Senate Bill sb0038E

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    Florida Senate - 2002                                  SB 38-E

    By Senator Silver





    309-2386A-02

  1                      A bill to be entitled

  2         An act relating to health care; amending s.

  3         16.59, F.S.; specifying additional requirements

  4         for the Medicaid Fraud Control Unit of the

  5         Department of Legal Affairs and the Medicaid

  6         program integrity program; amending s.

  7         112.3187, F.S.; extending whistle-blower

  8         protection to employees of Medicaid providers

  9         reporting Medicaid fraud or abuse; amending s.

10         400.179, F.S.; providing exceptions to bond

11         requirements; creating s. 408.831, F.S.;

12         allowing the Agency for Health Care

13         Administration to take action against a

14         licensee in certain circumstances; amending s.

15         409.8177, F.S.; requiring the Agency for Health

16         Care Administration to contract for an

17         evaluation of the Florida Kidcare program;

18         amending s. 409.902, F.S.; prescribing an

19         additional condition on Medicaid eligibility;

20         amending s. 409.904, F.S.; revising provisions

21         governing optional payments for medical

22         assistance and related services; amending s.

23         409.905, F.S.; providing additional criteria

24         for the agency to adjust a hospital's inpatient

25         per diem rate for Medicaid; amending s.

26         409.906, F.S.; authorizing the agency to make

27         payments for specified services which are

28         optional under Title XIX of the Social Security

29         Act; amending s. 409.9065, F.S.; revising

30         standards for pharmaceutical expense

31         assistance; amending s. 409.907, F.S.;

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    Florida Senate - 2002                                  SB 38-E
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 1         prescribing additional requirements with

 2         respect to provider enrollment; requiring that

 3         the Agency for Health Care Administration deny

 4         a provider's application under certain

 5         circumstances; amending s. 409.908, F.S.;

 6         providing additional requirements for

 7         cost-reporting; amending s. 409.910, F.S.;

 8         revising requirements for the distribution of

 9         funds recovered from third parties that are

10         liable for making payments for medical care

11         furnished to Medicaid recipients and in the

12         case of recoveries of overpayments; amending s.

13         409.912, F.S.; revising provisions governing

14         the purchase of goods and services for Medicaid

15         recipients; providing for quarterly reports to

16         the Governor and presiding officers of the

17         Legislature; amending s. 409.9116, F.S.;

18         revising the disproportionate share/financial

19         assistance program for rural hospitals;

20         amending s. 409.9122, F.S.; revising provisions

21         governing mandatory Medicaid managed care

22         enrollment; amending s. 409.913, F.S.;

23         requiring that the agency and Medicaid Fraud

24         Control Unit annually submit a report to the

25         Legislature; defining the term "complaint";

26         specifying additional requirements for the

27         Medicaid program integrity program and the

28         Medicaid Fraud Control Unit of the Department

29         of Legal Affairs; requiring imposition of

30         sanctions or disincentives, except under

31         certain circumstances; providing additional

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    Florida Senate - 2002                                  SB 38-E
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 1         sanctions and disincentives; providing

 2         additional grounds under which the agency may

 3         terminate a provider's participation in the

 4         Medicaid program; providing additional

 5         requirements for administrative hearings;

 6         providing additional grounds for withholding

 7         payments to a provider; authorizing the agency

 8         and the Medicaid Fraud Control Unit to review

 9         certain records; requiring review by the

10         Attorney General of certain settlements;

11         requiring review by the Auditor General of

12         certain cost reports; requiring that the agency

13         refund to a county any recovery of Medicaid

14         overpayment received for hospital inpatient and

15         nursing home services; providing a formula for

16         calculating the credit; amending s. 409.920,

17         F.S.; providing additional duties of the

18         Medicaid Fraud Control Unit; amending s.

19         499.012, F.S.; redefining the term "wholesale

20         distribution" with respect to regulation of

21         distribution of prescription drugs; requiring

22         the Agency for Health Care Administration to

23         conduct a study of health care services

24         provided to medically fragile or

25         medical-technology-dependent children;

26         requiring the Agency for Health Care

27         Administration to conduct a pilot program for a

28         subacute pediatric transitional care center;

29         requiring background screening of center

30         personnel; requiring the agency to amend the

31         Medicaid state plan and seek federal waivers as

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 1         necessary; requiring the center to have an

 2         advisory board; providing for membership on the

 3         advisory board; providing requirements for the

 4         admission, transfer, and discharge of a child

 5         to the center; requiring the agency to submit

 6         certain reports to the Legislature; providing

 7         guidelines for the agency to distribute

 8         disproportionate share funds during the

 9         2002-2003 fiscal year; authorizing the Agency

10         for Health Care Administration to conduct a

11         pilot project on overnight stays in an

12         ambulatory surgical center; amending s. 624.91,

13         F.S.; revising duties of the Florida Healthy

14         Kids Corporation with respect to annual

15         determination of participation in the Healthy

16         Kids Program; prescribing duties of the

17         corporation in establishing local match

18         requirements; revising the composition of the

19         board of directors; requiring recommendations

20         to the Legislature; repealing s. 414.41(5),

21         F.S., relating to interest imposed upon the

22         recovery amount of medical assistance

23         overpayments; providing for construction of

24         laws enacted at the 2002 Regular Session in

25         relation to this act; providing effective

26         dates.

27  

28  Be It Enacted by the Legislature of the State of Florida:

29  

30         Section 1.  Section 16.59, Florida Statutes, is amended

31  to read:

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    Florida Senate - 2002                                  SB 38-E
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 1         16.59  Medicaid fraud control.--There is created in the

 2  Department of Legal Affairs the Medicaid Fraud Control Unit,

 3  which may investigate all violations of s. 409.920 and any

 4  criminal violations discovered during the course of those

 5  investigations.  The Medicaid Fraud Control Unit may refer any

 6  criminal violation so uncovered to the appropriate prosecuting

 7  authority. Offices of the Medicaid Fraud Control Unit and the

 8  offices of the Agency for Health Care Administration Medicaid

 9  program integrity program shall, to the extent possible, be

10  collocated. The agency and the Department of Legal Affairs

11  shall conduct joint training and other joint activities

12  designed to increase communication and coordination in

13  recovering overpayments.

14         Section 2.  Subsections (3), (5), and (7) of section

15  112.3187, Florida Statutes, are amended to read:

16         112.3187  Adverse action against employee for

17  disclosing information of specified nature prohibited;

18  employee remedy and relief.--

19         (3)  DEFINITIONS.--As used in this act, unless

20  otherwise specified, the following words or terms shall have

21  the meanings indicated:

22         (a)  "Agency" means any state, regional, county, local,

23  or municipal government entity, whether executive, judicial,

24  or legislative; any official, officer, department, division,

25  bureau, commission, authority, or political subdivision

26  therein; or any public school, community college, or state

27  university.

28         (b)  "Employee" means a person who performs services

29  for, and under the control and direction of, or contracts

30  with, an agency or independent contractor for wages or other

31  remuneration.

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    Florida Senate - 2002                                  SB 38-E
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 1         (c)  "Adverse personnel action" means the discharge,

 2  suspension, transfer, or demotion of any employee or the

 3  withholding of bonuses, the reduction in salary or benefits,

 4  or any other adverse action taken against an employee within

 5  the terms and conditions of employment by an agency or

 6  independent contractor.

 7         (d)  "Independent contractor" means a person, other

 8  than an agency, engaged in any business and who enters into a

 9  contract or provider agreement with an agency.

10         (e)  "Gross mismanagement" means a continuous pattern

11  of managerial abuses, wrongful or arbitrary and capricious

12  actions, or fraudulent or criminal conduct which may have a

13  substantial adverse economic impact.

14         (5)  NATURE OF INFORMATION DISCLOSED.--The information

15  disclosed under this section must include:

16         (a)  Any violation or suspected violation of any

17  federal, state, or local law, rule, or regulation committed by

18  an employee or agent of an agency or independent contractor

19  which creates and presents a substantial and specific danger

20  to the public's health, safety, or welfare.

21         (b)  Any act or suspected act of gross mismanagement,

22  malfeasance, misfeasance, gross waste of public funds,

23  suspected or actual Medicaid fraud or abuse, or gross neglect

24  of duty committed by an employee or agent of an agency or

25  independent contractor.

26         (7)  EMPLOYEES AND PERSONS PROTECTED.--This section

27  protects employees and persons who disclose information on

28  their own initiative in a written and signed complaint; who

29  are requested to participate in an investigation, hearing, or

30  other inquiry conducted by any agency or federal government

31  entity; who refuse to participate in any adverse action

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    Florida Senate - 2002                                  SB 38-E
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 1  prohibited by this section; or who initiate a complaint

 2  through the whistle-blower's hotline or the hotline of the

 3  Medicaid Fraud Control Unit of the Department of Legal

 4  Affairs; or employees who file any written complaint to their

 5  supervisory officials or employees who submit a complaint to

 6  the Chief Inspector General in the Executive Office of the

 7  Governor, to the employee designated as agency inspector

 8  general under s. 112.3189(1), or to the Florida Commission on

 9  Human Relations.  The provisions of this section may not be

10  used by a person while he or she is under the care, custody,

11  or control of the state correctional system or, after release

12  from the care, custody, or control of the state correctional

13  system, with respect to circumstances that occurred during any

14  period of incarceration.  No remedy or other protection under

15  ss. 112.3187-112.31895 applies to any person who has committed

16  or intentionally participated in committing the violation or

17  suspected violation for which protection under ss.

18  112.3187-112.31895 is being sought.

19         Section 3.  Paragraph (d) of subsection (5) of section

20  400.179, Florida Statutes, is amended to read:

21         400.179  Sale or transfer of ownership of a nursing

22  facility; liability for Medicaid underpayments and

23  overpayments.--

24         (5)  Because any transfer of a nursing facility may

25  expose the fact that Medicaid may have underpaid or overpaid

26  the transferor, and because in most instances, any such

27  underpayment or overpayment can only be determined following a

28  formal field audit, the liabilities for any such underpayments

29  or overpayments shall be as follows:

30         (d)  Where the transfer involves a facility that has

31  been leased by the transferor:

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 1         1.  The transferee shall, as a condition to being

 2  issued a license by the agency, acquire, maintain, and provide

 3  proof to the agency of a bond with a term of 30 months,

 4  renewable annually, in an amount not less than the total of 3

 5  months Medicaid payments to the facility computed on the basis

 6  of the preceding 12-month average Medicaid payments to the

 7  facility.

 8         2.  The leasehold operator may meet the bond

 9  requirement through other arrangements acceptable to the

10  department.

11         3.  All existing nursing facility licensees, operating

12  the facility as a leasehold, shall acquire, maintain, and

13  provide proof to the agency of the 30-month bond required in

14  subparagraph 1., above, on and after July 1, 1993, for each

15  license renewal.

16         4.  It shall be the responsibility of all nursing

17  facility operators, operating the facility as a leasehold, to

18  renew the 30-month bond and to provide proof of such renewal

19  to the agency annually at the time of application for license

20  renewal.

21         5.  Any failure of the nursing facility operator to

22  acquire, maintain, renew annually, or provide proof to the

23  agency shall be grounds for the agency to deny, cancel,

24  revoke, or suspend the facility license to operate such

25  facility and to take any further action, including, but not

26  limited to, enjoining the facility, asserting a moratorium, or

27  applying for a receiver, deemed necessary to ensure compliance

28  with this section and to safeguard and protect the health,

29  safety, and welfare of the facility's residents.

30         6.  Notwithstanding other provisions of this section, a

31  lease agreement required as a condition of bond financing or

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 1  refinancing under s. 154.213 by a health facilities authority

 2  or under s. 159.30 by a county or municipality is not

 3  considered as a leasehold and therefore, is not subject to the

 4  bond requirement of this paragraph.

 5         Section 4.  Section 408.831, Florida Statutes, is

 6  created to read:

 7         408.831 Denial, suspension, revocation of a license,

 8  registration, certificate or application.--

 9         (1)  In addition to any other remedies provided by law,

10  the agency may deny each application or suspend or revoke each

11  license, registration, or certificate of entities regulated or

12  licensed by it:

13         (a)  If the applicant, licensee, registrant, or

14  certificateholder, or, in the case of a corporation,

15  partnership, or other business entity, if any officer,

16  director, agent, or managing employee of that business entity

17  or any affiliated person, partner, or shareholder having an

18  ownership interest equal to 5 percent or greater in that

19  business entity, has failed to pay all outstanding fines,

20  liens, or overpayments assessed by final order of the agency

21  or final order of the Centers for Medicare and Medicaid

22  Services unless a repayment plan is approved by the agency; or

23         (b)  For failure to comply with any repayment plan.

24         (2)  For all legal proceedings that may result from a

25  denial, suspension, or revocation under this section,

26  testimony or documentation from the financial entity charged

27  with monitoring such payment shall constitute evidence of the

28  failure to pay an outstanding fine, lien, or overpayment and

29  shall be sufficient grounds for the denial, suspension, or

30  revocation.

31  

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 1         (3)  This section provides standards of enforcement

 2  applicable to all entities licensed or regulated by the Agency

 3  for Health Care Administration. This section controls over any

 4  conflicting provisions of chapters 39, 381, 383, 390, 391,

 5  393, 394, 395, 400, 408, 468, 483, and 641 or rules adopted

 6  pursuant to those chapters.

 7         Section 5.  Section 409.8177, Florida Statutes, is

 8  amended to read:

 9         409.8177  Program evaluation.--

10         (1)  The agency, in consultation with the Department of

11  Health, the Department of Children and Family Services, and

12  the Florida Healthy Kids Corporation, shall contract for an

13  evaluation of the Florida Kidcare program and shall by January

14  1 of each year submit to the Governor, the President of the

15  Senate, and the Speaker of the House of Representatives a

16  report of the Florida Kidcare program. In addition to the

17  items specified under s. 2108 of Title XXI of the Social

18  Security Act, the report shall include an assessment of

19  crowd-out and access to health care, as well as the following:

20         (a)(1)  An assessment of the operation of the program,

21  including the progress made in reducing the number of

22  uncovered low-income children.

23         (b)(2)  An assessment of the effectiveness in

24  increasing the number of children with creditable health

25  coverage, including an assessment of the impact of outreach.

26         (c)(3)  The characteristics of the children and

27  families assisted under the program, including ages of the

28  children, family income, and access to or coverage by other

29  health insurance prior to the program and after disenrollment

30  from the program.

31  

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 1         (d)(4)  The quality of health coverage provided,

 2  including the types of benefits provided.

 3         (e)(5)  The amount and level, including payment of part

 4  or all of any premium, of assistance provided.

 5         (f)(6)  The average length of coverage of a child under

 6  the program.

 7         (g)(7)  The program's choice of health benefits

 8  coverage and other methods used for providing child health

 9  assistance.

10         (h)(8)  The sources of nonfederal funding used in the

11  program.

12         (i)(9)  An assessment of the effectiveness of Medikids,

13  Children's Medical Services network, and other public and

14  private programs in the state in increasing the availability

15  of affordable quality health insurance and health care for

16  children.

17         (j)(10)  A review and assessment of state activities to

18  coordinate the program with other public and private programs.

19         (k)(11)  An analysis of changes and trends in the state

20  that affect the provision of health insurance and health care

21  to children.

22         (l)(12)  A description of any plans the state has for

23  improving the availability of health insurance and health care

24  for children.

25         (m)(13)  Recommendations for improving the program.

26         (n)(14)  Other studies as necessary.

27         (2)  The agency shall also submit each month to the

28  Governor, the President of the Senate, and the Speaker of the

29  House of Representatives a report of enrollment for each

30  program component of the Florida Kidcare program.

31  

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 1         Section 6.  Section 409.902, Florida Statutes, is

 2  amended to read:

 3         409.902  Designated single state agency; payment

 4  requirements; program title; release of medical records.--The

 5  Agency for Health Care Administration is designated as the

 6  single state agency authorized to make payments for medical

 7  assistance and related services under Title XIX of the Social

 8  Security Act.  These payments shall be made, subject to any

 9  limitations or directions provided for in the General

10  Appropriations Act, only for services included in the program,

11  shall be made only on behalf of eligible individuals, and

12  shall be made only to qualified providers in accordance with

13  federal requirements for Title XIX of the Social Security Act

14  and the provisions of state law.  This program of medical

15  assistance is designated the "Medicaid program." The

16  Department of Children and Family Services is responsible for

17  Medicaid eligibility determinations, including, but not

18  limited to, policy, rules, and the agreement with the Social

19  Security Administration for Medicaid eligibility

20  determinations for Supplemental Security Income recipients, as

21  well as the actual determination of eligibility.  As a

22  condition of Medicaid eligibility, the Agency for Health Care

23  Administration and the Department of Children and Family

24  Services shall ensure that each recipient of Medicaid consents

25  to the release of her or his medical records to the Agency for

26  Health Care Administration and the Medicaid Fraud Control Unit

27  of the Department of Legal Affairs.

28         Section 7.  Effective July 1, 2002, subsection (2) of

29  section 409.904, Florida Statutes, as amended by section 2 of

30  chapter 2001-377, Laws of Florida, is amended to read:

31  

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    Florida Senate - 2002                                  SB 38-E
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 1         409.904  Optional payments for eligible persons.--The

 2  agency may make payments for medical assistance and related

 3  services on behalf of the following persons who are determined

 4  to be eligible subject to the income, assets, and categorical

 5  eligibility tests set forth in federal and state law. Payment

 6  on behalf of these Medicaid eligible persons is subject to the

 7  availability of moneys and any limitations established by the

 8  General Appropriations Act or chapter 216.

 9         (2)(a)  A caretaker relative/parent, a pregnant woman,

10  a child under age 19 who would otherwise qualify for Florida

11  Kidcare Medicaid, a child up to age 21 who would otherwise

12  qualify under s. 409.903(1), a person age 65 or over, or a

13  blind or disabled person who would otherwise be eligible for

14  Florida Medicaid, except that the income or assets of such

15  family or person exceed established limitations. A pregnant

16  woman who would otherwise qualify for Medicaid under s.

17  409.903(5) except for her level of income and whose assets

18  fall within the limits established by the Department of

19  Children and Family Services for the medically needy.  A

20  pregnant woman who applies for medically needy eligibility may

21  not be made presumptively eligible.

22         (b)  A child under age 21 who would otherwise qualify

23  for Medicaid or the Florida Kidcare program except for the

24  family's level of income and whose assets fall within the

25  limits established by the Department of Children and Family

26  Services for the medically needy.

27  

28  For a family or person in one of these coverage groups this

29  group, medical expenses are deductible from income in

30  accordance with federal requirements in order to make a

31  determination of eligibility. Expenses used to meet spend-down

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 1  liability are not reimbursable by Medicaid. Effective January

 2  1, 2003, when determining the eligibility of a pregnant woman,

 3  a child, or an aged, blind, or disabled individual, $270 will

 4  be deducted from the countable income of the filing unit. When

 5  determining the eligibility of the parent or caretaker

 6  relative as defined by Title XIX of the Social Security Act,

 7  the additional income disregard of $270 does not apply. A

 8  family or person eligible under the coverage in this group,

 9  which group is known as the "medically needy," is eligible to

10  receive the same services as other Medicaid recipients, with

11  the exception of services in skilled nursing facilities and

12  intermediate care facilities for the developmentally disabled.

13         Section 8.  Paragraph (c) of subsection (5) of section

14  409.905, Florida Statutes, is amended to read:

15         409.905  Mandatory Medicaid services.--The agency may

16  make payments for the following services, which are required

17  of the state by Title XIX of the Social Security Act,

18  furnished by Medicaid providers to recipients who are

19  determined to be eligible on the dates on which the services

20  were provided. Any service under this section shall be

21  provided only when medically necessary and in accordance with

22  state and federal law. Mandatory services rendered by

23  providers in mobile units to Medicaid recipients may be

24  restricted by the agency. Nothing in this section shall be

25  construed to prevent or limit the agency from adjusting fees,

26  reimbursement rates, lengths of stay, number of visits, number

27  of services, or any other adjustments necessary to comply with

28  the availability of moneys and any limitations or directions

29  provided for in the General Appropriations Act or chapter 216.

30         (5)  HOSPITAL INPATIENT SERVICES.--The agency shall pay

31  for all covered services provided for the medical care and

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 1  treatment of a recipient who is admitted as an inpatient by a

 2  licensed physician or dentist to a hospital licensed under

 3  part I of chapter 395.  However, the agency shall limit the

 4  payment for inpatient hospital services for a Medicaid

 5  recipient 21 years of age or older to 45 days or the number of

 6  days necessary to comply with the General Appropriations Act.

 7         (c)  Agency for Health Care Administration shall adjust

 8  a hospital's current inpatient per diem rate to reflect the

 9  cost of serving the Medicaid population at that institution

10  if:

11         1.  The hospital experiences an increase in Medicaid

12  caseload by more than 25 percent in any year, primarily

13  resulting from the closure of a hospital in the same service

14  area occurring after July 1, 1995; or

15         2.  The hospital's Medicaid per diem rate is at least

16  25 percent below the Medicaid per patient cost for that year;

17  or.

18         3.  The hospital is located in a county that has five

19  or fewer hospitals, began offering obstetrical services on or

20  after September 1999, and has submitted a request in writing

21  to the agency for a rate adjustment after July 1, 2000, but

22  before September 30, 2000, in which case such hospital's

23  Medicaid inpatient per diem rate shall be adjusted to cost,

24  effective July 1, 2002.

25  

26  No later than October 1 of each year November 1, 2001, the

27  agency must provide estimated costs for any adjustment in a

28  hospital inpatient per diem pursuant to this paragraph to the

29  Executive Office of the Governor, the House of Representatives

30  General Appropriations Committee, and the Senate

31  Appropriations Committee. Before the agency implements a

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 1  change in a hospital's inpatient per diem rate pursuant to

 2  this paragraph, the Legislature must have specifically

 3  appropriated sufficient funds in the General Appropriations

 4  Act to support the increase in cost as estimated by the

 5  agency.

 6         Section 9.  Effective July 1, 2002, subsections (1),

 7  (12), and (23) of section 409.906, Florida Statutes, as

 8  amended by section 3 of chapter 2001-377, Laws of Florida, are

 9  amended to read:

10         409.906  Optional Medicaid services.--Subject to

11  specific appropriations, the agency may make payments for

12  services which are optional to the state under Title XIX of

13  the Social Security Act and are furnished by Medicaid

14  providers to recipients who are determined to be eligible on

15  the dates on which the services were provided.  Any optional

16  service that is provided shall be provided only when medically

17  necessary and in accordance with state and federal law.

18  Optional services rendered by providers in mobile units to

19  Medicaid recipients may be restricted or prohibited by the

20  agency. Nothing in this section shall be construed to prevent

21  or limit the agency from adjusting fees, reimbursement rates,

22  lengths of stay, number of visits, or number of services, or

23  making any other adjustments necessary to comply with the

24  availability of moneys and any limitations or directions

25  provided for in the General Appropriations Act or chapter 216.

26  If necessary to safeguard the state's systems of providing

27  services to elderly and disabled persons and subject to the

28  notice and review provisions of s. 216.177, the Governor may

29  direct the Agency for Health Care Administration to amend the

30  Medicaid state plan to delete the optional Medicaid service

31  

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 1  known as "Intermediate Care Facilities for the Developmentally

 2  Disabled."  Optional services may include:

 3         (1)  ADULT DENTURE SERVICES.--The agency may pay for

 4  dentures, the procedures required to seat dentures, and the

 5  repair and reline of dentures, provided by or under the

 6  direction of a licensed dentist, for a recipient who is age 21

 7  or older. However, Medicaid will not provide reimbursement for

 8  dental services provided in a mobile dental unit, except for a

 9  mobile dental unit:

10         (a)  Owned by, operated by, or having a contractual

11  agreement with the Department of Health and complying with

12  Medicaid's county health department clinic services program

13  specifications as a county health department clinic services

14  provider.

15         (b)  Owned by, operated by, or having a contractual

16  arrangement with a federally qualified health center and

17  complying with Medicaid's federally qualified health center

18  specifications as a federally qualified health center

19  provider.

20         (c)  Rendering dental services to Medicaid recipients,

21  21 years of age and older, at nursing facilities.

22         (d)  Owned by, operated by, or having a contractual

23  agreement with a state-approved dental educational

24  institution.

25         (e)  This subsection is repealed July 1, 2002.

26         (12)  CHILDREN'S HEARING SERVICES.--The agency may pay

27  for hearing and related services, including hearing

28  evaluations, hearing aid devices, dispensing of the hearing

29  aid, and related repairs, if provided to a recipient under age

30  21 by a licensed hearing aid specialist, otolaryngologist,

31  otologist, audiologist, or physician.

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 1         (23)  CHILDREN'S VISUAL SERVICES.--The agency may pay

 2  for visual examinations, eyeglasses, and eyeglass repairs for

 3  a recipient under age 21, if they are prescribed by a licensed

 4  physician specializing in diseases of the eye or by a licensed

 5  optometrist.

 6         Section 10.  Subsection (2) of section 409.9065,

 7  Florida Statutes, as amended by section 5 of chapter 2001-377,

 8  Laws of Florida, is amended to read:

 9         409.9065  Pharmaceutical expense assistance.--

10         (2)  ELIGIBILITY.--Eligibility for the program is

11  limited to those individuals who qualify for limited

12  assistance under the Florida Medicaid program as a result of

13  being dually eligible for both Medicare and Medicaid, but

14  whose limited assistance or Medicare coverage does not include

15  any pharmacy benefit. To the extent funds are appropriated,

16  specifically eligible individuals are individuals low-income

17  senior citizens who:

18         (a)  Are Florida residents age 65 and over;

19         (b)  Have an income:

20         1.  Between 88 90 and 120 percent of the federal

21  poverty level;

22         2.  Between 88 and 150 percent of the federal poverty

23  level if the Federal Government increases the federal Medicaid

24  match for persons between 100 and 150 percent of the federal

25  poverty level; or

26         3.  Between 88 percent of the federal poverty level and

27  a level that can be supported with funds provided in the

28  General Appropriations Act for the program offered under this

29  section along with federal matching funds approved by the

30  Federal Government under a s. 1115 waiver. The agency is

31  authorized to submit and implement a federal waiver pursuant

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 1  to this subparagraph. The agency shall design a pharmacy

 2  benefit that includes annual per-member benefit limits and

 3  cost-sharing provisions and limits enrollment to available

 4  appropriations and matching federal funds. Prior to

 5  implementing this program, the agency must submit a budget

 6  amendment pursuant to chapter 216;

 7         (c)  Are eligible for both Medicare and Medicaid;

 8         (d)  Are not enrolled in a Medicare health maintenance

 9  organization that provides a pharmacy benefit; and

10         (e)  Request to be enrolled in the program.

11         Section 11.  Subsections (7) and (9) of section

12  409.907, Florida Statutes, as amended by section 6 of chapter

13  2001-377, Laws of Florida, are amended to read:

14         409.907  Medicaid provider agreements.--The agency may

15  make payments for medical assistance and related services

16  rendered to Medicaid recipients only to an individual or

17  entity who has a provider agreement in effect with the agency,

18  who is performing services or supplying goods in accordance

19  with federal, state, and local law, and who agrees that no

20  person shall, on the grounds of handicap, race, color, or

21  national origin, or for any other reason, be subjected to

22  discrimination under any program or activity for which the

23  provider receives payment from the agency.

24         (7)  The agency may require, as a condition of

25  participating in the Medicaid program and before entering into

26  the provider agreement, that the provider submit information,

27  in an initial and any required renewal applications,

28  concerning the professional, business, and personal background

29  of the provider and permit an onsite inspection of the

30  provider's service location by agency staff or other personnel

31  designated by the agency to perform this function. The agency

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 1  shall perform a random onsite inspection, within 60 days after

 2  receipt of a fully complete new provider's application, of the

 3  provider's service location prior to making its first payment

 4  to the provider for Medicaid services to determine the

 5  applicant's ability to provide the services that the applicant

 6  is proposing to provide for Medicaid reimbursement. The agency

 7  is not required to perform an onsite inspection of a provider

 8  or program that is licensed by the agency, that provides

 9  services under waiver programs for home and community-based

10  services, or that is licensed as a medical foster home by the

11  Department of Children and Family Services. As a continuing

12  condition of participation in the Medicaid program, a provider

13  shall immediately notify the agency of any current or pending

14  bankruptcy filing. Before entering into the provider

15  agreement, or as a condition of continuing participation in

16  the Medicaid program, the agency may also require that

17  Medicaid providers reimbursed on a fee-for-services basis or

18  fee schedule basis which is not cost-based, post a surety bond

19  not to exceed $50,000 or the total amount billed by the

20  provider to the program during the current or most recent

21  calendar year, whichever is greater. For new providers, the

22  amount of the surety bond shall be determined by the agency

23  based on the provider's estimate of its first year's billing.

24  If the provider's billing during the first year exceeds the

25  bond amount, the agency may require the provider to acquire an

26  additional bond equal to the actual billing level of the

27  provider. A provider's bond shall not exceed $50,000 if a

28  physician or group of physicians licensed under chapter 458,

29  chapter 459, or chapter 460 has a 50 percent or greater

30  ownership interest in the provider or if the provider is an

31  assisted living facility licensed under part III of chapter

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 1  400. The bonds permitted by this section are in addition to

 2  the bonds referenced in s. 400.179(4)(d). If the provider is a

 3  corporation, partnership, association, or other entity, the

 4  agency may require the provider to submit information

 5  concerning the background of that entity and of any principal

 6  of the entity, including any partner or shareholder having an

 7  ownership interest in the entity equal to 5 percent or

 8  greater, and any treating provider who participates in or

 9  intends to participate in Medicaid through the entity. The

10  information must include:

11         (a)  Proof of holding a valid license or operating

12  certificate, as applicable, if required by the state or local

13  jurisdiction in which the provider is located or if required

14  by the Federal Government.

15         (b)  Information concerning any prior violation, fine,

16  suspension, termination, or other administrative action taken

17  under the Medicaid laws, rules, or regulations of this state

18  or of any other state or the Federal Government; any prior

19  violation of the laws, rules, or regulations relating to the

20  Medicare program; any prior violation of the rules or

21  regulations of any other public or private insurer; and any

22  prior violation of the laws, rules, or regulations of any

23  regulatory body of this or any other state.

24         (c)  Full and accurate disclosure of any financial or

25  ownership interest that the provider, or any principal,

26  partner, or major shareholder thereof, may hold in any other

27  Medicaid provider or health care related entity or any other

28  entity that is licensed by the state to provide health or

29  residential care and treatment to persons.

30  

31  

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 1         (d)  If a group provider, identification of all members

 2  of the group and attestation that all members of the group are

 3  enrolled in or have applied to enroll in the Medicaid program.

 4         (9)  Upon receipt of a completed, signed, and dated

 5  application, and completion of any necessary background

 6  investigation and criminal history record check, the agency

 7  must either:

 8         (a)  Enroll the applicant as a Medicaid provider no

 9  earlier than the effective date of the approval of the

10  provider application. With respect to providers who were

11  recently granted a change of ownership and those who primarily

12  provide emergency medical services transportation or emergency

13  services and care pursuant to s. 401.45 or s. 395.1041, and

14  out-of-state providers, upon approval of the provider

15  application, the effective date of approval is considered to

16  be the date the agency receives the provider application; or

17         (b)  Deny the application if the agency finds that it

18  is in the best interest of the Medicaid program to do so. The

19  agency may consider the factors listed in subsection (10), as

20  well as any other factor that could affect the effective and

21  efficient administration of the program, including, but not

22  limited to, the applicant's demonstrated ability to provide

23  services, conduct business, and operate a financially viable

24  concern; the current availability of medical care, services,

25  or supplies to recipients, taking into account geographic

26  location and reasonable travel time; the number of providers

27  of the same type already enrolled in the same geographic area;

28  and the credentials, experience, success, and patient outcomes

29  of the provider for the services that it is making application

30  to provide in the Medicaid program. The agency shall deny the

31  application if the agency finds that a provider; any officer,

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 1  director, agent, managing employee, or affiliated person; or

 2  any partner or shareholder having an ownership interest equal

 3  to 5 percent or greater in the provider if the provider is a

 4  corporation, partnership, or other business entity, has failed

 5  to pay all outstanding fines or overpayments assessed by final

 6  order of the agency or final order of the Centers for Medicare

 7  and Medicaid Services, unless the provider agrees to a

 8  repayment plan that includes withholding Medicaid

 9  reimbursement until the amount due is paid in full.

10         Section 12.  Section 409.908, Florida Statutes, as

11  amended by section 7 of chapter 2001-377, Laws of Florida, is

12  amended to read:

13         409.908  Reimbursement of Medicaid providers.--Subject

14  to specific appropriations, the agency shall reimburse

15  Medicaid providers, in accordance with state and federal law,

16  according to methodologies set forth in the rules of the

17  agency and in policy manuals and handbooks incorporated by

18  reference therein.  These methodologies may include fee

19  schedules, reimbursement methods based on cost reporting,

20  negotiated fees, competitive bidding pursuant to s. 287.057,

21  and other mechanisms the agency considers efficient and

22  effective for purchasing services or goods on behalf of

23  recipients. If a provider is reimbursed based on cost

24  reporting and submits a cost report late and that cost report

25  would have been used to set a lower reimbursement rate for a

26  rate semester, then the provider's rate for that semester

27  shall be retroactively calculated using the new cost report,

28  and full payment at the recalculated rate shall be effected

29  retroactively. Medicare granted extensions for filing cost

30  reports, if applicable, shall also apply to Medicaid cost

31  reports. Payment for Medicaid compensable services made on

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 1  behalf of Medicaid eligible persons is subject to the

 2  availability of moneys and any limitations or directions

 3  provided for in the General Appropriations Act or chapter 216.

 4  Further, nothing in this section shall be construed to prevent

 5  or limit the agency from adjusting fees, reimbursement rates,

 6  lengths of stay, number of visits, or number of services, or

 7  making any other adjustments necessary to comply with the

 8  availability of moneys and any limitations or directions

 9  provided for in the General Appropriations Act, provided the

10  adjustment is consistent with legislative intent.

11         (1)  Reimbursement to hospitals licensed under part I

12  of chapter 395 must be made prospectively or on the basis of

13  negotiation.

14         (a)  Reimbursement for inpatient care is limited as

15  provided for in s. 409.905(5), except for:

16         1.  The raising of rate reimbursement caps, excluding

17  rural hospitals.

18         2.  Recognition of the costs of graduate medical

19  education.

20         3.  Other methodologies recognized in the General

21  Appropriations Act.

22         4.  Hospital inpatient rates shall be reduced by 6

23  percent effective July 1, 2001, and restored effective April

24  1, 2002.

25  

26  During the years funds are transferred from the Department of

27  Health, any reimbursement supported by such funds shall be

28  subject to certification by the Department of Health that the

29  hospital has complied with s. 381.0403. The agency is

30  authorized to receive funds from state entities, including,

31  but not limited to, the Department of Health, local

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 1  governments, and other local political subdivisions, for the

 2  purpose of making special exception payments, including

 3  federal matching funds, through the Medicaid inpatient

 4  reimbursement methodologies. Funds received from state

 5  entities or local governments for this purpose shall be

 6  separately accounted for and shall not be commingled with

 7  other state or local funds in any manner. The agency may

 8  certify all local governmental funds used as state match under

 9  Title XIX of the Social Security Act, to the extent that the

10  identified local health care provider that is otherwise

11  entitled to and is contracted to receive such local funds is

12  the benefactor under the state's Medicaid program as

13  determined under the General Appropriations Act and pursuant

14  to an agreement between the Agency for Health Care

15  Administration and the local governmental entity. The local

16  governmental entity shall use a certification form prescribed

17  by the agency. At a minimum, the certification form shall

18  identify the amount being certified and describe the

19  relationship between the certifying local governmental entity

20  and the local health care provider. The agency shall prepare

21  an annual statement of impact which documents the specific

22  activities undertaken during the previous fiscal year pursuant

23  to this paragraph, to be submitted to the Legislature no later

24  than January 1, annually.

25         (b)  Reimbursement for hospital outpatient care is

26  limited to $1,500 per state fiscal year per recipient, except

27  for:

28         1.  Such care provided to a Medicaid recipient under

29  age 21, in which case the only limitation is medical

30  necessity.

31         2.  Renal dialysis services.

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 1         3.  Other exceptions made by the agency.

 2  

 3  The agency is authorized to receive funds from state entities,

 4  including, but not limited to, the Department of Health, the

 5  Board of Regents, local governments, and other local political

 6  subdivisions, for the purpose of making payments, including

 7  federal matching funds, through the Medicaid outpatient

 8  reimbursement methodologies. Funds received from state

 9  entities and local governments for this purpose shall be

10  separately accounted for and shall not be commingled with

11  other state or local funds in any manner.

12         (c)  Hospitals that provide services to a

13  disproportionate share of low-income Medicaid recipients, or

14  that participate in the regional perinatal intensive care

15  center program under chapter 383, or that participate in the

16  statutory teaching hospital disproportionate share program may

17  receive additional reimbursement. The total amount of payment

18  for disproportionate share hospitals shall be fixed by the

19  General Appropriations Act. The computation of these payments

20  must be made in compliance with all federal regulations and

21  the methodologies described in ss. 409.911, 409.9112, and

22  409.9113.

23         (d)  The agency is authorized to limit inflationary

24  increases for outpatient hospital services as directed by the

25  General Appropriations Act.

26         (2)(a)1.  Reimbursement to nursing homes licensed under

27  part II of chapter 400 and state-owned-and-operated

28  intermediate care facilities for the developmentally disabled

29  licensed under chapter 393 must be made prospectively.

30         2.  Unless otherwise limited or directed in the General

31  Appropriations Act, reimbursement to hospitals licensed under

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 1  part I of chapter 395 for the provision of swing-bed nursing

 2  home services must be made on the basis of the average

 3  statewide nursing home payment, and reimbursement to a

 4  hospital licensed under part I of chapter 395 for the

 5  provision of skilled nursing services must be made on the

 6  basis of the average nursing home payment for those services

 7  in the county in which the hospital is located. When a

 8  hospital is located in a county that does not have any

 9  community nursing homes, reimbursement must be determined by

10  averaging the nursing home payments, in counties that surround

11  the county in which the hospital is located. Reimbursement to

12  hospitals, including Medicaid payment of Medicare copayments,

13  for skilled nursing services shall be limited to 30 days,

14  unless a prior authorization has been obtained from the

15  agency. Medicaid reimbursement may be extended by the agency

16  beyond 30 days, and approval must be based upon verification

17  by the patient's physician that the patient requires

18  short-term rehabilitative and recuperative services only, in

19  which case an extension of no more than 15 days may be

20  approved. Reimbursement to a hospital licensed under part I of

21  chapter 395 for the temporary provision of skilled nursing

22  services to nursing home residents who have been displaced as

23  the result of a natural disaster or other emergency may not

24  exceed the average county nursing home payment for those

25  services in the county in which the hospital is located and is

26  limited to the period of time which the agency considers

27  necessary for continued placement of the nursing home

28  residents in the hospital.

29         (b)  Subject to any limitations or directions provided

30  for in the General Appropriations Act, the agency shall

31  establish and implement a Florida Title XIX Long-Term Care

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 1  Reimbursement Plan (Medicaid) for nursing home care in order

 2  to provide care and services in conformance with the

 3  applicable state and federal laws, rules, regulations, and

 4  quality and safety standards and to ensure that individuals

 5  eligible for medical assistance have reasonable geographic

 6  access to such care.

 7         1.  Changes of ownership or of licensed operator do not

 8  qualify for increases in reimbursement rates associated with

 9  the change of ownership or of licensed operator. The agency

10  shall amend the Title XIX Long Term Care Reimbursement Plan to

11  provide that the initial nursing home reimbursement rates, for

12  the operating, patient care, and MAR components, associated

13  with related and unrelated party changes of ownership or

14  licensed operator filed on or after September 1, 2001, are

15  equivalent to the previous owner's reimbursement rate.

16         2.  The agency shall amend the long-term care

17  reimbursement plan and cost reporting system to create direct

18  care and indirect care subcomponents of the patient care

19  component of the per diem rate. These two subcomponents

20  together shall equal the patient care component of the per

21  diem rate. Separate cost-based ceilings shall be calculated

22  for each patient care subcomponent. The direct care

23  subcomponent of the per diem rate shall be limited by the

24  cost-based class ceiling, and the indirect care subcomponent

25  shall be limited by the lower of the cost-based class ceiling,

26  by the target rate class ceiling, or by the individual

27  provider target. The agency shall adjust the patient care

28  component effective January 1, 2002. The cost to adjust the

29  direct care subcomponent shall be net of the total funds

30  previously allocated for the case mix add-on. The agency shall

31  

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 1  make the required changes to the nursing home cost reporting

 2  forms to implement this requirement effective January 1, 2002.

 3         3.  The direct care subcomponent shall include salaries

 4  and benefits of direct care staff providing nursing services

 5  including registered nurses, licensed practical nurses, and

 6  certified nursing assistants who deliver care directly to

 7  residents in the nursing home facility. This excludes nursing

 8  administration, MDS, and care plan coordinators, staff

 9  development, and staffing coordinator.

10         4.  All other patient care costs shall be included in

11  the indirect care cost subcomponent of the patient care per

12  diem rate. There shall be no costs directly or indirectly

13  allocated to the direct care subcomponent from a home office

14  or management company.

15         5.  On July 1 of each year, the agency shall report to

16  the Legislature direct and indirect care costs, including

17  average direct and indirect care costs per resident per

18  facility and direct care and indirect care salaries and

19  benefits per category of staff member per facility.

20         6.  Under the plan, interim rate adjustments shall not

21  be granted to reflect increases in the cost of general or

22  professional liability insurance for nursing homes unless the

23  following criteria are met: have at least a 65 percent

24  Medicaid utilization in the most recent cost report submitted

25  to the agency, and the increase in general or professional

26  liability costs to the facility for the most recent policy

27  period affects the total Medicaid per diem by at least 5

28  percent. This rate adjustment shall not result in the per diem

29  exceeding the class ceiling. This provision shall be

30  implemented to the extent existing appropriations are

31  available.

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 1  

 2  It is the intent of the Legislature that the reimbursement

 3  plan achieve the goal of providing access to health care for

 4  nursing home residents who require large amounts of care while

 5  encouraging diversion services as an alternative to nursing

 6  home care for residents who can be served within the

 7  community. The agency shall base the establishment of any

 8  maximum rate of payment, whether overall or component, on the

 9  available moneys as provided for in the General Appropriations

10  Act. The agency may base the maximum rate of payment on the

11  results of scientifically valid analysis and conclusions

12  derived from objective statistical data pertinent to the

13  particular maximum rate of payment.

14         (3)  Subject to any limitations or directions provided

15  for in the General Appropriations Act, the following Medicaid

16  services and goods may be reimbursed on a fee-for-service

17  basis. For each allowable service or goods furnished in

18  accordance with Medicaid rules, policy manuals, handbooks, and

19  state and federal law, the payment shall be the amount billed

20  by the provider, the provider's usual and customary charge, or

21  the maximum allowable fee established by the agency, whichever

22  amount is less, with the exception of those services or goods

23  for which the agency makes payment using a methodology based

24  on capitation rates, average costs, or negotiated fees.

25         (a)  Advanced registered nurse practitioner services.

26         (b)  Birth center services.

27         (c)  Chiropractic services.

28         (d)  Community mental health services.

29         (e)  Dental services, including oral and maxillofacial

30  surgery.

31         (f)  Durable medical equipment.

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 1         (g)  Hearing services.

 2         (h)  Occupational therapy for Medicaid recipients under

 3  age 21.

 4         (i)  Optometric services.

 5         (j)  Orthodontic services.

 6         (k)  Personal care for Medicaid recipients under age

 7  21.

 8         (l)  Physical therapy for Medicaid recipients under age

 9  21.

10         (m)  Physician assistant services.

11         (n)  Podiatric services.

12         (o)  Portable X-ray services.

13         (p)  Private-duty nursing for Medicaid recipients under

14  age 21.

15         (q)  Registered nurse first assistant services.

16         (r)  Respiratory therapy for Medicaid recipients under

17  age 21.

18         (s)  Speech therapy for Medicaid recipients under age

19  21.

20         (t)  Visual services.

21         (4)  Subject to any limitations or directions provided

22  for in the General Appropriations Act, alternative health

23  plans, health maintenance organizations, and prepaid health

24  plans shall be reimbursed a fixed, prepaid amount negotiated,

25  or competitively bid pursuant to s. 287.057, by the agency and

26  prospectively paid to the provider monthly for each Medicaid

27  recipient enrolled.  The amount may not exceed the average

28  amount the agency determines it would have paid, based on

29  claims experience, for recipients in the same or similar

30  category of eligibility.  The agency shall calculate

31  capitation rates on a regional basis and, beginning September

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 1  1, 1995, shall include age-band differentials in such

 2  calculations. Effective July 1, 2001, the cost of exempting

 3  statutory teaching hospitals, specialty hospitals, and

 4  community hospital education program hospitals from

 5  reimbursement ceilings and the cost of special Medicaid

 6  payments shall not be included in premiums paid to health

 7  maintenance organizations or prepaid health care plans. Each

 8  rate semester, the agency shall calculate and publish a

 9  Medicaid hospital rate schedule that does not reflect either

10  special Medicaid payments or the elimination of rate

11  reimbursement ceilings, to be used by hospitals and Medicaid

12  health maintenance organizations, in order to determine the

13  Medicaid rate referred to in ss. 409.912(16), 409.9128(5), and

14  641.513(6).

15         (5)  An ambulatory surgical center shall be reimbursed

16  the lesser of the amount billed by the provider or the

17  Medicare-established allowable amount for the facility.

18         (6)  A provider of early and periodic screening,

19  diagnosis, and treatment services to Medicaid recipients who

20  are children under age 21 shall be reimbursed using an

21  all-inclusive rate stipulated in a fee schedule established by

22  the agency. A provider of the visual, dental, and hearing

23  components of such services shall be reimbursed the lesser of

24  the amount billed by the provider or the Medicaid maximum

25  allowable fee established by the agency.

26         (7)  A provider of family planning services shall be

27  reimbursed the lesser of the amount billed by the provider or

28  an all-inclusive amount per type of visit for physicians and

29  advanced registered nurse practitioners, as established by the

30  agency in a fee schedule.

31  

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 1         (8)  A provider of home-based or community-based

 2  services rendered pursuant to a federally approved waiver

 3  shall be reimbursed based on an established or negotiated rate

 4  for each service. These rates shall be established according

 5  to an analysis of the expenditure history and prospective

 6  budget developed by each contract provider participating in

 7  the waiver program, or under any other methodology adopted by

 8  the agency and approved by the Federal Government in

 9  accordance with the waiver. Effective July 1, 1996, privately

10  owned and operated community-based residential facilities

11  which meet agency requirements and which formerly received

12  Medicaid reimbursement for the optional intermediate care

13  facility for the mentally retarded service may participate in

14  the developmental services waiver as part of a

15  home-and-community-based continuum of care for Medicaid

16  recipients who receive waiver services.

17         (9)  A provider of home health care services or of

18  medical supplies and appliances shall be reimbursed on the

19  basis of competitive bidding or for the lesser of the amount

20  billed by the provider or the agency's established maximum

21  allowable amount, except that, in the case of the rental of

22  durable medical equipment, the total rental payments may not

23  exceed the purchase price of the equipment over its expected

24  useful life or the agency's established maximum allowable

25  amount, whichever amount is less.

26         (10)  A hospice shall be reimbursed through a

27  prospective system for each Medicaid hospice patient at

28  Medicaid rates using the methodology established for hospice

29  reimbursement pursuant to Title XVIII of the federal Social

30  Security Act.

31  

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 1         (11)  A provider of independent laboratory services

 2  shall be reimbursed on the basis of competitive bidding or for

 3  the least of the amount billed by the provider, the provider's

 4  usual and customary charge, or the Medicaid maximum allowable

 5  fee established by the agency.

 6         (12)(a)  A physician shall be reimbursed the lesser of

 7  the amount billed by the provider or the Medicaid maximum

 8  allowable fee established by the agency.

 9         (b)  The agency shall adopt a fee schedule, subject to

10  any limitations or directions provided for in the General

11  Appropriations Act, based on a resource-based relative value

12  scale for pricing Medicaid physician services. Under this fee

13  schedule, physicians shall be paid a dollar amount for each

14  service based on the average resources required to provide the

15  service, including, but not limited to, estimates of average

16  physician time and effort, practice expense, and the costs of

17  professional liability insurance.  The fee schedule shall

18  provide increased reimbursement for preventive and primary

19  care services and lowered reimbursement for specialty services

20  by using at least two conversion factors, one for cognitive

21  services and another for procedural services.  The fee

22  schedule shall not increase total Medicaid physician

23  expenditures unless moneys are available, and shall be phased

24  in over a 2-year period beginning on July 1, 1994. The Agency

25  for Health Care Administration shall seek the advice of a

26  16-member advisory panel in formulating and adopting the fee

27  schedule.  The panel shall consist of Medicaid physicians

28  licensed under chapters 458 and 459 and shall be composed of

29  50 percent primary care physicians and 50 percent specialty

30  care physicians.

31  

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 1         (c)  Notwithstanding paragraph (b), reimbursement fees

 2  to physicians for providing total obstetrical services to

 3  Medicaid recipients, which include prenatal, delivery, and

 4  postpartum care, shall be at least $1,500 per delivery for a

 5  pregnant woman with low medical risk and at least $2,000 per

 6  delivery for a pregnant woman with high medical risk. However,

 7  reimbursement to physicians working in Regional Perinatal

 8  Intensive Care Centers designated pursuant to chapter 383, for

 9  services to certain pregnant Medicaid recipients with a high

10  medical risk, may be made according to obstetrical care and

11  neonatal care groupings and rates established by the agency.

12  Nurse midwives licensed under part I of chapter 464 or

13  midwives licensed under chapter 467 shall be reimbursed at no

14  less than 80 percent of the low medical risk fee. The agency

15  shall by rule determine, for the purpose of this paragraph,

16  what constitutes a high or low medical risk pregnant woman and

17  shall not pay more based solely on the fact that a caesarean

18  section was performed, rather than a vaginal delivery. The

19  agency shall by rule determine a prorated payment for

20  obstetrical services in cases where only part of the total

21  prenatal, delivery, or postpartum care was performed. The

22  Department of Health shall adopt rules for appropriate

23  insurance coverage for midwives licensed under chapter 467.

24  Prior to the issuance and renewal of an active license, or

25  reactivation of an inactive license for midwives licensed

26  under chapter 467, such licensees shall submit proof of

27  coverage with each application.

28         (d)  For fiscal years 2001-2002 and 2002-2003 the

29  2001-2002 fiscal year only and if necessary to meet the

30  requirements for grants and donations for the special Medicaid

31  payments authorized in the 2001-2002 and 2002-2003 General

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 1  Appropriations Acts Act, the agency may make special Medicaid

 2  payments to qualified Medicaid providers designated by the

 3  agency, notwithstanding any provision of this subsection to

 4  the contrary, and may use intergovernmental transfers from

 5  state entities or other governmental entities to serve as the

 6  state share of such payments.

 7         (13)  Medicare premiums for persons eligible for both

 8  Medicare and Medicaid coverage shall be paid at the rates

 9  established by Title XVIII of the Social Security Act.  For

10  Medicare services rendered to Medicaid-eligible persons,

11  Medicaid shall pay Medicare deductibles and coinsurance as

12  follows:

13         (a)  Medicaid shall make no payment toward deductibles

14  and coinsurance for any service that is not covered by

15  Medicaid.

16         (b)  Medicaid's financial obligation for deductibles

17  and coinsurance payments shall be based on Medicare allowable

18  fees, not on a provider's billed charges.

19         (c)  Medicaid will pay no portion of Medicare

20  deductibles and coinsurance when payment that Medicare has

21  made for the service equals or exceeds what Medicaid would

22  have paid if it had been the sole payor.  The combined payment

23  of Medicare and Medicaid shall not exceed the amount Medicaid

24  would have paid had it been the sole payor. The Legislature

25  finds that there has been confusion regarding the

26  reimbursement for services rendered to dually eligible

27  Medicare beneficiaries. Accordingly, the Legislature clarifies

28  that it has always been the intent of the Legislature before

29  and after 1991 that, in reimbursing in accordance with fees

30  established by Title XVIII for premiums, deductibles, and

31  coinsurance for Medicare services rendered by physicians to

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 1  Medicaid eligible persons, physicians be reimbursed at the

 2  lesser of the amount billed by the physician or the Medicaid

 3  maximum allowable fee established by the Agency for Health

 4  Care Administration, as is permitted by federal law. It has

 5  never been the intent of the Legislature with regard to such

 6  services rendered by physicians that Medicaid be required to

 7  provide any payment for deductibles, coinsurance, or

 8  copayments for Medicare cost sharing, or any expenses incurred

 9  relating thereto, in excess of the payment amount provided for

10  under the State Medicaid plan for such service. This payment

11  methodology is applicable even in those situations in which

12  the payment for Medicare cost sharing for a qualified Medicare

13  beneficiary with respect to an item or service is reduced or

14  eliminated. This expression of the Legislature is in

15  clarification of existing law and shall apply to payment for,

16  and with respect to provider agreements with respect to, items

17  or services furnished on or after the effective date of this

18  act. This paragraph applies to payment by Medicaid for items

19  and services furnished before the effective date of this act

20  if such payment is the subject of a lawsuit that is based on

21  the provisions of this section, and that is pending as of, or

22  is initiated after, the effective date of this act.

23         (d)  Notwithstanding paragraphs (a)-(c):

24         1.  Medicaid payments for Nursing Home Medicare part A

25  coinsurance shall be the lesser of the Medicare coinsurance

26  amount or the Medicaid nursing home per diem rate.

27         2.  Medicaid shall pay all deductibles and coinsurance

28  for Medicare-eligible recipients receiving freestanding end

29  stage renal dialysis center services.

30         3.  Medicaid payments for general hospital inpatient

31  services shall be limited to the Medicare deductible per spell

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 1  of illness.  Medicaid shall make no payment toward coinsurance

 2  for Medicare general hospital inpatient services.

 3         4.  Medicaid shall pay all deductibles and coinsurance

 4  for Medicare emergency transportation services provided by

 5  ambulances licensed pursuant to chapter 401.

 6         (14)  A provider of prescribed drugs shall be

 7  reimbursed the least of the amount billed by the provider, the

 8  provider's usual and customary charge, or the Medicaid maximum

 9  allowable fee established by the agency, plus a dispensing

10  fee. The agency is directed to implement a variable dispensing

11  fee for payments for prescribed medicines while ensuring

12  continued access for Medicaid recipients.  The variable

13  dispensing fee may be based upon, but not limited to, either

14  or both the volume of prescriptions dispensed by a specific

15  pharmacy provider, the volume of prescriptions dispensed to an

16  individual recipient, and dispensing of preferred-drug-list

17  products. The agency shall increase the pharmacy dispensing

18  fee authorized by statute and in the annual General

19  Appropriations Act by $0.50 for the dispensing of a Medicaid

20  preferred-drug-list product and reduce the pharmacy dispensing

21  fee by $0.50 for the dispensing of a Medicaid product that is

22  not included on the preferred-drug list. The agency is

23  authorized to limit reimbursement for prescribed medicine in

24  order to comply with any limitations or directions provided

25  for in the General Appropriations Act, which may include

26  implementing a prospective or concurrent utilization review

27  program.

28         (15)  A provider of primary care case management

29  services rendered pursuant to a federally approved waiver

30  shall be reimbursed by payment of a fixed, prepaid monthly sum

31  for each Medicaid recipient enrolled with the provider.

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 1         (16)  A provider of rural health clinic services and

 2  federally qualified health center services shall be reimbursed

 3  a rate per visit based on total reasonable costs of the

 4  clinic, as determined by the agency in accordance with federal

 5  regulations.

 6         (17)  A provider of targeted case management services

 7  shall be reimbursed pursuant to an established fee, except

 8  where the Federal Government requires a public provider be

 9  reimbursed on the basis of average actual costs.

10         (18)  Unless otherwise provided for in the General

11  Appropriations Act, a provider of transportation services

12  shall be reimbursed the lesser of the amount billed by the

13  provider or the Medicaid maximum allowable fee established by

14  the agency, except when the agency has entered into a direct

15  contract with the provider, or with a community transportation

16  coordinator, for the provision of an all-inclusive service, or

17  when services are provided pursuant to an agreement negotiated

18  between the agency and the provider.  The agency, as provided

19  for in s. 427.0135, shall purchase transportation services

20  through the community coordinated transportation system, if

21  available, unless the agency determines a more cost-effective

22  method for Medicaid clients. Nothing in this subsection shall

23  be construed to limit or preclude the agency from contracting

24  for services using a prepaid capitation rate or from

25  establishing maximum fee schedules, individualized

26  reimbursement policies by provider type, negotiated fees,

27  prior authorization, competitive bidding, increased use of

28  mass transit, or any other mechanism that the agency considers

29  efficient and effective for the purchase of services on behalf

30  of Medicaid clients, including implementing a transportation

31  eligibility process. The agency shall not be required to

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 1  contract with any community transportation coordinator or

 2  transportation operator that has been determined by the

 3  agency, the Department of Legal Affairs Medicaid Fraud Control

 4  Unit, or any other state or federal agency to have engaged in

 5  any abusive or fraudulent billing activities. The agency is

 6  authorized to competitively procure transportation services or

 7  make other changes necessary to secure approval of federal

 8  waivers needed to permit federal financing of Medicaid

 9  transportation services at the service matching rate rather

10  than the administrative matching rate.

11         (19)  County health department services may be

12  reimbursed a rate per visit based on total reasonable costs of

13  the clinic, as determined by the agency in accordance with

14  federal regulations under the authority of 42 C.F.R. s.

15  431.615.

16         (20)  A renal dialysis facility that provides dialysis

17  services under s. 409.906(9) must be reimbursed the lesser of

18  the amount billed by the provider, the provider's usual and

19  customary charge, or the maximum allowable fee established by

20  the agency, whichever amount is less.

21         (21)  The agency shall reimburse school districts which

22  certify the state match pursuant to ss. 236.0812 and 409.9071

23  for the federal portion of the school district's allowable

24  costs to deliver the services, based on the reimbursement

25  schedule.  The school district shall determine the costs for

26  delivering services as authorized in ss. 236.0812 and 409.9071

27  for which the state match will be certified. Reimbursement of

28  school-based providers is contingent on such providers being

29  enrolled as Medicaid providers and meeting the qualifications

30  contained in 42 C.F.R. s. 440.110, unless otherwise waived by

31  the federal Health Care Financing Administration. Speech

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 1  therapy providers who are certified through the Department of

 2  Education pursuant to rule 6A-4.0176, Florida Administrative

 3  Code, are eligible for reimbursement for services that are

 4  provided on school premises. Any employee of the school

 5  district who has been fingerprinted and has received a

 6  criminal background check in accordance with Department of

 7  Education rules and guidelines shall be exempt from any agency

 8  requirements relating to criminal background checks.

 9         (22)  The agency shall request and implement Medicaid

10  waivers from the federal Health Care Financing Administration

11  to advance and treat a portion of the Medicaid nursing home

12  per diem as capital for creating and operating a

13  risk-retention group for self-insurance purposes, consistent

14  with federal and state laws and rules.

15         Section 13.  Paragraph (b) of subsection (7) of section

16  409.910, Florida Statutes, is amended to read:

17         409.910  Responsibility for payments on behalf of

18  Medicaid-eligible persons when other parties are liable.--

19         (7)  The agency shall recover the full amount of all

20  medical assistance provided by Medicaid on behalf of the

21  recipient to the full extent of third-party benefits.

22         (b)  Upon receipt of any recovery or other collection

23  pursuant to this section, the agency shall distribute the

24  amount collected as follows:

25         1.  To itself, an amount equal to the state Medicaid

26  expenditures for the recipient plus any incentive payment made

27  in accordance with paragraph (14)(a). From this share the

28  agency shall credit a county on its county billing invoice the

29  county's proportionate share of Medicaid third-party

30  recoveries in the areas of estate recoveries and casualty

31  claims, minus the agency's cost of recovering the third-party

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 1  payments, based on the county's percentage of the sum of total

 2  county billing divided by total Medicaid expenditures.

 3  However, if a county has been billed for its participation but

 4  has not paid the amount due, the agency shall offset that

 5  amount and notify the county of the amount of the offset. If

 6  the county has divided its financial responsibility between

 7  the county and a special taxing district or authority as

 8  contemplated in s. 409.915(6), the county must proportionately

 9  divide any refund or offset in accordance with the proration

10  that it has established.

11         2.  To the Federal Government, the federal share of the

12  state Medicaid expenditures minus any incentive payment made

13  in accordance with paragraph (14)(a) and federal law, and

14  minus any other amount permitted by federal law to be

15  deducted.

16         3.  To the recipient, after deducting any known amounts

17  owed to the agency for any related medical assistance or to

18  health care providers, any remaining amount. This amount shall

19  be treated as income or resources in determining eligibility

20  for Medicaid.

21  

22  The provisions of this subsection do not apply to any proceeds

23  received by the state, or any agency thereof, pursuant to a

24  final order, judgment, or settlement agreement, in any matter

25  in which the state asserts claims brought on its own behalf,

26  and not as a subrogee of a recipient, or under other theories

27  of liability. The provisions of this subsection do not apply

28  to any proceeds received by the state, or an agency thereof,

29  pursuant to a final order, judgment, or settlement agreement,

30  in any matter in which the state asserted both claims as a

31  subrogee and additional claims, except as to those sums

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 1  specifically identified in the final order, judgment, or

 2  settlement agreement as reimbursements to the recipient as

 3  expenditures for the named recipient on the subrogation claim.

 4         Section 14.  Paragraph (g) of subsection (3) and

 5  paragraph (c) of subsection (37) of section 409.912, Florida

 6  Statutes, as amended by sections 8 and 9 of chapter 2001-377,

 7  Laws of Florida, are amended to read:

 8         409.912  Cost-effective purchasing of health care.--The

 9  agency shall purchase goods and services for Medicaid

10  recipients in the most cost-effective manner consistent with

11  the delivery of quality medical care.  The agency shall

12  maximize the use of prepaid per capita and prepaid aggregate

13  fixed-sum basis services when appropriate and other

14  alternative service delivery and reimbursement methodologies,

15  including competitive bidding pursuant to s. 287.057, designed

16  to facilitate the cost-effective purchase of a case-managed

17  continuum of care. The agency shall also require providers to

18  minimize the exposure of recipients to the need for acute

19  inpatient, custodial, and other institutional care and the

20  inappropriate or unnecessary use of high-cost services. The

21  agency may establish prior authorization requirements for

22  certain populations of Medicaid beneficiaries, certain drug

23  classes, or particular drugs to prevent fraud, abuse, overuse,

24  and possible dangerous drug interactions. The Pharmaceutical

25  and Therapeutics Committee shall make recommendations to the

26  agency on drugs for which prior authorization is required. The

27  agency shall inform the Pharmaceutical and Therapeutics

28  Committee of its decisions regarding drugs subject to prior

29  authorization.

30         (3)  The agency may contract with:

31  

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 1         (g)  Children's provider networks that provide care

 2  coordination and care management for Medicaid-eligible

 3  pediatric patients, primary care, authorization of specialty

 4  care, and other urgent and emergency care through organized

 5  providers designed to service Medicaid eligibles under age 18

 6  and pediatric emergency departments' diversion programs. The

 7  networks shall provide after-hour operations, including

 8  evening and weekend hours, to promote, when appropriate, the

 9  use of the children's networks rather than hospital emergency

10  departments.

11         (37)

12         (c)  The agency shall submit quarterly reports a report

13  to the Governor, the President of the Senate, and the Speaker

14  of the House of Representatives which by January 15 of each

15  year. The report must include, but need not be limited to, the

16  progress made in implementing this subsection and its Medicaid

17  cost-containment measures and their effect on Medicaid

18  prescribed-drug expenditures.

19         Section 15.  Subsection (7) of section 409.9116,

20  Florida Statutes, is amended to read:

21         409.9116  Disproportionate share/financial assistance

22  program for rural hospitals.--In addition to the payments made

23  under s. 409.911, the Agency for Health Care Administration

24  shall administer a federally matched disproportionate share

25  program and a state-funded financial assistance program for

26  statutory rural hospitals. The agency shall make

27  disproportionate share payments to statutory rural hospitals

28  that qualify for such payments and financial assistance

29  payments to statutory rural hospitals that do not qualify for

30  disproportionate share payments. The disproportionate share

31  program payments shall be limited by and conform with federal

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 1  requirements. Funds shall be distributed quarterly in each

 2  fiscal year for which an appropriation is made.

 3  Notwithstanding the provisions of s. 409.915, counties are

 4  exempt from contributing toward the cost of this special

 5  reimbursement for hospitals serving a disproportionate share

 6  of low-income patients.

 7         (7)  This section applies only to hospitals that were

 8  defined as statutory rural hospitals, or their

 9  successor-in-interest hospital, prior to January 1, 2001 July

10  1, 1998. Any additional hospital that is defined as a

11  statutory rural hospital, or its successor-in-interest

12  hospital, on or after January 1, 2001 July 1, 1998, is not

13  eligible for programs under this section unless additional

14  funds are appropriated each fiscal year specifically to the

15  rural hospital disproportionate share and financial assistance

16  programs in an amount necessary to prevent any hospital, or

17  its successor-in-interest hospital, eligible for the programs

18  prior to January 1, 2001 July 1, 1998, from incurring a

19  reduction in payments because of the eligibility of an

20  additional hospital to participate in the programs. A

21  hospital, or its successor-in-interest hospital, which

22  received funds pursuant to this section before January 1, 2001

23  July 1, 1998, and which qualifies under s. 395.602(2)(e),

24  shall be included in the programs under this section and is

25  not required to seek additional appropriations under this

26  subsection.

27         Section 16.  Paragraphs (f) and (k) of subsection (2)

28  of section 409.9122, Florida Statutes, as amended by section

29  11 of chapter 2001-377, Laws of Florida, are amended to read:

30         409.9122  Mandatory Medicaid managed care enrollment;

31  programs and procedures.--

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 1         (2)

 2         (f)  When a Medicaid recipient does not choose a

 3  managed care plan or MediPass provider, the agency shall

 4  assign the Medicaid recipient to a managed care plan or

 5  MediPass provider. Medicaid recipients who are subject to

 6  mandatory assignment but who fail to make a choice shall be

 7  assigned to managed care plans or provider service networks

 8  until an equal enrollment of 45 50 percent in MediPass and 55

 9  50 percent in managed care plans is achieved.  Once that equal

10  enrollment is achieved, the assignments shall be divided in

11  order to maintain an equal enrollment in MediPass and managed

12  care plans which is in a 45 percent and 55 percent proportion,

13  respectively. Thereafter, assignment of Medicaid recipients

14  who fail to make a choice shall be based proportionally on the

15  preferences of recipients who have made a choice in the

16  previous period. Such proportions shall be revised at least

17  quarterly to reflect an update of the preferences of Medicaid

18  recipients. The agency shall also disproportionately assign

19  Medicaid-eligible children in families who are required to but

20  have failed to make a choice of managed care plan or MediPass

21  for their child and who are to be assigned to the MediPass

22  program or managed care plans to children's networks as

23  described in s. 409.912(3)(g) and where available. The

24  disproportionate assignment of children to children's networks

25  shall be made until the agency has determined that the

26  children's networks have sufficient numbers to be economically

27  operated. For purposes of this section paragraph, when

28  referring to assignment, the term "managed care plans"

29  includes health maintenance organizations, exclusive provider

30  organizations, provider service networks, minority physician

31  networks, children's medical service networks, and pediatric

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 1  emergency department diversion programs authorized by this

 2  chapter or the General Appropriations Act. When making

 3  assignments, the agency shall take into account the following

 4  criteria:

 5         1.  A managed care plan has sufficient network capacity

 6  to meet the need of members.

 7         2.  The managed care plan or MediPass has previously

 8  enrolled the recipient as a member, or one of the managed care

 9  plan's primary care providers or MediPass providers has

10  previously provided health care to the recipient.

11         3.  The agency has knowledge that the member has

12  previously expressed a preference for a particular managed

13  care plan or MediPass provider as indicated by Medicaid

14  fee-for-service claims data, but has failed to make a choice.

15         4.  The managed care plan's or MediPass primary care

16  providers are geographically accessible to the recipient's

17  residence.

18         (k)  When a Medicaid recipient does not choose a

19  managed care plan or MediPass provider, the agency shall

20  assign the Medicaid recipient to a managed care plan, except

21  in those counties in which there are fewer than two managed

22  care plans accepting Medicaid enrollees, in which case

23  assignment shall be to a managed care plan or a MediPass

24  provider. Medicaid recipients in counties with fewer than two

25  managed care plans accepting Medicaid enrollees who are

26  subject to mandatory assignment but who fail to make a choice

27  shall be assigned to managed care plans until an equal

28  enrollment of 45 50 percent in MediPass and provider service

29  networks and 55 50 percent in managed care plans is achieved.

30  Once that equal enrollment is achieved, the assignments shall

31  be divided in order to maintain an equal enrollment in

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 1  MediPass and managed care plans which is in a 45 percent and

 2  55 percent proportion, respectively. When making assignments,

 3  the agency shall take into account the following criteria:

 4         1.  A managed care plan has sufficient network capacity

 5  to meet the need of members.

 6         2.  The managed care plan or MediPass has previously

 7  enrolled the recipient as a member, or one of the managed care

 8  plan's primary care providers or MediPass providers has

 9  previously provided health care to the recipient.

10         3.  The agency has knowledge that the member has

11  previously expressed a preference for a particular managed

12  care plan or MediPass provider as indicated by Medicaid

13  fee-for-service claims data, but has failed to make a choice.

14         4.  The managed care plan's or MediPass primary care

15  providers are geographically accessible to the recipient's

16  residence.

17         5.  The agency has authority to make mandatory

18  assignments based on quality of service and performance of

19  managed care plans.

20         Section 17.  Section 409.913, Florida Statutes, as

21  amended by section 12 of chapter 2001-377, Laws of Florida, is

22  amended to read:

23         409.913  Oversight of the integrity of the Medicaid

24  program.--The agency shall operate a program to oversee the

25  activities of Florida Medicaid recipients, and providers and

26  their representatives, to ensure that fraudulent and abusive

27  behavior and neglect of recipients occur to the minimum extent

28  possible, and to recover overpayments and impose sanctions as

29  appropriate. Beginning January 1, 2003, and each year

30  thereafter, the agency and the Medicaid Fraud Control Unit of

31  the Department of Legal Affairs shall submit a joint report to

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 1  the Legislature documenting the effectiveness of the state's

 2  efforts to control Medicaid fraud and abuse and to recover

 3  Medicaid overpayments during the previous fiscal year. The

 4  report must describe the number of cases opened and

 5  investigated each year; the sources of the cases opened; the

 6  disposition of the cases closed each year; the amount of

 7  overpayments alleged in preliminary and final audit letters;

 8  the number and amount of fines or penalties imposed; any

 9  reductions in overpayment amounts negotiated in settlement

10  agreements or by other means; the amount of final agency

11  determinations of overpayments; the amount deducted from

12  federal claiming as a result of overpayments; the amount of

13  overpayments recovered each year; the amount of cost of

14  investigation recovered each year; the average length of time

15  to collect from the time the case was opened until the

16  overpayment is paid in full; the amount determined as

17  uncollectible and the portion of the uncollectible amount

18  subsequently reclaimed from the Federal Government; the number

19  of providers, by type, that are terminated from participation

20  in the Medicaid program as a result of fraud and abuse; and

21  all costs associated with discovering and prosecuting cases of

22  Medicaid overpayments and making recoveries in such cases. The

23  report must also document actions taken to prevent

24  overpayments and the number of providers prevented from

25  enrolling in or reenrolling in the Medicaid program as a

26  result of documented Medicaid fraud and abuse and must

27  recommend changes necessary to prevent or recover

28  overpayments.  For the 2001-2002 fiscal year, the agency shall

29  prepare a report that contains as much of this information as

30  is available to it.

31         (1)  For the purposes of this section, the term:

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 1         (a)  "Abuse" means:

 2         1.  Provider practices that are inconsistent with

 3  generally accepted business or medical practices and that

 4  result in an unnecessary cost to the Medicaid program or in

 5  reimbursement for goods or services that are not medically

 6  necessary or that fail to meet professionally recognized

 7  standards for health care.

 8         2.  Recipient practices that result in unnecessary cost

 9  to the Medicaid program.

10         (b)  "Complaint" means an allegation that fraud, abuse

11  or an overpayment has occurred.

12         (c)(b)  "Fraud" means an intentional deception or

13  misrepresentation made by a person with the knowledge that the

14  deception results in unauthorized benefit to herself or

15  himself or another person.  The term includes any act that

16  constitutes fraud under applicable federal or state law.

17         (d)(c)  "Medical necessity" or "medically necessary"

18  means any goods or services necessary to palliate the effects

19  of a terminal condition, or to prevent, diagnose, correct,

20  cure, alleviate, or preclude deterioration of a condition that

21  threatens life, causes pain or suffering, or results in

22  illness or infirmity, which goods or services are provided in

23  accordance with generally accepted standards of medical

24  practice.  For purposes of determining Medicaid reimbursement,

25  the agency is the final arbiter of medical necessity.

26  Determinations of medical necessity must be made by a licensed

27  physician employed by or under contract with the agency and

28  must be based upon information available at the time the goods

29  or services are provided.

30         (e)(d)  "Overpayment" includes any amount that is not

31  authorized to be paid by the Medicaid program whether paid as

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 1  a result of inaccurate or improper cost reporting, improper

 2  claiming, unacceptable practices, fraud, abuse, or mistake.

 3         (f)(e)  "Person" means any natural person, corporation,

 4  partnership, association, clinic, group, or other entity,

 5  whether or not such person is enrolled in the Medicaid program

 6  or is a provider of health care.

 7         (2)  The agency shall conduct, or cause to be conducted

 8  by contract or otherwise, reviews, investigations, analyses,

 9  audits, or any combination thereof, to determine possible

10  fraud, abuse, overpayment, or recipient neglect in the

11  Medicaid program and shall report the findings of any

12  overpayments in audit reports as appropriate.

13         (3)  The agency may conduct, or may contract for,

14  prepayment review of provider claims to ensure cost-effective

15  purchasing, billing, and provision of care to Medicaid

16  recipients.  Such prepayment reviews may be conducted as

17  determined appropriate by the agency, without any suspicion or

18  allegation of fraud, abuse, or neglect.

19         (4)  Any suspected criminal violation identified by the

20  agency must be referred to the Medicaid Fraud Control Unit of

21  the Office of the Attorney General for investigation. The

22  agency and the Attorney General shall enter into a memorandum

23  of understanding, which must include, but need not be limited

24  to, a protocol for regularly sharing information and

25  coordinating casework.  The protocol must establish a

26  procedure for the referral by the agency of cases involving

27  suspected Medicaid fraud to the Medicaid Fraud Control Unit

28  for investigation, and the return to the agency of those cases

29  where investigation determines that administrative action by

30  the agency is appropriate. Offices of the Medicaid program

31  integrity program and the Medicaid Fraud Control Unit of the

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 1  Department of Legal Affairs, shall, to the extent possible, be

 2  collocated. The agency and the Department of Legal Affairs

 3  shall periodically conduct joint training and other joint

 4  activities designed to increase communication and coordination

 5  in recovering overpayments.

 6         (5)  A Medicaid provider is subject to having goods and

 7  services that are paid for by the Medicaid program reviewed by

 8  an appropriate peer-review organization designated by the

 9  agency. The written findings of the applicable peer-review

10  organization are admissible in any court or administrative

11  proceeding as evidence of medical necessity or the lack

12  thereof.

13         (6)  Any notice required to be given to a provider

14  under this section is presumed to be sufficient notice if sent

15  to the address last shown on the provider enrollment file.  It

16  is the responsibility of the provider to furnish and keep the

17  agency informed of the provider's current address. United

18  States Postal Service proof of mailing or certified or

19  registered mailing of such notice to the provider at the

20  address shown on the provider enrollment file constitutes

21  sufficient proof of notice. Any notice required to be given to

22  the agency by this section must be sent to the agency at an

23  address designated by rule.

24         (7)  When presenting a claim for payment under the

25  Medicaid program, a provider has an affirmative duty to

26  supervise the provision of, and be responsible for, goods and

27  services claimed to have been provided, to supervise and be

28  responsible for preparation and submission of the claim, and

29  to present a claim that is true and accurate and that is for

30  goods and services that:

31  

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 1         (a)  Have actually been furnished to the recipient by

 2  the provider prior to submitting the claim.

 3         (b)  Are Medicaid-covered goods or services that are

 4  medically necessary.

 5         (c)  Are of a quality comparable to those furnished to

 6  the general public by the provider's peers.

 7         (d)  Have not been billed in whole or in part to a

 8  recipient or a recipient's responsible party, except for such

 9  copayments, coinsurance, or deductibles as are authorized by

10  the agency.

11         (e)  Are provided in accord with applicable provisions

12  of all Medicaid rules, regulations, handbooks, and policies

13  and in accordance with federal, state, and local law.

14         (f)  Are documented by records made at the time the

15  goods or services were provided, demonstrating the medical

16  necessity for the goods or services rendered. Medicaid goods

17  or services are excessive or not medically necessary unless

18  both the medical basis and the specific need for them are

19  fully and properly documented in the recipient's medical

20  record.

21         (8)  A Medicaid provider shall retain medical,

22  professional, financial, and business records pertaining to

23  services and goods furnished to a Medicaid recipient and

24  billed to Medicaid for a period of 5 years after the date of

25  furnishing such services or goods. The agency may investigate,

26  review, or analyze such records, which must be made available

27  during normal business hours. However, 24-hour notice must be

28  provided if patient treatment would be disrupted. The provider

29  is responsible for furnishing to the agency, and keeping the

30  agency informed of the location of, the provider's

31  Medicaid-related records.  The authority of the agency to

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 1  obtain Medicaid-related records from a provider is neither

 2  curtailed nor limited during a period of litigation between

 3  the agency and the provider.

 4         (9)  Payments for the services of billing agents or

 5  persons participating in the preparation of a Medicaid claim

 6  shall not be based on amounts for which they bill nor based on

 7  the amount a provider receives from the Medicaid program.

 8         (10)  The agency may require repayment for

 9  inappropriate, medically unnecessary, or excessive goods or

10  services from the person furnishing them, the person under

11  whose supervision they were furnished, or the person causing

12  them to be furnished.

13         (11)  The complaint and all information obtained

14  pursuant to an investigation of a Medicaid provider, or the

15  authorized representative or agent of a provider, relating to

16  an allegation of fraud, abuse, or neglect are confidential and

17  exempt from the provisions of s. 119.07(1):

18         (a)  Until the agency takes final agency action with

19  respect to the provider and requires repayment of any

20  overpayment, or imposes an administrative sanction;

21         (b)  Until the Attorney General refers the case for

22  criminal prosecution;

23         (c)  Until 10 days after the complaint is determined

24  without merit; or

25         (d)  At all times if the complaint or information is

26  otherwise protected by law.

27         (12)  The agency may terminate participation of a

28  Medicaid provider in the Medicaid program and may seek civil

29  remedies or impose other administrative sanctions against a

30  Medicaid provider, if the provider has been:

31  

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 1         (a)  Convicted of a criminal offense related to the

 2  delivery of any health care goods or services, including the

 3  performance of management or administrative functions relating

 4  to the delivery of health care goods or services;

 5         (b)  Convicted of a criminal offense under federal law

 6  or the law of any state relating to the practice of the

 7  provider's profession; or

 8         (c)  Found by a court of competent jurisdiction to have

 9  neglected or physically abused a patient in connection with

10  the delivery of health care goods or services.

11         (13)  If the provider has been suspended or terminated

12  from participation in the Medicaid program or the Medicare

13  program by the Federal Government or any state, the agency

14  must immediately suspend or terminate, as appropriate, the

15  provider's participation in the Florida Medicaid program for a

16  period no less than that imposed by the Federal Government or

17  any other state, and may not enroll such provider in the

18  Florida Medicaid program while such foreign suspension or

19  termination remains in effect.  This sanction is in addition

20  to all other remedies provided by law.

21         (14)  The agency may seek any remedy provided by law,

22  including, but not limited to, the remedies provided in

23  subsections (12) and (15) and s. 812.035, if:

24         (a)  The provider's license has not been renewed, or

25  has been revoked, suspended, or terminated, for cause, by the

26  licensing agency of any state;

27         (b)  The provider has failed to make available or has

28  refused access to Medicaid-related records to an auditor,

29  investigator, or other authorized employee or agent of the

30  agency, the Attorney General, a state attorney, or the Federal

31  Government;

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 1         (c)  The provider has not furnished or has failed to

 2  make available such Medicaid-related records as the agency has

 3  found necessary to determine whether Medicaid payments are or

 4  were due and the amounts thereof;

 5         (d)  The provider has failed to maintain medical

 6  records made at the time of service, or prior to service if

 7  prior authorization is required, demonstrating the necessity

 8  and appropriateness of the goods or services rendered;

 9         (e)  The provider is not in compliance with provisions

10  of Medicaid provider publications that have been adopted by

11  reference as rules in the Florida Administrative Code; with

12  provisions of state or federal laws, rules, or regulations;

13  with provisions of the provider agreement between the agency

14  and the provider; or with certifications found on claim forms

15  or on transmittal forms for electronically submitted claims

16  that are submitted by the provider or authorized

17  representative, as such provisions apply to the Medicaid

18  program;

19         (f)  The provider or person who ordered or prescribed

20  the care, services, or supplies has furnished, or ordered the

21  furnishing of, goods or services to a recipient which are

22  inappropriate, unnecessary, excessive, or harmful to the

23  recipient or are of inferior quality;

24         (g)  The provider has demonstrated a pattern of failure

25  to provide goods or services that are medically necessary;

26         (h)  The provider or an authorized representative of

27  the provider, or a person who ordered or prescribed the goods

28  or services, has submitted or caused to be submitted false or

29  a pattern of erroneous Medicaid claims that have resulted in

30  overpayments to a provider or that exceed those to which the

31  provider was entitled under the Medicaid program;

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 1         (i)  The provider or an authorized representative of

 2  the provider, or a person who has ordered or prescribed the

 3  goods or services, has submitted or caused to be submitted a

 4  Medicaid provider enrollment application, a request for prior

 5  authorization for Medicaid services, a drug exception request,

 6  or a Medicaid cost report that contains materially false or

 7  incorrect information;

 8         (j)  The provider or an authorized representative of

 9  the provider has collected from or billed a recipient or a

10  recipient's responsible party improperly for amounts that

11  should not have been so collected or billed by reason of the

12  provider's billing the Medicaid program for the same service;

13         (k)  The provider or an authorized representative of

14  the provider has included in a cost report costs that are not

15  allowable under a Florida Title XIX reimbursement plan, after

16  the provider or authorized representative had been advised in

17  an audit exit conference or audit report that the costs were

18  not allowable;

19         (l)  The provider is charged by information or

20  indictment with fraudulent billing practices.  The sanction

21  applied for this reason is limited to suspension of the

22  provider's participation in the Medicaid program for the

23  duration of the indictment unless the provider is found guilty

24  pursuant to the information or indictment;

25         (m)  The provider or a person who has ordered, or

26  prescribed the goods or services is found liable for negligent

27  practice resulting in death or injury to the provider's

28  patient;

29         (n)  The provider fails to demonstrate that it had

30  available during a specific audit or review period sufficient

31  quantities of goods, or sufficient time in the case of

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 1  services, to support the provider's billings to the Medicaid

 2  program;

 3         (o)  The provider has failed to comply with the notice

 4  and reporting requirements of s. 409.907; or

 5         (p)  The agency has received reliable information of

 6  patient abuse or neglect or of any act prohibited by s.

 7  409.920; or.

 8         (q)  The provider has failed to comply with an

 9  agreed-upon repayment schedule.

10         (15)  The agency shall may impose any of the following

11  sanctions or disincentives on a provider or a person for any

12  of the acts described in subsection (14):

13         (a)  Suspension for a specific period of time of not

14  more than 1 year.

15         (b)  Termination for a specific period of time of from

16  more than 1 year to 20 years.

17         (c)  Imposition of a fine of up to $5,000 for each

18  violation.  Each day that an ongoing violation continues, such

19  as refusing to furnish Medicaid-related records or refusing

20  access to records, is considered, for the purposes of this

21  section, to be a separate violation.  Each instance of

22  improper billing of a Medicaid recipient; each instance of

23  including an unallowable cost on a hospital or nursing home

24  Medicaid cost report after the provider or authorized

25  representative has been advised in an audit exit conference or

26  previous audit report of the cost unallowability; each

27  instance of furnishing a Medicaid recipient goods or

28  professional services that are inappropriate or of inferior

29  quality as determined by competent peer judgment; each

30  instance of knowingly submitting a materially false or

31  erroneous Medicaid provider enrollment application, request

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 1  for prior authorization for Medicaid services, drug exception

 2  request, or cost report; each instance of inappropriate

 3  prescribing of drugs for a Medicaid recipient as determined by

 4  competent peer judgment; and each false or erroneous Medicaid

 5  claim leading to an overpayment to a provider is considered,

 6  for the purposes of this section, to be a separate violation.

 7         (d)  Immediate suspension, if the agency has received

 8  information of patient abuse or neglect or of any act

 9  prohibited by s. 409.920. Upon suspension, the agency must

10  issue an immediate final order under s. 120.569(2)(n).

11         (e)  A fine, not to exceed $10,000, for a violation of

12  paragraph (14)(i).

13         (f)  Imposition of liens against provider assets,

14  including, but not limited to, financial assets and real

15  property, not to exceed the amount of fines or recoveries

16  sought, upon entry of an order determining that such moneys

17  are due or recoverable.

18         (g)  Prepayment reviews of claims for a specified

19  period of time.

20         (h)  Comprehensive follow-up reviews of providers every

21  6 months to ensure that they are billing Medicaid correctly.

22         (i)  Corrective-action plans that would remain in

23  effect for providers for up to 3 years and that would be

24  monitored by the agency every 6 months while in effect.

25         (j)(g)  Other remedies as permitted by law to effect

26  the recovery of a fine or overpayment.

27  

28  The Secretary of Health Care Administration may make a

29  determination that imposition of a sanction or disincentive is

30  not in the best interest of the Medicaid program, in which

31  case a sanction or disincentive shall not be imposed.

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 1         (16)  In determining the appropriate administrative

 2  sanction to be applied, or the duration of any suspension or

 3  termination, the agency shall consider:

 4         (a)  The seriousness and extent of the violation or

 5  violations.

 6         (b)  Any prior history of violations by the provider

 7  relating to the delivery of health care programs which

 8  resulted in either a criminal conviction or in administrative

 9  sanction or penalty.

10         (c)  Evidence of continued violation within the

11  provider's management control of Medicaid statutes, rules,

12  regulations, or policies after written notification to the

13  provider of improper practice or instance of violation.

14         (d)  The effect, if any, on the quality of medical care

15  provided to Medicaid recipients as a result of the acts of the

16  provider.

17         (e)  Any action by a licensing agency respecting the

18  provider in any state in which the provider operates or has

19  operated.

20         (f)  The apparent impact on access by recipients to

21  Medicaid services if the provider is suspended or terminated,

22  in the best judgment of the agency.

23  

24  The agency shall document the basis for all sanctioning

25  actions and recommendations.

26         (17)  The agency may take action to sanction, suspend,

27  or terminate a particular provider working for a group

28  provider, and may suspend or terminate Medicaid participation

29  at a specific location, rather than or in addition to taking

30  action against an entire group.

31  

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 1         (18)  The agency shall establish a process for

 2  conducting followup reviews of a sampling of providers who

 3  have a history of overpayment under the Medicaid program.

 4  This process must consider the magnitude of previous fraud or

 5  abuse and the potential effect of continued fraud or abuse on

 6  Medicaid costs.

 7         (19)  In making a determination of overpayment to a

 8  provider, the agency must use accepted and valid auditing,

 9  accounting, analytical, statistical, or peer-review methods,

10  or combinations thereof. Appropriate statistical methods may

11  include, but are not limited to, sampling and extension to the

12  population, parametric and nonparametric statistics, tests of

13  hypotheses, and other generally accepted statistical methods.

14  Appropriate analytical methods may include, but are not

15  limited to, reviews to determine variances between the

16  quantities of products that a provider had on hand and

17  available to be purveyed to Medicaid recipients during the

18  review period and the quantities of the same products paid for

19  by the Medicaid program for the same period, taking into

20  appropriate consideration sales of the same products to

21  non-Medicaid customers during the same period.  In meeting its

22  burden of proof in any administrative or court proceeding, the

23  agency may introduce the results of such statistical methods

24  as evidence of overpayment.

25         (20)  When making a determination that an overpayment

26  has occurred, the agency shall prepare and issue an audit

27  report to the provider showing the calculation of

28  overpayments.

29         (21)  The audit report, supported by agency work

30  papers, showing an overpayment to a provider constitutes

31  evidence of the overpayment. A provider may not present or

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 1  elicit testimony, either on direct examination or

 2  cross-examination in any court or administrative proceeding,

 3  regarding the purchase or acquisition by any means of drugs,

 4  goods, or supplies; sales or divestment by any means of drugs,

 5  goods, or supplies; or inventory of drugs, goods, or supplies,

 6  unless such acquisition, sales, divestment, or inventory is

 7  documented by written invoices, written inventory records, or

 8  other competent written documentary evidence maintained in the

 9  normal course of the provider's business. Notwithstanding the

10  applicable rules of discovery, all documentation that will be

11  offered as evidence at an administrative hearing on a Medicaid

12  overpayment must be exchanged by all parties at least 14 days

13  before the administrative hearing or must be excluded from

14  consideration.

15         (22)(a)  In an audit or investigation of a violation

16  committed by a provider which is conducted pursuant to this

17  section, the agency is entitled to recover all investigative,

18  legal, and expert witness costs if the agency's findings were

19  not contested by the provider or, if contested, the agency

20  ultimately prevailed.

21         (b)  The agency has the burden of documenting the

22  costs, which include salaries and employee benefits and

23  out-of-pocket expenses. The amount of costs that may be

24  recovered must be reasonable in relation to the seriousness of

25  the violation and must be set taking into consideration the

26  financial resources, earning ability, and needs of the

27  provider, who has the burden of demonstrating such factors.

28         (c)  The provider may pay the costs over a period to be

29  determined by the agency if the agency determines that an

30  extreme hardship would result to the provider from immediate

31  

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 1  full payment.  Any default in payment of costs may be

 2  collected by any means authorized by law.

 3         (23)  If the agency imposes an administrative sanction

 4  under this section upon any provider or other person who is

 5  regulated by another state entity, the agency shall notify

 6  that other entity of the imposition of the sanction.  Such

 7  notification must include the provider's or person's name and

 8  license number and the specific reasons for sanction.

 9         (24)(a)  The agency may withhold Medicaid payments, in

10  whole or in part, to a provider upon receipt of reliable

11  evidence that the circumstances giving rise to the need for a

12  withholding of payments involve fraud, willful

13  misrepresentation, or abuse under the Medicaid program, or a

14  crime committed while rendering goods or services to Medicaid

15  recipients, pending completion of legal proceedings. If it is

16  determined that fraud, willful misrepresentation, abuse, or a

17  crime did not occur, the payments withheld must be paid to the

18  provider within 14 days after such determination with interest

19  at the rate of 10 percent a year. Any money withheld in

20  accordance with this paragraph shall be placed in a suspended

21  account, readily accessible to the agency, so that any payment

22  ultimately due the provider shall be made within 14 days.

23         (b)  Overpayments owed to the agency bear interest at

24  the rate of 10 percent per year from the date of determination

25  of the overpayment by the agency, and payment arrangements

26  must be made at the conclusion of legal proceedings. A

27  provider who does not enter into or adhere to an agreed-upon

28  repayment schedule may be terminated by the agency for

29  nonpayment or partial payment.

30         (c)  The agency, upon entry of a final agency order, a

31  judgment or order of a court of competent jurisdiction, or a

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 1  stipulation or settlement, may collect the moneys owed by all

 2  means allowable by law, including, but not limited to,

 3  notifying any fiscal intermediary of Medicare benefits that

 4  the state has a superior right of payment.  Upon receipt of

 5  such written notification, the Medicare fiscal intermediary

 6  shall remit to the state the sum claimed.

 7         (25)  The agency may impose administrative sanctions

 8  against a Medicaid recipient, or the agency may seek any other

 9  remedy provided by law, including, but not limited to, the

10  remedies provided in s. 812.035, if the agency finds that a

11  recipient has engaged in solicitation in violation of s.

12  409.920 or that the recipient has otherwise abused the

13  Medicaid program.

14         (26)  When the Agency for Health Care Administration

15  has made a probable cause determination and alleged that an

16  overpayment to a Medicaid provider has occurred, the agency,

17  after notice to the provider, may:

18         (a)  Withhold, and continue to withhold during the

19  pendency of an administrative hearing pursuant to chapter 120,

20  any medical assistance reimbursement payments until such time

21  as the overpayment is recovered, unless within 30 days after

22  receiving notice thereof the provider:

23         1.  Makes repayment in full; or

24         2.  Establishes a repayment plan that is satisfactory

25  to the Agency for Health Care Administration.

26         (b)  Withhold, and continue to withhold during the

27  pendency of an administrative hearing pursuant to chapter 120,

28  medical assistance reimbursement payments if the terms of a

29  repayment plan are not adhered to by the provider.

30  

31  

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 1  If a provider requests an administrative hearing pursuant to

 2  chapter 120, such hearing must be conducted within 90 days

 3  following receipt by the provider of the final audit report,

 4  absent exceptionally good cause shown as determined by the

 5  administrative law judge or hearing officer. Upon issuance of

 6  a final order, the balance outstanding of the amount

 7  determined to constitute the overpayment shall become due. Any

 8  withholding of payments by the Agency for Health Care

 9  Administration pursuant to this section shall be limited so

10  that the monthly medical assistance payment is not reduced by

11  more than 10 percent.

12         (27)  Venue for all Medicaid program integrity

13  overpayment cases shall lie in Leon County, at the discretion

14  of the agency.

15         (28)  Notwithstanding other provisions of law, the

16  agency and the Medicaid Fraud Control Unit of the Department

17  of Legal Affairs may review a provider's Medicaid-related

18  records in order to determine the total output of a provider's

19  practice to reconcile quantities of goods or services billed

20  to Medicaid against quantities of goods or services used in

21  the provider's total practice.

22         (29)  The agency may terminate a provider's

23  participation in the Medicaid program if the provider fails to

24  reimburse an overpayment that has been determined by final

25  order within 35 days after the date of the final order, unless

26  the provider and the agency have entered into a repayment

27  agreement. If the final order is overturned on appeal, the

28  provider shall be reinstated.

29         (30)  If a provider requests an administrative hearing

30  pursuant to chapter 120, such hearing must be conducted within

31  90 days following assignment of an administrative law judge,

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 1  absent exceptionally good cause shown as determined by the

 2  administrative law judge or hearing officer. Upon issuance of

 3  a final order, the outstanding balance of the amount

 4  determined to constitute the overpayment shall become due. If

 5  a provider fails to make payments in full, fails to enter into

 6  a satisfactory repayment plan, or fails to comply with the

 7  terms of a repayment plan or settlement agreement, the agency

 8  may withhold medical-assistance-reimbursement payments until

 9  the amount due is paid in full.

10         (31)  Duly authorized agents and employees of the

11  agency shall have the power to inspect, during normal business

12  hours, the records of any pharmacy, wholesale establishment,

13  or manufacturer, or any other place in which drugs and medical

14  supplies are manufactured, packed, packaged, made, stored,

15  sold, or kept for sale, for the purpose of verifying the

16  amount of drugs and medical supplies ordered, delivered, or

17  purchased by a provider. The agency shall provide at least 2

18  business days' prior notice of any such inspection. The notice

19  must identify the provider whose records will be inspected,

20  and the inspection shall include only records specifically

21  related to that provider.

22         (32)  The agency shall request that the Attorney

23  General review any settlement of an overpayment in which the

24  agency reduces the amount due to the state by $10,000 or more.

25         (33)  With respect to recoveries of Medicaid

26  overpayments collected by the agency, by September 30 each

27  year the agency shall credit a county on its county billing

28  invoices for the county's proportionate share of Medicaid

29  overpayments recovered during the previous fiscal year from

30  hospitals for inpatient services and from nursing homes.

31  However, if a county has been billed for its participation but

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 1  has not paid the amount due, the agency shall offset that

 2  amount and notify the county of the amount of the offset. If

 3  the county has divided its financial responsibility between

 4  the county and a special taxing district or authority as

 5  provided in s. 409.915(6), the county must proportionately

 6  divide any credit or offset in accordance with the proration

 7  that it has established. The credit or offset shall be

 8  calculated separately for inpatient and nursing home services

 9  as follows:

10         (a)  The state share of the amount recovered from

11  hospitals for inpatient services and from nursing homes for

12  which the county has not previously received credit;

13         (b)  Less the state share of the agency's cost of

14  recovering such payment; and

15         (c)  Multiplied by the total county share. The total

16  county share shall be calculated as the sum of total county

17  billing for inpatient services and nursing home services,

18  respectively, divided by the state share of Medicaid

19  expenditures for inpatient services and nursing home services,

20  respectively.

21  

22  The credit given to each county shall be its proportionate

23  share of the total county share calculated under paragraph

24  (c).

25         Section 18.  Subsections (7) and (8) of section

26  409.920, Florida Statutes, are amended to read:

27         409.920  Medicaid provider fraud.--

28         (7)  The Attorney General shall conduct a statewide

29  program of Medicaid fraud control. To accomplish this purpose,

30  the Attorney General shall:

31  

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 1         (a)  Investigate the possible criminal violation of any

 2  applicable state law pertaining to fraud in the administration

 3  of the Medicaid program, in the provision of medical

 4  assistance, or in the activities of providers of health care

 5  under the Medicaid program.

 6         (b)  Investigate the alleged abuse or neglect of

 7  patients in health care facilities receiving payments under

 8  the Medicaid program, in coordination with the agency.

 9         (c)  Investigate the alleged misappropriation of

10  patients' private funds in health care facilities receiving

11  payments under the Medicaid program.

12         (d)  Refer to the Office of Statewide Prosecution or

13  the appropriate state attorney all violations indicating a

14  substantial potential for criminal prosecution.

15         (e)  Refer to the agency all suspected abusive

16  activities not of a criminal or fraudulent nature.

17         (f)  Refer to the agency for collection each instance

18  of overpayment to a provider of health care under the Medicaid

19  program which is discovered during the course of an

20  investigation.

21         (f)(g)  Safeguard the privacy rights of all individuals

22  and provide safeguards to prevent the use of patient medical

23  records for any reason beyond the scope of a specific

24  investigation for fraud or abuse, or both, without the

25  patient's written consent.

26         (g)  Publicize to state employees and the public the

27  ability of persons to bring suit under the provisions of the

28  Florida False Claims Act and the potential for the persons

29  bring a civil action under the Florida False Claims Act to

30  obtain a monetary award.

31  

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 1         (8)  In carrying out the duties and responsibilities

 2  under this section subsection, the Attorney General may:

 3         (a)  Enter upon the premises of any health care

 4  provider, excluding a physician, participating in the Medicaid

 5  program to examine all accounts and records that may, in any

 6  manner, be relevant in determining the existence of fraud in

 7  the Medicaid program, to investigate alleged abuse or neglect

 8  of patients, or to investigate alleged misappropriation of

 9  patients' private funds. A participating physician is required

10  to make available any accounts or records that may, in any

11  manner, be relevant in determining the existence of fraud in

12  the Medicaid program. The accounts or records of a

13  non-Medicaid patient may not be reviewed by, or turned over

14  to, the Attorney General without the patient's written

15  consent.

16         (b)  Subpoena witnesses or materials, including medical

17  records relating to Medicaid recipients, within or outside the

18  state and, through any duly designated employee, administer

19  oaths and affirmations and collect evidence for possible use

20  in either civil or criminal judicial proceedings.

21         (c)  Request and receive the assistance of any state

22  attorney or law enforcement agency in the investigation and

23  prosecution of any violation of this section.

24         (d)  Seek any civil remedy provided by law, including,

25  but not limited to, the remedies provided in ss.

26  68.081-68.092, s. 812.035, and this chapter.

27         (e)  Refer to the agency for collection each instance

28  of overpayment to a provider of health care under the Medicaid

29  program which is discovered during the course of an

30  investigation.

31  

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 1         Section 19.  Paragraph (a) of subsection (1) of section

 2  499.012, Florida Statutes, is amended to read:

 3         499.012  Wholesale distribution; definitions; permits;

 4  general requirements.--

 5         (1)  As used in this section, the term:

 6         (a)  "Wholesale distribution" means distribution of

 7  prescription drugs to persons other than a consumer or

 8  patient, but does not include:

 9         1.  Any of the following activities, which is not a

10  violation of s. 499.005(21) if such activity is conducted in

11  accordance with s. 499.014:

12         a.  The purchase or other acquisition by a hospital or

13  other health care entity that is a member of a group

14  purchasing organization of a prescription drug for its own use

15  from the group purchasing organization or from other hospitals

16  or health care entities that are members of that organization.

17         b.  The sale, purchase, or trade of a prescription drug

18  or an offer to sell, purchase, or trade a prescription drug by

19  a charitable organization described in s. 501(c)(3) of the

20  Internal Revenue Code of 1986, as amended and revised, to a

21  nonprofit affiliate of the organization to the extent

22  otherwise permitted by law.

23         c.  The sale, purchase, or trade of a prescription drug

24  or an offer to sell, purchase, or trade a prescription drug

25  among hospitals or other health care entities that are under

26  common control. For purposes of this section, "common control"

27  means the power to direct or cause the direction of the

28  management and policies of a person or an organization,

29  whether by ownership of stock, by voting rights, by contract,

30  or otherwise.

31  

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 1         d.  The sale, purchase, trade, or other transfer of a

 2  prescription drug from or for any federal, state, or local

 3  government agency or any entity eligible to purchase

 4  prescription drugs at public health services prices pursuant

 5  to Pub. L. No. 102-585, s. 602 to a contract provider or its

 6  subcontractor for eligible patients of the agency or entity

 7  under the following conditions:

 8         (I)  The agency or entity must obtain written

 9  authorization for the sale, purchase, trade, or other transfer

10  of a prescription drug under this sub-subparagraph from the

11  Secretary of Health or his or her designee.

12         (II)  The contract provider or subcontractor must be

13  authorized by law to administer or dispense prescription

14  drugs.

15         (III)  In the case of a subcontractor, the agency or

16  entity must be a party to and execute the subcontract.

17         (IV)  A contract provider or subcontractor must

18  maintain separate and apart from other prescription drug

19  inventory any prescription drugs of the agency or entity in

20  its possession.

21         (V)  The contract provider and subcontractor must

22  maintain and produce immediately for inspection all records of

23  movement or transfer of all the prescription drugs belonging

24  to the agency or entity, including, but not limited to, the

25  records of receipt and disposition of prescription drugs. Each

26  contractor and subcontractor dispensing or administering these

27  drugs must maintain and produce records documenting the

28  dispensing or administration. Records that are required to be

29  maintained include, but are not limited to, a perpetual

30  inventory itemizing drugs received and drugs dispensed by

31  

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 1  prescription number or administered by patient identifier,

 2  which must be submitted to the agency or entity quarterly.

 3         (VI)  The contract provider or subcontractor may

 4  administer or dispense the prescription drugs only to the

 5  eligible patients of the agency or entity or must return the

 6  prescription drugs for or to the agency or entity. The

 7  contract provider or subcontractor must require proof from

 8  each person seeking to fill a prescription or obtain treatment

 9  that the person is an eligible patient of the agency or entity

10  and must, at a minimum, maintain a copy of this proof as part

11  of the records of the contractor or subcontractor required

12  under sub-sub-subparagraph (V).

13         (VII)  The prescription drugs transferred pursuant to

14  this sub-subparagraph may not be billed to Medicaid.

15         (VII)(VIII)  In addition to the departmental inspection

16  authority set forth in s. 499.051, the establishment of the

17  contract provider and subcontractor and all records pertaining

18  to prescription drugs subject to this sub-subparagraph shall

19  be subject to inspection by the agency or entity.  All records

20  relating to prescription drugs of a manufacturer under this

21  sub-subparagraph shall be subject to audit by the manufacturer

22  of those drugs, without identifying individual patient

23  information.

24         2.  Any of the following activities, which is not a

25  violation of s. 499.005(21) if such activity is conducted in

26  accordance with rules established by the department:

27         a.  The sale, purchase, or trade of a prescription drug

28  among federal, state, or local government health care entities

29  that are under common control and are authorized to purchase

30  such prescription drug.

31  

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 1         b.  The sale, purchase, or trade of a prescription drug

 2  or an offer to sell, purchase, or trade a prescription drug

 3  for emergency medical reasons. For purposes of this

 4  sub-subparagraph, the term "emergency medical reasons"

 5  includes transfers of prescription drugs by a retail pharmacy

 6  to another retail pharmacy to alleviate a temporary shortage.

 7         c.  The transfer of a prescription drug acquired by a

 8  medical director on behalf of a licensed emergency medical

 9  services provider to that emergency medical services provider

10  and its transport vehicles for use in accordance with the

11  provider's license under chapter 401.

12         d.  The revocation of a sale or the return of a

13  prescription drug to the person's prescription drug wholesale

14  supplier.

15         e.  The donation of a prescription drug by a health

16  care entity to a charitable organization that has been granted

17  an exemption under s. 501(c)(3) of the Internal Revenue Code

18  of 1986, as amended, and that is authorized to possess

19  prescription drugs.

20         f.  The transfer of a prescription drug by a person

21  authorized to purchase or receive prescription drugs to a

22  person licensed or permitted to handle reverse distributions

23  or destruction under the laws of the jurisdiction in which the

24  person handling the reverse distribution or destruction

25  receives the drug.

26         3.  The distribution of prescription drug samples by

27  manufacturers' representatives or distributors'

28  representatives conducted in accordance with s. 499.028.

29         4.  The sale, purchase, or trade of blood and blood

30  components intended for transfusion.  As used in this

31  subparagraph, the term "blood" means whole blood collected

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 1  from a single donor and processed either for transfusion or

 2  further manufacturing, and the term "blood components" means

 3  that part of the blood separated by physical or mechanical

 4  means.

 5         5.  The lawful dispensing of a prescription drug in

 6  accordance with chapter 465.

 7         Section 20.  (1)  The Agency for Health Care

 8  Administration shall conduct a study of health care services

 9  provided to the medically fragile or

10  medical-technology-dependent children in the state and conduct

11  a pilot program in Miami-Dade County to provide subacute

12  pediatric transitional care to a maximum of 30 children at any

13  one time. The purposes of the study and the pilot program are

14  to determine ways to permit medically fragile or

15  medical-technology-dependent children to successfully make a

16  transition from acute care in a health care institution to

17  live with their families when possible, and to provide

18  cost-effective, subacute transitional care services.

19         (2)  The Agency for Health Care Administration, in

20  cooperation with the Children's Medical Services Program in

21  the Department of Health, shall conduct a study to identify

22  the total number of medically fragile or

23  medical-technology-dependent children, from birth through age

24  21, in the state. By January 1, 2003, the agency must report

25  to the Legislature regarding the children's ages, the

26  locations where the children are served, the types of services

27  received, itemized costs of the services, and the sources of

28  funding that pay for the services, including the proportional

29  share when more than one funding source pays for a service.

30  The study must include information regarding medically fragile

31  or medical-technology-dependent children residing in

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 1  hospitals, nursing homes, and medical foster care, and those

 2  who live with their parents. The study must describe children

 3  served in prescribed pediatric extended-care centers,

 4  including their ages and the services they receive. The report

 5  must identify the total services provided for each child and

 6  the method for paying for those services. The report must also

 7  identify the number of such children who could, if appropriate

 8  transitional services were available, return home or move to a

 9  less-institutional setting.

10         (3)  Within 30 days after the effective date of this

11  act, the agency shall establish minimum staffing standards and

12  quality requirements for a subacute pediatric transitional

13  care center to be operated as a 2-year pilot program in Dade

14  County. The pilot program must operate under the license of a

15  hospital licensed under chapter 395, Florida Statutes, or a

16  nursing home licensed under chapter 400, Florida Statutes, and

17  shall use existing beds in the hospital or nursing home. A

18  child's placement in the subacute pediatric transitional care

19  center may not exceed 90 days. The center shall arrange for an

20  alternative placement at the end of a child's stay and a

21  transitional plan for children expected to remain in the

22  facility for the maximum allowed stay.

23         (4)  Within 60 days after the effective date of this

24  act, the agency must amend the state Medicaid plan and request

25  any federal waivers necessary to implement and fund the pilot

26  program.

27         (5)  The subacute pediatric transitional care center

28  must require level I background screening as provided in

29  chapter 435, Florida Statutes, for all employees or

30  prospective employees of the center who are expected to, or

31  whose responsibilities may require them to, provide personal

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 1  care or services to children, have access to children's living

 2  areas, or have access to children's funds or personal

 3  property.

 4         (6)  The subacute pediatric transitional care center

 5  must have an advisory board. Membership on the advisory board

 6  must include, but need not be limited to:

 7         (a)  A physician and an advanced registered nurse

 8  practitioner who is familiar with services for medically

 9  fragile or medical-technology-dependent children;

10         (b)  A registered nurse who has experience in the care

11  of medically fragile or medical-technology-dependent children;

12         (c)  A child development specialist who has experience

13  in the care of medically fragile or

14  medical-technology-dependent children and their families;

15         (d)  A social worker who has experience in the care of

16  medically fragile or medical-technology-dependent children and

17  their families; and

18         (e)  A consumer representative who is a parent or

19  guardian of a child placed in the center.

20         (7)  The advisory board shall:

21         (a)  Review the policy and procedure components of the

22  center to assure conformance with applicable standards

23  developed by the Agency for Health Care Administration; and

24         (b)  Provide consultation with respect to the

25  operational and programmatic components of the center.

26         (8)  The subacute pediatric transitional care center

27  must have written policies and procedures governing the

28  admission, transfer, and discharge of children.

29         (9)  The admission of each child to the center must be

30  under the supervision of the center nursing administrator or

31  his or her designee, and must be in accordance with the

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 1  center's policies and procedures. Each Medicaid admission must

 2  be approved as appropriate for placement in the facility by

 3  the Children's Medical Services Multidisciplinary Assessment

 4  Team of the Department of Health, in conjunction with the

 5  Agency for Health Care Administration.

 6         (10)  Each child admitted to the center shall be

 7  admitted upon prescription of the medical director of the

 8  center, licensed pursuant to chapter 458 or chapter 459,

 9  Florida Statutes, and the child shall remain under the care of

10  the medical director and the advanced registered nurse

11  practitioner for the duration of his or her stay in the

12  center.

13         (11)  Each child admitted to the center must meet at

14  least the following criteria:

15         (a)  The child must be medically fragile or

16  medical-technology-dependent.

17         (b)  The child may not, prior to admission, present

18  significant risk of infection to other children or personnel.

19  The medical and nursing directors shall review, on a

20  case-by-case basis, the condition of any child who is

21  suspected of having an infectious disease to determine whether

22  admission is appropriate.

23         (c)  The child must be medically stabilized and require

24  skilled nursing care or other interventions.

25         (12)  If the child meets the criteria specified in

26  paragraphs (11)(a), (b), and (c), the medical director or

27  nursing director of the center shall implement a preadmission

28  plan that delineates services to be provided and appropriate

29  sources for such services.

30         (a)  If the child is hospitalized at the time of

31  referral, preadmission planning must include the participation

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 1  of the child's parent or guardian and relevant medical,

 2  nursing, social services, and developmental staff to assure

 3  that the hospital's discharge plans will be implemented

 4  following the child's placement in the center.

 5         (b)  A consent form, outlining the purpose of the

 6  center, family responsibilities, authorized treatment,

 7  appropriate release of liability, and emergency disposition

 8  plans, must be signed by the parent or guardian and witnessed

 9  before the child is admitted to the center. The parent or

10  guardian shall be provided a copy of the consent form.

11         (13)  By January 1, 2003, the Agency for Health Care

12  Administration shall report to the Legislature concerning the

13  progress of the pilot program. By January 1, 2004, the agency

14  shall submit to the Legislature a report on the success of the

15  pilot program.

16         Section 21.  The Office of Legislative Services shall

17  contract for a business case study of the feasibility of

18  outsourcing the administrative, investigative, legal, and

19  prosecutorial functions and other tasks and services that are

20  necessary to carry out the regulatory responsibilities of the

21  Board of Dentistry, employing its own executive director and

22  other staff, and obtaining authority over collections and

23  expenditures of funds paid by professions regulated by the

24  board into the Medical Quality Assurance Trust Fund. This

25  feasibility study must include a business plan and an

26  assessment of the direct and indirect costs associated with

27  outsourcing these functions. The sum of $50,000 is

28  appropriated from the Board of Dentistry account within the

29  Medical Quality Assurance Trust Fund to the Office of

30  Legislative Services for the purpose of contracting for the

31  study. The Office of Legislative Services shall submit the

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 1  completed study to the Governor, the President of the Senate,

 2  and the Speaker of the House of Representatives by January 1,

 3  2003.

 4         Section 22.  (1)  Notwithstanding section 409.911(3),

 5  Florida Statutes, for the state fiscal year 2002-2003 only,

 6  the agency shall distribute moneys under the regular

 7  disproportionate share program only to hospitals that meet the

 8  federal minimum requirements and to public hospitals. Public

 9  hospitals are defined as those hospitals identified as

10  government owned or operated in the Financial Hospital Uniform

11  Reporting System (FHURS) data available to the agency as of

12  January 1, 2002. The following methodology shall be used to

13  distribute disproportionate share dollars to hospitals that

14  meet the federal minimum requirements and to the public

15  hospitals:

16         (a)  For hospitals that meet the federal minimum

17  requirements, the following formula shall be used:

18  

19         TAA = TA  *  (1/5.5)

20         DSHP = (HMD/TMSD)*TA

21  

22         TAA = total amount available.

23         TA = total appropriation.

24         DSHP = disproportionate share hospital payment.

25         HMD = hospital Medicaid days.

26         TSD = total state Medicaid days.

27  

28         (b)  The following formulas shall be used to pay

29  disproportionate share dollars to public hospitals:

30         1.  For state mental health hospitals:

31  

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 1         DSHP = (HMD/TMD) * TAAMH

 2  

 3         The total amount available for the state mental

 4         health hospitals shall be the difference

 5         between the federal cap for Institutions for

 6         Mental Diseases and the amounts paid under the

 7         mental health disproportionate share program.

 8         2.  For non-state government owned or operated

 9  hospitals with 3,200 or more Medicaid days:

10  

11         DSHP = [(.85*HCCD/TCCD) + (.15*HMD/TMD)] *

12         TAAPH

13         TAAPH = TAA - TAAMH

14  

15         3.  For non-state government owned or operated

16  hospitals with less than 3,200 Medicaid days, a total of

17  $400,000 shall be distributed equally among these hospitals.

18  

19  Where:

20  

21         TAA = total available appropriation.

22         TAAPH = total amount available for public

23         hospitals.

24         TAAMH = total amount available for mental

25         health hospitals.

26         DSHP = disproportionate share hospital

27         payments.

28         HMD = hospital Medicaid days.

29         TMD = total state Medicaid days for public

30         hospitals.

31         HCCD = hospital charity care dollars.

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 1         TCCD = total state charity care dollars for

 2         public hospitals.

 3  

 4  In computing the above amounts for public hospitals and

 5  hospitals that qualify under the federal minimum requirements,

 6  the agency shall use the 1997 audited data. In the event there

 7  is no 1997 audited data for a hospital, the agency shall use

 8  the 1994 audited data.

 9         (2)  Notwithstanding section 409.9112, Florida

10  Statutes, for state fiscal year 2002-2003, only

11  disproportionate share payments to regional perinatal

12  intensive care centers shall be distributed in the same

13  proportion as the disproportionate share payments made to the

14  regional perinatal intensive care centers in the state fiscal

15  year 2001-2002.

16         (3)  Notwithstanding section 409.9117, Florida

17  Statutes, for state fiscal year 2002-2003 only,

18  disproportionate share payments to hospitals that qualify for

19  primary care disproportionate share payments shall be

20  distributed in the same proportion as the primary care

21  disproportionate share payments made to those hospitals in the

22  state fiscal year 2001-2002.

23         (4)  In the event the Centers for Medicare and Medicaid

24  Services does not approve Florida's inpatient hospital state

25  plan amendment for the public disproportionate share program

26  by November 1, 2002, the agency may make payments to hospitals

27  under the regular disproportionate share program, regional

28  perinatal intensive care centers disproportionate share

29  program, and the primary care disproportionate share program

30  using the same methodologies used in state fiscal year

31  2001-2002.

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 1         (5)  For state fiscal year 2002-2003 only, no

 2  disproportionate share payments shall be made to specialty

 3  hospitals for children under the provisions of section

 4  409.9119, Florida Statutes.

 5         (6)  This section expires July 1, 2003.

 6         Section 23.  The Agency for Health Care Administration

 7  may conduct a 2-year pilot project to authorize overnight

 8  stays in one ambulatory surgical center located in Acute Care

 9  Subdistrict 9-1. An overnight stay shall be permitted only to

10  perform plastic and reconstructive surgeries defined by

11  current procedural terminology code numbers 13000-19999. The

12  total time a patient is at the ambulatory surgical center

13  shall not exceed 23 hours and 59 minutes, including the

14  surgery time, and the maximum planned duration of all surgical

15  procedures combined shall not exceed 8 hours. Prior to

16  implementation of the pilot project, the agency shall

17  establish minimum requirements for protecting the health,

18  safety, and welfare of patients receiving overnight care.

19  These shall include, at a minimum, compliance with all

20  statutes and rules applicable to ambulatory surgical centers

21  and the requirements set forth in Rule 64B8-9.009, F.A.C.,

22  relating to Level II and Level III procedures. If the agency

23  implements the pilot project, it shall, within 6 months after

24  its completion, submit a report to the Legislature on whether

25  to expand the pilot to include all ambulatory surgical

26  centers. The recommendation shall be based on consideration of

27  the efficacy and impact to patient safety and quality of

28  patient care of providing plastic and reconstructive surgeries

29  in the ambulatory surgical center setting. The agency is

30  authorized to obtain such data as necessary to implement this

31  section.

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 1         Section 24.  Section 624.91, Florida Statutes, is

 2  amended to read:

 3         624.91  The Florida Healthy Kids Corporation Act.--

 4         (1)  SHORT TITLE.--This section may be cited as the

 5  "William G. 'Doc' Myers Healthy Kids Corporation Act."

 6         (2)  LEGISLATIVE INTENT.--

 7         (a)  The Legislature finds that increased access to

 8  health care services could improve children's health and

 9  reduce the incidence and costs of childhood illness and

10  disabilities among children in this state. Many children do

11  not have comprehensive, affordable health care services

12  available.  It is the intent of the Legislature that the

13  Florida Healthy Kids Corporation provide comprehensive health

14  insurance coverage to such children. The corporation is

15  encouraged to cooperate with any existing health service

16  programs funded by the public or the private sector and to

17  work cooperatively with the Florida Partnership for School

18  Readiness.

19         (b)  It is the intent of the Legislature that the

20  Florida Healthy Kids Corporation serve as one of several

21  providers of services to children eligible for medical

22  assistance under Title XXI of the Social Security Act.

23  Although the corporation may serve other children, the

24  Legislature intends the primary recipients of services

25  provided through the corporation be school-age children with a

26  family income below 200 percent of the federal poverty level,

27  who do not qualify for Medicaid.  It is also the intent of the

28  Legislature that state and local government Florida Healthy

29  Kids funds, to the extent permissible under federal law, be

30  used to continue and expand coverage, within available

31  

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 1  appropriations, to children not eligible for federal matching

 2  funds under Title XXI obtain matching federal dollars.

 3         (3)  NONENTITLEMENT.--Nothing in this section shall be

 4  construed as providing an individual with an entitlement to

 5  health care services.  No cause of action shall arise against

 6  the state, the Florida Healthy Kids Corporation, or a unit of

 7  local government for failure to make health services available

 8  under this section.

 9         (4)  CORPORATION AUTHORIZATION, DUTIES, POWERS.--

10         (a)  There is created the Florida Healthy Kids

11  Corporation, a not-for-profit corporation which operates on

12  sites designated by the corporation.

13         (b)  The Florida Healthy Kids Corporation shall phase

14  in a program to:

15         1.  Organize school children groups to facilitate the

16  provision of comprehensive health insurance coverage to

17  children;

18         2.  Arrange for the collection of any family, local

19  contributions, or employer payment or premium, in an amount to

20  be determined by the board of directors, to provide for

21  payment of premiums for comprehensive insurance coverage and

22  for the actual or estimated administrative expenses;

23         3.  Arrange for the collection of any voluntary

24  contributions to provide for payment of premiums for children

25  who are not eligible for medical assistance under Title XXI of

26  the Social Security Act. Each fiscal year, the corporation

27  shall establish a local-match policy for the enrollment of

28  non-Title XXI eligible children in the Healthy Kids program.

29  By May 1 of each year, the corporation shall provide written

30  notification of the amount to be remitted to the corporation

31  for the following fiscal year under that policy. Local-match

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 1  sources may include, but are not limited to, funds provided by

 2  municipalities, counties, school boards, hospitals, health

 3  care providers, charitable organizations, special taxing

 4  districts, and private organizations. The minimum local-match

 5  cash contributions required each fiscal year and local-match

 6  credits shall be determined by the General Appropriations Act.

 7  The corporation shall calculate a county's local-match rate

 8  based upon that county's percentage of the state's total

 9  non-Title XXI expenditures as reported in the corporation's

10  most recently audited financial statement. In awarding the

11  local-match credits, the corporation may consider factors

12  including, but not limited to, population density, per-capita

13  income, existing child-health-related expenditures and

14  services in awarding the credits.

15         4.  Accept voluntary supplemental local-match

16  contributions that comply with the requirements of Title XXI

17  of the Social Security Act for the purpose of providing

18  additional coverage in contributing counties under Title XXI.

19         5.3.  Establish the administrative and accounting

20  procedures for the operation of the corporation;

21         6.4.  Establish, with consultation from appropriate

22  professional organizations, standards for preventive health

23  services and providers and comprehensive insurance benefits

24  appropriate to children; provided that such standards for

25  rural areas shall not limit primary care providers to

26  board-certified pediatricians;

27         7.5.  Establish eligibility criteria which children

28  must meet in order to participate in the program;

29         8.6.  Establish procedures under which providers of

30  local match to, applicants to and participants in the program

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 1  may have grievances reviewed by an impartial body and reported

 2  to the board of directors of the corporation;

 3         9.7.  Establish participation criteria and, if

 4  appropriate, contract with an authorized insurer, health

 5  maintenance organization, or insurance administrator to

 6  provide administrative services to the corporation;

 7         10.8.  Establish enrollment criteria which shall

 8  include penalties or waiting periods of not fewer than 60 days

 9  for reinstatement of coverage upon voluntary cancellation for

10  nonpayment of family premiums;

11         11.9.  If a space is available, establish a special

12  open enrollment period of 30 days' duration for any child who

13  is enrolled in Medicaid or Medikids if such child loses

14  Medicaid or Medikids eligibility and becomes eligible for the

15  Florida Healthy Kids program;

16         12.10.  Contract with authorized insurers or any

17  provider of health care services, meeting standards

18  established by the corporation, for the provision of

19  comprehensive insurance coverage to participants.  Such

20  standards shall include criteria under which the corporation

21  may contract with more than one provider of health care

22  services in program sites. Health plans shall be selected

23  through a competitive bid process. The selection of health

24  plans shall be based primarily on quality criteria established

25  by the board. The health plan selection criteria and scoring

26  system, and the scoring results, shall be available upon

27  request for inspection after the bids have been awarded;

28         13.  Establish disenrollment criteria in the event

29  local matching funds are insufficient to cover enrollments.

30         14.11.  Develop and implement a plan to publicize the

31  Florida Healthy Kids Corporation, the eligibility requirements

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 1  of the program, and the procedures for enrollment in the

 2  program and to maintain public awareness of the corporation

 3  and the program;

 4         15.12.  Secure staff necessary to properly administer

 5  the corporation. Staff costs shall be funded from state and

 6  local matching funds and such other private or public funds as

 7  become available. The board of directors shall determine the

 8  number of staff members necessary to administer the

 9  corporation;

10         16.13.  As appropriate, enter into contracts with local

11  school boards or other agencies to provide onsite information,

12  enrollment, and other services necessary to the operation of

13  the corporation;

14         17.14.  Provide a report on an annual basis to the

15  Governor, Insurance Commissioner, Commissioner of Education,

16  Senate President, Speaker of the House of Representatives, and

17  Minority Leaders of the Senate and the House of

18  Representatives;

19         18.15.  Each fiscal year, establish a maximum number of

20  participants by county, on a statewide basis, who may enroll

21  in the program; and without the benefit of local matching

22  funds.  Thereafter, the corporation may establish local

23  matching requirements for supplemental participation in the

24  program. The corporation may vary local matching requirements

25  and enrollment by county depending on factors which may

26  influence the generation of local match, including, but not

27  limited to, population density, per capita income, existing

28  local tax effort, and other factors. The corporation also may

29  accept in-kind match in lieu of cash for the local match

30  requirement to the extent allowed by Title XXI of the Social

31  Security Act; and

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 1         19.16.  Establish eligibility criteria, premium and

 2  cost-sharing requirements, and benefit packages which conform

 3  to the provisions of the Florida Kidcare program, as created

 4  in ss. 409.810-409.820.

 5         (c)  Coverage under the corporation's program is

 6  secondary to any other available private coverage held by the

 7  participant child or family member. The corporation may

 8  establish procedures for coordinating benefits under this

 9  program with benefits under other public and private coverage.

10         (d)  The Florida Healthy Kids Corporation shall be a

11  private corporation not for profit, organized pursuant to

12  chapter 617, and shall have all powers necessary to carry out

13  the purposes of this act, including, but not limited to, the

14  power to receive and accept grants, loans, or advances of

15  funds from any public or private agency and to receive and

16  accept from any source contributions of money, property,

17  labor, or any other thing of value, to be held, used, and

18  applied for the purposes of this act.

19         (5)  BOARD OF DIRECTORS.--

20         (a)  The Florida Healthy Kids Corporation shall operate

21  subject to the supervision and approval of a board of

22  directors chaired by the Insurance Commissioner or her or his

23  designee, and composed of 14 12 other members selected for

24  3-year terms of office as follows:

25         1.  One member appointed by the Commissioner of

26  Education from among three persons nominated by the Florida

27  Association of School Administrators;

28         2.  One member appointed by the Commissioner of

29  Education from among three persons nominated by the Florida

30  Association of School Boards;

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 1         3.  One member appointed by the Commissioner of

 2  Education from the Office of School Health Programs of the

 3  Florida Department of Education;

 4         4.  One member appointed by the Governor from among

 5  three members nominated by the Florida Pediatric Society;

 6         5.  One member, appointed by the Governor, who

 7  represents the Children's Medical Services Program;

 8         6.  One member appointed by the Insurance Commissioner

 9  from among three members nominated by the Florida Hospital

10  Association;

11         7.  Two members, appointed by the Insurance

12  Commissioner, who are representatives of authorized health

13  care insurers or health maintenance organizations;

14         8.  One member, appointed by the Insurance

15  Commissioner, who represents the Institute for Child Health

16  Policy;

17         9.  One member, appointed by the Governor, from among

18  three members nominated by the Florida Academy of Family

19  Physicians;

20         10.  One member, appointed by the Governor, who

21  represents the Agency for Health Care Administration; and

22         11.  The State Health Officer or her or his designee;.

23         12.  One member, appointed by the Insurance

24  Commissioner from among three members nominated by the Florida

25  Association of Counties, representing rural counties; and

26         13.  One member, appointed by the Governor from among

27  three members nominated by the Florida Association of

28  Counties, representing urban counties.

29         (b)  A member of the board of directors may be removed

30  by the official who appointed that member.  The board shall

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 1  appoint an executive director, who is responsible for other

 2  staff authorized by the board.

 3         (c)  Board members are entitled to receive, from funds

 4  of the corporation, reimbursement for per diem and travel

 5  expenses as provided by s. 112.061.

 6         (d)  There shall be no liability on the part of, and no

 7  cause of action shall arise against, any member of the board

 8  of directors, or its employees or agents, for any action they

 9  take in the performance of their powers and duties under this

10  act.

11         (6)  LICENSING NOT REQUIRED; FISCAL OPERATION.--

12         (a)  The corporation shall not be deemed an insurer.

13  The officers, directors, and employees of the corporation

14  shall not be deemed to be agents of an insurer. Neither the

15  corporation nor any officer, director, or employee of the

16  corporation is subject to the licensing requirements of the

17  insurance code or the rules of the Department of Insurance.

18  However, any marketing representative utilized and compensated

19  by the corporation must be appointed as a representative of

20  the insurers or health services providers with which the

21  corporation contracts.

22         (b)  The board has complete fiscal control over the

23  corporation and is responsible for all corporate operations.

24         (c)  The Department of Insurance shall supervise any

25  liquidation or dissolution of the corporation and shall have,

26  with respect to such liquidation or dissolution, all power

27  granted to it pursuant to the insurance code.

28         (7)  ACCESS TO RECORDS; CONFIDENTIALITY;

29  PENALTIES.--Notwithstanding any other laws to the contrary,

30  the Florida Healthy Kids Corporation shall have access to the

31  medical records of a student upon receipt of permission from a

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 1  parent or guardian of the student.  Such medical records may

 2  be maintained by state and local agencies.  Any identifying

 3  information, including medical records and family financial

 4  information, obtained by the corporation pursuant to this

 5  subsection is confidential and is exempt from the provisions

 6  of s. 119.07(1).  Neither the corporation nor the staff or

 7  agents of the corporation may release, without the written

 8  consent of the participant or the parent or guardian of the

 9  participant, to any state or federal agency, to any private

10  business or person, or to any other entity, any confidential

11  information received pursuant to this subsection.  A violation

12  of this subsection is a misdemeanor of the second degree,

13  punishable as provided in s. 775.082 or s. 775.083.

14         Section 25.  By January 1, 2003, the Agency for Health

15  Care Administration shall make recommendations to the

16  Legislature as to limits in the amount of home office

17  management and administrative fees which should be allowable

18  for reimbursement for providers whose rates are set on a

19  cost-reimbursement basis.

20         Section 26.  Subsection (5) of section 414.41, Florida

21  Statutes, is repealed.

22         Section 27.  If any law that is amended by this act was

23  also amended by a law enacted at the 2002 Regular Session of

24  the Legislature, such laws shall be construed as if they had

25  been enacted at the same session of the Legislature, and full

26  effect should be given to each if that is possible.

27         Section 28.  Except as otherwise provided in this act,

28  this act shall take effect upon becoming a law.

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 2                          SENATE SUMMARY

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      of health care, including Medicaid. (See bill for
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