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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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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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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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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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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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.
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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.
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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.
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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:
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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
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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
31
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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;
31
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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
31
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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.
29
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2 SENATE SUMMARY
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