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:

31

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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.

31

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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

31

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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.

30

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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.

30

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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.

31

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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.

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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

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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.

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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.)
10

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