Senate Bill sb1108e1
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 A bill to be entitled
2 An act relating to health care; providing an
3 appropriation for a feasibility study relating
4 to outsourcing specified functions of the Board
5 of Dentistry; amending s. 409.8177, F.S.;
6 requiring the agency to contract for an
7 evaluation of the Florida Kidcare program;
8 amending s. 409.904, F.S.; revising provisions
9 governing optional payments for medical
10 assistance and related services; amending s.
11 409.905, F.S.; providing additional criteria
12 for the agency to adjust a hospital's inpatient
13 per diem rate for Medicaid; amending s.
14 409.906, F.S.; authorizing the agency to make
15 payments for specified services which are
16 optional under Title XIX of the Social Security
17 Act; amending s. 409.912, F.S.; revising
18 provisions governing the purchase of goods and
19 services for Medicaid recipients; providing for
20 quarterly reports to the Governor and presiding
21 officers of the Legislature; amending s.
22 409.9116, F.S.; revising the disproportionate
23 share/financial assistance program for rural
24 hospitals; amending s. 409.9122, F.S.; revising
25 provisions governing mandatory Medicaid managed
26 care enrollment; amending s. 499.012, F.S.;
27 redefining the term "wholesale distribution"
28 with respect to regulation of distribution of
29 prescription drugs; requiring the Agency for
30 Health Care Administration to conduct a study
31 of health care services provided to medically
1
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 fragile or medical-technology-dependent
2 children; requiring the Agency for Health Care
3 Administration to conduct a pilot program for a
4 subacute pediatric transitional care center;
5 requiring background screening of center
6 personnel; requiring the agency to amend the
7 Medicaid state plan and seek federal waivers as
8 necessary; requiring the center to have an
9 advisory board; providing for membership on the
10 advisory board; providing requirements for the
11 admission, transfer, and discharge of a child
12 to the center; requiring the agency to submit
13 certain reports to the Legislature; providing
14 guidelines for the agency to distribute
15 disproportionate share funds during the
16 2002-2003 fiscal year; providing an effective
17 date.
18
19 Be It Enacted by the Legislature of the State of Florida:
20
21 Section 1. Section 409.8177, Florida Statutes, is
22 amended to read:
23 409.8177 Program evaluation.--
24 (1) The agency, in consultation with the Department of
25 Health, the Department of Children and Family Services, and
26 the Florida Healthy Kids Corporation, shall contract for an
27 evaluation of the Florida Kidcare program and shall by January
28 1 of each year submit to the Governor, the President of the
29 Senate, and the Speaker of the House of Representatives a
30 report of the Florida Kidcare program. In addition to the
31 items specified under s. 2108 of Title XXI of the Social
2
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 Security Act, the report shall include an assessment of
2 crowd-out and access to health care, as well as the following:
3 (a)(1) An assessment of the operation of the program,
4 including the progress made in reducing the number of
5 uncovered low-income children.
6 (b)(2) An assessment of the effectiveness in
7 increasing the number of children with creditable health
8 coverage, including an assessment of the impact of outreach.
9 (c)(3) The characteristics of the children and
10 families assisted under the program, including ages of the
11 children, family income, and access to or coverage by other
12 health insurance prior to the program and after disenrollment
13 from the program.
14 (d)(4) The quality of health coverage provided,
15 including the types of benefits provided.
16 (e)(5) The amount and level, including payment of part
17 or all of any premium, of assistance provided.
18 (f)(6) The average length of coverage of a child under
19 the program.
20 (g)(7) The program's choice of health benefits
21 coverage and other methods used for providing child health
22 assistance.
23 (h)(8) The sources of nonfederal funding used in the
24 program.
25 (i)(9) An assessment of the effectiveness of Medikids,
26 Children's Medical Services network, and other public and
27 private programs in the state in increasing the availability
28 of affordable quality health insurance and health care for
29 children.
30 (j)(10) A review and assessment of state activities to
31 coordinate the program with other public and private programs.
3
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 (k)(11) An analysis of changes and trends in the state
2 that affect the provision of health insurance and health care
3 to children.
4 (l)(12) A description of any plans the state has for
5 improving the availability of health insurance and health care
6 for children.
7 (m)(13) Recommendations for improving the program.
8 (n)(14) Other studies as necessary.
9 (2) The agency shall also submit each month to the
10 Governor, the President of the Senate, and the Speaker of the
11 House of Representatives a report of enrollment for each
12 program component of the Florida Kidcare program.
13 Section 2. Effective July 1, 2002, subsection (2) of
14 section 409.904, Florida Statutes, as amended by section 2 of
15 chapter 2001-377, Laws of Florida, is amended to read:
16 409.904 Optional payments for eligible persons.--The
17 agency may make payments for medical assistance and related
18 services on behalf of the following persons who are determined
19 to be eligible subject to the income, assets, and categorical
20 eligibility tests set forth in federal and state law. Payment
21 on behalf of these Medicaid eligible persons is subject to the
22 availability of moneys and any limitations established by the
23 General Appropriations Act or chapter 216.
24 (2)(a) A family, a pregnant woman, a child under age
25 19 who would otherwise qualify for Florida Kidcare Medicaid, a
26 child up to age 21 who would otherwise qualify under s.
27 409.903(1), a person age 65 or over, or a blind or disabled
28 person who would otherwise be eligible for Florida Medicaid,
29 except that the income or assets of such family or person
30 exceed established limitations. A pregnant woman who would
31 otherwise qualify for Medicaid under s. 409.903(5) except for
4
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 her level of income and whose assets fall within the limits
2 established by the Department of Children and Family Services
3 for the medically needy. A pregnant woman who applies for
4 medically needy eligibility may not be made presumptively
5 eligible.
6 (b) A child under age 21 who would otherwise qualify
7 for Medicaid or the Florida Kidcare program except for the
8 family's level of income and whose assets fall within the
9 limits established by the Department of Children and Family
10 Services for the medically needy.
11
12 For a family or person in this group, medical expenses are
13 deductible from income in accordance with federal requirements
14 in order to make a determination of eligibility. Expenses used
15 to meet spend-down liability are not reimbursable by Medicaid.
16 The medically-needy income levels in effect on July 1, 2001,
17 are increased by $270 effective July 1, 2002. A family or
18 person in this group, which group is known as the "medically
19 needy," is eligible to receive the same services as other
20 Medicaid recipients, with the exception of services in skilled
21 nursing facilities and intermediate care facilities for the
22 developmentally disabled.
23 Section 3. Paragraph (c) of subsection (5) of section
24 409.905, Florida Statutes, is amended to read:
25 409.905 Mandatory Medicaid services.--The agency may
26 make payments for the following services, which are required
27 of the state by Title XIX of the Social Security Act,
28 furnished by Medicaid providers to recipients who are
29 determined to be eligible on the dates on which the services
30 were provided. Any service under this section shall be
31 provided only when medically necessary and in accordance with
5
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 state and federal law. Mandatory services rendered by
2 providers in mobile units to Medicaid recipients may be
3 restricted by the agency. Nothing in this section shall be
4 construed to prevent or limit the agency from adjusting fees,
5 reimbursement rates, lengths of stay, number of visits, number
6 of services, or any other adjustments necessary to comply with
7 the availability of moneys and any limitations or directions
8 provided for in the General Appropriations Act or chapter 216.
9 (5) HOSPITAL INPATIENT SERVICES.--The agency shall pay
10 for all covered services provided for the medical care and
11 treatment of a recipient who is admitted as an inpatient by a
12 licensed physician or dentist to a hospital licensed under
13 part I of chapter 395. However, the agency shall limit the
14 payment for inpatient hospital services for a Medicaid
15 recipient 21 years of age or older to 45 days or the number of
16 days necessary to comply with the General Appropriations Act.
17 (c) Agency for Health Care Administration shall adjust
18 a hospital's current inpatient per diem rate to reflect the
19 cost of serving the Medicaid population at that institution
20 if:
21 1. The hospital experiences an increase in Medicaid
22 caseload by more than 25 percent in any year, primarily
23 resulting from the closure of a hospital in the same service
24 area occurring after July 1, 1995; or
25 2. The hospital's Medicaid per diem rate is at least
26 25 percent below the Medicaid per patient cost for that year;
27 or.
28 3. The hospital is located in a county that has five
29 or fewer hospitals, began offering obstetrical services on or
30 after September 1999, and has submitted a request in writing
31 to the agency for a rate adjustment after July 1, 2000, but
6
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 before September 30, 2000, in which case such hospital's
2 Medicaid inpatient per diem rate shall be adjusted to cost,
3 effective July 1, 2002. Effective July 1, 2003, for subsequent
4 rate semesters, such hospital's rate will be set in accordance
5 with the methodology of the Medicaid inpatient reimbursement
6 plan.
7
8 No later than October 1 of each year November 1, 2001, the
9 agency must provide estimated costs for any adjustment in a
10 hospital inpatient per diem pursuant to this paragraph to the
11 Executive Office of the Governor, the House of Representatives
12 General Appropriations Committee, and the Senate
13 Appropriations Committee. Before the agency implements a
14 change in a hospital's inpatient per diem rate pursuant to
15 this paragraph, the Legislature must have specifically
16 appropriated sufficient funds in the General Appropriations
17 Act to support the increase in cost as estimated by the
18 agency.
19 Section 4. Effective July 1, 2002, subsections (1),
20 (12), and (23) of section 409.906, Florida Statutes, as
21 amended by section 3 of chapter 2001-377, Laws of Florida, are
22 amended to read:
23 409.906 Optional Medicaid services.--Subject to
24 specific appropriations, the agency may make payments for
25 services which are optional to the state under Title XIX of
26 the Social Security Act and are furnished by Medicaid
27 providers to recipients who are determined to be eligible on
28 the dates on which the services were provided. Any optional
29 service that is provided shall be provided only when medically
30 necessary and in accordance with state and federal law.
31 Optional services rendered by providers in mobile units to
7
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 Medicaid recipients may be restricted or prohibited by the
2 agency. Nothing in this section shall be construed to prevent
3 or limit the agency from adjusting fees, reimbursement rates,
4 lengths of stay, number of visits, or number of services, or
5 making any other adjustments necessary to comply with the
6 availability of moneys and any limitations or directions
7 provided for in the General Appropriations Act or chapter 216.
8 If necessary to safeguard the state's systems of providing
9 services to elderly and disabled persons and subject to the
10 notice and review provisions of s. 216.177, the Governor may
11 direct the Agency for Health Care Administration to amend the
12 Medicaid state plan to delete the optional Medicaid service
13 known as "Intermediate Care Facilities for the Developmentally
14 Disabled." Optional services may include:
15 (1) ADULT DENTURE SERVICES.--The agency may pay for
16 dentures, the procedures required to seat dentures, and the
17 repair and reline of dentures, provided by or under the
18 direction of a licensed dentist, for a recipient who is age 21
19 or older. However, Medicaid will not provide reimbursement for
20 dental services provided in a mobile dental unit, except for a
21 mobile dental unit:
22 (a) Owned by, operated by, or having a contractual
23 agreement with the Department of Health and complying with
24 Medicaid's county health department clinic services program
25 specifications as a county health department clinic services
26 provider.
27 (b) Owned by, operated by, or having a contractual
28 arrangement with a federally qualified health center and
29 complying with Medicaid's federally qualified health center
30 specifications as a federally qualified health center
31 provider.
8
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 (c) Rendering dental services to Medicaid recipients,
2 21 years of age and older, at nursing facilities.
3 (d) Owned by, operated by, or having a contractual
4 agreement with a state-approved dental educational
5 institution.
6 (e) This subsection is repealed July 1, 2002.
7 (12) CHILDREN'S HEARING SERVICES.--The agency may pay
8 for hearing and related services, including hearing
9 evaluations, hearing aid devices, dispensing of the hearing
10 aid, and related repairs, if provided to a recipient under age
11 21 by a licensed hearing aid specialist, otolaryngologist,
12 otologist, audiologist, or physician.
13 (23) CHILDREN'S VISUAL SERVICES.--The agency may pay
14 for visual examinations, eyeglasses, and eyeglass repairs for
15 a recipient under age 21, if they are prescribed by a licensed
16 physician specializing in diseases of the eye or by a licensed
17 optometrist.
18 Section 5. Section 409.912, Florida Statutes, as
19 amended by sections 8 and 9 of chapter 2001-377, Laws of
20 Florida, is amended to read:
21 409.912 Cost-effective purchasing of health care.--The
22 agency shall purchase goods and services for Medicaid
23 recipients in the most cost-effective manner consistent with
24 the delivery of quality medical care. The agency shall
25 maximize the use of prepaid per capita and prepaid aggregate
26 fixed-sum basis services when appropriate and other
27 alternative service delivery and reimbursement methodologies,
28 including competitive bidding pursuant to s. 287.057, designed
29 to facilitate the cost-effective purchase of a case-managed
30 continuum of care. The agency shall also require providers to
31 minimize the exposure of recipients to the need for acute
9
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 inpatient, custodial, and other institutional care and the
2 inappropriate or unnecessary use of high-cost services. The
3 agency may establish prior authorization requirements for
4 certain populations of Medicaid beneficiaries, certain drug
5 classes, or particular drugs to prevent fraud, abuse, overuse,
6 and possible dangerous drug interactions. The Pharmaceutical
7 and Therapeutics Committee, established pursuant to s.
8 409.91195, shall make recommendations to the agency on drugs
9 for which prior authorization is required, and. the agency
10 shall inform the Pharmaceutical and Therapeutics committee of
11 its decisions regarding drugs subject to prior authorization.
12 (1) The agency may enter into agreements with
13 appropriate agents of other state agencies or of any agency of
14 the Federal Government and accept such duties in respect to
15 social welfare or public aid as may be necessary to implement
16 the provisions of Title XIX of the Social Security Act and ss.
17 409.901-409.920.
18 (2) The agency may contract with health maintenance
19 organizations certified pursuant to part I of chapter 641 for
20 the provision of services to recipients.
21 (3) The agency may contract with:
22 (a) An entity that provides no prepaid health care
23 services other than Medicaid services under contract with the
24 agency and which is owned and operated by a county, county
25 health department, or county-owned and operated hospital to
26 provide health care services on a prepaid or fixed-sum basis
27 to recipients, which entity may provide such prepaid services
28 either directly or through arrangements with other providers.
29 Such prepaid health care services entities must be licensed
30 under parts I and III by January 1, 1998, and until then are
31 exempt from the provisions of part I of chapter 641. An entity
10
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 recognized under this paragraph which demonstrates to the
2 satisfaction of the Department of Insurance that it is backed
3 by the full faith and credit of the county in which it is
4 located may be exempted from s. 641.225.
5 (b) An entity that is providing comprehensive
6 behavioral health care services to certain Medicaid recipients
7 through a capitated, prepaid arrangement pursuant to the
8 federal waiver provided for by s. 409.905(5). Such an entity
9 must be licensed under chapter 624, chapter 636, or chapter
10 641 and must possess the clinical systems and operational
11 competence to manage risk and provide comprehensive behavioral
12 health care to Medicaid recipients. As used in this paragraph,
13 the term "comprehensive behavioral health care services" means
14 covered mental health and substance abuse treatment services
15 that are available to Medicaid recipients. The secretary of
16 the Department of Children and Family Services shall approve
17 provisions of procurements related to children in the
18 department's care or custody prior to enrolling such children
19 in a prepaid behavioral health plan. Any contract awarded
20 under this paragraph must be competitively procured. In
21 developing the behavioral health care prepaid plan procurement
22 document, the agency shall ensure that the procurement
23 document requires the contractor to develop and implement a
24 plan to ensure compliance with s. 394.4574 related to services
25 provided to residents of licensed assisted living facilities
26 that hold a limited mental health license. The agency must
27 ensure that Medicaid recipients have available the choice of
28 at least two managed care plans for their behavioral health
29 care services. The agency may reimburse for
30 substance-abuse-treatment services on a fee-for-service basis
31
11
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 until the agency finds that adequate funds are available for
2 capitated, prepaid arrangements.
3 1. By January 1, 2001, the agency shall modify the
4 contracts with the entities providing comprehensive inpatient
5 and outpatient mental health care services to Medicaid
6 recipients in Hillsborough, Highlands, Hardee, Manatee, and
7 Polk Counties, to include substance-abuse-treatment services.
8 2. By December 31, 2001, the agency shall contract
9 with entities providing comprehensive behavioral health care
10 services to Medicaid recipients through capitated, prepaid
11 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
12 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
13 and Walton Counties. The agency may contract with entities
14 providing comprehensive behavioral health care services to
15 Medicaid recipients through capitated, prepaid arrangements in
16 Alachua County. The agency may determine if Sarasota County
17 shall be included as a separate catchment area or included in
18 any other agency geographic area.
19 3. Children residing in a Department of Juvenile
20 Justice residential program approved as a Medicaid behavioral
21 health overlay services provider shall not be included in a
22 behavioral health care prepaid health plan pursuant to this
23 paragraph.
24 4. In converting to a prepaid system of delivery, the
25 agency shall in its procurement document require an entity
26 providing comprehensive behavioral health care services to
27 prevent the displacement of indigent care patients by
28 enrollees in the Medicaid prepaid health plan providing
29 behavioral health care services from facilities receiving
30 state funding to provide indigent behavioral health care, to
31 facilities licensed under chapter 395 which do not receive
12
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 state funding for indigent behavioral health care, or
2 reimburse the unsubsidized facility for the cost of behavioral
3 health care provided to the displaced indigent care patient.
4 5. Traditional community mental health providers under
5 contract with the Department of Children and Family Services
6 pursuant to part IV of chapter 394 and inpatient mental health
7 providers licensed pursuant to chapter 395 must be offered an
8 opportunity to accept or decline a contract to participate in
9 any provider network for prepaid behavioral health services.
10 (c) A federally qualified health center or an entity
11 owned by one or more federally qualified health centers or an
12 entity owned by other migrant and community health centers
13 receiving non-Medicaid financial support from the Federal
14 Government to provide health care services on a prepaid or
15 fixed-sum basis to recipients. Such prepaid health care
16 services entity must be licensed under parts I and III of
17 chapter 641, but shall be prohibited from serving Medicaid
18 recipients on a prepaid basis, until such licensure has been
19 obtained. However, such an entity is exempt from s. 641.225
20 if the entity meets the requirements specified in subsections
21 (14) and (15).
22 (d) No more than four provider service networks for
23 demonstration projects to test Medicaid direct contracting.
24 The demonstration projects may be reimbursed on a
25 fee-for-service or prepaid basis. A provider service network
26 which is reimbursed by the agency on a prepaid basis shall be
27 exempt from parts I and III of chapter 641, but must meet
28 appropriate financial reserve, quality assurance, and patient
29 rights requirements as established by the agency. The agency
30 shall award contracts on a competitive bid basis and shall
31 select bidders based upon price and quality of care. Medicaid
13
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 recipients assigned to a demonstration project shall be chosen
2 equally from those who would otherwise have been assigned to
3 prepaid plans and MediPass. The agency is authorized to seek
4 federal Medicaid waivers as necessary to implement the
5 provisions of this section. A demonstration project awarded
6 pursuant to this paragraph shall be for 4 years from the date
7 of implementation.
8 (e) An entity that provides comprehensive behavioral
9 health care services to certain Medicaid recipients through an
10 administrative services organization agreement. Such an entity
11 must possess the clinical systems and operational competence
12 to provide comprehensive health care to Medicaid recipients.
13 As used in this paragraph, the term "comprehensive behavioral
14 health care services" means covered mental health and
15 substance abuse treatment services that are available to
16 Medicaid recipients. Any contract awarded under this paragraph
17 must be competitively procured. The agency must ensure that
18 Medicaid recipients have available the choice of at least two
19 managed care plans for their behavioral health care services.
20 (f) An entity in Pasco County or Pinellas County that
21 provides in-home physician services to Medicaid recipients
22 with degenerative neurological diseases in order to test the
23 cost-effectiveness of enhanced home-based medical care. The
24 entity providing the services shall be reimbursed on a
25 fee-for-service basis at a rate not less than comparable
26 Medicare reimbursement rates. The agency may apply for waivers
27 of federal regulations necessary to implement such program.
28 This paragraph shall be repealed on July 1, 2002.
29 (g) Children's provider networks that provide care
30 coordination and care management for Medicaid-eligible
31 pediatric patients, primary care, authorization of specialty
14
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 care, and other urgent and emergency care through organized
2 providers designed to service Medicaid eligibles under age 18
3 and pediatric emergency departments' diversion programs. The
4 networks shall provide after-hour operations, including
5 evening and weekend hours, to promote, when appropriate, the
6 use of the children's networks rather than hospital emergency
7 departments.
8 (4) The agency may contract with any public or private
9 entity otherwise authorized by this section on a prepaid or
10 fixed-sum basis for the provision of health care services to
11 recipients. An entity may provide prepaid services to
12 recipients, either directly or through arrangements with other
13 entities, if each entity involved in providing services:
14 (a) Is organized primarily for the purpose of
15 providing health care or other services of the type regularly
16 offered to Medicaid recipients;
17 (b) Ensures that services meet the standards set by
18 the agency for quality, appropriateness, and timeliness;
19 (c) Makes provisions satisfactory to the agency for
20 insolvency protection and ensures that neither enrolled
21 Medicaid recipients nor the agency will be liable for the
22 debts of the entity;
23 (d) Submits to the agency, if a private entity, a
24 financial plan that the agency finds to be fiscally sound and
25 that provides for working capital in the form of cash or
26 equivalent liquid assets excluding revenues from Medicaid
27 premium payments equal to at least the first 3 months of
28 operating expenses or $200,000, whichever is greater;
29 (e) Furnishes evidence satisfactory to the agency of
30 adequate liability insurance coverage or an adequate plan of
31
15
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 self-insurance to respond to claims for injuries arising out
2 of the furnishing of health care;
3 (f) Provides, through contract or otherwise, for
4 periodic review of its medical facilities and services, as
5 required by the agency; and
6 (g) Provides organizational, operational, financial,
7 and other information required by the agency.
8 (5) The agency may contract on a prepaid or fixed-sum
9 basis with any health insurer that:
10 (a) Pays for health care services provided to enrolled
11 Medicaid recipients in exchange for a premium payment paid by
12 the agency;
13 (b) Assumes the underwriting risk; and
14 (c) Is organized and licensed under applicable
15 provisions of the Florida Insurance Code and is currently in
16 good standing with the Department of Insurance.
17 (6) The agency may contract on a prepaid or fixed-sum
18 basis with an exclusive provider organization to provide
19 health care services to Medicaid recipients provided that the
20 exclusive provider organization meets applicable managed care
21 plan requirements in this section, ss. 409.9122, 409.9123,
22 409.9128, and 627.6472, and other applicable provisions of
23 law.
24 (7) The Agency for Health Care Administration may
25 provide cost-effective purchasing of chiropractic services on
26 a fee-for-service basis to Medicaid recipients through
27 arrangements with a statewide chiropractic preferred provider
28 organization incorporated in this state as a not-for-profit
29 corporation. The agency shall ensure that the benefit limits
30 and prior authorization requirements in the current Medicaid
31
16
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 program shall apply to the services provided by the
2 chiropractic preferred provider organization.
3 (8) The agency shall not contract on a prepaid or
4 fixed-sum basis for Medicaid services with an entity which
5 knows or reasonably should know that any officer, director,
6 agent, managing employee, or owner of stock or beneficial
7 interest in excess of 5 percent common or preferred stock, or
8 the entity itself, has been found guilty of, regardless of
9 adjudication, or entered a plea of nolo contendere, or guilty,
10 to:
11 (a) Fraud;
12 (b) Violation of federal or state antitrust statutes,
13 including those proscribing price fixing between competitors
14 and the allocation of customers among competitors;
15 (c) Commission of a felony involving embezzlement,
16 theft, forgery, income tax evasion, bribery, falsification or
17 destruction of records, making false statements, receiving
18 stolen property, making false claims, or obstruction of
19 justice; or
20 (d) Any crime in any jurisdiction which directly
21 relates to the provision of health services on a prepaid or
22 fixed-sum basis.
23 (9) The agency, after notifying the Legislature, may
24 apply for waivers of applicable federal laws and regulations
25 as necessary to implement more appropriate systems of health
26 care for Medicaid recipients and reduce the cost of the
27 Medicaid program to the state and federal governments and
28 shall implement such programs, after legislative approval,
29 within a reasonable period of time after federal approval.
30 These programs must be designed primarily to reduce the need
31
17
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 for inpatient care, custodial care and other long-term or
2 institutional care, and other high-cost services.
3 (a) Prior to seeking legislative approval of such a
4 waiver as authorized by this subsection, the agency shall
5 provide notice and an opportunity for public comment. Notice
6 shall be provided to all persons who have made requests of the
7 agency for advance notice and shall be published in the
8 Florida Administrative Weekly not less than 28 days prior to
9 the intended action.
10 (b) Notwithstanding s. 216.292, funds that are
11 appropriated to the Department of Elderly Affairs for the
12 Assisted Living for the Elderly Medicaid waiver and are not
13 expended shall be transferred to the agency to fund
14 Medicaid-reimbursed nursing home care.
15 (10) The agency shall establish a postpayment
16 utilization control program designed to identify recipients
17 who may inappropriately overuse or underuse Medicaid services
18 and shall provide methods to correct such misuse.
19 (11) The agency shall develop and provide coordinated
20 systems of care for Medicaid recipients and may contract with
21 public or private entities to develop and administer such
22 systems of care among public and private health care providers
23 in a given geographic area.
24 (12) The agency shall operate or contract for the
25 operation of utilization management and incentive systems
26 designed to encourage cost-effective use services.
27 (13)(a) The agency shall identify health care
28 utilization and price patterns within the Medicaid program
29 which are not cost-effective or medically appropriate and
30 assess the effectiveness of new or alternate methods of
31 providing and monitoring service, and may implement such
18
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 methods as it considers appropriate. Such methods may include
2 disease management initiatives, an integrated and systematic
3 approach for managing the health care needs of recipients who
4 are at risk of or diagnosed with a specific disease by using
5 best practices, prevention strategies, clinical-practice
6 improvement, clinical interventions and protocols, outcomes
7 research, information technology, and other tools and
8 resources to reduce overall costs and improve measurable
9 outcomes.
10 (b) The responsibility of the agency under this
11 subsection shall include the development of capabilities to
12 identify actual and optimal practice patterns; patient and
13 provider educational initiatives; methods for determining
14 patient compliance with prescribed treatments; fraud, waste,
15 and abuse prevention and detection programs; and beneficiary
16 case management programs.
17 1. The practice pattern identification program shall
18 evaluate practitioner prescribing patterns based on national
19 and regional practice guidelines, comparing practitioners to
20 their peer groups. The agency and its Drug Utilization Review
21 Board shall consult with a panel of practicing health care
22 professionals consisting of the following: the Speaker of the
23 House of Representatives and the President of the Senate shall
24 each appoint three physicians licensed under chapter 458 or
25 chapter 459; and the Governor shall appoint two pharmacists
26 licensed under chapter 465 and one dentist licensed under
27 chapter 466 who is an oral surgeon. Terms of the panel members
28 shall expire at the discretion of the appointing official. The
29 panel shall begin its work by August 1, 1999, regardless of
30 the number of appointments made by that date. The advisory
31 panel shall be responsible for evaluating treatment guidelines
19
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 and recommending ways to incorporate their use in the practice
2 pattern identification program. Practitioners who are
3 prescribing inappropriately or inefficiently, as determined by
4 the agency, may have their prescribing of certain drugs
5 subject to prior authorization.
6 2. The agency shall also develop educational
7 interventions designed to promote the proper use of
8 medications by providers and beneficiaries.
9 3. The agency shall implement a pharmacy fraud, waste,
10 and abuse initiative that may include a surety bond or letter
11 of credit requirement for participating pharmacies, enhanced
12 provider auditing practices, the use of additional fraud and
13 abuse software, recipient management programs for
14 beneficiaries inappropriately using their benefits, and other
15 steps that will eliminate provider and recipient fraud, waste,
16 and abuse. The initiative shall address enforcement efforts to
17 reduce the number and use of counterfeit prescriptions.
18 4. The agency may apply for any federal waivers needed
19 to implement this paragraph.
20 (14) An entity contracting on a prepaid or fixed-sum
21 basis shall, in addition to meeting any applicable statutory
22 surplus requirements, also maintain at all times in the form
23 of cash, investments that mature in less than 180 days
24 allowable as admitted assets by the Department of Insurance,
25 and restricted funds or deposits controlled by the agency or
26 the Department of Insurance, a surplus amount equal to
27 one-and-one-half times the entity's monthly Medicaid prepaid
28 revenues. As used in this subsection, the term "surplus" means
29 the entity's total assets minus total liabilities. If an
30 entity's surplus falls below an amount equal to
31 one-and-one-half times the entity's monthly Medicaid prepaid
20
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 revenues, the agency shall prohibit the entity from engaging
2 in marketing and preenrollment activities, shall cease to
3 process new enrollments, and shall not renew the entity's
4 contract until the required balance is achieved. The
5 requirements of this subsection do not apply:
6 (a) Where a public entity agrees to fund any deficit
7 incurred by the contracting entity; or
8 (b) Where the entity's performance and obligations are
9 guaranteed in writing by a guaranteeing organization which:
10 1. Has been in operation for at least 5 years and has
11 assets in excess of $50 million; or
12 2. Submits a written guarantee acceptable to the
13 agency which is irrevocable during the term of the contracting
14 entity's contract with the agency and, upon termination of the
15 contract, until the agency receives proof of satisfaction of
16 all outstanding obligations incurred under the contract.
17 (15)(a) The agency may require an entity contracting
18 on a prepaid or fixed-sum basis to establish a restricted
19 insolvency protection account with a federally guaranteed
20 financial institution licensed to do business in this state.
21 The entity shall deposit into that account 5 percent of the
22 capitation payments made by the agency each month until a
23 maximum total of 2 percent of the total current contract
24 amount is reached. The restricted insolvency protection
25 account may be drawn upon with the authorized signatures of
26 two persons designated by the entity and two representatives
27 of the agency. If the agency finds that the entity is
28 insolvent, the agency may draw upon the account solely with
29 the two authorized signatures of representatives of the
30 agency, and the funds may be disbursed to meet financial
31 obligations incurred by the entity under the prepaid contract.
21
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 If the contract is terminated, expired, or not continued, the
2 account balance must be released by the agency to the entity
3 upon receipt of proof of satisfaction of all outstanding
4 obligations incurred under this contract.
5 (b) The agency may waive the insolvency protection
6 account requirement in writing when evidence is on file with
7 the agency of adequate insolvency insurance and reinsurance
8 that will protect enrollees if the entity becomes unable to
9 meet its obligations.
10 (16) An entity that contracts with the agency on a
11 prepaid or fixed-sum basis for the provision of Medicaid
12 services shall reimburse any hospital or physician that is
13 outside the entity's authorized geographic service area as
14 specified in its contract with the agency, and that provides
15 services authorized by the entity to its members, at a rate
16 negotiated with the hospital or physician for the provision of
17 services or according to the lesser of the following:
18 (a) The usual and customary charges made to the
19 general public by the hospital or physician; or
20 (b) The Florida Medicaid reimbursement rate
21 established for the hospital or physician.
22 (17) When a merger or acquisition of a Medicaid
23 prepaid contractor has been approved by the Department of
24 Insurance pursuant to s. 628.4615, the agency shall approve
25 the assignment or transfer of the appropriate Medicaid prepaid
26 contract upon request of the surviving entity of the merger or
27 acquisition if the contractor and the other entity have been
28 in good standing with the agency for the most recent 12-month
29 period, unless the agency determines that the assignment or
30 transfer would be detrimental to the Medicaid recipients or
31 the Medicaid program. To be in good standing, an entity must
22
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 not have failed accreditation or committed any material
2 violation of the requirements of s. 641.52 and must meet the
3 Medicaid contract requirements. For purposes of this section,
4 a merger or acquisition means a change in controlling interest
5 of an entity, including an asset or stock purchase.
6 (18) Any entity contracting with the agency pursuant
7 to this section to provide health care services to Medicaid
8 recipients is prohibited from engaging in any of the following
9 practices or activities:
10 (a) Practices that are discriminatory, including, but
11 not limited to, attempts to discourage participation on the
12 basis of actual or perceived health status.
13 (b) Activities that could mislead or confuse
14 recipients, or misrepresent the organization, its marketing
15 representatives, or the agency. Violations of this paragraph
16 include, but are not limited to:
17 1. False or misleading claims that marketing
18 representatives are employees or representatives of the state
19 or county, or of anyone other than the entity or the
20 organization by whom they are reimbursed.
21 2. False or misleading claims that the entity is
22 recommended or endorsed by any state or county agency, or by
23 any other organization which has not certified its endorsement
24 in writing to the entity.
25 3. False or misleading claims that the state or county
26 recommends that a Medicaid recipient enroll with an entity.
27 4. Claims that a Medicaid recipient will lose benefits
28 under the Medicaid program, or any other health or welfare
29 benefits to which the recipient is legally entitled, if the
30 recipient does not enroll with the entity.
31
23
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 (c) Granting or offering of any monetary or other
2 valuable consideration for enrollment, except as authorized by
3 subsection (21).
4 (d) Door-to-door solicitation of recipients who have
5 not contacted the entity or who have not invited the entity to
6 make a presentation.
7 (e) Solicitation of Medicaid recipients by marketing
8 representatives stationed in state offices unless approved and
9 supervised by the agency or its agent and approved by the
10 affected state agency when solicitation occurs in an office of
11 the state agency. The agency shall ensure that marketing
12 representatives stationed in state offices shall market their
13 managed care plans to Medicaid recipients only in designated
14 areas and in such a way as to not interfere with the
15 recipients' activities in the state office.
16 (f) Enrollment of Medicaid recipients.
17 (19) The agency may impose a fine for a violation of
18 this section or the contract with the agency by a person or
19 entity that is under contract with the agency. With respect
20 to any nonwillful violation, such fine shall not exceed $2,500
21 per violation. In no event shall such fine exceed an
22 aggregate amount of $10,000 for all nonwillful violations
23 arising out of the same action. With respect to any knowing
24 and willful violation of this section or the contract with the
25 agency, the agency may impose a fine upon the entity in an
26 amount not to exceed $20,000 for each such violation. In no
27 event shall such fine exceed an aggregate amount of $100,000
28 for all knowing and willful violations arising out of the same
29 action.
30 (20) A health maintenance organization or a person or
31 entity exempt from chapter 641 that is under contract with the
24
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 agency for the provision of health care services to Medicaid
2 recipients may not use or distribute marketing materials used
3 to solicit Medicaid recipients, unless such materials have
4 been approved by the agency. The provisions of this subsection
5 do not apply to general advertising and marketing materials
6 used by a health maintenance organization to solicit both
7 non-Medicaid subscribers and Medicaid recipients.
8 (21) Upon approval by the agency, health maintenance
9 organizations and persons or entities exempt from chapter 641
10 that are under contract with the agency for the provision of
11 health care services to Medicaid recipients may be permitted
12 within the capitation rate to provide additional health
13 benefits that the agency has found are of high quality, are
14 practicably available, provide reasonable value to the
15 recipient, and are provided at no additional cost to the
16 state.
17 (22) The agency shall utilize the statewide health
18 maintenance organization complaint hotline for the purpose of
19 investigating and resolving Medicaid and prepaid health plan
20 complaints, maintaining a record of complaints and confirmed
21 problems, and receiving disenrollment requests made by
22 recipients.
23 (23) The agency shall require the publication of the
24 health maintenance organization's and the prepaid health
25 plan's consumer services telephone numbers and the "800"
26 telephone number of the statewide health maintenance
27 organization complaint hotline on each Medicaid identification
28 card issued by a health maintenance organization or prepaid
29 health plan contracting with the agency to serve Medicaid
30 recipients and on each subscriber handbook issued to a
31 Medicaid recipient.
25
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 (24) The agency shall establish a health care quality
2 improvement system for those entities contracting with the
3 agency pursuant to this section, incorporating all the
4 standards and guidelines developed by the Medicaid Bureau of
5 the Health Care Financing Administration as a part of the
6 quality assurance reform initiative. The system shall
7 include, but need not be limited to, the following:
8 (a) Guidelines for internal quality assurance
9 programs, including standards for:
10 1. Written quality assurance program descriptions.
11 2. Responsibilities of the governing body for
12 monitoring, evaluating, and making improvements to care.
13 3. An active quality assurance committee.
14 4. Quality assurance program supervision.
15 5. Requiring the program to have adequate resources to
16 effectively carry out its specified activities.
17 6. Provider participation in the quality assurance
18 program.
19 7. Delegation of quality assurance program activities.
20 8. Credentialing and recredentialing.
21 9. Enrollee rights and responsibilities.
22 10. Availability and accessibility to services and
23 care.
24 11. Ambulatory care facilities.
25 12. Accessibility and availability of medical records,
26 as well as proper recordkeeping and process for record review.
27 13. Utilization review.
28 14. A continuity of care system.
29 15. Quality assurance program documentation.
30 16. Coordination of quality assurance activity with
31 other management activity.
26
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 17. Delivering care to pregnant women and infants; to
2 elderly and disabled recipients, especially those who are at
3 risk of institutional placement; to persons with developmental
4 disabilities; and to adults who have chronic, high-cost
5 medical conditions.
6 (b) Guidelines which require the entities to conduct
7 quality-of-care studies which:
8 1. Target specific conditions and specific health
9 service delivery issues for focused monitoring and evaluation.
10 2. Use clinical care standards or practice guidelines
11 to objectively evaluate the care the entity delivers or fails
12 to deliver for the targeted clinical conditions and health
13 services delivery issues.
14 3. Use quality indicators derived from the clinical
15 care standards or practice guidelines to screen and monitor
16 care and services delivered.
17 (c) Guidelines for external quality review of each
18 contractor which require: focused studies of patterns of care;
19 individual care review in specific situations; and followup
20 activities on previous pattern-of-care study findings and
21 individual-care-review findings. In designing the external
22 quality review function and determining how it is to operate
23 as part of the state's overall quality improvement system, the
24 agency shall construct its external quality review
25 organization and entity contracts to address each of the
26 following:
27 1. Delineating the role of the external quality review
28 organization.
29 2. Length of the external quality review organization
30 contract with the state.
31
27
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 3. Participation of the contracting entities in
2 designing external quality review organization review
3 activities.
4 4. Potential variation in the type of clinical
5 conditions and health services delivery issues to be studied
6 at each plan.
7 5. Determining the number of focused pattern-of-care
8 studies to be conducted for each plan.
9 6. Methods for implementing focused studies.
10 7. Individual care review.
11 8. Followup activities.
12 (25) In order to ensure that children receive health
13 care services for which an entity has already been
14 compensated, an entity contracting with the agency pursuant to
15 this section shall achieve an annual Early and Periodic
16 Screening, Diagnosis, and Treatment (EPSDT) Service screening
17 rate of at least 60 percent for those recipients continuously
18 enrolled for at least 8 months. The agency shall develop a
19 method by which the EPSDT screening rate shall be calculated.
20 For any entity which does not achieve the annual 60 percent
21 rate, the entity must submit a corrective action plan for the
22 agency's approval. If the entity does not meet the standard
23 established in the corrective action plan during the specified
24 timeframe, the agency is authorized to impose appropriate
25 contract sanctions. At least annually, the agency shall
26 publicly release the EPSDT Services screening rates of each
27 entity it has contracted with on a prepaid basis to serve
28 Medicaid recipients.
29 (26) The agency shall perform enrollments and
30 disenrollments for Medicaid recipients who are eligible for
31 MediPass or managed care plans. Notwithstanding the
28
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 prohibition contained in paragraph (18)(f), managed care plans
2 may perform preenrollments of Medicaid recipients under the
3 supervision of the agency or its agents. For the purposes of
4 this section, "preenrollment" means the provision of marketing
5 and educational materials to a Medicaid recipient and
6 assistance in completing the application forms, but shall not
7 include actual enrollment into a managed care plan. An
8 application for enrollment shall not be deemed complete until
9 the agency or its agent verifies that the recipient made an
10 informed, voluntary choice. The agency, in cooperation with
11 the Department of Children and Family Services, may test new
12 marketing initiatives to inform Medicaid recipients about
13 their managed care options at selected sites. The agency
14 shall report to the Legislature on the effectiveness of such
15 initiatives. The agency may contract with a third party to
16 perform managed care plan and MediPass enrollment and
17 disenrollment services for Medicaid recipients and is
18 authorized to adopt rules to implement such services. The
19 agency may adjust the capitation rate only to cover the costs
20 of a third-party enrollment and disenrollment contract, and
21 for agency supervision and management of the managed care plan
22 enrollment and disenrollment contract.
23 (27) Any lists of providers made available to Medicaid
24 recipients, MediPass enrollees, or managed care plan enrollees
25 shall be arranged alphabetically showing the provider's name
26 and specialty and, separately, by specialty in alphabetical
27 order.
28 (28) The agency shall establish an enhanced managed
29 care quality assurance oversight function, to include at least
30 the following components:
31
29
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 (a) At least quarterly analysis and followup,
2 including sanctions as appropriate, of managed care
3 participant utilization of services.
4 (b) At least quarterly analysis and followup,
5 including sanctions as appropriate, of quality findings of the
6 Medicaid peer review organization and other external quality
7 assurance programs.
8 (c) At least quarterly analysis and followup,
9 including sanctions as appropriate, of the fiscal viability of
10 managed care plans.
11 (d) At least quarterly analysis and followup,
12 including sanctions as appropriate, of managed care
13 participant satisfaction and disenrollment surveys.
14 (e) The agency shall conduct regular and ongoing
15 Medicaid recipient satisfaction surveys.
16
17 The analyses and followup activities conducted by the agency
18 under its enhanced managed care quality assurance oversight
19 function shall not duplicate the activities of accreditation
20 reviewers for entities regulated under part III of chapter
21 641, but may include a review of the finding of such
22 reviewers.
23 (29) Each managed care plan that is under contract
24 with the agency to provide health care services to Medicaid
25 recipients shall annually conduct a background check with the
26 Florida Department of Law Enforcement of all persons with
27 ownership interest of 5 percent or more or executive
28 management responsibility for the managed care plan and shall
29 submit to the agency information concerning any such person
30 who has been found guilty of, regardless of adjudication, or
31
30
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 has entered a plea of nolo contendere or guilty to, any of the
2 offenses listed in s. 435.03.
3 (30) The agency shall, by rule, develop a process
4 whereby a Medicaid managed care plan enrollee who wishes to
5 enter hospice care may be disenrolled from the managed care
6 plan within 24 hours after contacting the agency regarding
7 such request. The agency rule shall include a methodology for
8 the agency to recoup managed care plan payments on a pro rata
9 basis if payment has been made for the enrollment month when
10 disenrollment occurs.
11 (31) The agency and entities which contract with the
12 agency to provide health care services to Medicaid recipients
13 under this section or s. 409.9122 must comply with the
14 provisions of s. 641.513 in providing emergency services and
15 care to Medicaid recipients and MediPass recipients.
16 (32) All entities providing health care services to
17 Medicaid recipients shall make available, and encourage all
18 pregnant women and mothers with infants to receive, and
19 provide documentation in the medical records to reflect, the
20 following:
21 (a) Healthy Start prenatal or infant screening.
22 (b) Healthy Start care coordination, when screening or
23 other factors indicate need.
24 (c) Healthy Start enhanced services in accordance with
25 the prenatal or infant screening results.
26 (d) Immunizations in accordance with recommendations
27 of the Advisory Committee on Immunization Practices of the
28 United States Public Health Service and the American Academy
29 of Pediatrics, as appropriate.
30 (e) Counseling and services for family planning to all
31 women and their partners.
31
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 (f) A scheduled postpartum visit for the purpose of
2 voluntary family planning, to include discussion of all
3 methods of contraception, as appropriate.
4 (g) Referral to the Special Supplemental Nutrition
5 Program for Women, Infants, and Children (WIC).
6 (33) Any entity that provides Medicaid prepaid health
7 plan services shall ensure the appropriate coordination of
8 health care services with an assisted living facility in cases
9 where a Medicaid recipient is both a member of the entity's
10 prepaid health plan and a resident of the assisted living
11 facility. If the entity is at risk for Medicaid targeted case
12 management and behavioral health services, the entity shall
13 inform the assisted living facility of the procedures to
14 follow should an emergent condition arise.
15 (34) The agency may seek and implement federal waivers
16 necessary to provide for cost-effective purchasing of home
17 health services, private duty nursing services,
18 transportation, independent laboratory services, and durable
19 medical equipment and supplies through competitive bidding
20 pursuant to s. 287.057. The agency may request appropriate
21 waivers from the federal Health Care Financing Administration
22 in order to competitively bid such services. The agency may
23 exclude providers not selected through the bidding process
24 from the Medicaid provider network.
25 (35) The Agency for Health Care Administration is
26 directed to issue a request for proposal or intent to
27 negotiate to implement on a demonstration basis an outpatient
28 specialty services pilot project in a rural and urban county
29 in the state. As used in this subsection, the term
30 "outpatient specialty services" means clinical laboratory,
31 diagnostic imaging, and specified home medical services to
32
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 include durable medical equipment, prosthetics and orthotics,
2 and infusion therapy.
3 (a) The entity that is awarded the contract to provide
4 Medicaid managed care outpatient specialty services must, at a
5 minimum, meet the following criteria:
6 1. The entity must be licensed by the Department of
7 Insurance under part II of chapter 641.
8 2. The entity must be experienced in providing
9 outpatient specialty services.
10 3. The entity must demonstrate to the satisfaction of
11 the agency that it provides high-quality services to its
12 patients.
13 4. The entity must demonstrate that it has in place a
14 complaints and grievance process to assist Medicaid recipients
15 enrolled in the pilot managed care program to resolve
16 complaints and grievances.
17 (b) The pilot managed care program shall operate for a
18 period of 3 years. The objective of the pilot program shall
19 be to determine the cost-effectiveness and effects on
20 utilization, access, and quality of providing outpatient
21 specialty services to Medicaid recipients on a prepaid,
22 capitated basis.
23 (c) The agency shall conduct a quality assurance
24 review of the prepaid health clinic each year that the
25 demonstration program is in effect. The prepaid health clinic
26 is responsible for all expenses incurred by the agency in
27 conducting a quality assurance review.
28 (d) The entity that is awarded the contract to provide
29 outpatient specialty services to Medicaid recipients shall
30 report data required by the agency in a format specified by
31
33
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 the agency, for the purpose of conducting the evaluation
2 required in paragraph (e).
3 (e) The agency shall conduct an evaluation of the
4 pilot managed care program and report its findings to the
5 Governor and the Legislature by no later than January 1, 2001.
6 (36) The agency shall enter into agreements with
7 not-for-profit organizations based in this state for the
8 purpose of providing vision screening.
9 (37)(a) The agency shall implement a Medicaid
10 prescribed-drug spending-control program that includes the
11 following components:
12 1. Medicaid prescribed-drug coverage for brand-name
13 drugs for adult Medicaid recipients is limited to the
14 dispensing of four brand-name drugs per month per recipient.
15 Children are exempt from this restriction. Antiretroviral
16 agents are excluded from this limitation. No requirements for
17 prior authorization or other restrictions on medications used
18 to treat mental illnesses such as schizophrenia, severe
19 depression, or bipolar disorder may be imposed on Medicaid
20 recipients. Medications that will be available without
21 restriction for persons with mental illnesses include atypical
22 antipsychotic medications, conventional antipsychotic
23 medications, selective serotonin reuptake inhibitors, and
24 other medications used for the treatment of serious mental
25 illnesses. The agency shall also limit the amount of a
26 prescribed drug dispensed to no more than a 34-day supply. The
27 agency shall continue to provide unlimited generic drugs,
28 contraceptive drugs and items, and diabetic supplies. Although
29 a drug may be included on the preferred drug formulary, it
30 would not be exempt from the four-brand limit. The agency may
31 authorize exceptions to the brand-name-drug restriction based
34
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 upon the treatment needs of the patients, only when such
2 exceptions are based on prior consultation provided by the
3 agency or an agency contractor, but the agency must establish
4 procedures to ensure that:
5 a. There will be a response to a request for prior
6 consultation by telephone or other telecommunication device
7 within 24 hours after receipt of a request for prior
8 consultation;
9 b. A 72-hour supply of the drug prescribed will be
10 provided in an emergency or when the agency does not provide a
11 response within 24 hours as required by sub-subparagraph a.;
12 and
13 c. Except for the exception for nursing home residents
14 and other institutionalized adults and except for drugs on the
15 restricted formulary for which prior authorization may be
16 sought by an institutional or community pharmacy, prior
17 authorization for an exception to the brand-name-drug
18 restriction is sought by the prescriber and not by the
19 pharmacy. When prior authorization is granted for a patient in
20 an institutional setting beyond the brand-name-drug
21 restriction, such approval is authorized for 12 months and
22 monthly prior authorization is not required for that patient.
23 2. Reimbursement to pharmacies for Medicaid prescribed
24 drugs shall be set at the average wholesale price less 13.25
25 percent.
26 3. The agency shall develop and implement a process
27 for managing the drug therapies of Medicaid recipients who are
28 using significant numbers of prescribed drugs each month. The
29 management process may include, but is not limited to,
30 comprehensive, physician-directed medical-record reviews,
31 claims analyses, and case evaluations to determine the medical
35
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 necessity and appropriateness of a patient's treatment plan
2 and drug therapies. The agency may contract with a private
3 organization to provide drug-program-management services. The
4 Medicaid drug benefit management program shall include
5 initiatives to manage drug therapies for HIV/AIDS patients,
6 patients using 20 or more unique prescriptions in a 180-day
7 period, and the top 1,000 patients in annual spending.
8 4. The agency may limit the size of its pharmacy
9 network based on need, competitive bidding, price
10 negotiations, credentialing, or similar criteria. The agency
11 shall give special consideration to rural areas in determining
12 the size and location of pharmacies included in the Medicaid
13 pharmacy network. A pharmacy credentialing process may include
14 criteria such as a pharmacy's full-service status, location,
15 size, patient educational programs, patient consultation,
16 disease-management services, and other characteristics. The
17 agency may impose a moratorium on Medicaid pharmacy enrollment
18 when it is determined that it has a sufficient number of
19 Medicaid-participating providers.
20 5. The agency shall develop and implement a program
21 that requires Medicaid practitioners who prescribe drugs to
22 use a counterfeit-proof prescription pad for Medicaid
23 prescriptions. The agency shall require the use of
24 standardized counterfeit-proof prescription pads by
25 Medicaid-participating prescribers or prescribers who write
26 prescriptions for Medicaid recipients. The agency may
27 implement the program in targeted geographic areas or
28 statewide.
29 6. The agency may enter into arrangements that require
30 manufacturers of generic drugs prescribed to Medicaid
31 recipients to provide rebates of at least 15.1 percent of the
36
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 average manufacturer price for the manufacturer's generic
2 products. These arrangements shall require that if a
3 generic-drug manufacturer pays federal rebates for
4 Medicaid-reimbursed drugs at a level below 15.1 percent, the
5 manufacturer must provide a supplemental rebate to the state
6 in an amount necessary to achieve a 15.1-percent rebate level.
7 7. The agency may establish a preferred drug formulary
8 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
9 establishment of such formulary, it is authorized to negotiate
10 supplemental rebates from manufacturers that are in addition
11 to those required by Title XIX of the Social Security Act and
12 at no less than 10 percent of the average manufacturer price
13 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
14 unless the federal or supplemental rebate, or both, equals or
15 exceeds 25 percent. There is no upper limit on the
16 supplemental rebates the agency may negotiate. The agency may
17 determine that specific products, brand-name or generic, are
18 competitive at lower rebate percentages. Agreement to pay the
19 minimum supplemental rebate percentage will guarantee a
20 manufacturer that the Medicaid Pharmaceutical and Therapeutics
21 Committee will consider a product for inclusion on the
22 preferred drug formulary. However, a pharmaceutical
23 manufacturer is not guaranteed placement on the formulary by
24 simply paying the minimum supplemental rebate. Agency
25 decisions will be made on the clinical efficacy of a drug and
26 recommendations of the Medicaid Pharmaceutical and
27 Therapeutics Committee, as well as the price of competing
28 products minus federal and state rebates. The agency is
29 authorized to contract with an outside agency or contractor to
30 conduct negotiations for supplemental rebates. For the
31 purposes of this section, the term "supplemental rebates" may
37
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 include, at the agency's discretion, cash rebates and other
2 program benefits that offset a Medicaid expenditure. Such
3 other program benefits may include, but are not limited to,
4 disease management programs, drug product donation programs,
5 drug utilization control programs, prescriber and beneficiary
6 counseling and education, fraud and abuse initiatives, and
7 other services or administrative investments with guaranteed
8 savings to the Medicaid program in the same year the rebate
9 reduction is included in the General Appropriations Act. The
10 agency is authorized to seek any federal waivers to implement
11 this initiative.
12 8. The agency shall establish an advisory committee
13 for the purposes of studying the feasibility of using a
14 restricted drug formulary for nursing home residents and other
15 institutionalized adults. The committee shall be comprised of
16 seven members appointed by the Secretary of Health Care
17 Administration. The committee members shall include two
18 physicians licensed under chapter 458 or chapter 459; three
19 pharmacists licensed under chapter 465 and appointed from a
20 list of recommendations provided by the Florida Long-Term Care
21 Pharmacy Alliance; and two pharmacists licensed under chapter
22 465.
23 9. The Agency for Health Care Administration shall
24 expand home delivery of pharmacy products. To assist Medicaid
25 patients in securing their prescriptions and reduce program
26 costs, the agency shall expand its current mail-order-pharmacy
27 diabetes-supply program to include all generic and brand-name
28 drugs used by Medicaid patients with diabetes. Medicaid
29 recipients in the current program may obtain nondiabetes drugs
30 on a voluntary basis. This initiative is limited to the
31 geographic area covered by the current contract. The agency
38
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 may seek and implement any federal waivers necessary to
2 implement this subparagraph.
3 (b) The agency shall implement this subsection to the
4 extent that funds are appropriated to administer the Medicaid
5 prescribed-drug spending-control program. The agency may
6 contract all or any part of this program to private
7 organizations.
8 (c) The agency shall submit quarterly reports a report
9 to the Governor, the President of the Senate, and the Speaker
10 of the House of Representatives which by January 15 of each
11 year. The report must include, but need not be limited to, the
12 progress made in implementing this subsection and its Medicaid
13 cost-containment measures and their effect on Medicaid
14 prescribed-drug expenditures.
15 (38) Notwithstanding the provisions of chapter 287,
16 the agency may, at its discretion, renew a contract or
17 contracts for fiscal intermediary services one or more times
18 for such periods as the agency may decide; however, all such
19 renewals may not combine to exceed a total period longer than
20 the term of the original contract.
21 (39) The agency shall provide for the development of a
22 demonstration project by establishment in Miami-Dade County of
23 a long-term-care facility licensed pursuant to chapter 395 to
24 improve access to health care for a predominantly minority,
25 medically underserved, and medically complex population and to
26 evaluate alternatives to nursing home care and general acute
27 care for such population. Such project is to be located in a
28 health care condominium and colocated with licensed facilities
29 providing a continuum of care. The establishment of this
30 project is not subject to the provisions of s. 408.036 or s.
31 408.039. The agency shall report its findings to the
39
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 Governor, the President of the Senate, and the Speaker of the
2 House of Representatives by January 1, 2003.
3 Section 6. Subsection (7) of section 409.9116, Florida
4 Statutes, is amended to read:
5 409.9116 Disproportionate share/financial assistance
6 program for rural hospitals.--In addition to the payments made
7 under s. 409.911, the Agency for Health Care Administration
8 shall administer a federally matched disproportionate share
9 program and a state-funded financial assistance program for
10 statutory rural hospitals. The agency shall make
11 disproportionate share payments to statutory rural hospitals
12 that qualify for such payments and financial assistance
13 payments to statutory rural hospitals that do not qualify for
14 disproportionate share payments. The disproportionate share
15 program payments shall be limited by and conform with federal
16 requirements. Funds shall be distributed quarterly in each
17 fiscal year for which an appropriation is made.
18 Notwithstanding the provisions of s. 409.915, counties are
19 exempt from contributing toward the cost of this special
20 reimbursement for hospitals serving a disproportionate share
21 of low-income patients.
22 (7) This section applies only to hospitals that were
23 defined as statutory rural hospitals, or their
24 successor-in-interest hospital, prior to January 1, 2001 July
25 1, 1998. Any additional hospital that is defined as a
26 statutory rural hospital, or its successor-in-interest
27 hospital, on or after January 1, 2001 July 1, 1998, is not
28 eligible for programs under this section unless additional
29 funds are appropriated each fiscal year specifically to the
30 rural hospital disproportionate share and financial assistance
31 programs in an amount necessary to prevent any hospital, or
40
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 its successor-in-interest hospital, eligible for the programs
2 prior to January 1, 2001 July 1, 1998, from incurring a
3 reduction in payments because of the eligibility of an
4 additional hospital to participate in the programs. A
5 hospital, or its successor-in-interest hospital, which
6 received funds pursuant to this section before January 1, 2001
7 July 1, 1998, and which qualifies under s. 395.602(2)(e),
8 shall be included in the programs under this section and is
9 not required to seek additional appropriations under this
10 subsection.
11 Section 7. Paragraphs (f) and (k) of subsection (2) of
12 section 409.9122, Florida Statutes, as amended by section 11
13 of chapter 2001-377, Laws of Florida, are amended to read:
14 409.9122 Mandatory Medicaid managed care enrollment;
15 programs and procedures.--
16 (2)
17 (f) When a Medicaid recipient does not choose a
18 managed care plan or MediPass provider, the agency shall
19 assign the Medicaid recipient to a managed care plan or
20 MediPass provider. Medicaid recipients who are subject to
21 mandatory assignment but who fail to make a choice shall be
22 assigned to managed care plans or provider service networks
23 until an equal enrollment of 45 50 percent in MediPass and 55
24 50 percent in managed care plans is achieved. Once that equal
25 enrollment is achieved, the assignments shall be divided in
26 order to maintain an equal enrollment in MediPass and managed
27 care plans which is in a 45 percent and 55 percent proportion,
28 respectively. Thereafter, assignment of Medicaid recipients
29 who fail to make a choice shall be based proportionally on the
30 preferences of recipients who have made a choice in the
31 previous period. Such proportions shall be revised at least
41
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 quarterly to reflect an update of the preferences of Medicaid
2 recipients. The agency shall also disproportionately assign
3 Medicaid-eligible children in families who are required to but
4 have failed to make a choice of managed care plan or MediPass
5 for their child and who are to be assigned to the MediPass
6 program or managed care plans to children's networks as
7 described in s. 409.912(3)(g) and where available. The
8 disproportionate assignment of children to children's networks
9 shall be made until the agency has determined that the
10 children's networks have sufficient numbers to be economically
11 operated. For purposes of this paragraph, when referring to
12 assignment, the term "managed care plans" includes exclusive
13 provider organizations, provider service networks, minority
14 physician networks, and pediatric emergency department
15 diversion programs authorized by this chapter or the General
16 Appropriations Act. When making assignments, the agency shall
17 take into account the following criteria:
18 1. A managed care plan has sufficient network capacity
19 to meet the need of members.
20 2. The managed care plan or MediPass has previously
21 enrolled the recipient as a member, or one of the managed care
22 plan's primary care providers or MediPass providers has
23 previously provided health care to the recipient.
24 3. The agency has knowledge that the member has
25 previously expressed a preference for a particular managed
26 care plan or MediPass provider as indicated by Medicaid
27 fee-for-service claims data, but has failed to make a choice.
28 4. The managed care plan's or MediPass primary care
29 providers are geographically accessible to the recipient's
30 residence.
31
42
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 (k) When a Medicaid recipient does not choose a
2 managed care plan or MediPass provider, the agency shall
3 assign the Medicaid recipient to a managed care plan, except
4 in those counties in which there are fewer than two managed
5 care plans accepting Medicaid enrollees, in which case
6 assignment shall be to a managed care plan or a MediPass
7 provider. Medicaid recipients in counties with fewer than two
8 managed care plans accepting Medicaid enrollees who are
9 subject to mandatory assignment but who fail to make a choice
10 shall be assigned to managed care plans until an equal
11 enrollment of 45 50 percent in MediPass and provider service
12 networks and 55 50 percent in managed care plans is achieved.
13 Once that equal enrollment is achieved, the assignments shall
14 be divided in order to maintain an equal enrollment in
15 MediPass and managed care plans which is in a 45 percent and
16 55 percent proportion, respectively. When making assignments,
17 the agency shall take into account the following criteria:
18 1. A managed care plan has sufficient network capacity
19 to meet the need of members.
20 2. The managed care plan or MediPass has previously
21 enrolled the recipient as a member, or one of the managed care
22 plan's primary care providers or MediPass providers has
23 previously provided health care to the recipient.
24 3. The agency has knowledge that the member has
25 previously expressed a preference for a particular managed
26 care plan or MediPass provider as indicated by Medicaid
27 fee-for-service claims data, but has failed to make a choice.
28 4. The managed care plan's or MediPass primary care
29 providers are geographically accessible to the recipient's
30 residence.
31
43
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 5. The agency has authority to make mandatory
2 assignments based on quality of service and performance of
3 managed care plans.
4 Section 8. Paragraph (a) of subsection (1) of section
5 499.012, Florida Statutes, is amended to read:
6 499.012 Wholesale distribution; definitions; permits;
7 general requirements.--
8 (1) As used in this section, the term:
9 (a) "Wholesale distribution" means distribution of
10 prescription drugs to persons other than a consumer or
11 patient, but does not include:
12 1. Any of the following activities, which is not a
13 violation of s. 499.005(21) if such activity is conducted in
14 accordance with s. 499.014:
15 a. The purchase or other acquisition by a hospital or
16 other health care entity that is a member of a group
17 purchasing organization of a prescription drug for its own use
18 from the group purchasing organization or from other hospitals
19 or health care entities that are members of that organization.
20 b. The sale, purchase, or trade of a prescription drug
21 or an offer to sell, purchase, or trade a prescription drug by
22 a charitable organization described in s. 501(c)(3) of the
23 Internal Revenue Code of 1986, as amended and revised, to a
24 nonprofit affiliate of the organization to the extent
25 otherwise permitted by law.
26 c. The sale, purchase, or trade of a prescription drug
27 or an offer to sell, purchase, or trade a prescription drug
28 among hospitals or other health care entities that are under
29 common control. For purposes of this section, "common control"
30 means the power to direct or cause the direction of the
31 management and policies of a person or an organization,
44
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 whether by ownership of stock, by voting rights, by contract,
2 or otherwise.
3 d. The sale, purchase, trade, or other transfer of a
4 prescription drug from or for any federal, state, or local
5 government agency or any entity eligible to purchase
6 prescription drugs at public health services prices pursuant
7 to Pub. L. No. 102-585, s. 602 to a contract provider or its
8 subcontractor for eligible patients of the agency or entity
9 under the following conditions:
10 (I) The agency or entity must obtain written
11 authorization for the sale, purchase, trade, or other transfer
12 of a prescription drug under this sub-subparagraph from the
13 Secretary of Health or his or her designee.
14 (II) The contract provider or subcontractor must be
15 authorized by law to administer or dispense prescription
16 drugs.
17 (III) In the case of a subcontractor, the agency or
18 entity must be a party to and execute the subcontract.
19 (IV) A contract provider or subcontractor must
20 maintain separate and apart from other prescription drug
21 inventory any prescription drugs of the agency or entity in
22 its possession.
23 (V) The contract provider and subcontractor must
24 maintain and produce immediately for inspection all records of
25 movement or transfer of all the prescription drugs belonging
26 to the agency or entity, including, but not limited to, the
27 records of receipt and disposition of prescription drugs. Each
28 contractor and subcontractor dispensing or administering these
29 drugs must maintain and produce records documenting the
30 dispensing or administration. Records that are required to be
31 maintained include, but are not limited to, a perpetual
45
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 inventory itemizing drugs received and drugs dispensed by
2 prescription number or administered by patient identifier,
3 which must be submitted to the agency or entity quarterly.
4 (VI) The contract provider or subcontractor may
5 administer or dispense the prescription drugs only to the
6 eligible patients of the agency or entity or must return the
7 prescription drugs for or to the agency or entity. The
8 contract provider or subcontractor must require proof from
9 each person seeking to fill a prescription or obtain treatment
10 that the person is an eligible patient of the agency or entity
11 and must, at a minimum, maintain a copy of this proof as part
12 of the records of the contractor or subcontractor required
13 under sub-sub-subparagraph (V).
14 (VII) The prescription drugs transferred pursuant to
15 this sub-subparagraph may not be billed to Medicaid.
16 (VII)(VIII) In addition to the departmental inspection
17 authority set forth in s. 499.051, the establishment of the
18 contract provider and subcontractor and all records pertaining
19 to prescription drugs subject to this sub-subparagraph shall
20 be subject to inspection by the agency or entity. All records
21 relating to prescription drugs of a manufacturer under this
22 sub-subparagraph shall be subject to audit by the manufacturer
23 of those drugs, without identifying individual patient
24 information.
25 2. Any of the following activities, which is not a
26 violation of s. 499.005(21) if such activity is conducted in
27 accordance with rules established by the department:
28 a. The sale, purchase, or trade of a prescription drug
29 among federal, state, or local government health care entities
30 that are under common control and are authorized to purchase
31 such prescription drug.
46
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 b. The sale, purchase, or trade of a prescription drug
2 or an offer to sell, purchase, or trade a prescription drug
3 for emergency medical reasons. For purposes of this
4 sub-subparagraph, the term "emergency medical reasons"
5 includes transfers of prescription drugs by a retail pharmacy
6 to another retail pharmacy to alleviate a temporary shortage.
7 c. The transfer of a prescription drug acquired by a
8 medical director on behalf of a licensed emergency medical
9 services provider to that emergency medical services provider
10 and its transport vehicles for use in accordance with the
11 provider's license under chapter 401.
12 d. The revocation of a sale or the return of a
13 prescription drug to the person's prescription drug wholesale
14 supplier.
15 e. The donation of a prescription drug by a health
16 care entity to a charitable organization that has been granted
17 an exemption under s. 501(c)(3) of the Internal Revenue Code
18 of 1986, as amended, and that is authorized to possess
19 prescription drugs.
20 f. The transfer of a prescription drug by a person
21 authorized to purchase or receive prescription drugs to a
22 person licensed or permitted to handle reverse distributions
23 or destruction under the laws of the jurisdiction in which the
24 person handling the reverse distribution or destruction
25 receives the drug.
26 3. The distribution of prescription drug samples by
27 manufacturers' representatives or distributors'
28 representatives conducted in accordance with s. 499.028.
29 4. The sale, purchase, or trade of blood and blood
30 components intended for transfusion. As used in this
31 subparagraph, the term "blood" means whole blood collected
47
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 from a single donor and processed either for transfusion or
2 further manufacturing, and the term "blood components" means
3 that part of the blood separated by physical or mechanical
4 means.
5 5. The lawful dispensing of a prescription drug in
6 accordance with chapter 465.
7 Section 9. The Agency for Health Care Administration
8 shall conduct a study of health care services provided to the
9 medically fragile or medical-technology-dependent children in
10 the state and conduct a pilot program in Dade County to
11 provide subacute pediatric transitional care to a maximum of
12 30 children at any one time. The purposes of the study and the
13 pilot program are to determine ways to permit medically
14 fragile or medical-technology-dependent children to
15 successfully make a transition from acute care in a health
16 care institution to live with their families when possible,
17 and to provide cost-effective, subacute transitional care
18 services.
19 Section 10. The Agency for Health Care Administration,
20 in cooperation with the Children's Medical Services Program in
21 the Department of Health, shall conduct a study to identify
22 the total number of medically fragile or
23 medical-technology-dependent children, from birth through age
24 21, in the state. By January 1, 2003, the agency must report
25 to the Legislature regarding the children's ages, the
26 locations where the children are served, the types of services
27 received, itemized costs of the services, and the sources of
28 funding that pay for the services, including the proportional
29 share when more than one funding source pays for a service.
30 The study must include information regarding medically fragile
31 or medical-technology-dependent children residing in
48
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 hospitals, nursing homes, and medical foster care, and those
2 who live with their parents. The study must describe children
3 served in prescribed pediatric extended-care centers,
4 including their ages and the services they receive. The report
5 must identify the total services provided for each child and
6 the method for paying for those services. The report must also
7 identify the number of such children who could, if appropriate
8 transitional services were available, return home or move to a
9 less-institutional setting.
10 Section 11. (1) Within 30 days after the effective
11 date of this act, the agency shall establish minimum staffing
12 standards and quality requirements for a subacute pediatric
13 transitional care center to be operated as a 2-year pilot
14 program in Dade County. The pilot program must operate under
15 the license of a hospital licensed under chapter 395, Florida
16 Statutes, or a nursing home licensed under chapter 400,
17 Florida Statutes, and shall use existing beds in the hospital
18 or nursing home. A child's placement in the subacute pediatric
19 transitional care center may not exceed 90 days. The center
20 shall arrange for an alternative placement at the end of a
21 child's stay and a transitional plan for children expected to
22 remain in the facility for the maximum allowed stay.
23 (2) Within 60 days after the effective date of this
24 act, the agency must amend the state Medicaid plan and request
25 any federal waivers necessary to implement and fund the pilot
26 program.
27 (3) The subacute pediatric transitional care center
28 must require level I background screening as provided in
29 chapter 435, Florida Statutes, for all employees or
30 prospective employees of the center who are expected to, or
31 whose responsibilities may require them to, provide personal
49
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 care or services to children, have access to children's living
2 areas, or have access to children's funds or personal
3 property.
4 Section 12. (1) The subacute pediatric transitional
5 care center must have an advisory board. Membership on the
6 advisory board must include, but need not be limited to:
7 (a) A physician and an advanced registered nurse
8 practitioner who is familiar with services for medically
9 fragile or medical-technology-dependent children;
10 (b) A registered nurse who has experience in the care
11 of medically fragile or medical-technology-dependent children;
12 (c) A child development specialist who has experience
13 in the care of medically fragile or
14 medical-technology-dependent children and their families;
15 (d) A social worker who has experience in the care of
16 medically fragile or medical-technology-dependent children and
17 their families; and
18 (e) A consumer representative who is a parent or
19 guardian of a child placed in the center.
20 (2) The advisory board shall:
21 (a) Review the policy and procedure components of the
22 center to assure conformance with applicable standards
23 developed by the Agency for Health Care Administration; and
24 (b) Provide consultation with respect to the
25 operational and programmatic components of the center.
26 Section 13. (1) The subacute pediatric transitional
27 care center must have written policies and procedures
28 governing the admission, transfer, and discharge of children.
29 (2) The admission of each child to the center must be
30 under the supervision of the center nursing administrator or
31 his or her designee, and must be in accordance with the
50
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 center's policies and procedures. Each Medicaid admission must
2 be approved as appropriate for placement in the facility by
3 the Children's Medical Services Multidisciplinary Assessment
4 Team of the Department of Health, in conjunction with the
5 Agency for Health Care Administration.
6 (3) Each child admitted to the center shall be
7 admitted upon prescription of the medical director of the
8 center, licensed pursuant to chapter 458 or chapter 459,
9 Florida Statutes, and the child shall remain under the care of
10 the medical director and the advanced registered nurse
11 practitioner for the duration of his or her stay in the
12 center.
13 (4) Each child admitted to the center must meet at
14 least the following criteria:
15 (a) The child must be medically fragile or
16 medical-technology-dependent.
17 (b) The child may not, prior to admission, present
18 significant risk of infection to other children or personnel.
19 The medical and nursing directors shall review, on a
20 case-by-case basis, the condition of any child who is
21 suspected of having an infectious disease to determine whether
22 admission is appropriate.
23 (c) The child must be medically stabilized and require
24 skilled nursing care or other interventions.
25 (5) If the child meets the criteria specified in
26 paragraphs (4)(a), (b), and (c), the medical director or
27 nursing director of the center shall implement a preadmission
28 plan that delineates services to be provided and appropriate
29 sources for such services.
30 (a) If the child is hospitalized at the time of
31 referral, preadmission planning must include the participation
51
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 of the child's parent or guardian and relevant medical,
2 nursing, social services, and developmental staff to assure
3 that the hospital's discharge plans will be implemented
4 following the child's placement in the center.
5 (b) A consent form, outlining the purpose of the
6 center, family responsibilities, authorized treatment,
7 appropriate release of liability, and emergency disposition
8 plans, must be signed by the parent or guardian and witnessed
9 before the child is admitted to the center. The parent or
10 guardian shall be provided a copy of the consent form.
11 Section 14. By January 1, 2003, the Agency for Health
12 Care Administration shall report to the Legislature concerning
13 the progress of the pilot program. By January 1, 2004, the
14 agency shall submit to the Legislature a report on the success
15 of the pilot program.
16 Section 15. The Office of Legislative Services shall
17 contract for a business case study of the feasibility of
18 outsourcing the administrative, investigative, legal, and
19 prosecutorial functions and other tasks and services that are
20 necessary to carry out the regulatory responsibilities of the
21 Board of Dentistry, employing its own executive director and
22 other staff, and obtaining authority over collections and
23 expenditures of funds paid by professions regulated by the
24 board into the Medical Quality Assurance Trust Fund. This
25 feasibility study must include a business plan and an
26 assessment of the direct and indirect costs associated with
27 outsourcing these functions. The sum of $50,000 is
28 appropriated from the Board of Dentistry account within the
29 Medical Quality Assurance Trust Fund to the Office of
30 Legislative Services for the purpose of contracting for the
31 study. The Office of Legislative Services shall submit the
52
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 completed study to the Governor, the President of the Senate,
2 and the Speaker of the House of Representatives by January 1,
3 2003.
4 Section 16. (1) Notwithstanding section 409.911,
5 Florida Statutes, for the state fiscal year 2002-2003 only,
6 the Agency for Health Care Administration shall distribute
7 moneys under the regular disproportionate share program only
8 to public hospitals. Public hospitals are defined as those
9 hospitals included in the agency's calculation of the Medicaid
10 Upper Payment Limit in accordance with 42 C.F.R. 447.272. The
11 following methodology shall be used to distribute
12 disproportionate share dollars to the public hospitals:
13
14 For nonstate government-owned or operated hospitals:
15
16 DSHP = [(.9*HCCD)+(.1*HMD)/(CCD+TMD)]*TAAPH
17 TAAPH = TA - TAAMH
18
19 For state-owned or operated mental health hospitals:
20 DSHP = (HMD/TMHMD)*TAAMH
21
22 Where:
23 TA = total appropriation.
24 TAAPH = total amount available for public hospitals.
25 TAAMH = total amount available for mental health
26 hospitals.
27 DSHP = disproportionate share hospital payments.
28 HMD = hospital Medicaid days.
29 TMD = total state Medicaid days for public hospital.
30 HCCD = hospital charity care days.
31
53
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 1108 First Engrossed
1 TCCD = total state charity care days for public
2 hospitals.
3
4 (2) Notwithstanding section 409.9112, Florida
5 Statutes, for state fiscal year 2002-2003 only,
6 disproportionate share payments to regional perinatal
7 intensive care centers shall be equal to the disproportionate
8 payments made to the regional perinatal intensive care centers
9 in state fiscal year 2001-2002.
10 (3) Notwithstanding section 409.9117, Florida
11 Statutes, for state fiscal year 2002-2003 only,
12 disproportionate share payments to hospitals that qualify for
13 primary care disproportionate payments shall be equal to the
14 primary care disproportionate payments made to those hospitals
15 in state fiscal year 2001-2002.
16 (4) For state fiscal year 2002-2003 only, no
17 disproportionate share payments shall be made to hospitals
18 under the provisions of section 409.9119, Florida Statutes.
19 (5) In the event the Centers for Medicare and Medicaid
20 Services does not approve Florida's inpatient hospital state
21 plan amendment for the public disproportionate share program
22 by November 1, 2002, the agency may make payments to hospitals
23 under the regular disproportionate share program, regional
24 perinatal intensive care centers disproportionate share
25 program, primary care disproportionate share program, and
26 children's disproportionate share program using the same
27 methodologies used in state fiscal year 2001-2002.
28 (6) This section expires July 1, 2003.
29 Section 17. This act shall take effect July 1, 2002.
30
31
54
CODING: Words stricken are deletions; words underlined are additions.