.
13 (l)(12) A description of any plans the state has for
14 improving the availability of health insurance and health care
15 for children.
16 (m)(13) Recommendations for improving the program.
17 (n)(14) Other studies as necessary.
18 (2) The agency shall also submit each month to the
19 Governor, the President of the Senate, and the Speaker of the
20 House of Representatives a report of enrollment for each
21 program component of the Florida Kidcare program.
22 Section 2. Effective July 1, 2002, subsection (2) of
23 section 409.904, Florida Statutes, as amended by section 2 of
24 chapter 2001-377, Laws of Florida, is amended to read:
25 409.904 Optional payments for eligible persons.--The
26 agency may make payments for medical assistance and related
27 services on behalf of the following persons who are determined
28 to be eligible subject to the income, assets, and categorical
29 eligibility tests set forth in federal and state law. Payment
30 on behalf of these Medicaid eligible persons is subject to the
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1 availability of moneys and any limitations established by the
2 General Appropriations Act or chapter 216.
3 (2)(a) A family, a pregnant woman, a child under age
4 19 who would otherwise qualify for Florida Kidcare Medicaid, a
5 child up to age 21 who would otherwise qualify under s.
6 409.903(1), a person age 65 or over, or a blind or disabled
7 person who would otherwise be eligible for Florida Medicaid,
8 except that the income or assets of such family or person
9 exceed established limitations. A pregnant woman who would
10 otherwise qualify for Medicaid under s. 409.903(5) except for
11 her level of income and whose assets fall within the limits
12 established by the Department of Children and Family Services
13 for the medically needy. A pregnant woman who applies for
14 medically needy eligibility may not be made presumptively
15 eligible.
16 (b) A child under age 21 who would otherwise qualify
17 for Medicaid or the Florida Kidcare program except for the
18 family's level of income and whose assets fall within the
19 limits established by the Department of Children and Family
20 Services for the medically needy.
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22 For a family or person in this group, medical expenses are
23 deductible from income in accordance with federal requirements
24 in order to make a determination of eligibility. Expenses used
25 to meet spend-down liability are not reimbursable by Medicaid.
26 The medically-needy income levels in effect on July 1, 2001,
27 are increased by $270 effective July 1, 2002. A family or
28 person in this group, which group is known as the "medically
29 needy," is eligible to receive the same services as other
30 Medicaid recipients, with the exception of services in skilled
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1 nursing facilities and intermediate care facilities for the
2 developmentally disabled.
3 Section 3. Paragraph (c) of subsection (5) of section
4 409.905, Florida Statutes, is amended to read:
5 409.905 Mandatory Medicaid services.--The agency may
6 make payments for the following services, which are required
7 of the state by Title XIX of the Social Security Act,
8 furnished by Medicaid providers to recipients who are
9 determined to be eligible on the dates on which the services
10 were provided. Any service under this section shall be
11 provided only when medically necessary and in accordance with
12 state and federal law. Mandatory services rendered by
13 providers in mobile units to Medicaid recipients may be
14 restricted by the agency. Nothing in this section shall be
15 construed to prevent or limit the agency from adjusting fees,
16 reimbursement rates, lengths of stay, number of visits, number
17 of services, or any other adjustments necessary to comply with
18 the availability of moneys and any limitations or directions
19 provided for in the General Appropriations Act or chapter 216.
20 (5) HOSPITAL INPATIENT SERVICES.--The agency shall pay
21 for all covered services provided for the medical care and
22 treatment of a recipient who is admitted as an inpatient by a
23 licensed physician or dentist to a hospital licensed under
24 part I of chapter 395. However, the agency shall limit the
25 payment for inpatient hospital services for a Medicaid
26 recipient 21 years of age or older to 45 days or the number of
27 days necessary to comply with the General Appropriations Act.
28 (c) Agency for Health Care Administration shall adjust
29 a hospital's current inpatient per diem rate to reflect the
30 cost of serving the Medicaid population at that institution
31 if:
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1 1. The hospital experiences an increase in Medicaid
2 caseload by more than 25 percent in any year, primarily
3 resulting from the closure of a hospital in the same service
4 area occurring after July 1, 1995; or
5 2. The hospital's Medicaid per diem rate is at least
6 25 percent below the Medicaid per patient cost for that year;
7 or.
8 3. The hospital is located in a county that has five
9 or fewer hospitals, began offering obstetrical services on or
10 after September 1999, and has submitted a request in writing
11 to the agency for a rate adjustment after July 1, 2000, but
12 before September 30, 2000, in which case such hospital's
13 Medicaid inpatient per diem rate shall be adjusted to cost,
14 effective July 1, 2002. For subsequent rate semesters, such
15 hospital's rate will be set in accordance with the methodology
16 of the Medicaid inpatient reimbursement plan.
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18 No later than October 1 of each year November 1, 2001, the
19 agency must provide estimated costs for any adjustment in a
20 hospital inpatient per diem pursuant to this paragraph to the
21 Executive Office of the Governor, the House of Representatives
22 General Appropriations Committee, and the Senate
23 Appropriations Committee. Before the agency implements a
24 change in a hospital's inpatient per diem rate pursuant to
25 this paragraph, the Legislature must have specifically
26 appropriated sufficient funds in the General Appropriations
27 Act to support the increase in cost as estimated by the
28 agency.
29 Section 4. Effective July 1, 2002, subsections (1),
30 (12), and (23) of section 409.906, Florida Statutes, as
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1 amended by section 3 of chapter 2001-377, Laws of Florida, are
2 amended to read:
3 409.906 Optional Medicaid services.--Subject to
4 specific appropriations, the agency may make payments for
5 services which are optional to the state under Title XIX of
6 the Social Security Act and are furnished by Medicaid
7 providers to recipients who are determined to be eligible on
8 the dates on which the services were provided. Any optional
9 service that is provided shall be provided only when medically
10 necessary and in accordance with state and federal law.
11 Optional services rendered by providers in mobile units to
12 Medicaid recipients may be restricted or prohibited by the
13 agency. Nothing in this section shall be construed to prevent
14 or limit the agency from adjusting fees, reimbursement rates,
15 lengths of stay, number of visits, or number of services, or
16 making any other adjustments necessary to comply with the
17 availability of moneys and any limitations or directions
18 provided for in the General Appropriations Act or chapter 216.
19 If necessary to safeguard the state's systems of providing
20 services to elderly and disabled persons and subject to the
21 notice and review provisions of s. 216.177, the Governor may
22 direct the Agency for Health Care Administration to amend the
23 Medicaid state plan to delete the optional Medicaid service
24 known as "Intermediate Care Facilities for the Developmentally
25 Disabled." Optional services may include:
26 (1) ADULT DENTURE SERVICES.--The agency may pay for
27 dentures, the procedures required to seat dentures, and the
28 repair and reline of dentures, provided by or under the
29 direction of a licensed dentist, for a recipient who is age 21
30 or older. However, Medicaid will not provide reimbursement for
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1 dental services provided in a mobile dental unit, except for a
2 mobile dental unit:
3 (a) Owned by, operated by, or having a contractual
4 agreement with the Department of Health and complying with
5 Medicaid's county health department clinic services program
6 specifications as a county health department clinic services
7 provider.
8 (b) Owned by, operated by, or having a contractual
9 arrangement with a federally qualified health center and
10 complying with Medicaid's federally qualified health center
11 specifications as a federally qualified health center
12 provider.
13 (c) Rendering dental services to Medicaid recipients,
14 21 years of age and older, at nursing facilities.
15 (d) Owned by, operated by, or having a contractual
16 agreement with a state-approved dental educational
17 institution.
18 (e) This subsection is repealed July 1, 2002.
19 (12) CHILDREN'S HEARING SERVICES.--The agency may pay
20 for hearing and related services, including hearing
21 evaluations, hearing aid devices, dispensing of the hearing
22 aid, and related repairs, if provided to a recipient under age
23 21 by a licensed hearing aid specialist, otolaryngologist,
24 otologist, audiologist, or physician.
25 (23) CHILDREN'S VISUAL SERVICES.--The agency may pay
26 for visual examinations, eyeglasses, and eyeglass repairs for
27 a recipient under age 21, if they are prescribed by a licensed
28 physician specializing in diseases of the eye or by a licensed
29 optometrist.
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1 Section 5. Section 409.912, Florida Statutes, as
2 amended by sections 8 and 9 of chapter 2001-377, Laws of
3 Florida, is amended to read:
4 409.912 Cost-effective purchasing of health care.--The
5 agency shall purchase goods and services for Medicaid
6 recipients in the most cost-effective manner consistent with
7 the delivery of quality medical care. The agency shall
8 maximize the use of prepaid per capita and prepaid aggregate
9 fixed-sum basis services when appropriate and other
10 alternative service delivery and reimbursement methodologies,
11 including competitive bidding pursuant to s. 287.057, designed
12 to facilitate the cost-effective purchase of a case-managed
13 continuum of care. The agency shall also require providers to
14 minimize the exposure of recipients to the need for acute
15 inpatient, custodial, and other institutional care and the
16 inappropriate or unnecessary use of high-cost services. The
17 agency may establish prior authorization requirements for
18 certain populations of Medicaid beneficiaries, certain drug
19 classes, or particular drugs to prevent fraud, abuse, overuse,
20 and possible dangerous drug interactions. The Pharmaceutical
21 and Therapeutics Committee, established pursuant to s.
22 409.91195, shall make recommendations to the agency on drugs
23 for which prior authorization is required, and. the agency
24 shall inform the Pharmaceutical and Therapeutics committee of
25 its decisions regarding drugs subject to prior authorization.
26 (1) The agency may enter into agreements with
27 appropriate agents of other state agencies or of any agency of
28 the Federal Government and accept such duties in respect to
29 social welfare or public aid as may be necessary to implement
30 the provisions of Title XIX of the Social Security Act and ss.
31 409.901-409.920.
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1 (2) The agency may contract with health maintenance
2 organizations certified pursuant to part I of chapter 641 for
3 the provision of services to recipients.
4 (3) The agency may contract with:
5 (a) An entity that provides no prepaid health care
6 services other than Medicaid services under contract with the
7 agency and which is owned and operated by a county, county
8 health department, or county-owned and operated hospital to
9 provide health care services on a prepaid or fixed-sum basis
10 to recipients, which entity may provide such prepaid services
11 either directly or through arrangements with other providers.
12 Such prepaid health care services entities must be licensed
13 under parts I and III by January 1, 1998, and until then are
14 exempt from the provisions of part I of chapter 641. An entity
15 recognized under this paragraph which demonstrates to the
16 satisfaction of the Department of Insurance that it is backed
17 by the full faith and credit of the county in which it is
18 located may be exempted from s. 641.225.
19 (b) An entity that is providing comprehensive
20 behavioral health care services to certain Medicaid recipients
21 through a capitated, prepaid arrangement pursuant to the
22 federal waiver provided for by s. 409.905(5). Such an entity
23 must be licensed under chapter 624, chapter 636, or chapter
24 641 and must possess the clinical systems and operational
25 competence to manage risk and provide comprehensive behavioral
26 health care to Medicaid recipients. As used in this paragraph,
27 the term "comprehensive behavioral health care services" means
28 covered mental health and substance abuse treatment services
29 that are available to Medicaid recipients. The secretary of
30 the Department of Children and Family Services shall approve
31 provisions of procurements related to children in the
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1 department's care or custody prior to enrolling such children
2 in a prepaid behavioral health plan. Any contract awarded
3 under this paragraph must be competitively procured. In
4 developing the behavioral health care prepaid plan procurement
5 document, the agency shall ensure that the procurement
6 document requires the contractor to develop and implement a
7 plan to ensure compliance with s. 394.4574 related to services
8 provided to residents of licensed assisted living facilities
9 that hold a limited mental health license. The agency must
10 ensure that Medicaid recipients have available the choice of
11 at least two managed care plans for their behavioral health
12 care services. The agency may reimburse for
13 substance-abuse-treatment services on a fee-for-service basis
14 until the agency finds that adequate funds are available for
15 capitated, prepaid arrangements.
16 1. By January 1, 2001, the agency shall modify the
17 contracts with the entities providing comprehensive inpatient
18 and outpatient mental health care services to Medicaid
19 recipients in Hillsborough, Highlands, Hardee, Manatee, and
20 Polk Counties, to include substance-abuse-treatment services.
21 2. By December 31, 2001, the agency shall contract
22 with entities providing comprehensive behavioral health care
23 services to Medicaid recipients through capitated, prepaid
24 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
25 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
26 and Walton Counties. The agency may contract with entities
27 providing comprehensive behavioral health care services to
28 Medicaid recipients through capitated, prepaid arrangements in
29 Alachua County. The agency may determine if Sarasota County
30 shall be included as a separate catchment area or included in
31 any other agency geographic area.
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1 3. Children residing in a Department of Juvenile
2 Justice residential program approved as a Medicaid behavioral
3 health overlay services provider shall not be included in a
4 behavioral health care prepaid health plan pursuant to this
5 paragraph.
6 4. In converting to a prepaid system of delivery, the
7 agency shall in its procurement document require an entity
8 providing comprehensive behavioral health care services to
9 prevent the displacement of indigent care patients by
10 enrollees in the Medicaid prepaid health plan providing
11 behavioral health care services from facilities receiving
12 state funding to provide indigent behavioral health care, to
13 facilities licensed under chapter 395 which do not receive
14 state funding for indigent behavioral health care, or
15 reimburse the unsubsidized facility for the cost of behavioral
16 health care provided to the displaced indigent care patient.
17 5. Traditional community mental health providers under
18 contract with the Department of Children and Family Services
19 pursuant to part IV of chapter 394 and inpatient mental health
20 providers licensed pursuant to chapter 395 must be offered an
21 opportunity to accept or decline a contract to participate in
22 any provider network for prepaid behavioral health services.
23 (c) A federally qualified health center or an entity
24 owned by one or more federally qualified health centers or an
25 entity owned by other migrant and community health centers
26 receiving non-Medicaid financial support from the Federal
27 Government to provide health care services on a prepaid or
28 fixed-sum basis to recipients. Such prepaid health care
29 services entity must be licensed under parts I and III of
30 chapter 641, but shall be prohibited from serving Medicaid
31 recipients on a prepaid basis, until such licensure has been
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1 obtained. However, such an entity is exempt from s. 641.225
2 if the entity meets the requirements specified in subsections
3 (14) and (15).
4 (d) No more than four provider service networks for
5 demonstration projects to test Medicaid direct contracting.
6 The demonstration projects may be reimbursed on a
7 fee-for-service or prepaid basis. A provider service network
8 which is reimbursed by the agency on a prepaid basis shall be
9 exempt from parts I and III of chapter 641, but must meet
10 appropriate financial reserve, quality assurance, and patient
11 rights requirements as established by the agency. The agency
12 shall award contracts on a competitive bid basis and shall
13 select bidders based upon price and quality of care. Medicaid
14 recipients assigned to a demonstration project shall be chosen
15 equally from those who would otherwise have been assigned to
16 prepaid plans and MediPass. The agency is authorized to seek
17 federal Medicaid waivers as necessary to implement the
18 provisions of this section. A demonstration project awarded
19 pursuant to this paragraph shall be for 4 years from the date
20 of implementation.
21 (e) An entity that provides comprehensive behavioral
22 health care services to certain Medicaid recipients through an
23 administrative services organization agreement. Such an entity
24 must possess the clinical systems and operational competence
25 to provide comprehensive health care to Medicaid recipients.
26 As used in this paragraph, the term "comprehensive behavioral
27 health care services" means covered mental health and
28 substance abuse treatment services that are available to
29 Medicaid recipients. Any contract awarded under this paragraph
30 must be competitively procured. The agency must ensure that
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1 Medicaid recipients have available the choice of at least two
2 managed care plans for their behavioral health care services.
3 (f) An entity in Pasco County or Pinellas County that
4 provides in-home physician services to Medicaid recipients
5 with degenerative neurological diseases in order to test the
6 cost-effectiveness of enhanced home-based medical care. The
7 entity providing the services shall be reimbursed on a
8 fee-for-service basis at a rate not less than comparable
9 Medicare reimbursement rates. The agency may apply for waivers
10 of federal regulations necessary to implement such program.
11 This paragraph shall be repealed on July 1, 2002.
12 (g) Children's provider networks that provide care
13 coordination and care management for Medicaid-eligible
14 pediatric patients, primary care, authorization of specialty
15 care, and other urgent and emergency care through organized
16 providers designed to service Medicaid eligibles under age 18.
17 The networks shall provide after-hour operations, including
18 evening and weekend hours, to promote, when appropriate, the
19 use of the children's networks rather than hospital emergency
20 departments.
21 (4) The agency may contract with any public or private
22 entity otherwise authorized by this section on a prepaid or
23 fixed-sum basis for the provision of health care services to
24 recipients. An entity may provide prepaid services to
25 recipients, either directly or through arrangements with other
26 entities, if each entity involved in providing services:
27 (a) Is organized primarily for the purpose of
28 providing health care or other services of the type regularly
29 offered to Medicaid recipients;
30 (b) Ensures that services meet the standards set by
31 the agency for quality, appropriateness, and timeliness;
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1 (c) Makes provisions satisfactory to the agency for
2 insolvency protection and ensures that neither enrolled
3 Medicaid recipients nor the agency will be liable for the
4 debts of the entity;
5 (d) Submits to the agency, if a private entity, a
6 financial plan that the agency finds to be fiscally sound and
7 that provides for working capital in the form of cash or
8 equivalent liquid assets excluding revenues from Medicaid
9 premium payments equal to at least the first 3 months of
10 operating expenses or $200,000, whichever is greater;
11 (e) Furnishes evidence satisfactory to the agency of
12 adequate liability insurance coverage or an adequate plan of
13 self-insurance to respond to claims for injuries arising out
14 of the furnishing of health care;
15 (f) Provides, through contract or otherwise, for
16 periodic review of its medical facilities and services, as
17 required by the agency; and
18 (g) Provides organizational, operational, financial,
19 and other information required by the agency.
20 (5) The agency may contract on a prepaid or fixed-sum
21 basis with any health insurer that:
22 (a) Pays for health care services provided to enrolled
23 Medicaid recipients in exchange for a premium payment paid by
24 the agency;
25 (b) Assumes the underwriting risk; and
26 (c) Is organized and licensed under applicable
27 provisions of the Florida Insurance Code and is currently in
28 good standing with the Department of Insurance.
29 (6) The agency may contract on a prepaid or fixed-sum
30 basis with an exclusive provider organization to provide
31 health care services to Medicaid recipients provided that the
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1 exclusive provider organization meets applicable managed care
2 plan requirements in this section, ss. 409.9122, 409.9123,
3 409.9128, and 627.6472, and other applicable provisions of
4 law.
5 (7) The Agency for Health Care Administration may
6 provide cost-effective purchasing of chiropractic services on
7 a fee-for-service basis to Medicaid recipients through
8 arrangements with a statewide chiropractic preferred provider
9 organization incorporated in this state as a not-for-profit
10 corporation. The agency shall ensure that the benefit limits
11 and prior authorization requirements in the current Medicaid
12 program shall apply to the services provided by the
13 chiropractic preferred provider organization.
14 (8) The agency shall not contract on a prepaid or
15 fixed-sum basis for Medicaid services with an entity which
16 knows or reasonably should know that any officer, director,
17 agent, managing employee, or owner of stock or beneficial
18 interest in excess of 5 percent common or preferred stock, or
19 the entity itself, has been found guilty of, regardless of
20 adjudication, or entered a plea of nolo contendere, or guilty,
21 to:
22 (a) Fraud;
23 (b) Violation of federal or state antitrust statutes,
24 including those proscribing price fixing between competitors
25 and the allocation of customers among competitors;
26 (c) Commission of a felony involving embezzlement,
27 theft, forgery, income tax evasion, bribery, falsification or
28 destruction of records, making false statements, receiving
29 stolen property, making false claims, or obstruction of
30 justice; or
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1 (d) Any crime in any jurisdiction which directly
2 relates to the provision of health services on a prepaid or
3 fixed-sum basis.
4 (9) The agency, after notifying the Legislature, may
5 apply for waivers of applicable federal laws and regulations
6 as necessary to implement more appropriate systems of health
7 care for Medicaid recipients and reduce the cost of the
8 Medicaid program to the state and federal governments and
9 shall implement such programs, after legislative approval,
10 within a reasonable period of time after federal approval.
11 These programs must be designed primarily to reduce the need
12 for inpatient care, custodial care and other long-term or
13 institutional care, and other high-cost services.
14 (a) Prior to seeking legislative approval of such a
15 waiver as authorized by this subsection, the agency shall
16 provide notice and an opportunity for public comment. Notice
17 shall be provided to all persons who have made requests of the
18 agency for advance notice and shall be published in the
19 Florida Administrative Weekly not less than 28 days prior to
20 the intended action.
21 (b) Notwithstanding s. 216.292, funds that are
22 appropriated to the Department of Elderly Affairs for the
23 Assisted Living for the Elderly Medicaid waiver and are not
24 expended shall be transferred to the agency to fund
25 Medicaid-reimbursed nursing home care.
26 (10) The agency shall establish a postpayment
27 utilization control program designed to identify recipients
28 who may inappropriately overuse or underuse Medicaid services
29 and shall provide methods to correct such misuse.
30 (11) The agency shall develop and provide coordinated
31 systems of care for Medicaid recipients and may contract with
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1 public or private entities to develop and administer such
2 systems of care among public and private health care providers
3 in a given geographic area.
4 (12) The agency shall operate or contract for the
5 operation of utilization management and incentive systems
6 designed to encourage cost-effective use services.
7 (13)(a) The agency shall identify health care
8 utilization and price patterns within the Medicaid program
9 which are not cost-effective or medically appropriate and
10 assess the effectiveness of new or alternate methods of
11 providing and monitoring service, and may implement such
12 methods as it considers appropriate. Such methods may include
13 disease management initiatives, an integrated and systematic
14 approach for managing the health care needs of recipients who
15 are at risk of or diagnosed with a specific disease by using
16 best practices, prevention strategies, clinical-practice
17 improvement, clinical interventions and protocols, outcomes
18 research, information technology, and other tools and
19 resources to reduce overall costs and improve measurable
20 outcomes.
21 (b) The responsibility of the agency under this
22 subsection shall include the development of capabilities to
23 identify actual and optimal practice patterns; patient and
24 provider educational initiatives; methods for determining
25 patient compliance with prescribed treatments; fraud, waste,
26 and abuse prevention and detection programs; and beneficiary
27 case management programs.
28 1. The practice pattern identification program shall
29 evaluate practitioner prescribing patterns based on national
30 and regional practice guidelines, comparing practitioners to
31 their peer groups. The agency and its Drug Utilization Review
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1 Board shall consult with a panel of practicing health care
2 professionals consisting of the following: the Speaker of the
3 House of Representatives and the President of the Senate shall
4 each appoint three physicians licensed under chapter 458 or
5 chapter 459; and the Governor shall appoint two pharmacists
6 licensed under chapter 465 and one dentist licensed under
7 chapter 466 who is an oral surgeon. Terms of the panel members
8 shall expire at the discretion of the appointing official. The
9 panel shall begin its work by August 1, 1999, regardless of
10 the number of appointments made by that date. The advisory
11 panel shall be responsible for evaluating treatment guidelines
12 and recommending ways to incorporate their use in the practice
13 pattern identification program. Practitioners who are
14 prescribing inappropriately or inefficiently, as determined by
15 the agency, may have their prescribing of certain drugs
16 subject to prior authorization.
17 2. The agency shall also develop educational
18 interventions designed to promote the proper use of
19 medications by providers and beneficiaries.
20 3. The agency shall implement a pharmacy fraud, waste,
21 and abuse initiative that may include a surety bond or letter
22 of credit requirement for participating pharmacies, enhanced
23 provider auditing practices, the use of additional fraud and
24 abuse software, recipient management programs for
25 beneficiaries inappropriately using their benefits, and other
26 steps that will eliminate provider and recipient fraud, waste,
27 and abuse. The initiative shall address enforcement efforts to
28 reduce the number and use of counterfeit prescriptions.
29 4. The agency may apply for any federal waivers needed
30 to implement this paragraph.
31
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1 (14) An entity contracting on a prepaid or fixed-sum
2 basis shall, in addition to meeting any applicable statutory
3 surplus requirements, also maintain at all times in the form
4 of cash, investments that mature in less than 180 days
5 allowable as admitted assets by the Department of Insurance,
6 and restricted funds or deposits controlled by the agency or
7 the Department of Insurance, a surplus amount equal to
8 one-and-one-half times the entity's monthly Medicaid prepaid
9 revenues. As used in this subsection, the term "surplus" means
10 the entity's total assets minus total liabilities. If an
11 entity's surplus falls below an amount equal to
12 one-and-one-half times the entity's monthly Medicaid prepaid
13 revenues, the agency shall prohibit the entity from engaging
14 in marketing and preenrollment activities, shall cease to
15 process new enrollments, and shall not renew the entity's
16 contract until the required balance is achieved. The
17 requirements of this subsection do not apply:
18 (a) Where a public entity agrees to fund any deficit
19 incurred by the contracting entity; or
20 (b) Where the entity's performance and obligations are
21 guaranteed in writing by a guaranteeing organization which:
22 1. Has been in operation for at least 5 years and has
23 assets in excess of $50 million; or
24 2. Submits a written guarantee acceptable to the
25 agency which is irrevocable during the term of the contracting
26 entity's contract with the agency and, upon termination of the
27 contract, until the agency receives proof of satisfaction of
28 all outstanding obligations incurred under the contract.
29 (15)(a) The agency may require an entity contracting
30 on a prepaid or fixed-sum basis to establish a restricted
31 insolvency protection account with a federally guaranteed
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1 financial institution licensed to do business in this state.
2 The entity shall deposit into that account 5 percent of the
3 capitation payments made by the agency each month until a
4 maximum total of 2 percent of the total current contract
5 amount is reached. The restricted insolvency protection
6 account may be drawn upon with the authorized signatures of
7 two persons designated by the entity and two representatives
8 of the agency. If the agency finds that the entity is
9 insolvent, the agency may draw upon the account solely with
10 the two authorized signatures of representatives of the
11 agency, and the funds may be disbursed to meet financial
12 obligations incurred by the entity under the prepaid contract.
13 If the contract is terminated, expired, or not continued, the
14 account balance must be released by the agency to the entity
15 upon receipt of proof of satisfaction of all outstanding
16 obligations incurred under this contract.
17 (b) The agency may waive the insolvency protection
18 account requirement in writing when evidence is on file with
19 the agency of adequate insolvency insurance and reinsurance
20 that will protect enrollees if the entity becomes unable to
21 meet its obligations.
22 (16) An entity that contracts with the agency on a
23 prepaid or fixed-sum basis for the provision of Medicaid
24 services shall reimburse any hospital or physician that is
25 outside the entity's authorized geographic service area as
26 specified in its contract with the agency, and that provides
27 services authorized by the entity to its members, at a rate
28 negotiated with the hospital or physician for the provision of
29 services or according to the lesser of the following:
30 (a) The usual and customary charges made to the
31 general public by the hospital or physician; or
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1 (b) The Florida Medicaid reimbursement rate
2 established for the hospital or physician.
3 (17) When a merger or acquisition of a Medicaid
4 prepaid contractor has been approved by the Department of
5 Insurance pursuant to s. 628.4615, the agency shall approve
6 the assignment or transfer of the appropriate Medicaid prepaid
7 contract upon request of the surviving entity of the merger or
8 acquisition if the contractor and the other entity have been
9 in good standing with the agency for the most recent 12-month
10 period, unless the agency determines that the assignment or
11 transfer would be detrimental to the Medicaid recipients or
12 the Medicaid program. To be in good standing, an entity must
13 not have failed accreditation or committed any material
14 violation of the requirements of s. 641.52 and must meet the
15 Medicaid contract requirements. For purposes of this section,
16 a merger or acquisition means a change in controlling interest
17 of an entity, including an asset or stock purchase.
18 (18) Any entity contracting with the agency pursuant
19 to this section to provide health care services to Medicaid
20 recipients is prohibited from engaging in any of the following
21 practices or activities:
22 (a) Practices that are discriminatory, including, but
23 not limited to, attempts to discourage participation on the
24 basis of actual or perceived health status.
25 (b) Activities that could mislead or confuse
26 recipients, or misrepresent the organization, its marketing
27 representatives, or the agency. Violations of this paragraph
28 include, but are not limited to:
29 1. False or misleading claims that marketing
30 representatives are employees or representatives of the state
31
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1 or county, or of anyone other than the entity or the
2 organization by whom they are reimbursed.
3 2. False or misleading claims that the entity is
4 recommended or endorsed by any state or county agency, or by
5 any other organization which has not certified its endorsement
6 in writing to the entity.
7 3. False or misleading claims that the state or county
8 recommends that a Medicaid recipient enroll with an entity.
9 4. Claims that a Medicaid recipient will lose benefits
10 under the Medicaid program, or any other health or welfare
11 benefits to which the recipient is legally entitled, if the
12 recipient does not enroll with the entity.
13 (c) Granting or offering of any monetary or other
14 valuable consideration for enrollment, except as authorized by
15 subsection (21).
16 (d) Door-to-door solicitation of recipients who have
17 not contacted the entity or who have not invited the entity to
18 make a presentation.
19 (e) Solicitation of Medicaid recipients by marketing
20 representatives stationed in state offices unless approved and
21 supervised by the agency or its agent and approved by the
22 affected state agency when solicitation occurs in an office of
23 the state agency. The agency shall ensure that marketing
24 representatives stationed in state offices shall market their
25 managed care plans to Medicaid recipients only in designated
26 areas and in such a way as to not interfere with the
27 recipients' activities in the state office.
28 (f) Enrollment of Medicaid recipients.
29 (19) The agency may impose a fine for a violation of
30 this section or the contract with the agency by a person or
31 entity that is under contract with the agency. With respect
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1 to any nonwillful violation, such fine shall not exceed $2,500
2 per violation. In no event shall such fine exceed an
3 aggregate amount of $10,000 for all nonwillful violations
4 arising out of the same action. With respect to any knowing
5 and willful violation of this section or the contract with the
6 agency, the agency may impose a fine upon the entity in an
7 amount not to exceed $20,000 for each such violation. In no
8 event shall such fine exceed an aggregate amount of $100,000
9 for all knowing and willful violations arising out of the same
10 action.
11 (20) A health maintenance organization or a person or
12 entity exempt from chapter 641 that is under contract with the
13 agency for the provision of health care services to Medicaid
14 recipients may not use or distribute marketing materials used
15 to solicit Medicaid recipients, unless such materials have
16 been approved by the agency. The provisions of this subsection
17 do not apply to general advertising and marketing materials
18 used by a health maintenance organization to solicit both
19 non-Medicaid subscribers and Medicaid recipients.
20 (21) Upon approval by the agency, health maintenance
21 organizations and persons or entities exempt from chapter 641
22 that are under contract with the agency for the provision of
23 health care services to Medicaid recipients may be permitted
24 within the capitation rate to provide additional health
25 benefits that the agency has found are of high quality, are
26 practicably available, provide reasonable value to the
27 recipient, and are provided at no additional cost to the
28 state.
29 (22) The agency shall utilize the statewide health
30 maintenance organization complaint hotline for the purpose of
31 investigating and resolving Medicaid and prepaid health plan
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1 complaints, maintaining a record of complaints and confirmed
2 problems, and receiving disenrollment requests made by
3 recipients.
4 (23) The agency shall require the publication of the
5 health maintenance organization's and the prepaid health
6 plan's consumer services telephone numbers and the "800"
7 telephone number of the statewide health maintenance
8 organization complaint hotline on each Medicaid identification
9 card issued by a health maintenance organization or prepaid
10 health plan contracting with the agency to serve Medicaid
11 recipients and on each subscriber handbook issued to a
12 Medicaid recipient.
13 (24) The agency shall establish a health care quality
14 improvement system for those entities contracting with the
15 agency pursuant to this section, incorporating all the
16 standards and guidelines developed by the Medicaid Bureau of
17 the Health Care Financing Administration as a part of the
18 quality assurance reform initiative. The system shall
19 include, but need not be limited to, the following:
20 (a) Guidelines for internal quality assurance
21 programs, including standards for:
22 1. Written quality assurance program descriptions.
23 2. Responsibilities of the governing body for
24 monitoring, evaluating, and making improvements to care.
25 3. An active quality assurance committee.
26 4. Quality assurance program supervision.
27 5. Requiring the program to have adequate resources to
28 effectively carry out its specified activities.
29 6. Provider participation in the quality assurance
30 program.
31 7. Delegation of quality assurance program activities.
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1 8. Credentialing and recredentialing.
2 9. Enrollee rights and responsibilities.
3 10. Availability and accessibility to services and
4 care.
5 11. Ambulatory care facilities.
6 12. Accessibility and availability of medical records,
7 as well as proper recordkeeping and process for record review.
8 13. Utilization review.
9 14. A continuity of care system.
10 15. Quality assurance program documentation.
11 16. Coordination of quality assurance activity with
12 other management activity.
13 17. Delivering care to pregnant women and infants; to
14 elderly and disabled recipients, especially those who are at
15 risk of institutional placement; to persons with developmental
16 disabilities; and to adults who have chronic, high-cost
17 medical conditions.
18 (b) Guidelines which require the entities to conduct
19 quality-of-care studies which:
20 1. Target specific conditions and specific health
21 service delivery issues for focused monitoring and evaluation.
22 2. Use clinical care standards or practice guidelines
23 to objectively evaluate the care the entity delivers or fails
24 to deliver for the targeted clinical conditions and health
25 services delivery issues.
26 3. Use quality indicators derived from the clinical
27 care standards or practice guidelines to screen and monitor
28 care and services delivered.
29 (c) Guidelines for external quality review of each
30 contractor which require: focused studies of patterns of care;
31 individual care review in specific situations; and followup
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1 activities on previous pattern-of-care study findings and
2 individual-care-review findings. In designing the external
3 quality review function and determining how it is to operate
4 as part of the state's overall quality improvement system, the
5 agency shall construct its external quality review
6 organization and entity contracts to address each of the
7 following:
8 1. Delineating the role of the external quality review
9 organization.
10 2. Length of the external quality review organization
11 contract with the state.
12 3. Participation of the contracting entities in
13 designing external quality review organization review
14 activities.
15 4. Potential variation in the type of clinical
16 conditions and health services delivery issues to be studied
17 at each plan.
18 5. Determining the number of focused pattern-of-care
19 studies to be conducted for each plan.
20 6. Methods for implementing focused studies.
21 7. Individual care review.
22 8. Followup activities.
23 (25) In order to ensure that children receive health
24 care services for which an entity has already been
25 compensated, an entity contracting with the agency pursuant to
26 this section shall achieve an annual Early and Periodic
27 Screening, Diagnosis, and Treatment (EPSDT) Service screening
28 rate of at least 60 percent for those recipients continuously
29 enrolled for at least 8 months. The agency shall develop a
30 method by which the EPSDT screening rate shall be calculated.
31 For any entity which does not achieve the annual 60 percent
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1 rate, the entity must submit a corrective action plan for the
2 agency's approval. If the entity does not meet the standard
3 established in the corrective action plan during the specified
4 timeframe, the agency is authorized to impose appropriate
5 contract sanctions. At least annually, the agency shall
6 publicly release the EPSDT Services screening rates of each
7 entity it has contracted with on a prepaid basis to serve
8 Medicaid recipients.
9 (26) The agency shall perform enrollments and
10 disenrollments for Medicaid recipients who are eligible for
11 MediPass or managed care plans. Notwithstanding the
12 prohibition contained in paragraph (18)(f), managed care plans
13 may perform preenrollments of Medicaid recipients under the
14 supervision of the agency or its agents. For the purposes of
15 this section, "preenrollment" means the provision of marketing
16 and educational materials to a Medicaid recipient and
17 assistance in completing the application forms, but shall not
18 include actual enrollment into a managed care plan. An
19 application for enrollment shall not be deemed complete until
20 the agency or its agent verifies that the recipient made an
21 informed, voluntary choice. The agency, in cooperation with
22 the Department of Children and Family Services, may test new
23 marketing initiatives to inform Medicaid recipients about
24 their managed care options at selected sites. The agency
25 shall report to the Legislature on the effectiveness of such
26 initiatives. The agency may contract with a third party to
27 perform managed care plan and MediPass enrollment and
28 disenrollment services for Medicaid recipients and is
29 authorized to adopt rules to implement such services. The
30 agency may adjust the capitation rate only to cover the costs
31 of a third-party enrollment and disenrollment contract, and
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1 for agency supervision and management of the managed care plan
2 enrollment and disenrollment contract.
3 (27) Any lists of providers made available to Medicaid
4 recipients, MediPass enrollees, or managed care plan enrollees
5 shall be arranged alphabetically showing the provider's name
6 and specialty and, separately, by specialty in alphabetical
7 order.
8 (28) The agency shall establish an enhanced managed
9 care quality assurance oversight function, to include at least
10 the following components:
11 (a) At least quarterly analysis and followup,
12 including sanctions as appropriate, of managed care
13 participant utilization of services.
14 (b) At least quarterly analysis and followup,
15 including sanctions as appropriate, of quality findings of the
16 Medicaid peer review organization and other external quality
17 assurance programs.
18 (c) At least quarterly analysis and followup,
19 including sanctions as appropriate, of the fiscal viability of
20 managed care plans.
21 (d) At least quarterly analysis and followup,
22 including sanctions as appropriate, of managed care
23 participant satisfaction and disenrollment surveys.
24 (e) The agency shall conduct regular and ongoing
25 Medicaid recipient satisfaction surveys.
26
27 The analyses and followup activities conducted by the agency
28 under its enhanced managed care quality assurance oversight
29 function shall not duplicate the activities of accreditation
30 reviewers for entities regulated under part III of chapter
31
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1 641, but may include a review of the finding of such
2 reviewers.
3 (29) Each managed care plan that is under contract
4 with the agency to provide health care services to Medicaid
5 recipients shall annually conduct a background check with the
6 Florida Department of Law Enforcement of all persons with
7 ownership interest of 5 percent or more or executive
8 management responsibility for the managed care plan and shall
9 submit to the agency information concerning any such person
10 who has been found guilty of, regardless of adjudication, or
11 has entered a plea of nolo contendere or guilty to, any of the
12 offenses listed in s. 435.03.
13 (30) The agency shall, by rule, develop a process
14 whereby a Medicaid managed care plan enrollee who wishes to
15 enter hospice care may be disenrolled from the managed care
16 plan within 24 hours after contacting the agency regarding
17 such request. The agency rule shall include a methodology for
18 the agency to recoup managed care plan payments on a pro rata
19 basis if payment has been made for the enrollment month when
20 disenrollment occurs.
21 (31) The agency and entities which contract with the
22 agency to provide health care services to Medicaid recipients
23 under this section or s. 409.9122 must comply with the
24 provisions of s. 641.513 in providing emergency services and
25 care to Medicaid recipients and MediPass recipients.
26 (32) All entities providing health care services to
27 Medicaid recipients shall make available, and encourage all
28 pregnant women and mothers with infants to receive, and
29 provide documentation in the medical records to reflect, the
30 following:
31 (a) Healthy Start prenatal or infant screening.
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1 (b) Healthy Start care coordination, when screening or
2 other factors indicate need.
3 (c) Healthy Start enhanced services in accordance with
4 the prenatal or infant screening results.
5 (d) Immunizations in accordance with recommendations
6 of the Advisory Committee on Immunization Practices of the
7 United States Public Health Service and the American Academy
8 of Pediatrics, as appropriate.
9 (e) Counseling and services for family planning to all
10 women and their partners.
11 (f) A scheduled postpartum visit for the purpose of
12 voluntary family planning, to include discussion of all
13 methods of contraception, as appropriate.
14 (g) Referral to the Special Supplemental Nutrition
15 Program for Women, Infants, and Children (WIC).
16 (33) Any entity that provides Medicaid prepaid health
17 plan services shall ensure the appropriate coordination of
18 health care services with an assisted living facility in cases
19 where a Medicaid recipient is both a member of the entity's
20 prepaid health plan and a resident of the assisted living
21 facility. If the entity is at risk for Medicaid targeted case
22 management and behavioral health services, the entity shall
23 inform the assisted living facility of the procedures to
24 follow should an emergent condition arise.
25 (34) The agency may seek and implement federal waivers
26 necessary to provide for cost-effective purchasing of home
27 health services, private duty nursing services,
28 transportation, independent laboratory services, and durable
29 medical equipment and supplies through competitive bidding
30 pursuant to s. 287.057. The agency may request appropriate
31 waivers from the federal Health Care Financing Administration
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1 in order to competitively bid such services. The agency may
2 exclude providers not selected through the bidding process
3 from the Medicaid provider network.
4 (35) The Agency for Health Care Administration is
5 directed to issue a request for proposal or intent to
6 negotiate to implement on a demonstration basis an outpatient
7 specialty services pilot project in a rural and urban county
8 in the state. As used in this subsection, the term
9 "outpatient specialty services" means clinical laboratory,
10 diagnostic imaging, and specified home medical services to
11 include durable medical equipment, prosthetics and orthotics,
12 and infusion therapy.
13 (a) The entity that is awarded the contract to provide
14 Medicaid managed care outpatient specialty services must, at a
15 minimum, meet the following criteria:
16 1. The entity must be licensed by the Department of
17 Insurance under part II of chapter 641.
18 2. The entity must be experienced in providing
19 outpatient specialty services.
20 3. The entity must demonstrate to the satisfaction of
21 the agency that it provides high-quality services to its
22 patients.
23 4. The entity must demonstrate that it has in place a
24 complaints and grievance process to assist Medicaid recipients
25 enrolled in the pilot managed care program to resolve
26 complaints and grievances.
27 (b) The pilot managed care program shall operate for a
28 period of 3 years. The objective of the pilot program shall
29 be to determine the cost-effectiveness and effects on
30 utilization, access, and quality of providing outpatient
31
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1 specialty services to Medicaid recipients on a prepaid,
2 capitated basis.
3 (c) The agency shall conduct a quality assurance
4 review of the prepaid health clinic each year that the
5 demonstration program is in effect. The prepaid health clinic
6 is responsible for all expenses incurred by the agency in
7 conducting a quality assurance review.
8 (d) The entity that is awarded the contract to provide
9 outpatient specialty services to Medicaid recipients shall
10 report data required by the agency in a format specified by
11 the agency, for the purpose of conducting the evaluation
12 required in paragraph (e).
13 (e) The agency shall conduct an evaluation of the
14 pilot managed care program and report its findings to the
15 Governor and the Legislature by no later than January 1, 2001.
16 (36) The agency shall enter into agreements with
17 not-for-profit organizations based in this state for the
18 purpose of providing vision screening.
19 (37)(a) The agency shall implement a Medicaid
20 prescribed-drug spending-control program that includes the
21 following components:
22 1. Medicaid prescribed-drug coverage for brand-name
23 drugs for adult Medicaid recipients is limited to the
24 dispensing of four brand-name drugs per month per recipient.
25 Children are exempt from this restriction. Antiretroviral
26 agents are excluded from this limitation. No requirements for
27 prior authorization or other restrictions on medications used
28 to treat mental illnesses such as schizophrenia, severe
29 depression, or bipolar disorder may be imposed on Medicaid
30 recipients. Medications that will be available without
31 restriction for persons with mental illnesses include atypical
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1 antipsychotic medications, conventional antipsychotic
2 medications, selective serotonin reuptake inhibitors, and
3 other medications used for the treatment of serious mental
4 illnesses. The agency shall also limit the amount of a
5 prescribed drug dispensed to no more than a 34-day supply. The
6 agency shall continue to provide unlimited generic drugs,
7 contraceptive drugs and items, and diabetic supplies. Although
8 a drug may be included on the preferred drug formulary, it
9 would not be exempt from the four-brand limit. The agency may
10 authorize exceptions to the brand-name-drug restriction based
11 upon the treatment needs of the patients, only when such
12 exceptions are based on prior consultation provided by the
13 agency or an agency contractor, but the agency must establish
14 procedures to ensure that:
15 a. There will be a response to a request for prior
16 consultation by telephone or other telecommunication device
17 within 24 hours after receipt of a request for prior
18 consultation;
19 b. A 72-hour supply of the drug prescribed will be
20 provided in an emergency or when the agency does not provide a
21 response within 24 hours as required by sub-subparagraph a.;
22 and
23 c. Except for the exception for nursing home residents
24 and other institutionalized adults and except for drugs on the
25 restricted formulary for which prior authorization may be
26 sought by an institutional or community pharmacy, prior
27 authorization for an exception to the brand-name-drug
28 restriction is sought by the prescriber and not by the
29 pharmacy. When prior authorization is granted for a patient in
30 an institutional setting beyond the brand-name-drug
31
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1 restriction, such approval is authorized for 12 months and
2 monthly prior authorization is not required for that patient.
3 2. Reimbursement to pharmacies for Medicaid prescribed
4 drugs shall be set at the average wholesale price less 13.25
5 percent.
6 3. The agency shall develop and implement a process
7 for managing the drug therapies of Medicaid recipients who are
8 using significant numbers of prescribed drugs each month. The
9 management process may include, but is not limited to,
10 comprehensive, physician-directed medical-record reviews,
11 claims analyses, and case evaluations to determine the medical
12 necessity and appropriateness of a patient's treatment plan
13 and drug therapies. The agency may contract with a private
14 organization to provide drug-program-management services. The
15 Medicaid drug benefit management program shall include
16 initiatives to manage drug therapies for HIV/AIDS patients,
17 patients using 20 or more unique prescriptions in a 180-day
18 period, and the top 1,000 patients in annual spending.
19 4. The agency may limit the size of its pharmacy
20 network based on need, competitive bidding, price
21 negotiations, credentialing, or similar criteria. The agency
22 shall give special consideration to rural areas in determining
23 the size and location of pharmacies included in the Medicaid
24 pharmacy network. A pharmacy credentialing process may include
25 criteria such as a pharmacy's full-service status, location,
26 size, patient educational programs, patient consultation,
27 disease-management services, and other characteristics. The
28 agency may impose a moratorium on Medicaid pharmacy enrollment
29 when it is determined that it has a sufficient number of
30 Medicaid-participating providers.
31
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1 5. The agency shall develop and implement a program
2 that requires Medicaid practitioners who prescribe drugs to
3 use a counterfeit-proof prescription pad for Medicaid
4 prescriptions. The agency shall require the use of
5 standardized counterfeit-proof prescription pads by
6 Medicaid-participating prescribers or prescribers who write
7 prescriptions for Medicaid recipients. The agency may
8 implement the program in targeted geographic areas or
9 statewide.
10 6. The agency may enter into arrangements that require
11 manufacturers of generic drugs prescribed to Medicaid
12 recipients to provide rebates of at least 15.1 percent of the
13 average manufacturer price for the manufacturer's generic
14 products. These arrangements shall require that if a
15 generic-drug manufacturer pays federal rebates for
16 Medicaid-reimbursed drugs at a level below 15.1 percent, the
17 manufacturer must provide a supplemental rebate to the state
18 in an amount necessary to achieve a 15.1-percent rebate level.
19 7. The agency may establish a preferred drug formulary
20 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
21 establishment of such formulary, it is authorized to negotiate
22 supplemental rebates from manufacturers that are in addition
23 to those required by Title XIX of the Social Security Act and
24 at no less than 10 percent of the average manufacturer price
25 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
26 unless the federal or supplemental rebate, or both, equals or
27 exceeds 25 percent. There is no upper limit on the
28 supplemental rebates the agency may negotiate. The agency may
29 determine that specific products, brand-name or generic, are
30 competitive at lower rebate percentages. Agreement to pay the
31 minimum supplemental rebate percentage will guarantee a
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1 manufacturer that the Medicaid Pharmaceutical and Therapeutics
2 Committee will consider a product for inclusion on the
3 preferred drug formulary. However, a pharmaceutical
4 manufacturer is not guaranteed placement on the formulary by
5 simply paying the minimum supplemental rebate. Agency
6 decisions will be made on the clinical efficacy of a drug and
7 recommendations of the Medicaid Pharmaceutical and
8 Therapeutics Committee, as well as the price of competing
9 products minus federal and state rebates. The agency is
10 authorized to contract with an outside agency or contractor to
11 conduct negotiations for supplemental rebates. For the
12 purposes of this section, the term "supplemental rebates" may
13 include, at the agency's discretion, cash rebates and other
14 program benefits that offset a Medicaid expenditure. Such
15 other program benefits may include, but are not limited to,
16 disease management programs, drug product donation programs,
17 drug utilization control programs, prescriber and beneficiary
18 counseling and education, fraud and abuse initiatives, and
19 other services or administrative investments with guaranteed
20 savings to the Medicaid program in the same year the rebate
21 reduction is included in the General Appropriations Act. The
22 agency is authorized to seek any federal waivers to implement
23 this initiative.
24 8. The agency shall establish an advisory committee
25 for the purposes of studying the feasibility of using a
26 restricted drug formulary for nursing home residents and other
27 institutionalized adults. The committee shall be comprised of
28 seven members appointed by the Secretary of Health Care
29 Administration. The committee members shall include two
30 physicians licensed under chapter 458 or chapter 459; three
31 pharmacists licensed under chapter 465 and appointed from a
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1 list of recommendations provided by the Florida Long-Term Care
2 Pharmacy Alliance; and two pharmacists licensed under chapter
3 465.
4 9. The Agency for Health Care Administration shall
5 expand home delivery of pharmacy products. To assist Medicaid
6 patients in securing their prescriptions and reduce program
7 costs, the agency shall expand its current mail-order-pharmacy
8 diabetes-supply program to include all generic and brand-name
9 drugs used by Medicaid patients with diabetes. Medicaid
10 recipients in the current program may obtain nondiabetes drugs
11 on a voluntary basis. This initiative is limited to the
12 geographic area covered by the current contract. The agency
13 may seek and implement any federal waivers necessary to
14 implement this subparagraph.
15 (b) The agency shall implement this subsection to the
16 extent that funds are appropriated to administer the Medicaid
17 prescribed-drug spending-control program. The agency may
18 contract all or any part of this program to private
19 organizations.
20 (c) The agency shall submit quarterly reports a report
21 to the Governor, the President of the Senate, and the Speaker
22 of the House of Representatives which by January 15 of each
23 year. The report must include, but need not be limited to, the
24 progress made in implementing this subsection and its Medicaid
25 cost-containment measures and their effect on Medicaid
26 prescribed-drug expenditures.
27 (38) Notwithstanding the provisions of chapter 287,
28 the agency may, at its discretion, renew a contract or
29 contracts for fiscal intermediary services one or more times
30 for such periods as the agency may decide; however, all such
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1 renewals may not combine to exceed a total period longer than
2 the term of the original contract.
3 (39) The agency shall provide for the development of a
4 demonstration project by establishment in Miami-Dade County of
5 a long-term-care facility licensed pursuant to chapter 395 to
6 improve access to health care for a predominantly minority,
7 medically underserved, and medically complex population and to
8 evaluate alternatives to nursing home care and general acute
9 care for such population. Such project is to be located in a
10 health care condominium and colocated with licensed facilities
11 providing a continuum of care. The establishment of this
12 project is not subject to the provisions of s. 408.036 or s.
13 408.039. The agency shall report its findings to the
14 Governor, the President of the Senate, and the Speaker of the
15 House of Representatives by January 1, 2003.
16 Section 6. Subsection (7) of section 409.9116, Florida
17 Statutes, is amended to read:
18 409.9116 Disproportionate share/financial assistance
19 program for rural hospitals.--In addition to the payments made
20 under s. 409.911, the Agency for Health Care Administration
21 shall administer a federally matched disproportionate share
22 program and a state-funded financial assistance program for
23 statutory rural hospitals. The agency shall make
24 disproportionate share payments to statutory rural hospitals
25 that qualify for such payments and financial assistance
26 payments to statutory rural hospitals that do not qualify for
27 disproportionate share payments. The disproportionate share
28 program payments shall be limited by and conform with federal
29 requirements. Funds shall be distributed quarterly in each
30 fiscal year for which an appropriation is made.
31 Notwithstanding the provisions of s. 409.915, counties are
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1 exempt from contributing toward the cost of this special
2 reimbursement for hospitals serving a disproportionate share
3 of low-income patients.
4 (7) This section applies only to hospitals that were
5 defined as statutory rural hospitals, or their
6 successor-in-interest hospital, prior to July 1, 1999 1998.
7 Any additional hospital that is defined as a statutory rural
8 hospital, or its successor-in-interest hospital, on or after
9 July 1, 1999 1998, is not eligible for programs under this
10 section unless additional funds are appropriated each fiscal
11 year specifically to the rural hospital disproportionate share
12 and financial assistance programs in an amount necessary to
13 prevent any hospital, or its successor-in-interest hospital,
14 eligible for the programs prior to July 1, 1999 1998, from
15 incurring a reduction in payments because of the eligibility
16 of an additional hospital to participate in the programs. A
17 hospital, or its successor-in-interest hospital, which
18 received funds pursuant to this section before July 1, 1999
19 1998, and which qualifies under s. 395.602(2)(e), shall be
20 included in the programs under this section and is not
21 required to seek additional appropriations under this
22 subsection.
23 Section 7. Paragraphs (f) and (k) of subsection (2) of
24 section 409.9122, Florida Statutes, as amended by section 11
25 of chapter 2001-377, Laws of Florida, are amended to read:
26 409.9122 Mandatory Medicaid managed care enrollment;
27 programs and procedures.--
28 (2)
29 (f) When a Medicaid recipient does not choose a
30 managed care plan or MediPass provider, the agency shall
31 assign the Medicaid recipient to a managed care plan or
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1 MediPass provider. Medicaid recipients who are subject to
2 mandatory assignment but who fail to make a choice shall be
3 assigned to managed care plans or provider service networks
4 until an equal enrollment of 45 50 percent in MediPass and 55
5 50 percent in managed care plans is achieved. Once that equal
6 enrollment is achieved, the assignments shall be divided in
7 order to maintain an equal enrollment in MediPass and managed
8 care plans which is in a 45 percent and 55 percent proportion,
9 respectively. Thereafter, assignment of Medicaid recipients
10 who fail to make a choice shall be based proportionally on the
11 preferences of recipients who have made a choice in the
12 previous period. Such proportions shall be revised at least
13 quarterly to reflect an update of the preferences of Medicaid
14 recipients. The agency shall also disproportionately assign
15 Medicaid-eligible children in families who are required to but
16 have failed to make a choice of managed care plan or MediPass
17 for their child and who are to be assigned to the MediPass
18 program to children's networks as described in s.
19 409.912(3)(g) and where available. The disproportionate
20 assignment of children to children's networks shall be made
21 until the agency has determined that the children's networks
22 have sufficient numbers to be economically operated. For
23 purposes of this paragraph, when referring to assignment, the
24 term "managed care plans" includes exclusive provider
25 organizations, provider service networks, minority physician
26 networks, and pediatric emergency department diversion
27 programs authorized by this chapter or the General
28 Appropriations Act. When making assignments, the agency shall
29 take into account the following criteria:
30 1. A managed care plan has sufficient network capacity
31 to meet the need of members.
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1 2. The managed care plan or MediPass has previously
2 enrolled the recipient as a member, or one of the managed care
3 plan's primary care providers or MediPass providers has
4 previously provided health care to the recipient.
5 3. The agency has knowledge that the member has
6 previously expressed a preference for a particular managed
7 care plan or MediPass provider as indicated by Medicaid
8 fee-for-service claims data, but has failed to make a choice.
9 4. The managed care plan's or MediPass primary care
10 providers are geographically accessible to the recipient's
11 residence.
12 (k) When a Medicaid recipient does not choose a
13 managed care plan or MediPass provider, the agency shall
14 assign the Medicaid recipient to a managed care plan, except
15 in those counties in which there are fewer than two managed
16 care plans accepting Medicaid enrollees, in which case
17 assignment shall be to a managed care plan or a MediPass
18 provider. Medicaid recipients in counties with fewer than two
19 managed care plans accepting Medicaid enrollees who are
20 subject to mandatory assignment but who fail to make a choice
21 shall be assigned to managed care plans until an equal
22 enrollment of 45 50 percent in MediPass and provider service
23 networks and 55 50 percent in managed care plans is achieved.
24 Once that equal enrollment is achieved, the assignments shall
25 be divided in order to maintain an equal enrollment in
26 MediPass and managed care plans which is in a 45 percent and
27 55 percent proportion, respectively. When making assignments,
28 the agency shall take into account the following criteria:
29 1. A managed care plan has sufficient network capacity
30 to meet the need of members.
31
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1 2. The managed care plan or MediPass has previously
2 enrolled the recipient as a member, or one of the managed care
3 plan's primary care providers or MediPass providers has
4 previously provided health care to the recipient.
5 3. The agency has knowledge that the member has
6 previously expressed a preference for a particular managed
7 care plan or MediPass provider as indicated by Medicaid
8 fee-for-service claims data, but has failed to make a choice.
9 4. The managed care plan's or MediPass primary care
10 providers are geographically accessible to the recipient's
11 residence.
12 5. The agency has authority to make mandatory
13 assignments based on quality of service and performance of
14 managed care plans.
15 Section 8. This act shall take effect July 1, 2002.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 1108
3
4 The committee substitute makes a number of changes to the
Medicaid program that are required in order to implement the
5 General Appropriations Act for FY 2002-03. Specifically, the
bill:
6
. Requires the Agency for Health Care Administration, in
7 consultation with other departments and the Florida
Healthy Kids Corporation, to contract for an annual
8 evaluation of the Florida Kidcare program.
9 . Restores coverage for adults in the Medically Needy
program but revises program policy to increase the
10 medically needy income level by $270 (from $180 to $450)
and prohibits Medicaid reimbursement for expenses used
11 to meet the spend-down liability for a family or person.
12 . Restores Medicaid coverage for Adult Dental, Visual and
Hearing services.
13
. Requires the Agency to submit quarterly reports on the
14 progress made in implementing cost-effective purchasing
of health care and the Medicaid prescribed drug program.
15
. Changes the date used to qualify a hospital for
16 participation in the disproportionate share/financial
assistance program for rural hospitals to July 1, 1999.
17
. Revises the enrollment goal of managed care to 55
18 percent managed care and 45 percent MediPass.
19 . Provides for an adjustment to a hospital's current
inpatient per diem rate based on specified criteria that
20 will provide for a more equitable reimbursement to
certain hospitals.
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