House Bill hb0059Eer

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    ENROLLED

    2002 Legislature                     HB 59-E, Second Engrossed



  1

  2         An act relating to health care; amending s.

  3         16.59, F.S.; specifying additional requirements

  4         for the Medicaid Fraud Control Unit of the

  5         Department of Legal Affairs and the Medicaid

  6         program integrity program; amending s.

  7         240.4075, F.S.; revising priority of awards

  8         under the Nursing Student Loan Forgiveness

  9         Program; amending s. 395.002, F.S.; redefining

10         "premises" for purposes of hospital licensing

11         and regulation; amending s. 395.003, F.S.;

12         revising provisions relating to such licensing,

13         including licensing of teaching hospitals;

14         amending s. 112.3187, F.S.; revising procedures

15         and requirements relating to whistle-blower

16         protection for reporting Medicaid fraud or

17         abuse; amending s. 400.141, F.S.; requiring

18         licensed nursing home facilities to maintain

19         general and professional liability insurance

20         coverage; requiring facilities to submit

21         information to the Agency for Health Care

22         Administration which shall provide reports

23         regarding facilities' litigation, complaints,

24         and deficiencies; amending s. 400.147, F.S.;

25         revising reporting requirements under facility

26         internal risk management and quality assurance

27         programs; providing for funding to expedite the

28         availability of nursing home liability

29         insurance; amending s. 400.179, F.S.; providing

30         an alternative to certain bond requirements for

31         protection against nursing home Medicaid


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    ENROLLED

    2002 Legislature                     HB 59-E, Second Engrossed



  1         overpayments; providing for review and

  2         rulemaking authority of the Agency for Health

  3         Care Administration; providing for future

  4         repeal; requiring a study and report; amending

  5         s. 400.925, F.S.; eliminating the regulation of

  6         certain home medical equipment by the Agency

  7         for Health Care Administration; creating s.

  8         408.831, F.S.; allowing the Agency for Health

  9         Care Administration to take action against a

10         licensee in certain circumstances; reenacting

11         s. 409.8132(4), F.S., to incorporate amendments

12         to ss. 409.902, 409.907, 409.908, and 409.913,

13         F.S., in references thereto; amending s.

14         409.8177, F.S.; requiring the agency to

15         contract for evaluation of the Florida Kidcare

16         program; amending s. 409.902, F.S.; requiring

17         consent for release of medical records to the

18         agency and the Medicaid Fraud Control Unit as a

19         condition of Medicaid eligibility; amending s.

20         409.904, F.S.; revising eligibility standards

21         for certain Medicaid optional medical

22         assistance; amending s. 409.905, F.S.;

23         providing additional criteria for the agency to

24         adjust a hospital's inpatient per diem rate for

25         Medicaid; amending s. 409.906, F.S.;

26         authorizing the agency to make payments for

27         specified services which are optional under

28         Title XIX of the Social Security Act; amending

29         s. 409.9065, F.S.; providing a program name;

30         revising standards for pharmaceutical expense

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


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    2002 Legislature                     HB 59-E, Second Engrossed



  1         prescribing additional requirements with

  2         respect to provider enrollment; requiring that

  3         the Agency for Health Care Administration deny

  4         a provider's application under certain

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

  6         requiring retroactive calculation of cost

  7         report if requirements for cost reporting are

  8         not met; revising provisions relating to rate

  9         adjustments to offset the cost of general and

10         professional liability insurance for nursing

11         homes; extending authorization for special

12         Medicaid payments to qualified providers;

13         providing for intergovernmental transfer of

14         payments; amending s. 409.911, F.S.; expanding

15         application of definitions; amending s.

16         409.9116, F.S.; revising the disproportionate

17         share/financial assistance program for rural

18         hospitals; amending s. 409.91195, F.S.;

19         granting interested parties opportunity to

20         present public testimony before the Medicaid

21         Pharmaceutical and Therapeutics Committee;

22         amending s. 409.912, F.S.; providing

23         requirements for contracts for Medicaid

24         behavioral health care services; revising

25         provisions governing the purchase of goods and

26         services for Medicaid recipients; providing for

27         quarterly reports to the Governor and presiding

28         officers of the Legislature; amending s.

29         409.9122, F.S.; revising procedures relating to

30         assignment of a Medicaid recipient to a managed

31         care plan or MediPass provider; granting agency


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    ENROLLED

    2002 Legislature                     HB 59-E, Second Engrossed



  1         discretion to renew contracts; amending s.

  2         409.913, F.S.; requiring that the agency and

  3         Medicaid Fraud Control Unit annually submit a

  4         report to the Legislature; defining

  5         "complaint"; specifying additional requirements

  6         for the Medicaid program integrity program and

  7         the Medicaid Fraud Control Unit of the

  8         Department of Legal Affairs; requiring

  9         imposition of sanctions or disincentives,

10         except under certain circumstances; providing

11         additional sanctions and disincentives;

12         providing additional grounds under which the

13         agency may terminate a provider's participation

14         in the Medicaid program; providing additional

15         requirements for administrative hearings;

16         providing additional grounds for withholding

17         payments to a provider; authorizing the agency

18         and the Medicaid Fraud Control Unit to review

19         certain records; requiring review by the

20         Attorney General of certain settlements;

21         requiring review by the Auditor General of

22         certain cost reports; amending s. 409.920,

23         F.S.; providing additional duties of the

24         Medicaid Fraud Control Unit; amending s.

25         624.91, F.S.; revising duties of the Florida

26         Healthy Kids Corporation with respect to annual

27         determination of participation in the Healthy

28         Kids program; prescribing duties of the

29         corporation in establishing local match

30         requirements; revising composition of the board

31         of directors; amending s. 627.6425, F.S.;


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    ENROLLED

    2002 Legislature                     HB 59-E, Second Engrossed



  1         revising requirements for nonrenewal or

  2         discontinuance of individual health insurance

  3         coverage; amending s. 766.110, F.S.; removing

  4         certain restrictions on the authority of

  5         licensed hospitals to provide self-insurance

  6         coverage for hospital medical staff; amending

  7         s. 393.063, F.S.; authorizing licensure of

  8         certain comprehensive transitional education

  9         programs for persons with developmental

10         disabilities; revising definition of

11         "intermediate care facility for the

12         developmentally disabled"; amending ss. 400.965

13         and 400.968, F.S.; providing penalties for

14         violation of pt. XI of ch. 400, F.S., relating

15         to intermediate care facilities for

16         developmentally disabled persons; amending s.

17         499.012, F.S.; redefining "wholesale

18         distribution" with respect to regulation of

19         distribution of prescription drugs; requiring

20         the Department of Children and Family Services

21         to develop and implement a comprehensive

22         redesign of the home and community-based

23         services delivery system for persons with

24         developmental disabilities; restricting certain

25         release of funds; providing an implementation

26         schedule; requiring the Agency for Health Care

27         Administration to conduct a study of health

28         care services provided to children who are

29         medically fragile or dependent on medical

30         technology; requiring the Agency for Health

31         Care Administration to conduct a pilot program


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    2002 Legislature                     HB 59-E, Second Engrossed



  1         for a subacute pediatric transitional care

  2         center; requiring background screening of

  3         center personnel; requiring the agency to amend

  4         the Medicaid state plan and seek federal

  5         waivers as necessary; requiring the center to

  6         have an advisory board; providing for

  7         membership on the advisory board; providing

  8         requirements for the admission, transfer, and

  9         discharge of a child to the center; requiring

10         the agency to submit certain reports to the

11         Legislature; providing guidelines for the

12         agency regarding distribution of

13         disproportionate share funds during the

14         2002-2003 fiscal year; authorizing the Agency

15         for Health Care Administration to conduct a

16         pilot project on overnight stays in an

17         ambulatory surgical center; directing the

18         Office of Program Policy Analysis and

19         Government Accountability to perform a study of

20         county contributions to Medicaid nursing home

21         costs; requiring a report and recommendations;

22         transferring to the Department of Health the

23         powers, duties, functions, and assets that

24         relate to the consumer complaint services,

25         investigations, and prosecutorial services

26         performed by the Agency for Health Care

27         Administration under contract with the

28         department; transferring full-time equivalent

29         positions and the practitioner regulation

30         component from the agency to the department;

31         terminating an interagency agreement;


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    ENROLLED

    2002 Legislature                     HB 59-E, Second Engrossed



  1         authorizing the department to contract with the

  2         Department of Legal Affairs; amending s. 20.43,

  3         F.S.; deleting the provision authorizing the

  4         department to enter into such contract with the

  5         agency, to conform; repealing s. 456.047, F.S.,

  6         relating to standardized credentialing for

  7         health care practitioners; repealing s.

  8         414.41(5), F.S., relating to interest imposed

  9         upon the recovery amount of medical assistance

10         overpayments; providing severability; providing

11         for construction of laws enacted at the 2002

12         Regular Session in relation to this act;

13         providing effective dates.

14

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

16

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

18  to read:

19         16.59  Medicaid fraud control.--There is created in the

20  Department of Legal Affairs the Medicaid Fraud Control Unit,

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

22  criminal violations discovered during the course of those

23  investigations.  The Medicaid Fraud Control Unit may refer any

24  criminal violation so uncovered to the appropriate prosecuting

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

26  offices of the Agency for Health Care Administration Medicaid

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

28  collocated. The agency and the Department of Legal Affairs

29  shall conduct joint training and other joint activities

30  designed to increase communication and coordination in

31  recovering overpayments.


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    ENROLLED

    2002 Legislature                     HB 59-E, Second Engrossed



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

  2  112.3187, Florida Statutes, are amended to read:

  3         112.3187  Adverse action against employee for

  4  disclosing information of specified nature prohibited;

  5  employee remedy and relief.--

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

  7  otherwise specified, the following words or terms shall have

  8  the meanings indicated:

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

10  or municipal government entity, whether executive, judicial,

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

12  bureau, commission, authority, or political subdivision

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

14  university.

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

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

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

18  remuneration.

19         (c)  "Adverse personnel action" means the discharge,

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

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

22  or any other adverse action taken against an employee within

23  the terms and conditions of employment by an agency or

24  independent contractor.

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

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

27  contract, including a provider agreement, with an agency.

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

29  of managerial abuses, wrongful or arbitrary and capricious

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

31  substantial adverse economic impact.


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    2002 Legislature                     HB 59-E, Second Engrossed



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

  2  disclosed under this section must include:

  3         (a)  Any violation or suspected violation of any

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

  5  an employee or agent of an agency or independent contractor

  6  which creates and presents a substantial and specific danger

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

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

  9  malfeasance, misfeasance, gross waste of public funds,

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

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

12  independent contractor.

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

14  protects employees and persons who disclose information on

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

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

17  other inquiry conducted by any agency or federal government

18  entity; who refuse to participate in any adverse action

19  prohibited by this section; or who initiate a complaint

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

21  Medicaid Fraud Control Unit of the Department of Legal

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

23  supervisory officials or employees who submit a complaint to

24  the Chief Inspector General in the Executive Office of the

25  Governor, to the employee designated as agency inspector

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

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

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

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

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

31  system, with respect to circumstances that occurred during any


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    2002 Legislature                     HB 59-E, Second Engrossed



  1  period of incarceration.  No remedy or other protection under

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

  3  or intentionally participated in committing the violation or

  4  suspected violation for which protection under ss.

  5  112.3187-112.31895 is being sought.

  6         Section 3.  Paragraph (a) of subsection (7) of section

  7  240.4075, Florida Statutes, is amended to read:

  8         240.4075  Nursing Student Loan Forgiveness Program.--

  9         (7)(a)  Funds contained in the Nursing Student Loan

10  Forgiveness Trust Fund which are to be used for loan

11  forgiveness for those nurses employed by hospitals, birth

12  centers, and nursing homes must be matched on a

13  dollar-for-dollar basis by contributions from the employing

14  institutions, except that this provision shall not apply to

15  state-operated medical and health care facilities, public

16  schools, county health departments, federally sponsored

17  community health centers, teaching hospitals as defined in s.

18  408.07, family practice teaching hospitals as defined in s.

19  395.805, or specialty hospitals for children as used in s.

20  409.9119. An estimate of the annual trust fund dollars shall

21  be made at the beginning of the fiscal year based on historic

22  expenditures from the trust fund. Applicant requests shall be

23  reviewed on a quarterly basis, and applicant awards shall be

24  based on the following priority of employer until all such

25  estimated trust funds are awarded: state-operated medical and

26  health care facilities; public schools; If in any given fiscal

27  quarter there are insufficient funds in the trust fund to

28  grant all eligible applicant requests, awards shall be based

29  on the following priority of employer: county health

30  departments; federally sponsored community health centers;

31  state-operated medical and health care facilities; public


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  1  schools; teaching hospitals as defined in s. 408.07; family

  2  practice teaching hospitals as defined in s. 395.805;

  3  specialty hospitals for children as used in s. 409.9119; and

  4  other hospitals, birth centers, and nursing homes.

  5         Section 4.  Subsection (24) of section 395.002, Florida

  6  Statutes, is amended to read:

  7         395.002  Definitions.--As used in this chapter:

  8         (24)  "Premises" means those buildings, beds, and

  9  equipment located at the address of the licensed facility and

10  all other buildings, beds, and equipment for the provision of

11  hospital, ambulatory surgical, or mobile surgical care located

12  in such reasonable proximity to the address of the licensed

13  facility as to appear to the public to be under the dominion

14  and control of the licensee. For any licensee that is a

15  teaching hospital as defined in s. 408.07(44), reasonable

16  proximity includes any buildings, beds, services, programs,

17  and equipment under the dominion and control of the licensee

18  that are located at a site with a main address that is within

19  1 mile of the main address of the licensed facility; and all

20  such buildings, beds, and equipment may, at the request of a

21  licensee or applicant, be included on the facility license as

22  a single premises.

23         Section 5.  Subsection (2) of section 395.003, Florida

24  Statutes, is amended to read:

25         395.003  Licensure; issuance, renewal, denial, and

26  revocation.--

27         (2)(a)  Upon the receipt of an application for a

28  license and the license fee, the agency shall issue a license

29  if the applicant and facility have received all approvals

30  required by law and meet the requirements established under

31


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    ENROLLED

    2002 Legislature                     HB 59-E, Second Engrossed



  1  this part and in rules. Such license shall include all beds

  2  and services located on the premises of the facility.

  3         (b)  A provisional license may be issued to a new

  4  facility or a facility that is in substantial compliance with

  5  this part and with the rules of the agency.  A provisional

  6  license shall be granted for a period of no more than 1 year

  7  and shall expire automatically at the end of its term.  A

  8  provisional license may not be renewed.

  9         (c)  A license, unless sooner suspended or revoked,

10  shall automatically expire 2 years from the date of issuance

11  and shall be renewable biennially upon application for renewal

12  and payment of the fee prescribed by s. 395.004(2), provided

13  the applicant and licensed facility meet the requirements

14  established under this part and in rules.  An application for

15  renewal of a license shall be made 90 days prior to expiration

16  of the license, on forms provided by the agency.

17         (d)  The agency shall, at the request of a licensee,

18  issue a single license to a licensee for facilities located on

19  separate premises.  Such a license shall specifically state

20  the location of the facilities, the services, and the licensed

21  beds available on each separate premises.  If a licensee

22  requests a single license, the licensee shall designate which

23  facility or office is responsible for receipt of information,

24  payment of fees, service of process, and all other activities

25  necessary for the agency to carry out the provisions of this

26  part.

27         (e)  The agency shall, at the request of a licensee

28  that is a teaching hospital as defined in s. 408.07(44), issue

29  a single license to a licensee for facilities that have been

30  previously licensed as separate premises, provided such

31  separately licensed facilities, taken together, constitute the


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    2002 Legislature                     HB 59-E, Second Engrossed



  1  same premises as defined in s. 395.002(24). Such license for

  2  the single premises shall include all of the beds, services,

  3  and programs that were previously included on the licenses for

  4  the separate premises. The granting of a single license under

  5  this paragraph shall not in any manner reduce the number of

  6  beds, services, or programs operated by the licensee.

  7         (f)(e)  Intensive residential treatment programs for

  8  children and adolescents which have received accreditation

  9  from the Joint Commission on Accreditation of Healthcare

10  Organizations and which meet the minimum standards developed

11  by rule of the agency for such programs shall be licensed by

12  the agency under this part.

13         Section 6.  Subsection (20) of section 400.141, Florida

14  Statutes, is amended to read:

15         400.141  Administration and management of nursing home

16  facilities.--Every licensed facility shall comply with all

17  applicable standards and rules of the agency and shall:

18         (20)  Maintain general and professional liability

19  insurance coverage that is in force at all times.

20         Section 7.  (1)  For the period beginning June 30,

21  2001, and ending June 30, 2005, the Agency for Health Care

22  Administration shall provide a report to the Governor, the

23  President of the Senate, and the Speaker of the House of

24  Representatives with respect to nursing homes.  The first

25  report shall be submitted no later than December 30, 2002, and

26  subsequent reports shall be submitted every 6 months

27  thereafter.  The report shall identify facilities based on

28  their ownership characteristics, size, business structure,

29  for-profit or not-for-profit status, and any other

30  characteristics the agency determines useful in analyzing the

31


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  1  varied segments of the nursing home industry and shall

  2  report:

  3         (a)  The number of Notices of Intent to litigate

  4  received by each facility each month.

  5         (b)  The number of complaints on behalf of a resident

  6  or resident legal representative that were filed with the

  7  clerk of the court each month.

  8         (c)  The month in which the injury which is the basis

  9  for the suit occurred or was discovered or, if unavailable,

10  the dates of residency of the resident involved, beginning

11  with the date of initial admission and latest discharge date.

12         (d)  Information regarding deficiencies cited,

13  including information used to develop the Nursing Home Guide

14  WATCH LIST pursuant to s. 400.191, Florida Statutes, and

15  applicable rules, a summary of data generated on nursing homes

16  by Centers for Medicare and Medicaid Services Nursing Home

17  Quality Information Project, and information collected

18  pursuant to s. 400.147(9), Florida Statutes, relating to

19  litigation.

20         (2)  Facilities subject to part II of chapter 400,

21  Florida Statutes, must submit the information necessary to

22  compile this report each month on existing forms, as modified,

23  provided by the agency.

24         (3)  The agency shall delineate the available

25  information on a monthly basis.

26         Section 8.  Subsection (9) of section 400.147, Florida

27  Statutes, is amended to read:

28         400.147  Internal risk management and quality assurance

29  program.--

30         (9)  By the 10th of each month, each facility subject

31  to this section shall report monthly any notice received


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  1  pursuant to s. 400.0233(2) and each initial complaint that was

  2  filed with the clerk of the court and served on the facility

  3  during the previous month by a resident or a resident's family

  4  member, guardian, conservator, or personal legal

  5  representative liability claim filed against it. The report

  6  must include the name of the resident, the resident's date of

  7  birth and social security number, the Medicaid identification

  8  number for Medicaid-eligible persons, the date or dates of the

  9  incident leading to the claim or dates of residency, if

10  applicable, and the type of injury or violation of rights

11  alleged to have occurred.  Each facility shall also submit a

12  copy of the notices received pursuant to s. 400.0233(2) and

13  complaints filed with the clerk of the court.  This report is

14  confidential as provided by law and is not discoverable or

15  admissible in any civil or administrative action, except in

16  such actions brought by the agency to enforce the provisions

17  of this part.

18         Section 9.  In order to expedite the availability of

19  general and professional liability insurance for nursing

20  homes, the Agency for Health Care Administration, subject to

21  appropriations included in the General Appropriation Act,

22  shall advance $6 million for the purpose of capitalizing the

23  risk retention group. The terms of repayment may not extend

24  beyond 3 years from the date of funding.  For purposes of this

25  project, notwithstanding the provisions of s. 631.271, Florida

26  Statutes, the agency's claim shall be considered a class 3

27  claim.

28         Section 10.  Effective upon becoming a law and

29  applicable to any pending license renewal, paragraph (d) of

30  subsection (5) of section 400.179, Florida Statutes, is

31  amended to read:


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    2002 Legislature                     HB 59-E, Second Engrossed



  1         400.179  Sale or transfer of ownership of a nursing

  2  facility; liability for Medicaid underpayments and

  3  overpayments.--

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

  5  expose the fact that Medicaid may have underpaid or overpaid

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

  7  underpayment or overpayment can only be determined following a

  8  formal field audit, the liabilities for any such underpayments

  9  or overpayments shall be as follows:

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

11  been leased by the transferor:

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

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

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

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

16  months Medicaid payments to the facility computed on the basis

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

18  facility.

19         2.  A leasehold licensee may meet the requirements of

20  subparagraph 1. by payment of a nonrefundable fee, paid at

21  initial licensure, paid at the time of any subsequent change

22  of ownership, and paid at the time of any subsequent annual

23  license renewal, in the amount of 2 percent of the total of 3

24  months' Medicaid payments to the facility computed on the

25  basis of the preceding 12-month average Medicaid payments to

26  the facility. If a preceding 12-month average is not

27  available, projected Medicaid payments may be used. The fee

28  shall be deposited into the Health Care Trust Fund and shall

29  be accounted for separately as a Medicaid nursing home

30  overpayment account. These fees shall be used at the sole

31  discretion of the agency to repay nursing home Medicaid


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  1  overpayments. Payment of this fee shall not release the

  2  licensee from any liability for any Medicaid overpayments, nor

  3  shall payment bar the agency from seeking to recoup

  4  overpayments from the licensee and any other liable party.  As

  5  a condition of exercising this lease bond alternative,

  6  licensees paying this fee must maintain an existing lease bond

  7  through the end of the 30-month term period of that bond.  The

  8  agency is herein granted specific authority to promulgate all

  9  rules pertaining to the administration and management of this

10  account, including withdrawals from the account, subject to

11  federal review and approval. This subparagraph is repealed on

12  June 30, 2003.  This provision shall take effect upon becoming

13  law and shall apply to any leasehold license application.

14         a.  The financial viability of the Medicaid nursing

15  home overpayment account shall be determined by the agency

16  through annual review of the account balance and the amount of

17  total outstanding, unpaid Medicaid overpayments owing from

18  leasehold licensees to the agency as determined by final

19  agency audits.

20         b.  The agency, in consultation with the Florida Health

21  Care Association and the Florida Association of Homes for the

22  Aging, shall study and make recommendations on the minimum

23  amount to be held in reserve to protect against Medicaid

24  overpayments to leasehold licensees and on the issue of

25  successor liability for Medicaid overpayments upon sale or

26  transfer of ownership of a nursing facility. The agency shall

27  submit the findings and recommendations of the study to the

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

29  House of Representatives by January 1, 2003.

30         3.2.  The leasehold licensee operator may meet the bond

31  requirement through other arrangements acceptable to the


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  1  agency Department. The agency is herein granted specific

  2  authority to promulgate rules pertaining to lease bond

  3  arrangements.

  4         4.3.  All existing nursing facility licensees,

  5  operating the facility as a leasehold, shall acquire,

  6  maintain, and provide proof to the agency of the 30-month bond

  7  required in subparagraph 1., above, on and after July 1, 1993,

  8  for each license renewal.

  9         5.4.  It shall be the responsibility of all nursing

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

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

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

13  renewal.

14         6.5.  Any failure of the nursing facility operator to

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

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

17  revoke, or suspend the facility license to operate such

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

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

20  applying for a receiver, deemed necessary to ensure compliance

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

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

23         Section 11.  Subsection (8) of section 400.925, Florida

24  Statutes, is amended to read:

25         400.925  Definitions.--As used in this part, the term:

26         (8)  "Home medical equipment" includes any product as

27  defined by the Federal Drug Administration's Drugs, Devices

28  and Cosmetics Act, any products reimbursed under the Medicare

29  Part B Durable Medical Equipment benefits, or any products

30  reimbursed under the Florida Medicaid durable medical

31  equipment program. Home medical equipment includes, but is not


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  1  limited to, oxygen and related respiratory equipment; manual,

  2  motorized, or. Home medical equipment includes customized

  3  wheelchairs and related seating and positioning, but does not

  4  include prosthetics or orthotics or any splints, braces, or

  5  aids custom fabricated by a licensed health care

  6  practitioner;. Home medical equipment includes assistive

  7  technology devices, including: manual wheelchairs, motorized

  8  wheelchairs, motorized scooters;, voice-synthesized computer

  9  modules, optical scanners, talking software, braille printers,

10  environmental control devices for use by person with

11  quadriplegia, motor vehicle adaptive transportation aids,

12  devices that enable persons with severe speech disabilities to

13  in effect speak, personal transfer systems; and specialty

14  beds, including demonstrator, for use by a person with a

15  medical need.

16         Section 12.  Section 408.831, Florida Statutes, is

17  created to read:

18         408.831  Denial, suspension, or revocation of a

19  license, registration, certificate, or application.--

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

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

22  license, registration, or certificate of entities regulated or

23  licensed by it:

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

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

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

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

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

29  ownership interest equal to 5 percent or greater in that

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

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


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  1  or final order of the Centers for Medicare and Medicaid

  2  Services, not subject to further appeal, unless a repayment

  3  plan is approved by the agency; or

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

  5         (2)  This section provides standards of enforcement

  6  applicable to all entities licensed or regulated by the Agency

  7  for Health Care Administration. This section controls over any

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

  9  393, 394, 395, 400, 408, 468, 483, and 641 or rules adopted

10  pursuant to those chapters.

11         Section 13.  For the purpose of incorporating the

12  amendments made by this act to sections 409.902, 409.907,

13  409.908, and 409.913, Florida Statutes, in references thereto,

14  subsection (4) of section 409.8132, Florida Statutes, is

15  reenacted to read:

16         409.8132  Medikids program component.--

17         (4)  APPLICABILITY OF LAWS RELATING TO MEDICAID.--The

18  provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,

19  409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,

20  409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205

21  apply to the administration of the Medikids program component

22  of the Florida Kidcare program, except that s. 409.9122

23  applies to Medikids as modified by the provisions of

24  subsection (7).

25         Section 14.  Section 409.8177, Florida Statutes, is

26  amended to read:

27         409.8177  Program evaluation.--

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

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

30  the Florida Healthy Kids Corporation, shall contract for an

31  evaluation of the Florida Kidcare program and shall by January


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

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

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

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

  5  Security Act, the report shall include an assessment of

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

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

  8  including the progress made in reducing the number of

  9  uncovered low-income children.

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

11  increasing the number of children with creditable health

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

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

14  families assisted under the program, including ages of the

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

16  health insurance prior to the program and after disenrollment

17  from the program.

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

19  including the types of benefits provided.

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

21  or all of any premium, of assistance provided.

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

23  the program.

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

25  coverage and other methods used for providing child health

26  assistance.

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

28  program.

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

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

31  private programs in the state in increasing the availability


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  1  of affordable quality health insurance and health care for

  2  children.

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

  4  coordinate the program with other public and private programs.

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

  6  that affect the provision of health insurance and health care

  7  to children.

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

  9  improving the availability of health insurance and health care

10  for children.

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

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

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

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

15  House of Representatives a report of enrollment for each

16  program component of the Florida Kidcare program.

17         Section 15.  Section 409.902, Florida Statutes, is

18  amended to read:

19         409.902  Designated single state agency; payment

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

21  Agency for Health Care Administration is designated as the

22  single state agency authorized to make payments for medical

23  assistance and related services under Title XIX of the Social

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

25  limitations or directions provided for in the General

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

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

28  shall be made only to qualified providers in accordance with

29  federal requirements for Title XIX of the Social Security Act

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

31  assistance is designated the "Medicaid program." The


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  1  Department of Children and Family Services is responsible for

  2  Medicaid eligibility determinations, including, but not

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

  4  Security Administration for Medicaid eligibility

  5  determinations for Supplemental Security Income recipients, as

  6  well as the actual determination of eligibility.  As a

  7  condition of Medicaid eligibility, subject to federal

  8  approval, the Agency for Health Care Administration and the

  9  Department of Children and Family Services shall ensure that

10  each recipient of Medicaid consents to the release of her or

11  his medical records to the Agency for Health Care

12  Administration and the Medicaid Fraud Control Unit of the

13  Department of Legal Affairs.

14         Section 16.  Effective July 1, 2002, subsection (2) of

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

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

17         409.904  Optional payments for eligible persons.--The

18  agency may make payments for medical assistance and related

19  services on behalf of the following persons who are determined

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

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

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

23  availability of moneys and any limitations established by the

24  General Appropriations Act or chapter 216.

25         (2)(a)  A caretaker relative or parent, a pregnant

26  woman, a child under age 19 who would otherwise qualify for

27  Florida Kidcare Medicaid, a child up to age 21 who would

28  otherwise qualify under s. 409.903(1), a person age 65 or

29  over, or a blind or disabled person, who would otherwise be

30  eligible for Florida Medicaid, except that the income or

31  assets of such family or person exceed established


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  1  limitations. A pregnant woman who would otherwise qualify for

  2  Medicaid under s. 409.903(5) except for her level of income

  3  and whose assets fall within the limits established by the

  4  Department of Children and Family Services for the medically

  5  needy.  A pregnant woman who applies for medically needy

  6  eligibility may not be made presumptively eligible.

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

  8  for Medicaid or the Florida Kidcare program except for the

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

10  limits established by the Department of Children and Family

11  Services for the medically needy.

12

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

14  group, medical expenses are deductible from income in

15  accordance with federal requirements in order to make a

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

17  liability are not reimbursable by Medicaid. Effective May 1,

18  2003, when determining the eligibility of a pregnant woman, a

19  child, or an aged, blind, or disabled individual, $270 shall

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

21  determining the eligibility of the parent or caretaker

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

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

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

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

26  receive the same services as other Medicaid recipients, with

27  the exception of services in skilled nursing facilities and

28  intermediate care facilities for the developmentally disabled.

29         Section 17.  Subsection (10) of section 409.904,

30  Florida Statutes, is amended to read:

31


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  1         409.904  Optional payments for eligible persons.--The

  2  agency may make payments for medical assistance and related

  3  services on behalf of the following persons who are determined

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

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

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

  7  availability of moneys and any limitations established by the

  8  General Appropriations Act or chapter 216.

  9         (10)(a)  Eligible women with incomes at or below 200

10  percent of the federal poverty level and under age 65, for

11  cancer treatment pursuant to the federal Breast and Cervical

12  Cancer Prevention and Treatment Act of 2000, screened through

13  the Mary Brogan National Breast and Cervical Cancer Early

14  Detection Program established under s. 381.93.

15         (b)  A woman who has not attained 65 years of age and

16  who has been screened for breast or cervical cancer by a

17  qualified entity under the Mary Brogan Breast and Cervical

18  Cancer Early Detection Program of the Department of Health and

19  needs treatment for breast or cervical cancer and is not

20  otherwise covered under creditable coverage, as defined in s.

21  2701(c) of the Public Health Service Act. For purposes of this

22  subsection, the term "qualified entity" means a county public

23  health department or other entity that has contracted with the

24  Department of Health to provide breast and cervical cancer

25  screening services paid for under this act. In determining the

26  eligibility of such a woman, an assets test is not required. A

27  presumptive eligibility period begins on the date on which all

28  eligibility criteria appear to be met and ends on the date

29  determination is made with respect to the eligibility of such

30  woman for services under the state plan or, in the case of

31  such a woman who does not file an application, by the last day


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  1  of the month following the month in which the presumptive

  2  eligibility determination is made. A woman is eligible until

  3  she gains creditable coverage, until treatment is no longer

  4  necessary, or until attainment of 65 years of age.

  5         Section 18.  Paragraph (c) of subsection (5) of section

  6  409.905, Florida Statutes, is amended to read:

  7         409.905  Mandatory Medicaid services.--The agency may

  8  make payments for the following services, which are required

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

10  furnished by Medicaid providers to recipients who are

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

12  were provided. Any service under this section shall be

13  provided only when medically necessary and in accordance with

14  state and federal law. Mandatory services rendered by

15  providers in mobile units to Medicaid recipients may be

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

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

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

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

20  the availability of moneys and any limitations or directions

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

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

23  for all covered services provided for the medical care and

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

25  licensed physician or dentist to a hospital licensed under

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

27  payment for inpatient hospital services for a Medicaid

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

29  days necessary to comply with the General Appropriations Act.

30         (c)  Agency for Health Care Administration shall adjust

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


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  1  cost of serving the Medicaid population at that institution

  2  if:

  3         1.  The hospital experiences an increase in Medicaid

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

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

  6  area occurring after July 1, 1995; or

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

  8  25 percent below the Medicaid per patient cost for that year;

  9  or.

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

11  or fewer hospitals, began offering obstetrical services on or

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

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

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

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

16  effective July 1, 2002.

17

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

19  agency must provide estimated costs for any adjustment in a

20  hospital inpatient per diem pursuant to this paragraph to the

21  Executive Office of the Governor, the House of Representatives

22  General Appropriations Committee, and the Senate

23  Appropriations Committee. Before the agency implements a

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

25  this paragraph, the Legislature must have specifically

26  appropriated sufficient funds in the General Appropriations

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

28  agency.

29         Section 19.  Effective July 1, 2002, subsections (1),

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

31


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

  2  amended to read:

  3         409.906  Optional Medicaid services.--Subject to

  4  specific appropriations, the agency may make payments for

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

  6  the Social Security Act and are furnished by Medicaid

  7  providers to recipients who are determined to be eligible on

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

  9  service that is provided shall be provided only when medically

10  necessary and in accordance with state and federal law.

11  Optional services rendered by providers in mobile units to

12  Medicaid recipients may be restricted or prohibited by the

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

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

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

16  making any other adjustments necessary to comply with the

17  availability of moneys and any limitations or directions

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

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

20  services to elderly and disabled persons and subject to the

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

22  direct the Agency for Health Care Administration to amend the

23  Medicaid state plan to delete the optional Medicaid service

24  known as "Intermediate Care Facilities for the Developmentally

25  Disabled."  Optional services may include:

26         (1)  ADULT DENTAL DENTURE SERVICES.--The agency may pay

27  for medically necessary, emergency dental procedures to

28  alleviate pain or infection. Emergency dental care shall be

29  limited to emergency oral examinations, necessary radiographs,

30  extractions, and incision and drainage of abscess dentures,

31  the procedures required to seat dentures, and the repair and


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  1  reline of dentures, provided by or under the direction of a

  2  licensed dentist, for a recipient who is age 21 or older.

  3  However, Medicaid will not provide reimbursement for dental

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

  5  dental unit:

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

  7  agreement with the Department of Health and complying with

  8  Medicaid's county health department clinic services program

  9  specifications as a county health department clinic services

10  provider.

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

12  arrangement with a federally qualified health center and

13  complying with Medicaid's federally qualified health center

14  specifications as a federally qualified health center

15  provider.

16         (c)  Rendering dental services to Medicaid recipients,

17  21 years of age and older, at nursing facilities.

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

19  agreement with a state-approved dental educational

20  institution.

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

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

23  for hearing and related services, including hearing

24  evaluations, hearing aid devices, dispensing of the hearing

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

26  21 by a licensed hearing aid specialist, otolaryngologist,

27  otologist, audiologist, or physician.

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

29  for visual examinations, eyeglasses, and eyeglass repairs for

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

31


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

  2  optometrist.

  3         Section 20.  Subsections (1) and (2) of section

  4  409.9065, Florida Statutes, as amended by section 5 of chapter

  5  2001-377, Laws of Florida, are amended to read:

  6         409.9065  Pharmaceutical expense assistance.--

  7         (1)  PROGRAM ESTABLISHED.--There is established a

  8  program to provide pharmaceutical expense assistance to

  9  certain low-income elderly individuals, which shall be known

10  as the "Ron Silver Senior Drug Program."

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

12  limited to those individuals who qualify for limited

13  assistance under the Florida Medicaid program as a result of

14  being dually eligible for both Medicare and Medicaid, but

15  whose limited assistance or Medicare coverage does not include

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

17  specifically eligible individuals are individuals low-income

18  senior citizens who:

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

20         (b)  Have an income:

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

22  poverty level;

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

24  level if the Federal Government increases the federal Medicaid

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

26  poverty level; or

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

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

29  General Appropriations Act for the program offered under this

30  section along with federal matching funds approved by the

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


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  1  authorized to submit and implement a federal waiver pursuant

  2  to this subparagraph. The agency shall design a pharmacy

  3  benefit that includes annual per-member benefit limits and

  4  cost-sharing provisions and limits enrollment to available

  5  appropriations and matching federal funds. Prior to

  6  implementing this program, the agency must submit a budget

  7  amendment pursuant to chapter 216;

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

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

10  organization that provides a pharmacy benefit; and

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

12         Section 21.  Subsections (7) and (9) of section

13  409.907, Florida Statutes, as amended by section 6 of chapter

14  2001-377, Laws of Florida, are amended to read:

15         409.907  Medicaid provider agreements.--The agency may

16  make payments for medical assistance and related services

17  rendered to Medicaid recipients only to an individual or

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

19  who is performing services or supplying goods in accordance

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

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

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

23  discrimination under any program or activity for which the

24  provider receives payment from the agency.

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

26  participating in the Medicaid program and before entering into

27  the provider agreement, that the provider submit information,

28  in an initial and any required renewal applications,

29  concerning the professional, business, and personal background

30  of the provider and permit an onsite inspection of the

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


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

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

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

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

  5  to the provider for Medicaid services to determine the

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

  7  is proposing to provide for Medicaid reimbursement. The agency

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

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

10  services under waiver programs for home and community-based

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

12  Department of Children and Family Services. As a continuing

13  condition of participation in the Medicaid program, a provider

14  shall immediately notify the agency of any current or pending

15  bankruptcy filing. Before entering into the provider

16  agreement, or as a condition of continuing participation in

17  the Medicaid program, the agency may also require that

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

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

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

21  provider to the program during the current or most recent

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

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

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

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

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

27  additional bond equal to the actual billing level of the

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

29  physician or group of physicians licensed under chapter 458,

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

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


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  1  assisted living facility licensed under part III of chapter

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

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

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

  5  agency may require the provider to submit information

  6  concerning the background of that entity and of any principal

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

  8  ownership interest in the entity equal to 5 percent or

  9  greater, and any treating provider who participates in or

10  intends to participate in Medicaid through the entity. The

11  information must include:

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

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

14  jurisdiction in which the provider is located or if required

15  by the Federal Government.

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

17  suspension, termination, or other administrative action taken

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

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

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

21  Medicare program; any prior violation of the rules or

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

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

24  regulatory body of this or any other state.

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

26  ownership interest that the provider, or any principal,

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

28  Medicaid provider or health care related entity or any other

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

30  residential care and treatment to persons.

31


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

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

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

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

  5  application, and completion of any necessary background

  6  investigation and criminal history record check, the agency

  7  must either:

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

  9  earlier than the effective date of the approval of the

10  provider application. With respect to providers who were

11  recently granted a change of ownership and those who primarily

12  provide emergency medical services transportation or emergency

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

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

15  application, the effective date of approval is considered to

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

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

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

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

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

21  efficient administration of the program, including, but not

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

23  services, conduct business, and operate a financially viable

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

25  or supplies to recipients, taking into account geographic

26  location and reasonable travel time; the number of providers

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

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

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

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

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


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

  2  any partner or shareholder having an ownership interest equal

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

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

  5  to pay all outstanding fines or overpayments assessed by final

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

  7  and Medicaid Services, not subject to further appeal, unless

  8  the provider agrees to a repayment plan that includes

  9  withholding Medicaid reimbursement until the amount due is

10  paid in full.

11         Section 22.  Section 409.908, Florida Statutes, as

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

13  amended to read:

14         409.908  Reimbursement of Medicaid providers.--Subject

15  to specific appropriations, the agency shall reimburse

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

17  according to methodologies set forth in the rules of the

18  agency and in policy manuals and handbooks incorporated by

19  reference therein.  These methodologies may include fee

20  schedules, reimbursement methods based on cost reporting,

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

22  and other mechanisms the agency considers efficient and

23  effective for purchasing services or goods on behalf of

24  recipients. If a provider is reimbursed based on cost

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

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

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

28  shall be retroactively calculated using the new cost report,

29  and full payment at the recalculated rate shall be affected

30  retroactively. Medicare-granted extensions for filing cost

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


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  1  reports. Payment for Medicaid compensable services made on

  2  behalf of Medicaid eligible persons is subject to the

  3  availability of moneys and any limitations or directions

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

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

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

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

  8  making any other adjustments necessary to comply with the

  9  availability of moneys and any limitations or directions

10  provided for in the General Appropriations Act, provided the

11  adjustment is consistent with legislative intent.

12         (1)  Reimbursement to hospitals licensed under part I

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

14  negotiation.

15         (a)  Reimbursement for inpatient care is limited as

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

17         1.  The raising of rate reimbursement caps, excluding

18  rural hospitals.

19         2.  Recognition of the costs of graduate medical

20  education.

21         3.  Other methodologies recognized in the General

22  Appropriations Act.

23         4.  Hospital inpatient rates shall be reduced by 6

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

25  1, 2002.

26

27  During the years funds are transferred from the Department of

28  Health, any reimbursement supported by such funds shall be

29  subject to certification by the Department of Health that the

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

31  authorized to receive funds from state entities, including,


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

  2  governments, and other local political subdivisions, for the

  3  purpose of making special exception payments, including

  4  federal matching funds, through the Medicaid inpatient

  5  reimbursement methodologies. Funds received from state

  6  entities or local governments for this purpose shall be

  7  separately accounted for and shall not be commingled with

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

  9  certify all local governmental funds used as state match under

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

11  identified local health care provider that is otherwise

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

13  the benefactor under the state's Medicaid program as

14  determined under the General Appropriations Act and pursuant

15  to an agreement between the Agency for Health Care

16  Administration and the local governmental entity. The local

17  governmental entity shall use a certification form prescribed

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

19  identify the amount being certified and describe the

20  relationship between the certifying local governmental entity

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

22  an annual statement of impact which documents the specific

23  activities undertaken during the previous fiscal year pursuant

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

25  than January 1, annually.

26         (b)  Reimbursement for hospital outpatient care is

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

28  for:

29         1.  Such care provided to a Medicaid recipient under

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

31  necessity.


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  1         2.  Renal dialysis services.

  2         3.  Other exceptions made by the agency.

  3

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

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

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

  7  subdivisions, for the purpose of making payments, including

  8  federal matching funds, through the Medicaid outpatient

  9  reimbursement methodologies. Funds received from state

10  entities and local governments for this purpose shall be

11  separately accounted for and shall not be commingled with

12  other state or local funds in any manner.

13         (c)  Hospitals that provide services to a

14  disproportionate share of low-income Medicaid recipients, or

15  that participate in the regional perinatal intensive care

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

17  statutory teaching hospital disproportionate share program may

18  receive additional reimbursement. The total amount of payment

19  for disproportionate share hospitals shall be fixed by the

20  General Appropriations Act. The computation of these payments

21  must be made in compliance with all federal regulations and

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

23  409.9113.

24         (d)  The agency is authorized to limit inflationary

25  increases for outpatient hospital services as directed by the

26  General Appropriations Act.

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

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

29  intermediate care facilities for the developmentally disabled

30  licensed under chapter 393 must be made prospectively.

31


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  1         2.  Unless otherwise limited or directed in the General

  2  Appropriations Act, reimbursement to hospitals licensed under

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

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

  5  statewide nursing home payment, and reimbursement to a

  6  hospital licensed under part I of chapter 395 for the

  7  provision of skilled nursing services must be made on the

  8  basis of the average nursing home payment for those services

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

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

11  community nursing homes, reimbursement must be determined by

12  averaging the nursing home payments, in counties that surround

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

14  hospitals, including Medicaid payment of Medicare copayments,

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

16  unless a prior authorization has been obtained from the

17  agency. Medicaid reimbursement may be extended by the agency

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

19  by the patient's physician that the patient requires

20  short-term rehabilitative and recuperative services only, in

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

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

23  chapter 395 for the temporary provision of skilled nursing

24  services to nursing home residents who have been displaced as

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

26  exceed the average county nursing home payment for those

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

28  limited to the period of time which the agency considers

29  necessary for continued placement of the nursing home

30  residents in the hospital.

31


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  1         (b)  Subject to any limitations or directions provided

  2  for in the General Appropriations Act, the agency shall

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

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

  5  to provide care and services in conformance with the

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

  7  quality and safety standards and to ensure that individuals

  8  eligible for medical assistance have reasonable geographic

  9  access to such care.

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

11  qualify for increases in reimbursement rates associated with

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

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

14  provide that the initial nursing home reimbursement rates, for

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

16  with related and unrelated party changes of ownership or

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

18  equivalent to the previous owner's reimbursement rate.

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

20  reimbursement plan and cost reporting system to create direct

21  care and indirect care subcomponents of the patient care

22  component of the per diem rate. These two subcomponents

23  together shall equal the patient care component of the per

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

25  for each patient care subcomponent. The direct care

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

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

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

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

30  provider target. The agency shall adjust the patient care

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


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  1  direct care subcomponent shall be net of the total funds

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

  3  make the required changes to the nursing home cost reporting

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

  5         3.  The direct care subcomponent shall include salaries

  6  and benefits of direct care staff providing nursing services

  7  including registered nurses, licensed practical nurses, and

  8  certified nursing assistants who deliver care directly to

  9  residents in the nursing home facility. This excludes nursing

10  administration, MDS, and care plan coordinators, staff

11  development, and staffing coordinator.

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

13  the indirect care cost subcomponent of the patient care per

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

15  allocated to the direct care subcomponent from a home office

16  or management company.

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

18  the Legislature direct and indirect care costs, including

19  average direct and indirect care costs per resident per

20  facility and direct care and indirect care salaries and

21  benefits per category of staff member per facility.

22         6.  In order to offset the cost of general and

23  professional liability insurance, the agency shall amend Under

24  the plan to allow for, interim rate adjustments shall not be

25  granted to reflect increases in the cost of general or

26  professional liability insurance for nursing homes unless the

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

28  Medicaid utilization in the most recent cost report submitted

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

30  liability costs to the facility for the most recent policy

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


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

  2  exceeding the class ceiling. This provision shall be

  3  implemented to the extent existing appropriations are

  4  available.

  5

  6  It is the intent of the Legislature that the reimbursement

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

  8  nursing home residents who require large amounts of care while

  9  encouraging diversion services as an alternative to nursing

10  home care for residents who can be served within the

11  community. The agency shall base the establishment of any

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

13  available moneys as provided for in the General Appropriations

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

15  results of scientifically valid analysis and conclusions

16  derived from objective statistical data pertinent to the

17  particular maximum rate of payment.

18         (3)  Subject to any limitations or directions provided

19  for in the General Appropriations Act, the following Medicaid

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

21  basis. For each allowable service or goods furnished in

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

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

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

25  the maximum allowable fee established by the agency, whichever

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

27  for which the agency makes payment using a methodology based

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

29         (a)  Advanced registered nurse practitioner services.

30         (b)  Birth center services.

31         (c)  Chiropractic services.


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  1         (d)  Community mental health services.

  2         (e)  Dental services, including oral and maxillofacial

  3  surgery.

  4         (f)  Durable medical equipment.

  5         (g)  Hearing services.

  6         (h)  Occupational therapy for Medicaid recipients under

  7  age 21.

  8         (i)  Optometric services.

  9         (j)  Orthodontic services.

10         (k)  Personal care for Medicaid recipients under age

11  21.

12         (l)  Physical therapy for Medicaid recipients under age

13  21.

14         (m)  Physician assistant services.

15         (n)  Podiatric services.

16         (o)  Portable X-ray services.

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

18  age 21.

19         (q)  Registered nurse first assistant services.

20         (r)  Respiratory therapy for Medicaid recipients under

21  age 21.

22         (s)  Speech therapy for Medicaid recipients under age

23  21.

24         (t)  Visual services.

25         (4)  Subject to any limitations or directions provided

26  for in the General Appropriations Act, alternative health

27  plans, health maintenance organizations, and prepaid health

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

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

30  prospectively paid to the provider monthly for each Medicaid

31  recipient enrolled.  The amount may not exceed the average


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

  2  claims experience, for recipients in the same or similar

  3  category of eligibility.  The agency shall calculate

  4  capitation rates on a regional basis and, beginning September

  5  1, 1995, shall include age-band differentials in such

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

  7  statutory teaching hospitals, specialty hospitals, and

  8  community hospital education program hospitals from

  9  reimbursement ceilings and the cost of special Medicaid

10  payments shall not be included in premiums paid to health

11  maintenance organizations or prepaid health care plans. Each

12  rate semester, the agency shall calculate and publish a

13  Medicaid hospital rate schedule that does not reflect either

14  special Medicaid payments or the elimination of rate

15  reimbursement ceilings, to be used by hospitals and Medicaid

16  health maintenance organizations, in order to determine the

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

18  641.513(6).

19         (5)  An ambulatory surgical center shall be reimbursed

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

21  Medicare-established allowable amount for the facility.

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

23  diagnosis, and treatment services to Medicaid recipients who

24  are children under age 21 shall be reimbursed using an

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

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

27  components of such services shall be reimbursed the lesser of

28  the amount billed by the provider or the Medicaid maximum

29  allowable fee established by the agency.

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

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


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

  2  advanced registered nurse practitioners, as established by the

  3  agency in a fee schedule.

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

  5  services rendered pursuant to a federally approved waiver

  6  shall be reimbursed based on an established or negotiated rate

  7  for each service. These rates shall be established according

  8  to an analysis of the expenditure history and prospective

  9  budget developed by each contract provider participating in

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

11  the agency and approved by the Federal Government in

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

13  owned and operated community-based residential facilities

14  which meet agency requirements and which formerly received

15  Medicaid reimbursement for the optional intermediate care

16  facility for the mentally retarded service may participate in

17  the developmental services waiver as part of a

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

19  recipients who receive waiver services.

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

21  medical supplies and appliances shall be reimbursed on the

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

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

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

25  durable medical equipment, the total rental payments may not

26  exceed the purchase price of the equipment over its expected

27  useful life or the agency's established maximum allowable

28  amount, whichever amount is less.

29         (10)  A hospice shall be reimbursed through a

30  prospective system for each Medicaid hospice patient at

31  Medicaid rates using the methodology established for hospice


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  1  reimbursement pursuant to Title XVIII of the federal Social

  2  Security Act.

  3         (11)  A provider of independent laboratory services

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

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

  6  usual and customary charge, or the Medicaid maximum allowable

  7  fee established by the agency.

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

  9  the amount billed by the provider or the Medicaid maximum

10  allowable fee established by the agency.

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

12  any limitations or directions provided for in the General

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

14  scale for pricing Medicaid physician services. Under this fee

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

16  service based on the average resources required to provide the

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

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

19  professional liability insurance.  The fee schedule shall

20  provide increased reimbursement for preventive and primary

21  care services and lowered reimbursement for specialty services

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

23  services and another for procedural services.  The fee

24  schedule shall not increase total Medicaid physician

25  expenditures unless moneys are available, and shall be phased

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

27  for Health Care Administration shall seek the advice of a

28  16-member advisory panel in formulating and adopting the fee

29  schedule.  The panel shall consist of Medicaid physicians

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

31


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  1  50 percent primary care physicians and 50 percent specialty

  2  care physicians.

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

  4  to physicians for providing total obstetrical services to

  5  Medicaid recipients, which include prenatal, delivery, and

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

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

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

  9  reimbursement to physicians working in Regional Perinatal

10  Intensive Care Centers designated pursuant to chapter 383, for

11  services to certain pregnant Medicaid recipients with a high

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

13  neonatal care groupings and rates established by the agency.

14  Nurse midwives licensed under part I of chapter 464 or

15  midwives licensed under chapter 467 shall be reimbursed at no

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

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

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

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

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

21  agency shall by rule determine a prorated payment for

22  obstetrical services in cases where only part of the total

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

24  Department of Health shall adopt rules for appropriate

25  insurance coverage for midwives licensed under chapter 467.

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

27  reactivation of an inactive license for midwives licensed

28  under chapter 467, such licensees shall submit proof of

29  coverage with each application.

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

31  2001-2002 fiscal year only and if necessary to meet the


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  1  requirements for grants and donations for the special Medicaid

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

  3  Appropriations Acts Act, the agency may make special Medicaid

  4  payments to qualified Medicaid providers designated by the

  5  agency, notwithstanding any provision of this subsection to

  6  the contrary, and may use intergovernmental transfers from

  7  state entities or other governmental entities to serve as the

  8  state share of such payments.

  9         (13)  Medicare premiums for persons eligible for both

10  Medicare and Medicaid coverage shall be paid at the rates

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

12  Medicare services rendered to Medicaid-eligible persons,

13  Medicaid shall pay Medicare deductibles and coinsurance as

14  follows:

15         (a)  Medicaid shall make no payment toward deductibles

16  and coinsurance for any service that is not covered by

17  Medicaid.

18         (b)  Medicaid's financial obligation for deductibles

19  and coinsurance payments shall be based on Medicare allowable

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

21         (c)  Medicaid will pay no portion of Medicare

22  deductibles and coinsurance when payment that Medicare has

23  made for the service equals or exceeds what Medicaid would

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

25  of Medicare and Medicaid shall not exceed the amount Medicaid

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

27  finds that there has been confusion regarding the

28  reimbursement for services rendered to dually eligible

29  Medicare beneficiaries. Accordingly, the Legislature clarifies

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

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


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  1  established by Title XVIII for premiums, deductibles, and

  2  coinsurance for Medicare services rendered by physicians to

  3  Medicaid eligible persons, physicians be reimbursed at the

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

  5  maximum allowable fee established by the Agency for Health

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

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

  8  services rendered by physicians that Medicaid be required to

  9  provide any payment for deductibles, coinsurance, or

10  copayments for Medicare cost sharing, or any expenses incurred

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

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

13  methodology is applicable even in those situations in which

14  the payment for Medicare cost sharing for a qualified Medicare

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

16  eliminated. This expression of the Legislature is in

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

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

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

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

21  and services furnished before the effective date of this act

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

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

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

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

26         1.  Medicaid payments for Nursing Home Medicare part A

27  coinsurance shall be the lesser of the Medicare coinsurance

28  amount or the Medicaid nursing home per diem rate.

29         2.  Medicaid shall pay all deductibles and coinsurance

30  for Medicare-eligible recipients receiving freestanding end

31  stage renal dialysis center services.


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  1         3.  Medicaid payments for general hospital inpatient

  2  services shall be limited to the Medicare deductible per spell

  3  of illness.  Medicaid shall make no payment toward coinsurance

  4  for Medicare general hospital inpatient services.

  5         4.  Medicaid shall pay all deductibles and coinsurance

  6  for Medicare emergency transportation services provided by

  7  ambulances licensed pursuant to chapter 401.

  8         (14)  A provider of prescribed drugs shall be

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

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

11  allowable fee established by the agency, plus a dispensing

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

13  fee for payments for prescribed medicines while ensuring

14  continued access for Medicaid recipients.  The variable

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

16  or both the volume of prescriptions dispensed by a specific

17  pharmacy provider, the volume of prescriptions dispensed to an

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

19  products. The agency shall increase the pharmacy dispensing

20  fee authorized by statute and in the annual General

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

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

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

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

25  authorized to limit reimbursement for prescribed medicine in

26  order to comply with any limitations or directions provided

27  for in the General Appropriations Act, which may include

28  implementing a prospective or concurrent utilization review

29  program.

30         (15)  A provider of primary care case management

31  services rendered pursuant to a federally approved waiver


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

  2  for each Medicaid recipient enrolled with the provider.

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

  4  federally qualified health center services shall be reimbursed

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

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

  7  regulations.

  8         (17)  A provider of targeted case management services

  9  shall be reimbursed pursuant to an established fee, except

10  where the Federal Government requires a public provider be

11  reimbursed on the basis of average actual costs.

12         (18)  Unless otherwise provided for in the General

13  Appropriations Act, a provider of transportation services

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

15  provider or the Medicaid maximum allowable fee established by

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

17  contract with the provider, or with a community transportation

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

19  when services are provided pursuant to an agreement negotiated

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

21  for in s. 427.0135, shall purchase transportation services

22  through the community coordinated transportation system, if

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

24  method for Medicaid clients. Nothing in this subsection shall

25  be construed to limit or preclude the agency from contracting

26  for services using a prepaid capitation rate or from

27  establishing maximum fee schedules, individualized

28  reimbursement policies by provider type, negotiated fees,

29  prior authorization, competitive bidding, increased use of

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

31  efficient and effective for the purchase of services on behalf


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  1  of Medicaid clients, including implementing a transportation

  2  eligibility process. The agency shall not be required to

  3  contract with any community transportation coordinator or

  4  transportation operator that has been determined by the

  5  agency, the Department of Legal Affairs Medicaid Fraud Control

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

  7  any abusive or fraudulent billing activities. The agency is

  8  authorized to competitively procure transportation services or

  9  make other changes necessary to secure approval of federal

10  waivers needed to permit federal financing of Medicaid

11  transportation services at the service matching rate rather

12  than the administrative matching rate.

13         (19)  County health department services may be

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

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

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

17  431.615.

18         (20)  A renal dialysis facility that provides dialysis

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

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

21  customary charge, or the maximum allowable fee established by

22  the agency, whichever amount is less.

23         (21)  The agency shall reimburse school districts which

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

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

26  costs to deliver the services, based on the reimbursement

27  schedule.  The school district shall determine the costs for

28  delivering services as authorized in ss. 236.0812 and 409.9071

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

30  school-based providers is contingent on such providers being

31  enrolled as Medicaid providers and meeting the qualifications


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

  2  the federal Health Care Financing Administration. Speech

  3  therapy providers who are certified through the Department of

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

  5  Code, are eligible for reimbursement for services that are

  6  provided on school premises. Any employee of the school

  7  district who has been fingerprinted and has received a

  8  criminal background check in accordance with Department of

  9  Education rules and guidelines shall be exempt from any agency

10  requirements relating to criminal background checks.

11         (22)  The agency shall request and implement Medicaid

12  waivers from the federal Health Care Financing Administration

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

14  per diem as capital for creating and operating a

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

16  with federal and state laws and rules.

17         Section 23.  Subsection (1) of section 409.911, Florida

18  Statutes, is amended to read:

19         409.911  Disproportionate share program.--Subject to

20  specific allocations established within the General

21  Appropriations Act and any limitations established pursuant to

22  chapter 216, the agency shall distribute, pursuant to this

23  section, moneys to hospitals providing a disproportionate

24  share of Medicaid or charity care services by making quarterly

25  Medicaid payments as required. Notwithstanding the provisions

26  of s. 409.915, counties are exempt from contributing toward

27  the cost of this special reimbursement for hospitals serving a

28  disproportionate share of low-income patients.

29         (1)  Definitions.--As used in this section, and s.

30  409.9112, and the Florida Hospital Uniform Reporting System

31  manual:


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  1         (a)  "Adjusted patient days" means the sum of acute

  2  care patient days and intensive care patient days as reported

  3  to the Agency for Health Care Administration, divided by the

  4  ratio of inpatient revenues generated from acute, intensive,

  5  ambulatory, and ancillary patient services to gross revenues.

  6         (b)  "Actual audited data" or "actual audited

  7  experience" means data reported to the Agency for Health Care

  8  Administration which has been audited in accordance with

  9  generally accepted auditing standards by the agency or

10  representatives under contract with the agency.

11         (c)  "Base Medicaid per diem" means the hospital's

12  Medicaid per diem rate initially established by the Agency for

13  Health Care Administration on January 1, 1999. The base

14  Medicaid per diem rate shall not include any additional per

15  diem increases received as a result of the disproportionate

16  share distribution.

17         (d)  "Charity care" or "uncompensated charity care"

18  means that portion of hospital charges reported to the Agency

19  for Health Care Administration for which there is no

20  compensation, other than restricted or unrestricted revenues

21  provided to a hospital by local governments or tax districts

22  regardless of the method of payment, for care provided to a

23  patient whose family income for the 12 months preceding the

24  determination is less than or equal to 200 percent of the

25  federal poverty level, unless the amount of hospital charges

26  due from the patient exceeds 25 percent of the annual family

27  income.  However, in no case shall the hospital charges for a

28  patient whose family income exceeds four times the federal

29  poverty level for a family of four be considered charity.

30         (e)  "Charity care days" means the sum of the

31  deductions from revenues for charity care minus 50 percent of


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  1  restricted and unrestricted revenues provided to a hospital by

  2  local governments or tax districts, divided by gross revenues

  3  per adjusted patient day.

  4         (f)  "Disproportionate share percentage" means a rate

  5  of increase in the Medicaid per diem rate as calculated under

  6  this section.

  7         (g)  "Hospital" means a health care institution

  8  licensed as a hospital pursuant to chapter 395, but does not

  9  include ambulatory surgical centers.

10         (h)  "Medicaid days" means the number of actual days

11  attributable to Medicaid patients as determined by the Agency

12  for Health Care Administration.

13         Section 24.  Subsection (7) of section 409.9116,

14  Florida Statutes, is amended to read:

15         409.9116  Disproportionate share/financial assistance

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

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

18  shall administer a federally matched disproportionate share

19  program and a state-funded financial assistance program for

20  statutory rural hospitals. The agency shall make

21  disproportionate share payments to statutory rural hospitals

22  that qualify for such payments and financial assistance

23  payments to statutory rural hospitals that do not qualify for

24  disproportionate share payments. The disproportionate share

25  program payments shall be limited by and conform with federal

26  requirements. Funds shall be distributed quarterly in each

27  fiscal year for which an appropriation is made.

28  Notwithstanding the provisions of s. 409.915, counties are

29  exempt from contributing toward the cost of this special

30  reimbursement for hospitals serving a disproportionate share

31  of low-income patients.


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

  2  defined as statutory rural hospitals, or their

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

  4  1, 1998. Any additional hospital that is defined as a

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

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

  7  eligible for programs under this section unless additional

  8  funds are appropriated each fiscal year specifically to the

  9  rural hospital disproportionate share and financial assistance

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

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

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

13  reduction in payments because of the eligibility of an

14  additional hospital to participate in the programs. A

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

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

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

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

19  not required to seek additional appropriations under this

20  subsection.

21         Section 25.  Subsection (7) of section 409.91195,

22  Florida Statutes, is amended to read:

23         409.91195  Medicaid Pharmaceutical and Therapeutics

24  Committee.--There is created a Medicaid Pharmaceutical and

25  Therapeutics Committee within the Agency for Health Care

26  Administration for the purpose of developing a preferred drug

27  formulary pursuant to 42 U.S.C. s. 1396r-8.

28         (7)  The committee shall ensure that interested

29  parties, including pharmaceutical manufacturers agreeing to

30  provide a supplemental rebate as outlined in this chapter,

31  have an opportunity to present public testimony to the


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  1  committee with information or evidence supporting inclusion of

  2  a product on the preferred drug list. Such public testimony

  3  shall occur prior to any recommendations made by the committee

  4  for inclusion or exclusion from the preferred drug list. Upon

  5  timely notice, the agency shall ensure that any drug that has

  6  been approved or had any of its particular uses approved by

  7  the United States Food and Drug Administration under a

  8  priority review classification will be reviewed by the

  9  Medicaid Pharmaceutical and Therapeutics Committee at the next

10  regularly scheduled meeting. To the extent possible, upon

11  notice by a manufacturer the agency shall also schedule a

12  product review for any new product at the next regularly

13  scheduled Medicaid Pharmaceutical and Therapeutics Committee.

14         Section 26.  Paragraph (b) of subsection (3) and

15  paragraph (b) of subsection (13) of section 409.912, Florida

16  Statutes, are amended to read:

17         409.912  Cost-effective purchasing of health care.--The

18  agency shall purchase goods and services for Medicaid

19  recipients in the most cost-effective manner consistent with

20  the delivery of quality medical care.  The agency shall

21  maximize the use of prepaid per capita and prepaid aggregate

22  fixed-sum basis services when appropriate and other

23  alternative service delivery and reimbursement methodologies,

24  including competitive bidding pursuant to s. 287.057, designed

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

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

27  minimize the exposure of recipients to the need for acute

28  inpatient, custodial, and other institutional care and the

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

30  agency may establish prior authorization requirements for

31  certain populations of Medicaid beneficiaries, certain drug


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

  2  and possible dangerous drug interactions. The Pharmaceutical

  3  and Therapeutics Committee shall make recommendations to the

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

  5  agency shall inform the Pharmaceutical and Therapeutics

  6  Committee of its decisions regarding drugs subject to prior

  7  authorization.

  8         (3)  The agency may contract with:

  9         (b)  An entity that is providing comprehensive

10  behavioral health care services to certain Medicaid recipients

11  through a capitated, prepaid arrangement pursuant to the

12  federal waiver provided for by s. 409.905(5). Such an entity

13  must be licensed under chapter 624, chapter 636, or chapter

14  641 and must possess the clinical systems and operational

15  competence to manage risk and provide comprehensive behavioral

16  health care to Medicaid recipients. As used in this paragraph,

17  the term "comprehensive behavioral health care services" means

18  covered mental health and substance abuse treatment services

19  that are available to Medicaid recipients. The secretary of

20  the Department of Children and Family Services shall approve

21  provisions of procurements related to children in the

22  department's care or custody prior to enrolling such children

23  in a prepaid behavioral health plan. Any contract awarded

24  under this paragraph must be competitively procured. In

25  developing the behavioral health care prepaid plan procurement

26  document, the agency shall ensure that the procurement

27  document requires the contractor to develop and implement a

28  plan to ensure compliance with s. 394.4574 related to services

29  provided to residents of licensed assisted living facilities

30  that hold a limited mental health license. The agency must

31  ensure that Medicaid recipients have available the choice of


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  1  at least two managed care plans for their behavioral health

  2  care services. To ensure unimpaired access to behavioral

  3  health care services by Medicaid recipients, all contracts

  4  issued pursuant to this paragraph shall require 80 percent of

  5  the capitation paid to the managed care plan, including health

  6  maintenance organizations, to be expended for the provision of

  7  behavioral health care services. In the event the managed care

  8  plan expends less than 80 percent of the capitation paid

  9  pursuant to this paragraph for the provision of behavioral

10  health care services, the difference shall be returned to the

11  agency. The agency shall provide the managed care plan with a

12  certification letter indicating the amount of capitation paid

13  during each calendar year for the provision of behavioral

14  health care services pursuant to this section. The agency may

15  reimburse for substance-abuse-treatment services on a

16  fee-for-service basis until the agency finds that adequate

17  funds are available for capitated, prepaid arrangements.

18         1.  By January 1, 2001, the agency shall modify the

19  contracts with the entities providing comprehensive inpatient

20  and outpatient mental health care services to Medicaid

21  recipients in Hillsborough, Highlands, Hardee, Manatee, and

22  Polk Counties, to include substance-abuse-treatment services.

23         2.  By December 31, 2001, the agency shall contract

24  with entities providing comprehensive behavioral health care

25  services to Medicaid recipients through capitated, prepaid

26  arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,

27  Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,

28  and Walton Counties. The agency may contract with entities

29  providing comprehensive behavioral health care services to

30  Medicaid recipients through capitated, prepaid arrangements in

31  Alachua County. The agency may determine if Sarasota County


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  1  shall be included as a separate catchment area or included in

  2  any other agency geographic area.

  3         3.  Children residing in a Department of Juvenile

  4  Justice residential program approved as a Medicaid behavioral

  5  health overlay services provider shall not be included in a

  6  behavioral health care prepaid health plan pursuant to this

  7  paragraph.

  8         4.  In converting to a prepaid system of delivery, the

  9  agency shall in its procurement document require an entity

10  providing comprehensive behavioral health care services to

11  prevent the displacement of indigent care patients by

12  enrollees in the Medicaid prepaid health plan providing

13  behavioral health care services from facilities receiving

14  state funding to provide indigent behavioral health care, to

15  facilities licensed under chapter 395 which do not receive

16  state funding for indigent behavioral health care, or

17  reimburse the unsubsidized facility for the cost of behavioral

18  health care provided to the displaced indigent care patient.

19         5.  Traditional community mental health providers under

20  contract with the Department of Children and Family Services

21  pursuant to part IV of chapter 394 and inpatient mental health

22  providers licensed pursuant to chapter 395 must be offered an

23  opportunity to accept or decline a contract to participate in

24  any provider network for prepaid behavioral health services.

25         (13)

26         (b)  The responsibility of the agency under this

27  subsection shall include the development of capabilities to

28  identify actual and optimal practice patterns; patient and

29  provider educational initiatives; methods for determining

30  patient compliance with prescribed treatments; fraud, waste,

31


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  1  and abuse prevention and detection programs; and beneficiary

  2  case management programs.

  3         1.  The practice pattern identification program shall

  4  evaluate practitioner prescribing patterns based on national

  5  and regional practice guidelines, comparing practitioners to

  6  their peer groups. The agency and its Drug Utilization Review

  7  Board shall consult with a panel of practicing health care

  8  professionals consisting of the following: the Speaker of the

  9  House of Representatives and the President of the Senate shall

10  each appoint three physicians licensed under chapter 458 or

11  chapter 459; and the Governor shall appoint two pharmacists

12  licensed under chapter 465 and one dentist licensed under

13  chapter 466 who is an oral surgeon. Terms of the panel members

14  shall expire at the discretion of the appointing official. The

15  panel shall begin its work by August 1, 1999, regardless of

16  the number of appointments made by that date. The advisory

17  panel shall be responsible for evaluating treatment guidelines

18  and recommending ways to incorporate their use in the practice

19  pattern identification program. Practitioners who are

20  prescribing inappropriately or inefficiently, as determined by

21  the agency, may have their prescribing of certain drugs

22  subject to prior authorization.

23         2.  The agency shall also develop educational

24  interventions designed to promote the proper use of

25  medications by providers and beneficiaries.

26         3.  The agency shall implement a pharmacy fraud, waste,

27  and abuse initiative that may include a surety bond or letter

28  of credit requirement for participating pharmacies, enhanced

29  provider auditing practices, the use of additional fraud and

30  abuse software, recipient management programs for

31  beneficiaries inappropriately using their benefits, and other


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  1  steps that will eliminate provider and recipient fraud, waste,

  2  and abuse. The initiative shall address enforcement efforts to

  3  reduce the number and use of counterfeit prescriptions.

  4         4.  By September 30, 2002, the agency shall contract

  5  with an entity in the state to implement a wireless handheld

  6  clinical pharmacology drug information database for

  7  practitioners. The initiative shall be designed to enhance the

  8  agency's efforts to reduce fraud, abuse, and errors in the

  9  prescription drug benefit program and to otherwise further the

10  intent of this paragraph.

11         5.4.  The agency may apply for any federal waivers

12  needed to implement this paragraph.

13         Section 27.  Paragraph (g) of subsection (3) and

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

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

16  Laws of Florida, are amended, and paragraph (h) is added to

17  said subsection (3), to read:

18         409.912  Cost-effective purchasing of health care.--The

19  agency shall purchase goods and services for Medicaid

20  recipients in the most cost-effective manner consistent with

21  the delivery of quality medical care.  The agency shall

22  maximize the use of prepaid per capita and prepaid aggregate

23  fixed-sum basis services when appropriate and other

24  alternative service delivery and reimbursement methodologies,

25  including competitive bidding pursuant to s. 287.057, designed

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

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

28  minimize the exposure of recipients to the need for acute

29  inpatient, custodial, and other institutional care and the

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

31  agency may establish prior authorization requirements for


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  1  certain populations of Medicaid beneficiaries, certain drug

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

  3  and possible dangerous drug interactions. The Pharmaceutical

  4  and Therapeutics Committee shall make recommendations to the

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

  6  agency shall inform the Pharmaceutical and Therapeutics

  7  Committee of its decisions regarding drugs subject to prior

  8  authorization.

  9         (3)  The agency may contract with:

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

11  coordination and care management for Medicaid-eligible

12  pediatric patients, primary care, authorization of specialty

13  care, and other urgent and emergency care through organized

14  providers designed to service Medicaid eligibles under age 18

15  and pediatric emergency departments' diversion programs. The

16  networks shall provide after-hour operations, including

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

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

19  departments.

20         (h)  A Children's Medical Services network, as defined

21  in s. 391.021.

22         (37)

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

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

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

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

27  progress made in implementing this subsection and its Medicaid

28  cost-containment measures and their effect on Medicaid

29  prescribed-drug expenditures.

30

31


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  1         Section 28.  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 this 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 recipients children in families who are

25  required to but have failed to make a choice of managed care

26  plan or MediPass, including children, for their child and who

27  are to be assigned to the MediPass program to children's

28  networks as described in s. 409.912(3)(g), Children's Medical

29  Services network as defined in s. 391.021, exclusive provider

30  organizations, provider service networks, minority physician

31  networks, and pediatric emergency department diversion


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  1  programs authorized by this chapter or the General

  2  Appropriations Act, in such manner as the agency deems

  3  appropriate, and where available. The disproportionate

  4  assignment of children to children's networks shall be made

  5  until the agency has determined that the children's networks

  6  and programs have sufficient numbers to be economically

  7  operated. For purposes of this paragraph, when referring to

  8  assignment, the term "managed care plans" includes health

  9  maintenance organizations, exclusive provider organizations,

10  provider service networks, minority physician networks,

11  Children's Medical Services network, and pediatric emergency

12  department diversion programs authorized by this chapter or

13  the General Appropriations Act. Beginning July 1, 2002, the

14  agency shall assign all children in families who have not made

15  a choice of a managed care plan or MediPass in the required

16  timeframe to a pediatric emergency room diversion program

17  described in s. 409.912(3)(g) that, as of July 1, 2002, has

18  executed a contract with the agency, until such network or

19  program has reached an enrollment of 15,000 children. Once

20  that minimum enrollment level has been reached, the agency

21  shall assign children who have not chosen a managed care plan

22  or MediPass to the network or program in a manner that

23  maintains the minimum enrollment in the network or program at

24  not less than 15,000 children. To the extent practicable, the

25  agency shall also assign all eligible children in the same

26  family to such network or program. When making assignments,

27  the agency shall take into account the following criteria:

28         1.  A managed care plan has sufficient network capacity

29  to meet the need of members.

30         2.  The managed care plan or MediPass has previously

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


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  1  plan's primary care providers or MediPass providers has

  2  previously provided health care to the recipient.

  3         3.  The agency has knowledge that the member has

  4  previously expressed a preference for a particular managed

  5  care plan or MediPass provider as indicated by Medicaid

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

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

  8  providers are geographically accessible to the recipient's

  9  residence.

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

11  managed care plan or MediPass provider, the agency shall

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

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

14  care plans accepting Medicaid enrollees, in which case

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

16  provider. Medicaid recipients in counties with fewer than two

17  managed care plans accepting Medicaid enrollees who are

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

19  shall be assigned to managed care plans until an equal

20  enrollment of 45 50 percent in MediPass and provider service

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

22  Once that equal enrollment is achieved, the assignments shall

23  be divided in order to maintain an equal enrollment in

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

25  55 percent proportion, respectively. In geographic areas where

26  the agency is contracting for the provision of comprehensive

27  behavioral health services through a capitated prepaid

28  arrangement, recipients who fail to make a choice shall be

29  assigned equally to MediPass or a managed care plan. For

30  purposes of this paragraph, when referring to assignment, the

31  term "managed care plans" includes exclusive provider


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  1  organizations, provider service networks, Children's Medical

  2  Services network, minority physician networks, and pediatric

  3  emergency department diversion programs authorized by this

  4  chapter or the General Appropriations Act. When making

  5  assignments, the agency shall take into account the following

  6  criteria:

  7         1.  A managed care plan has sufficient network capacity

  8  to meet the need of members.

  9         2.  The managed care plan or MediPass has previously

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

11  plan's primary care providers or MediPass providers has

12  previously provided health care to the recipient.

13         3.  The agency has knowledge that the member has

14  previously expressed a preference for a particular managed

15  care plan or MediPass provider as indicated by Medicaid

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

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

18  providers are geographically accessible to the recipient's

19  residence.

20         5.  The agency has authority to make mandatory

21  assignments based on quality of service and performance of

22  managed care plans.

23         Section 29.  Paragraph (l) is added to subsection (2)

24  of section 409.9122, Florida Statutes, to read:

25         409.9122  Mandatory Medicaid managed care enrollment;

26  programs and procedures.--

27         (2)

28         (l)  Notwithstanding the provisions of chapter 287, the

29  agency may, at its discretion, renew cost-effective contracts

30  for choice counseling services once or more for such periods

31  as the agency may decide. However, all such renewals may not


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  1  combine to exceed a total period longer than the term of the

  2  original contract.

  3         Section 30.  Section 409.913, Florida Statutes, as

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

  5  amended to read:

  6         409.913  Oversight of the integrity of the Medicaid

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

  8  activities of Florida Medicaid recipients, and providers and

  9  their representatives, to ensure that fraudulent and abusive

10  behavior and neglect of recipients occur to the minimum extent

11  possible, and to recover overpayments and impose sanctions as

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

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

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

15  the Legislature documenting the effectiveness of the state's

16  efforts to control Medicaid fraud and abuse and to recover

17  Medicaid overpayments during the previous fiscal year. The

18  report must describe the number of cases opened and

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

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

21  overpayments alleged in preliminary and final audit letters;

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

23  reductions in overpayment amounts negotiated in settlement

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

25  determinations of overpayments; the amount deducted from

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

27  overpayments recovered each year; the amount of cost of

28  investigation recovered each year; the average length of time

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

30  overpayment is paid in full; the amount determined as

31  uncollectible and the portion of the uncollectible amount


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  1  subsequently reclaimed from the Federal Government; the number

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

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

  4  all costs associated with discovering and prosecuting cases of

  5  Medicaid overpayments and making recoveries in such cases. The

  6  report must also document actions taken to prevent

  7  overpayments and the number of providers prevented from

  8  enrolling in or reenrolling in the Medicaid program as a

  9  result of documented Medicaid fraud and abuse and must

10  recommend changes necessary to prevent or recover

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

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

13  is available to it.

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

15         (a)  "Abuse" means:

16         1.  Provider practices that are inconsistent with

17  generally accepted business or medical practices and that

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

19  reimbursement for goods or services that are not medically

20  necessary or that fail to meet professionally recognized

21  standards for health care.

22         2.  Recipient practices that result in unnecessary cost

23  to the Medicaid program.

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

25  or an overpayment has occurred.

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

27  misrepresentation made by a person with the knowledge that the

28  deception results in unauthorized benefit to herself or

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

30  constitutes fraud under applicable federal or state law.

31


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

  2  means any goods or services necessary to palliate the effects

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

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

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

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

  7  accordance with generally accepted standards of medical

  8  practice.  For purposes of determining Medicaid reimbursement,

  9  the agency is the final arbiter of medical necessity.

10  Determinations of medical necessity must be made by a licensed

11  physician employed by or under contract with the agency and

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

13  or services are provided.

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

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

16  a result of inaccurate or improper cost reporting, improper

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

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

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

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

21  or is a provider of health care.

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

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

24  audits, or any combination thereof, to determine possible

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

26  Medicaid program and shall report the findings of any

27  overpayments in audit reports as appropriate.

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

29  prepayment review of provider claims to ensure cost-effective

30  purchasing, billing, and provision of care to Medicaid

31  recipients.  Such prepayment reviews may be conducted as


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  1  determined appropriate by the agency, without any suspicion or

  2  allegation of fraud, abuse, or neglect.

  3         (4)  Any suspected criminal violation identified by the

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

  5  the Office of the Attorney General for investigation. The

  6  agency and the Attorney General shall enter into a memorandum

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

  8  to, a protocol for regularly sharing information and

  9  coordinating casework.  The protocol must establish a

10  procedure for the referral by the agency of cases involving

11  suspected Medicaid fraud to the Medicaid Fraud Control Unit

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

13  where investigation determines that administrative action by

14  the agency is appropriate. Offices of the Medicaid program

15  integrity program and the Medicaid Fraud Control Unit of the

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

17  collocated. The agency and the Department of Legal Affairs

18  shall periodically conduct joint training and other joint

19  activities designed to increase communication and coordination

20  in recovering overpayments.

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

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

23  an appropriate peer-review organization designated by the

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

25  organization are admissible in any court or administrative

26  proceeding as evidence of medical necessity or the lack

27  thereof.

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

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

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

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


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

  2  States Postal Service proof of mailing or certified or

  3  registered mailing of such notice to the provider at the

  4  address shown on the provider enrollment file constitutes

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

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

  7  address designated by rule.

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

  9  Medicaid program, a provider has an affirmative duty to

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

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

12  responsible for preparation and submission of the claim, and

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

14  goods and services that:

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

16  the provider prior to submitting the claim.

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

18  medically necessary.

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

20  the general public by the provider's peers.

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

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

23  copayments, coinsurance, or deductibles as are authorized by

24  the agency.

25         (e)  Are provided in accord with applicable provisions

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

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

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

29  goods or services were provided, demonstrating the medical

30  necessity for the goods or services rendered. Medicaid goods

31  or services are excessive or not medically necessary unless


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

  2  fully and properly documented in the recipient's medical

  3  record.

  4         (8)  A Medicaid provider shall retain medical,

  5  professional, financial, and business records pertaining to

  6  services and goods furnished to a Medicaid recipient and

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

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

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

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

11  provided if patient treatment would be disrupted. The provider

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

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

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

15  obtain Medicaid-related records from a provider is neither

16  curtailed nor limited during a period of litigation between

17  the agency and the provider.

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

19  persons participating in the preparation of a Medicaid claim

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

21  the amount a provider receives from the Medicaid program.

22         (10)  The agency may require repayment for

23  inappropriate, medically unnecessary, or excessive goods or

24  services from the person furnishing them, the person under

25  whose supervision they were furnished, or the person causing

26  them to be furnished.

27         (11)  The complaint and all information obtained

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

29  authorized representative or agent of a provider, relating to

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

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


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

  2  respect to the provider and requires repayment of any

  3  overpayment, or imposes an administrative sanction;

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

  5  criminal prosecution;

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

  7  without merit; or

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

  9  otherwise protected by law.

10         (12)  The agency may terminate participation of a

11  Medicaid provider in the Medicaid program and may seek civil

12  remedies or impose other administrative sanctions against a

13  Medicaid provider, if the provider has been:

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

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

16  performance of management or administrative functions relating

17  to the delivery of health care goods or services;

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

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

20  provider's profession; or

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

22  neglected or physically abused a patient in connection with

23  the delivery of health care goods or services.

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

25  from participation in the Medicaid program or the Medicare

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

27  must immediately suspend or terminate, as appropriate, the

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

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

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

31  Florida Medicaid program while such foreign suspension or


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  1  termination remains in effect.  This sanction is in addition

  2  to all other remedies provided by law.

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

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

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

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

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

  8  licensing agency of any state;

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

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

11  investigator, or other authorized employee or agent of the

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

13  Government;

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

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

16  found necessary to determine whether Medicaid payments are or

17  were due and the amounts thereof;

18         (d)  The provider has failed to maintain medical

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

20  prior authorization is required, demonstrating the necessity

21  and appropriateness of the goods or services rendered;

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

23  of Medicaid provider publications that have been adopted by

24  reference as rules in the Florida Administrative Code; with

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

26  with provisions of the provider agreement between the agency

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

28  or on transmittal forms for electronically submitted claims

29  that are submitted by the provider or authorized

30  representative, as such provisions apply to the Medicaid

31  program;


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

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

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

  4  inappropriate, unnecessary, excessive, or harmful to the

  5  recipient or are of inferior quality;

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

  7  to provide goods or services that are medically necessary;

  8         (h)  The provider or an authorized representative of

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

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

11  a pattern of erroneous Medicaid claims that have resulted in

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

13  provider was entitled under the Medicaid program;

14         (i)  The provider or an authorized representative of

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

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

17  Medicaid provider enrollment application, a request for prior

18  authorization for Medicaid services, a drug exception request,

19  or a Medicaid cost report that contains materially false or

20  incorrect information;

21         (j)  The provider or an authorized representative of

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

23  recipient's responsible party improperly for amounts that

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

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

26         (k)  The provider or an authorized representative of

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

28  allowable under a Florida Title XIX reimbursement plan, after

29  the provider or authorized representative had been advised in

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

31  not allowable;


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  1         (l)  The provider is charged by information or

  2  indictment with fraudulent billing practices.  The sanction

  3  applied for this reason is limited to suspension of the

  4  provider's participation in the Medicaid program for the

  5  duration of the indictment unless the provider is found guilty

  6  pursuant to the information or indictment;

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

  8  prescribed the goods or services is found liable for negligent

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

10  patient;

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

12  available during a specific audit or review period sufficient

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

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

15  program;

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

17  and reporting requirements of s. 409.907; or

18         (p)  The agency has received reliable information of

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

20  409.920; or.

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

22  agreed-upon repayment schedule.

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

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

25  of the acts described in subsection (14):

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

27  more than 1 year.

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

29  more than 1 year to 20 years.

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

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


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  1  as refusing to furnish Medicaid-related records or refusing

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

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

  4  improper billing of a Medicaid recipient; each instance of

  5  including an unallowable cost on a hospital or nursing home

  6  Medicaid cost report after the provider or authorized

  7  representative has been advised in an audit exit conference or

  8  previous audit report of the cost unallowability; each

  9  instance of furnishing a Medicaid recipient goods or

10  professional services that are inappropriate or of inferior

11  quality as determined by competent peer judgment; each

12  instance of knowingly submitting a materially false or

13  erroneous Medicaid provider enrollment application, request

14  for prior authorization for Medicaid services, drug exception

15  request, or cost report; each instance of inappropriate

16  prescribing of drugs for a Medicaid recipient as determined by

17  competent peer judgment; and each false or erroneous Medicaid

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

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

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

21  information of patient abuse or neglect or of any act

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

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

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

25  paragraph (14)(i).

26         (f)  Imposition of liens against provider assets,

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

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

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

30  are due or recoverable.

31


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  1         (g)  Prepayment reviews of claims for a specified

  2  period of time.

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

  4  6 months to ensure that they are billing Medicaid correctly.

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

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

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

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

  9  the recovery of a fine or overpayment.

10

11  The Secretary of Health Care Administration may make a

12  determination that imposition of a sanction or disincentive is

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

14  case a sanction or disincentive shall not be imposed.

15         (16)  In determining the appropriate administrative

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

17  termination, the agency shall consider:

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

19  violations.

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

21  relating to the delivery of health care programs which

22  resulted in either a criminal conviction or in administrative

23  sanction or penalty.

24         (c)  Evidence of continued violation within the

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

26  regulations, or policies after written notification to the

27  provider of improper practice or instance of violation.

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

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

30  provider.

31


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

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

  3  operated.

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

  5  Medicaid services if the provider is suspended or terminated,

  6  in the best judgment of the agency.

  7

  8  The agency shall document the basis for all sanctioning

  9  actions and recommendations.

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

11  or terminate a particular provider working for a group

12  provider, and may suspend or terminate Medicaid participation

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

14  action against an entire group.

15         (18)  The agency shall establish a process for

16  conducting followup reviews of a sampling of providers who

17  have a history of overpayment under the Medicaid program.

18  This process must consider the magnitude of previous fraud or

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

20  Medicaid costs.

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

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

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

24  or combinations thereof. Appropriate statistical methods may

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

26  population, parametric and nonparametric statistics, tests of

27  hypotheses, and other generally accepted statistical methods.

28  Appropriate analytical methods may include, but are not

29  limited to, reviews to determine variances between the

30  quantities of products that a provider had on hand and

31  available to be purveyed to Medicaid recipients during the


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

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

  3  appropriate consideration sales of the same products to

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

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

  6  agency may introduce the results of such statistical methods

  7  as evidence of overpayment.

  8         (20)  When making a determination that an overpayment

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

10  report to the provider showing the calculation of

11  overpayments.

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

13  papers, showing an overpayment to a provider constitutes

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

15  elicit testimony, either on direct examination or

16  cross-examination in any court or administrative proceeding,

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

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

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

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

21  documented by written invoices, written inventory records, or

22  other competent written documentary evidence maintained in the

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

24  applicable rules of discovery, all documentation that will be

25  offered as evidence at an administrative hearing on a Medicaid

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

27  before the administrative hearing or must be excluded from

28  consideration.

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

30  committed by a provider which is conducted pursuant to this

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


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

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

  3  ultimately prevailed.

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

  5  costs, which include salaries and employee benefits and

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

  7  recovered must be reasonable in relation to the seriousness of

  8  the violation and must be set taking into consideration the

  9  financial resources, earning ability, and needs of the

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

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

12  determined by the agency if the agency determines that an

13  extreme hardship would result to the provider from immediate

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

15  collected by any means authorized by law.

16         (23)  If the agency imposes an administrative sanction

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

18  regulated by another state entity, the agency shall notify

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

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

21  license number and the specific reasons for sanction.

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

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

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

25  withholding of payments involve fraud, willful

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

27  crime committed while rendering goods or services to Medicaid

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

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

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

31  provider within 14 days after such determination with interest


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

  2  accordance with this paragraph shall be placed in a suspended

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

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

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

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

  7  of the overpayment by the agency, and payment arrangements

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

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

10  repayment schedule may be terminated by the agency for

11  nonpayment or partial payment.

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

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

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

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

16  notifying any fiscal intermediary of Medicare benefits that

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

18  such written notification, the Medicare fiscal intermediary

19  shall remit to the state the sum claimed.

20         (25)  The agency may impose administrative sanctions

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

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

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

24  recipient has engaged in solicitation in violation of s.

25  409.920 or that the recipient has otherwise abused the

26  Medicaid program.

27         (26)  When the Agency for Health Care Administration

28  has made a probable cause determination and alleged that an

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

30  after notice to the provider, may:

31


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

  2  pendency of an administrative hearing pursuant to chapter 120,

  3  any medical assistance reimbursement payments until such time

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

  5  receiving notice thereof the provider:

  6         1.  Makes repayment in full; or

  7         2.  Establishes a repayment plan that is satisfactory

  8  to the Agency for Health Care Administration.

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

10  pendency of an administrative hearing pursuant to chapter 120,

11  medical assistance reimbursement payments if the terms of a

12  repayment plan are not adhered to by the provider.

13

14  If a provider requests an administrative hearing pursuant to

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

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

17  absent exceptionally good cause shown as determined by the

18  administrative law judge or hearing officer. Upon issuance of

19  a final order, the balance outstanding of the amount

20  determined to constitute the overpayment shall become due. Any

21  withholding of payments by the Agency for Health Care

22  Administration pursuant to this section shall be limited so

23  that the monthly medical assistance payment is not reduced by

24  more than 10 percent.

25         (27)  Venue for all Medicaid program integrity

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

27  of the agency.

28         (28)  Notwithstanding other provisions of law, the

29  agency and the Medicaid Fraud Control Unit of the Department

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

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


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  1  practice to reconcile quantities of goods or services billed

  2  to Medicaid against quantities of goods or services used in

  3  the provider's total practice.

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

  5  participation in the Medicaid program if the provider fails to

  6  reimburse an overpayment that has been determined by final

  7  order, not subject to further appeal, within 35 days after the

  8  date of the final order, unless the provider and the agency

  9  have entered into a repayment agreement.

10         (30)  If a provider requests an administrative hearing

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

12  90 days following assignment of an administrative law judge,

13  absent exceptionally good cause shown as determined by the

14  administrative law judge or hearing officer. Upon issuance of

15  a final order, the outstanding balance of the amount

16  determined to constitute the overpayment shall become due. If

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

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

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

20  may withhold medical assistance reimbursement payments until

21  the amount due is paid in full.

22         (31)  Duly authorized agents and employees of the

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

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

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

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

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

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

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

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

31  must identify the provider whose records will be inspected,


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  1  and the inspection shall include only records specifically

  2  related to that provider.

  3         Section 31.  Subsections (7) and (8) of section

  4  409.920, Florida Statutes, are amended to read:

  5         409.920  Medicaid provider fraud.--

  6         (7)  The Attorney General shall conduct a statewide

  7  program of Medicaid fraud control. To accomplish this purpose,

  8  the Attorney General shall:

  9         (a)  Investigate the possible criminal violation of any

10  applicable state law pertaining to fraud in the administration

11  of the Medicaid program, in the provision of medical

12  assistance, or in the activities of providers of health care

13  under the Medicaid program.

14         (b)  Investigate the alleged abuse or neglect of

15  patients in health care facilities receiving payments under

16  the Medicaid program, in coordination with the agency.

17         (c)  Investigate the alleged misappropriation of

18  patients' private funds in health care facilities receiving

19  payments under the Medicaid program.

20         (d)  Refer to the Office of Statewide Prosecution or

21  the appropriate state attorney all violations indicating a

22  substantial potential for criminal prosecution.

23         (e)  Refer to the agency all suspected abusive

24  activities not of a criminal or fraudulent nature.

25         (f)  Refer to the agency for collection each instance

26  of overpayment to a provider of health care under the Medicaid

27  program which is discovered during the course of an

28  investigation.

29         (f)(g)  Safeguard the privacy rights of all individuals

30  and provide safeguards to prevent the use of patient medical

31  records for any reason beyond the scope of a specific


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  1  investigation for fraud or abuse, or both, without the

  2  patient's written consent.

  3         (g)  Publicize to state employees and the public the

  4  ability of persons to bring suit under the provisions of the

  5  Florida False Claims Act and the potential for the persons

  6  bringing a civil action under the Florida False Claims Act to

  7  obtain a monetary award.

  8         (8)  In carrying out the duties and responsibilities

  9  under this section subsection, the Attorney General may:

10         (a)  Enter upon the premises of any health care

11  provider, excluding a physician, participating in the Medicaid

12  program to examine all accounts and records that may, in any

13  manner, be relevant in determining the existence of fraud in

14  the Medicaid program, to investigate alleged abuse or neglect

15  of patients, or to investigate alleged misappropriation of

16  patients' private funds. A participating physician is required

17  to make available any accounts or records that may, in any

18  manner, be relevant in determining the existence of fraud in

19  the Medicaid program. The accounts or records of a

20  non-Medicaid patient may not be reviewed by, or turned over

21  to, the Attorney General without the patient's written

22  consent.

23         (b)  Subpoena witnesses or materials, including medical

24  records relating to Medicaid recipients, within or outside the

25  state and, through any duly designated employee, administer

26  oaths and affirmations and collect evidence for possible use

27  in either civil or criminal judicial proceedings.

28         (c)  Request and receive the assistance of any state

29  attorney or law enforcement agency in the investigation and

30  prosecution of any violation of this section.

31


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  1         (d)  Seek any civil remedy provided by law, including,

  2  but not limited to, the remedies provided in ss.

  3  68.081-68.092, s. 812.035, and this chapter.

  4         (e)  Refer to the agency for collection each instance

  5  of overpayment to a provider of health care under the Medicaid

  6  program which is discovered during the course of an

  7  investigation.

  8         Section 32.  Section 624.91, Florida Statutes, is

  9  amended to read:

10         624.91  The Florida Healthy Kids Corporation Act.--

11         (1)  SHORT TITLE.--This section may be cited as the

12  "William G. 'Doc' Myers Healthy Kids Corporation Act."

13         (2)  LEGISLATIVE INTENT.--

14         (a)  The Legislature finds that increased access to

15  health care services could improve children's health and

16  reduce the incidence and costs of childhood illness and

17  disabilities among children in this state. Many children do

18  not have comprehensive, affordable health care services

19  available.  It is the intent of the Legislature that the

20  Florida Healthy Kids Corporation provide comprehensive health

21  insurance coverage to such children. The corporation is

22  encouraged to cooperate with any existing health service

23  programs funded by the public or the private sector and to

24  work cooperatively with the Florida Partnership for School

25  Readiness.

26         (b)  It is the intent of the Legislature that the

27  Florida Healthy Kids Corporation serve as one of several

28  providers of services to children eligible for medical

29  assistance under Title XXI of the Social Security Act.

30  Although the corporation may serve other children, the

31  Legislature intends the primary recipients of services


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  1  provided through the corporation be school-age children with a

  2  family income below 200 percent of the federal poverty level,

  3  who do not qualify for Medicaid.  It is also the intent of the

  4  Legislature that state and local government Florida Healthy

  5  Kids funds, to the extent permissible under federal law, be

  6  used to continue and expand coverage, within available

  7  appropriations, to children not eligible for federal matching

  8  funds under Title XXI obtain matching federal dollars.

  9         (3)  NONENTITLEMENT.--Nothing in this section shall be

10  construed as providing an individual with an entitlement to

11  health care services.  No cause of action shall arise against

12  the state, the Florida Healthy Kids Corporation, or a unit of

13  local government for failure to make health services available

14  under this section.

15         (4)  CORPORATION AUTHORIZATION, DUTIES, POWERS.--

16         (a)  There is created the Florida Healthy Kids

17  Corporation, a not-for-profit corporation which operates on

18  sites designated by the corporation.

19         (b)  The Florida Healthy Kids Corporation shall phase

20  in a program to:

21         1.  Organize school children groups to facilitate the

22  provision of comprehensive health insurance coverage to

23  children;

24         2.  Arrange for the collection of any family, local

25  contributions, or employer payment or premium, in an amount to

26  be determined by the board of directors, to provide for

27  payment of premiums for comprehensive insurance coverage and

28  for the actual or estimated administrative expenses;

29         3.  Arrange for the collection of any voluntary

30  contributions to provide for payment of premiums for children

31  who are not eligible for medical assistance under Title XXI of


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  1  the Social Security Act. Each fiscal year, the corporation

  2  shall establish a local match policy for the enrollment of

  3  non-Title-XXI-eligible children in the Healthy Kids program.

  4  By May 1 of each year, the corporation shall provide written

  5  notification of the amount to be remitted to the corporation

  6  for the following fiscal year under that policy. Local match

  7  sources may include, but are not limited to, funds provided by

  8  municipalities, counties, school boards, hospitals, health

  9  care providers, charitable organizations, special taxing

10  districts, and private organizations. The minimum local match

11  cash contributions required each fiscal year and local match

12  credits shall be determined by the General Appropriations Act.

13  The corporation shall calculate a county's local match rate

14  based upon that county's percentage of the state's total

15  non-Title-XXI expenditures as reported in the corporation's

16  most recently audited financial statement. In awarding the

17  local match credits, the corporation may consider factors

18  including, but not limited to, population density, per-capita

19  income, and existing child-health-related expenditures and

20  services;

21         4.  Accept voluntary supplemental local match

22  contributions that comply with the requirements of Title XXI

23  of the Social Security Act for the purpose of providing

24  additional coverage in contributing counties under Title XXI;

25         5.3.  Establish the administrative and accounting

26  procedures for the operation of the corporation;

27         6.4.  Establish, with consultation from appropriate

28  professional organizations, standards for preventive health

29  services and providers and comprehensive insurance benefits

30  appropriate to children; provided that such standards for

31


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  1  rural areas shall not limit primary care providers to

  2  board-certified pediatricians;

  3         7.5.  Establish eligibility criteria which children

  4  must meet in order to participate in the program;

  5         8.6.  Establish procedures under which providers of

  6  local match to, applicants to and participants in the program

  7  may have grievances reviewed by an impartial body and reported

  8  to the board of directors of the corporation;

  9         9.7.  Establish participation criteria and, if

10  appropriate, contract with an authorized insurer, health

11  maintenance organization, or insurance administrator to

12  provide administrative services to the corporation;

13         10.8.  Establish enrollment criteria which shall

14  include penalties or waiting periods of not fewer than 60 days

15  for reinstatement of coverage upon voluntary cancellation for

16  nonpayment of family premiums;

17         11.9.  If a space is available, establish a special

18  open enrollment period of 30 days' duration for any child who

19  is enrolled in Medicaid or Medikids if such child loses

20  Medicaid or Medikids eligibility and becomes eligible for the

21  Florida Healthy Kids program;

22         12.10.  Contract with authorized insurers or any

23  provider of health care services, meeting standards

24  established by the corporation, for the provision of

25  comprehensive insurance coverage to participants.  Such

26  standards shall include criteria under which the corporation

27  may contract with more than one provider of health care

28  services in program sites. Health plans shall be selected

29  through a competitive bid process. The selection of health

30  plans shall be based primarily on quality criteria established

31  by the board. The health plan selection criteria and scoring


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  1  system, and the scoring results, shall be available upon

  2  request for inspection after the bids have been awarded;

  3         13.  Establish disenrollment criteria in the event

  4  local matching funds are insufficient to cover enrollments;

  5         14.11.  Develop and implement a plan to publicize the

  6  Florida Healthy Kids Corporation, the eligibility requirements

  7  of the program, and the procedures for enrollment in the

  8  program and to maintain public awareness of the corporation

  9  and the program;

10         15.12.  Secure staff necessary to properly administer

11  the corporation. Staff costs shall be funded from state and

12  local matching funds and such other private or public funds as

13  become available. The board of directors shall determine the

14  number of staff members necessary to administer the

15  corporation;

16         16.13.  As appropriate, enter into contracts with local

17  school boards or other agencies to provide onsite information,

18  enrollment, and other services necessary to the operation of

19  the corporation;

20         17.14.  Provide a report on an annual basis to the

21  Governor, Insurance Commissioner, Commissioner of Education,

22  Senate President, Speaker of the House of Representatives, and

23  Minority Leaders of the Senate and the House of

24  Representatives;

25         18.15.  Each fiscal year, establish a maximum number of

26  participants by county, on a statewide basis, who may enroll

27  in the program without the benefit of local matching funds.

28  Thereafter, the corporation may establish local matching

29  requirements for supplemental participation in the program.

30  The corporation may vary local matching requirements and

31  enrollment by county depending on factors which may influence


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  1  the generation of local match, including, but not limited to,

  2  population density, per capita income, existing local tax

  3  effort, and other factors. The corporation also may accept

  4  in-kind match in lieu of cash for the local match requirement

  5  to the extent allowed by Title XXI of the Social Security Act;

  6  and

  7         19.16.  Establish eligibility criteria, premium and

  8  cost-sharing requirements, and benefit packages which conform

  9  to the provisions of the Florida Kidcare program, as created

10  in ss. 409.810-409.820.

11         (c)  Coverage under the corporation's program is

12  secondary to any other available private coverage held by the

13  participant child or family member. The corporation may

14  establish procedures for coordinating benefits under this

15  program with benefits under other public and private coverage.

16         (d)  The Florida Healthy Kids Corporation shall be a

17  private corporation not for profit, organized pursuant to

18  chapter 617, and shall have all powers necessary to carry out

19  the purposes of this act, including, but not limited to, the

20  power to receive and accept grants, loans, or advances of

21  funds from any public or private agency and to receive and

22  accept from any source contributions of money, property,

23  labor, or any other thing of value, to be held, used, and

24  applied for the purposes of this act.

25         (5)  BOARD OF DIRECTORS.--

26         (a)  The Florida Healthy Kids Corporation shall operate

27  subject to the supervision and approval of a board of

28  directors chaired by the Insurance Commissioner or her or his

29  designee, and composed of 14 12 other members selected for

30  3-year terms of office as follows:

31


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  1         1.  One member appointed by the Commissioner of

  2  Education from among three persons nominated by the Florida

  3  Association of School Administrators;

  4         2.  One member appointed by the Commissioner of

  5  Education from among three persons nominated by the Florida

  6  Association of School Boards;

  7         3.  One member appointed by the Commissioner of

  8  Education from the Office of School Health Programs of the

  9  Florida Department of Education;

10         4.  One member appointed by the Governor from among

11  three members nominated by the Florida Pediatric Society;

12         5.  One member, appointed by the Governor, who

13  represents the Children's Medical Services Program;

14         6.  One member appointed by the Insurance Commissioner

15  from among three members nominated by the Florida Hospital

16  Association;

17         7.  Two members, appointed by the Insurance

18  Commissioner, who are representatives of authorized health

19  care insurers or health maintenance organizations;

20         8.  One member, appointed by the Insurance

21  Commissioner, who represents the Institute for Child Health

22  Policy;

23         9.  One member, appointed by the Governor, from among

24  three members nominated by the Florida Academy of Family

25  Physicians;

26         10.  One member, appointed by the Governor, who

27  represents the Agency for Health Care Administration; and

28         11.  The State Health Officer or her or his designee;.

29         12.  One member, appointed by the Insurance

30  Commissioner from among three members nominated by the Florida

31  Association of Counties, representing rural counties; and


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  1         13.  One member, appointed by the Governor from among

  2  three members nominated by the Florida Association of

  3  Counties, representing urban counties.

  4         (b)  A member of the board of directors may be removed

  5  by the official who appointed that member.  The board shall

  6  appoint an executive director, who is responsible for other

  7  staff authorized by the board.

  8         (c)  Board members are entitled to receive, from funds

  9  of the corporation, reimbursement for per diem and travel

10  expenses as provided by s. 112.061.

11         (d)  There shall be no liability on the part of, and no

12  cause of action shall arise against, any member of the board

13  of directors, or its employees or agents, for any action they

14  take in the performance of their powers and duties under this

15  act.

16         (6)  LICENSING NOT REQUIRED; FISCAL OPERATION.--

17         (a)  The corporation shall not be deemed an insurer.

18  The officers, directors, and employees of the corporation

19  shall not be deemed to be agents of an insurer. Neither the

20  corporation nor any officer, director, or employee of the

21  corporation is subject to the licensing requirements of the

22  insurance code or the rules of the Department of Insurance.

23  However, any marketing representative utilized and compensated

24  by the corporation must be appointed as a representative of

25  the insurers or health services providers with which the

26  corporation contracts.

27         (b)  The board has complete fiscal control over the

28  corporation and is responsible for all corporate operations.

29         (c)  The Department of Insurance shall supervise any

30  liquidation or dissolution of the corporation and shall have,

31


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  1  with respect to such liquidation or dissolution, all power

  2  granted to it pursuant to the insurance code.

  3         (7)  ACCESS TO RECORDS; CONFIDENTIALITY;

  4  PENALTIES.--Notwithstanding any other laws to the contrary,

  5  the Florida Healthy Kids Corporation shall have access to the

  6  medical records of a student upon receipt of permission from a

  7  parent or guardian of the student.  Such medical records may

  8  be maintained by state and local agencies.  Any identifying

  9  information, including medical records and family financial

10  information, obtained by the corporation pursuant to this

11  subsection is confidential and is exempt from the provisions

12  of s. 119.07(1).  Neither the corporation nor the staff or

13  agents of the corporation may release, without the written

14  consent of the participant or the parent or guardian of the

15  participant, to any state or federal agency, to any private

16  business or person, or to any other entity, any confidential

17  information received pursuant to this subsection.  A violation

18  of this subsection is a misdemeanor of the second degree,

19  punishable as provided in s. 775.082 or s. 775.083.

20         Section 33.  Paragraph (a) of subsection (2) of section

21  627.6425, Florida Statutes, is amended to read:

22         627.6425  Renewability of individual coverage.--

23         (2)  An insurer may nonrenew or discontinue health

24  insurance coverage of an individual in the individual market

25  based only on one or more of the following:

26         (a)  The individual has failed to pay premiums, or

27  contributions, or a required copayment payable to the insurer

28  in accordance with the terms of the health insurance coverage

29  or the insurer has not received timely premium payments. When

30  the copayment is payable to the insurer and exceeds $300, the

31  insurer shall allow the insured up to 90 days after the date


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  1  of the procedure to pay the required copayment. The insurer

  2  shall print in 10-point type on the Declaration of Benefits

  3  page notification that the insured could be terminated for

  4  failure to make any required copayment to the insurer.

  5         Section 34.  Subsection (2) of section 766.110, Florida

  6  Statutes, is amended to read:

  7         766.110  Liability of health care facilities.--

  8         (2)  Every hospital licensed under chapter 395 may

  9  carry liability insurance or adequately insure itself in an

10  amount of not less than $1.5 million per claim, $5 million

11  annual aggregate to cover all medical injuries to patients

12  resulting from negligent acts or omissions on the part of

13  those members of its medical staff who are covered thereby in

14  furtherance of the requirements of ss. 458.320 and 459.0085.

15  Self-insurance coverage extended hereunder to a member of a

16  hospital's medical staff meets the financial responsibility

17  requirements of ss. 458.320 and 459.0085 if the physician's

18  coverage limits are not less than the minimum limits

19  established in ss. 458.320 and 459.0085 and the hospital is a

20  verified trauma center as of July 1, 1990, that has extended

21  self-insurance coverage continuously to members of its medical

22  staff for activities both inside and outside of the hospital

23  since January 1, 1987.  Any insurer authorized to write

24  casualty insurance may make available, but shall not be

25  required to write, such coverage.  The hospital may assess on

26  an equitable and pro rata basis the following professional

27  health care providers for a portion of the total hospital

28  insurance cost for this coverage:  physicians licensed under

29  chapter 458, osteopathic physicians licensed under chapter

30  459, podiatric physicians licensed under chapter 461, dentists

31  licensed under chapter 466, and nurses licensed under part I


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  1  of chapter 464. The hospital may provide for a deductible

  2  amount to be applied against any individual health care

  3  provider found liable in a law suit in tort or for breach of

  4  contract.  The legislative intent in providing for the

  5  deductible to be applied to individual health care providers

  6  found negligent or in breach of contract is to instill in each

  7  individual health care provider the incentive to avoid the

  8  risk of injury to the fullest extent and ensure that the

  9  citizens of this state receive the highest quality health care

10  obtainable.

11         Section 35.  Paragraph (e) of subsection (8) and

12  subsection (28) of section 393.063, Florida Statutes, are

13  amended to read:

14         393.063  Definitions.--For the purposes of this

15  chapter:

16         (8)  "Comprehensive transitional education program"

17  means a group of jointly operating centers or units, the

18  collective purpose of which is to provide a sequential series

19  of educational care, training, treatment, habilitation, and

20  rehabilitation services to persons who have developmental

21  disabilities, as defined in subsection (12), and who have

22  severe or moderate maladaptive behaviors.  However, nothing in

23  this subsection shall require comprehensive transitional

24  education programs to provide services only to persons with

25  developmental disabilities, as defined in subsection (12).

26  All such services shall be temporary in nature and delivered

27  in a structured residential setting with the primary goal of

28  incorporating the normalization principle to establish

29  permanent residence for persons with maladaptive behaviors in

30  facilities not associated with the comprehensive transitional

31  education program.  The staff shall include psychologists and


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  1  teachers, and such staff personnel shall be available to

  2  provide services in each component center or unit of the

  3  program. The psychologists shall be individuals who are

  4  licensed in this state and certified as behavior analysts in

  5  this state, or individuals who meet the professional

  6  requirements established by the department for district

  7  behavior analysts and are certified as behavior analysts in

  8  this state.

  9         (e)  This subsection shall authorize licensure for

10  comprehensive transitional education programs which by July 1,

11  1989:

12         1.  Are in actual operation; or

13         2.  Own a fee simple interest in real property for

14  which a county or city government has approved zoning allowing

15  for the placement of the facilities described in this

16  subsection, and have registered an intent with the department

17  to operate a comprehensive transitional education program.

18  However, nothing shall prohibit the assignment by such a

19  registrant to another entity at a different site within the

20  state, so long as there is compliance with all criteria of the

21  comprehensive transitional education program and local zoning

22  requirements and provided that each residential facility

23  within the component centers or units of the program

24  authorized under this subparagraph shall not exceed a capacity

25  of 15 persons.

26         (28)  "Intermediate care facility for the

27  developmentally disabled" or "ICF/DD" means a

28  state-owned-and-operated residential facility licensed and

29  certified in accordance with state law, and certified by the

30  Federal Government pursuant to the Social Security Act, as a

31  provider of Medicaid services to persons who are


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  1  developmentally disabled mentally retarded or who have related

  2  conditions. The capacity of such a facility shall not be more

  3  than 120 clients.

  4         Section 36.  Section 400.965, Florida Statutes, is

  5  amended to read:

  6         400.965  Action by agency against licensee; grounds.--

  7         (1)  Any of the following conditions constitute grounds

  8  for action by the agency against a licensee:

  9         (a)  A misrepresentation of a material fact in the

10  application;

11         (b)  The commission of an intentional or negligent act

12  materially affecting the health or safety of residents of the

13  facility;

14         (c)  A violation of any provision of this part or rules

15  adopted under this part; or

16         (d)  The commission of any act constituting a ground

17  upon which application for a license may be denied.

18         (2)  If the agency has a reasonable belief that any of

19  such conditions exists, it shall:

20         (a)  In the case of an applicant for original

21  licensure, deny the application.

22         (b)  In the case of an applicant for relicensure or a

23  current licensee, take administrative action as provided in s.

24  400.968 or s. 400.969 or injunctive action as authorized by s.

25  400.963.

26         (c)  In the case of a facility operating without a

27  license, take injunctive action as authorized in s. 400.963.

28         Section 37.  Subsection (4) of section 400.968, Florida

29  Statutes, is renumbered as section 400.969, Florida Statutes,

30  and amended to read:

31         400.969  Violation of part; penalties.--


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  1         (1)(4)(a)  Except as provided in s. 400.967(3), a

  2  violation of any provision of this part section or rules

  3  adopted by the agency under this part section is punishable by

  4  payment of an administrative or civil penalty not to exceed

  5  $5,000.

  6         (2)(b)  A violation of this part section or of rules

  7  adopted under this part section is a misdemeanor of the first

  8  degree, punishable as provided in s. 775.082 or s. 775.083.

  9  Each day of a continuing violation is a separate offense.

10         Section 38.  Paragraph (a) of subsection (1) of section

11  499.012, Florida Statutes, is amended to read:

12         499.012  Wholesale distribution; definitions; permits;

13  general requirements.--

14         (1)  As used in this section, the term:

15         (a)  "Wholesale distribution" means distribution of

16  prescription drugs to persons other than a consumer or

17  patient, but does not include:

18         1.  Any of the following activities, which is not a

19  violation of s. 499.005(21) if such activity is conducted in

20  accordance with s. 499.014:

21         a.  The purchase or other acquisition by a hospital or

22  other health care entity that is a member of a group

23  purchasing organization of a prescription drug for its own use

24  from the group purchasing organization or from other hospitals

25  or health care entities that are members of that organization.

26         b.  The sale, purchase, or trade of a prescription drug

27  or an offer to sell, purchase, or trade a prescription drug by

28  a charitable organization described in s. 501(c)(3) of the

29  Internal Revenue Code of 1986, as amended and revised, to a

30  nonprofit affiliate of the organization to the extent

31  otherwise permitted by law.


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  1         c.  The sale, purchase, or trade of a prescription drug

  2  or an offer to sell, purchase, or trade a prescription drug

  3  among hospitals or other health care entities that are under

  4  common control. For purposes of this section, "common control"

  5  means the power to direct or cause the direction of the

  6  management and policies of a person or an organization,

  7  whether by ownership of stock, by voting rights, by contract,

  8  or otherwise.

  9         d.  The sale, purchase, trade, or other transfer of a

10  prescription drug from or for any federal, state, or local

11  government agency or any entity eligible to purchase

12  prescription drugs at public health services prices pursuant

13  to Pub. L. No. 102-585, s. 602 to a contract provider or its

14  subcontractor for eligible patients of the agency or entity

15  under the following conditions:

16         (I)  The agency or entity must obtain written

17  authorization for the sale, purchase, trade, or other transfer

18  of a prescription drug under this sub-subparagraph from the

19  Secretary of Health or his or her designee.

20         (II)  The contract provider or subcontractor must be

21  authorized by law to administer or dispense prescription

22  drugs.

23         (III)  In the case of a subcontractor, the agency or

24  entity must be a party to and execute the subcontract.

25         (IV)  A contract provider or subcontractor must

26  maintain separate and apart from other prescription drug

27  inventory any prescription drugs of the agency or entity in

28  its possession.

29         (V)  The contract provider and subcontractor must

30  maintain and produce immediately for inspection all records of

31  movement or transfer of all the prescription drugs belonging


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  1  to the agency or entity, including, but not limited to, the

  2  records of receipt and disposition of prescription drugs. Each

  3  contractor and subcontractor dispensing or administering these

  4  drugs must maintain and produce records documenting the

  5  dispensing or administration. Records that are required to be

  6  maintained include, but are not limited to, a perpetual

  7  inventory itemizing drugs received and drugs dispensed by

  8  prescription number or administered by patient identifier,

  9  which must be submitted to the agency or entity quarterly.

10         (VI)  The contract provider or subcontractor may

11  administer or dispense the prescription drugs only to the

12  eligible patients of the agency or entity or must return the

13  prescription drugs for or to the agency or entity. The

14  contract provider or subcontractor must require proof from

15  each person seeking to fill a prescription or obtain treatment

16  that the person is an eligible patient of the agency or entity

17  and must, at a minimum, maintain a copy of this proof as part

18  of the records of the contractor or subcontractor required

19  under sub-sub-subparagraph (V).

20         (VII)  The prescription drugs transferred pursuant to

21  this sub-subparagraph may not be billed to Medicaid.

22         (VII)(VIII)  In addition to the departmental inspection

23  authority set forth in s. 499.051, the establishment of the

24  contract provider and subcontractor and all records pertaining

25  to prescription drugs subject to this sub-subparagraph shall

26  be subject to inspection by the agency or entity.  All records

27  relating to prescription drugs of a manufacturer under this

28  sub-subparagraph shall be subject to audit by the manufacturer

29  of those drugs, without identifying individual patient

30  information.

31


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  1         2.  Any of the following activities, which is not a

  2  violation of s. 499.005(21) if such activity is conducted in

  3  accordance with rules established by the department:

  4         a.  The sale, purchase, or trade of a prescription drug

  5  among federal, state, or local government health care entities

  6  that are under common control and are authorized to purchase

  7  such prescription drug.

  8         b.  The sale, purchase, or trade of a prescription drug

  9  or an offer to sell, purchase, or trade a prescription drug

10  for emergency medical reasons. For purposes of this

11  sub-subparagraph, the term "emergency medical reasons"

12  includes transfers of prescription drugs by a retail pharmacy

13  to another retail pharmacy to alleviate a temporary shortage.

14         c.  The transfer of a prescription drug acquired by a

15  medical director on behalf of a licensed emergency medical

16  services provider to that emergency medical services provider

17  and its transport vehicles for use in accordance with the

18  provider's license under chapter 401.

19         d.  The revocation of a sale or the return of a

20  prescription drug to the person's prescription drug wholesale

21  supplier.

22         e.  The donation of a prescription drug by a health

23  care entity to a charitable organization that has been granted

24  an exemption under s. 501(c)(3) of the Internal Revenue Code

25  of 1986, as amended, and that is authorized to possess

26  prescription drugs.

27         f.  The transfer of a prescription drug by a person

28  authorized to purchase or receive prescription drugs to a

29  person licensed or permitted to handle reverse distributions

30  or destruction under the laws of the jurisdiction in which the

31


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  1  person handling the reverse distribution or destruction

  2  receives the drug.

  3         3.  The distribution of prescription drug samples by

  4  manufacturers' representatives or distributors'

  5  representatives conducted in accordance with s. 499.028.

  6         4.  The sale, purchase, or trade of blood and blood

  7  components intended for transfusion.  As used in this

  8  subparagraph, the term "blood" means whole blood collected

  9  from a single donor and processed either for transfusion or

10  further manufacturing, and the term "blood components" means

11  that part of the blood separated by physical or mechanical

12  means.

13         5.  The lawful dispensing of a prescription drug in

14  accordance with chapter 465.

15         Section 39.  The Legislature finds that the home and

16  community-based services delivery system for persons with

17  developmental disabilities and the availability of

18  appropriated funds are two of the critical elements in making

19  services available.  Therefore, it is the intent of the

20  Legislature that the Department of Children and Family

21  Services shall develop and implement a comprehensive redesign

22  of the system.  The redesign shall include, at a minimum, all

23  actions necessary to achieve an appropriate rate structure,

24  client choice within a specified service package, appropriate

25  assessment strategies, an efficient billing process that

26  contains reconciliation and monitoring components, a redefined

27  role for support coordinators that avoids potential conflicts

28  of interest, and family/client budgets linked to levels of

29  need.  Prior to the release of funds in the lump-sum

30  appropriation, the department shall present a plan to the

31  Executive Office of the Governor, the House Fiscal


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  1  Responsibility Council, and the Senate Appropriations

  2  Committee.  The plan must result in a full implementation of

  3  the redesigned system no later than July 1, 2003.  At a

  4  minimum, the plan must provide that the portions related to

  5  direct provider enrollment and billing will be operational no

  6  later than March 31, 2003.  The plan must further provide that

  7  a more effective needs assessment instrument will be deployed

  8  by January 1, 2003, and that all clients will be assessed with

  9  this device by June 30, 2003.  In no event may the department

10  select an assessment instrument without appropriate evidence

11  that it will be reliable and valid.  Once such evidence has

12  been obtained, however, the department shall determine the

13  feasibility of contracting with an external vendor to apply

14  the new assessment device to all clients receiving services

15  through the Medicaid waiver. In lieu of using an external

16  vendor, the department may use support coordinators for the

17  assessments if it develops sufficient safeguards and training

18  to significantly improve the inter-rater reliability of the

19  support coordinators administering the assessment.

20         Section 40.  (1)  The Agency for Health Care

21  Administration shall conduct a study of health care services

22  provided to children in the state who are medically fragile or

23  dependent on medical technology and conduct a pilot program in

24  Miami-Dade County to provide subacute pediatric transitional

25  care to a maximum of 30 children at any one time. The purposes

26  of the study and the pilot program are to determine ways to

27  permit children who are medically fragile or dependent on

28  medical technology to successfully make a transition from

29  acute care in a health care institution to live with their

30  families when possible, and to provide cost-effective,

31  subacute transitional care services.


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  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 residing in hospitals, nursing homes, and medical

14  foster care, and those who live with their parents. The study

15  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


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  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 and 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.


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  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 assure conformance with applicable standards

  6  developed by the agency.

  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


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  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 assure

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         Section 41.  (1)  Notwithstanding s. 409.911(3),

31  Florida Statutes, for the state fiscal year 2002-2003 only,


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  1  the agency shall distribute moneys under the regular

  2  disproportionate share program only to hospitals that meet the

  3  federal minimum requirements and to public hospitals. Public

  4  hospitals are defined as those hospitals identified as

  5  government owned or operated in the Financial Hospital Uniform

  6  Reporting System (FHURS) data available to the agency as of

  7  January 1, 2002. The following methodology shall be used to

  8  distribute disproportionate share dollars to hospitals that

  9  meet the federal minimum requirements and to the public

10  hospitals:

11         (a)  For hospitals that meet the federal minimum

12  requirements and do not qualify as a public hospital, the

13  following formula shall be used:

14

15         DSHP = (HMD/TMSD)*$1 million

16

17         DSHP = disproportionate share hospital payment.

18         HMD = hospital Medicaid days.

19         TSD = total state Medicaid days.

20

21         (b)  The following formulas shall be used to pay

22  disproportionate share dollars to public hospitals:

23         1.  For state mental health hospitals:

24

25         DSHP = (HMD/TMDMH) * TAAMH

26

27         The total amount available for the state mental

28         health hospitals shall be the difference

29         between the federal cap for Institutions for

30         Mental Diseases and the amounts paid under the

31         mental health disproportionate share program.


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  1         2.  For non-state government owned or operated

  2  hospitals with 3,200 or more Medicaid days:

  3

  4         DSHP = [(.82*HCCD/TCCD) + (.18*HMD/TMD)] *

  5         TAAPH

  6         TAAPH = TAA - TAAMH

  7

  8         3.  For non-state government owned or operated

  9  hospitals with less than 3,200 Medicaid days, a total of

10  $400,000 shall be distributed equally among these hospitals.

11

12  Where:

13

14         TAA = total available appropriation.

15         TAAPH = total amount available for public

16         hospitals.

17         TAAMH = total amount available for mental

18         health hospitals.

19         DSHP = disproportionate share hospital

20         payments.

21         HMD = hospital Medicaid days.

22         TMDMH = total state Medicaid days for mental

23         health days.

24         TMD = total state Medicaid days for public

25         hospitals.

26         HCCD = hospital charity care dollars.

27         TCCD = total state charity care dollars for

28         public non-state hospitals.

29

30  In computing the above amounts for public hospitals and

31  hospitals that qualify under the federal minimum requirements,


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  1  the agency shall use the 1997 audited data. In the event there

  2  is no complete 1997 audited data for a hospital, the agency

  3  shall use the 1994 audited data.

  4         (2)  Notwithstanding s. 409.9112, Florida Statutes, for

  5  state fiscal year 2002-2003, only disproportionate share

  6  payments to regional perinatal intensive care centers shall be

  7  distributed in the same proportion as the disproportionate

  8  share payments made to the regional perinatal intensive care

  9  centers in the state fiscal year 2001-2002.

10         (3)  Notwithstanding s. 409.9117, Florida Statutes, for

11  state fiscal year 2002-2003 only, disproportionate share

12  payments to hospitals that qualify for primary care

13  disproportionate share payments shall be distributed in the

14  same proportion as the primary care disproportionate share

15  payments made to those hospitals in the state fiscal year

16  2001-2002.

17         (4)  For state fiscal year 2002-2003 only, no

18  disproportionate share payments shall be made to hospitals

19  under the provisions of s. 409.9119, Florida Statutes. If the

20  Centers for Medicare and Medicaid Services does not approve

21  Florida's inpatient hospital plan amendment for the public

22  disproportionate share program by November 1, 2002, the agency

23  may make payments to the two children's hospitals in the

24  amount of $3,682,293, distributed in the same proportion as

25  the children's disproportionate share payments in state fiscal

26  year 2001-2002.

27         (5)  In the event the Centers for Medicare and Medicaid

28  Services does not approve Florida's inpatient hospital state

29  plan amendment for the public disproportionate share program

30  by November 1, 2002, the agency may make payments to hospitals

31  under the regular disproportionate share program, regional


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  1  perinatal intensive care centers disproportionate share

  2  program, the children's hospital 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         (6)  This section is repealed on July 1, 2003.

  7         Section 42.  The Agency for Health Care Administration

  8  may conduct a 2-year pilot project to authorize overnight

  9  stays in one ambulatory surgical center located in Acute Care

10  Subdistrict 9-1. An overnight stay shall be permitted only to

11  perform plastic and reconstructive surgeries defined by

12  current procedural terminology code numbers 13000-19999. The

13  total time a patient is at the ambulatory surgical center

14  shall not exceed 23 hours and 59 minutes, including the

15  surgery time, and the maximum planned duration of all surgical

16  procedures combined shall not exceed 8 hours. Prior to

17  implementation of the pilot project, the agency shall

18  establish minimum requirements for protecting the health,

19  safety, and welfare of patients receiving overnight care.

20  These shall include, at a minimum, compliance with all

21  statutes and rules applicable to ambulatory surgical centers

22  and the requirements set forth in Rule 64B8-9.009, Florida

23  Administrative Code, relating to Level II and Level III

24  procedures. If the agency implements the pilot project, it

25  shall, within 6 months after its completion, submit a report

26  to the Legislature on whether to expand the pilot project to

27  include all ambulatory surgical centers. The recommendation

28  shall be based on consideration of the efficacy and impact to

29  patient safety and quality of patient care of providing

30  plastic and reconstructive surgeries in the ambulatory

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  1  surgical center setting. The agency is authorized to obtain

  2  such data as necessary to implement this section.

  3         Section 43.  The Office of Program Policy Analysis and

  4  Government Accountability, assisted by the Agency for Health

  5  Care Administration, and the Florida Association of Counties,

  6  shall perform a study to determine the fair share of the

  7  counties' contribution to Medicaid nursing home costs. The

  8  Office of Program Policy Analysis and Government

  9  Accountability shall submit a report on the study to the

10  President of the Senate and the Speaker of the House of

11  Representatives by January 1, 2003. The report shall set out

12  no less than two options and shall make a recommendation as to

13  what would be a fair share of the costs for the counties'

14  contribution for fiscal year 2003-2004. The report shall also

15  set out options and make a recommendation to be considered to

16  ensure that the counties pay their fair share in subsequent

17  years. No recommendation shall be less than the counties'

18  current share of 1.5 percent. Each option shall include a

19  detailed explanation of the analysis that led to the

20  conclusion.

21         Section 44.  (1)  Effective July 1, 2002, all powers,

22  duties, functions, records, personnel, property, and

23  unexpended balances of appropriations, allocations, and other

24  funds of the Agency for Health Care Administration that relate

25  to consumer complaint services, investigations, and

26  prosecutorial services currently provided by the Agency for

27  Health Care Administration under a contract with the

28  Department of Health are transferred to the Department of

29  Health by a type two transfer, as defined in s. 20.06, Florida

30  Statutes. This transfer of funds shall include all advance

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  1  payments made from the Medical Quality Assurance Trust Fund to

  2  the Agency for Health Care Administration.

  3         (2)  Effective July 1, 2002, 259 full-time equivalent

  4  positions are eliminated from the Agency for Health Care

  5  Administration's total number of authorized positions and

  6  added to the Department of Health's total number of authorized

  7  positions. However, should the General Appropriations Act for

  8  fiscal year 2002-2003 reduce the number of positions from the

  9  agency's practitioner regulation component, that provision

10  shall be construed to reduce the same number of full-time

11  equivalent positions from the practitioner regulation

12  component which are hereby transferred to the department.

13         (3)  The interagency agreement between the Department

14  of Health and the Agency for Health Care Administration shall

15  terminate on June 30, 2002.

16         (4)  The Department of Health may contract with the

17  Department of Legal Affairs for the investigative and

18  prosecutorial services transferred to the department.

19         Section 45.  Paragraph (g) of subsection (3) of section

20  20.43, Florida Statutes, is amended to read:

21         20.43  Department of Health.--There is created a

22  Department of Health.

23         (3)  The following divisions of the Department of

24  Health are established:

25         (g)  Division of Medical Quality Assurance, which is

26  responsible for the following boards and professions

27  established within the division:

28         1.  The Board of Acupuncture, created under chapter

29  457.

30         2.  The Board of Medicine, created under chapter 458.

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  1         3.  The Board of Osteopathic Medicine, created under

  2  chapter 459.

  3         4.  The Board of Chiropractic Medicine, created under

  4  chapter 460.

  5         5.  The Board of Podiatric Medicine, created under

  6  chapter 461.

  7         6.  Naturopathy, as provided under chapter 462.

  8         7.  The Board of Optometry, created under chapter 463.

  9         8.  The Board of Nursing, created under part I of

10  chapter 464.

11         9.  Nursing assistants, as provided under part II of

12  chapter 464.

13         10.  The Board of Pharmacy, created under chapter 465.

14         11.  The Board of Dentistry, created under chapter 466.

15         12.  Midwifery, as provided under chapter 467.

16         13.  The Board of Speech-Language Pathology and

17  Audiology, created under part I of chapter 468.

18         14.  The Board of Nursing Home Administrators, created

19  under part II of chapter 468.

20         15.  The Board of Occupational Therapy, created under

21  part III of chapter 468.

22         16.  Respiratory therapy, as provided under part V of

23  chapter 468.

24         17.  Dietetics and nutrition practice, as provided

25  under part X of chapter 468.

26         18.  The Board of Athletic Training, created under part

27  XIII of chapter 468.

28         19.  The Board of Orthotists and Prosthetists, created

29  under part XIV of chapter 468.

30         20.  Electrolysis, as provided under chapter 478.

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  1         21.  The Board of Massage Therapy, created under

  2  chapter 480.

  3         22.  The Board of Clinical Laboratory Personnel,

  4  created under part III of chapter 483.

  5         23.  Medical physicists, as provided under part IV of

  6  chapter 483.

  7         24.  The Board of Opticianry, created under part I of

  8  chapter 484.

  9         25.  The Board of Hearing Aid Specialists, created

10  under part II of chapter 484.

11         26.  The Board of Physical Therapy Practice, created

12  under chapter 486.

13         27.  The Board of Psychology, created under chapter

14  490.

15         28.  School psychologists, as provided under chapter

16  490.

17         29.  The Board of Clinical Social Work, Marriage and

18  Family Therapy, and Mental Health Counseling, created under

19  chapter 491.

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21  The department may contract with the Agency for Health Care

22  Administration who shall provide consumer complaint,

23  investigative, and prosecutorial services required by the

24  Division of Medical Quality Assurance, councils, or boards, as

25  appropriate.

26         Section 46.  Effective July 1, 2002, section 456.047,

27  Florida Statutes, is repealed.

28         Section 47.  Subsection (5) of section 414.41, Florida

29  Statutes, is repealed.

30         Section 48.  If any provision of this act or its

31  application to any person or circumstance is held invalid, the


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  1  invalidity shall not affect other provisions or applications

  2  of the act which can be given effect without the invalid

  3  provision or application, and to this end the provisions of

  4  this act are declared severable.

  5         Section 49.  If any law amended by this act was also

  6  amended by a law enacted during the 2002 Regular Session of

  7  the Legislature, such laws shall be construed to have been

  8  enacted during the same session of the Legislature and full

  9  effect shall be given to each if possible.

10         Section 50.  Except as otherwise provided herein, this

11  act shall take effect upon becoming a law.

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