HB 1901 2003
1	A bill to be entitled
2	An act relating to health care; amending s. 120.80, F.S.;
3	excluding hearings conducted by the Agency for Health Care
4	Administration from certain administrative law judge
5	assignment requirements; amending s. 154.503, F.S.;
6	requiring the Department of Health to include the Florida
7	Healthy Kids program within certain coordination activity
8	requirements; amending s. 381.90, F.S.; deleting the
9	Florida Healthy Kids Corporation representative from
10	membership in the Health Information Systems Council;
11	amending s. 400.0255, F.S.; designating the agency’s
12	Office of Fair Hearings as the entity initiating and
13	conducting certain hearings; providing rulemaking
14	authority for hearing proceedings; amending s. 400.179,
15	F.S.; revising a provision relating to accountability for
16	certain outstanding liabilities to the state under certain
17	circumstances; amending s. 408.15, F.S.; authorizing the
18	agency to establish and conduct Medicaid fair hearings
19	unrelated to eligibility determination; amending s.
20	409.811, F.S.; defining "managed care plan"; amending s.
21	409.813, F.S.; specifying health benefit coverage for the
22	Florida Kidcare program under the Florida Healthy Kids
23	program; amending s. 409.8132, F.S.; providing
24	specifications for managed care plans relating to
25	preenrollment in the Medikids program; amending ss.
26	409.814, 409.816, 409.818, and 409.820, F.S.; revising and
27	clarifying responsibilities of the Department of Health,
28	the Department of Children and Family Services, and the
29	Agency for Health Care Administration in administering the
30	Florida Healthy Kids program; providing certain minimum
31	premiums for the program; providing for provider standards
32	for primary and specialty care providers; authorizing the
33	agency to contract with certain entities; providing duties
34	of the agency; amending s. 409.904, F.S.; clarifying
35	provisions relating to optional payment for eligible
36	persons; amending s. 409.905, F.S.; increasing a time
37	limit for automatic authorization for inpatient service;
38	amending s. 409.906, F.S.; revising agency authorization
39	to pay for adult dental services; limiting the agency’s
40	authority to provide hearing and visual services to
41	children; amending s. 409.9081, F.S.; establishing
42	copayments for nonemergency emergency room visits and for
43	prescription drugs; amending s. 409.9117, F.S.; deleting
44	reference to the Florida Healthy Kids Corporation;
45	amending s. 409.91188, F.S.; providing for a prepaid
46	health plan for Medicaid HIV/AIDS recipients; requiring
47	the agency to issue a request for proposal or intent to
48	implement such plan; providing entity requirements;
49	directing the agency to modify existing waiver
50	applications; specifying reporting requirements; requiring
51	risk sharing; amending s. 409.91195, F.S.; providing that
52	the class review by the Medicaid Pharmaceutical and
53	Therapeutics Committee shall be the top 75 percent of
54	therapeutic classes based on number of prescriptions and
55	biennial review for all other classes; providing for
56	Medicaid recipients to appeal certain agency decisions to
57	the Office of Fair Hearings; amending s. 409.912, F.S.;
58	requiring the agency to ensure certain provider choice for
59	Medicaid recipients; revising provisions authorizing the
60	agency to contract for prepaid behavioral health services
61	under certain circumstances; clarifying certain provider
62	network provisions; specifying that certain provisions
63	prevail in the event of conflict with other sections of
64	law; authorizing the agency to contract for certain dental
65	services; increasing fines for certain violations;
66	deleting authority for managed care plans to perform
67	preenrollments of Medicaid recipients; amending s.
68	409.9122, F.S.; revising provisions relating to agency
69	assignments of certain Medicaid recipients to managed care
70	plans under certain circumstances; amending s. 409.913,
71	F.S.; permitting rather than requiring the agency to
72	impose certain sanctions; increasing certain fines;
73	deleting a 90-day time period requirement for conducting
74	an administrative hearing in cases of fraud and abuse
75	within Medicaid; amending s. 409.919, F.S.; providing
76	rulemaking authority for the agency to create interagency
77	agreements; amending s. 411.01, F.S.; requiring the
78	Florida Partnership for School Readiness to submit a
79	report to the agency; deleting a reporting requirement to
80	the Florida Healthy Kids Corporation; amending s.
81	465.0255, F.S.; requiring the display of the expiration
82	date of prescribed drugs; providing an effective date.
83
84	Be It Enacted by the Legislature of the State of Florida:
85
86	Section 1. Subsection (7) of section 120.80, Florida
87	Statutes, is amended to read:
88	120.80 Exceptions and special requirements; agencies.--
89	(7) DEPARTMENT OF CHILDREN AND FAMILY SERVICES AND THE
90	AGENCY FOR HEALTH CARE ADMINISTRATION.--Notwithstanding s.
91	120.57(1)(a), hearings conducted within the Department of
92	Children and Family Services and the Agency for Health Care
93	Administrationin the execution of those social and economic
94	programs administered by the former Division of Family Services
95	of the former Department of Health and Rehabilitative Services
96	prior to the reorganization effected by chapter 75-48, Laws of
97	Florida, need not be conducted by an administrative law judge
98	assigned by the division.
99	Section 2. Paragraph (e) of subsection (2) of section
100	154.503, Florida Statutes, is amended to read:
101	154.503 Primary Care for Children and Families Challenge
102	Grant Program; creation; administration.--
103	(2) The department shall:
104	(e) Coordinate with the primary care program developed
105	pursuant to s. 154.011, the Florida Healthy Kids Corporation
106	program administered by the Agency for Health Care
107	Administration created in s. 624.91, the school health services
108	program created in ss. 381.0056 and 381.0057, the Healthy
109	Communities, Healthy People Program created in s. 381.734, and
110	the volunteer health care provider program developed pursuant to
111	s. 766.1115.
112	Section 3. Subsection (3) of section 381.90, Florida
113	Statutes, is amended to read:
114	381.90 Health Information Systems Council; legislative
115	intent; creation, appointment, duties.--
116	(3) The council shall be composed of the following members
117	or their senior executive-level designees:
118	(a) The secretary of the Department of Health;
119	(b) The secretary of the Department of Business and
120	Professional Regulation;
121	(c) The secretary of the Department of Children and Family
122	Services;
123	(d) The Secretary of Health Care Administration;
124	(e) The secretary of the Department of Corrections;
125	(f) The Attorney General;
126	(g) The executive director of the Correctional Medical
127	Authority;
128	(h) Two members representing county health departments,
129	one from a small county and one from a large county, appointed
130	by the Governor;
131	(i) A representative from the Florida Association of
132	Counties;
133	(j) The State Treasurer and Insurance Commissioner;
134	(k) A representative from the Florida Healthy Kids
135	Corporation;
136	(k)(l)A representative from a school of public health
137	chosen by the Board of Regents;
138	(l)(m)The Commissioner of Education;
139	(m)(n)The secretary of the Department of Elderly Affairs;
140	and
141	(n)(o)The secretary of the Department of Juvenile
142	Justice.
143
144	Representatives of the Federal Government may serve without
145	voting rights.
146	Section 4. Subsections (8), (15), and (16) of section
147	400.0255, Florida Statutes, are amended to read:
148	400.0255 Resident transfer or discharge; requirements and
149	procedures; hearings.--
150	(8) The notice required by subsection (7) must be in
151	writing and must contain all information required by state and
152	federal law, rules, or regulations applicable to Medicaid or
153	Medicare cases. The agency shall develop a standard document to
154	be used by all facilities licensed under this part for purposes
155	of notifying residents of a discharge or transfer. Such document
156	must include a means for a resident to request the local long-
157	term care ombudsman council to review the notice and request
158	information about or assistance with initiating a fair hearing
159	with the agency’sdepartment's Office of FairAppealsHearings.
160	In addition to any other pertinent information included, the
161	form shall specify the reason allowed under federal or state law
162	that the resident is being discharged or transferred, with an
163	explanation to support this action. Further, the form shall
164	state the effective date of the discharge or transfer and the
165	location to which the resident is being discharged or
166	transferred. The form shall clearly describe the resident's
167	appeal rights and the procedures for filing an appeal, including
168	the right to request the local ombudsman council to review the
169	notice of discharge or transfer. A copy of the notice must be
170	placed in the resident's clinical record, and a copy must be
171	transmitted to the resident's legal guardian or representative
172	and to the local ombudsman council within 5 business days after
173	signature by the resident or resident designee.
174	(15)(a) The agency’sdepartment's Office of FairAppeals
175	Hearings shall conduct hearings under this section. The office
176	shall notify the facility of a resident's request for a hearing.
177	(b) The agencydepartmentshall, by rule, establish
178	procedures to be used for fair hearings requested by residents.
179	These procedures shall be equivalent to the procedures used for
180	fair hearings for other Medicaid cases, chapter 10-2, part VI,
181	Florida Administrative Code. The burden of proof must be clear
182	and convincing evidence. A hearing decision must be rendered
183	within 90 days after receipt of the request for hearing.
184	(c) If the hearing decision is favorable to the resident
185	who has been transferred or discharged, the resident must be
186	readmitted to the facility's first available bed.
187	(d) The decision of the hearing officer shall be final.
188	Any aggrieved party may appeal the decision to the district
189	court of appeal in the appellate district where the facility is
190	located. Review procedures shall be conducted in accordance with
191	the Florida Rules of Appellate Procedure.
192	(16) The agencydepartmentmay adopt rules necessary to
193	administer this section.
194	Section 5. Paragraph (c) of subsection (5) of section
195	400.179, Florida Statutes, is amended to read:
196	400.179 Sale or transfer of ownership of a nursing
197	facility; liability for Medicaid underpayments and
198	overpayments.--
199	(5) Because any transfer of a nursing facility may expose
200	the fact that Medicaid may have underpaid or overpaid the
201	transferor, and because in most instances, any such underpayment
202	or overpayment can only be determined following a formal field
203	audit, the liabilities for any such underpayments or
204	overpayments shall be as follows:
205	(c) If a Medicaid overpayment determination is deemed by
206	the agency to be unrecoverable from a transfer or other source,
207	where athe facility transfer takes any form of a sale or
208	transfer of assets, in addition to the transferor's continuing
209	liability for any such overpayments, if the transferor fails to
210	meet these obligations, the transferee shall be held accountable
211	for any outstanding liability to the state, regardless of when
212	identified, resulting from changes to allowable costs affecting
213	provider reimbursement for Medicaid participation; Medicaid
214	program integrity overpayment determinations; compliance
215	violations, administrative sanctions, and fines. The transferee
216	shall pay or make arrangements to pay to the agency any amount
217	owed to the agency. Payment assurances may be in the form of an
218	irrevocable credit instrument or payment bond acceptable to the
219	agency or the department provided by or on behalf of the
220	transferor. The issuance of a license to the transferee shall be
221	delayed pending payment or until arrangement for payment
222	acceptable to the agency or the department is madeliable for
223	all liabilities that can be readily identifiable 90 days in
224	advance of the transfer. Such liability shall continue in
225	succession until the debt is ultimately paid or otherwise
226	resolved. It shall be the burden of the transferee to determine
227	the amount of all such readily identifiable overpayments from
228	the Agency for Health Care Administration, and the agency shall
229	cooperate in every way with the identification of such amounts.
230	Readily identifiable overpayments shall include overpayments
231	that will result from, but not be limited to:
232	1. Medicaid rate changes or adjustments;
233	2. Any depreciation recapture;
234	3. Any recapture of fair rental value system indexing; or
235	4. Audits completed by the agency.
236
237	The transferor shall remain liable for any such Medicaid
238	overpayments that were not readily identifiable 90 days in
239	advance of the nursing facility transfer.
240	Section 6. Subsection (13) is added to section 408.15,
241	Florida Statutes, to read:
242	408.15 Powers of the agency.--In addition to the powers
243	granted to the agency elsewhere in this chapter, the agency is
244	authorized to:
245	(13) Establish and conduct those Medicaid fair hearings
246	that are unrelated to eligibility determinations, in accordance
247	with 42 C.F.R. s. 431.200 and other applicable federal and state
248	laws.
249	Section 7. Subsections (17) through (27) of section
250	409.811, Florida Statutes, are renumbered as subsections (18)
251	through (28), respectively, and a new subsection (17) is added
252	to said section, to read:
253	409.811 Definitions relating to Florida Kidcare Act.--As
254	used in ss. 409.810-409.820, the term:
255	(17) “Managed care plan” means a health maintenance
256	organization authorized pursuant to chapter 641 or a prepaid
257	health plan authorized pursuant to s. 409.912.
258	Section 8. Subsection (3) of section 409.813, Florida
259	Statutes, is amended to read:
260	409.813 Program components; entitlement and
261	nonentitlement.--The Florida Kidcare program includes health
262	benefits coverage provided to children through:
263	(3) The Florida Healthy Kids programCorporationas
264	created in s. 624.91;
265
266	Except for coverage under the Medicaid program, coverage under
267	the Florida Kidcare program is not an entitlement. No cause of
268	action shall arise against the state, the department, the
269	Department of Children and Family Services, or the agency for
270	failure to make health services available to any person under
271	ss. 409.810-409.820.
272	Section 9. Subsection (7) of section 409.8132, Florida
273	Statutes, is amended to read:
274	409.8132 Medikids program component.--
275	(7) ENROLLMENT.--Enrollment in the Medikids program
276	component may only occur during periodic open enrollment periods
277	as specified by the agency. An applicant may apply for
278	enrollment in the Medikids program component and proceed through
279	the eligibility determination process at any time throughout the
280	year. However, enrollment in Medikids shall not begin until the
281	next open enrollment period; and a child may not receive
282	services under the Medikids program until the child is enrolled
283	in a managed care plan as defined in s. 409.811 or inMediPass.
284	In addition, once determined eligible, an applicant may receive
285	choice counseling and select a managed care plan or MediPass.
286	The agency may initiate mandatory assignment for a Medikids
287	applicant who has not chosen a managed care plan or MediPass
288	provider after the applicant's voluntary choice period ends. An
289	applicant may select MediPass under the Medikids program
290	component only in counties that have fewer than two managed care
291	plans available to serve Medicaid recipients and only if the
292	federal Health Care Financing Administration determines that
293	MediPass constitutes "health insurance coverage" as defined in
294	Title XXI of the Social Security Act.
295	Section 10. Section 409.814, Florida Statutes, is amended
296	to read:
297	409.814 Eligibility.--A child whose family income is equal
298	to or below 200 percent of the federal poverty level is eligible
299	for the Florida Kidcare program as provided in this section. In
300	determining the eligibility of such a child, an assets test is
301	not required. An applicant under 19 years of age who, based on a
302	complete application, appears to be eligible for the Medicaid
303	component of the Florida Kidcare program is presumed eligible
304	for coverage under Medicaid, subject to federal rules. A child
305	who has been deemed presumptively eligible for Medicaid shall
306	not be enrolled in a managed care plan until the child's full
307	eligibility determination for Medicaid has been completed. The
308	Florida Healthy Kids Corporation ismay, subject to compliance
309	with applicable requirements of the Agency for Health Care
310	Administration and the Department of Children and Family
311	Services, bedesignated as an entity to conduct presumptive
312	eligibility determinations. An applicant under 19 years of age
313	who, based on a complete application, appears to be eligible for
314	the Medikids, Florida Healthy Kids, or Children's Medical
315	Services network program component, who is screened as
316	ineligible for Medicaid and prior to the monthly verification of
317	the applicant's enrollment in Medicaid or of eligibility for
318	coverage under the state employee health benefit plan, may be
319	enrolled in and begin receiving coverage from the appropriate
320	program component on the first day of the month following the
321	receipt of a completed application. For enrollment in the
322	Children's Medical Services network, a complete application
323	includes the medical or behavioral health screening. If, after
324	verification, an individual is determined to be ineligible for
325	coverage, he or she must be disenrolled from the respective
326	Title XXI-funded Kidcare program component.
327	(1) A child who is eligible for Medicaid coverage under s.
328	409.903 or s. 409.904 must be enrolled in Medicaid and is not
329	eligible to receive health benefits under any other health
330	benefits coverage authorized under ss. 409.810-409.820.
331	(2) A child who is not eligible for Medicaid, but who is
332	eligible for the Florida Kidcare program, may obtain coverage
333	under any of the other types of health benefits coverage
334	authorized in ss. 409.810-409.820 if such coverage is approved
335	and available in the county in which the child resides. However,
336	a child who is eligible for Medikids may participate in the
337	Florida Healthy Kids program only if the child has a sibling
338	participating in the Florida Healthy Kids program and the
339	child's county of residence permits such enrollment.
340	(3) A child who is eligible for the Florida Kidcare
341	program who is a child with special health care needs, as
342	determined through a medical or behavioral screening instrument,
343	is eligible for health benefits coverage from and shall be
344	referred to the Children's Medical Services network.
345	(4) The following children are not eligible to receive
346	premium assistance for health benefits coverage under ss.
347	409.810-409.820, except under Medicaid if the child would have
348	been eligible for Medicaid under s. 409.903 or s. 409.904 as of
349	June 1, 1997:
350	(a) A child who is eligible for coverage under a state
351	health benefit plan on the basis of a family member's employment
352	with a public agency in the state.
353	(b) A child who is covered under a group health benefit
354	plan or under other health insurance coverage, excluding
355	coverage provided under the Florida Healthy Kids Corporation as
356	established under s. 624.91.
357	(c) A child who is seeking premium assistance for
358	employer-sponsored group coverage, if the child has been covered
359	by the same employer's group coverage during the 6 months prior
360	to the family's submitting an application for determination of
361	eligibility under the Florida Kidcare program.
362	(d) A child who is an alien, but who does not meet the
363	definition of qualified alien, in the United States.
364	(e) A child who is an inmate of a public institution or a
365	patient in an institution for mental diseases.
366	(5) A child whose family income is above 200 percent of
367	the federal poverty level or a child who is excluded under the
368	provisions of subsection (4) may participate in the Florida
369	Kidcare program, excluding the Medicaid program, but is subject
370	to the following provisions:
371	(a) The family is not eligible for premium assistance
372	payments and must pay the full cost of the premium, including
373	any administrative costs.
374	(b) The agency is authorized to place limits on enrollment
375	in Medikids by these children in order to avoid adverse
376	selection. The number of children participating in Medikids
377	whose family income exceeds 200 percent of the federal poverty
378	level must not exceed 10 percent of total enrollees in the
379	Medikids program.
380	(c) The agencyboard of directors of the Florida Healthy
381	Kids Corporation is authorized to place limits on enrollment of
382	these children in the Florida Healthy Kids program inorder to
383	avoid adverse selection. In addition, the board is authorized to
384	offer a reduced benefit package to these children in order to
385	limit program costs for such families. The number of children
386	participating in the Florida Healthy Kids program whose family
387	income exceeds 200 percent of the federal poverty level must not
388	exceed 10 percent of total enrollees in the Florida Healthy Kids
389	program.
390	(d) Children described in this subsection are not counted
391	in the annual enrollment ceiling for the Florida Kidcare
392	program.
393	(6) Once a child is enrolled in the Florida Kidcare
394	program, the child is eligible for coverage under the program
395	for 6 months without a redetermination or reverification of
396	eligibility, if the family continues to pay the applicable
397	premium. Effective January 1, 1999, a child who has not attained
398	the age of 5 and who has been determined eligible for the
399	Medicaid program is eligible for coverage for 12 months without
400	a redetermination or reverification of eligibility.
401	(7) When determining or reviewing a child's eligibility
402	under the program, the applicant shall be provided with
403	reasonable notice of changes in eligibility which may affect
404	enrollment in one or more of the program components. When a
405	transition from one program component to another is appropriate,
406	there shall be cooperation between the program components and
407	the affected family which promotes continuity of health care
408	coverage.
409	Section 11. Subsection (3) of section 409.816, Florida
410	Statutes, is amended to read:
411	409.816 Limitations on premiums and cost-sharing.--The
412	following limitations on premiums and cost-sharing are
413	established for the program.
414	(3) Enrollees in families with a family income above 150
415	percent of the federal poverty level, who are not receiving
416	coverage under the Medicaid program or who are not eligible
417	under s. 409.814(5), may be required to pay enrollment fees;,
418	premiums that shall include $15 for one child, $30 for two
419	children, and $45 for three or more children;, copayments;,
420	deductibles;, coinsurance;,or similar charges on a sliding
421	scale related to income, except that the total annual aggregate
422	cost-sharing with respect to all children in a family may not
423	exceed 5 percent of the family's income. However, copayments,
424	deductibles, coinsurance, or similar charges may not be imposed
425	for preventive services, including well-baby and well-child
426	care, age-appropriate immunizations, and routine hearing and
427	vision screenings.
428	Section 12. Paragraph (b) of subsection (1), paragraphs
429	(a) and (d) of subsection (2), paragraph (a) of subsection (3),
430	and subsections (4) and (6) of section 409.818, Florida
431	Statutes, are amended to read:
432	409.818 Administration.--In order to implement ss.
433	409.810-409.820, the following agencies shall have the following
434	duties:
435	(1) The Department of Children and Family Services shall:
436	(b) Establish and maintain the eligibility determination
437	process under the program except as specified in subsection (5).
438	The department shall directly, or through the services of a
439	contracted third-party administrator, establish and maintain a
440	process for determining eligibility of children for coverage
441	under the program. The eligibility determination process must be
442	used solely for determining eligibility of applicants for health
443	benefits coverage under the program. The eligibility
444	determination process must include an initial determination of
445	eligibility for any coverage offered under the program, as well
446	as a redetermination or reverification of eligibility each
447	subsequent 6 months. Effective January 1, 1999, a child who has
448	not attained the age of 5 and who has been determined eligible
449	for the Medicaid program is eligible for coverage for 12 months
450	without a redetermination or reverification of eligibility. In
451	conducting an eligibility determination, the department shall
452	determine if the child has special health care needs. The
453	department, in consultation with the Agency for Health Care
454	Administration and the Florida Healthy Kids Corporation, shall
455	develop procedures for redetermining eligibility which enable a
456	family to easily update any change in circumstances which could
457	affect eligibility. The department may accept changes in a
458	family's status as reported to the department by the Florida
459	Healthy Kids Corporation without requiring a new application
460	from the family. Redetermination of a child's eligibility for
461	Medicaid may not be linked to a child's eligibility
462	determination for other programs.
463	(2) The Department of Health shall:
464	(a) Design an eligibility intake process for the program,
465	in coordination with the Department of Children and Family
466	Services and, the agency, and the Florida Healthy Kids
467	Corporation. The eligibility intake process may include local
468	intake points that are determined by the Department of Health in
469	coordination with the Department of Children and Family
470	Services.
471	(d) In consultation with the agencyFlorida Healthy Kids
472	Corporationand the Department of Children and Family Services,
473	establishing a toll-free telephone line to assist families with
474	questions about the program.
475	(3) The Agency for Health Care Administration, under the
476	authority granted in s. 409.914(1), shall:
477	(a) Calculate the premium assistance payment necessary to
478	comply with the premium and cost-sharing limitations specified
479	in s. 409.816. The premium assistance payment for each enrollee
480	in a health insurance plan participating in the Florida Healthy
481	Kids programCorporation shall equal the premium approved by the
482	agencyFlorida Healthy Kids Corporationand the Department of
483	Insurance pursuant to ss. 627.410 and 641.31, less any
484	enrollee's share of the premium established within the
485	limitations specified in s. 409.816. The premium assistance
486	payment for each enrollee in an employer-sponsored health
487	insurance plan approved under ss. 409.810-409.820 shall equal
488	the premium for the plan adjusted for any benchmark benefit plan
489	actuarial equivalent benefit rider approved by the Department of
490	Insurance pursuant to ss. 627.410 and 641.31, less any
491	enrollee's share of the premium established within the
492	limitations specified in s. 409.816. In calculating the premium
493	assistance payment levels for children with family coverage, the
494	agency shall set the premium assistance payment levels for each
495	child proportionately to the total cost of family coverage.
496
497	The agency is designated the lead state agency for Title XXI of
498	the Social Security Act for purposes of receipt of federal
499	funds, for reporting purposes, and for ensuring compliance with
500	federal and state regulations and rules.
501	(4) The Department of Insurance shall certify that health
502	benefits coverage plans that seek to provide services under the
503	Florida Kidcare program, except those offered through the
504	Florida Healthy Kids programCorporationor the Children's
505	Medical Services network, meet, exceed, or are actuarially
506	equivalent to the benchmark benefit plan and that health
507	insurance plans will be offered at an approved rate. In
508	determining actuarial equivalence of benefits coverage, the
509	Department of Insurance and health insurance plans must comply
510	with the requirements of s. 2103 of Title XXI of the Social
511	Security Act. The department shall adopt rules necessary for
512	certifying health benefits coverage plans.
513	(6) The agency, the Department of Health, the Department
514	of Children and Family Services, the Florida Healthy Kids
515	Corporation,and the Department of Insurance, after consultation
516	with and approval of the Speaker of the House of Representatives
517	and the President of the Senate, are authorized to make program
518	modifications that are necessary to overcome any objections of
519	the United States Department of Health and Human Services to
520	obtain approval of the state's child health insurance plan under
521	Title XXI of the Social Security Act.
522	Section 13. Section 409.820, Florida Statutes, is amended
523	to read:
524	409.820 Providerquality assurance and access standards.--
525	(1) The Deputy Secretary for Children’s Medical Services
526	of Except for Medicaid, the Department of Health, in
527	coordinationconsultation with the agency and the Florida
528	Healthy Kids Corporation, shall develop a minimum set of
529	providerquality assurance and access standards for all program
530	components. Provider standards shall apply to primary and
531	specialty care providers as well as facilities.The standards
532	must include a process for granting exceptions, to be approved
533	by the Deputy Secretary for Children’s Medical Services,to
534	specific requirements for quality assurance and access.
535	Compliance with the standards shall be a condition of program
536	participation by health benefits coverage providers. These
537	standards shall comply with the provisions of this chapter and
538	chapter 641 and Title XXI of the Social Security Act.
539	(2) The agency shall contract only with those managed care
540	plans and providers meeting the standards developed pursuant to
541	this section. The agency shall work with the Department of
542	Health to develop and implement quality assurance monitoring of
543	plans and providers with regard to such standards, including
544	peer review, review of capacity, and credentialing of providers.
545	Section 14. Subsection (2) of section 409.904, Florida
546	Statutes, is amended to read:
547	409.904 Optional payments for eligible persons.--The
548	agency may make payments for medical assistance and related
549	services on behalf of the following persons who are determined
550	to be eligible subject to the income, assets, and categorical
551	eligibility tests set forth in federal and state law. Payment on
552	behalf of these Medicaid eligible persons is subject to the
553	availability of moneys and any limitations established by the
554	General Appropriations Act or chapter 216.
555	(2) A caretaker relative or parent, a pregnant woman, a
556	child under age 19 who would otherwise qualify for Florida
557	Kidcare Medicaid or,a child up to age 21 who would otherwise
558	qualify under s. 409.903(1), a person age 65 or over, or a blind
559	or disabled person, who would otherwise be eligible for Florida
560	Medicaid, except that the income or assets of such family or
561	person exceed established limitations. For a family or person in
562	one of these coverage groups, medical expenses are deductible
563	from income in accordance with federal requirements in order to
564	make a determination of eligibility. Expenses used to meet
565	spend-down liability are not reimbursable by Medicaid. Effective
566	JulyMay 1, 2003, when determining the eligibility of ana
567	pregnant woman, a child, or an aged, blind, or disabled
568	individual, $270 shall be deducted from the countable income of
569	the filing unit. When determining the eligibility of the parent
570	or caretaker relative as defined by Title XIX of the Social
571	Security Act, the additional income disregard of $270 does not
572	apply.A family or person eligible under the coverage known as
573	the "medically needy," is eligible to receive the same services
574	as other Medicaid recipients, with the exception of services in
575	skilled nursing facilities and intermediate care facilities for
576	the developmentally disabled.
577	Section 15. Paragraph (a) of subsection (5) of section
578	409.905, Florida Statutes, is amended to read:
579	409.905 Mandatory Medicaid services.--The agency may make
580	payments for the following services, which are required of the
581	state by Title XIX of the Social Security Act, furnished by
582	Medicaid providers to recipients who are determined to be
583	eligible on the dates on which the services were provided. Any
584	service under this section shall be provided only when medically
585	necessary and in accordance with state and federal law.
586	Mandatory services rendered by providers in mobile units to
587	Medicaid recipients may be restricted by the agency. Nothing in
588	this section shall be construed to prevent or limit the agency
589	from adjusting fees, reimbursement rates, lengths of stay,
590	number of visits, number of services, or any other adjustments
591	necessary to comply with the availability of moneys and any
592	limitations or directions provided for in the General
593	Appropriations Act or chapter 216.
594	(5) HOSPITAL INPATIENT SERVICES.--The agency shall pay for
595	all covered services provided for the medical care and treatment
596	of a recipient who is admitted as an inpatient by a licensed
597	physician or dentist to a hospital licensed under part I of
598	chapter 395. However, the agency shall limit the payment for
599	inpatient hospital services for a Medicaid recipient 21 years of
600	age or older to 45 days or the number of days necessary to
601	comply with the General Appropriations Act.
602	(a) The agency is authorized to implement reimbursement
603	and utilization management reforms in order to comply with any
604	limitations or directions in the General Appropriations Act,
605	which may include, but are not limited to: prior authorization
606	for inpatient psychiatric days; prior authorization for
607	nonemergency hospital inpatient admissions for individuals 21
608	years of age and older; authorization of emergency and urgent-
609	care admissions within 24 hours after admission; enhanced
610	utilization and concurrent review programs for highly utilized
611	services; reduction or elimination of covered days of service;
612	adjusting reimbursement ceilings for variable costs; adjusting
613	reimbursement ceilings for fixed and property costs; and
614	implementing target rates of increase. The agency may limit
615	prior authorization for hospital inpatient services to selected
616	diagnosis-related groups, based on an analysis of the cost and
617	potential for unnecessary hospitalizations represented by
618	certain diagnoses. Admissions for normal delivery and newborns
619	are exempt from requirements for prior authorization. In
620	implementing the provisions of this section related to prior
621	authorization, the agency shall ensure that the process for
622	authorization is accessible 24 hours per day, 7 days per week
623	and authorization is automatically granted when not denied
624	within 244hours after the request. Authorization procedures
625	must include steps for review of denials. Upon implementing the
626	prior authorization program for hospital inpatient services, the
627	agency shall discontinue its hospital retrospective review
628	program.
629	Section 16. Subsections (1), (12), and (23) of section
630	409.906, Florida Statutes, are amended to read:
631	409.906 Optional Medicaid services.--Subject to specific
632	appropriations, the agency may make payments for services which
633	are optional to the state under Title XIX of the Social Security
634	Act and are furnished by Medicaid providers to recipients who
635	are determined to be eligible on the dates on which the services
636	were provided. Any optional service that is provided shall be
637	provided only when medically necessary and in accordance with
638	state and federal law. Optional services rendered by providers
639	in mobile units to Medicaid recipients may be restricted or
640	prohibited by the agency. Nothing in this section shall be
641	construed to prevent or limit the agency from adjusting fees,
642	reimbursement rates, lengths of stay, number of visits, or
643	number of services, or making any other adjustments necessary to
644	comply with the availability of moneys and any limitations or
645	directions provided for in the General Appropriations Act or
646	chapter 216. If necessary to safeguard the state's systems of
647	providing services to elderly and disabled persons and subject
648	to the notice and review provisions of s. 216.177, the Governor
649	may direct the Agency for Health Care Administration to amend
650	the Medicaid state plan to delete the optional Medicaid service
651	known as "Intermediate Care Facilities for the Developmentally
652	Disabled." Optional services may include:
653	(1) ADULT DENTAL SERVICES.--The agency may pay for
654	denturesmedically necessary, theemergency dental procedures
655	required to seat dentures, and the repair and relining of
656	dentures, provided by or under the direction of a licensed
657	dentistalleviate pain or infection. Emergency dental care shall
658	be limited to emergency oral examinations, necessary
659	radiographs, extractions, and incision and drainage of abscess,
660	for a recipient who is age 6521or older. However, Medicaid
661	will not provide reimbursement for dental services provided in a
662	mobile dental unit, except for a mobile dental unit:
663	(a) Owned by, operated by, or having a contractual
664	agreement with the Department of Health and complying with
665	Medicaid's county health department clinic services program
666	specifications as a county health department clinic services
667	provider.
668	(b) Owned by, operated by, or having a contractual
669	arrangement with a federally qualified health center and
670	complying with Medicaid's federally qualified health center
671	specifications as a federally qualified health center provider.
672	(c) Rendering dental services to Medicaid recipients, 21
673	years of age and older, at nursing facilities.
674	(d) Owned by, operated by, or having a contractual
675	agreement with a state-approved dental educational institution.
676	(12) CHILDREN’SHEARING SERVICES.--The agency may pay for
677	hearing and related services, including hearing evaluations,
678	hearing aid devices, dispensing of the hearing aid, and related
679	repairs, if provided to a recipient younger than 21 years of age
680	by a licensed hearing aid specialist, otolaryngologist,
681	otologist, audiologist, or physician.
682	(23) CHILDREN’SVISUAL SERVICES.--The agency may pay for
683	visual examinations, eyeglasses, and eyeglass repairs for a
684	recipient younger than 21 years of age, if they are prescribed
685	by a licensed physician specializing in diseases of the eye or
686	by a licensed optometrist.
687	Section 17. Paragraphs (c) and (d) are added to subsection
688	(1) of section 409.9081, Florida Statutes, to read:
689	409.9081 Copayments.--
690	(1) The agency shall require, subject to federal
691	regulations and limitations, each Medicaid recipient to pay at
692	the time of service a nominal copayment for the following
693	Medicaid services:
694	(c) Prescribed drug services: a $2 copayment for each
695	generic drug, $5 for each Medicaid preferred drug list product,
696	and $15 for each non-Medicaid preferred drug list brand name
697	drug.
698	(d) Hospital outpatient services, emergency department: up
699	to $15 for each hospital outpatient emergency department
700	encounter that is for nonemergency purposes.
701	Section 18. Paragraph (h) of subsection (2) of section
702	409.9117, Florida Statutes, is amended to read:
703	409.9117 Primary care disproportionate share program.--
704	(2) In the establishment and funding of this program, the
705	agency shall use the following criteria in addition to those
706	specified in s. 409.911, payments may not be made to a hospital
707	unless the hospital agrees to:
708	(h) Work with the Florida Healthy Kids Corporation,the
709	Florida Health Care Purchasing Cooperative,and business health
710	coalitions, as appropriate, to develop a feasibility study and
711	plan to provide a low-cost comprehensive health insurance plan
712	to persons who reside within the area and who do not have access
713	to such a plan.
714
715	Any hospital that fails to comply with any of the provisions of
716	this subsection, or any other contractual condition, may not
717	receive payments under this section until full compliance is
718	achieved.
719	Section 19. Section 409.91188, Florida Statutes, is
720	amended to read:
721	409.91188 Specialty prepaid health plans for Medicaid
722	recipients with HIV or AIDS.—
723	(1) The Agency for Health Care Administration shall issue
724	a request for proposal or intent to implement ais authorized to
725	contract with specialty prepaid health plans authorized pursuant
726	to subsection (2)and pay them on a prepaid capitated basis to
727	provide Medicaid benefits to Medicaid-eligible recipients who
728	have human immunodeficiency syndrome (HIV) or acquired
729	immunodeficiency syndrome (AIDS). The agency shall apply for or
730	amend existing applications for and is authorized toimplement
731	federal waivers or other necessary federal authorization to
732	implement the prepaid health plans authorized by this section.
733	The agency shall procure the specialty prepaid health plans
734	through a competitive procurement. In awarding a contract to a
735	managed care plan, the agency shall take into account price,
736	quality, accessibility, linkages to community-based
737	organizations, experience in operating and administering
738	specialty prepaid capitated health plans for AIDS and HIV
739	populations,and the comprehensiveness of the benefit package
740	offered by the plan. The agency may bid the HIV/AIDS specialty
741	plans on a county, regional, or statewide basis. Qualified plans
742	must be licensed under chapter 641.The agency shall monitor and
743	evaluate the implementation of this waiver program if it is
744	approved by the Federal Government and shall report on its
745	status to the President of the Senate and the Speaker of the
746	House of Representatives by February 1, 20042001. To improve
747	coordination of medical care delivery and to increase cost
748	efficiency for the Medicaid program in treating HIV disease, the
749	Agency for Health Care Administration shall seek all necessary
750	federal waivers to allow participation in the Medipass HIV
751	disease management program for Medicare beneficiaries who test
752	positive for HIV infection and who also qualify for Medicaid
753	benefits such as prescription medications not covered by
754	Medicare.
755	(2) The agency may contract with any public or private
756	entity authorized by this section, on a prepaid or fixed-sum
757	basis, for the provision of health care services to recipients.
758	An entity may provide prepaid services to recipients, either
759	directly or through arrangements with other entities. Each
760	entity shall:
761	(a) Be organized primarily for the purpose of providing
762	health care or other services of the type regularly offered to
763	Medicaid recipients in compliance with federal laws.
764	(b) Ensure that services meet the standards set by the
765	agency for quality, appropriateness, and timeliness.
766	(c) Make provisions satisfactory to the agency for
767	insolvency protection and ensure that neither enrolled Medicaid
768	recipients nor the agency is liable for the debts of the entity.
769	(d) Provide to the agency a financial plan which ensures
770	fiscal soundness and which may include provisions pursuant to
771	which the entity and the agency share in the risk of providing
772	health care services. The contractual arrangement between an
773	entity and the agency shall provide for risk sharing, in which
774	the entity assumes 75 percent or more of risk and the agency
775	assumes the smaller percentage of risk. The agency may bear the
776	cost of providing services when those costs exceed established
777	risk limits or arrangements whereby services are specifically
778	excluded under the terms of the contract between an entity and
779	the agency.
780	(e) Provide, through contract or otherwise, for periodic
781	review of its medical facilities and services, as required by
782	the agency.
783	(f) Furnish evidence satisfactory to the agency of
784	adequate liability insurance coverage or an adequate plan of
785	self-insurance to respond to claims for injuries arising out of
786	furnishing health care.
787	(g) Provide organizational, operational, financial, and
788	other information required by the agency.
789	Section 20. Subsections (4) and (11) of section 409.91195,
790	Florida Statutes, are amended to read:
791	409.91195 Medicaid Pharmaceutical and Therapeutics
792	Committee.--There is created a Medicaid Pharmaceutical and
793	Therapeutics Committee within the Agency for Health Care
794	Administration for the purpose of developing a preferred drug
795	formulary pursuant to 42 U.S.C. s. 1396r-8.
796	(4) Upon recommendation of the Medicaid Pharmaceutical and
797	Therapeutics Committee, the agency shall adopt a preferred drug
798	list. To the extent feasible, the committee shall review the top
799	75 percent of all drug classes, based on utilization,included
800	in the formulary at least every 12 months, and all other
801	therapeutic classes biennially. The committeemay recommend
802	additions to and deletions from the formulary, such that the
803	formulary provides for medically appropriate drug therapies for
804	Medicaid patients which achieve cost savings contained in the
805	General Appropriations Act.
806	(11) Medicaid recipients may appeal agency preferred drug
807	formulary decisions using the Medicaid fair hearing process
808	administered by the agency’s Office of Fair HearingsDepartment
809	of Children and Family Services.
810	Section 21. Paragraphs (b), (d), and (g) of subsection (3)
811	and subsections (6), (20), and (27) of section 409.912, Florida
812	Statutes, are amended, and subsection (41) is added to said
813	section, to read:
814	409.912 Cost-effective purchasing of health care.--The
815	agency shall purchase goods and services for Medicaid recipients
816	in the most cost-effective manner consistent with the delivery
817	of quality medical care. The agency shall maximize the use of
818	prepaid per capita and prepaid aggregate fixed-sum basis
819	services when appropriate and other alternative service delivery
820	and reimbursement methodologies, including competitive bidding
821	pursuant to s. 287.057, designed to facilitate the cost-
822	effective purchase of a case-managed continuum of care. The
823	agency shall also require providers to minimize the exposure of
824	recipients to the need for acute inpatient, custodial, and other
825	institutional care and the inappropriate or unnecessary use of
826	high-cost services. The agency may establish prior authorization
827	requirements for certain populations of Medicaid beneficiaries,
828	certain drug classes, or particular drugs to prevent fraud,
829	abuse, overuse, and possible dangerous drug interactions. The
830	Pharmaceutical and Therapeutics Committee shall make
831	recommendations to the agency on drugs for which prior
832	authorization is required. The agency shall inform the
833	Pharmaceutical and Therapeutics Committee of its decisions
834	regarding drugs subject to prior authorization.
835	(3) The agency may contract with:
836	(b) An entity that is providing comprehensive behavioral
837	health care services to certain Medicaid recipients through a
838	capitated, prepaid arrangement pursuant to the federal waiver
839	provided for by s. 409.905(5). Such an entity must be licensed
840	under chapter 624, chapter 636, or chapter 641 and must possess
841	the clinical systems and operational competence to manage risk
842	and provide comprehensive behavioral health care to Medicaid
843	recipients. As used in this paragraph, the term "comprehensive
844	behavioral health care services" means covered mental health and
845	substance abuse treatment services that are available to
846	Medicaid recipients. The secretary of the Department of Children
847	and Family Services shall approve provisions of procurements
848	related to children in the department's care or custody prior to
849	enrolling such children in a prepaid behavioral health plan. Any
850	contract awarded under this paragraph must be competitively
851	procured. In developing the behavioral health care prepaid plan
852	procurement document, the agency shall ensure that the
853	procurement document requires the contractor to develop and
854	implement a plan to ensure compliance with s. 394.4574 related
855	to services provided to residents of licensed assisted living
856	facilities that hold a limited mental health license. The agency
857	must ensure that Medicaid recipients are offered a choice of
858	behavioral health care providers within the managed care plan.
859	The agency may seek and implement federal waivers to allow the
860	state to require certain Medicaid recipients to be assigned to a
861	single prepaid mental health plan for comprehensive behavioral
862	health care services with the provision that individuals will
863	have a choice of providers and the provider network meets the
864	agency’s specificationshave available the choice of at least
865	two managed care plans for their behavioral health care
866	services. To ensure unimpaired access to behavioral health care
867	services by Medicaid recipients, all contracts issued pursuant
868	to this paragraph shall require 80 percent of the capitation
869	paid to the managed care plan, including health maintenance
870	organizations, to be expended for the provision of behavioral
871	health care services. In the event the managed care plan expends
872	less than 80 percent of the capitation paid pursuant to this
873	paragraph for the provision of behavioral health care services,
874	the difference shall be returned to the agency. The agency shall
875	provide the managed care plan with a certification letter
876	indicating the amount of capitation paid during each calendar
877	year for the provision of behavioral health care services
878	pursuant to this section. The agency may reimburse for
879	substance-abuse-treatment services on a fee-for-service basis
880	until the agency finds that adequate funds are available for
881	capitated, prepaid arrangements.
882	1. The agency may contract for prepaid behavioral health
883	services anywhere in the state if the agency has determined, in
884	consultation with the Department of Children and Family
885	Services, that a geographic area is prepared for a prepaid,
886	capitated behavioral health system of care.By January 1, 2001,
887	the agency shall modify the contracts with the entities
888	providing comprehensive inpatient and outpatient mental health
889	care services to Medicaid recipients in Hillsborough, Highlands,
890	Hardee, Manatee, and Polk Counties, to include substance-abuse-
891	treatment services.
892	2. By December 31, 2001, the agency shall contract with
893	entities providing comprehensive behavioral health care services
894	to Medicaid recipients through capitated, prepaid arrangements
895	in Charlotte, Collier, DeSoto, Escambia, Glades, Hendry, Lee,
896	Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota, and Walton
897	Counties. The agency may contract with entities providing
898	comprehensive behavioral health care services to Medicaid
899	recipients through capitated, prepaid arrangements in Alachua
900	County. The agency may determine if Sarasota County shall be
901	included as a separate catchment area or included in any other
902	agency geographic area.
903	2.3.Children residing in a Department of Juvenile Justice
904	residential program approved as a Medicaid behavioral health
905	overlay services provider shall not be included in a behavioral
906	health care prepaid health plan pursuant to this paragraph.
907	3.4.In converting to a prepaid system of delivery, the
908	agency shall in its procurement document require an entity
909	providing comprehensive behavioral health care services to
910	prevent the displacement of indigent care patients by enrollees
911	in the Medicaid prepaid health plan providing behavioral health
912	care services from facilities receiving state funding to provide
913	indigent behavioral health care, to facilities licensed under
914	chapter 395 which do not receive state funding for indigent
915	behavioral health care, or reimburse the unsubsidized facility
916	for the cost of behavioral health care provided to the displaced
917	indigent care patient.
918	4.5.Traditional community mental health providers under
919	contract with the Department of Children and Family Services
920	pursuant to part IV of chapter 394 and inpatient mental health
921	providers licensed pursuant to chapter 395 must be offered an
922	opportunity to accept or decline a contract to participate in
923	any provider network for prepaid behavioral health services.
924	(d) A provider networkNo more than four provider service
925	networks for demonstration projects to test Medicaid direct
926	contracting. The demonstration projectsmay be reimbursed on a
927	fee-for-service or prepaid basis. A provider service network
928	which is reimbursed by the agency on a prepaid basis shall be
929	exempt from parts I and III of chapter 641, but must meet
930	appropriate financial reserve, quality assurance, and patient
931	rights requirements as established by the agency. The agency
932	shall award contracts on a competitive bid basis and shall
933	select bidders based upon price and quality of care. Medicaid
934	recipients assigned to a demonstration project shall be chosen
935	equally from those who would otherwise have been assigned to
936	prepaid plans and MediPass.The agency is authorized to seek
937	federal Medicaid waivers as necessary to implement the
938	provisions of this section. A demonstration project awarded
939	pursuant to this paragraph shall be for 4 years from the date of
940	implementation.
941	(g) Children's or adult’sprovider networks that provide
942	care coordination and care management for Medicaid-eligible
943	pediatricpatients, primary care, authorization of specialty
944	care, and other urgent and emergency care through organized
945	providers designed to service Medicaid eligibles under age 18
946	and pediatricemergency departments' diversion programs. The
947	networks shall provide after-hour operations, including evening
948	and weekend hours, to promote, when appropriate, the use of the
949	children's and adult’snetworks rather than hospital emergency
950	departments.
951	(6) The agency may contract on a prepaid or fixed-sum
952	basis with an exclusive provider organization to provide health
953	care services to Medicaid recipients provided that the exclusive
954	provider organization meets applicable managed care plan
955	requirements in this section, ss. 409.9122, 409.9123, 409.9128,
956	and 627.6472, and other applicable provisions of law. The
957	provisions of this section and ss. 409.9122, 409.9123, 409.9128,
958	and 641.31 shall prevail to the extent of any conflict with any
959	provision of s. 627.6472.
960	(20) The agency may impose a fine for a violation of this
961	section or the contract with the agency by a person or entity
962	that is under contract with the agency. With respect to any
963	nonwillful violation, such fine shall not exceed $5,000$2,500
964	per violation. In no event shall such fine exceed an aggregate
965	amount of $20,000$10,000for all nonwillful violations arising
966	out of the same action. With respect to any knowing and willful
967	violation of this section or the contract with the agency, the
968	agency may impose a fine upon the entity in an amount not to
969	exceed $40,000$20,000for each such violation. In no event
970	shall such fine exceed an aggregate amount of $200,000$100,000
971	for all knowing and willful violations arising out of the same
972	action.
973	(27) The agency shall perform enrollments and
974	disenrollments for Medicaid recipients who are eligible for
975	MediPass or managed care plans. Notwithstanding the prohibition
976	contained in paragraph (18)(f), managed care plans may perform
977	preenrollments of Medicaid recipients under the supervision of
978	the agency or its agents. For the purposes of this section,
979	"preenrollment" means the provision of marketing and educational
980	materials to a Medicaid recipient and assistance in completing
981	the application forms, but shall not include actual enrollment
982	into a managed care plan.An application for enrollment shall
983	not be deemed complete until the agency or its agent verifies
984	that the recipient made an informed, voluntary choice. The
985	agency, in cooperation with the Department of Children and
986	Family Services, may test new marketing initiatives to inform
987	Medicaid recipients about their managed care options at selected
988	sites. The agency shall report to the Legislature on the
989	effectiveness of such initiatives. The agency may contract with
990	a third party to perform managed care plan and MediPass
991	enrollment and disenrollment services for Medicaid recipients
992	and is authorized to adopt rules to implement such services. The
993	agency may adjust the capitation rate only to cover the costs of
994	a third-party enrollment and disenrollment contract, and for
995	agency supervision and management of the managed care plan
996	enrollment and disenrollment contract.
997	(41) The agency may contract, on a prepaid or fixed-sum
998	basis, with an appropriately licensed prepaid dental health plan
999	to provide Medicaid covered dental services to child or adult
1000	Medicaid recipients.
1001	Section 22. Paragraphs (f) and (k) of subsection (2) of
1002	section 409.9122, Florida Statutes, are amended to read:
1003	409.9122 Mandatory Medicaid managed care enrollment;
1004	programs and procedures.--
1005	(2)
1006	(f) When a Medicaid recipient does not choose a managed
1007	care plan or MediPass provider, the agency shall assign the
1008	Medicaid recipient to a managed care plan or MediPass provider.
1009	Medicaid recipients who are subject to mandatory assignment but
1010	who fail to make a choice shall be assigned to managed care
1011	plans until an enrollment of 45 percent in MediPass and 55
1012	percent in managed care plans is achieved. Once this enrollment
1013	is achieved, the assignments shall be divided in order to
1014	maintain an enrollment in MediPass and managed care plans which
1015	is in a 45 percent and 55 percent proportion, respectively.
1016	Thereafter, assignment of Medicaid recipients who fail to make a
1017	choice shall be based proportionally on the preferences of
1018	recipients who have made a choice in the previous period. Such
1019	proportions shall be revised at least quarterly to reflect an
1020	update of the preferences of Medicaid recipients. The agency
1021	shall disproportionately assign Medicaid-eligible recipients who
1022	are required to but have failed to make a choice of managed care
1023	plan or MediPass, including children, and who are to be assigned
1024	to the MediPass program to children's networks as described in
1025	s. 409.912(3)(g), Children's Medical Services network as defined
1026	in s. 391.021, exclusive provider organizations, provider
1027	service networks, minority physician networks, and pediatric
1028	emergency department diversion programs authorized by this
1029	chapter or the General Appropriations Act, in such manner as the
1030	agency deems appropriate, until the agency has determined that
1031	the networks and programs have sufficient numbers to be
1032	economically operated.For purposes of this paragraph, when
1033	referring to assignment, the term "managed care plans" includes
1034	health maintenance organizations, exclusive provider
1035	organizations, provider service networks, minority physician
1036	networks, Children's Medical Services network, and pediatric
1037	emergency department diversion programs authorized by this
1038	chapter or the General Appropriations Act. Beginning July 1,
1039	2002, the agency shall assign all children in families who have
1040	not made a choice of a managed care plan or MediPass in the
1041	required timeframe to a pediatric emergency room diversion
1042	program described in s. 409.912(3)(g) that, as of July 1, 2002,
1043	has executed a contract with the agency, until such network or
1044	program has reached an enrollment of 15,000 children. Once that
1045	minimum enrollment level has been reached, the agency shall
1046	assign children who have not chosen a managed care plan or
1047	MediPass to the network or program in a manner that maintains
1048	the minimum enrollment in the network or program at not less
1049	than 15,000 children. To the extent practicable, the agency
1050	shall also assign all eligible children in the same family to
1051	such network or program. When making assignments, the agency
1052	shall take into account the following criteria:
1053	1. A managed care plan has sufficient network capacity to
1054	meet the need of members.
1055	2. The managed care plan or MediPasshas previously
1056	enrolled the recipient as a member, or one of the managed care
1057	plan's primary care providers or MediPass providershas
1058	previously provided health care to the recipient.
1059	3. The agency has knowledge that the member has previously
1060	expressed a preference for a particular managed care plan or
1061	MediPass provideras indicated by Medicaid fee-for-service
1062	claims data, but has failed to make a choice.
1063	4. The managed care plan's or MediPassprimary care
1064	providers are geographically accessible to the recipient's
1065	residence.
1066	(k) When a Medicaid recipient does not choose a managed
1067	care plan or MediPass provider, the agency shall assign the
1068	Medicaid recipient to a managed care plan, except in those
1069	counties in which there are fewer than two managed care plans
1070	accepting Medicaid enrollees, in which case assignment shall be
1071	to a managed care plan or a MediPass provider. Medicaid
1072	recipients in counties with fewer than two managed care plans
1073	accepting Medicaid enrollees who are subject to mandatory
1074	assignment but who fail to make a choice shall be assigned to
1075	managed care plans until an enrollment of 45 percent in MediPass
1076	and 55 percent in managed care plans is achieved. Once that
1077	enrollment is achieved, the assignments shall be divided in
1078	order to maintain an enrollment in MediPass and managed care
1079	plans which is in a 45 percent and 55 percent proportion,
1080	respectively. In geographic areas where the agency is
1081	contracting for the provision of comprehensive behavioral health
1082	services through a capitated prepaid arrangement, recipients who
1083	fail to make a choice shall be assigned equally to MediPass or a
1084	managed care plan. For purposes of this paragraph, when
1085	referring to assignment, the term "managed care plans" includes
1086	exclusive provider organizations, provider service networks,
1087	Children's Medical Services network, minority physician
1088	networks, and pediatric emergency department diversion programs
1089	authorized by this chapter or the General Appropriations Act.
1090	When making assignments, the agency shall take into account the
1091	following criteria:
1092	1. A managed care plan has sufficient network capacity to
1093	meet the need of members.
1094	2. The managed care plan or MediPasshas previously
1095	enrolled the recipient as a member, or one of the managed care
1096	plan's primary care providers or MediPass providershas
1097	previously provided health care to the recipient.
1098	3. The agency has knowledge that the member has previously
1099	expressed a preference for a particular managed care plan or
1100	MediPass provideras indicated by Medicaid fee-for-service
1101	claims data, but has failed to make a choice.
1102	4. The managed care plan's or MediPassprimary care
1103	providers are geographically accessible to the recipient's
1104	residence.
1105	5. The agency has authority to make mandatory assignments
1106	based on quality of service and performance of managed care
1107	plans.
1108	Section 23. Subsections (15) and (30) of section 409.913,
1109	Florida Statutes, are amended to read:
1110	409.913 Oversight of the integrity of the Medicaid
1111	program.--The agency shall operate a program to oversee the
1112	activities of Florida Medicaid recipients, and providers and
1113	their representatives, to ensure that fraudulent and abusive
1114	behavior and neglect of recipients occur to the minimum extent
1115	possible, and to recover overpayments and impose sanctions as
1116	appropriate. Beginning January 1, 2003, and each year
1117	thereafter, the agency and the Medicaid Fraud Control Unit of
1118	the Department of Legal Affairs shall submit a joint report to
1119	the Legislature documenting the effectiveness of the state's
1120	efforts to control Medicaid fraud and abuse and to recover
1121	Medicaid overpayments during the previous fiscal year. The
1122	report must describe the number of cases opened and investigated
1123	each year; the sources of the cases opened; the disposition of
1124	the cases closed each year; the amount of overpayments alleged
1125	in preliminary and final audit letters; the number and amount of
1126	fines or penalties imposed; any reductions in overpayment
1127	amounts negotiated in settlement agreements or by other means;
1128	the amount of final agency determinations of overpayments; the
1129	amount deducted from federal claiming as a result of
1130	overpayments; the amount of overpayments recovered each year;
1131	the amount of cost of investigation recovered each year; the
1132	average length of time to collect from the time the case was
1133	opened until the overpayment is paid in full; the amount
1134	determined as uncollectible and the portion of the uncollectible
1135	amount subsequently reclaimed from the Federal Government; the
1136	number of providers, by type, that are terminated from
1137	participation in the Medicaid program as a result of fraud and
1138	abuse; and all costs associated with discovering and prosecuting
1139	cases of Medicaid overpayments and making recoveries in such
1140	cases. The report must also document actions taken to prevent
1141	overpayments and the number of providers prevented from
1142	enrolling in or reenrolling in the Medicaid program as a result
1143	of documented Medicaid fraud and abuse and must recommend
1144	changes necessary to prevent or recover overpayments. For the
1145	2001-2002 fiscal year, the agency shall prepare a report that
1146	contains as much of this information as is available to it.
1147	(15) The agency mayshallimpose any of the following
1148	sanctions or disincentives on a provider or a person for any of
1149	the acts described in subsection (14):
1150	(a) Suspension for a specific period of time of not more
1151	than 1 year.
1152	(b) Termination for a specific period of time of from more
1153	than 1 year to 20 years.
1154	(c) Imposition of a fine of up to $10,000$5,000for each
1155	violation. Each day that an ongoing violation continues, such as
1156	refusing to furnish Medicaid-related records or refusing access
1157	to records, is considered, for the purposes of this section, to
1158	be a separate violation. Each instance of improper billing of a
1159	Medicaid recipient; each instance of including an unallowable
1160	cost on a hospital or nursing home Medicaid cost report after
1161	the provider or authorized representative has been advised in an
1162	audit exit conference or previous audit report of the cost
1163	unallowability; each instance of furnishing a Medicaid recipient
1164	goods or professional services that are inappropriate or of
1165	inferior quality as determined by competent peer judgment; each
1166	instance of knowingly submitting a materially false or erroneous
1167	Medicaid provider enrollment application, request for prior
1168	authorization for Medicaid services, drug exception request, or
1169	cost report; each instance of inappropriate prescribing of drugs
1170	for a Medicaid recipient as determined by competent peer
1171	judgment; and each false or erroneous Medicaid claim leading to
1172	an overpayment to a provider is considered, for the purposes of
1173	this section, to be a separate violation.
1174	(d) Immediate suspension, if the agency has received
1175	information of patient abuse or neglect or of any act prohibited
1176	by s. 409.920. Upon suspension, the agency must issue an
1177	immediate final order under s. 120.569(2)(n).
1178	(e) A fine, not to exceed $20,000$10,000, for a violation
1179	of paragraph (14)(i).
1180	(f) Imposition of liens against provider assets,
1181	including, but not limited to, financial assets and real
1182	property, not to exceed the amount of fines or recoveries
1183	sought, upon entry of an order determining that such moneys are
1184	due or recoverable.
1185	(g) Prepayment reviews of claims for a specified period of
1186	time.
1187	(h) Comprehensive followup reviews of providers every 6
1188	months to ensure that they are billing Medicaid correctly.
1189	(i) Corrective-action plans that would remain in effect
1190	for providers for up to 3 years and that would be monitored by
1191	the agency every 6 months while in effect.
1192	(j) Other remedies as permitted by law to effect the
1193	recovery of a fine or overpayment.
1194
1195	The Secretary of Health Care Administration may make a
1196	determination that imposition of a sanction or disincentive is
1197	not in the best interest of the Medicaid program, in which case
1198	a sanction or disincentive shall not be imposed.
1199	(30) If a provider requests an administrative hearing
1200	pursuant to chapter 120, such hearing must be conducted within
1201	90 days following assignment of an administrative law judge,
1202	absent exceptionally good cause shown as determined by the
1203	administrative law judge or hearing officer.Upon issuance of a
1204	final order, the outstanding balance of the amount determined to
1205	constitute a Medicaidtheoverpayment shall become due. If a
1206	provider fails to make payments in full, fails to enter into a
1207	satisfactory repayment plan, or fails to comply with the terms
1208	of a repayment plan or settlement agreement, the agency may
1209	withhold medical assistance reimbursement payments until the
1210	amount due is paid in full.
1211	Section 24. Section 409.919, Florida Statutes, is amended
1212	to read:
1213	409.919 Rules.--The agency shall adopt any rules necessary
1214	to comply with or administer ss. 409.901-409.920, and those
1215	rules necessary to effect and implement interagency agreements
1216	between the agency and other departments,and all rules
1217	necessary to comply with federal requirements. In addition, the
1218	Department of Children and Family Services shall adopt and
1219	accept transfer of any rules necessary to carry out its
1220	responsibilities for receiving and processing Medicaid
1221	applications and determining Medicaid eligibility, and for
1222	assuring compliance with and administering ss. 409.901-409.906,
1223	as they relate to these responsibilities, and any other
1224	provisions related to responsibility for the determination of
1225	Medicaid eligibility.
1226	Section 25. Paragraph (s) of subsection (4) of section
1227	411.01, Florida Statutes, is amended to read:
1228	411.01 Florida Partnership for School Readiness; school
1229	readiness coalitions.--
1230	(4) FLORIDA PARTNERSHIP FOR SCHOOL READINESS.--
1231	(s) The partnership shall submit an annual report of its
1232	activities to the Governor, the Agency for Health Care
1233	Administrationthe executive director of the Florida Healthy
1234	Kids Corporation, the President of the Senate, the Speaker of
1235	the House of Representatives, and the minority leaders of both
1236	houses of the Legislature. In addition, the partnership's
1237	reports and recommendations shall be made available to the
1238	Florida Board of Education, other appropriate state agencies and
1239	entities, district school boards, central agencies for child
1240	care, and county health departments. The annual report must
1241	provide an analysis of school readiness activities across the
1242	state, including the number of children who were served in the
1243	programs and the number of children who were ready for school.
1244
1245	To ensure that the system for measuring school readiness is
1246	comprehensive and appropriate statewide, as the system is
1247	developed and implemented, the partnership must consult with
1248	representatives of district school systems, providers of public
1249	and private child care, health care providers, large and small
1250	employers, experts in education for children with disabilities,
1251	and experts in child development.
1252	Section 26. Subsection (2) of section 465.0255, Florida
1253	Statutes, is amended to read:
1254	465.0255 Expiration date of medicinal drugs; display;
1255	related use and storage instructions.--
1256	(2) Each pharmacist for a community pharmacy dispensing
1257	medicinal drugs and each practitioner dispensing medicinal drugs
1258	on an outpatient basis shall display on the outside of the
1259	container of each medicinal drug dispensed, or in other written
1260	form delivered to the purchaser, the expiration date when
1261	provided by the manufacturer, repackager, or other distributor
1262	of the drug, which shall be consistent with the manufacturer’s
1263	expiration date,and appropriate instructions regarding the
1264	proper use and storage of the drug. Nothing in this section
1265	shall impose liability on the dispensing pharmacist or
1266	practitioner for damages related to, or caused by, a medicinal
1267	drug that loses its effectiveness prior to the expiration date
1268	displayed by the dispensing pharmacist or practitioner.
1269	Section 27. This act shall take effect July 1, 2003.