Senate Bill sb2356
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Florida Senate - 2002 SB 2356
By Senator Silver
38-1161-02
1 A bill to be entitled
2 An act relating to health care services;
3 amending s. 215.5601, F.S., relating to the
4 Lawton Chiles Endowment Fund; revising the
5 amount transferred to the fund; amending s.
6 381.93, F.S.; revising funding requirements for
7 the Mary Brogan Breast and Cervical Cancer
8 Early Detection Program; revising services
9 provided under the program; amending s.
10 391.021, F.S.; redefining the term "children
11 with special health care needs" for purposes of
12 ch. 391, F.S., relating to children's medical
13 services; amending ss. 391.025, 391.029, F.S.;
14 revising eligibility requirements for
15 children's medical services; creating s.
16 391.309, F.S.; authorizing the Department of
17 Health to implement the federal Individuals
18 with Disabilities Education Act; requiring a
19 grant application; limiting the services that
20 may be provided without certain waivers;
21 amending s. 404.122, F.S.; authorizing the
22 Department of Health to use the Radiation
23 Protection Trust Fund for additional purposes;
24 amending s. 409.8132, F.S.; removing a
25 requirement for choice counseling under the
26 Medikids program; amending s. 409.814, F.S.;
27 revising eligibility requirements for the
28 Florida Kidcare program; amending s. 409.8177,
29 F.S.; requiring the Agency for Health Care
30 Administration to contract for an evaluation of
31 the Florida Kidcare program; amending s.
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1 409.903, F.S.; authorizing the agency to adjust
2 fees, reimbursement rates, and services
3 provided under Medicaid under certain
4 circumstances; revising certain Medicaid
5 eligibility requirements for children;
6 authorizing certain services for noncitizens
7 who are otherwise eligible; amending s.
8 409.904, F.S.; requiring premiums and
9 copayments under the optional payment program
10 for Medicaid-eligible persons; providing
11 criteria for determining a person's
12 responsibility for the cost of care; revising
13 certain eligibility requirements for children
14 and pregnant women; revising eligibility for
15 certain screening services for breast and
16 cervical cancer; revising the income limitation
17 for certain elderly persons; amending s. 1 of
18 ch. 2001-377, Laws of Florida, delaying the
19 repeal of provisions that provide for optional
20 medical assistance for certain persons;
21 amending s. 409.908, F.S.; providing for
22 reimbursements for Medicaid providers to be
23 based on performance and certain other factors;
24 amending s. 409.9117, F.S.; requiring the
25 agency to determine a hospital's eligibility to
26 participate in the primary care
27 disproportionate share program; amending s.
28 409.912, F.S.; increasing the frequency at
29 which the agency is required to report to the
30 Governor and Legislature concerning its
31 Medicaid prescribed-drug spending-control
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1 program; amending s. 409.9122, F.S.; revising
2 requirements for the agency with respect to
3 assigning Medicaid recipients to a managed care
4 plan or to MediPass; specifying those
5 organizations, plans, or networks that qualify
6 as a managed care plan for purposes of
7 mandatory enrollment; repealing s. 154.02(5),
8 F.S., relating to required reserves for county
9 health department trust funds; providing
10 effective dates.
11
12 Be It Enacted by the Legislature of the State of Florida:
13
14 Section 1. Subsection (3) of section 215.5601, Florida
15 Statutes, is amended to read:
16 215.5601 Lawton Chiles Endowment Fund.--
17 (3) LAWTON CHILES ENDOWMENT FUND; CREATION;
18 PRINCIPAL.--
19 (a) There is created the Lawton Chiles Endowment Fund,
20 to be administered by the State Board of Administration. The
21 endowment shall serve as a clearing trust fund, not subject to
22 termination under s. 19(f), Art. III of the State
23 Constitution. The endowment fund shall be exempt from the
24 service charges imposed by s. 215.20.
25 (b) The endowment shall receive moneys from the sale
26 of the state's right, title, and interest in and to the
27 tobacco settlement agreement as defined in s. 215.56005,
28 including the right to receive payments under such agreement,
29 and from accounts transferred from the Department of Banking
30 and Finance Tobacco Settlement Clearing Trust Fund established
31 under s. 17.41. Amounts to be transferred from the Department
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1 of Banking and Finance Tobacco Settlement Clearing Trust Fund
2 to the endowment shall be in the following amounts for the
3 following fiscal years:
4 1. For fiscal year 1999-2000, $1.1 billion;
5 2. For fiscal year 2000-2001, $200 million;
6 3. For fiscal year 2001-2002, $200 million; and
7 4. For fiscal year 2002-2003, $63.9 $200 million.; and
8 (c) Amounts to be transferred under subparagraphs
9 (b)2., 3., and 4. may be reduced by an amount equal to the
10 lesser of $200 million or the amount the endowment receives in
11 that fiscal year from the sale of the state's right, title,
12 and interest in and to the tobacco settlement agreement.
13 (d) For fiscal year 2001-2002, $150 million of the
14 existing principal in the endowment shall be reserved and
15 accounted for within the endowment, the income from which
16 shall be used solely for the funding for biomedical research
17 activities as provided in s. 215.5602. The income from the
18 remaining principal shall be used solely as the source of
19 funding for health and human services programs for children
20 and elders as provided in subsection (5). The separate account
21 for biomedical research shall be dissolved and the entire
22 principal in the endowment shall be used exclusively for
23 health and human services programs when cures have been found
24 for tobacco-related cancer, heart, and lung disease.
25 Section 2. Section 381.93, Florida Statutes, is
26 amended to read:
27 381.93 Breast and cervical cancer early detection
28 program.--This section may be cited as the "Mary Brogan Breast
29 and Cervical Cancer Early Detection Program Act."
30 (1) It is the intent of the Legislature to reduce the
31 rates of death due to breast and cervical cancer through early
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1 diagnosis and increased access to early screening, diagnosis,
2 and treatment programs.
3 (2) The Department of Health, pursuant to the federal
4 Breast and Cervical Cancer Mortality Prevention Act of 1990,
5 may using available federal funds and state funds appropriated
6 for that purpose, is authorized to establish the Mary Brogan
7 Breast and Cervical Cancer Screening and Early Detection
8 Program to provide screening, diagnosis, evaluation,
9 treatment, case management, and followup and referral to the
10 Medicaid program Agency for Health Care Administration for
11 coverage of treatment services pursuant to s. 409.904.
12 (3) The Mary Brogan Breast and Cervical Cancer Early
13 Detection Program shall be funded through grants for such
14 screening and early detection purposes from the federal
15 Centers for Disease Control and Prevention under Title XV of
16 the Public Health Service Act, 42 U.S.C. ss. 300k et seq.
17 (3)(4) The department shall limit enrollment in the
18 program to persons with incomes at or below up to and
19 including 200 percent of the federal poverty level. The
20 department shall establish an eligibility process that
21 includes an income-verification process to ensure that persons
22 served under the program meet income guidelines.
23 (5) The department may provide other breast and
24 cervical cancer screening and diagnostic services; however,
25 such services shall be funded separately through other sources
26 than this act.
27 Section 3. Section 391.021, Florida Statutes, is
28 amended to read:
29 391.021 Definitions.--When used in this chapter, the
30 term act, unless the context clearly indicates otherwise:
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1 (1) "Children's Medical Services network" or "network"
2 means a statewide managed care service system that includes
3 health care providers, as defined in this section.
4 (2) "Children with special health care needs" means
5 those children who have, or are at increased risk for,
6 chronic, physical, developmental, behavioral, or emotional
7 conditions and who also require health care and related
8 services of a type or amount beyond that required by children
9 generally under age 21 years whose serious or chronic physical
10 or developmental conditions require extensive preventive and
11 maintenance care beyond that required by typically healthy
12 children. Health care utilization by these children exceeds
13 the statistically expected usage of the normal child adjusted
14 for chronological age. These children often need complex care
15 requiring multiple providers, rehabilitation services, and
16 specialized equipment in a number of different settings.
17 (3) "Department" means the Department of Health.
18 (4) "Eligible individual" means a child with a special
19 health care need or a female with a high-risk pregnancy, who
20 meets the financial and medical eligibility standards
21 established in s. 391.029.
22 (5) "Health care provider" means a health care
23 professional, health care facility, or entity licensed or
24 certified to provide health services in this state that meets
25 the criteria as established by the department.
26 (6) "Health services" includes the prevention,
27 diagnosis, and treatment of human disease, pain, injury,
28 deformity, or disabling conditions.
29 (7) "Participant" means an eligible individual who is
30 enrolled in the Children's Medical Services program.
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1 (8) "Program" means the Children's Medical Services
2 program established in the department.
3 Section 4. Section 391.025, Florida Statutes, is
4 amended to read:
5 391.025 Applicability and scope.--
6 (1) This act applies to health services provided to
7 eligible individuals who are:
8 (a) Enrolled in the Medicaid program;
9 (b) Enrolled in the Florida Kidcare program; and
10 (c) Uninsured or underinsured, provided that they meet
11 the financial eligibility requirements established in this
12 act, and to the extent that resources are appropriated for
13 their care.
14 (1)(2) The Children's Medical Services program
15 consists of the following components:
16 (a) The infant metabolic screening program established
17 in s. 383.14.
18 (b) The regional perinatal intensive care centers
19 program established in ss. 383.15-383.21.
20 (c) A federal or state program authorized by the
21 Legislature.
22 (d) The developmental evaluation and intervention
23 program.
24 (e) The Children's Medical Services network.
25 (2)(3) The Children's Medical Services program shall
26 not be deemed an insurer and is not subject to the licensing
27 requirements of the Florida Insurance Code or the rules of the
28 Department of Insurance, when providing services to children
29 who receive Medicaid benefits, other Medicaid-eligible
30 children with special health care needs, and children
31 participating in the Florida Kidcare program.
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1 Section 5. Section 391.029, Florida Statutes, is
2 amended to read:
3 391.029 Program eligibility.--
4 (1) The department shall establish the medical
5 criteria to determine if an applicant for the Children's
6 Medical Services program is an eligible individual.
7 (2) The following individuals are financially eligible
8 to receive services through for the program:
9 (a) A high-risk pregnant female who is eligible for
10 Medicaid.
11 (b) A child with special health care needs from birth
12 to age 21 years who is eligible for Medicaid.
13 (c) A child with special health care needs from birth
14 to age 19 years who is eligible for a program under Title XXI
15 of the Social Security Act.
16 (3) Subject to the availability of funds, the
17 following individuals may receive services through the
18 program:
19 (a)(d) A child with special health care needs from
20 birth to age 21 years whose family income is above the
21 requirements for financial eligibility under Title XXI of the
22 Social Security Act and whose projected annual cost of care
23 adjusts the family income to Medicaid financial criteria. In
24 cases where the family income is adjusted based on a projected
25 annual cost of care, the family shall participate financially
26 in the cost of care based on criteria established by the
27 department.
28 (b)(e) A child with special health care needs from
29 birth to age 21 as provided defined in Title V of the Social
30 Security Act relating to children with special health care
31 needs.
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1
2 The department may continue to serve certain children with
3 special health care needs who are 21 years of age or older and
4 who were receiving services from the program prior to April 1,
5 1998. Such children may be served by the department until
6 July 1, 2000.
7 (4)(3) The department shall determine the financial
8 and medical eligibility of children for the program. The
9 department shall also determine the financial ability of the
10 parents, or persons or other agencies having legal custody
11 over such individuals, to pay the costs of health services
12 under the program. The department may pay reasonable travel
13 expenses related to the determination of eligibility for or
14 the provision of health services.
15 (5)(4) Any child who has been provided with surgical
16 or medical care or treatment under this act prior to being
17 adopted shall continue to be eligible to be provided with such
18 care or treatment after his or her adoption, regardless of the
19 financial ability of the persons adopting the child.
20 Section 6. Section 391.309, Florida Statutes, is
21 created to read:
22 391.309 Individuals with Disabilities Education
23 Act.--The Department of Health may implement and administer
24 Part C of the federal Individuals with Disabilities Education
25 Act (I.D.E.A.).
26 (1) The Department of Health, jointly with the
27 Department of Education, shall annually prepare a grant
28 application to the United States Department of Education for
29 funding for early intervention services for infants and
30 toddlers with disabilities, ages birth through 36 months, and
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1 their families pursuant to Part C of the federal Individuals
2 with Disabilities Education Act.
3 (2) The department shall ensure that an early
4 intervention provider participating in the Part C program does
5 not provide both core and required services without a waiver
6 from the Deputy Secretary for Children's Medical Services as
7 is expressed in the contract between the department and the
8 provider. As used in this section, "core" services are limited
9 to identification and referral services, family support
10 planning, service coordination, and multidisciplinary
11 evaluation.
12 Section 7. Subsection (1) of section 404.122, Florida
13 Statutes, is amended to read:
14 404.122 Radiation Protection Trust Fund.--
15 (1) The department may use the Radiation Protection
16 Trust Fund to pay for measures to prevent or mitigate the
17 adverse effects from a licensee's abandonment of radioactive
18 materials, default on lawful obligations, insolvency, or other
19 inability to meet the requirements of the department or
20 applicable state statutes or rules, or inability to pay
21 expenses related to protection from nuclear or radiological
22 terrorism and to assure the protection of the public health
23 and safety and the environment from the adverse effects of
24 ionizing radiation.
25 Section 8. Subsection (7) of section 409.8132, Florida
26 Statutes, is amended to read:
27 409.8132 Medikids program component.--
28 (7) ENROLLMENT.--Enrollment in the Medikids program
29 component may only occur during periodic open enrollment
30 periods as specified by the agency. An applicant may apply for
31 enrollment in the Medikids program component and proceed
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1 through the eligibility determination process at any time
2 throughout the year. However, enrollment in Medikids shall not
3 begin until the next open enrollment period; and a child may
4 not receive services under the Medikids program until the
5 child is enrolled in a managed care plan or MediPass. In
6 addition, Once determined eligible, an applicant may choose
7 receive choice counseling and select a managed care plan or
8 MediPass. The agency may initiate mandatory assignment for a
9 Medikids applicant who has not chosen a managed care plan or
10 MediPass provider after the applicant's voluntary choice
11 period ends. An applicant may select MediPass under the
12 Medikids program component only in counties that have fewer
13 than two managed care plans available to serve Medicaid
14 recipients and only if the federal Health Care Financing
15 Administration determines that MediPass constitutes "health
16 insurance coverage" as defined in Title XXI of the Social
17 Security Act.
18 Section 9. Section 409.814, Florida Statutes, is
19 amended to read:
20 409.814 Eligibility.--A child whose family income is
21 equal to or below 200 percent of the federal poverty level is
22 eligible for the Florida Kidcare program as provided in this
23 section. In determining the eligibility of such a child, an
24 assets test is not required. An applicant under 19 years of
25 age who, based on a complete application, appears to be
26 eligible for the Medicaid component of the Florida Kidcare
27 program is presumed eligible for coverage under Medicaid,
28 subject to federal rules. A child who has been deemed
29 presumptively eligible for Medicaid shall not be enrolled in a
30 managed care plan until the child's full eligibility
31 determination for Medicaid has been completed. The Florida
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1 Healthy Kids Corporation may, subject to compliance with
2 applicable requirements of the Agency for Health Care
3 Administration and the Department of Children and Family
4 Services, be designated as an entity to conduct presumptive
5 eligibility determinations. An applicant under 19 years of age
6 who, based on a complete application, appears to be eligible
7 for the Medikids, Florida Healthy Kids, or Children's Medical
8 Services network program component, who is screened as
9 ineligible for Medicaid and prior to the monthly verification
10 of the applicant's enrollment in Medicaid or of eligibility
11 for coverage under the state employee health benefit plan, may
12 be enrolled in and begin receiving coverage from the
13 appropriate program component on the first day of the month
14 following the receipt of a completed application. For
15 enrollment in the Children's Medical Services network, a
16 complete application includes the medical or behavioral health
17 screening. If, after verification, an individual is determined
18 to be ineligible for coverage, he or she must be disenrolled
19 from the respective Title XXI-funded Kidcare program
20 component.
21 (1) A child who is eligible for Medicaid coverage
22 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
23 and is not eligible to receive health benefits under any other
24 health benefits coverage authorized under ss. 409.810-409.820.
25 (2) A child who is not eligible for Medicaid, but who
26 is eligible for the Florida Kidcare program, may obtain
27 coverage under any of the other types of health benefits
28 coverage authorized in ss. 409.810-409.820 if such coverage is
29 approved and available in the county in which the child
30 resides. However, a child who is eligible for Medikids may
31 participate in the Florida Healthy Kids program only if the
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1 child has a sibling participating in the Florida Healthy Kids
2 program and the child's county of residence permits such
3 enrollment.
4 (3) A child who is eligible for the Florida Kidcare
5 program who is a child with special health care needs, as
6 determined through a medical or behavioral screening
7 instrument, is eligible for health benefits coverage from and
8 shall be referred to the Children's Medical Services network.
9 (4) The following children are not eligible to receive
10 premium assistance for health benefits coverage under ss.
11 409.810-409.820, except under Medicaid if the child would have
12 been eligible for Medicaid under s. 409.903 or s. 409.904 as
13 of June 1, 1997:
14 (a) A child who is eligible for coverage under a state
15 health benefit plan on the basis of a family member's
16 employment with a public agency in the state.
17 (b) A child who is covered under a group health
18 benefit plan or under other health insurance coverage,
19 excluding coverage provided under the Florida Healthy Kids
20 Corporation as established under s. 624.91.
21 (c) A child who is seeking premium assistance for
22 employer-sponsored group coverage, if the child has been
23 covered by the same employer's group coverage during the 6
24 months prior to the family's submitting an application for
25 determination of eligibility under the Florida Kidcare
26 program.
27 (d) A child who is an alien, but who does not meet the
28 definition of qualified alien, in the United States.
29 (e) A child who is an inmate of a public institution
30 or a patient in an institution for mental diseases.
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1 (5) A child whose family income is above 200 percent
2 of the federal poverty level or a child who is excluded under
3 the provisions of subsection (4) may participate in the
4 Florida Healthy Kids Kidcare program or the Medikids program,
5 excluding the Medicaid program, but is subject to the
6 following provisions:
7 (a) The family is not eligible for premium assistance
8 payments and must pay the full cost of the premium, including
9 any administrative costs.
10 (b) The agency is authorized to place limits on
11 enrollment in Medikids by these children in order to avoid
12 adverse selection. The number of children participating in
13 Medikids whose family income exceeds 200 percent of the
14 federal poverty level must not exceed 10 percent of total
15 enrollees in the Medikids program.
16 (c) The board of directors of the Florida Healthy Kids
17 Corporation is authorized to place limits on enrollment of
18 these children in order to avoid adverse selection. In
19 addition, the board is authorized to offer a reduced benefit
20 package to these children in order to limit program costs for
21 such families. The number of children participating in the
22 Florida Healthy Kids program whose family income exceeds 200
23 percent of the federal poverty level must not exceed 10
24 percent of total enrollees in the Florida Healthy Kids
25 program.
26 (d) Children described in this subsection are not
27 counted in the annual enrollment ceiling for the Florida
28 Kidcare program.
29 (6) Once a child is enrolled in the Florida Kidcare
30 program, the child is eligible for coverage under the program
31 for 6 months without a redetermination or reverification of
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1 eligibility, if the family continues to pay the applicable
2 premium. Effective January 1, 1999, a child who has not
3 attained the age of 5 and who has been determined eligible for
4 the Medicaid program is eligible for coverage for 12 months
5 without a redetermination or reverification of eligibility.
6 (7) When determining or reviewing a child's
7 eligibility under the program, the applicant shall be provided
8 with reasonable notice of changes in eligibility which may
9 affect enrollment in one or more of the program components.
10 When a transition from one program component to another is
11 appropriate, there shall be cooperation between the program
12 components and the affected family which promotes continuity
13 of health care coverage.
14 Section 10. Section 409.8177, Florida Statutes, is
15 amended to read:
16 409.8177 Program evaluation.--
17 (1) The agency, in consultation with the Department of
18 Health, the Department of Children and Family Services, and
19 the Florida Healthy Kids Corporation, shall contract for an
20 evaluation of the Florida Kidcare program and shall by January
21 1 of each year submit to the Governor, the President of the
22 Senate, and the Speaker of the House of Representatives a
23 report of the Florida Kidcare program. In addition to the
24 items specified under s. 2108 of Title XXI of the Social
25 Security Act, the report shall include an assessment of
26 crowd-out and access to health care, as well as the following:
27 (a)(1) An assessment of the operation of the program,
28 including the progress made in reducing the number of
29 uncovered low-income children.
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1 (b)(2) An assessment of the effectiveness in
2 increasing the number of children with creditable health
3 coverage, including an assessment of the impact of outreach.
4 (c)(3) The characteristics of the children and
5 families assisted under the program, including ages of the
6 children, family income, and access to or coverage by other
7 health insurance prior to the program and after disenrollment
8 from the program.
9 (d)(4) The quality of health coverage provided,
10 including the types of benefits provided.
11 (e)(5) The amount and level, including payment of part
12 or all of any premium, of assistance provided.
13 (f)(6) The average length of coverage of a child under
14 the program.
15 (g)(7) The program's choice of health benefits
16 coverage and other methods used for providing child health
17 assistance.
18 (h)(8) The sources of nonfederal funding used in the
19 program.
20 (i)(9) An assessment of the effectiveness of Medikids,
21 Children's Medical Services network, and other public and
22 private programs in the state in increasing the availability
23 of affordable quality health insurance and health care for
24 children.
25 (j)(10) A review and assessment of state activities to
26 coordinate the program with other public and private programs.
27 (k)(11) An analysis of changes and trends in the state
28 that affect the provision of health insurance and health care
29 to children.
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1 (l)(12) A description of any plans the state has for
2 improving the availability of health insurance and health care
3 for children.
4 (m)(13) Recommendations for improving the program.
5 (n)(14) Other studies as necessary.
6 (2) The agency shall also submit each month to the
7 Governor, the President of the Senate, and the Speaker of the
8 House of Representatives a report of enrollment for each
9 program component of the Florida Kidcare program.
10 Section 11. Section 409.903, Florida Statutes, is
11 amended to read:
12 409.903 Mandatory payments for eligible persons.--The
13 agency shall make payments for medical assistance and related
14 services on behalf of the following persons who the
15 department, or the Social Security Administration by contract
16 with the Department of Children and Family Services,
17 determines to be eligible, subject to the income, assets, and
18 categorical eligibility tests set forth in federal and state
19 law. This section does not prevent or limit the agency from
20 adjusting fees, reimbursement rates, lengths of stay, number
21 of visits, number of services, or any other adjustments
22 necessary to conform to Payment on behalf of these Medicaid
23 eligible persons is subject to the availability of moneys and
24 any limitations established by the General Appropriations Act
25 or chapter 216.
26 (1) Low-income families with children are eligible for
27 Medicaid provided they meet the following requirements:
28 (a) The family includes a dependent child who is
29 living with a caretaker relative.
30 (b) The family's income does not exceed the gross
31 income test limit.
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1 (c) The family's countable income and resources do not
2 exceed the applicable Aid to Families with Dependent Children
3 (AFDC) income and resource standards under the AFDC state plan
4 in effect in July 1996, except as amended in the Medicaid
5 state plan to conform as closely as possible to the
6 requirements of the welfare transition program, to the extent
7 permitted by federal law.
8 (2) A person who receives payments from, who is
9 determined eligible for, or who was eligible for but lost cash
10 benefits from the federal program known as the Supplemental
11 Security Income program (SSI). This category includes a
12 low-income person age 65 or over and a low-income person under
13 age 65 considered to be permanently and totally disabled.
14 (3) A child under age 21 living in a low-income,
15 two-parent family, and a child under age 7 living with a
16 nonrelative, if the income and assets of the family or child,
17 as applicable, do not exceed the resource limits under the
18 WAGES Program.
19 (4) A child who is eligible under Title IV-E of the
20 Social Security Act for subsidized board payments, foster
21 care, or adoption subsidies, and a child for whom the state
22 has assumed temporary or permanent responsibility and who does
23 not qualify for Title IV-E assistance but is in foster care,
24 shelter or emergency shelter care, or subsidized adoption.
25 (5) A pregnant woman for the duration of her pregnancy
26 and for the postpartum period as defined in federal law and
27 rule, or a child under age 1, if either is living in a family
28 that has an income which is at or below 150 percent of the
29 most current federal poverty level, or, effective January 1,
30 1992, that has an income which is at or below 185 percent of
31 the most current federal poverty level. Such a person is not
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1 subject to an assets test. Further, a pregnant woman who
2 applies for eligibility for the Medicaid program through a
3 qualified Medicaid provider must be offered the opportunity,
4 subject to federal rules, to be made presumptively eligible
5 for the Medicaid program.
6 (6) A child born after September 30, 1983, living in a
7 family that has an income which is at or below 100 percent of
8 the current federal poverty level, who has attained the age of
9 6, but has not attained the age of 19. In determining the
10 eligibility of such a child, an assets test is not required. A
11 child who is eligible for Medicaid under this subsection must
12 be offered the opportunity, subject to federal rules, to be
13 made presumptively eligible. A child who has been deemed
14 presumptively eligible for Medicaid shall not be enrolled in a
15 managed care plan until the child's full eligibility
16 determination for Medicaid has been completed.
17 (7) A child living in a family that has an income
18 which is at or below 133 percent of the current federal
19 poverty level, who has attained the age of 1, but has not
20 attained the age of 6. In determining the eligibility of such
21 a child, an assets test is not required. A child who is
22 eligible for Medicaid under this subsection must be offered
23 the opportunity, subject to federal rules, to be made
24 presumptively eligible. A child who has been deemed
25 presumptively eligible for Medicaid shall not be enrolled in a
26 managed care plan until the child's full eligibility
27 determination for Medicaid has been completed.
28 (8) A person who is age 65 or over or is determined by
29 the agency to be disabled, whose income is at or below 100
30 percent of the most current federal poverty level and whose
31 assets do not exceed limitations established by the agency.
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1 However, the agency may only pay for premiums, coinsurance,
2 and deductibles, as required by federal law, unless additional
3 coverage is provided for any or all members of this group by
4 s. 409.904(1).
5 (9) A low-income person who meets all other
6 requirements for Medicaid eligibility except citizenship and
7 who is in need of emergency medical services. In accordance
8 with federal rules, the eligibility of such a recipient is
9 limited to the period of the emergency.
10 Section 12. Section 409.904, Florida Statutes, as
11 amended by section 2 of chapter 2001-377, Laws of Florida, is
12 amended to read:
13 409.904 Optional payments for eligible persons.--The
14 agency may make payments for medical assistance and related
15 services on behalf of the following persons who are determined
16 to be eligible subject to the income, assets, and categorical
17 eligibility tests set forth in federal and state law and rule.
18 Payment on behalf of these Medicaid eligible persons is
19 subject to the availability of moneys and any limitations
20 established by the General Appropriations Act or chapter 216.
21 (1) A person who is age 65 or older or is determined
22 to be disabled, whose income is at or below 90 88 percent of
23 federal poverty level, and whose assets do not exceed
24 established limitations. Effective January 1, 2003, and
25 subject to federal approval, such person shall pay a premium
26 and copayment that may not exceed 5 percent of the person's
27 annual income. The agency may seek and implement all waivers
28 necessary to administer this subsection.
29 (2)(a) A pregnant woman who would otherwise qualify
30 for Medicaid under s. 409.903(5) except for her level of
31 income and whose assets fall within the limits established by
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1 the Department of Children and Family Services for the
2 medically needy. A pregnant woman who applies for medically
3 needy eligibility may not be made presumptively eligible.
4 (b) A child under age 21 who would otherwise qualify
5 for Medicaid or the Florida Kidcare program except for the
6 family's level of income and whose assets fall within the
7 limits established by the Department of Children and Family
8 Services for the medically needy.
9
10 For a person in this group, medical expenses are deductible
11 from income in accordance with federal requirements in order
12 to make a determination of eligibility. A person in this
13 group, which group is known as the "medically needy," is
14 eligible to receive the same services as other Medicaid
15 recipients, with the exception of services in skilled nursing
16 facilities, and intermediate care facilities for the
17 developmentally disabled, and home and community-based
18 services. Effective January 1, 2003, and subject to federal
19 approval, such family or person shall pay a premium and
20 copayment that may not exceed 5 percent of the family's or
21 person's annual income. The agency may seek and implement all
22 waivers necessary to administer this subsection. As required
23 by federal rule, medical expenses used to spend down to the
24 income eligibility limitations are not reimbursable under
25 Medicaid.
26 (3) A person who is in need of the services of a
27 licensed nursing facility, a licensed intermediate care
28 facility for the developmentally disabled, or a state mental
29 hospital, whose income does not exceed 300 percent of the SSI
30 income standard, and who meets the assets standards
31 established under federal and state law.
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1 (a) In determining the person's responsibility for the
2 cost of care, the following amounts shall be deducted from the
3 person's income:
4 1. The monthly personal-needs allowance for residents,
5 as provided in the annual appropriations act;
6 2. The monthly amount, up to the current monthly
7 Medicare Part B premium, for noncovered physician services,
8 noncovered equipment and medical supplies, and services
9 provided by other practitioners licensed under state law but
10 not included as a covered benefit under the Florida Medicaid
11 program; and
12 3. Medicare and other health insurance premiums,
13 deductibles, or coinsurance charges.
14 (b) Where spousal-impoverishment determinations are
15 required by federal law, the resource-allocation limit is the
16 maximum standard allowed by federal statute and the income
17 allocation is the minimal amount recognized by federal
18 statute.
19 (4) A low-income person who meets all other
20 requirements for Medicaid eligibility except citizenship and
21 who is in need of emergency medical services. The eligibility
22 of such a recipient is limited to the period of the emergency,
23 in accordance with federal regulations.
24 (4)(5) Subject to specific federal authorization, a
25 postpartum woman living in a family that has an income that is
26 at or below 185 percent of the most current federal poverty
27 level is eligible for family planning services as specified in
28 s. 409.905(3) for a period of up to 24 months following a
29 pregnancy for which Medicaid paid for pregnancy-related
30 services.
31
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1 (5)(6) A child born before October 1, 1983, living in
2 a family that has an income which is at or below 100 percent
3 of the current federal poverty level, who has attained the age
4 of 6, but has not attained the age of 19, and who would be
5 eligible in s. 409.903(6), if the child had been born on or
6 after such date. In determining the eligibility of such a
7 child, an assets test is not required. A child who is eligible
8 for Medicaid under this subsection must be offered the
9 opportunity, subject to federal rules, to be made
10 presumptively eligible. A child who has been deemed
11 presumptively eligible for Medicaid shall not be enrolled in a
12 managed care plan until the child's full eligibility
13 determination for Medicaid has been completed.
14 (6)(7) A child who has not attained the age of 19 who
15 has been determined eligible for the Medicaid program is
16 deemed to be eligible for a total of 6 months, regardless of
17 changes in circumstances other than attainment of the maximum
18 age. Effective January 1, 1999, a child who has not attained
19 the age of 5 and who has been determined eligible for the
20 Medicaid program is deemed to be eligible for a total of 12
21 months regardless of changes in circumstances other than
22 attainment of the maximum age.
23 (7)(8) A pregnant woman for the duration of her
24 pregnancy and for the postpartum period as defined in federal
25 law and rule, or a child under age 1, if either is living in a
26 family that has an income that is at or below 185 percent of
27 the most current federal poverty level, or a child under 1
28 year of age who lives in a family that has an income above 185
29 percent of the most recently published federal poverty level,
30 but which is at or below 200 percent of such poverty level. In
31 determining the eligibility of such child, an assets test is
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1 not required. A pregnant woman who applies for eligibility for
2 the Medicaid program shall be offered the opportunity, subject
3 to federal rules, to be made presumptively eligible. A child
4 who is eligible for Medicaid under this subsection must be
5 offered the opportunity, subject to federal rules, to be made
6 presumptively eligible.
7 (8)(9) A Medicaid-eligible individual for the
8 individual's health insurance premiums, if the agency
9 determines that such payments are cost-effective.
10 (9)(10)(a) Eligible women with incomes at or below 200
11 percent of the federal poverty level and under age 65, for
12 cancer treatment pursuant to the federal Breast and Cervical
13 Cancer Prevention and Treatment Act of 2000, screened through
14 the Mary Brogan National Breast and Cervical Cancer Early
15 Detection program established under s. 381.93.
16 (b) A woman who has not attained 65 years of age and
17 who has been screened for breast or cervical cancer by a
18 qualified entity under the Mary Brogan Breast and Cervical
19 Cancer Early Detection Program of the Department of Health and
20 needs treatment for breast or cervical cancer and is not
21 otherwise covered under creditable coverage, as defined in s.
22 2701(c) of the Public Health Service Act. For purposes of this
23 subsection, the term "qualified entity" means a county public
24 health department or other entity that has contracted with the
25 Department of Health to provide breast and cervical cancer
26 screening services paid for under this act. In determining the
27 eligibility of such a woman, an assets test is not required. A
28 presumptive eligibility period begins on the date on which all
29 eligibility criteria appear to be met and ends on the date
30 determination is made with respect to the eligibility of such
31 woman for services under the state plan or, in the case of
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1 such a woman who does not file an application, by the last day
2 of the month following the month in which the presumptive
3 eligibility determination is made. A woman is eligible until
4 she gains creditable coverage, until treatment is no longer
5 necessary, or until attainment of 65 years of age.
6 (10)(11) Subject to specific federal authorization, a
7 person who, but for earnings in excess of the limit
8 established under s. 1905(q)(2)(B) of the Social Security Act,
9 would be considered for receiving supplemental security
10 income, who is at least 16 but less than 65 years of age, and
11 whose assets, resources, and earned or unearned income, or
12 both, do not exceed 250 percent of the most current federal
13 poverty level. Such persons may be eligible for Medicaid
14 services as part of a Medicaid buy-in established under s.
15 409.914(2) specifically designed to accommodate those persons
16 made eligible for such a buy-in by Title II of Pub. L. No.
17 106-170. Such buy-in shall include income-related premiums and
18 cost sharing.
19 Section 13. Effective July 1, 2003, subsections (1)
20 and (2) of section 409.904, Florida Statutes, as amended by
21 section 2 of chapter 2001-377, Laws of Florida, and as amended
22 by this act, are amended to read:
23 409.904 Optional payments for eligible persons.--The
24 agency may make payments for medical assistance and related
25 services on behalf of the following persons who are determined
26 to be eligible subject to the income, assets, and eligibility
27 tests set forth in federal and state law and rule. Payment on
28 behalf of these Medicaid eligible persons is subject to the
29 availability of moneys and any limitations established by the
30 General Appropriations Act or chapter 216.
31
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1 (1) A person who is age 65 or older or is determined
2 to be disabled, whose income is at or below 88 90 percent of
3 federal poverty level, and whose assets do not exceed
4 established limitations. Effective January 1, 2003, and
5 subject to federal approval, Such person shall pay a premium
6 and copayment that may not exceed 5 percent of the person's
7 annual income. The agency may seek and implement all waivers
8 necessary to administer this subsection.
9 (2)(a) A pregnant woman who would otherwise qualify
10 for Medicaid under subsection (8) s. 409.903(5) except for her
11 level of income and whose assets fall within the limits
12 established by the Department of Children and Family Services
13 for the medically needy. A pregnant woman who applies for
14 medically needy eligibility may not be made presumptively
15 eligible.
16 (b) A child under age 21 who would otherwise qualify
17 for Medicaid or the Florida Kidcare program except for the
18 family's level of income and whose assets fall within the
19 limits established by the Department of Children and Family
20 Services for the medically needy.
21
22 For a person in this group, medical expenses are deductible
23 from income in accordance with federal requirements in order
24 to make a determination of eligibility. A person in this
25 group, which group is known as the "medically needy," is
26 eligible to receive the same services as other Medicaid
27 recipients, with the exception of services in skilled nursing
28 facilities, intermediate care facilities for the
29 developmentally disabled, and home and community-based
30 services. Effective January 1, 2003, and subject to federal
31 approval, Such family or person shall pay a premium and
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1 copayment that may not exceed 5 percent of the family's or
2 person's annual income. The agency may seek and implement all
3 waivers necessary to administer this subsection. As required
4 by federal rule, medical expenses used to spend down to the
5 income eligibility limitations are not reimbursable under
6 Medicaid.
7 Section 14. Section 1 of chapter 2001-377, Laws of
8 Florida, is amended to read:
9 Section 1. Effective July 1, 2003 2002, subsection
10 (10) (11) of section 409.904, Florida Statutes, as amended by
11 this act, is repealed.
12 Section 15. Subsection (15) of section 409.908,
13 Florida Statutes, as amended by section 7 of chapter 2001-377,
14 Laws of Florida, is amended to read:
15 409.908 Reimbursement of Medicaid providers.--Subject
16 to specific appropriations, the agency shall reimburse
17 Medicaid providers, in accordance with state and federal law,
18 according to methodologies set forth in the rules of the
19 agency and in policy manuals and handbooks incorporated by
20 reference therein. These methodologies may include fee
21 schedules, reimbursement methods based on cost reporting,
22 negotiated fees, competitive bidding pursuant to s. 287.057,
23 and other mechanisms the agency considers efficient and
24 effective for purchasing services or goods on behalf of
25 recipients. Payment for Medicaid compensable services made on
26 behalf of Medicaid eligible persons is subject to the
27 availability of moneys and any limitations or directions
28 provided for in the General Appropriations Act or chapter 216.
29 Further, nothing in this section shall be construed to prevent
30 or limit the agency from adjusting fees, reimbursement rates,
31 lengths of stay, number of visits, or number of services, or
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1 making any other adjustments necessary to comply with the
2 availability of moneys and any limitations or directions
3 provided for in the General Appropriations Act, provided the
4 adjustment is consistent with legislative intent.
5 (15) A provider of primary care case management
6 services rendered pursuant to a federally approved waiver
7 shall be reimbursed by payment of a fixed, prepaid monthly sum
8 for each Medicaid recipient enrolled with the provider. Fees
9 may vary based on the provider's performance and an incentive
10 system tied to the recipient's disease state, the recipient's
11 age, and the complexity of primary case management required.
12 Section 16. Section 409.9117, Florida Statutes, is
13 amended to read:
14 409.9117 Primary care disproportionate share
15 program.--
16 (1) If federal funds are available for
17 disproportionate share programs In addition to other
18 disproportionate share programs those otherwise provided by
19 law and subject to the availability of funds, there shall be
20 created a primary care disproportionate share program. The
21 agency shall determine the eligibility of a hospital to
22 participate in the program.
23 (2) In the establishment and funding of this program,
24 the agency shall use the following criteria In addition to
25 criteria those specified in s. 409.911, payments may not be
26 made to a hospital unless the hospital agrees to:
27 (1)(a) Cooperate with a Medicaid prepaid health plan,
28 if one exists in the community.
29 (2)(b) Ensure the availability of primary and
30 specialty care physicians to Medicaid recipients who are not
31
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1 enrolled in a prepaid capitated arrangement and who are in
2 need of access to such physicians.
3 (3)(c) Coordinate and provide primary care services
4 free of charge, except copayments, to all persons with incomes
5 up to 100 percent of the federal poverty level who are not
6 otherwise covered by Medicaid or another program administered
7 by a governmental entity, and to provide such services based
8 on a sliding fee scale to all persons with incomes up to 200
9 percent of the federal poverty level who are not otherwise
10 covered by Medicaid or another program administered by a
11 governmental entity, except that eligibility may be limited to
12 persons who reside within a more limited area, as agreed to by
13 the agency and the hospital.
14 (4)(d) Contract with any federally qualified health
15 center, if one exists within the agreed geopolitical
16 boundaries, concerning the provision of primary care services,
17 in order to guarantee delivery of services in a nonduplicative
18 fashion, and to provide for referral arrangements, privileges,
19 and admissions, as appropriate. The hospital shall agree to
20 provide at an onsite or offsite facility primary care services
21 within 24 hours to which all Medicaid recipients and persons
22 eligible under this paragraph who do not require emergency
23 room services are referred during normal daylight hours.
24 (5)(e) Cooperate with the agency, the county, and
25 other entities to ensure the provision of certain public
26 health services, case management, referral and acceptance of
27 patients, and sharing of epidemiological data, as the agency
28 and the hospital find mutually necessary and desirable to
29 promote and protect the public health within the agreed
30 geopolitical boundaries.
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1 (6)(f) In cooperation with the county in which the
2 hospital resides, develop a low-cost, outpatient, prepaid
3 health care program to persons who are not eligible for the
4 Medicaid program, and who reside within the area.
5 (7)(g) Provide inpatient services to residents within
6 the area who are not eligible for Medicaid or Medicare, and
7 who do not have private health insurance, regardless of
8 ability to pay, on the basis of available space, except that
9 nothing shall prevent the hospital from establishing bill
10 collection programs based on ability to pay.
11 (8)(h) Work with the Florida Healthy Kids Corporation,
12 the Florida Health Care Purchasing Cooperative, and business
13 health coalitions, as appropriate, to develop a feasibility
14 study and plan to provide a low-cost comprehensive health
15 insurance plan to persons who reside within the area and who
16 do not have access to such a plan.
17 (9)(i) Work with public health officials and other
18 experts to provide community health education and prevention
19 activities designed to promote healthy lifestyles and
20 appropriate use of health services.
21 (10)(j) Work with the local health council to develop
22 a plan for promoting access to affordable health care services
23 for all persons who reside within the area, including, but not
24 limited to, public health services, primary care services,
25 inpatient services, and affordable health insurance generally.
26
27 Any hospital that fails to comply with any of the provisions
28 of this section subsection, or any other contractual
29 condition, may not receive payments under this section until
30 full compliance is achieved.
31
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1 Section 17. Section 409.912, Florida Statutes, as
2 amended by sections 8 and 9 of chapter 2001-377, Laws of
3 Florida, is amended to read:
4 409.912 Cost-effective purchasing of health care.--The
5 agency shall purchase goods and services for Medicaid
6 recipients in the most cost-effective manner consistent with
7 the delivery of quality medical care. The agency shall
8 maximize the use of prepaid per capita and prepaid aggregate
9 fixed-sum basis services when appropriate and other
10 alternative service delivery and reimbursement methodologies,
11 including competitive bidding pursuant to s. 287.057, designed
12 to facilitate the cost-effective purchase of a case-managed
13 continuum of care. The agency shall also require providers to
14 minimize the exposure of recipients to the need for acute
15 inpatient, custodial, and other institutional care and the
16 inappropriate or unnecessary use of high-cost services. The
17 agency may establish prior authorization requirements for
18 certain populations of Medicaid beneficiaries, certain drug
19 classes, or particular drugs to prevent fraud, abuse, overuse,
20 and possible dangerous drug interactions. The Pharmaceutical
21 and Therapeutics Committee, established under s. 409.91195,
22 shall make recommendations to the agency on drugs for which
23 prior authorization is required, and. the agency shall inform
24 the Pharmaceutical and Therapeutics committee of its decisions
25 regarding drugs subject to prior authorization.
26 (1) The agency may enter into agreements with
27 appropriate agents of other state agencies or of any agency of
28 the Federal Government and accept such duties in respect to
29 social welfare or public aid as may be necessary to implement
30 the provisions of Title XIX of the Social Security Act and ss.
31 409.901-409.920.
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1 (2) The agency may contract with health maintenance
2 organizations certified pursuant to part I of chapter 641 for
3 the provision of services to recipients.
4 (3) The agency may contract with:
5 (a) An entity that provides no prepaid health care
6 services other than Medicaid services under contract with the
7 agency and which is owned and operated by a county, county
8 health department, or county-owned and operated hospital to
9 provide health care services on a prepaid or fixed-sum basis
10 to recipients, which entity may provide such prepaid services
11 either directly or through arrangements with other providers.
12 Such prepaid health care services entities must be licensed
13 under parts I and III by January 1, 1998, and until then are
14 exempt from the provisions of part I of chapter 641. An entity
15 recognized under this paragraph which demonstrates to the
16 satisfaction of the Department of Insurance that it is backed
17 by the full faith and credit of the county in which it is
18 located may be exempted from s. 641.225.
19 (b) An entity that is providing comprehensive
20 behavioral health care services to certain Medicaid recipients
21 through a capitated, prepaid arrangement pursuant to the
22 federal waiver provided for by s. 409.905(5). Such an entity
23 must be licensed under chapter 624, chapter 636, or chapter
24 641 and must possess the clinical systems and operational
25 competence to manage risk and provide comprehensive behavioral
26 health care to Medicaid recipients. As used in this paragraph,
27 the term "comprehensive behavioral health care services" means
28 covered mental health and substance abuse treatment services
29 that are available to Medicaid recipients. The secretary of
30 the Department of Children and Family Services shall approve
31 provisions of procurements related to children in the
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1 department's care or custody prior to enrolling such children
2 in a prepaid behavioral health plan. Any contract awarded
3 under this paragraph must be competitively procured. In
4 developing the behavioral health care prepaid plan procurement
5 document, the agency shall ensure that the procurement
6 document requires the contractor to develop and implement a
7 plan to ensure compliance with s. 394.4574 related to services
8 provided to residents of licensed assisted living facilities
9 that hold a limited mental health license. The agency must
10 ensure that Medicaid recipients have available the choice of
11 at least two managed care plans for their behavioral health
12 care services. The agency may reimburse for
13 substance-abuse-treatment services on a fee-for-service basis
14 until the agency finds that adequate funds are available for
15 capitated, prepaid arrangements.
16 1. By January 1, 2001, the agency shall modify the
17 contracts with the entities providing comprehensive inpatient
18 and outpatient mental health care services to Medicaid
19 recipients in Hillsborough, Highlands, Hardee, Manatee, and
20 Polk Counties, to include substance-abuse-treatment services.
21 2. By December 31, 2001, the agency shall contract
22 with entities providing comprehensive behavioral health care
23 services to Medicaid recipients through capitated, prepaid
24 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
25 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
26 and Walton Counties. The agency may contract with entities
27 providing comprehensive behavioral health care services to
28 Medicaid recipients through capitated, prepaid arrangements in
29 Alachua County. The agency may determine if Sarasota County
30 shall be included as a separate catchment area or included in
31 any other agency geographic area.
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1 3. Children residing in a Department of Juvenile
2 Justice residential program approved as a Medicaid behavioral
3 health overlay services provider shall not be included in a
4 behavioral health care prepaid health plan pursuant to this
5 paragraph.
6 4. In converting to a prepaid system of delivery, the
7 agency shall in its procurement document require an entity
8 providing comprehensive behavioral health care services to
9 prevent the displacement of indigent care patients by
10 enrollees in the Medicaid prepaid health plan providing
11 behavioral health care services from facilities receiving
12 state funding to provide indigent behavioral health care, to
13 facilities licensed under chapter 395 which do not receive
14 state funding for indigent behavioral health care, or
15 reimburse the unsubsidized facility for the cost of behavioral
16 health care provided to the displaced indigent care patient.
17 5. Traditional community mental health providers under
18 contract with the Department of Children and Family Services
19 pursuant to part IV of chapter 394 and inpatient mental health
20 providers licensed pursuant to chapter 395 must be offered an
21 opportunity to accept or decline a contract to participate in
22 any provider network for prepaid behavioral health services.
23 (c) A federally qualified health center or an entity
24 owned by one or more federally qualified health centers or an
25 entity owned by other migrant and community health centers
26 receiving non-Medicaid financial support from the Federal
27 Government to provide health care services on a prepaid or
28 fixed-sum basis to recipients. Such prepaid health care
29 services entity must be licensed under parts I and III of
30 chapter 641, but shall be prohibited from serving Medicaid
31 recipients on a prepaid basis, until such licensure has been
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1 obtained. However, such an entity is exempt from s. 641.225
2 if the entity meets the requirements specified in subsections
3 (14) and (15).
4 (d) No more than four provider service networks for
5 demonstration projects to test Medicaid direct contracting.
6 The demonstration projects may be reimbursed on a
7 fee-for-service or prepaid basis. A provider service network
8 which is reimbursed by the agency on a prepaid basis shall be
9 exempt from parts I and III of chapter 641, but must meet
10 appropriate financial reserve, quality assurance, and patient
11 rights requirements as established by the agency. The agency
12 shall award contracts on a competitive bid basis and shall
13 select bidders based upon price and quality of care. Medicaid
14 recipients assigned to a demonstration project shall be chosen
15 equally from those who would otherwise have been assigned to
16 prepaid plans and MediPass. The agency is authorized to seek
17 federal Medicaid waivers as necessary to implement the
18 provisions of this section. A demonstration project awarded
19 pursuant to this paragraph shall be for 4 years from the date
20 of implementation.
21 (e) An entity that provides comprehensive behavioral
22 health care services to certain Medicaid recipients through an
23 administrative services organization agreement. Such an entity
24 must possess the clinical systems and operational competence
25 to provide comprehensive health care to Medicaid recipients.
26 As used in this paragraph, the term "comprehensive behavioral
27 health care services" means covered mental health and
28 substance abuse treatment services that are available to
29 Medicaid recipients. Any contract awarded under this paragraph
30 must be competitively procured. The agency must ensure that
31
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1 Medicaid recipients have available the choice of at least two
2 managed care plans for their behavioral health care services.
3 (f) An entity in Pasco County or Pinellas County that
4 provides in-home physician services to Medicaid recipients
5 with degenerative neurological diseases in order to test the
6 cost-effectiveness of enhanced home-based medical care. The
7 entity providing the services shall be reimbursed on a
8 fee-for-service basis at a rate not less than comparable
9 Medicare reimbursement rates. The agency may apply for waivers
10 of federal regulations necessary to implement such program.
11 This paragraph shall be repealed on July 1, 2002.
12 (g) Children's provider networks that provide care
13 coordination and care management for Medicaid-eligible
14 pediatric patients, primary care, authorization of specialty
15 care, and other urgent and emergency care through organized
16 providers designed to service Medicaid eligibles under age 18.
17 The networks shall provide after-hour operations, including
18 evening and weekend hours, to promote, when appropriate, the
19 use of the children's networks rather than hospital emergency
20 departments.
21 (4) The agency may contract with any public or private
22 entity otherwise authorized by this section on a prepaid or
23 fixed-sum basis for the provision of health care services to
24 recipients. An entity may provide prepaid services to
25 recipients, either directly or through arrangements with other
26 entities, if each entity involved in providing services:
27 (a) Is organized primarily for the purpose of
28 providing health care or other services of the type regularly
29 offered to Medicaid recipients;
30 (b) Ensures that services meet the standards set by
31 the agency for quality, appropriateness, and timeliness;
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1 (c) Makes provisions satisfactory to the agency for
2 insolvency protection and ensures that neither enrolled
3 Medicaid recipients nor the agency will be liable for the
4 debts of the entity;
5 (d) Submits to the agency, if a private entity, a
6 financial plan that the agency finds to be fiscally sound and
7 that provides for working capital in the form of cash or
8 equivalent liquid assets excluding revenues from Medicaid
9 premium payments equal to at least the first 3 months of
10 operating expenses or $200,000, whichever is greater;
11 (e) Furnishes evidence satisfactory to the agency of
12 adequate liability insurance coverage or an adequate plan of
13 self-insurance to respond to claims for injuries arising out
14 of the furnishing of health care;
15 (f) Provides, through contract or otherwise, for
16 periodic review of its medical facilities and services, as
17 required by the agency; and
18 (g) Provides organizational, operational, financial,
19 and other information required by the agency.
20 (5) The agency may contract on a prepaid or fixed-sum
21 basis with any health insurer that:
22 (a) Pays for health care services provided to enrolled
23 Medicaid recipients in exchange for a premium payment paid by
24 the agency;
25 (b) Assumes the underwriting risk; and
26 (c) Is organized and licensed under applicable
27 provisions of the Florida Insurance Code and is currently in
28 good standing with the Department of Insurance.
29 (6) The agency may contract on a prepaid or fixed-sum
30 basis with an exclusive provider organization to provide
31 health care services to Medicaid recipients provided that the
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1 exclusive provider organization meets applicable managed care
2 plan requirements in this section, ss. 409.9122, 409.9123,
3 409.9128, and 627.6472, and other applicable provisions of
4 law.
5 (7) The Agency for Health Care Administration may
6 provide cost-effective purchasing of chiropractic services on
7 a fee-for-service basis to Medicaid recipients through
8 arrangements with a statewide chiropractic preferred provider
9 organization incorporated in this state as a not-for-profit
10 corporation. The agency shall ensure that the benefit limits
11 and prior authorization requirements in the current Medicaid
12 program shall apply to the services provided by the
13 chiropractic preferred provider organization.
14 (8) The agency shall not contract on a prepaid or
15 fixed-sum basis for Medicaid services with an entity which
16 knows or reasonably should know that any officer, director,
17 agent, managing employee, or owner of stock or beneficial
18 interest in excess of 5 percent common or preferred stock, or
19 the entity itself, has been found guilty of, regardless of
20 adjudication, or entered a plea of nolo contendere, or guilty,
21 to:
22 (a) Fraud;
23 (b) Violation of federal or state antitrust statutes,
24 including those proscribing price fixing between competitors
25 and the allocation of customers among competitors;
26 (c) Commission of a felony involving embezzlement,
27 theft, forgery, income tax evasion, bribery, falsification or
28 destruction of records, making false statements, receiving
29 stolen property, making false claims, or obstruction of
30 justice; or
31
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1 (d) Any crime in any jurisdiction which directly
2 relates to the provision of health services on a prepaid or
3 fixed-sum basis.
4 (9) The agency, after notifying the Legislature, may
5 apply for waivers of applicable federal laws and regulations
6 as necessary to implement more appropriate systems of health
7 care for Medicaid recipients and reduce the cost of the
8 Medicaid program to the state and federal governments and
9 shall implement such programs, after legislative approval,
10 within a reasonable period of time after federal approval.
11 These programs must be designed primarily to reduce the need
12 for inpatient care, custodial care and other long-term or
13 institutional care, and other high-cost services.
14 (a) Prior to seeking legislative approval of such a
15 waiver as authorized by this subsection, the agency shall
16 provide notice and an opportunity for public comment. Notice
17 shall be provided to all persons who have made requests of the
18 agency for advance notice and shall be published in the
19 Florida Administrative Weekly not less than 28 days prior to
20 the intended action.
21 (b) Notwithstanding s. 216.292, funds that are
22 appropriated to the Department of Elderly Affairs for the
23 Assisted Living for the Elderly Medicaid waiver and are not
24 expended shall be transferred to the agency to fund
25 Medicaid-reimbursed nursing home care.
26 (10) The agency shall establish a postpayment
27 utilization control program designed to identify recipients
28 who may inappropriately overuse or underuse Medicaid services
29 and shall provide methods to correct such misuse.
30 (11) The agency shall develop and provide coordinated
31 systems of care for Medicaid recipients and may contract with
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1 public or private entities to develop and administer such
2 systems of care among public and private health care providers
3 in a given geographic area.
4 (12) The agency shall operate or contract for the
5 operation of utilization management and incentive systems
6 designed to encourage cost-effective use services.
7 (13)(a) The agency shall identify health care
8 utilization and price patterns within the Medicaid program
9 which are not cost-effective or medically appropriate and
10 assess the effectiveness of new or alternate methods of
11 providing and monitoring service, and may implement such
12 methods as it considers appropriate. Such methods may include
13 disease management initiatives, an integrated and systematic
14 approach for managing the health care needs of recipients who
15 are at risk of or diagnosed with a specific disease by using
16 best practices, prevention strategies, clinical-practice
17 improvement, clinical interventions and protocols, outcomes
18 research, information technology, and other tools and
19 resources to reduce overall costs and improve measurable
20 outcomes.
21 (b) The responsibility of the agency under this
22 subsection shall include the development of capabilities to
23 identify actual and optimal practice patterns; patient and
24 provider educational initiatives; methods for determining
25 patient compliance with prescribed treatments; fraud, waste,
26 and abuse prevention and detection programs; and beneficiary
27 case management programs.
28 1. The practice pattern identification program shall
29 evaluate practitioner prescribing patterns based on national
30 and regional practice guidelines, comparing practitioners to
31 their peer groups. The agency and its Drug Utilization Review
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1 Board shall consult with a panel of practicing health care
2 professionals consisting of the following: the Speaker of the
3 House of Representatives and the President of the Senate shall
4 each appoint three physicians licensed under chapter 458 or
5 chapter 459; and the Governor shall appoint two pharmacists
6 licensed under chapter 465 and one dentist licensed under
7 chapter 466 who is an oral surgeon. Terms of the panel members
8 shall expire at the discretion of the appointing official. The
9 panel shall begin its work by August 1, 1999, regardless of
10 the number of appointments made by that date. The advisory
11 panel shall be responsible for evaluating treatment guidelines
12 and recommending ways to incorporate their use in the practice
13 pattern identification program. Practitioners who are
14 prescribing inappropriately or inefficiently, as determined by
15 the agency, may have their prescribing of certain drugs
16 subject to prior authorization.
17 2. The agency shall also develop educational
18 interventions designed to promote the proper use of
19 medications by providers and beneficiaries.
20 3. The agency shall implement a pharmacy fraud, waste,
21 and abuse initiative that may include a surety bond or letter
22 of credit requirement for participating pharmacies, enhanced
23 provider auditing practices, the use of additional fraud and
24 abuse software, recipient management programs for
25 beneficiaries inappropriately using their benefits, and other
26 steps that will eliminate provider and recipient fraud, waste,
27 and abuse. The initiative shall address enforcement efforts to
28 reduce the number and use of counterfeit prescriptions.
29 4. The agency may apply for any federal waivers needed
30 to implement this paragraph.
31
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1 (14) An entity contracting on a prepaid or fixed-sum
2 basis shall, in addition to meeting any applicable statutory
3 surplus requirements, also maintain at all times in the form
4 of cash, investments that mature in less than 180 days
5 allowable as admitted assets by the Department of Insurance,
6 and restricted funds or deposits controlled by the agency or
7 the Department of Insurance, a surplus amount equal to
8 one-and-one-half times the entity's monthly Medicaid prepaid
9 revenues. As used in this subsection, the term "surplus" means
10 the entity's total assets minus total liabilities. If an
11 entity's surplus falls below an amount equal to
12 one-and-one-half times the entity's monthly Medicaid prepaid
13 revenues, the agency shall prohibit the entity from engaging
14 in marketing and preenrollment activities, shall cease to
15 process new enrollments, and shall not renew the entity's
16 contract until the required balance is achieved. The
17 requirements of this subsection do not apply:
18 (a) Where a public entity agrees to fund any deficit
19 incurred by the contracting entity; or
20 (b) Where the entity's performance and obligations are
21 guaranteed in writing by a guaranteeing organization which:
22 1. Has been in operation for at least 5 years and has
23 assets in excess of $50 million; or
24 2. Submits a written guarantee acceptable to the
25 agency which is irrevocable during the term of the contracting
26 entity's contract with the agency and, upon termination of the
27 contract, until the agency receives proof of satisfaction of
28 all outstanding obligations incurred under the contract.
29 (15)(a) The agency may require an entity contracting
30 on a prepaid or fixed-sum basis to establish a restricted
31 insolvency protection account with a federally guaranteed
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1 financial institution licensed to do business in this state.
2 The entity shall deposit into that account 5 percent of the
3 capitation payments made by the agency each month until a
4 maximum total of 2 percent of the total current contract
5 amount is reached. The restricted insolvency protection
6 account may be drawn upon with the authorized signatures of
7 two persons designated by the entity and two representatives
8 of the agency. If the agency finds that the entity is
9 insolvent, the agency may draw upon the account solely with
10 the two authorized signatures of representatives of the
11 agency, and the funds may be disbursed to meet financial
12 obligations incurred by the entity under the prepaid contract.
13 If the contract is terminated, expired, or not continued, the
14 account balance must be released by the agency to the entity
15 upon receipt of proof of satisfaction of all outstanding
16 obligations incurred under this contract.
17 (b) The agency may waive the insolvency protection
18 account requirement in writing when evidence is on file with
19 the agency of adequate insolvency insurance and reinsurance
20 that will protect enrollees if the entity becomes unable to
21 meet its obligations.
22 (16) An entity that contracts with the agency on a
23 prepaid or fixed-sum basis for the provision of Medicaid
24 services shall reimburse any hospital or physician that is
25 outside the entity's authorized geographic service area as
26 specified in its contract with the agency, and that provides
27 services authorized by the entity to its members, at a rate
28 negotiated with the hospital or physician for the provision of
29 services or according to the lesser of the following:
30 (a) The usual and customary charges made to the
31 general public by the hospital or physician; or
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1 (b) The Florida Medicaid reimbursement rate
2 established for the hospital or physician.
3 (17) When a merger or acquisition of a Medicaid
4 prepaid contractor has been approved by the Department of
5 Insurance pursuant to s. 628.4615, the agency shall approve
6 the assignment or transfer of the appropriate Medicaid prepaid
7 contract upon request of the surviving entity of the merger or
8 acquisition if the contractor and the other entity have been
9 in good standing with the agency for the most recent 12-month
10 period, unless the agency determines that the assignment or
11 transfer would be detrimental to the Medicaid recipients or
12 the Medicaid program. To be in good standing, an entity must
13 not have failed accreditation or committed any material
14 violation of the requirements of s. 641.52 and must meet the
15 Medicaid contract requirements. For purposes of this section,
16 a merger or acquisition means a change in controlling interest
17 of an entity, including an asset or stock purchase.
18 (18) Any entity contracting with the agency pursuant
19 to this section to provide health care services to Medicaid
20 recipients is prohibited from engaging in any of the following
21 practices or activities:
22 (a) Practices that are discriminatory, including, but
23 not limited to, attempts to discourage participation on the
24 basis of actual or perceived health status.
25 (b) Activities that could mislead or confuse
26 recipients, or misrepresent the organization, its marketing
27 representatives, or the agency. Violations of this paragraph
28 include, but are not limited to:
29 1. False or misleading claims that marketing
30 representatives are employees or representatives of the state
31
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1 or county, or of anyone other than the entity or the
2 organization by whom they are reimbursed.
3 2. False or misleading claims that the entity is
4 recommended or endorsed by any state or county agency, or by
5 any other organization which has not certified its endorsement
6 in writing to the entity.
7 3. False or misleading claims that the state or county
8 recommends that a Medicaid recipient enroll with an entity.
9 4. Claims that a Medicaid recipient will lose benefits
10 under the Medicaid program, or any other health or welfare
11 benefits to which the recipient is legally entitled, if the
12 recipient does not enroll with the entity.
13 (c) Granting or offering of any monetary or other
14 valuable consideration for enrollment, except as authorized by
15 subsection (21).
16 (d) Door-to-door solicitation of recipients who have
17 not contacted the entity or who have not invited the entity to
18 make a presentation.
19 (e) Solicitation of Medicaid recipients by marketing
20 representatives stationed in state offices unless approved and
21 supervised by the agency or its agent and approved by the
22 affected state agency when solicitation occurs in an office of
23 the state agency. The agency shall ensure that marketing
24 representatives stationed in state offices shall market their
25 managed care plans to Medicaid recipients only in designated
26 areas and in such a way as to not interfere with the
27 recipients' activities in the state office.
28 (f) Enrollment of Medicaid recipients.
29 (19) The agency may impose a fine for a violation of
30 this section or the contract with the agency by a person or
31 entity that is under contract with the agency. With respect
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1 to any nonwillful violation, such fine shall not exceed $2,500
2 per violation. In no event shall such fine exceed an
3 aggregate amount of $10,000 for all nonwillful violations
4 arising out of the same action. With respect to any knowing
5 and willful violation of this section or the contract with the
6 agency, the agency may impose a fine upon the entity in an
7 amount not to exceed $20,000 for each such violation. In no
8 event shall such fine exceed an aggregate amount of $100,000
9 for all knowing and willful violations arising out of the same
10 action.
11 (20) A health maintenance organization or a person or
12 entity exempt from chapter 641 that is under contract with the
13 agency for the provision of health care services to Medicaid
14 recipients may not use or distribute marketing materials used
15 to solicit Medicaid recipients, unless such materials have
16 been approved by the agency. The provisions of this subsection
17 do not apply to general advertising and marketing materials
18 used by a health maintenance organization to solicit both
19 non-Medicaid subscribers and Medicaid recipients.
20 (21) Upon approval by the agency, health maintenance
21 organizations and persons or entities exempt from chapter 641
22 that are under contract with the agency for the provision of
23 health care services to Medicaid recipients may be permitted
24 within the capitation rate to provide additional health
25 benefits that the agency has found are of high quality, are
26 practicably available, provide reasonable value to the
27 recipient, and are provided at no additional cost to the
28 state.
29 (22) The agency shall utilize the statewide health
30 maintenance organization complaint hotline for the purpose of
31 investigating and resolving Medicaid and prepaid health plan
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1 complaints, maintaining a record of complaints and confirmed
2 problems, and receiving disenrollment requests made by
3 recipients.
4 (23) The agency shall require the publication of the
5 health maintenance organization's and the prepaid health
6 plan's consumer services telephone numbers and the "800"
7 telephone number of the statewide health maintenance
8 organization complaint hotline on each Medicaid identification
9 card issued by a health maintenance organization or prepaid
10 health plan contracting with the agency to serve Medicaid
11 recipients and on each subscriber handbook issued to a
12 Medicaid recipient.
13 (24) The agency shall establish a health care quality
14 improvement system for those entities contracting with the
15 agency pursuant to this section, incorporating all the
16 standards and guidelines developed by the Medicaid Bureau of
17 the Health Care Financing Administration as a part of the
18 quality assurance reform initiative. The system shall
19 include, but need not be limited to, the following:
20 (a) Guidelines for internal quality assurance
21 programs, including standards for:
22 1. Written quality assurance program descriptions.
23 2. Responsibilities of the governing body for
24 monitoring, evaluating, and making improvements to care.
25 3. An active quality assurance committee.
26 4. Quality assurance program supervision.
27 5. Requiring the program to have adequate resources to
28 effectively carry out its specified activities.
29 6. Provider participation in the quality assurance
30 program.
31 7. Delegation of quality assurance program activities.
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1 8. Credentialing and recredentialing.
2 9. Enrollee rights and responsibilities.
3 10. Availability and accessibility to services and
4 care.
5 11. Ambulatory care facilities.
6 12. Accessibility and availability of medical records,
7 as well as proper recordkeeping and process for record review.
8 13. Utilization review.
9 14. A continuity of care system.
10 15. Quality assurance program documentation.
11 16. Coordination of quality assurance activity with
12 other management activity.
13 17. Delivering care to pregnant women and infants; to
14 elderly and disabled recipients, especially those who are at
15 risk of institutional placement; to persons with developmental
16 disabilities; and to adults who have chronic, high-cost
17 medical conditions.
18 (b) Guidelines which require the entities to conduct
19 quality-of-care studies which:
20 1. Target specific conditions and specific health
21 service delivery issues for focused monitoring and evaluation.
22 2. Use clinical care standards or practice guidelines
23 to objectively evaluate the care the entity delivers or fails
24 to deliver for the targeted clinical conditions and health
25 services delivery issues.
26 3. Use quality indicators derived from the clinical
27 care standards or practice guidelines to screen and monitor
28 care and services delivered.
29 (c) Guidelines for external quality review of each
30 contractor which require: focused studies of patterns of care;
31 individual care review in specific situations; and followup
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1 activities on previous pattern-of-care study findings and
2 individual-care-review findings. In designing the external
3 quality review function and determining how it is to operate
4 as part of the state's overall quality improvement system, the
5 agency shall construct its external quality review
6 organization and entity contracts to address each of the
7 following:
8 1. Delineating the role of the external quality review
9 organization.
10 2. Length of the external quality review organization
11 contract with the state.
12 3. Participation of the contracting entities in
13 designing external quality review organization review
14 activities.
15 4. Potential variation in the type of clinical
16 conditions and health services delivery issues to be studied
17 at each plan.
18 5. Determining the number of focused pattern-of-care
19 studies to be conducted for each plan.
20 6. Methods for implementing focused studies.
21 7. Individual care review.
22 8. Followup activities.
23 (25) In order to ensure that children receive health
24 care services for which an entity has already been
25 compensated, an entity contracting with the agency pursuant to
26 this section shall achieve an annual Early and Periodic
27 Screening, Diagnosis, and Treatment (EPSDT) Service screening
28 rate of at least 60 percent for those recipients continuously
29 enrolled for at least 8 months. The agency shall develop a
30 method by which the EPSDT screening rate shall be calculated.
31 For any entity which does not achieve the annual 60 percent
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1 rate, the entity must submit a corrective action plan for the
2 agency's approval. If the entity does not meet the standard
3 established in the corrective action plan during the specified
4 timeframe, the agency is authorized to impose appropriate
5 contract sanctions. At least annually, the agency shall
6 publicly release the EPSDT Services screening rates of each
7 entity it has contracted with on a prepaid basis to serve
8 Medicaid recipients.
9 (26) The agency shall perform enrollments and
10 disenrollments for Medicaid recipients who are eligible for
11 MediPass or managed care plans. Notwithstanding the
12 prohibition contained in paragraph (18)(f), managed care plans
13 may perform preenrollments of Medicaid recipients under the
14 supervision of the agency or its agents. For the purposes of
15 this section, "preenrollment" means the provision of marketing
16 and educational materials to a Medicaid recipient and
17 assistance in completing the application forms, but shall not
18 include actual enrollment into a managed care plan. An
19 application for enrollment shall not be deemed complete until
20 the agency or its agent verifies that the recipient made an
21 informed, voluntary choice. The agency, in cooperation with
22 the Department of Children and Family Services, may test new
23 marketing initiatives to inform Medicaid recipients about
24 their managed care options at selected sites. The agency
25 shall report to the Legislature on the effectiveness of such
26 initiatives. The agency may contract with a third party to
27 perform managed care plan and MediPass enrollment and
28 disenrollment services for Medicaid recipients and is
29 authorized to adopt rules to implement such services. The
30 agency may adjust the capitation rate only to cover the costs
31 of a third-party enrollment and disenrollment contract, and
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1 for agency supervision and management of the managed care plan
2 enrollment and disenrollment contract.
3 (27) Any lists of providers made available to Medicaid
4 recipients, MediPass enrollees, or managed care plan enrollees
5 shall be arranged alphabetically showing the provider's name
6 and specialty and, separately, by specialty in alphabetical
7 order.
8 (28) The agency shall establish an enhanced managed
9 care quality assurance oversight function, to include at least
10 the following components:
11 (a) At least quarterly analysis and followup,
12 including sanctions as appropriate, of managed care
13 participant utilization of services.
14 (b) At least quarterly analysis and followup,
15 including sanctions as appropriate, of quality findings of the
16 Medicaid peer review organization and other external quality
17 assurance programs.
18 (c) At least quarterly analysis and followup,
19 including sanctions as appropriate, of the fiscal viability of
20 managed care plans.
21 (d) At least quarterly analysis and followup,
22 including sanctions as appropriate, of managed care
23 participant satisfaction and disenrollment surveys.
24 (e) The agency shall conduct regular and ongoing
25 Medicaid recipient satisfaction surveys.
26
27 The analyses and followup activities conducted by the agency
28 under its enhanced managed care quality assurance oversight
29 function shall not duplicate the activities of accreditation
30 reviewers for entities regulated under part III of chapter
31
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1 641, but may include a review of the finding of such
2 reviewers.
3 (29) Each managed care plan that is under contract
4 with the agency to provide health care services to Medicaid
5 recipients shall annually conduct a background check with the
6 Florida Department of Law Enforcement of all persons with
7 ownership interest of 5 percent or more or executive
8 management responsibility for the managed care plan and shall
9 submit to the agency information concerning any such person
10 who has been found guilty of, regardless of adjudication, or
11 has entered a plea of nolo contendere or guilty to, any of the
12 offenses listed in s. 435.03.
13 (30) The agency shall, by rule, develop a process
14 whereby a Medicaid managed care plan enrollee who wishes to
15 enter hospice care may be disenrolled from the managed care
16 plan within 24 hours after contacting the agency regarding
17 such request. The agency rule shall include a methodology for
18 the agency to recoup managed care plan payments on a pro rata
19 basis if payment has been made for the enrollment month when
20 disenrollment occurs.
21 (31) The agency and entities which contract with the
22 agency to provide health care services to Medicaid recipients
23 under this section or s. 409.9122 must comply with the
24 provisions of s. 641.513 in providing emergency services and
25 care to Medicaid recipients and MediPass recipients.
26 (32) All entities providing health care services to
27 Medicaid recipients shall make available, and encourage all
28 pregnant women and mothers with infants to receive, and
29 provide documentation in the medical records to reflect, the
30 following:
31 (a) Healthy Start prenatal or infant screening.
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1 (b) Healthy Start care coordination, when screening or
2 other factors indicate need.
3 (c) Healthy Start enhanced services in accordance with
4 the prenatal or infant screening results.
5 (d) Immunizations in accordance with recommendations
6 of the Advisory Committee on Immunization Practices of the
7 United States Public Health Service and the American Academy
8 of Pediatrics, as appropriate.
9 (e) Counseling and services for family planning to all
10 women and their partners.
11 (f) A scheduled postpartum visit for the purpose of
12 voluntary family planning, to include discussion of all
13 methods of contraception, as appropriate.
14 (g) Referral to the Special Supplemental Nutrition
15 Program for Women, Infants, and Children (WIC).
16 (33) Any entity that provides Medicaid prepaid health
17 plan services shall ensure the appropriate coordination of
18 health care services with an assisted living facility in cases
19 where a Medicaid recipient is both a member of the entity's
20 prepaid health plan and a resident of the assisted living
21 facility. If the entity is at risk for Medicaid targeted case
22 management and behavioral health services, the entity shall
23 inform the assisted living facility of the procedures to
24 follow should an emergent condition arise.
25 (34) The agency may seek and implement federal waivers
26 necessary to provide for cost-effective purchasing of home
27 health services, private duty nursing services,
28 transportation, independent laboratory services, and durable
29 medical equipment and supplies through competitive bidding
30 pursuant to s. 287.057. The agency may request appropriate
31 waivers from the federal Health Care Financing Administration
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1 in order to competitively bid such services. The agency may
2 exclude providers not selected through the bidding process
3 from the Medicaid provider network.
4 (35) The Agency for Health Care Administration is
5 directed to issue a request for proposal or intent to
6 negotiate to implement on a demonstration basis an outpatient
7 specialty services pilot project in a rural and urban county
8 in the state. As used in this subsection, the term
9 "outpatient specialty services" means clinical laboratory,
10 diagnostic imaging, and specified home medical services to
11 include durable medical equipment, prosthetics and orthotics,
12 and infusion therapy.
13 (a) The entity that is awarded the contract to provide
14 Medicaid managed care outpatient specialty services must, at a
15 minimum, meet the following criteria:
16 1. The entity must be licensed by the Department of
17 Insurance under part II of chapter 641.
18 2. The entity must be experienced in providing
19 outpatient specialty services.
20 3. The entity must demonstrate to the satisfaction of
21 the agency that it provides high-quality services to its
22 patients.
23 4. The entity must demonstrate that it has in place a
24 complaints and grievance process to assist Medicaid recipients
25 enrolled in the pilot managed care program to resolve
26 complaints and grievances.
27 (b) The pilot managed care program shall operate for a
28 period of 3 years. The objective of the pilot program shall
29 be to determine the cost-effectiveness and effects on
30 utilization, access, and quality of providing outpatient
31
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1 specialty services to Medicaid recipients on a prepaid,
2 capitated basis.
3 (c) The agency shall conduct a quality assurance
4 review of the prepaid health clinic each year that the
5 demonstration program is in effect. The prepaid health clinic
6 is responsible for all expenses incurred by the agency in
7 conducting a quality assurance review.
8 (d) The entity that is awarded the contract to provide
9 outpatient specialty services to Medicaid recipients shall
10 report data required by the agency in a format specified by
11 the agency, for the purpose of conducting the evaluation
12 required in paragraph (e).
13 (e) The agency shall conduct an evaluation of the
14 pilot managed care program and report its findings to the
15 Governor and the Legislature by no later than January 1, 2001.
16 (36) The agency shall enter into agreements with
17 not-for-profit organizations based in this state for the
18 purpose of providing vision screening.
19 (37)(a) The agency shall implement a Medicaid
20 prescribed-drug spending-control program that includes the
21 following components:
22 1. Medicaid prescribed-drug coverage for brand-name
23 drugs for adult Medicaid recipients is limited to the
24 dispensing of four brand-name drugs per month per recipient.
25 Children are exempt from this restriction. Antiretroviral
26 agents are excluded from this limitation. No requirements for
27 prior authorization or other restrictions on medications used
28 to treat mental illnesses such as schizophrenia, severe
29 depression, or bipolar disorder may be imposed on Medicaid
30 recipients. Medications that will be available without
31 restriction for persons with mental illnesses include atypical
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1 antipsychotic medications, conventional antipsychotic
2 medications, selective serotonin reuptake inhibitors, and
3 other medications used for the treatment of serious mental
4 illnesses. The agency shall also limit the amount of a
5 prescribed drug dispensed to no more than a 34-day supply. The
6 agency shall continue to provide unlimited generic drugs,
7 contraceptive drugs and items, and diabetic supplies. Although
8 a drug may be included on the preferred drug formulary, it
9 would not be exempt from the four-brand limit. The agency may
10 authorize exceptions to the brand-name-drug restriction based
11 upon the treatment needs of the patients, only when such
12 exceptions are based on prior consultation provided by the
13 agency or an agency contractor, but the agency must establish
14 procedures to ensure that:
15 a. There will be a response to a request for prior
16 consultation by telephone or other telecommunication device
17 within 24 hours after receipt of a request for prior
18 consultation;
19 b. A 72-hour supply of the drug prescribed will be
20 provided in an emergency or when the agency does not provide a
21 response within 24 hours as required by sub-subparagraph a.;
22 and
23 c. Except for the exception for nursing home residents
24 and other institutionalized adults and except for drugs on the
25 restricted formulary for which prior authorization may be
26 sought by an institutional or community pharmacy, prior
27 authorization for an exception to the brand-name-drug
28 restriction is sought by the prescriber and not by the
29 pharmacy. When prior authorization is granted for a patient in
30 an institutional setting beyond the brand-name-drug
31
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1 restriction, such approval is authorized for 12 months and
2 monthly prior authorization is not required for that patient.
3 2. Reimbursement to pharmacies for Medicaid prescribed
4 drugs shall be set at the average wholesale price less 13.25
5 percent.
6 3. The agency shall develop and implement a process
7 for managing the drug therapies of Medicaid recipients who are
8 using significant numbers of prescribed drugs each month. The
9 management process may include, but is not limited to,
10 comprehensive, physician-directed medical-record reviews,
11 claims analyses, and case evaluations to determine the medical
12 necessity and appropriateness of a patient's treatment plan
13 and drug therapies. The agency may contract with a private
14 organization to provide drug-program-management services. The
15 Medicaid drug benefit management program shall include
16 initiatives to manage drug therapies for HIV/AIDS patients,
17 patients using 20 or more unique prescriptions in a 180-day
18 period, and the top 1,000 patients in annual spending.
19 4. The agency may limit the size of its pharmacy
20 network based on need, competitive bidding, price
21 negotiations, credentialing, or similar criteria. The agency
22 shall give special consideration to rural areas in determining
23 the size and location of pharmacies included in the Medicaid
24 pharmacy network. A pharmacy credentialing process may include
25 criteria such as a pharmacy's full-service status, location,
26 size, patient educational programs, patient consultation,
27 disease-management services, and other characteristics. The
28 agency may impose a moratorium on Medicaid pharmacy enrollment
29 when it is determined that it has a sufficient number of
30 Medicaid-participating providers.
31
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1 5. The agency shall develop and implement a program
2 that requires Medicaid practitioners who prescribe drugs to
3 use a counterfeit-proof prescription pad for Medicaid
4 prescriptions. The agency shall require the use of
5 standardized counterfeit-proof prescription pads by
6 Medicaid-participating prescribers or prescribers who write
7 prescriptions for Medicaid recipients. The agency may
8 implement the program in targeted geographic areas or
9 statewide.
10 6. The agency may enter into arrangements that require
11 manufacturers of generic drugs prescribed to Medicaid
12 recipients to provide rebates of at least 15.1 percent of the
13 average manufacturer price for the manufacturer's generic
14 products. These arrangements shall require that if a
15 generic-drug manufacturer pays federal rebates for
16 Medicaid-reimbursed drugs at a level below 15.1 percent, the
17 manufacturer must provide a supplemental rebate to the state
18 in an amount necessary to achieve a 15.1-percent rebate level.
19 7. The agency may establish a preferred drug formulary
20 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
21 establishment of such formulary, it is authorized to negotiate
22 supplemental rebates from manufacturers that are in addition
23 to those required by Title XIX of the Social Security Act and
24 at no less than 10 percent of the average manufacturer price
25 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
26 unless the federal or supplemental rebate, or both, equals or
27 exceeds 25 percent. There is no upper limit on the
28 supplemental rebates the agency may negotiate. The agency may
29 determine that specific products, brand-name or generic, are
30 competitive at lower rebate percentages. Agreement to pay the
31 minimum supplemental rebate percentage will guarantee a
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1 manufacturer that the Medicaid Pharmaceutical and Therapeutics
2 Committee will consider a product for inclusion on the
3 preferred drug formulary. However, a pharmaceutical
4 manufacturer is not guaranteed placement on the formulary by
5 simply paying the minimum supplemental rebate. Agency
6 decisions will be made on the clinical efficacy of a drug and
7 recommendations of the Medicaid Pharmaceutical and
8 Therapeutics Committee, as well as the price of competing
9 products minus federal and state rebates. The agency is
10 authorized to contract with an outside agency or contractor to
11 conduct negotiations for supplemental rebates. For the
12 purposes of this section, the term "supplemental rebates" may
13 include, at the agency's discretion, cash rebates and other
14 program benefits that offset a Medicaid expenditure. Such
15 other program benefits may include, but are not limited to,
16 disease management programs, drug product donation programs,
17 drug utilization control programs, prescriber and beneficiary
18 counseling and education, fraud and abuse initiatives, and
19 other services or administrative investments with guaranteed
20 savings to the Medicaid program in the same year the rebate
21 reduction is included in the General Appropriations Act. The
22 agency is authorized to seek any federal waivers to implement
23 this initiative.
24 8. The agency shall establish an advisory committee
25 for the purposes of studying the feasibility of using a
26 restricted drug formulary for nursing home residents and other
27 institutionalized adults. The committee shall be comprised of
28 seven members appointed by the Secretary of Health Care
29 Administration. The committee members shall include two
30 physicians licensed under chapter 458 or chapter 459; three
31 pharmacists licensed under chapter 465 and appointed from a
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1 list of recommendations provided by the Florida Long-Term Care
2 Pharmacy Alliance; and two pharmacists licensed under chapter
3 465.
4 9. The Agency for Health Care Administration shall
5 expand home delivery of pharmacy products. To assist Medicaid
6 patients in securing their prescriptions and reduce program
7 costs, the agency shall expand its current mail-order-pharmacy
8 diabetes-supply program to include all generic and brand-name
9 drugs used by Medicaid patients with diabetes. Medicaid
10 recipients in the current program may obtain nondiabetes drugs
11 on a voluntary basis. This initiative is limited to the
12 geographic area covered by the current contract. The agency
13 may seek and implement any federal waivers necessary to
14 implement this subparagraph.
15 (b) The agency shall implement this subsection to the
16 extent that funds are appropriated to administer the Medicaid
17 prescribed-drug spending-control program. The agency may
18 contract all or any part of this program to private
19 organizations.
20 (c) The agency shall submit quarterly reports a report
21 to the Governor, the President of the Senate, and the Speaker
22 of the House of Representatives which by January 15 of each
23 year. The report must include, but need not be limited to, the
24 progress made in implementing this subsection and its Medicaid
25 cost-containment measures and their effect on Medicaid
26 prescribed-drug expenditures.
27 (38) Notwithstanding the provisions of chapter 287,
28 the agency may, at its discretion, renew a contract or
29 contracts for fiscal intermediary services one or more times
30 for such periods as the agency may decide; however, all such
31
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1 renewals may not combine to exceed a total period longer than
2 the term of the original contract.
3 (39) The agency shall provide for the development of a
4 demonstration project by establishment in Miami-Dade County of
5 a long-term-care facility licensed pursuant to chapter 395 to
6 improve access to health care for a predominantly minority,
7 medically underserved, and medically complex population and to
8 evaluate alternatives to nursing home care and general acute
9 care for such population. Such project is to be located in a
10 health care condominium and colocated with licensed facilities
11 providing a continuum of care. The establishment of this
12 project is not subject to the provisions of s. 408.036 or s.
13 408.039. The agency shall report its findings to the
14 Governor, the President of the Senate, and the Speaker of the
15 House of Representatives by January 1, 2003.
16 Section 18. Subsection (2) of section 409.9122,
17 Florida Statutes, as amended by sections 10 and 11 of chapter
18 2001-377, Laws of Florida, is amended to read:
19 409.9122 Mandatory Medicaid managed care enrollment;
20 programs and procedures.--
21 (2)(a) The agency shall enroll in a managed care plan
22 or MediPass all Medicaid recipients, except those Medicaid
23 recipients who are: in an institution; enrolled in the
24 Medicaid medically needy program; or eligible for both
25 Medicaid and Medicare. However, to the extent permitted by
26 federal law, the agency may enroll in a managed care plan or
27 MediPass a Medicaid recipient who is exempt from mandatory
28 managed care enrollment, provided that:
29 1. The recipient's decision to enroll in a managed
30 care plan or MediPass is voluntary;
31
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1 2. If the recipient chooses to enroll in a managed
2 care plan, the agency has determined that the managed care
3 plan provides specific programs and services which address the
4 special health needs of the recipient; and
5 3. The agency receives any necessary waivers from the
6 federal Health Care Financing Administration.
7
8 The agency shall develop rules to establish policies by which
9 exceptions to the mandatory managed care enrollment
10 requirement may be made on a case-by-case basis. The rules
11 shall include the specific criteria to be applied when making
12 a determination as to whether to exempt a recipient from
13 mandatory enrollment in a managed care plan or MediPass.
14 School districts participating in the certified school match
15 program pursuant to ss. 236.0812 and 409.908(21) shall be
16 reimbursed by Medicaid, subject to the limitations of s.
17 236.0812(1) and (2), for a Medicaid-eligible child
18 participating in the services as authorized in s. 236.0812, as
19 provided for in s. 409.9071, regardless of whether the child
20 is enrolled in MediPass or a managed care plan. Managed care
21 plans shall make a good faith effort to execute agreements
22 with school districts regarding the coordinated provision of
23 services authorized under s. 236.0812. County health
24 departments delivering school-based services pursuant to ss.
25 381.0056 and 381.0057 shall be reimbursed by Medicaid for the
26 federal share for a Medicaid-eligible child who receives
27 Medicaid-covered services in a school setting, regardless of
28 whether the child is enrolled in MediPass or a managed care
29 plan. Managed care plans shall make a good faith effort to
30 execute agreements with county health departments regarding
31 the coordinated provision of services to a Medicaid-eligible
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1 child. To ensure continuity of care for Medicaid patients, the
2 agency, the Department of Health, and the Department of
3 Education shall develop procedures for ensuring that a
4 student's managed care plan or MediPass provider receives
5 information relating to services provided in accordance with
6 ss. 236.0812, 381.0056, 381.0057, and 409.9071.
7 (b) A Medicaid recipient shall not be enrolled in or
8 assigned to a managed care plan or MediPass unless the managed
9 care plan or MediPass has complied with the quality-of-care
10 standards specified in paragraphs (3)(a) and (b),
11 respectively.
12 (c) Medicaid recipients shall have a choice of managed
13 care plans or MediPass. The Agency for Health Care
14 Administration, the Department of Health, the Department of
15 Children and Family Services, and the Department of Elderly
16 Affairs shall cooperate to ensure that each Medicaid recipient
17 receives clear and easily understandable information that
18 meets the following requirements:
19 1. Explains the concept of managed care, including
20 MediPass.
21 2. Provides information on the comparative performance
22 of managed care plans and MediPass in the areas of quality,
23 credentialing, preventive health programs, network size and
24 availability, and patient satisfaction.
25 3. Explains where additional information on each
26 managed care plan and MediPass in the recipient's area can be
27 obtained.
28 4. Explains that recipients have the right to choose
29 their own managed care plans or MediPass. However, if a
30 recipient does not choose a managed care plan or MediPass, the
31
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1 agency will assign the recipient to a managed care plan or
2 MediPass according to the criteria specified in this section.
3 5. Explains the recipient's right to complain, file a
4 grievance, or change managed care plans or MediPass providers
5 if the recipient is not satisfied with the managed care plan
6 or MediPass.
7 (d) The agency shall develop a mechanism for providing
8 information to Medicaid recipients for the purpose of making a
9 managed care plan or MediPass selection. Examples of such
10 mechanisms may include, but not be limited to, interactive
11 information systems, mailings, and mass marketing materials.
12 Managed care plans and MediPass providers are prohibited from
13 providing inducements to Medicaid recipients to select their
14 plans or from prejudicing Medicaid recipients against other
15 managed care plans or MediPass providers.
16 (e) Medicaid recipients who are already enrolled in a
17 managed care plan or MediPass shall be offered the opportunity
18 to change managed care plans or MediPass providers on a
19 staggered basis, as defined by the agency. All Medicaid
20 recipients shall have 90 days in which to make a choice of
21 managed care plans or MediPass providers. Those Medicaid
22 recipients who do not make a choice shall be assigned to a
23 managed care plan if a managed care plan with sufficient
24 network capacity is available in the recipient's geographic
25 area or MediPass in accordance with paragraph (f).
26 1. To facilitate continuity of care, for a Medicaid
27 recipient who is also a recipient of Supplemental Security
28 Income (SSI), prior to assigning the SSI recipient to a
29 managed care plan or MediPass, the agency shall determine
30 whether the SSI recipient has an ongoing relationship with a
31 MediPass provider or managed care plan, and if so, the agency
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1 shall assign the SSI recipient to that MediPass provider or
2 managed care plan. Those SSI recipients who do not have such a
3 provider relationship shall be assigned to a managed care plan
4 or MediPass provider in accordance with paragraph (f).
5 2. In geographic areas where the agency is contracting
6 for the provision of comprehensive behavioral health services
7 through a capitated, prepaid arrangement, recipients who fail
8 to make a choice shall be assigned equally to MediPass or a
9 managed care plan.
10 (f) When a Medicaid recipient does not choose a
11 managed care plan or MediPass provider, the agency shall
12 assign the Medicaid recipient to a managed care plan or
13 MediPass provider. Medicaid recipients who are subject to
14 mandatory assignment but who fail to make a choice shall be
15 assigned to managed care plans or provider service networks
16 until an equal enrollment of 50 percent in MediPass and 50
17 percent in managed care plans is achieved. Once equal
18 enrollment is achieved, the assignments shall be divided in
19 order to maintain an equal enrollment in MediPass and managed
20 care plans. Thereafter, assignment of Medicaid recipients who
21 fail to make a choice shall be based proportionally on the
22 preferences of recipients who have made a choice in the
23 previous period. Such proportions shall be revised at least
24 quarterly to reflect an update of the preferences of Medicaid
25 recipients. The agency shall also disproportionately assign
26 Medicaid-eligible children in families who are required to but
27 have failed to make a choice of managed care plan or MediPass
28 for their child and who are to be assigned to the MediPass
29 program to children's networks as described in s.
30 409.912(3)(g) and where available. The disproportionate
31 assignment of children to children's networks shall be made
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1 until the agency has determined that the children's networks
2 have sufficient numbers to be economically operated. For
3 purposes of this paragraph, when referring to assignment, the
4 term "managed care plans" includes exclusive provider
5 organizations, provider service networks, minority physician
6 networks, and pediatric emergency department diversion
7 programs authorized by this chapter or the General
8 Appropriations Act. When making assignments, the agency shall
9 take into account the following criteria:
10 1. A managed care plan has sufficient network capacity
11 to meet the need of members.
12 2. The managed care plan or MediPass has previously
13 enrolled the recipient as a member, or one of the managed care
14 plan's primary care providers or MediPass providers has
15 previously provided health care to the recipient.
16 3. The agency has knowledge that the member has
17 previously expressed a preference for a particular managed
18 care plan or MediPass provider as indicated by Medicaid
19 fee-for-service claims data, but has failed to make a choice.
20 4. The managed care plan's or MediPass primary care
21 providers are geographically accessible to the recipient's
22 residence.
23 (g) When more than one managed care plan or MediPass
24 provider meets the criteria specified in paragraph (f), the
25 agency shall make recipient assignments consecutively by
26 family unit.
27 (f)(h) The agency may not engage in practices that are
28 designed to favor one managed care plan over another or that
29 are designed to influence Medicaid recipients to enroll in
30 MediPass rather than in a managed care plan or to enroll in a
31 managed care plan rather than in MediPass. This subsection
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1 does not prohibit the agency from reporting on the performance
2 of MediPass or any managed care plan, as measured by
3 performance criteria developed by the agency.
4 (g)(i) After a recipient has made a selection or has
5 been enrolled in a managed care plan or MediPass, the
6 recipient shall have 90 days in which to voluntarily disenroll
7 and select another managed care plan or MediPass provider.
8 After 90 days, no further changes may be made except for
9 cause. Cause shall include, but not be limited to, poor
10 quality of care, lack of access to necessary specialty
11 services, an unreasonable delay or denial of service, or
12 fraudulent enrollment. The agency shall develop criteria for
13 good cause disenrollment for chronically ill and disabled
14 populations who are assigned to managed care plans if more
15 appropriate care is available through the MediPass program.
16 The agency must make a determination as to whether cause
17 exists. However, the agency may require a recipient to use
18 the managed care plan's or MediPass grievance process prior to
19 the agency's determination of cause, except in cases in which
20 immediate risk of permanent damage to the recipient's health
21 is alleged. The grievance process, when utilized, must be
22 completed in time to permit the recipient to disenroll no
23 later than the first day of the second month after the month
24 the disenrollment request was made. If the managed care plan
25 or MediPass, as a result of the grievance process, approves an
26 enrollee's request to disenroll, the agency is not required to
27 make a determination in the case. The agency must make a
28 determination and take final action on a recipient's request
29 so that disenrollment occurs no later than the first day of
30 the second month after the month the request was made. If the
31 agency fails to act within the specified timeframe, the
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1 recipient's request to disenroll is deemed to be approved as
2 of the date agency action was required. Recipients who
3 disagree with the agency's finding that cause does not exist
4 for disenrollment shall be advised of their right to pursue a
5 Medicaid fair hearing to dispute the agency's finding.
6 (h)(j) The agency shall apply for a federal waiver
7 from the Health Care Financing Administration to lock eligible
8 Medicaid recipients into a managed care plan or MediPass for
9 12 months after an open enrollment period. After 12 months'
10 enrollment, a recipient may select another managed care plan
11 or MediPass provider. However, nothing shall prevent a
12 Medicaid recipient from changing primary care providers within
13 the managed care plan or MediPass program during the 12-month
14 period. As used in this subsection, the term "managed care
15 plan" includes health maintenance organizations, prepaid
16 health plans, exclusive provider organizations, provider
17 service networks, minority physician networks, children's
18 medical service networks, and pediatric emergency department
19 diversion programs authorized by this chapter or the General
20 Appropriations Act.
21 (k) When a Medicaid recipient does not choose a
22 managed care plan or MediPass provider, the agency shall
23 assign the Medicaid recipient to a managed care plan, except
24 in those counties in which there are fewer than two managed
25 care plans accepting Medicaid enrollees, in which case
26 assignment shall be to a managed care plan or a MediPass
27 provider. Medicaid recipients in counties with fewer than two
28 managed care plans accepting Medicaid enrollees who are
29 subject to mandatory assignment but who fail to make a choice
30 shall be assigned to managed care plans until an equal
31 enrollment of 50 percent in MediPass and provider service
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1 networks and 50 percent in managed care plans is achieved.
2 Once equal enrollment is achieved, the assignments shall be
3 divided in order to maintain an equal enrollment in MediPass
4 and managed care plans. When making assignments, the agency
5 shall take into account the following criteria:
6 1. A managed care plan has sufficient network capacity
7 to meet the need of members.
8 2. The managed care plan or MediPass has previously
9 enrolled the recipient as a member, or one of the managed care
10 plan's primary care providers or MediPass providers has
11 previously provided health care to the recipient.
12 3. The agency has knowledge that the member has
13 previously expressed a preference for a particular managed
14 care plan or MediPass provider as indicated by Medicaid
15 fee-for-service claims data, but has failed to make a choice.
16 4. The managed care plan's or MediPass primary care
17 providers are geographically accessible to the recipient's
18 residence.
19 5. The agency has authority to make mandatory
20 assignments based on quality of service and performance of
21 managed care plans.
22 (3)(a) The agency shall establish quality-of-care
23 standards for managed care plans. These standards shall be
24 based upon, but are not limited to:
25 1. Compliance with the accreditation requirements as
26 provided in s. 641.512.
27 2. Compliance with Early and Periodic Screening,
28 Diagnosis, and Treatment screening requirements.
29 3. The percentage of voluntary disenrollments.
30 4. Immunization rates.
31
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1 5. Standards of the National Committee for Quality
2 Assurance and other approved accrediting bodies.
3 6. Recommendations of other authoritative bodies.
4 7. Specific requirements of the Medicaid program, or
5 standards designed to specifically assist the unique needs of
6 Medicaid recipients.
7 8. Compliance with the health quality improvement
8 system as established by the agency, which incorporates
9 standards and guidelines developed by the Medicaid Bureau of
10 the Health Care Financing Administration as part of the
11 quality assurance reform initiative.
12 (b) For the MediPass program, the agency shall
13 establish standards which are based upon, but are not limited
14 to:
15 1. Quality-of-care standards which are comparable to
16 those required of managed care plans.
17 2. Credentialing standards for MediPass providers.
18 3. Compliance with Early and Periodic Screening,
19 Diagnosis, and Treatment screening requirements.
20 4. Immunization rates.
21 5. Specific requirements of the Medicaid program, or
22 standards designed to specifically assist the unique needs of
23 Medicaid recipients.
24 (4)(a) Each female recipient may select as her primary
25 care provider an obstetrician/gynecologist who has agreed to
26 participate as a MediPass primary care case manager.
27 (b) The agency shall establish a complaints and
28 grievance process to assist Medicaid recipients enrolled in
29 the MediPass program to resolve complaints and grievances.
30 The agency shall investigate reports of quality-of-care
31
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1 grievances which remain unresolved to the satisfaction of the
2 enrollee.
3 (5)(a) The agency shall work cooperatively with the
4 Social Security Administration to identify beneficiaries who
5 are jointly eligible for Medicare and Medicaid and shall
6 develop cooperative programs to encourage these beneficiaries
7 to enroll in a Medicare participating health maintenance
8 organization or prepaid health plans.
9 (b) The agency shall work cooperatively with the
10 Department of Elderly Affairs to assess the potential
11 cost-effectiveness of providing MediPass to beneficiaries who
12 are jointly eligible for Medicare and Medicaid on a voluntary
13 choice basis. If the agency determines that enrollment of
14 these beneficiaries in MediPass has the potential for being
15 cost-effective for the state, the agency shall offer MediPass
16 to these beneficiaries on a voluntary choice basis in the
17 counties where MediPass operates.
18 (6) MediPass enrolled recipients may receive up to 10
19 visits of reimbursable services by participating Medicaid
20 physicians licensed under chapter 460 and up to four visits of
21 reimbursable services by participating Medicaid physicians
22 licensed under chapter 461. Any further visits must be by
23 prior authorization by the MediPass primary care provider.
24 However, nothing in this subsection may be construed to
25 increase the total number of visits or the total amount of
26 dollars per year per person under current Medicaid rules,
27 unless otherwise provided for in the General Appropriations
28 Act.
29 (7) The agency shall investigate the feasibility of
30 developing managed care plan and MediPass options for the
31 following groups of Medicaid recipients:
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1 (a) Pregnant women and infants.
2 (b) Elderly and disabled recipients, especially those
3 who are at risk of nursing home placement.
4 (c) Persons with developmental disabilities.
5 (d) Qualified Medicare beneficiaries.
6 (e) Adults who have chronic, high-cost medical
7 conditions.
8 (f) Adults and children who have mental health
9 problems.
10 (g) Other recipients for whom managed care plans and
11 MediPass offer the opportunity of more cost-effective care and
12 greater access to qualified providers.
13 (8)(a) The agency shall encourage the development of
14 public and private partnerships to foster the growth of health
15 maintenance organizations and prepaid health plans that will
16 provide high-quality health care to Medicaid recipients.
17 (b) Subject to the availability of moneys and any
18 limitations established by the General Appropriations Act or
19 chapter 216, the agency is authorized to enter into contracts
20 with traditional providers of health care to low-income
21 persons to assist such providers with the technical aspects of
22 cooperatively developing Medicaid prepaid health plans.
23 1. The agency may contract with disproportionate share
24 hospitals, county health departments, federally initiated or
25 federally funded community health centers, and counties that
26 operate either a hospital or a community clinic.
27 2. A contract may not be for more than $100,000 per
28 year, and no contract may be extended with any particular
29 provider for more than 2 years. The contract is intended only
30 as seed or development funding and requires a commitment from
31 the interested party.
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1 3. A contract must require participation by at least
2 one community health clinic and one disproportionate share
3 hospital.
4 (9)(a) The agency shall develop and implement a
5 comprehensive plan to ensure that recipients are adequately
6 informed of their choices and rights under all Medicaid
7 managed care programs and that Medicaid managed care programs
8 meet acceptable standards of quality in patient care, patient
9 satisfaction, and financial solvency.
10 (b) The agency shall provide adequate means for
11 informing patients of their choice and rights under a managed
12 care plan at the time of eligibility determination.
13 (c) The agency shall require managed care plans and
14 MediPass providers to demonstrate and document plans and
15 activities, as defined by rule, including outreach and
16 followup, undertaken to ensure that Medicaid recipients
17 receive the health care service to which they are entitled.
18 (10) The agency shall consult with Medicaid consumers
19 and their representatives on an ongoing basis regarding
20 measurements of patient satisfaction, procedures for resolving
21 patient grievances, standards for ensuring quality of care,
22 mechanisms for providing patient access to services, and
23 policies affecting patient care.
24 (11) The agency may extend eligibility for Medicaid
25 recipients enrolled in licensed and accredited health
26 maintenance organizations for the duration of the enrollment
27 period or for 6 months, whichever is earlier, provided the
28 agency certifies that such an offer will not increase state
29 expenditures.
30 (12) A managed care plan that has a Medicaid contract
31 shall at least annually review each primary care physician's
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1 active patient load and shall ensure that additional Medicaid
2 recipients are not assigned to physicians who have a total
3 active patient load of more than 3,000 patients. As used in
4 this subsection, the term "active patient" means a patient who
5 is seen by the same primary care physician, or by a physician
6 assistant or advanced registered nurse practitioner under the
7 supervision of the primary care physician, at least three
8 times within a calendar year. Each primary care physician
9 shall annually certify to the managed care plan whether or not
10 his or her patient load exceeds the limits established under
11 this subsection and the managed care plan shall accept such
12 certification on face value as compliance with this
13 subsection. The agency shall accept the managed care plan's
14 representations that it is in compliance with this subsection
15 based on the certification of its primary care physicians,
16 unless the agency has an objective indication that access to
17 primary care is being compromised, such as receiving
18 complaints or grievances relating to access to care. If the
19 agency determines that an objective indication exists that
20 access to primary care is being compromised, it may verify the
21 patient load certifications submitted by the managed care
22 plan's primary care physicians and that the managed care plan
23 is not assigning Medicaid recipients to primary care
24 physicians who have an active patient load of more than 3,000
25 patients.
26 Section 19. Subsection (5) of section 154.02, Florida
27 Statutes, as created by section 3 of chapter 2001-53, Laws of
28 Florida, is repealed.
29 Section 20. Except as otherwise expressly provided in
30 this act, this act shall take effect July 1, 2002.
31
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1 *****************************************
2 SENATE SUMMARY
3 Revises various provisions governing state-funded health
care services. Decreases the amount transferred to the
4 Lawton Chiles Endowment Fund for the 2002-2003 fiscal
year. Revises funding for and the services provided under
5 the Mary Brogan Breast and Cervical Cancer Early
Detection Program. Revises various eligibility
6 requirements for certain medical services, including the
Florida Kidcare program, Medicaid programs for children
7 and pregnant women, and programs for certain elderly
persons. Requires an evaluation of the Florida Kidcare
8 program. Revises requirements for reimbursements to
Medicaid providers. Revises criteria for assigning
9 Medicaid recipients to a managed care plan or to
MediPass. (See bill for details.)
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CODING: Words stricken are deletions; words underlined are additions.