House Bill hb0059Ee1
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 A bill to be entitled
2 An act relating to health care; amending s.
3 112.3187, F.S.; revising procedures and
4 requirements relating to whistle-blower
5 protection for reporting Medicaid fraud or
6 abuse; amending s. 400.141, F.S.; requiring
7 licensed nursing home facilities to maintain
8 general and professional liability insurance
9 coverage; requiring facilities to submit
10 information to the Agency for Health Care
11 Administration which shall provide reports
12 regarding facilities' litigation, complaints,
13 and deficiencies; amending s. 400.147, F.S.;
14 revising reporting requirements under facility
15 internal risk management and quality assurance
16 programs; providing for funding to expedite the
17 availability of nursing home liability
18 insurance; amending s. 400.179, F.S.; providing
19 an alternative to certain bond requirements for
20 protection against nursing home Medicaid
21 overpayments; providing for review and
22 rulemaking authority of the Agency for Health
23 Care Administration; providing for future
24 repeal; requiring a report; creating s.
25 408.831, F.S.; authorizing the Agency for
26 Health Care Administration to take action
27 against a regulated entity under certain
28 circumstances; reenacting s. 409.8132(4), F.S.,
29 to incorporate amendments to ss. 409.902,
30 409.907, 409.908, and 409.913, F.S., in
31 references thereto; amending s. 409.8177, F.S.;
1
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 requiring the agency to contract for evaluation
2 of the Florida Kidcare program; amending s.
3 409.902, F.S.; requiring consent for release of
4 medical records to the agency and the Medicaid
5 Fraud Control Unit as a condition of Medicaid
6 eligibility; amending s. 409.903, F.S.;
7 revising eligibility for certain Medicaid
8 mandatory medical assistance; amending s.
9 409.904, F.S.; revising eligibility standards
10 for certain Medicaid optional medical
11 assistance; amending s. 409.9065, F.S.;
12 revising eligibility standards for the
13 pharmaceutical expense assistance program;
14 amending s. 409.907, F.S.; prescribing
15 additional requirements with respect to
16 Medicaid provider enrollment; requiring the
17 agency to deny a provider's application under
18 certain circumstances; amending s. 409.908,
19 F.S.; requiring retroactive calculation of cost
20 report if requirements for cost reporting are
21 not met; revising provisions relating to rate
22 adjustments to offset the cost of general and
23 professional liability insurance for nursing
24 homes; extending authorization for special
25 Medicaid payments to qualified providers;
26 providing for intergovernmental transfer of
27 payments; amending s. 409.911, F.S.; expanding
28 application of definitions; amending s.
29 409.9116, F.S.; revising applicability of the
30 disproportionate share/financial assistance
31 program for rural hospitals; amending s.
2
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 409.91195, F.S.; granting interested parties
2 opportunity to present public testimony before
3 the Medicaid Pharmaceutical and Therapeutics
4 Committee; amending s. 409.912, F.S.; providing
5 requirements for contracts for Medicaid
6 behavioral health care services; amending s.
7 409.9122, F.S.; revising procedures relating to
8 assignment of a Medicaid recipient to a managed
9 care plan or MediPass provider; granting agency
10 discretion to renew contracts; amending s.
11 409.913, F.S.; requiring the agency and the
12 Medicaid Fraud Control Unit to annually submit
13 a joint report to the Legislature; defining the
14 term "complaint" with respect to Medicaid fraud
15 or abuse; specifying additional requirements
16 for the Medicaid program integrity program and
17 the Medicaid Fraud Control Unit; providing
18 additional sanctions and disincentives which
19 may be imposed; providing additional grounds
20 for termination of a provider's participation
21 in the Medicaid program; providing additional
22 requirements for administrative hearings;
23 providing additional grounds for withholding
24 payments to a provider; authorizing the agency
25 and the Medicaid Fraud Control Unit to review
26 certain records; amending s. 409.920, F.S.;
27 providing additional duties of the Attorney
28 General with respect to Medicaid fraud control;
29 amending s. 624.91, F.S.; revising duties of
30 the Florida Healthy Kids Corporation with
31 respect to annual determination of
3
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 participation in the Healthy Kids program;
2 prescribing duties of the corporation in
3 establishing local match requirements; revising
4 composition of the board of directors; amending
5 s. 383.19, F.S.; revising limitation on the
6 establishment of regional perinatal intensive
7 care centers; amending s. 393.063, F.S.;
8 revising definition of the term "intermediate
9 care facility for the developmentally disabled"
10 for purposes of ch. 393, F.S.; amending ss.
11 400.965 and 400.968, F.S.; providing penalties
12 for violation of pt. XI of ch. 400, F.S.,
13 relating to intermediate care facilities for
14 developmentally disabled persons; requiring the
15 Department of Children and Family Services to
16 develop and implement a comprehensive redesign
17 of the home and community-based services
18 delivery system for persons with developmental
19 disabilities; restricting certain release of
20 funds; providing an implementation schedule;
21 requiring the Agency for Health Care
22 Administration to conduct a study of health
23 care services provided to children who are
24 medically fragile or dependent on medical
25 technology; requiring the agency to conduct a
26 pilot program for a subacute pediatric
27 transitional care center; requiring background
28 screening of center personnel; requiring the
29 agency to amend the Medicaid state plan or seek
30 federal waivers as necessary; requiring the
31 center to have an advisory board; providing for
4
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 membership and duties of the advisory board;
2 providing requirements for the admission,
3 transfer, and discharge of a child to the
4 center; requiring the agency to submit certain
5 reports to the Legislature; requiring the
6 agency to make recommendations to the
7 Legislature regarding limitations on certain
8 Medicaid provider reimbursements; providing
9 guidelines for the agency regarding
10 distribution of disproportionate share funds
11 during the 2002-2003 fiscal year; directing the
12 Office of Program Policy Analysis and
13 Government Accountability to perform a study of
14 county contributions to Medicaid nursing home
15 costs; requiring a report and recommendations;
16 repealing s. 1, ch. 2001-377, Laws of Florida,
17 relating to eligibility of specified persons
18 for certain optional medical assistance;
19 providing severability; providing effective
20 dates.
21
22 Be It Enacted by the Legislature of the State of Florida:
23
24 Section 1. Subsections (3), (5), and (7) of section
25 112.3187, Florida Statutes, are amended to read:
26 112.3187 Adverse action against employee for
27 disclosing information of specified nature prohibited;
28 employee remedy and relief.--
29 (3) DEFINITIONS.--As used in this act, unless
30 otherwise specified, the following words or terms shall have
31 the meanings indicated:
5
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (a) "Agency" means any state, regional, county, local,
2 or municipal government entity, whether executive, judicial,
3 or legislative; any official, officer, department, division,
4 bureau, commission, authority, or political subdivision
5 therein; or any public school, community college, or state
6 university.
7 (b) "Employee" means a person who performs services
8 for, and under the control and direction of, or contracts
9 with, an agency or independent contractor for wages or other
10 remuneration.
11 (c) "Adverse personnel action" means the discharge,
12 suspension, transfer, or demotion of any employee or the
13 withholding of bonuses, the reduction in salary or benefits,
14 or any other adverse action taken against an employee within
15 the terms and conditions of employment by an agency or
16 independent contractor.
17 (d) "Independent contractor" means a person, other
18 than an agency, engaged in any business and who enters into a
19 contract, including a provider agreement, with an agency.
20 (e) "Gross mismanagement" means a continuous pattern
21 of managerial abuses, wrongful or arbitrary and capricious
22 actions, or fraudulent or criminal conduct which may have a
23 substantial adverse economic impact.
24 (5) NATURE OF INFORMATION DISCLOSED.--The information
25 disclosed under this section must include:
26 (a) Any violation or suspected violation of any
27 federal, state, or local law, rule, or regulation committed by
28 an employee or agent of an agency or independent contractor
29 which creates and presents a substantial and specific danger
30 to the public's health, safety, or welfare.
31
6
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (b) Any act or suspected act of gross mismanagement,
2 malfeasance, misfeasance, gross waste of public funds,
3 suspected or actual Medicaid fraud or abuse, or gross neglect
4 of duty committed by an employee or agent of an agency or
5 independent contractor.
6 (7) EMPLOYEES AND PERSONS PROTECTED.--This section
7 protects employees and persons who disclose information on
8 their own initiative in a written and signed complaint; who
9 are requested to participate in an investigation, hearing, or
10 other inquiry conducted by any agency or federal government
11 entity; who refuse to participate in any adverse action
12 prohibited by this section; or who initiate a complaint
13 through the whistle-blower's hotline or the hotline of the
14 Medicaid Fraud Control Unit of the Department of Legal
15 Affairs; or employees who file any written complaint to their
16 supervisory officials or employees who submit a complaint to
17 the Chief Inspector General in the Executive Office of the
18 Governor, to the employee designated as agency inspector
19 general under s. 112.3189(1), or to the Florida Commission on
20 Human Relations. The provisions of this section may not be
21 used by a person while he or she is under the care, custody,
22 or control of the state correctional system or, after release
23 from the care, custody, or control of the state correctional
24 system, with respect to circumstances that occurred during any
25 period of incarceration. No remedy or other protection under
26 ss. 112.3187-112.31895 applies to any person who has committed
27 or intentionally participated in committing the violation or
28 suspected violation for which protection under ss.
29 112.3187-112.31895 is being sought.
30 Section 2. Subsection (20) of section 400.141, Florida
31 Statutes, is amended to read:
7
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 400.141 Administration and management of nursing home
2 facilities.--Every licensed facility shall comply with all
3 applicable standards and rules of the agency and shall:
4 (20) Maintain general and professional liability
5 insurance coverage that is in force at all times.
6 Section 3. (1) For the period beginning June 30,
7 2001, and ending June 30, 2005, the Agency for Health Care
8 Administration shall provide a report to the Governor, the
9 President of the Senate, and the Speaker of the House of
10 Representatives with respect to nursing homes. The first
11 report shall be submitted no later than December 30, 2002, and
12 every six (6) months thereafter. The report shall identify
13 facilities based on their ownership characteristics, size,
14 business structure, for-profit or not-for-profit status; and
15 any other characteristics the agency determines useful in
16 analyzing the varied segments of the nursing home industry and
17 shall report:
18 (a) The number of Notices of Intent to litigate
19 received by each facility each month;
20 (b) The number of complaints on behalf of a resident
21 or resident legal representative that were filed with the
22 clerk of the court each month;
23 (c) The month in which the injury which is the basis
24 for the suit occurred or was discovered or, if unavailable,
25 the dates of residency of the resident involved beginning with
26 the date of initial admission and latest discharge date;
27 (d) Information regarding deficiencies cited including
28 information used to develop the Nursing Home Guide pursuant to
29 s. 400.191 and applicable rules, a summary of data generated
30 on nursing homes by Centers for Medicare and Medicaid Services
31
8
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Nursing Home Quality Information Project and information
2 collected pursuant to s. 400.147(9) relating to litigation.
3 (2) Facilities subject to part II of Chapter 400 must
4 submit the information necessary to compile this report each
5 month on existing forms, as modified, provided by the agency.
6 (3) The agency shall delineate the available
7 information on a monthly basis.
8 Section 4. Subsection (9) of section 400.147, Florida
9 Statutes, is amended to read:
10 400.147 Internal risk management and quality assurance
11 program.--
12 (9) By the 10th of each month, each facility subject
13 to this section shall report monthly any notice received
14 pursuant to s. 400.0233(2)liability claim filed against it.
15 and each initial complaint that was filed with the clerk of
16 the court and served on the facility during the previous month
17 by a resident, family member, guardian, conservator, or
18 personal legal representative. The report must include the
19 name of the resident, date of birth, social security number,
20 the Medicaid identification number for Medicaid eligible
21 persons, the date or dates of the incident leading to the
22 claim or dates of residency, if applicable, and the type of
23 injury or violation of rights alleged to have occurred. Each
24 facility shall also submit a copy of the notices received
25 pursuant to s. 400.0233(2) and complaints filed with the clerk
26 of the court. This report is confidential as provided by law
27 and is not discoverable or admissible in any civil or
28 administrative action, except in such actions brought by the
29 agency to enforce the provisions of this part.
30 Section 5. In order to expedite the availability of
31 general and professional liability insurance for nursing
9
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 homes, the agency, subject to appropriations included in the
2 General Appropriation Act, shall advance $6 million for the
3 purpose of capitalizing the risk retention group. The terms of
4 repayment may not extend beyond 3 years from the date of
5 funding. For purposes of this project, notwithstanding the
6 provisions of s. 631.271, the agency's claim shall be
7 considered a class 3 claim.
8 Section 6. Effective upon becoming a law and
9 applicable to any pending license renewal, paragraph (d) of
10 subsection (5) of section 400.179, Florida Statutes, is
11 amended to read:
12 400.179 Sale or transfer of ownership of a nursing
13 facility; liability for Medicaid underpayments and
14 overpayments.--
15 (5) Because any transfer of a nursing facility may
16 expose the fact that Medicaid may have underpaid or overpaid
17 the transferor, and because in most instances, any such
18 underpayment or overpayment can only be determined following a
19 formal field audit, the liabilities for any such underpayments
20 or overpayments shall be as follows:
21 (d) Where the transfer involves a facility that has
22 been leased by the transferor:
23 1. The transferee shall, as a condition to being
24 issued a license by the agency, acquire, maintain, and provide
25 proof to the agency of a bond with a term of 30 months,
26 renewable annually, in an amount not less than the total of 3
27 months Medicaid payments to the facility computed on the basis
28 of the preceding 12-month average Medicaid payments to the
29 facility.
30 2. Subject to federal review and approval, a leasehold
31 licensee may meet the requirements of subparagraph 1. by
10
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 payment of a nonrefundable fee paid at initial licensure, paid
2 at the time of any subsequent change of ownership, and paid at
3 the time of any subsequent annual license renewal, in the
4 amount of 2 percent of the total of 3 months' Medicaid
5 payments to the facility computed on the basis of the
6 preceding 12-month average Medicaid payments to the facility.
7 If a preceding 12-month average is not available, projected
8 Medicaid payments may be used. The fee shall be deposited into
9 the Health Care Trust Fund and shall be accounted for
10 separately as a Medicaid nursing home overpayment account.
11 These fees shall be used at the sole discretion of the agency
12 to repay nursing home Medicaid overpayments. Payment of this
13 fee shall not release the operator from any liability for any
14 Medicaid overpayments nor shall payment bar the agency from
15 seeking to recoup overpayments from the operator and any other
16 liable party. As a condition of exercising this lease bond
17 alternative, licensees paying this fee must maintain the
18 remaining portion of an existing 30-month lease bond. The
19 agency is granted specific authority to promulgate all rules
20 pertaining to the administration and management of this
21 account, including withdrawals from the account. This
22 subparagraph is repealed on June 30, 2003.
23 a. The financial viability of the Medicaid nursing
24 home overpayment account shall be determined by the agency
25 through annual review of the account balance and the amount of
26 total outstanding, unpaid Medicaid overpayments owing from
27 leasehold licensees to the agency as determined by final
28 agency audits.
29 (I) If the amount of the Medicaid nursing home
30 overpayment account at any time becomes less than the total
31 amount of such outstanding overpayments, then participation in
11
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 the account shall cease to be an acceptable alternative
2 assurance under this section and leasehold licensees shall be
3 required to immediately obtain lease bonds.
4 (II) Upon determining a deficit in the balance of the
5 account relative to such outstanding overpayments, the agency
6 shall determine the amount to be contributed by each
7 participating provider necessary to increase the account
8 balance to an amount in excess of the total outstanding amount
9 of such overpayments. The agency shall notify each licensee
10 participating in the account at the time a deficit was
11 determined of the amount each licensee must contribute to
12 eliminate the deficit. Upon elimination of the deficit in the
13 account, participation in the account shall be an acceptable
14 alternative assurance under this section.
15 b. The agency, in consultation with the Florida Health
16 Care Association and the Florida Association of Homes for the
17 Aging, shall study and make recommendations on the minimum
18 amount to be held in reserve to protect against Medicaid
19 overpayments to leasehold operators and on the issue of
20 successor liability for Medicaid overpayments upon sale or
21 transfer of ownership of a nursing facility. The agency shall
22 submit the findings and recommendations of the study to the
23 Governor, the President of the Senate, and the Speaker of the
24 House of Representatives by January 1, 2003.
25 3.2. The leasehold operator may meet the bond
26 requirement through other arrangements acceptable to the
27 agency department.
28 4.3. All existing nursing facility licensees,
29 operating the facility as a leasehold, shall acquire,
30 maintain, and provide proof to the agency of the 30-month bond
31
12
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 required in subparagraph 1., above, on and after July 1, 1993,
2 for each license renewal.
3 5.4. It shall be the responsibility of all nursing
4 facility operators, operating the facility as a leasehold, to
5 renew the 30-month bond and to provide proof of such renewal
6 to the agency annually at the time of application for license
7 renewal.
8 6.5. Any failure of the nursing facility operator to
9 acquire, maintain, renew annually, or provide proof to the
10 agency shall be grounds for the agency to deny, cancel,
11 revoke, or suspend the facility license to operate such
12 facility and to take any further action, including, but not
13 limited to, enjoining the facility, asserting a moratorium, or
14 applying for a receiver, deemed necessary to ensure compliance
15 with this section and to safeguard and protect the health,
16 safety, and welfare of the facility's residents.
17 Section 7. Section 408.831, Florida Statutes, is
18 created to read:
19 408.831 Denial of application; suspension or
20 revocation of license, registration, or certificate.--
21 (1) In addition to any other remedies provided by law,
22 the agency may deny each application or suspend or revoke each
23 license, registration, or certificate of entities regulated or
24 licensed by it:
25 (a) If the applicant, licensee, registrant, or
26 certificateholder, or, in the case of a corporation,
27 partnership, or other business entity, if any officer,
28 director, agent, or managing employee of that business entity
29 or any affiliated person, partner, or shareholder having an
30 ownership interest equal to 5 percent or greater in that
31 business entity, has failed to pay all outstanding fines,
13
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 liens, or overpayments assessed by final order of the agency
2 or final order of the Centers for Medicare and Medicaid
3 Services unless a repayment plan is approved by the agency; or
4 (b) For failure to comply with any repayment plan.
5 (2) For all legal proceedings that may result from a
6 denial, suspension, or revocation under this section,
7 testimony or documentation from the financial entity charged
8 with monitoring such payment shall constitute evidence of the
9 failure to pay an outstanding fine, lien, or overpayment and
10 shall be sufficient grounds for the denial, suspension, or
11 revocation.
12 (3) This section provides standards of enforcement
13 applicable to all entities licensed or regulated by the Agency
14 for Health Care Administration. This section controls over any
15 conflicting provisions of chapters 39, 381, 383, 390, 391,
16 393, 394, 395, 400, 408, 468, 483, and 641 or rules adopted
17 pursuant to those chapters.
18 Section 8. For the purpose of incorporating the
19 amendments made by this act to sections 409.902, 409.907,
20 409.908, and 409.913, Florida Statutes, in references thereto,
21 subsection (4) of section 409.8132, Florida Statutes, is
22 reenacted to read:
23 409.8132 Medikids program component.--
24 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
25 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
26 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
27 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205
28 apply to the administration of the Medikids program component
29 of the Florida Kidcare program, except that s. 409.9122
30 applies to Medikids as modified by the provisions of
31 subsection (7).
14
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Section 9. Section 409.8177, Florida Statutes, is
2 amended to read:
3 409.8177 Program evaluation.--
4 (1) The agency, in consultation with the Department of
5 Health, the Department of Children and Family Services, and
6 the Florida Healthy Kids Corporation, shall contract for an
7 evaluation of the Florida Kidcare program and shall by January
8 1 of each year submit to the Governor, the President of the
9 Senate, and the Speaker of the House of Representatives a
10 report of the Florida Kidcare program. In addition to the
11 items specified under s. 2108 of Title XXI of the Social
12 Security Act, the report shall include an assessment of
13 crowd-out and access to health care, as well as the following:
14 (a)(1) An assessment of the operation of the program,
15 including the progress made in reducing the number of
16 uncovered low-income children.
17 (b)(2) An assessment of the effectiveness in
18 increasing the number of children with creditable health
19 coverage, including an assessment of the impact of outreach.
20 (c)(3) The characteristics of the children and
21 families assisted under the program, including ages of the
22 children, family income, and access to or coverage by other
23 health insurance prior to the program and after disenrollment
24 from the program.
25 (d)(4) The quality of health coverage provided,
26 including the types of benefits provided.
27 (e)(5) The amount and level, including payment of part
28 or all of any premium, of assistance provided.
29 (f)(6) The average length of coverage of a child under
30 the program.
31
15
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (g)(7) The program's choice of health benefits
2 coverage and other methods used for providing child health
3 assistance.
4 (h)(8) The sources of nonfederal funding used in the
5 program.
6 (i)(9) An assessment of the effectiveness of Medikids,
7 Children's Medical Services network, and other public and
8 private programs in the state in increasing the availability
9 of affordable quality health insurance and health care for
10 children.
11 (j)(10) A review and assessment of state activities to
12 coordinate the program with other public and private programs.
13 (k)(11) An analysis of changes and trends in the state
14 that affect the provision of health insurance and health care
15 to children.
16 (l)(12) A description of any plans the state has for
17 improving the availability of health insurance and health care
18 for children.
19 (m)(13) Recommendations for improving the program.
20 (n)(14) Other studies as necessary.
21 (2) The agency shall also submit each month to the
22 Governor, the President of the Senate, and the Speaker of the
23 House of Representatives a report of enrollment for each
24 program component of the Florida Kidcare program.
25 Section 10. Section 409.902, Florida Statutes, is
26 amended to read:
27 409.902 Designated single state agency; payment
28 requirements; program title; release of medical records.--The
29 Agency for Health Care Administration is designated as the
30 single state agency authorized to make payments for medical
31 assistance and related services under Title XIX of the Social
16
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Security Act. These payments shall be made, subject to any
2 limitations or directions provided for in the General
3 Appropriations Act, only for services included in the program,
4 shall be made only on behalf of eligible individuals, and
5 shall be made only to qualified providers in accordance with
6 federal requirements for Title XIX of the Social Security Act
7 and the provisions of state law. This program of medical
8 assistance is designated the "Medicaid program." The
9 Department of Children and Family Services is responsible for
10 Medicaid eligibility determinations, including, but not
11 limited to, policy, rules, and the agreement with the Social
12 Security Administration for Medicaid eligibility
13 determinations for Supplemental Security Income recipients, as
14 well as the actual determination of eligibility. As a
15 condition of Medicaid eligibility, subject to federal
16 approval, the Agency for Health Care Administration and the
17 Department of Children and Family Services shall ensure that
18 each recipient of Medicaid consents to the release of her or
19 his medical records to the Agency for Health Care
20 Administration and the Medicaid Fraud Control Unit of the
21 Department of Legal Affairs.
22 Section 11. Effective January 1, 2003, subsection (2)
23 of section 409.904, Florida Statutes, as amended by section 2
24 of chapter 2001-377, Laws of Florida, is amended to read:
25 409.904 Optional payments for eligible persons.--The
26 agency may make payments for medical assistance and related
27 services on behalf of the following persons who are determined
28 to be eligible subject to the income, assets, and categorical
29 eligibility tests set forth in federal and state law. Payment
30 on behalf of these Medicaid eligible persons is subject to the
31
17
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 availability of moneys and any limitations established by the
2 General Appropriations Act or chapter 216.
3 (2)(a) A caretaker relative or parent, a pregnant
4 woman, a child under age 19 who would otherwise qualify for
5 Medicaid or the Florida Kidcare program, a child up to age 21
6 who would otherwise qualify under s. 409.903(1), a person age
7 65 or over, or a blind or disabled person, who would otherwise
8 be eligible for Medicaid except that the income or assets of
9 such family or person exceed established limitations. A
10 pregnant woman who would otherwise qualify for Medicaid under
11 s. 409.903(5) except for her level of income and whose assets
12 fall within the limits established by the Department of
13 Children and Family Services for the medically needy. A
14 pregnant woman who applies for medically needy eligibility may
15 not be made presumptively eligible.
16 (b) A child under age 21 who would otherwise qualify
17 for Medicaid or the Florida Kidcare program except for the
18 family's level of income and whose assets fall within the
19 limits established by the Department of Children and Family
20 Services for the medically needy. For a family or person in
21 one of these coverage groups this group, medical expenses are
22 deductible from income in accordance with federal requirements
23 in order to make a determination of eligibility. Expenses
24 used to meet spend-down liability are not reimbursable by
25 Medicaid. Effective January 1, 2003, when determining the
26 eligibility of a pregnant woman, a child, or an aged, blind,
27 or disabled individual, $360 shall be deducted from the
28 countable income of the filing unit. When determining the
29 eligibility of the caretaker relative or parent, as defined by
30 Title XIX of the Social Security Act, the additional income
31 disregard of $360 does not apply. A family or person who is
18
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 eligible under this coverage, in this group, which group is
2 known as the "medically needy," is eligible to receive the
3 same services as other Medicaid recipients, with the exception
4 of services in skilled nursing facilities and intermediate
5 care facilities for the developmentally disabled.
6 Section 12. Subsection (5) of section 409.903, Florida
7 Statutes, is amended to read:
8 409.903 Mandatory payments for eligible persons.--The
9 agency shall make payments for medical assistance and related
10 services on behalf of the following persons who the
11 department, or the Social Security Administration by contract
12 with the Department of Children and Family Services,
13 determines to be eligible, subject to the income, assets, and
14 categorical eligibility tests set forth in federal and state
15 law. Payment on behalf of these Medicaid eligible persons is
16 subject to the availability of moneys and any limitations
17 established by the General Appropriations Act or chapter 216.
18 (5) A pregnant woman for the duration of her pregnancy
19 and for the postpartum period as defined in federal law and
20 rule, or a child under age 1, if either is living in a family
21 that has an income which is at or below 150 percent of the
22 most current federal poverty level, or, effective January 1,
23 1992, that has an income which is at or below 185 percent of
24 the most current federal poverty level. Such a person is not
25 subject to an assets test. Further, a pregnant woman who
26 applies for eligibility for the Medicaid program through a
27 qualified Medicaid provider must be offered the opportunity,
28 subject to federal rules, to be made presumptively eligible
29 for the Medicaid program.
30 Section 13. Present subsection (10) of section
31 409.904, Florida Statutes, is amended, present subsections
19
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (9), (10), and (11) are renumbered as subsections (10), (11),
2 and (12), respectively, and a new subsection (9) is added to
3 said section, to read:
4 409.904 Optional payments for eligible persons.--The
5 agency may make payments for medical assistance and related
6 services on behalf of the following persons who are determined
7 to be eligible subject to the income, assets, and categorical
8 eligibility tests set forth in federal and state law. Payment
9 on behalf of these Medicaid eligible persons is subject to the
10 availability of moneys and any limitations established by the
11 General Appropriations Act or chapter 216.
12 (9) A pregnant woman for the duration of her pregnancy
13 and for the postpartum period as defined in federal law and
14 regulation, who has an income above 150 percent but not in
15 excess of 185 percent of the federal poverty level. Countable
16 income shall be determined in accordance with state and
17 federal regulation. A pregnant woman who applies for
18 eligibility for the Medicaid program shall be offered the
19 opportunity, subject to federal regulations, to be made
20 presumptively eligible.
21 (11)(10)(a) Eligible women with incomes at or below
22 200 percent of the federal poverty level and under age 65, for
23 cancer treatment pursuant to the federal Breast and Cervical
24 Cancer Prevention and Treatment Act of 2000, screened through
25 the Mary Brogan National Breast and Cervical Cancer Early
26 Detection Program established under s. 381.93.
27 (b) A woman who has not attained 65 years of age and
28 who has been screened for breast or cervical cancer by a
29 qualified entity under the Mary Brogan Breast and Cervical
30 Cancer Early Detection Program of the Department of Health and
31 needs treatment for breast or cervical cancer and is not
20
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 otherwise covered under creditable coverage, as defined in s.
2 2701(c) of the Public Health Service Act. For purposes of this
3 subsection, the term "qualified entity" means a county public
4 health department or other entity that has contracted with the
5 Department of Health to provide breast and cervical cancer
6 screening services paid for under this act. In determining the
7 eligibility of such a woman, an assets test is not required. A
8 presumptive eligibility period begins on the date on which all
9 eligibility criteria appear to be met and ends on the date
10 determination is made with respect to the eligibility of such
11 woman for services under the state plan or, in the case of
12 such a woman who does not file an application, by the last day
13 of the month following the month in which the presumptive
14 eligibility determination is made. A woman is eligible until
15 she gains creditable coverage, until treatment is no longer
16 necessary, or until attainment of 65 years of age.
17 Section 14. Effective July 1, 2002, subsection (2) of
18 section 409.9065, Florida Statutes, is amended to read:
19 409.9065 Pharmaceutical expense assistance.--
20 (2) ELIGIBILITY.--Eligibility for the program is
21 limited to those individuals who qualify for limited
22 assistance under the Florida Medicaid program as a result of
23 being dually eligible for both Medicare and Medicaid, but
24 whose limited assistance or Medicare coverage does not include
25 any pharmacy benefit. To the extent that funds are
26 appropriated, specifically eligible individuals are
27 individuals low-income senior citizens who:
28 (a) Are Florida residents age 65 and over;
29 (b) Have an income:
30 1. Between 90 and 120 percent of the federal poverty
31 level;
21
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 2. Between 90 and 150 percent of the federal poverty
2 level if the Federal Government increases the federal Medicaid
3 match for persons with incomes between 100 and 150 percent of
4 the federal poverty level; or
5 3. Between 90 percent of the federal poverty level and
6 a level that can be supported with funds provided in the
7 General Appropriations Act for the program offered under this
8 section along with federal matching funds approved by the
9 Federal Government under a Section 1115 waiver. The agency is
10 authorized to submit and implement a federal waiver pursuant
11 to provisions of this subparagraph. The agency shall design a
12 pharmacy benefit that includes annual per-member benefit
13 limits and cost-sharing provisions, and limits enrollment to
14 available appropriations and matching federal funds. Prior to
15 implementing this program, the agency must submit a budget
16 amendment pursuant to chapter 216;
17 (c) Are eligible for both Medicare and Medicaid;
18 (d) Are not enrolled in a Medicare health maintenance
19 organization that provides a pharmacy benefit; and
20 (e) Request to be enrolled in the program.
21 Section 15. Subsections (7) and (9) of section
22 409.907, Florida Statutes, as amended by section 6 of chapter
23 2001-377, Laws of Florida, are amended to read:
24 409.907 Medicaid provider agreements.--The agency may
25 make payments for medical assistance and related services
26 rendered to Medicaid recipients only to an individual or
27 entity who has a provider agreement in effect with the agency,
28 who is performing services or supplying goods in accordance
29 with federal, state, and local law, and who agrees that no
30 person shall, on the grounds of handicap, race, color, or
31 national origin, or for any other reason, be subjected to
22
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 discrimination under any program or activity for which the
2 provider receives payment from the agency.
3 (7) The agency may require, as a condition of
4 participating in the Medicaid program and before entering into
5 the provider agreement, that the provider submit information,
6 in an initial and any required renewal applications,
7 concerning the professional, business, and personal background
8 of the provider and permit an onsite inspection of the
9 provider's service location by agency staff or other personnel
10 designated by the agency to perform this function. After
11 receipt of the fully completed application of a new provider,
12 the agency shall perform onsite inspections of randomly
13 selected providers' service locations, to assist in
14 determining the applicant's ability to provide the services
15 that the applicant is proposing to provide for Medicaid
16 reimbursement. The agency is not required to perform an onsite
17 inspection of a provider or program that is licensed by the
18 agency or the Department of Health or of a provider that
19 provides services under home and community-based services
20 waiver programs or is licensed as a medical foster home by the
21 Department of Children and Family Services. As a continuing
22 condition of participation in the Medicaid program, a provider
23 shall immediately notify the agency of any current or pending
24 bankruptcy filing. Before entering into the provider
25 agreement, or as a condition of continuing participation in
26 the Medicaid program, the agency may also require that
27 Medicaid providers reimbursed on a fee-for-services basis or
28 fee schedule basis which is not cost-based, post a surety bond
29 not to exceed $50,000 or the total amount billed by the
30 provider to the program during the current or most recent
31 calendar year, whichever is greater. For new providers, the
23
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 amount of the surety bond shall be determined by the agency
2 based on the provider's estimate of its first year's billing.
3 If the provider's billing during the first year exceeds the
4 bond amount, the agency may require the provider to acquire an
5 additional bond equal to the actual billing level of the
6 provider. A provider's bond shall not exceed $50,000 if a
7 physician or group of physicians licensed under chapter 458,
8 chapter 459, or chapter 460 has a 50 percent or greater
9 ownership interest in the provider or if the provider is an
10 assisted living facility licensed under part III of chapter
11 400. The bonds permitted by this section are in addition to
12 the bonds referenced in s. 400.179(4)(d). If the provider is a
13 corporation, partnership, association, or other entity, the
14 agency may require the provider to submit information
15 concerning the background of that entity and of any principal
16 of the entity, including any partner or shareholder having an
17 ownership interest in the entity equal to 5 percent or
18 greater, and any treating provider who participates in or
19 intends to participate in Medicaid through the entity. The
20 information must include:
21 (a) Proof of holding a valid license or operating
22 certificate, as applicable, if required by the state or local
23 jurisdiction in which the provider is located or if required
24 by the Federal Government.
25 (b) Information concerning any prior violation, fine,
26 suspension, termination, or other administrative action taken
27 under the Medicaid laws, rules, or regulations of this state
28 or of any other state or the Federal Government; any prior
29 violation of the laws, rules, or regulations relating to the
30 Medicare program; any prior violation of the rules or
31 regulations of any other public or private insurer; and any
24
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 prior violation of the laws, rules, or regulations of any
2 regulatory body of this or any other state.
3 (c) Full and accurate disclosure of any financial or
4 ownership interest that the provider, or any principal,
5 partner, or major shareholder thereof, may hold in any other
6 Medicaid provider or health care related entity or any other
7 entity that is licensed by the state to provide health or
8 residential care and treatment to persons.
9 (d) If a group provider, identification of all members
10 of the group and attestation that all members of the group are
11 enrolled in or have applied to enroll in the Medicaid program.
12 (9) Upon receipt of a completed, signed, and dated
13 application, and completion of any necessary background
14 investigation and criminal history record check, the agency
15 must either:
16 (a) Enroll the applicant as a Medicaid provider no
17 earlier than the effective date of the approval of the
18 provider application. With respect to providers who were
19 recently granted a change of ownership and those who primarily
20 provide emergency medical services transportation or emergency
21 services and care pursuant to s. 401.45 or s. 395.1041, and
22 out-of-state providers, upon approval of the provider
23 application, the effective date of approval is considered to
24 be the date the agency receives the provider application; or
25 (b) Deny the application if the agency finds that it
26 is in the best interest of the Medicaid program to do so. The
27 agency may consider the factors listed in subsection (10), as
28 well as any other factor that could affect the effective and
29 efficient administration of the program, including, but not
30 limited to, the applicant's demonstrated ability to provide
31 services, conduct business, and operate a financially viable
25
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 concern; the current availability of medical care, services,
2 or supplies to recipients, taking into account geographic
3 location and reasonable travel time; the number of providers
4 of the same type already enrolled in the same geographic area;
5 and the credentials, experience, success, and patient outcomes
6 of the provider for the services that it is making application
7 to provide in the Medicaid program. The agency shall deny the
8 application if the agency finds that a provider; any officer,
9 director, agent, managing employee, or affiliated person; or
10 any partner or shareholder having an ownership interest of 5
11 percent or more in the provider if the provider is a
12 corporation, partnership, or other business entity has failed
13 to pay all outstanding fines or overpayments assessed by final
14 order of the agency or final order of the Centers for Medicare
15 and Medicaid Services, unless the provider agrees to a
16 repayment plan that includes withholding Medicaid
17 reimbursement until the amount due is paid in full.
18 Section 16. Section 409.908, Florida Statutes, as
19 amended by section 7 of chapter 2001-377, Laws of Florida, is
20 amended to read:
21 409.908 Reimbursement of Medicaid providers.--Subject
22 to specific appropriations, the agency shall reimburse
23 Medicaid providers, in accordance with state and federal law,
24 according to methodologies set forth in the rules of the
25 agency and in policy manuals and handbooks incorporated by
26 reference therein. These methodologies may include fee
27 schedules, reimbursement methods based on cost reporting,
28 negotiated fees, competitive bidding pursuant to s. 287.057,
29 and other mechanisms the agency considers efficient and
30 effective for purchasing services or goods on behalf of
31 recipients. If a provider is reimbursed based on cost
26
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 reporting and submits a cost report late and that cost report
2 would have been used to set a lower reimbursement rate for a
3 rate semester, then the provider's rate for that semester
4 shall be retroactively calculated using the new cost report,
5 and full payment at the recalculated rate shall be affected
6 retroactively. Medicare-granted extensions for filing cost
7 reports, if applicable, shall also apply to Medicaid cost
8 reports. Payment for Medicaid compensable services made on
9 behalf of Medicaid eligible persons is subject to the
10 availability of moneys and any limitations or directions
11 provided for in the General Appropriations Act or chapter 216.
12 Further, nothing in this section shall be construed to prevent
13 or limit the agency from adjusting fees, reimbursement rates,
14 lengths of stay, number of visits, or number of services, or
15 making any other adjustments necessary to comply with the
16 availability of moneys and any limitations or directions
17 provided for in the General Appropriations Act, provided the
18 adjustment is consistent with legislative intent.
19 (1) Reimbursement to hospitals licensed under part I
20 of chapter 395 must be made prospectively or on the basis of
21 negotiation.
22 (a) Reimbursement for inpatient care is limited as
23 provided for in s. 409.905(5), except for:
24 1. The raising of rate reimbursement caps, excluding
25 rural hospitals.
26 2. Recognition of the costs of graduate medical
27 education.
28 3. Other methodologies recognized in the General
29 Appropriations Act.
30
31
27
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 4. Hospital inpatient rates shall be reduced by 6
2 percent effective July 1, 2001, and restored effective April
3 1, 2002.
4
5 During the years funds are transferred from the Department of
6 Health, any reimbursement supported by such funds shall be
7 subject to certification by the Department of Health that the
8 hospital has complied with s. 381.0403. The agency is
9 authorized to receive funds from state entities, including,
10 but not limited to, the Department of Health, local
11 governments, and other local political subdivisions, for the
12 purpose of making special exception payments, including
13 federal matching funds, through the Medicaid inpatient
14 reimbursement methodologies. Funds received from state
15 entities or local governments for this purpose shall be
16 separately accounted for and shall not be commingled with
17 other state or local funds in any manner. The agency may
18 certify all local governmental funds used as state match under
19 Title XIX of the Social Security Act, to the extent that the
20 identified local health care provider that is otherwise
21 entitled to and is contracted to receive such local funds is
22 the benefactor under the state's Medicaid program as
23 determined under the General Appropriations Act and pursuant
24 to an agreement between the Agency for Health Care
25 Administration and the local governmental entity. The local
26 governmental entity shall use a certification form prescribed
27 by the agency. At a minimum, the certification form shall
28 identify the amount being certified and describe the
29 relationship between the certifying local governmental entity
30 and the local health care provider. The agency shall prepare
31 an annual statement of impact which documents the specific
28
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 activities undertaken during the previous fiscal year pursuant
2 to this paragraph, to be submitted to the Legislature no later
3 than January 1, annually.
4 (b) Reimbursement for hospital outpatient care is
5 limited to $1,500 per state fiscal year per recipient, except
6 for:
7 1. Such care provided to a Medicaid recipient under
8 age 21, in which case the only limitation is medical
9 necessity.
10 2. Renal dialysis services.
11 3. Other exceptions made by the agency.
12
13 The agency is authorized to receive funds from state entities,
14 including, but not limited to, the Department of Health, the
15 Board of Regents, local governments, and other local political
16 subdivisions, for the purpose of making payments, including
17 federal matching funds, through the Medicaid outpatient
18 reimbursement methodologies. Funds received from state
19 entities and local governments for this purpose shall be
20 separately accounted for and shall not be commingled with
21 other state or local funds in any manner.
22 (c) Hospitals that provide services to a
23 disproportionate share of low-income Medicaid recipients, or
24 that participate in the regional perinatal intensive care
25 center program under chapter 383, or that participate in the
26 statutory teaching hospital disproportionate share program may
27 receive additional reimbursement. The total amount of payment
28 for disproportionate share hospitals shall be fixed by the
29 General Appropriations Act. The computation of these payments
30 must be made in compliance with all federal regulations and
31
29
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 the methodologies described in ss. 409.911, 409.9112, and
2 409.9113.
3 (d) The agency is authorized to limit inflationary
4 increases for outpatient hospital services as directed by the
5 General Appropriations Act.
6 (2)(a)1. Reimbursement to nursing homes licensed under
7 part II of chapter 400 and state-owned-and-operated
8 intermediate care facilities for the developmentally disabled
9 licensed under chapter 393 must be made prospectively.
10 2. Unless otherwise limited or directed in the General
11 Appropriations Act, reimbursement to hospitals licensed under
12 part I of chapter 395 for the provision of swing-bed nursing
13 home services must be made on the basis of the average
14 statewide nursing home payment, and reimbursement to a
15 hospital licensed under part I of chapter 395 for the
16 provision of skilled nursing services must be made on the
17 basis of the average nursing home payment for those services
18 in the county in which the hospital is located. When a
19 hospital is located in a county that does not have any
20 community nursing homes, reimbursement must be determined by
21 averaging the nursing home payments, in counties that surround
22 the county in which the hospital is located. Reimbursement to
23 hospitals, including Medicaid payment of Medicare copayments,
24 for skilled nursing services shall be limited to 30 days,
25 unless a prior authorization has been obtained from the
26 agency. Medicaid reimbursement may be extended by the agency
27 beyond 30 days, and approval must be based upon verification
28 by the patient's physician that the patient requires
29 short-term rehabilitative and recuperative services only, in
30 which case an extension of no more than 15 days may be
31 approved. Reimbursement to a hospital licensed under part I of
30
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 chapter 395 for the temporary provision of skilled nursing
2 services to nursing home residents who have been displaced as
3 the result of a natural disaster or other emergency may not
4 exceed the average county nursing home payment for those
5 services in the county in which the hospital is located and is
6 limited to the period of time which the agency considers
7 necessary for continued placement of the nursing home
8 residents in the hospital.
9 (b) Subject to any limitations or directions provided
10 for in the General Appropriations Act, the agency shall
11 establish and implement a Florida Title XIX Long-Term Care
12 Reimbursement Plan (Medicaid) for nursing home care in order
13 to provide care and services in conformance with the
14 applicable state and federal laws, rules, regulations, and
15 quality and safety standards and to ensure that individuals
16 eligible for medical assistance have reasonable geographic
17 access to such care.
18 1. Changes of ownership or of licensed operator do not
19 qualify for increases in reimbursement rates associated with
20 the change of ownership or of licensed operator. The agency
21 shall amend the Title XIX Long Term Care Reimbursement Plan to
22 provide that the initial nursing home reimbursement rates, for
23 the operating, patient care, and MAR components, associated
24 with related and unrelated party changes of ownership or
25 licensed operator filed on or after September 1, 2001, are
26 equivalent to the previous owner's reimbursement rate.
27 2. The agency shall amend the long-term care
28 reimbursement plan and cost reporting system to create direct
29 care and indirect care subcomponents of the patient care
30 component of the per diem rate. These two subcomponents
31 together shall equal the patient care component of the per
31
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 diem rate. Separate cost-based ceilings shall be calculated
2 for each patient care subcomponent. The direct care
3 subcomponent of the per diem rate shall be limited by the
4 cost-based class ceiling, and the indirect care subcomponent
5 shall be limited by the lower of the cost-based class ceiling,
6 by the target rate class ceiling, or by the individual
7 provider target. The agency shall adjust the patient care
8 component effective January 1, 2002. The cost to adjust the
9 direct care subcomponent shall be net of the total funds
10 previously allocated for the case mix add-on. The agency shall
11 make the required changes to the nursing home cost reporting
12 forms to implement this requirement effective January 1, 2002.
13 3. The direct care subcomponent shall include salaries
14 and benefits of direct care staff providing nursing services
15 including registered nurses, licensed practical nurses, and
16 certified nursing assistants who deliver care directly to
17 residents in the nursing home facility. This excludes nursing
18 administration, MDS, and care plan coordinators, staff
19 development, and staffing coordinator.
20 4. All other patient care costs shall be included in
21 the indirect care cost subcomponent of the patient care per
22 diem rate. There shall be no costs directly or indirectly
23 allocated to the direct care subcomponent from a home office
24 or management company.
25 5. On July 1 of each year, the agency shall report to
26 the Legislature direct and indirect care costs, including
27 average direct and indirect care costs per resident per
28 facility and direct care and indirect care salaries and
29 benefits per category of staff member per facility.
30 6. In order to offset the cost of general and
31 professional liability insurance, the agency shall amend Under
32
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 the plan to allow for, interim rate adjustments shall not be
2 granted to reflect increases in the cost of general or
3 professional liability insurance for nursing homes unless the
4 following criteria are met: have at least a 65 percent
5 Medicaid utilization in the most recent cost report submitted
6 to the agency, and the increase in general or professional
7 liability costs to the facility for the most recent policy
8 period affects the total Medicaid per diem by at least 5
9 percent. This rate adjustment shall not result in the per diem
10 exceeding the class ceiling. This provision shall be
11 implemented to the extent existing appropriations are
12 available. The agency shall adjust the operating component of
13 the per diem rate to allow for an add-on for general and
14 professional liability insurance for nursing facilities,
15 effective July 1, 2002. The add-on shall be calculated by
16 multiplying $500 times the number of Medicaid certified beds
17 divided by the total patient days as reported on the cost
18 report used for the July 2002 rate setting. The total
19 operating cost per diem, including the add-on, shall not be
20 greater than the provider's actual, inflated operating cost
21 per diem.
22
23 It is the intent of the Legislature that the reimbursement
24 plan achieve the goal of providing access to health care for
25 nursing home residents who require large amounts of care while
26 encouraging diversion services as an alternative to nursing
27 home care for residents who can be served within the
28 community. The agency shall base the establishment of any
29 maximum rate of payment, whether overall or component, on the
30 available moneys as provided for in the General Appropriations
31 Act. The agency may base the maximum rate of payment on the
33
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 results of scientifically valid analysis and conclusions
2 derived from objective statistical data pertinent to the
3 particular maximum rate of payment.
4 (3) Subject to any limitations or directions provided
5 for in the General Appropriations Act, the following Medicaid
6 services and goods may be reimbursed on a fee-for-service
7 basis. For each allowable service or goods furnished in
8 accordance with Medicaid rules, policy manuals, handbooks, and
9 state and federal law, the payment shall be the amount billed
10 by the provider, the provider's usual and customary charge, or
11 the maximum allowable fee established by the agency, whichever
12 amount is less, with the exception of those services or goods
13 for which the agency makes payment using a methodology based
14 on capitation rates, average costs, or negotiated fees.
15 (a) Advanced registered nurse practitioner services.
16 (b) Birth center services.
17 (c) Chiropractic services.
18 (d) Community mental health services.
19 (e) Dental services, including oral and maxillofacial
20 surgery.
21 (f) Durable medical equipment.
22 (g) Hearing services.
23 (h) Occupational therapy for Medicaid recipients under
24 age 21.
25 (i) Optometric services.
26 (j) Orthodontic services.
27 (k) Personal care for Medicaid recipients under age
28 21.
29 (l) Physical therapy for Medicaid recipients under age
30 21.
31 (m) Physician assistant services.
34
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (n) Podiatric services.
2 (o) Portable X-ray services.
3 (p) Private-duty nursing for Medicaid recipients under
4 age 21.
5 (q) Registered nurse first assistant services.
6 (r) Respiratory therapy for Medicaid recipients under
7 age 21.
8 (s) Speech therapy for Medicaid recipients under age
9 21.
10 (t) Visual services.
11 (4) Subject to any limitations or directions provided
12 for in the General Appropriations Act, alternative health
13 plans, health maintenance organizations, and prepaid health
14 plans shall be reimbursed a fixed, prepaid amount negotiated,
15 or competitively bid pursuant to s. 287.057, by the agency and
16 prospectively paid to the provider monthly for each Medicaid
17 recipient enrolled. The amount may not exceed the average
18 amount the agency determines it would have paid, based on
19 claims experience, for recipients in the same or similar
20 category of eligibility. The agency shall calculate
21 capitation rates on a regional basis and, beginning September
22 1, 1995, shall include age-band differentials in such
23 calculations. Effective July 1, 2001, the cost of exempting
24 statutory teaching hospitals, specialty hospitals, and
25 community hospital education program hospitals from
26 reimbursement ceilings and the cost of special Medicaid
27 payments shall not be included in premiums paid to health
28 maintenance organizations or prepaid health care plans. Each
29 rate semester, the agency shall calculate and publish a
30 Medicaid hospital rate schedule that does not reflect either
31 special Medicaid payments or the elimination of rate
35
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 reimbursement ceilings, to be used by hospitals and Medicaid
2 health maintenance organizations, in order to determine the
3 Medicaid rate referred to in ss. 409.912(16), 409.9128(5), and
4 641.513(6).
5 (5) An ambulatory surgical center shall be reimbursed
6 the lesser of the amount billed by the provider or the
7 Medicare-established allowable amount for the facility.
8 (6) A provider of early and periodic screening,
9 diagnosis, and treatment services to Medicaid recipients who
10 are children under age 21 shall be reimbursed using an
11 all-inclusive rate stipulated in a fee schedule established by
12 the agency. A provider of the visual, dental, and hearing
13 components of such services shall be reimbursed the lesser of
14 the amount billed by the provider or the Medicaid maximum
15 allowable fee established by the agency.
16 (7) A provider of family planning services shall be
17 reimbursed the lesser of the amount billed by the provider or
18 an all-inclusive amount per type of visit for physicians and
19 advanced registered nurse practitioners, as established by the
20 agency in a fee schedule.
21 (8) A provider of home-based or community-based
22 services rendered pursuant to a federally approved waiver
23 shall be reimbursed based on an established or negotiated rate
24 for each service. These rates shall be established according
25 to an analysis of the expenditure history and prospective
26 budget developed by each contract provider participating in
27 the waiver program, or under any other methodology adopted by
28 the agency and approved by the Federal Government in
29 accordance with the waiver. Effective July 1, 1996, privately
30 owned and operated community-based residential facilities
31 which meet agency requirements and which formerly received
36
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Medicaid reimbursement for the optional intermediate care
2 facility for the mentally retarded service may participate in
3 the developmental services waiver as part of a
4 home-and-community-based continuum of care for Medicaid
5 recipients who receive waiver services.
6 (9) A provider of home health care services or of
7 medical supplies and appliances shall be reimbursed on the
8 basis of competitive bidding or for the lesser of the amount
9 billed by the provider or the agency's established maximum
10 allowable amount, except that, in the case of the rental of
11 durable medical equipment, the total rental payments may not
12 exceed the purchase price of the equipment over its expected
13 useful life or the agency's established maximum allowable
14 amount, whichever amount is less.
15 (10) A hospice shall be reimbursed through a
16 prospective system for each Medicaid hospice patient at
17 Medicaid rates using the methodology established for hospice
18 reimbursement pursuant to Title XVIII of the federal Social
19 Security Act.
20 (11) A provider of independent laboratory services
21 shall be reimbursed on the basis of competitive bidding or for
22 the least of the amount billed by the provider, the provider's
23 usual and customary charge, or the Medicaid maximum allowable
24 fee established by the agency.
25 (12)(a) A physician shall be reimbursed the lesser of
26 the amount billed by the provider or the Medicaid maximum
27 allowable fee established by the agency.
28 (b) The agency shall adopt a fee schedule, subject to
29 any limitations or directions provided for in the General
30 Appropriations Act, based on a resource-based relative value
31 scale for pricing Medicaid physician services. Under this fee
37
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 schedule, physicians shall be paid a dollar amount for each
2 service based on the average resources required to provide the
3 service, including, but not limited to, estimates of average
4 physician time and effort, practice expense, and the costs of
5 professional liability insurance. The fee schedule shall
6 provide increased reimbursement for preventive and primary
7 care services and lowered reimbursement for specialty services
8 by using at least two conversion factors, one for cognitive
9 services and another for procedural services. The fee
10 schedule shall not increase total Medicaid physician
11 expenditures unless moneys are available, and shall be phased
12 in over a 2-year period beginning on July 1, 1994. The Agency
13 for Health Care Administration shall seek the advice of a
14 16-member advisory panel in formulating and adopting the fee
15 schedule. The panel shall consist of Medicaid physicians
16 licensed under chapters 458 and 459 and shall be composed of
17 50 percent primary care physicians and 50 percent specialty
18 care physicians.
19 (c) Notwithstanding paragraph (b), reimbursement fees
20 to physicians for providing total obstetrical services to
21 Medicaid recipients, which include prenatal, delivery, and
22 postpartum care, shall be at least $1,500 per delivery for a
23 pregnant woman with low medical risk and at least $2,000 per
24 delivery for a pregnant woman with high medical risk. However,
25 reimbursement to physicians working in Regional Perinatal
26 Intensive Care Centers designated pursuant to chapter 383, for
27 services to certain pregnant Medicaid recipients with a high
28 medical risk, may be made according to obstetrical care and
29 neonatal care groupings and rates established by the agency.
30 Nurse midwives licensed under part I of chapter 464 or
31 midwives licensed under chapter 467 shall be reimbursed at no
38
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 less than 80 percent of the low medical risk fee. The agency
2 shall by rule determine, for the purpose of this paragraph,
3 what constitutes a high or low medical risk pregnant woman and
4 shall not pay more based solely on the fact that a caesarean
5 section was performed, rather than a vaginal delivery. The
6 agency shall by rule determine a prorated payment for
7 obstetrical services in cases where only part of the total
8 prenatal, delivery, or postpartum care was performed. The
9 Department of Health shall adopt rules for appropriate
10 insurance coverage for midwives licensed under chapter 467.
11 Prior to the issuance and renewal of an active license, or
12 reactivation of an inactive license for midwives licensed
13 under chapter 467, such licensees shall submit proof of
14 coverage with each application.
15 (d) For fiscal years 2001-2002 and 2002-2003 the
16 2001-2002 fiscal year only and if necessary to meet the
17 requirements for grants and donations for the special Medicaid
18 payments authorized in the 2001-2002 and 2002-2003 General
19 Appropriations Acts Act, the agency may make special Medicaid
20 payments to qualified Medicaid providers designated by the
21 agency, notwithstanding any provision of this subsection to
22 the contrary, and may use intergovernmental transfers from
23 state entities or other governmental entities to serve as the
24 state share of such payments.
25 (13) Medicare premiums for persons eligible for both
26 Medicare and Medicaid coverage shall be paid at the rates
27 established by Title XVIII of the Social Security Act. For
28 Medicare services rendered to Medicaid-eligible persons,
29 Medicaid shall pay Medicare deductibles and coinsurance as
30 follows:
31
39
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (a) Medicaid shall make no payment toward deductibles
2 and coinsurance for any service that is not covered by
3 Medicaid.
4 (b) Medicaid's financial obligation for deductibles
5 and coinsurance payments shall be based on Medicare allowable
6 fees, not on a provider's billed charges.
7 (c) Medicaid will pay no portion of Medicare
8 deductibles and coinsurance when payment that Medicare has
9 made for the service equals or exceeds what Medicaid would
10 have paid if it had been the sole payor. The combined payment
11 of Medicare and Medicaid shall not exceed the amount Medicaid
12 would have paid had it been the sole payor. The Legislature
13 finds that there has been confusion regarding the
14 reimbursement for services rendered to dually eligible
15 Medicare beneficiaries. Accordingly, the Legislature clarifies
16 that it has always been the intent of the Legislature before
17 and after 1991 that, in reimbursing in accordance with fees
18 established by Title XVIII for premiums, deductibles, and
19 coinsurance for Medicare services rendered by physicians to
20 Medicaid eligible persons, physicians be reimbursed at the
21 lesser of the amount billed by the physician or the Medicaid
22 maximum allowable fee established by the Agency for Health
23 Care Administration, as is permitted by federal law. It has
24 never been the intent of the Legislature with regard to such
25 services rendered by physicians that Medicaid be required to
26 provide any payment for deductibles, coinsurance, or
27 copayments for Medicare cost sharing, or any expenses incurred
28 relating thereto, in excess of the payment amount provided for
29 under the State Medicaid plan for such service. This payment
30 methodology is applicable even in those situations in which
31 the payment for Medicare cost sharing for a qualified Medicare
40
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 beneficiary with respect to an item or service is reduced or
2 eliminated. This expression of the Legislature is in
3 clarification of existing law and shall apply to payment for,
4 and with respect to provider agreements with respect to, items
5 or services furnished on or after the effective date of this
6 act. This paragraph applies to payment by Medicaid for items
7 and services furnished before the effective date of this act
8 if such payment is the subject of a lawsuit that is based on
9 the provisions of this section, and that is pending as of, or
10 is initiated after, the effective date of this act.
11 (d) Notwithstanding paragraphs (a)-(c):
12 1. Medicaid payments for Nursing Home Medicare part A
13 coinsurance shall be the lesser of the Medicare coinsurance
14 amount or the Medicaid nursing home per diem rate.
15 2. Medicaid shall pay all deductibles and coinsurance
16 for Medicare-eligible recipients receiving freestanding end
17 stage renal dialysis center services.
18 3. Medicaid payments for general hospital inpatient
19 services shall be limited to the Medicare deductible per spell
20 of illness. Medicaid shall make no payment toward coinsurance
21 for Medicare general hospital inpatient services.
22 4. Medicaid shall pay all deductibles and coinsurance
23 for Medicare emergency transportation services provided by
24 ambulances licensed pursuant to chapter 401.
25 (14) A provider of prescribed drugs shall be
26 reimbursed the least of the amount billed by the provider, the
27 provider's usual and customary charge, or the Medicaid maximum
28 allowable fee established by the agency, plus a dispensing
29 fee. The agency is directed to implement a variable dispensing
30 fee for payments for prescribed medicines while ensuring
31 continued access for Medicaid recipients. The variable
41
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 dispensing fee may be based upon, but not limited to, either
2 or both the volume of prescriptions dispensed by a specific
3 pharmacy provider, the volume of prescriptions dispensed to an
4 individual recipient, and dispensing of preferred-drug-list
5 products. The agency shall increase the pharmacy dispensing
6 fee authorized by statute and in the annual General
7 Appropriations Act by $0.50 for the dispensing of a Medicaid
8 preferred-drug-list product and reduce the pharmacy dispensing
9 fee by $0.50 for the dispensing of a Medicaid product that is
10 not included on the preferred-drug list. The agency is
11 authorized to limit reimbursement for prescribed medicine in
12 order to comply with any limitations or directions provided
13 for in the General Appropriations Act, which may include
14 implementing a prospective or concurrent utilization review
15 program.
16 (15) A provider of primary care case management
17 services rendered pursuant to a federally approved waiver
18 shall be reimbursed by payment of a fixed, prepaid monthly sum
19 for each Medicaid recipient enrolled with the provider.
20 (16) A provider of rural health clinic services and
21 federally qualified health center services shall be reimbursed
22 a rate per visit based on total reasonable costs of the
23 clinic, as determined by the agency in accordance with federal
24 regulations.
25 (17) A provider of targeted case management services
26 shall be reimbursed pursuant to an established fee, except
27 where the Federal Government requires a public provider be
28 reimbursed on the basis of average actual costs.
29 (18) Unless otherwise provided for in the General
30 Appropriations Act, a provider of transportation services
31 shall be reimbursed the lesser of the amount billed by the
42
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 provider or the Medicaid maximum allowable fee established by
2 the agency, except when the agency has entered into a direct
3 contract with the provider, or with a community transportation
4 coordinator, for the provision of an all-inclusive service, or
5 when services are provided pursuant to an agreement negotiated
6 between the agency and the provider. The agency, as provided
7 for in s. 427.0135, shall purchase transportation services
8 through the community coordinated transportation system, if
9 available, unless the agency determines a more cost-effective
10 method for Medicaid clients. Nothing in this subsection shall
11 be construed to limit or preclude the agency from contracting
12 for services using a prepaid capitation rate or from
13 establishing maximum fee schedules, individualized
14 reimbursement policies by provider type, negotiated fees,
15 prior authorization, competitive bidding, increased use of
16 mass transit, or any other mechanism that the agency considers
17 efficient and effective for the purchase of services on behalf
18 of Medicaid clients, including implementing a transportation
19 eligibility process. The agency shall not be required to
20 contract with any community transportation coordinator or
21 transportation operator that has been determined by the
22 agency, the Department of Legal Affairs Medicaid Fraud Control
23 Unit, or any other state or federal agency to have engaged in
24 any abusive or fraudulent billing activities. The agency is
25 authorized to competitively procure transportation services or
26 make other changes necessary to secure approval of federal
27 waivers needed to permit federal financing of Medicaid
28 transportation services at the service matching rate rather
29 than the administrative matching rate.
30 (19) County health department services may be
31 reimbursed a rate per visit based on total reasonable costs of
43
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 the clinic, as determined by the agency in accordance with
2 federal regulations under the authority of 42 C.F.R. s.
3 431.615.
4 (20) A renal dialysis facility that provides dialysis
5 services under s. 409.906(9) must be reimbursed the lesser of
6 the amount billed by the provider, the provider's usual and
7 customary charge, or the maximum allowable fee established by
8 the agency, whichever amount is less.
9 (21) The agency shall reimburse school districts which
10 certify the state match pursuant to ss. 236.0812 and 409.9071
11 for the federal portion of the school district's allowable
12 costs to deliver the services, based on the reimbursement
13 schedule. The school district shall determine the costs for
14 delivering services as authorized in ss. 236.0812 and 409.9071
15 for which the state match will be certified. Reimbursement of
16 school-based providers is contingent on such providers being
17 enrolled as Medicaid providers and meeting the qualifications
18 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
19 the federal Health Care Financing Administration. Speech
20 therapy providers who are certified through the Department of
21 Education pursuant to rule 6A-4.0176, Florida Administrative
22 Code, are eligible for reimbursement for services that are
23 provided on school premises. Any employee of the school
24 district who has been fingerprinted and has received a
25 criminal background check in accordance with Department of
26 Education rules and guidelines shall be exempt from any agency
27 requirements relating to criminal background checks.
28 (22) The agency shall request and implement Medicaid
29 waivers from the federal Health Care Financing Administration
30 to advance and treat a portion of the Medicaid nursing home
31 per diem as capital for creating and operating a
44
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 risk-retention group for self-insurance purposes, consistent
2 with federal and state laws and rules.
3 Section 17. Subsection (1) of section 409.911, Florida
4 Statutes, is amended to read:
5 409.911 Disproportionate share program.--Subject to
6 specific allocations established within the General
7 Appropriations Act and any limitations established pursuant to
8 chapter 216, the agency shall distribute, pursuant to this
9 section, moneys to hospitals providing a disproportionate
10 share of Medicaid or charity care services by making quarterly
11 Medicaid payments as required. Notwithstanding the provisions
12 of s. 409.915, counties are exempt from contributing toward
13 the cost of this special reimbursement for hospitals serving a
14 disproportionate share of low-income patients.
15 (1) Definitions.--As used in this section, and s.
16 409.9112, and the Florida Hospital Uniform Reporting System
17 manual:
18 (a) "Adjusted patient days" means the sum of acute
19 care patient days and intensive care patient days as reported
20 to the Agency for Health Care Administration, divided by the
21 ratio of inpatient revenues generated from acute, intensive,
22 ambulatory, and ancillary patient services to gross revenues.
23 (b) "Actual audited data" or "actual audited
24 experience" means data reported to the Agency for Health Care
25 Administration which has been audited in accordance with
26 generally accepted auditing standards by the agency or
27 representatives under contract with the agency.
28 (c) "Base Medicaid per diem" means the hospital's
29 Medicaid per diem rate initially established by the Agency for
30 Health Care Administration on January 1, 1999. The base
31 Medicaid per diem rate shall not include any additional per
45
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 diem increases received as a result of the disproportionate
2 share distribution.
3 (d) "Charity care" or "uncompensated charity care"
4 means that portion of hospital charges reported to the Agency
5 for Health Care Administration for which there is no
6 compensation, other than restricted or unrestricted revenues
7 provided to a hospital by local governments or tax districts
8 regardless of the method of payment, for care provided to a
9 patient whose family income for the 12 months preceding the
10 determination is less than or equal to 200 percent of the
11 federal poverty level, unless the amount of hospital charges
12 due from the patient exceeds 25 percent of the annual family
13 income. However, in no case shall the hospital charges for a
14 patient whose family income exceeds four times the federal
15 poverty level for a family of four be considered charity.
16 (e) "Charity care days" means the sum of the
17 deductions from revenues for charity care minus 50 percent of
18 restricted and unrestricted revenues provided to a hospital by
19 local governments or tax districts, divided by gross revenues
20 per adjusted patient day.
21 (f) "Disproportionate share percentage" means a rate
22 of increase in the Medicaid per diem rate as calculated under
23 this section.
24 (g) "Hospital" means a health care institution
25 licensed as a hospital pursuant to chapter 395, but does not
26 include ambulatory surgical centers.
27 (h) "Medicaid days" means the number of actual days
28 attributable to Medicaid patients as determined by the Agency
29 for Health Care Administration.
30 Section 18. Subsection (7) of section 409.9116,
31 Florida Statutes, is amended to read:
46
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 409.9116 Disproportionate share/financial assistance
2 program for rural hospitals.--In addition to the payments made
3 under s. 409.911, the Agency for Health Care Administration
4 shall administer a federally matched disproportionate share
5 program and a state-funded financial assistance program for
6 statutory rural hospitals. The agency shall make
7 disproportionate share payments to statutory rural hospitals
8 that qualify for such payments and financial assistance
9 payments to statutory rural hospitals that do not qualify for
10 disproportionate share payments. The disproportionate share
11 program payments shall be limited by and conform with federal
12 requirements. Funds shall be distributed quarterly in each
13 fiscal year for which an appropriation is made.
14 Notwithstanding the provisions of s. 409.915, counties are
15 exempt from contributing toward the cost of this special
16 reimbursement for hospitals serving a disproportionate share
17 of low-income patients.
18 (7) This section applies only to hospitals that were
19 defined as statutory rural hospitals, or their
20 successor-in-interest hospital, prior to July 1, 1999 1998.
21 Any additional hospital that is defined as a statutory rural
22 hospital, or its successor-in-interest hospital, on or after
23 July 1, 1999 1998, is not eligible for programs under this
24 section unless additional funds are appropriated each fiscal
25 year specifically to the rural hospital disproportionate share
26 and financial assistance programs in an amount necessary to
27 prevent any hospital, or its successor-in-interest hospital,
28 eligible for the programs prior to July 1, 1999 1998, from
29 incurring a reduction in payments because of the eligibility
30 of an additional hospital to participate in the programs. A
31 hospital, or its successor-in-interest hospital, which
47
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 received funds pursuant to this section before July 1, 1999
2 1998, and which qualifies under s. 395.602(2)(e), shall be
3 included in the programs under this section and is not
4 required to seek additional appropriations under this
5 subsection.
6 Section 19. Subsection (7) of section 409.91195,
7 Florida Statutes, is amended to read:
8 409.91195 Medicaid Pharmaceutical and Therapeutics
9 Committee.--There is created a Medicaid Pharmaceutical and
10 Therapeutics Committee within the Agency for Health Care
11 Administration for the purpose of developing a preferred drug
12 formulary pursuant to 42 U.S.C. s. 1396r-8.
13 (7) The committee shall ensure that interested
14 parties, including pharmaceutical manufacturers agreeing to
15 provide a supplemental rebate as outlined in this chapter,
16 have an opportunity to present public testimony to the
17 committee with information or evidence supporting inclusion of
18 a product on the preferred drug list. Such public testimony
19 shall occur prior to any recommendations made by the committee
20 for inclusion or exclusion from the preferred drug list. Upon
21 timely notice, the agency shall ensure that any drug that has
22 been approved or had any of its particular uses approved by
23 the United States Food and Drug Administration under a
24 priority review classification will be reviewed by the
25 Medicaid Pharmaceutical and Therapeutics Committee at the next
26 regularly scheduled meeting. To the extent possible, upon
27 notice by a manufacturer the agency shall also schedule a
28 product review for any new product at the next regularly
29 scheduled Medicaid Pharmaceutical and Therapeutics Committee.
30
31
48
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Section 20. Paragraph (b) of subsection (3) and
2 paragraph (b) of subsection (13) of section 409.912, Florida
3 Statutes, are amended to read:
4 409.912 Cost-effective purchasing of health care.--The
5 agency shall purchase goods and services for Medicaid
6 recipients in the most cost-effective manner consistent with
7 the delivery of quality medical care. The agency shall
8 maximize the use of prepaid per capita and prepaid aggregate
9 fixed-sum basis services when appropriate and other
10 alternative service delivery and reimbursement methodologies,
11 including competitive bidding pursuant to s. 287.057, designed
12 to facilitate the cost-effective purchase of a case-managed
13 continuum of care. The agency shall also require providers to
14 minimize the exposure of recipients to the need for acute
15 inpatient, custodial, and other institutional care and the
16 inappropriate or unnecessary use of high-cost services. The
17 agency may establish prior authorization requirements for
18 certain populations of Medicaid beneficiaries, certain drug
19 classes, or particular drugs to prevent fraud, abuse, overuse,
20 and possible dangerous drug interactions. The Pharmaceutical
21 and Therapeutics Committee shall make recommendations to the
22 agency on drugs for which prior authorization is required. The
23 agency shall inform the Pharmaceutical and Therapeutics
24 Committee of its decisions regarding drugs subject to prior
25 authorization.
26 (3) The agency may contract with:
27 (b) An entity that is providing comprehensive
28 behavioral health care services to certain Medicaid recipients
29 through a capitated, prepaid arrangement pursuant to the
30 federal waiver provided for by s. 409.905(5). Such an entity
31 must be licensed under chapter 624, chapter 636, or chapter
49
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 641 and must possess the clinical systems and operational
2 competence to manage risk and provide comprehensive behavioral
3 health care to Medicaid recipients. As used in this paragraph,
4 the term "comprehensive behavioral health care services" means
5 covered mental health and substance abuse treatment services
6 that are available to Medicaid recipients. The secretary of
7 the Department of Children and Family Services shall approve
8 provisions of procurements related to children in the
9 department's care or custody prior to enrolling such children
10 in a prepaid behavioral health plan. Any contract awarded
11 under this paragraph must be competitively procured. In
12 developing the behavioral health care prepaid plan procurement
13 document, the agency shall ensure that the procurement
14 document requires the contractor to develop and implement a
15 plan to ensure compliance with s. 394.4574 related to services
16 provided to residents of licensed assisted living facilities
17 that hold a limited mental health license. The agency must
18 ensure that Medicaid recipients have available the choice of
19 at least two managed care plans for their behavioral health
20 care services. To ensure unimpaired access to behavioral
21 health care services by Medicaid recipients, all contracts
22 issued pursuant to this paragraph shall require 80 percent of
23 the capitation paid to the managed care plan, including health
24 maintenance organizations, to be expended for the provision of
25 behavioral health care services. In the event the managed care
26 plan expends less than 80 percent of the capitation paid
27 pursuant to this paragraph for the provision of behavioral
28 health care services, the difference shall be returned to the
29 agency. The agency shall provide the managed care plan with a
30 certification letter indicating the amount of capitation paid
31 during each calendar year for the provision of behavioral
50
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 health care services pursuant to this section. The agency may
2 reimburse for substance-abuse-treatment services on a
3 fee-for-service basis until the agency finds that adequate
4 funds are available for capitated, prepaid arrangements.
5 1. By January 1, 2001, the agency shall modify the
6 contracts with the entities providing comprehensive inpatient
7 and outpatient mental health care services to Medicaid
8 recipients in Hillsborough, Highlands, Hardee, Manatee, and
9 Polk Counties, to include substance-abuse-treatment services.
10 2. By December 31, 2001, the agency shall contract
11 with entities providing comprehensive behavioral health care
12 services to Medicaid recipients through capitated, prepaid
13 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
14 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
15 and Walton Counties. The agency may contract with entities
16 providing comprehensive behavioral health care services to
17 Medicaid recipients through capitated, prepaid arrangements in
18 Alachua County. The agency may determine if Sarasota County
19 shall be included as a separate catchment area or included in
20 any other agency geographic area.
21 3. Children residing in a Department of Juvenile
22 Justice residential program approved as a Medicaid behavioral
23 health overlay services provider shall not be included in a
24 behavioral health care prepaid health plan pursuant to this
25 paragraph.
26 4. In converting to a prepaid system of delivery, the
27 agency shall in its procurement document require an entity
28 providing comprehensive behavioral health care services to
29 prevent the displacement of indigent care patients by
30 enrollees in the Medicaid prepaid health plan providing
31 behavioral health care services from facilities receiving
51
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 state funding to provide indigent behavioral health care, to
2 facilities licensed under chapter 395 which do not receive
3 state funding for indigent behavioral health care, or
4 reimburse the unsubsidized facility for the cost of behavioral
5 health care provided to the displaced indigent care patient.
6 5. Traditional community mental health providers under
7 contract with the Department of Children and Family Services
8 pursuant to part IV of chapter 394 and inpatient mental health
9 providers licensed pursuant to chapter 395 must be offered an
10 opportunity to accept or decline a contract to participate in
11 any provider network for prepaid behavioral health services.
12 (13)
13 (b) The responsibility of the agency under this
14 subsection shall include the development of capabilities to
15 identify actual and optimal practice patterns; patient and
16 provider educational initiatives; methods for determining
17 patient compliance with prescribed treatments; fraud, waste,
18 and abuse prevention and detection programs; and beneficiary
19 case management programs.
20 1. The practice pattern identification program shall
21 evaluate practitioner prescribing patterns based on national
22 and regional practice guidelines, comparing practitioners to
23 their peer groups. The agency and its Drug Utilization Review
24 Board shall consult with a panel of practicing health care
25 professionals consisting of the following: the Speaker of the
26 House of Representatives and the President of the Senate shall
27 each appoint three physicians licensed under chapter 458 or
28 chapter 459; and the Governor shall appoint two pharmacists
29 licensed under chapter 465 and one dentist licensed under
30 chapter 466 who is an oral surgeon. Terms of the panel members
31 shall expire at the discretion of the appointing official. The
52
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 panel shall begin its work by August 1, 1999, regardless of
2 the number of appointments made by that date. The advisory
3 panel shall be responsible for evaluating treatment guidelines
4 and recommending ways to incorporate their use in the practice
5 pattern identification program. Practitioners who are
6 prescribing inappropriately or inefficiently, as determined by
7 the agency, may have their prescribing of certain drugs
8 subject to prior authorization.
9 2. The agency shall also develop educational
10 interventions designed to promote the proper use of
11 medications by providers and beneficiaries.
12 3. The agency shall implement a pharmacy fraud, waste,
13 and abuse initiative that may include a surety bond or letter
14 of credit requirement for participating pharmacies, enhanced
15 provider auditing practices, the use of additional fraud and
16 abuse software, recipient management programs for
17 beneficiaries inappropriately using their benefits, and other
18 steps that will eliminate provider and recipient fraud, waste,
19 and abuse. The initiative shall address enforcement efforts to
20 reduce the number and use of counterfeit prescriptions.
21 4. By September 30, 2002, the agency shall contract
22 with an entity in the state to implement a wireless handheld
23 clinical pharmacology drug information database for
24 practitioners. The initiative shall be designed to enhance the
25 agency's efforts to reduce fraud, abuse, and errors in the
26 prescription drug benefit program and to otherwise further the
27 intent of this paragraph.
28 5.4. The agency may apply for any federal waivers
29 needed to implement this paragraph.
30
31
53
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Section 21. Paragraphs (f) and (k) of subsection (2)
2 of section 409.9122, Florida Statutes, as amended by section
3 11 of chapter 2001-377, Laws of Florida, are amended to read:
4 409.9122 Mandatory Medicaid managed care enrollment;
5 programs and procedures.--
6 (2)
7 (f) When a Medicaid recipient does not choose a
8 managed care plan or MediPass provider, the agency shall
9 assign the Medicaid recipient to a managed care plan or
10 MediPass provider. Medicaid recipients who are subject to
11 mandatory assignment but who fail to make a choice shall be
12 assigned to managed care plans or provider service networks
13 until an equal enrollment of 45 50 percent in MediPass and 55
14 50 percent in managed care plans is achieved. Once that equal
15 enrollment is achieved, the assignments shall be divided in
16 order to maintain an equal enrollment in MediPass and managed
17 care plans which is in a 45 percent and 55 percent proportion,
18 respectively. Thereafter, assignment of Medicaid recipients
19 who fail to make a choice shall be based proportionally on the
20 preferences of recipients who have made a choice in the
21 previous period. Such proportions shall be revised at least
22 quarterly to reflect an update of the preferences of Medicaid
23 recipients. The agency shall also disproportionately assign
24 Medicaid-eligible children in families who are required to but
25 have failed to make a choice of managed care plan or MediPass
26 for their child and who are to be assigned to the MediPass
27 program or managed care plans to children's networks as
28 described in s. 409.912(3)(g) and where available. The
29 disproportionate assignment of children to children's networks
30 shall be made until the agency has determined that the
31 children's networks have sufficient numbers to be economically
54
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 operated. In geographic areas where the agency is contracting
2 for the provision of comprehensive behavioral health services
3 through a capitated prepaid arrangement, recipients who fail
4 to make a choice shall be assigned equally to MediPass or a
5 managed care plan. For purposes of this paragraph, when
6 referring to assignment, the term "managed care plans"
7 includes exclusive provider organizations, provider service
8 networks, Children's Medical Services primary and specialty
9 networks, minority physician networks, and pediatric emergency
10 department diversion programs authorized by this chapter or
11 the General Appropriations Act. When making assignments, the
12 agency shall take into account the following criteria:
13 1. A managed care plan has sufficient network capacity
14 to meet the need of members.
15 2. The managed care plan or MediPass has previously
16 enrolled the recipient as a member, or one of the managed care
17 plan's primary care providers or MediPass providers has
18 previously provided health care to the recipient.
19 3. The agency has knowledge that the member has
20 previously expressed a preference for a particular managed
21 care plan or MediPass provider as indicated by Medicaid
22 fee-for-service claims data, but has failed to make a choice.
23 4. The managed care plan's or MediPass primary care
24 providers are geographically accessible to the recipient's
25 residence.
26 (k) When a Medicaid recipient does not choose a
27 managed care plan or MediPass provider, the agency shall
28 assign the Medicaid recipient to a managed care plan, except
29 in those counties in which there are fewer than two managed
30 care plans accepting Medicaid enrollees, in which case
31 assignment shall be to a managed care plan or a MediPass
55
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 provider. Medicaid recipients in counties with fewer than two
2 managed care plans accepting Medicaid enrollees who are
3 subject to mandatory assignment but who fail to make a choice
4 shall be assigned to managed care plans until an equal
5 enrollment of 45 50 percent in MediPass and provider service
6 networks and 55 50 percent in managed care plans is achieved.
7 Once that equal enrollment is achieved, the assignments shall
8 be divided in order to maintain an equal enrollment in
9 MediPass and managed care plans which is in a 45 percent and
10 55 percent proportion, respectively. In geographic areas where
11 the agency is contracting for the provision of comprehensive
12 behavioral health services through a capitated prepaid
13 arrangement, recipients who fail to make a choice shall be
14 assigned equally to MediPass or a managed care plan. For
15 purposes of this paragraph, when referring to assignment, the
16 term "managed care plans" includes exclusive provider
17 organizations, provider service networks, Children's Medical
18 Services primary and specialty networks, minority physician
19 networks, and pediatric emergency department diversion
20 programs authorized by this chapter or the General
21 Appropriations Act. When making assignments, the agency shall
22 take into account the following criteria:
23 1. A managed care plan has sufficient network capacity
24 to meet the need of members.
25 2. The managed care plan or MediPass has previously
26 enrolled the recipient as a member, or one of the managed care
27 plan's primary care providers or MediPass providers has
28 previously provided health care to the recipient.
29 3. The agency has knowledge that the member has
30 previously expressed a preference for a particular managed
31
56
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 care plan or MediPass provider as indicated by Medicaid
2 fee-for-service claims data, but has failed to make a choice.
3 4. The managed care plan's or MediPass primary care
4 providers are geographically accessible to the recipient's
5 residence.
6 5. The agency has authority to make mandatory
7 assignments based on quality of service and performance of
8 managed care plans.
9 Section 22. Paragraph (l) is added to subsection (2)
10 of section 409.9122, Florida Statutes, to read:
11 409.9122 Mandatory Medicaid managed care enrollment;
12 programs and procedures.--
13 (2)
14 (l) Notwithstanding the provisions of chapter 287, the
15 agency may, at its discretion, renew cost-effective contracts
16 for choice counseling services once or more for such periods
17 as the agency may decide. However, all such renewals may not
18 combine to exceed a total period longer than the term of the
19 original contract.
20 Section 23. 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
57
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 the Legislature documenting the effectiveness of the state's
2 efforts to control Medicaid fraud and abuse.
3 (1) For the purposes of this section, the term:
4 (a) "Abuse" means:
5 1. Provider practices that are inconsistent with
6 generally accepted business or medical practices and that
7 result in an unnecessary cost to the Medicaid program or in
8 reimbursement for goods or services that are not medically
9 necessary or that fail to meet professionally recognized
10 standards for health care.
11 2. Recipient practices that result in unnecessary cost
12 to the Medicaid program.
13 (b) "Complaint" means an allegation that fraud, abuse,
14 or an overpayment has occurred.
15 (c)(b) "Fraud" means an intentional deception or
16 misrepresentation made by a person with the knowledge that the
17 deception results in unauthorized benefit to herself or
18 himself or another person. The term includes any act that
19 constitutes fraud under applicable federal or state law.
20 (d)(c) "Medical necessity" or "medically necessary"
21 means any goods or services necessary to palliate the effects
22 of a terminal condition, or to prevent, diagnose, correct,
23 cure, alleviate, or preclude deterioration of a condition that
24 threatens life, causes pain or suffering, or results in
25 illness or infirmity, which goods or services are provided in
26 accordance with generally accepted standards of medical
27 practice. For purposes of determining Medicaid reimbursement,
28 the agency is the final arbiter of medical necessity.
29 Determinations of medical necessity must be made by a licensed
30 physician employed by or under contract with the agency and
31
58
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 must be based upon information available at the time the goods
2 or services are provided.
3 (e)(d) "Overpayment" includes any amount that is not
4 authorized to be paid by the Medicaid program whether paid as
5 a result of inaccurate or improper cost reporting, improper
6 claiming, unacceptable practices, fraud, abuse, or mistake.
7 (f)(e) "Person" means any natural person, corporation,
8 partnership, association, clinic, group, or other entity,
9 whether or not such person is enrolled in the Medicaid program
10 or is a provider of health care.
11 (2) The agency shall conduct, or cause to be conducted
12 by contract or otherwise, reviews, investigations, analyses,
13 audits, or any combination thereof, to determine possible
14 fraud, abuse, overpayment, or recipient neglect in the
15 Medicaid program and shall report the findings of any
16 overpayments in audit reports as appropriate.
17 (3) The agency may conduct, or may contract for,
18 prepayment review of provider claims to ensure cost-effective
19 purchasing, billing, and provision of care to Medicaid
20 recipients. Such prepayment reviews may be conducted as
21 determined appropriate by the agency, without any suspicion or
22 allegation of fraud, abuse, or neglect.
23 (4) Any suspected criminal violation identified by the
24 agency must be referred to the Medicaid Fraud Control Unit of
25 the Office of the Attorney General for investigation. The
26 agency and the Attorney General shall enter into a memorandum
27 of understanding, which must include, but need not be limited
28 to, a protocol for regularly sharing information and
29 coordinating casework. The protocol must establish a
30 procedure for the referral by the agency of cases involving
31 suspected Medicaid fraud to the Medicaid Fraud Control Unit
59
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 for investigation, and the return to the agency of those cases
2 where investigation determines that administrative action by
3 the agency is appropriate.
4 (5) A Medicaid provider is subject to having goods and
5 services that are paid for by the Medicaid program reviewed by
6 an appropriate peer-review organization designated by the
7 agency. The written findings of the applicable peer-review
8 organization are admissible in any court or administrative
9 proceeding as evidence of medical necessity or the lack
10 thereof.
11 (6) Any notice required to be given to a provider
12 under this section is presumed to be sufficient notice if sent
13 to the address last shown on the provider enrollment file. It
14 is the responsibility of the provider to furnish and keep the
15 agency informed of the provider's current address. United
16 States Postal Service proof of mailing or certified or
17 registered mailing of such notice to the provider at the
18 address shown on the provider enrollment file constitutes
19 sufficient proof of notice. Any notice required to be given to
20 the agency by this section must be sent to the agency at an
21 address designated by rule.
22 (7) When presenting a claim for payment under the
23 Medicaid program, a provider has an affirmative duty to
24 supervise the provision of, and be responsible for, goods and
25 services claimed to have been provided, to supervise and be
26 responsible for preparation and submission of the claim, and
27 to present a claim that is true and accurate and that is for
28 goods and services that:
29 (a) Have actually been furnished to the recipient by
30 the provider prior to submitting the claim.
31
60
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (b) Are Medicaid-covered goods or services that are
2 medically necessary.
3 (c) Are of a quality comparable to those furnished to
4 the general public by the provider's peers.
5 (d) Have not been billed in whole or in part to a
6 recipient or a recipient's responsible party, except for such
7 copayments, coinsurance, or deductibles as are authorized by
8 the agency.
9 (e) Are provided in accord with applicable provisions
10 of all Medicaid rules, regulations, handbooks, and policies
11 and in accordance with federal, state, and local law.
12 (f) Are documented by records made at the time the
13 goods or services were provided, demonstrating the medical
14 necessity for the goods or services rendered. Medicaid goods
15 or services are excessive or not medically necessary unless
16 both the medical basis and the specific need for them are
17 fully and properly documented in the recipient's medical
18 record.
19 (8) A Medicaid provider shall retain medical,
20 professional, financial, and business records pertaining to
21 services and goods furnished to a Medicaid recipient and
22 billed to Medicaid for a period of 5 years after the date of
23 furnishing such services or goods. The agency may investigate,
24 review, or analyze such records, which must be made available
25 during normal business hours. However, 24-hour notice must be
26 provided if patient treatment would be disrupted. The provider
27 is responsible for furnishing to the agency, and keeping the
28 agency informed of the location of, the provider's
29 Medicaid-related records. The authority of the agency to
30 obtain Medicaid-related records from a provider is neither
31
61
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 curtailed nor limited during a period of litigation between
2 the agency and the provider.
3 (9) Payments for the services of billing agents or
4 persons participating in the preparation of a Medicaid claim
5 shall not be based on amounts for which they bill nor based on
6 the amount a provider receives from the Medicaid program.
7 (10) The agency may require repayment for
8 inappropriate, medically unnecessary, or excessive goods or
9 services from the person furnishing them, the person under
10 whose supervision they were furnished, or the person causing
11 them to be furnished.
12 (11) The complaint and all information obtained
13 pursuant to an investigation of a Medicaid provider, or the
14 authorized representative or agent of a provider, relating to
15 an allegation of fraud, abuse, or neglect are confidential and
16 exempt from the provisions of s. 119.07(1):
17 (a) Until the agency takes final agency action with
18 respect to the provider and requires repayment of any
19 overpayment, or imposes an administrative sanction;
20 (b) Until the Attorney General refers the case for
21 criminal prosecution;
22 (c) Until 10 days after the complaint is determined
23 without merit; or
24 (d) At all times if the complaint or information is
25 otherwise protected by law.
26 (12) The agency may terminate participation of a
27 Medicaid provider in the Medicaid program and may seek civil
28 remedies or impose other administrative sanctions against a
29 Medicaid provider, if the provider has been:
30 (a) Convicted of a criminal offense related to the
31 delivery of any health care goods or services, including the
62
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 performance of management or administrative functions relating
2 to the delivery of health care goods or services;
3 (b) Convicted of a criminal offense under federal law
4 or the law of any state relating to the practice of the
5 provider's profession; or
6 (c) Found by a court of competent jurisdiction to have
7 neglected or physically abused a patient in connection with
8 the delivery of health care goods or services.
9 (13) If the provider has been suspended or terminated
10 from participation in the Medicaid program or the Medicare
11 program by the Federal Government or any state, the agency
12 must immediately suspend or terminate, as appropriate, the
13 provider's participation in the Florida Medicaid program for a
14 period no less than that imposed by the Federal Government or
15 any other state, and may not enroll such provider in the
16 Florida Medicaid program while such foreign suspension or
17 termination remains in effect. This sanction is in addition
18 to all other remedies provided by law.
19 (14) The agency may seek any remedy provided by law,
20 including, but not limited to, the remedies provided in
21 subsections (12) and (15) and s. 812.035, if:
22 (a) The provider's license has not been renewed, or
23 has been revoked, suspended, or terminated, for cause, by the
24 licensing agency of any state;
25 (b) The provider has failed to make available or has
26 refused access to Medicaid-related records to an auditor,
27 investigator, or other authorized employee or agent of the
28 agency, the Attorney General, a state attorney, or the Federal
29 Government;
30 (c) The provider has not furnished or has failed to
31 make available such Medicaid-related records as the agency has
63
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 found necessary to determine whether Medicaid payments are or
2 were due and the amounts thereof;
3 (d) The provider has failed to maintain medical
4 records made at the time of service, or prior to service if
5 prior authorization is required, demonstrating the necessity
6 and appropriateness of the goods or services rendered;
7 (e) The provider is not in compliance with provisions
8 of Medicaid provider publications that have been adopted by
9 reference as rules in the Florida Administrative Code; with
10 provisions of state or federal laws, rules, or regulations;
11 with provisions of the provider agreement between the agency
12 and the provider; or with certifications found on claim forms
13 or on transmittal forms for electronically submitted claims
14 that are submitted by the provider or authorized
15 representative, as such provisions apply to the Medicaid
16 program;
17 (f) The provider or person who ordered or prescribed
18 the care, services, or supplies has furnished, or ordered the
19 furnishing of, goods or services to a recipient which are
20 inappropriate, unnecessary, excessive, or harmful to the
21 recipient or are of inferior quality;
22 (g) The provider has demonstrated a pattern of failure
23 to provide goods or services that are medically necessary;
24 (h) The provider or an authorized representative of
25 the provider, or a person who ordered or prescribed the goods
26 or services, has submitted or caused to be submitted false or
27 a pattern of erroneous Medicaid claims that have resulted in
28 overpayments to a provider or that exceed those to which the
29 provider was entitled under the Medicaid program;
30 (i) The provider or an authorized representative of
31 the provider, or a person who has ordered or prescribed the
64
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 goods or services, has submitted or caused to be submitted a
2 Medicaid provider enrollment application, a request for prior
3 authorization for Medicaid services, a drug exception request,
4 or a Medicaid cost report that contains materially false or
5 incorrect information;
6 (j) The provider or an authorized representative of
7 the provider has collected from or billed a recipient or a
8 recipient's responsible party improperly for amounts that
9 should not have been so collected or billed by reason of the
10 provider's billing the Medicaid program for the same service;
11 (k) The provider or an authorized representative of
12 the provider has included in a cost report costs that are not
13 allowable under a Florida Title XIX reimbursement plan, after
14 the provider or authorized representative had been advised in
15 an audit exit conference or audit report that the costs were
16 not allowable;
17 (l) The provider is charged by information or
18 indictment with fraudulent billing practices. The sanction
19 applied for this reason is limited to suspension of the
20 provider's participation in the Medicaid program for the
21 duration of the indictment unless the provider is found guilty
22 pursuant to the information or indictment;
23 (m) The provider or a person who has ordered, or
24 prescribed the goods or services is found liable for negligent
25 practice resulting in death or injury to the provider's
26 patient;
27 (n) The provider fails to demonstrate that it had
28 available during a specific audit or review period sufficient
29 quantities of goods, or sufficient time in the case of
30 services, to support the provider's billings to the Medicaid
31 program;
65
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (o) The provider has failed to comply with the notice
2 and reporting requirements of s. 409.907; or
3 (p) The agency has received reliable information of
4 patient abuse or neglect or of any act prohibited by s.
5 409.920; or.
6 (q) The provider has failed to comply with an
7 agreed-upon repayment schedule.
8 (15) The agency may impose any of the following
9 sanctions or disincentives on a provider or a person for any
10 of the acts described in subsection (14):
11 (a) Suspension for a specific period of time of not
12 more than 1 year.
13 (b) Termination for a specific period of time of from
14 more than 1 year to 20 years.
15 (c) Imposition of a fine of up to $5,000 for each
16 violation. Each day that an ongoing violation continues, such
17 as refusing to furnish Medicaid-related records or refusing
18 access to records, is considered, for the purposes of this
19 section, to be a separate violation. Each instance of
20 improper billing of a Medicaid recipient; each instance of
21 including an unallowable cost on a hospital or nursing home
22 Medicaid cost report after the provider or authorized
23 representative has been advised in an audit exit conference or
24 previous audit report of the cost unallowability; each
25 instance of furnishing a Medicaid recipient goods or
26 professional services that are inappropriate or of inferior
27 quality as determined by competent peer judgment; each
28 instance of knowingly submitting a materially false or
29 erroneous Medicaid provider enrollment application, request
30 for prior authorization for Medicaid services, drug exception
31 request, or cost report; each instance of inappropriate
66
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 prescribing of drugs for a Medicaid recipient as determined by
2 competent peer judgment; and each false or erroneous Medicaid
3 claim leading to an overpayment to a provider is considered,
4 for the purposes of this section, to be a separate violation.
5 (d) Immediate suspension, if the agency has received
6 information of patient abuse or neglect or of any act
7 prohibited by s. 409.920. Upon suspension, the agency must
8 issue an immediate final order under s. 120.569(2)(n).
9 (e) A fine, not to exceed $10,000, for a violation of
10 paragraph (14)(i).
11 (f) Imposition of liens against provider assets,
12 including, but not limited to, financial assets and real
13 property, not to exceed the amount of fines or recoveries
14 sought, upon entry of an order determining that such moneys
15 are due or recoverable.
16 (g) Prepayment reviews of claims for a specified
17 period of time.
18 (h) Followup reviews of providers every 6 months until
19 the agency is satisfied that the deficiencies have been
20 corrected.
21 (i) Corrective action plans that would remain in
22 effect for providers for up to 3 years and that would be
23 monitored by the agency every 6 months while in effect.
24 (j)(g) Other remedies as permitted by law to effect
25 the recovery of a fine or overpayment.
26 (16) In determining the appropriate administrative
27 sanction to be applied, or the duration of any suspension or
28 termination, the agency shall consider:
29 (a) The seriousness and extent of the violation or
30 violations.
31
67
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (b) Any prior history of violations by the provider
2 relating to the delivery of health care programs which
3 resulted in either a criminal conviction or in administrative
4 sanction or penalty.
5 (c) Evidence of continued violation within the
6 provider's management control of Medicaid statutes, rules,
7 regulations, or policies after written notification to the
8 provider of improper practice or instance of violation.
9 (d) The effect, if any, on the quality of medical care
10 provided to Medicaid recipients as a result of the acts of the
11 provider.
12 (e) Any action by a licensing agency respecting the
13 provider in any state in which the provider operates or has
14 operated.
15 (f) The apparent impact on access by recipients to
16 Medicaid services if the provider is suspended or terminated,
17 in the best judgment of the agency.
18
19 The agency shall document the basis for all sanctioning
20 actions and recommendations.
21 (17) The agency may take action to sanction, suspend,
22 or terminate a particular provider working for a group
23 provider, and may suspend or terminate Medicaid participation
24 at a specific location, rather than or in addition to taking
25 action against an entire group.
26 (18) The agency shall establish a process for
27 conducting followup reviews of a sampling of providers who
28 have a history of overpayment under the Medicaid program.
29 This process must consider the magnitude of previous fraud or
30 abuse and the potential effect of continued fraud or abuse on
31 Medicaid costs.
68
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (19) In making a determination of overpayment to a
2 provider, the agency must use accepted and valid auditing,
3 accounting, analytical, statistical, or peer-review methods,
4 or combinations thereof. Appropriate statistical methods may
5 include, but are not limited to, sampling and extension to the
6 population, parametric and nonparametric statistics, tests of
7 hypotheses, and other generally accepted statistical methods.
8 Appropriate analytical methods may include, but are not
9 limited to, reviews to determine variances between the
10 quantities of products that a provider had on hand and
11 available to be purveyed to Medicaid recipients during the
12 review period and the quantities of the same products paid for
13 by the Medicaid program for the same period, taking into
14 appropriate consideration sales of the same products to
15 non-Medicaid customers during the same period. In meeting its
16 burden of proof in any administrative or court proceeding, the
17 agency may introduce the results of such statistical methods
18 as evidence of overpayment.
19 (20) When making a determination that an overpayment
20 has occurred, the agency shall prepare and issue an audit
21 report to the provider showing the calculation of
22 overpayments.
23 (21) The audit report, supported by agency work
24 papers, showing an overpayment to a provider constitutes
25 evidence of the overpayment. A provider may not present or
26 elicit testimony, either on direct examination or
27 cross-examination in any court or administrative proceeding,
28 regarding the purchase or acquisition by any means of drugs,
29 goods, or supplies; sales or divestment by any means of drugs,
30 goods, or supplies; or inventory of drugs, goods, or supplies,
31 unless such acquisition, sales, divestment, or inventory is
69
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 documented by written invoices, written inventory records, or
2 other competent written documentary evidence maintained in the
3 normal course of the provider's business. Notwithstanding the
4 applicable rules of discovery, all documentation that will be
5 offered as evidence at an administrative hearing on a Medicaid
6 overpayment must be exchanged by all parties at least 14 days
7 before the administrative hearing or must be excluded from
8 consideration.
9 (22)(a) In an audit or investigation of a violation
10 committed by a provider which is conducted pursuant to this
11 section, the agency is entitled to recover all investigative,
12 legal, and expert witness costs if the agency's findings were
13 not contested by the provider or, if contested, the agency
14 ultimately prevailed.
15 (b) The agency has the burden of documenting the
16 costs, which include salaries and employee benefits and
17 out-of-pocket expenses. The amount of costs that may be
18 recovered must be reasonable in relation to the seriousness of
19 the violation and must be set taking into consideration the
20 financial resources, earning ability, and needs of the
21 provider, who has the burden of demonstrating such factors.
22 (c) The provider may pay the costs over a period to be
23 determined by the agency if the agency determines that an
24 extreme hardship would result to the provider from immediate
25 full payment. Any default in payment of costs may be
26 collected by any means authorized by law.
27 (23) If the agency imposes an administrative sanction
28 under this section upon any provider or other person who is
29 regulated by another state entity, the agency shall notify
30 that other entity of the imposition of the sanction. Such
31
70
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 notification must include the provider's or person's name and
2 license number and the specific reasons for sanction.
3 (24)(a) The agency may withhold Medicaid payments, in
4 whole or in part, to a provider upon receipt of reliable
5 evidence that the circumstances giving rise to the need for a
6 withholding of payments involve fraud, willful
7 misrepresentation, or abuse under the Medicaid program, or a
8 crime committed while rendering goods or services to Medicaid
9 recipients, pending completion of legal proceedings. If it is
10 determined that fraud, willful misrepresentation, abuse, or a
11 crime did not occur, the payments withheld must be paid to the
12 provider within 14 days after such determination with interest
13 at the rate of 10 percent a year. Any money withheld in
14 accordance with this paragraph shall be placed in a suspended
15 account, readily accessible to the agency, so that any payment
16 ultimately due the provider shall be made within 14 days.
17 (b) Overpayments owed to the agency bear interest at
18 the rate of 10 percent per year from the date of determination
19 of the overpayment by the agency, and payment arrangements
20 must be made at the conclusion of legal proceedings. A
21 provider who does not enter into or adhere to an agreed-upon
22 repayment schedule may be terminated by the agency for
23 nonpayment or partial payment.
24 (c) The agency, upon entry of a final agency order, a
25 judgment or order of a court of competent jurisdiction, or a
26 stipulation or settlement, may collect the moneys owed by all
27 means allowable by law, including, but not limited to,
28 notifying any fiscal intermediary of Medicare benefits that
29 the state has a superior right of payment. Upon receipt of
30 such written notification, the Medicare fiscal intermediary
31 shall remit to the state the sum claimed.
71
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (25) The agency may impose administrative sanctions
2 against a Medicaid recipient, or the agency may seek any other
3 remedy provided by law, including, but not limited to, the
4 remedies provided in s. 812.035, if the agency finds that a
5 recipient has engaged in solicitation in violation of s.
6 409.920 or that the recipient has otherwise abused the
7 Medicaid program.
8 (26) When the Agency for Health Care Administration
9 has made a probable cause determination and alleged that an
10 overpayment to a Medicaid provider has occurred, the agency,
11 after notice to the provider, may:
12 (a) Withhold, and continue to withhold during the
13 pendency of an administrative hearing pursuant to chapter 120,
14 any medical assistance reimbursement payments until such time
15 as the overpayment is recovered, unless within 30 days after
16 receiving notice thereof the provider:
17 1. Makes repayment in full; or
18 2. Establishes a repayment plan that is satisfactory
19 to the Agency for Health Care Administration.
20 (b) Withhold, and continue to withhold during the
21 pendency of an administrative hearing pursuant to chapter 120,
22 medical assistance reimbursement payments if the terms of a
23 repayment plan are not adhered to by the provider.
24
25 If a provider requests an administrative hearing pursuant to
26 chapter 120, such hearing must be conducted within 90 days
27 following receipt by the provider of the final audit report,
28 absent exceptionally good cause shown as determined by the
29 administrative law judge or hearing officer. Upon issuance of
30 a final order, the balance outstanding of the amount
31 determined to constitute the overpayment shall become due. Any
72
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 withholding of payments by the Agency for Health Care
2 Administration pursuant to this section shall be limited so
3 that the monthly medical assistance payment is not reduced by
4 more than 10 percent.
5 (27) Venue for all Medicaid program integrity
6 overpayment cases shall lie in Leon County, at the discretion
7 of the agency.
8 (28) Notwithstanding other provisions of law, the
9 agency and the Medicaid Fraud Control Unit of the Department
10 of Legal Affairs may review a provider's non-Medicaid-related
11 records in order to determine the total output of a provider's
12 practice to reconcile quantities of goods or services billed
13 to Medicaid against quantities of goods or services used in
14 the provider's total practice.
15 (29) The agency may terminate a provider's
16 participation in the Medicaid program if the provider fails to
17 reimburse an overpayment that has been determined by final
18 order within 35 days after the date of the final order, unless
19 the provider and the agency have entered into a repayment
20 agreement. If the final order is overturned on appeal, the
21 provider shall be reinstated.
22 (30) If a provider requests an administrative hearing
23 pursuant to chapter 120, such hearing must be conducted within
24 90 days following assignment of an administrative law judge,
25 absent exceptionally good cause shown as determined by the
26 administrative law judge or hearing officer.
27 (31) Upon issuance of a final order, the outstanding
28 balance of the amount determined to constitute the overpayment
29 shall become due. If a provider fails to make payments in
30 full, fails to enter into a satisfactory repayment plan, or
31 fails to comply with the terms of a repayment plan or
73
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 settlement agreement, the agency may withhold all medical
2 assistance reimbursement payments until the amount due is paid
3 in full.
4 (32) Duly authorized agents and employees of the
5 agency and the Medicaid Fraud Control Unit of the Department
6 of Legal Affairs shall have the power to inspect, at all
7 reasonable hours and upon proper notice, the records of any
8 pharmacy, wholesale establishment, or manufacturer, or any
9 other place in the state in which drugs and medical supplies
10 are manufactured, packed, packaged, made, stored, sold, or
11 kept for sale, for the purpose of verifying the amount of
12 drugs and medical supplies ordered, delivered, or purchased by
13 a provider.
14 Section 24. Subsections (7) and (8) of section
15 409.920, Florida Statutes, are amended to read:
16 409.920 Medicaid provider fraud.--
17 (7) The Attorney General shall conduct a statewide
18 program of Medicaid fraud control. To accomplish this purpose,
19 the Attorney General shall:
20 (a) Investigate the possible criminal violation of any
21 applicable state law pertaining to fraud in the administration
22 of the Medicaid program, in the provision of medical
23 assistance, or in the activities of providers of health care
24 under the Medicaid program.
25 (b) Investigate the alleged abuse or neglect of
26 patients in health care facilities receiving payments under
27 the Medicaid program, in coordination with the agency.
28 (c) Investigate the alleged misappropriation of
29 patients' private funds in health care facilities receiving
30 payments under the Medicaid program.
31
74
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (d) Refer to the Office of Statewide Prosecution or
2 the appropriate state attorney all violations indicating a
3 substantial potential for criminal prosecution.
4 (e) Refer to the agency all suspected abusive
5 activities not of a criminal or fraudulent nature.
6 (f) Refer to the agency for collection each instance
7 of overpayment to a provider of health care under the Medicaid
8 program which is discovered during the course of an
9 investigation.
10 (f)(g) Safeguard the privacy rights of all individuals
11 and provide safeguards to prevent the use of patient medical
12 records for any reason beyond the scope of a specific
13 investigation for fraud or abuse, or both, without the
14 patient's written consent.
15 (g) Publicize to state employees and the public the
16 ability of persons to bring suit under the provisions of the
17 Florida False Claims Act and the potential for the persons
18 bringing a civil action under the Florida False Claims Act to
19 obtain a monetary award.
20 (8) In carrying out the duties and responsibilities
21 under this section subsection, the Attorney General may:
22 (a) Enter upon the premises of any health care
23 provider, excluding a physician, participating in the Medicaid
24 program to examine all accounts and records that may, in any
25 manner, be relevant in determining the existence of fraud in
26 the Medicaid program, to investigate alleged abuse or neglect
27 of patients, or to investigate alleged misappropriation of
28 patients' private funds. A participating physician is required
29 to make available any accounts or records that may, in any
30 manner, be relevant in determining the existence of fraud in
31 the Medicaid program. The accounts or records of a
75
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 non-Medicaid patient may not be reviewed by, or turned over
2 to, the Attorney General without the patient's written
3 consent.
4 (b) Subpoena witnesses or materials, including medical
5 records relating to Medicaid recipients, within or outside the
6 state and, through any duly designated employee, administer
7 oaths and affirmations and collect evidence for possible use
8 in either civil or criminal judicial proceedings.
9 (c) Request and receive the assistance of any state
10 attorney or law enforcement agency in the investigation and
11 prosecution of any violation of this section.
12 (d) Seek any civil remedy provided by law, including,
13 but not limited to, the remedies provided in ss.
14 68.081-68.092, s. 812.035, and this chapter.
15 (e) Refer to the agency for collection each instance
16 of overpayment to a provider of health care under the Medicaid
17 program which is discovered during the course of an
18 investigation.
19 Section 25. Section 624.91, Florida Statutes, is
20 amended to read:
21 624.91 The Florida Healthy Kids Corporation Act.--
22 (1) SHORT TITLE.--This section may be cited as the
23 "William G. 'Doc' Myers Healthy Kids Corporation Act."
24 (2) LEGISLATIVE INTENT.--
25 (a) The Legislature finds that increased access to
26 health care services could improve children's health and
27 reduce the incidence and costs of childhood illness and
28 disabilities among children in this state. Many children do
29 not have comprehensive, affordable health care services
30 available. It is the intent of the Legislature that the
31 Florida Healthy Kids Corporation provide comprehensive health
76
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 insurance coverage to such children. The corporation is
2 encouraged to cooperate with any existing health service
3 programs funded by the public or the private sector and to
4 work cooperatively with the Florida Partnership for School
5 Readiness.
6 (b) It is the intent of the Legislature that the
7 Florida Healthy Kids Corporation serve as one of several
8 providers of services to children eligible for medical
9 assistance under Title XXI of the Social Security Act.
10 Although the corporation may serve other children, the
11 Legislature intends the primary recipients of services
12 provided through the corporation be school-age children with a
13 family income below 200 percent of the federal poverty level,
14 who do not qualify for Medicaid. It is also the intent of the
15 Legislature that state and local government Florida Healthy
16 Kids funds, to the extent permissible under federal law, be
17 used to continue and expand coverage, within available
18 appropriations, to children not eligible for federal matching
19 funds under Title XXI obtain matching federal dollars.
20 (3) NONENTITLEMENT.--Nothing in this section shall be
21 construed as providing an individual with an entitlement to
22 health care services. No cause of action shall arise against
23 the state, the Florida Healthy Kids Corporation, or a unit of
24 local government for failure to make health services available
25 under this section.
26 (4) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
27 (a) There is created the Florida Healthy Kids
28 Corporation, a not-for-profit corporation which operates on
29 sites designated by the corporation.
30 (b) The Florida Healthy Kids Corporation shall phase
31 in a program to:
77
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 1. Organize school children groups to facilitate the
2 provision of comprehensive health insurance coverage to
3 children;
4 2. Arrange for the collection of any family, local
5 contributions, or employer payment or premium, in an amount to
6 be determined by the board of directors, to provide for
7 payment of premiums for comprehensive insurance coverage and
8 for the actual or estimated administrative expenses;
9 3. Arrange for the collection of any contributions to
10 provide for payment of premiums for children who are not
11 eligible for medical assistance under Title XXI of the Social
12 Security Act. Each fiscal year, the corporation shall
13 establish a local match policy for the enrollment of
14 non-Title-XXI-eligible children in the Healthy Kids program.
15 By May 1 of each year, the corporation shall provide written
16 notification of the amount to be remitted to the corporation
17 for the following fiscal year under that policy. Local match
18 sources may include, but are not limited to, funds provided by
19 municipalities, counties, school boards, hospitals, health
20 care providers, charitable organizations, special taxing
21 districts, and private organizations. The minimum local match
22 cash contributions required each fiscal year and local match
23 credits shall be determined by the General Appropriations Act.
24 The corporation shall calculate a county's local match rate
25 based upon that county's percentage of the state's total
26 non-Title-XXI expenditures as reported in the corporation's
27 most recently audited financial statement. In awarding the
28 local match credits, the corporation may consider factors,
29 including, but not limited to, population density, per capita
30 income, existing child-health-related expenditures, and
31 services in awarding the credits;
78
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 4. Accept supplemental local match contributions that
2 comply with the requirements of Title XXI of the Social
3 Security Act for the purpose of providing additional coverage
4 in contributing counties under Title XXI;
5 5.3. Establish the administrative and accounting
6 procedures for the operation of the corporation;
7 6.4. Establish, with consultation from appropriate
8 professional organizations, standards for preventive health
9 services and providers and comprehensive insurance benefits
10 appropriate to children; provided that such standards for
11 rural areas shall not limit primary care providers to
12 board-certified pediatricians;
13 7.5. Establish eligibility criteria which children
14 must meet in order to participate in the program;
15 8.6. Establish procedures under which providers of
16 local match to, applicants to, and participants in the program
17 may have grievances reviewed by an impartial body and reported
18 to the board of directors of the corporation;
19 9.7. Establish participation criteria and, if
20 appropriate, contract with an authorized insurer, health
21 maintenance organization, or insurance administrator to
22 provide administrative services to the corporation;
23 10.8. Establish enrollment criteria which shall
24 include penalties or waiting periods of not fewer than 60 days
25 for reinstatement of coverage upon voluntary cancellation for
26 nonpayment of family premiums;
27 11.9. If a space is available, establish a special
28 open enrollment period of 30 days' duration for any child who
29 is enrolled in Medicaid or Medikids if such child loses
30 Medicaid or Medikids eligibility and becomes eligible for the
31 Florida Healthy Kids program;
79
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 12.10. Contract with authorized insurers or any
2 provider of health care services, meeting standards
3 established by the corporation, for the provision of
4 comprehensive insurance coverage to participants. Such
5 standards shall include criteria under which the corporation
6 may contract with more than one provider of health care
7 services in program sites. Health plans shall be selected
8 through a competitive bid process. The selection of health
9 plans shall be based primarily on quality criteria established
10 by the board. The health plan selection criteria and scoring
11 system, and the scoring results, shall be available upon
12 request for inspection after the bids have been awarded;
13 13.11. Develop and implement a plan to publicize the
14 Florida Healthy Kids Corporation, the eligibility requirements
15 of the program, and the procedures for enrollment in the
16 program and to maintain public awareness of the corporation
17 and the program;
18 14.12. Secure staff necessary to properly administer
19 the corporation. Staff costs shall be funded from state and
20 local matching funds and such other private or public funds as
21 become available. The board of directors shall determine the
22 number of staff members necessary to administer the
23 corporation;
24 15.13. As appropriate, enter into contracts with local
25 school boards or other agencies to provide onsite information,
26 enrollment, and other services necessary to the operation of
27 the corporation;
28 16.14. Provide a report on an annual basis to the
29 Governor, Insurance Commissioner, Commissioner of Education,
30 Senate President, Speaker of the House of Representatives, and
31
80
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Minority Leaders of the Senate and the House of
2 Representatives;
3 17.15. Each fiscal year, establish a maximum number of
4 participants by county, on a statewide basis, who may enroll
5 in the program without the benefit of local matching funds.
6 Thereafter, the corporation may establish local matching
7 requirements for supplemental participation in the program.
8 The corporation may vary local matching requirements and
9 enrollment by county depending on factors which may influence
10 the generation of local match, including, but not limited to,
11 population density, per capita income, existing local tax
12 effort, and other factors. The corporation also may accept
13 in-kind match in lieu of cash for the local match requirement
14 to the extent allowed by Title XXI of the Social Security Act;
15 and
16 18.16. Establish eligibility criteria, premium and
17 cost-sharing requirements, and benefit packages which conform
18 to the provisions of the Florida Kidcare program, as created
19 in ss. 409.810-409.820.
20 (c) Coverage under the corporation's program is
21 secondary to any other available private coverage held by the
22 participant child or family member. The corporation may
23 establish procedures for coordinating benefits under this
24 program with benefits under other public and private coverage.
25 (d) The Florida Healthy Kids Corporation shall be a
26 private corporation not for profit, organized pursuant to
27 chapter 617, and shall have all powers necessary to carry out
28 the purposes of this act, including, but not limited to, the
29 power to receive and accept grants, loans, or advances of
30 funds from any public or private agency and to receive and
31 accept from any source contributions of money, property,
81
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 labor, or any other thing of value, to be held, used, and
2 applied for the purposes of this act.
3 (5) BOARD OF DIRECTORS.--
4 (a) The Florida Healthy Kids Corporation shall operate
5 subject to the supervision and approval of a board of
6 directors chaired by the Insurance Commissioner or her or his
7 designee, and composed of 14 12 other members selected for
8 3-year terms of office as follows:
9 1. One member appointed by the Commissioner of
10 Education from among three persons nominated by the Florida
11 Association of School Administrators;
12 2. One member appointed by the Commissioner of
13 Education from among three persons nominated by the Florida
14 Association of School Boards;
15 3. One member appointed by the Commissioner of
16 Education from the Office of School Health Programs of the
17 Florida Department of Education;
18 4. One member appointed by the Governor from among
19 three members nominated by the Florida Pediatric Society;
20 5. One member, appointed by the Governor, who
21 represents the Children's Medical Services Program;
22 6. One member appointed by the Insurance Commissioner
23 from among three members nominated by the Florida Hospital
24 Association;
25 7. Two members, appointed by the Insurance
26 Commissioner, who are representatives of authorized health
27 care insurers or health maintenance organizations;
28 8. One member, appointed by the Insurance
29 Commissioner, who represents the Institute for Child Health
30 Policy;
31
82
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 9. One member, appointed by the Governor, from among
2 three members nominated by the Florida Academy of Family
3 Physicians;
4 10. One member, appointed by the Governor, who
5 represents the Agency for Health Care Administration; and
6 11. The State Health Officer or her or his designee;
7 12. One member, appointed by the Insurance
8 Commissioner from among three members nominated by the Florida
9 Association of Counties, representing rural counties; and
10 13. One member, appointed by the Governor from among
11 three members nominated by the Florida Association of
12 Counties, representing urban counties.
13 (b) A member of the board of directors may be removed
14 by the official who appointed that member. The board shall
15 appoint an executive director, who is responsible for other
16 staff authorized by the board.
17 (c) Board members are entitled to receive, from funds
18 of the corporation, reimbursement for per diem and travel
19 expenses as provided by s. 112.061.
20 (d) There shall be no liability on the part of, and no
21 cause of action shall arise against, any member of the board
22 of directors, or its employees or agents, for any action they
23 take in the performance of their powers and duties under this
24 act.
25 (6) LICENSING NOT REQUIRED; FISCAL OPERATION.--
26 (a) The corporation shall not be deemed an insurer.
27 The officers, directors, and employees of the corporation
28 shall not be deemed to be agents of an insurer. Neither the
29 corporation nor any officer, director, or employee of the
30 corporation is subject to the licensing requirements of the
31 insurance code or the rules of the Department of Insurance.
83
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 However, any marketing representative utilized and compensated
2 by the corporation must be appointed as a representative of
3 the insurers or health services providers with which the
4 corporation contracts.
5 (b) The board has complete fiscal control over the
6 corporation and is responsible for all corporate operations.
7 (c) The Department of Insurance shall supervise any
8 liquidation or dissolution of the corporation and shall have,
9 with respect to such liquidation or dissolution, all power
10 granted to it pursuant to the insurance code.
11 (7) ACCESS TO RECORDS; CONFIDENTIALITY;
12 PENALTIES.--Notwithstanding any other laws to the contrary,
13 the Florida Healthy Kids Corporation shall have access to the
14 medical records of a student upon receipt of permission from a
15 parent or guardian of the student. Such medical records may
16 be maintained by state and local agencies. Any identifying
17 information, including medical records and family financial
18 information, obtained by the corporation pursuant to this
19 subsection is confidential and is exempt from the provisions
20 of s. 119.07(1). Neither the corporation nor the staff or
21 agents of the corporation may release, without the written
22 consent of the participant or the parent or guardian of the
23 participant, to any state or federal agency, to any private
24 business or person, or to any other entity, any confidential
25 information received pursuant to this subsection. A violation
26 of this subsection is a misdemeanor of the second degree,
27 punishable as provided in s. 775.082 or s. 775.083.
28 (8) NOTICE OF FAILURE TO MEET LOCAL MATCH.--The
29 corporation shall notify the Senate President, the Speaker of
30 the House of Representatives, the Governor, and the Department
31
84
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 of Banking and Finance of any county not meeting its local
2 match requirement.
3 Section 26. Subsection (2) of section 383.19, Florida
4 Statutes, is amended to read:
5 383.19 Standards; funding; ineligibility.--
6 (2) The department shall designate at least one center
7 to serve a geographic area representing each region of the
8 state in which at least 10,000 live births occur per year, but
9 in no case may there be more than 12 11 regional perinatal
10 intensive care centers established unless specifically
11 authorized in the appropriations act or in this subsection.
12 Medicaid reimbursement shall be made for services provided to
13 patients who are Medicaid recipients. Medicaid reimbursement
14 for in-center obstetrical physician services shall be based
15 upon the obstetrical care group payment system. Medicaid
16 reimbursement for in-center neonatal physician services shall
17 be based upon the neonatal care group payment system. These
18 prospective payment systems, developed by the department, must
19 place patients into homogeneous groups based on clinical
20 factors, severity of illness, and intensity of care.
21 Outpatient obstetrical services and other related services,
22 such as consultations, shall be reimbursed based on the usual
23 Medicaid method of payment for outpatient medical services.
24 Section 27. Subsection (28) of section 393.063,
25 Florida Statutes, is amended to read:
26 393.063 Definitions.--For the purposes of this
27 chapter:
28 (28) "Intermediate care facility for the
29 developmentally disabled" or "ICF/DD" means a
30 state-owned-and-operated residential facility licensed and
31 certified in accordance with state law, and certified by the
85
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Federal Government pursuant to the Social Security Act, as a
2 provider of Medicaid services to persons who are
3 developmentally disabled mentally retarded or who have related
4 conditions. The capacity of such a facility shall not be more
5 than 120 clients.
6 Section 28. Section 400.965, Florida Statutes, is
7 amended to read:
8 400.965 Action by agency against licensee; grounds.--
9 (1) Any of the following conditions constitute grounds
10 for action by the agency against a licensee:
11 (a) A misrepresentation of a material fact in the
12 application;
13 (b) The commission of an intentional or negligent act
14 materially affecting the health or safety of residents of the
15 facility;
16 (c) A violation of any provision of this part or rules
17 adopted under this part; or
18 (d) The commission of any act constituting a ground
19 upon which application for a license may be denied.
20 (2) If the agency has a reasonable belief that any of
21 such conditions exists, it shall:
22 (a) In the case of an applicant for original
23 licensure, deny the application.
24 (b) In the case of an applicant for relicensure or a
25 current licensee, take administrative action as provided in s.
26 400.968 or s. 400.969 or injunctive action as authorized by s.
27 400.963.
28 (c) In the case of a facility operating without a
29 license, take injunctive action as authorized in s. 400.963.
30
31
86
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Section 29. Subsection (4) of section 400.968, Florida
2 Statutes, is renumbered as section 400.969, Florida Statutes,
3 and amended to read:
4 400.969 Violation of part; penalties.--
5 (1)(4)(a) Except as provided in s. 400.967(3), a
6 violation of any provision of this part section or rules
7 adopted by the agency under this part section is punishable by
8 payment of an administrative or civil penalty not to exceed
9 $5,000.
10 (2)(b) A violation of this part section or of rules
11 adopted under this part section is a misdemeanor of the first
12 degree, punishable as provided in s. 775.082 or s. 775.083.
13 Each day of a continuing violation is a separate offense.
14 Section 30. The Legislature finds that the home and
15 community-based services delivery system for persons with
16 developmental disabilities and the availability of
17 appropriated funds are two of the critical elements in making
18 services available. Therefore, it is the intent of the
19 Legislature that the Department of Children and Family
20 Services shall develop and implement a comprehensive redesign
21 of the system. The redesign shall include, at a minimum, all
22 actions necessary to achieve an appropriate rate structure,
23 client choice within a specified service package, appropriate
24 assessment strategies, an efficient billing process that
25 contains reconciliation and monitoring components, a redefined
26 role for support coordinators that avoids potential conflicts
27 of interest, and family/client budgets linked to levels of
28 need. Prior to the release of funds in the lump-sum
29 appropriation, the department shall present a plan to the
30 Executive Office of the Governor, the House Fiscal
31 Responsibility Council, and the Senate Appropriations
87
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Committee. The plan must result in a full implementation of
2 the redesigned system no later than July 1, 2003. At a
3 minimum, the plan must provide that the portions related to
4 direct provider enrollment and billing will be operational no
5 later than March 31, 2003. The plan must further provide that
6 a more effective needs assessment instrument will be deployed
7 by January 1, 2003, and that all clients will be assessed with
8 this device by June 30, 2003. In no event may the department
9 select an assessment instrument without appropriate evidence
10 that it will be reliable and valid. Once such evidence has
11 been obtained, however, the department shall determine the
12 feasibility of contracting with an external vendor to apply
13 the new assessment device to all clients receiving services
14 through the Medicaid waiver. In lieu of using an external
15 vendor, the department may use support coordinators for the
16 assessments if it develops sufficient safeguards and training
17 to significantly improve the inter-rater reliability of the
18 support coordinators administering the assessment.
19 Section 31. (1) The Agency for Health Care
20 Administration shall conduct a study of health care services
21 provided to children in the state who are medically fragile or
22 dependent on medical technology and conduct a pilot program in
23 Miami-Dade County to provide subacute pediatric transitional
24 care to a maximum of 30 children at any one time. The purposes
25 of the study and the pilot program are to determine ways to
26 permit children who are medically fragile or dependent on
27 medical technology to successfully make a transition from
28 acute care in a health care institution to living with their
29 families when possible, and to provide cost-effective,
30 subacute transitional care services.
31
88
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (2) The agency, in cooperation with the Children's
2 Medical Services Program in the Department of Health, shall
3 conduct a study to identify the total number of children who
4 are medically fragile or dependent on medical technology, from
5 birth through age 21, in the state. By January 1, 2003, the
6 agency must report to the Legislature regarding the children's
7 ages, the locations where the children are served, the types
8 of services received, itemized costs of the services, and the
9 sources of funding that pay for the services, including the
10 proportional share when more than one funding source pays for
11 a service. The study must include information regarding
12 children who are medically fragile or dependent on medical
13 technology who reside in hospitals, nursing homes, and medical
14 foster care, and those who reside with their parents. The
15 study must describe children served in prescribed pediatric
16 extended care centers, including their ages and the services
17 they receive. The report must identify the total services
18 provided for each child and the method for paying for those
19 services. The report must also identify the number of such
20 children who could, if appropriate transitional services were
21 available, return home or move to a less institutional
22 setting.
23 (3) Within 30 days after the effective date of this
24 act, the agency shall establish minimum staffing standards and
25 quality requirements for a subacute pediatric transitional
26 care center to be operated as a 2-year pilot program in
27 Miami-Dade County. The pilot program must operate under the
28 license of a hospital licensed under chapter 395, Florida
29 Statutes, or a nursing home licensed under chapter 400,
30 Florida Statutes, and shall use existing beds in the hospital
31 or nursing home. A child's placement in the subacute pediatric
89
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 transitional care center may not exceed 90 days. The center
2 shall arrange for an alternative placement at the end of a
3 child's stay and a transitional plan for children expected to
4 remain in the facility for the maximum allowed stay.
5 (4) Within 60 days after the effective date of this
6 act, the agency must amend the state Medicaid plan or request
7 any federal waivers necessary to implement and fund the pilot
8 program.
9 (5) The subacute pediatric transitional care center
10 must require level 1 background screening as provided in
11 chapter 435, Florida Statutes, for all employees or
12 prospective employees of the center who are expected to, or
13 whose responsibilities may require them to, provide personal
14 care or services to children, have access to children's living
15 areas, or have access to children's funds or personal
16 property.
17 (6) The subacute pediatric transitional care center
18 must have an advisory board. Membership on the advisory board
19 must include, but need not be limited to:
20 (a) A physician and an advanced registered nurse
21 practitioner who is familiar with services for children who
22 are medically fragile or dependent on medical technology.
23 (b) A registered nurse who has experience in the care
24 of children who are medically fragile or dependent on medical
25 technology.
26 (c) A child development specialist who has experience
27 in the care of children who are medically fragile or dependent
28 on medical technology, and their families.
29 (d) A social worker who has experience in the care of
30 children who are medically fragile or dependent on medical
31 technology, and their families.
90
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (e) A consumer representative who is a parent or
2 guardian of a child placed in the center.
3 (7) The advisory board shall:
4 (a) Review the policy and procedure components of the
5 center to ensure conformance with applicable standards
6 developed by the agency; and
7 (b) Provide consultation with respect to the
8 operational and programmatic components of the center.
9 (8) The subacute pediatric transitional care center
10 must have written policies and procedures governing the
11 admission, transfer, and discharge of children.
12 (9) The admission of each child to the center must be
13 under the supervision of the center nursing administrator or
14 his or her designee and must be in accordance with the
15 center's policies and procedures. Each Medicaid admission must
16 be approved as appropriate for placement in the facility by
17 the Children's Medical Services Multidisciplinary Assessment
18 Team of the Department of Health, in conjunction with the
19 agency.
20 (10) Each child admitted to the center shall be
21 admitted upon prescription of the medical director of the
22 center, licensed pursuant to chapter 458 or chapter 459,
23 Florida Statutes, and the child shall remain under the care of
24 the medical director and the advanced registered nurse
25 practitioner for the duration of his or her stay in the
26 center.
27 (11) Each child admitted to the center must meet at
28 least the following criteria:
29 (a) The child must be medically fragile or dependent
30 on medical technology.
31
91
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 (b) The child may not, prior to admission, present
2 significant risk of infection to other children or personnel.
3 The medical and nursing directors shall review, on a
4 case-by-case basis, the condition of any child who is
5 suspected of having an infectious disease to determine whether
6 admission is appropriate.
7 (c) The child must be medically stabilized and require
8 skilled nursing care or other interventions.
9 (12) If the child meets the criteria specified in
10 paragraphs (11)(a), (b), and (c), the medical director or
11 nursing director of the center shall implement a preadmission
12 plan that delineates services to be provided and appropriate
13 sources for such services.
14 (a) If the child is hospitalized at the time of
15 referral, preadmission planning must include the participation
16 of the child's parent or guardian and relevant medical,
17 nursing, social services, and developmental staff to ensure
18 that the hospital's discharge plans will be implemented
19 following the child's placement in the center.
20 (b) A consent form outlining the purpose of the
21 center, family responsibilities, authorized treatment,
22 appropriate release of liability, and emergency disposition
23 plans must be signed by the parent or guardian and witnessed
24 before the child is admitted to the center. The parent or
25 guardian shall be provided a copy of the consent form.
26 (13) By January 1, 2003, the agency shall report to
27 the Legislature concerning the progress of the pilot program.
28 By January 1, 2004, the agency shall submit to the Legislature
29 a report on the success of the pilot program.
30 (14) This section is subject to the availability of
31 funds and subject to any limitations or directions provided
92
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 for in the General Appropriations Act or chapter 216, Florida
2 Statutes.
3 Section 32. By January 1, 2003, the Agency for Health
4 Care Administration shall make recommendations to the
5 Legislature as to limits in the amount of home office
6 management and administrative fees which should be allowable
7 for reimbursement for Medicaid providers whose rates are set
8 on a cost-reimbursement basis.
9 Section 33. (1) Notwithstanding s. 409.911(3),
10 Florida Statutes, for the state fiscal year 2002-2003 only,
11 the agency shall distribute moneys under the regular
12 disproportionate share program only to hospitals that meet the
13 federal minimum requirements and to public hospitals. Public
14 hospitals are defined as those hospitals identified as
15 government owned or operated in the Financial Hospital Uniform
16 Reporting System (FHURS) data available to the agency as of
17 January 1, 2002. The following methodology shall be used to
18 distribute disproportionate share dollars to hospitals that
19 meet the federal minimum requirements and to the public
20 hospitals:
21 (a) For hospitals that meet the federal minimum
22 requirements, the following formula shall be used:
23
24 TAA = TA * (1/5.5)
25 DSHP = (HMD/TMSD)*TA
26
27 TAA = total amount available.
28 TA = total appropriation.
29 DSHP = disproportionate share hospital payment.
30 HMD = hospital Medicaid days.
31 TSD = total state Medicaid days.
93
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1
2 (b) The following formulas shall be used to pay
3 disproportionate share dollars to public hospitals:
4 1. For state mental health hospitals:
5
6 DSHP = (HMD/TMD) * TAAMH
7
8 The total amount available for the state mental
9 health hospitals shall be the difference
10 between the federal cap for Institutions for
11 Mental Diseases and the amounts paid under the
12 mental health disproportionate share program.
13 2. For non-state government owned or operated
14 hospitals with 3,200 or more Medicaid days:
15
16 DSHP = [(.85*HCCD/TCCD) + (.15*HMD/TMD)] *
17 TAAPH
18 TAAPH = TAA - TAAMH
19
20 3. For non-state government owned or operated
21 hospitals with less than 3,200 Medicaid days, a total of
22 $400,000 shall be distributed equally among these hospitals.
23
24 Where:
25
26 TAA = total available appropriation.
27 TAAPH = total amount available for public
28 hospitals.
29 TAAMH = total amount available for mental
30 health hospitals.
31
94
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 DSHP = disproportionate share hospital
2 payments.
3 HMD = hospital Medicaid days.
4 TMD = total state Medicaid days for public
5 hospitals.
6 HCCD = hospital charity care dollars.
7 TCCD = total state charity care dollars for
8 public hospitals.
9
10 In computing the above amounts for public hospitals and
11 hospitals that qualify under the federal minimum requirements,
12 the agency shall use the 1997 audited data. In the event there
13 is no 1997 audited data for a hospital, the agency shall use
14 the 1994 audited data.
15 (2) Notwithstanding s. 409.9112, Florida Statutes, for
16 state fiscal year 2002-2003, only disproportionate share
17 payments to regional perinatal intensive care centers shall be
18 distributed in the same proportion as the disproportionate
19 share payments made to the regional perinatal intensive care
20 centers in the state fiscal year 2001-2002.
21 (3) Notwithstanding s. 409.9117, Florida Statutes, for
22 state fiscal year 2002-2003 only, disproportionate share
23 payments to hospitals that qualify for primary care
24 disproportionate share payments shall be distributed in the
25 same proportion as the primary care disproportionate share
26 payments made to those hospitals in the state fiscal year
27 2001-2002.
28 (4) In the event the Centers for Medicare and Medicaid
29 Services does not approve Florida's inpatient hospital state
30 plan amendment for the public disproportionate share program
31 by November 1, 2002, the agency may make payments to hospitals
95
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 under the regular disproportionate share program, regional
2 perinatal intensive care centers disproportionate share
3 program, and the primary care disproportionate share program
4 using the same methodologies used in state fiscal year
5 2001-2002.
6 (5) For state fiscal year 2002-2003 only, no
7 disproportionate share payments shall be made to hospitals
8 under the provisions of s. 409.9119, Florida Statutes.
9 (6) This section is repealed on July 1, 2003.
10 Section 34. The Office of Program Policy Analysis and
11 Government Accountability, assisted by the Agency for Health
12 Care Administration, and the Florida Association of Counties,
13 shall perform a study to determine the fair share of the
14 counties' contribution to Medicaid nursing home costs. The
15 Office of Program Policy Analysis and Government
16 Accountability shall submit a report on the study to the
17 President of the Senate and the Speaker of the House of
18 Representatives by January 1, 2003. The report shall set out
19 no less than two options and shall make a recommendation as to
20 what would be a fair share of the costs for the counties'
21 contribution for fiscal year 2003-2004. The report shall also
22 set out options and make a recommendation to be considered to
23 ensure that the counties pay their fair share in subsequent
24 years. No recommendation shall be less than the counties'
25 current share of 1.5 percent. Each option shall include a
26 detailed explanation of the analysis that led to the
27 conclusion.
28 Section 35. Effective July 1, 2002, section 1 of
29 chapter 2001-377, Laws of Florida, which repealed subsection
30 (11) of section 409.904, Florida Statutes, is repealed.
31
96
CODING: Words stricken are deletions; words underlined are additions.
HB 59-E, First Engrossed
1 Section 36. If any provision of this act or its
2 application to any person or circumstance is held invalid, the
3 invalidity shall not affect other provisions or applications
4 of the act which can be given effect without the invalid
5 provision or application, and to this end the provisions of
6 this act are declared severable.
7 Section 37. If any law amended by this act was also
8 amended by a law enacted during the 2002 Regular Session of
9 the Legislature, such laws shall be construed to have been
10 enacted during the same session of the Legislature and full
11 effect shall be given to each if possible.
12 Section 38. Except as otherwise provided herein, this
13 act shall take effect upon becoming a law.
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
97
CODING: Words stricken are deletions; words underlined are additions.