Senate Bill sb0022A
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Florida Senate - 2003 SB 22-A
By Senator Peaden
2-2587-03
1 A bill to be entitled
2 An act relating to health care; amending s.
3 400.179, F.S.; deleting a repeal of provisions
4 requiring payment of certain fees upon the
5 transfer of the leasehold license for a nursing
6 facility; amending s. 400.23, F.S.; delaying
7 the effective date of certain requirements
8 concerning hours of direct care per resident
9 for nursing home facilities; amending s.
10 409.901, F.S.; defining the term "third party"
11 to include a third-party administrator or
12 pharmacy benefits manager; amending s. 409.904,
13 F.S.; revising provisions governing the payment
14 of optional medical benefits for certain
15 Medicaid-eligible persons; amending s. 409.906,
16 F.S.; deleting provisions authorizing payment
17 for adult dental services; revising
18 requirements for hearing and visual services to
19 limit such services to persons younger than 21
20 years of age; amending s. 409.908, F.S.,
21 relating to reimbursement of Medicaid
22 providers; providing for a fee to be paid to
23 providers returning unused medications and
24 credited to the Medicaid program; conforming a
25 cross-reference; amending s. 409.9081, F.S.;
26 providing a copayment under the Medicaid
27 program for certain nonemergency hospital
28 visits; amending ss. 409.911, 409.9112,
29 409.9116, and 409.9117, F.S.; revising the
30 disproportionate share program; deleting
31 definitions; requiring the Agency for Health
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1 Care Administration to use actual audited data
2 to determine the Medicaid days and charity care
3 to be used to calculate the disproportionate
4 share payment; revising formulas for
5 calculating payments; revising the formula for
6 calculating payments under the disproportionate
7 share program for regional perinatal intensive
8 care centers; providing for estimates of the
9 payments under the rural disproportionate share
10 and financial assistance programs; providing a
11 formula for calculating payments under the
12 primary care disproportionate share program;
13 repealing s. 409.9119, F.S., relating to
14 disproportionate share program for specialty
15 hospitals for children; amending s. 409.912,
16 F.S.; providing for reimbursement of provider
17 service networks; removing certain requirements
18 for prior authorization for nursing home
19 residents and institutionalized adults;
20 prohibiting value-added rebates to a
21 pharmaceutical manufacturer; deleting
22 provisions authorizing certain benefits in
23 conjunction with supplemental rebates;
24 authorizing the agency to implement a
25 utilization management program for certain
26 services; amending s. 409.9122, F.S.; revising
27 the percentage of Medicaid recipients required
28 to be enrolled in managed care; providing for
29 construction of the act in pari materia with
30 laws enacted during the Regular Session of the
31 Legislature; providing an effective date.
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1 Be It Enacted by the Legislature of the State of Florida:
2
3 Section 1. Effective upon this act becoming a law,
4 paragraph (d) of subsection (5) of section 400.179, Florida
5 Statutes, is amended to read:
6 400.179 Sale or transfer of ownership of a nursing
7 facility; liability for Medicaid underpayments and
8 overpayments.--
9 (5) Because any transfer of a nursing facility may
10 expose the fact that Medicaid may have underpaid or overpaid
11 the transferor, and because in most instances, any such
12 underpayment or overpayment can only be determined following a
13 formal field audit, the liabilities for any such underpayments
14 or overpayments shall be as follows:
15 (d) Where the transfer involves a facility that has
16 been leased by the transferor:
17 1. The transferee shall, as a condition to being
18 issued a license by the agency, acquire, maintain, and provide
19 proof to the agency of a bond with a term of 30 months,
20 renewable annually, in an amount not less than the total of 3
21 months Medicaid payments to the facility computed on the basis
22 of the preceding 12-month average Medicaid payments to the
23 facility.
24 2. A leasehold licensee may meet the requirements of
25 subparagraph 1. by payment of a nonrefundable fee, paid at
26 initial licensure, paid at the time of any subsequent change
27 of ownership, and paid at the time of any subsequent annual
28 license renewal, in the amount of 2 percent of the total of 3
29 months' Medicaid payments to the facility computed on the
30 basis of the preceding 12-month average Medicaid payments to
31 the facility. If a preceding 12-month average is not
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1 available, projected Medicaid payments may be used. The fee
2 shall be deposited into the Health Care Trust Fund and shall
3 be accounted for separately as a Medicaid nursing home
4 overpayment account. These fees shall be used at the sole
5 discretion of the agency to repay nursing home Medicaid
6 overpayments. Payment of this fee shall not release the
7 licensee from any liability for any Medicaid overpayments, nor
8 shall payment bar the agency from seeking to recoup
9 overpayments from the licensee and any other liable party. As
10 a condition of exercising this lease bond alternative,
11 licensees paying this fee must maintain an existing lease bond
12 through the end of the 30-month term period of that bond. The
13 agency is herein granted specific authority to promulgate all
14 rules pertaining to the administration and management of this
15 account, including withdrawals from the account, subject to
16 federal review and approval. This subparagraph is repealed on
17 June 30, 2003. This provision shall take effect upon becoming
18 law and shall apply to any leasehold license application.
19 a. The financial viability of the Medicaid nursing
20 home overpayment account shall be determined by the agency
21 through annual review of the account balance and the amount of
22 total outstanding, unpaid Medicaid overpayments owing from
23 leasehold licensees to the agency as determined by final
24 agency audits.
25 b. The agency, in consultation with the Florida Health
26 Care Association and the Florida Association of Homes for the
27 Aging, shall study and make recommendations on the minimum
28 amount to be held in reserve to protect against Medicaid
29 overpayments to leasehold licensees and on the issue of
30 successor liability for Medicaid overpayments upon sale or
31 transfer of ownership of a nursing facility. The agency shall
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1 submit the findings and recommendations of the study to the
2 Governor, the President of the Senate, and the Speaker of the
3 House of Representatives by January 1, 2003.
4 3. The leasehold licensee may meet the bond
5 requirement through other arrangements acceptable to the
6 agency. The agency is herein granted specific authority to
7 promulgate rules pertaining to lease bond arrangements.
8 4. All existing nursing facility licensees, operating
9 the facility as a leasehold, shall acquire, maintain, and
10 provide proof to the agency of the 30-month bond required in
11 subparagraph 1., above, on and after July 1, 1993, for each
12 license renewal.
13 5. It shall be the responsibility of all nursing
14 facility operators, operating the facility as a leasehold, to
15 renew the 30-month bond and to provide proof of such renewal
16 to the agency annually at the time of application for license
17 renewal.
18 6. Any failure of the nursing facility operator to
19 acquire, maintain, renew annually, or provide proof to the
20 agency shall be grounds for the agency to deny, cancel,
21 revoke, or suspend the facility license to operate such
22 facility and to take any further action, including, but not
23 limited to, enjoining the facility, asserting a moratorium, or
24 applying for a receiver, deemed necessary to ensure compliance
25 with this section and to safeguard and protect the health,
26 safety, and welfare of the facility's residents. A lease
27 agreement required as a condition of bond financing or
28 refinancing under s. 154.213 by a health facilities authority
29 or required under s. 159.30 by a county or municipality is not
30 a leasehold for purposes of this paragraph and is not subject
31 to the bond requirement of this paragraph.
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1 Section 2. Paragraph (a) of subsection (3) of section
2 400.23, Florida Statutes, is amended to read:
3 400.23 Rules; evaluation and deficiencies; licensure
4 status.--
5 (3)(a) The agency shall adopt rules providing for the
6 minimum staffing requirements for nursing homes. These
7 requirements shall include, for each nursing home facility, a
8 minimum certified nursing assistant staffing of 2.3 hours of
9 direct care per resident per day beginning January 1, 2002,
10 increasing to 2.6 hours of direct care per resident per day
11 beginning January 1, 2003, and increasing to 2.9 hours of
12 direct care per resident per day beginning July January 1,
13 2004. Beginning January 1, 2002, no facility shall staff below
14 one certified nursing assistant per 20 residents, and a
15 minimum licensed nursing staffing of 1.0 hour of direct
16 resident care per resident per day but never below one
17 licensed nurse per 40 residents. Nursing assistants employed
18 under s. 400.211(2) may be included in computing the staffing
19 ratio for certified nursing assistants only if they provide
20 nursing assistance services to residents on a full-time basis.
21 Each nursing home must document compliance with staffing
22 standards as required under this paragraph and post daily the
23 names of staff on duty for the benefit of facility residents
24 and the public. The agency shall recognize the use of licensed
25 nurses for compliance with minimum staffing requirements for
26 certified nursing assistants, provided that the facility
27 otherwise meets the minimum staffing requirements for licensed
28 nurses and that the licensed nurses so recognized are
29 performing the duties of a certified nursing assistant. Unless
30 otherwise approved by the agency, licensed nurses counted
31 towards the minimum staffing requirements for certified
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1 nursing assistants must exclusively perform the duties of a
2 certified nursing assistant for the entire shift and shall not
3 also be counted towards the minimum staffing requirements for
4 licensed nurses. If the agency approved a facility's request
5 to use a licensed nurse to perform both licensed nursing and
6 certified nursing assistant duties, the facility must allocate
7 the amount of staff time specifically spent on certified
8 nursing assistant duties for the purpose of documenting
9 compliance with minimum staffing requirements for certified
10 and licensed nursing staff. In no event may the hours of a
11 licensed nurse with dual job responsibilities be counted
12 twice.
13 Section 3. Subsection (25) of section 409.901, Florida
14 Statutes, is amended to read:
15 409.901 Definitions; ss. 409.901-409.920.--As used in
16 ss. 409.901-409.920, except as otherwise specifically
17 provided, the term:
18 (25) "Third party" means an individual, entity, or
19 program, excluding Medicaid, that is, may be, could be, should
20 be, or has been liable for all or part of the cost of medical
21 services related to any medical assistance covered by
22 Medicaid. A third party includes a third-party administrator
23 or a pharmacy benefits manager.
24 Section 4. Subsection (2) of section 409.904, Florida
25 Statutes, as amended by section 1 of chapter 2003-9, Laws of
26 Florida, is amended to read:
27 409.904 Optional payments for eligible persons.--The
28 agency may make payments for medical assistance and related
29 services on behalf of the following persons who are determined
30 to be eligible subject to the income, assets, and categorical
31 eligibility tests set forth in federal and state law. Payment
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1 on behalf of these Medicaid eligible persons is subject to the
2 availability of moneys and any limitations established by the
3 General Appropriations Act or chapter 216.
4 (2) A family caretaker relative or parent, a pregnant
5 woman, a child under age 21 19 who would otherwise qualify for
6 Florida Kidcare Medicaid, a child up to age 21 who would
7 otherwise qualify under s. 409.903(1), a person age 65 or
8 over, or a blind or disabled person, who would otherwise be
9 eligible under any group listed in s. 409.903(1), (2), or (3)
10 for Florida Medicaid, except that the income or assets of such
11 family or person exceed established limitations. For a family
12 or person in one of these coverage groups, medical expenses
13 are deductible from income in accordance with federal
14 requirements in order to make a determination of eligibility.
15 Expenses used to meet spend-down liability are not
16 reimbursable by Medicaid. Effective July 1, 2003, when
17 determining the eligibility of a pregnant woman, a child, or
18 an aged, blind, or disabled individual, $270 shall be deducted
19 from the countable income of the filing unit. When determining
20 the eligibility of the parent or caretaker relative as defined
21 by Title XIX of the Social Security Act, the additional income
22 disregard of $270 does not apply. A family or person eligible
23 under the coverage known as the "medically needy," is eligible
24 to receive the same services as other Medicaid recipients,
25 with the exception of services in skilled nursing facilities
26 and intermediate care facilities for the developmentally
27 disabled.
28 Section 5. Section 409.906, Florida Statutes, is
29 amended to read:
30 409.906 Optional Medicaid services.--Subject to
31 specific appropriations, the agency may make payments for
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1 services which are optional to the state under Title XIX of
2 the Social Security Act and are furnished by Medicaid
3 providers to recipients who are determined to be eligible on
4 the dates on which the services were provided. Any optional
5 service that is provided shall be provided only when medically
6 necessary and in accordance with state and federal law.
7 Optional services rendered by providers in mobile units to
8 Medicaid recipients may be restricted or prohibited by the
9 agency. Nothing in this section shall be construed to prevent
10 or limit the agency from adjusting fees, reimbursement rates,
11 lengths of stay, number of visits, or number of services, or
12 making any other adjustments necessary to comply with the
13 availability of moneys and any limitations or directions
14 provided for in the General Appropriations Act or chapter 216.
15 If necessary to safeguard the state's systems of providing
16 services to elderly and disabled persons and subject to the
17 notice and review provisions of s. 216.177, the Governor may
18 direct the Agency for Health Care Administration to amend the
19 Medicaid state plan to delete the optional Medicaid service
20 known as "Intermediate Care Facilities for the Developmentally
21 Disabled." Optional services may include:
22 (1) ADULT DENTAL SERVICES.--The agency may pay for
23 medically necessary, emergency dental procedures to alleviate
24 pain or infection. Emergency dental care shall be limited to
25 emergency oral examinations, necessary radiographs,
26 extractions, and incision and drainage of abscess, for a
27 recipient who is age 21 or older. However, Medicaid will not
28 provide reimbursement for dental services provided in a mobile
29 dental unit, except for a mobile dental unit:
30 (a) Owned by, operated by, or having a contractual
31 agreement with the Department of Health and complying with
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1 Medicaid's county health department clinic services program
2 specifications as a county health department clinic services
3 provider.
4 (b) Owned by, operated by, or having a contractual
5 arrangement with a federally qualified health center and
6 complying with Medicaid's federally qualified health center
7 specifications as a federally qualified health center
8 provider.
9 (c) Rendering dental services to Medicaid recipients,
10 21 years of age and older, at nursing facilities.
11 (d) Owned by, operated by, or having a contractual
12 agreement with a state-approved dental educational
13 institution.
14 (1)(2) ADULT HEALTH SCREENING SERVICES.--The agency
15 may pay for an annual routine physical examination, conducted
16 by or under the direction of a licensed physician, for a
17 recipient age 21 or older, without regard to medical
18 necessity, in order to detect and prevent disease, disability,
19 or other health condition or its progression.
20 (2)(3) AMBULATORY SURGICAL CENTER SERVICES.--The
21 agency may pay for services provided to a recipient in an
22 ambulatory surgical center licensed under part I of chapter
23 395, by or under the direction of a licensed physician or
24 dentist.
25 (3)(4) BIRTH CENTER SERVICES.--The agency may pay for
26 examinations and delivery, recovery, and newborn assessment,
27 and related services, provided in a licensed birth center
28 staffed with licensed physicians, certified nurse midwives,
29 and midwives licensed in accordance with chapter 467, to a
30 recipient expected to experience a low-risk pregnancy and
31 delivery.
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1 (4)(5) CASE MANAGEMENT SERVICES.--The agency may pay
2 for primary care case management services rendered to a
3 recipient pursuant to a federally approved waiver, and
4 targeted case management services for specific groups of
5 targeted recipients, for which funding has been provided and
6 which are rendered pursuant to federal guidelines. The agency
7 is authorized to limit reimbursement for targeted case
8 management services in order to comply with any limitations or
9 directions provided for in the General Appropriations Act.
10 Notwithstanding s. 216.292, the Department of Children and
11 Family Services may transfer general funds to the Agency for
12 Health Care Administration to fund state match requirements
13 exceeding the amount specified in the General Appropriations
14 Act for targeted case management services.
15 (5)(6) CHILDREN'S DENTAL SERVICES.--The agency may pay
16 for diagnostic, preventive, or corrective procedures,
17 including orthodontia in severe cases, provided to a recipient
18 under age 21, by or under the supervision of a licensed
19 dentist. Services provided under this program include
20 treatment of the teeth and associated structures of the oral
21 cavity, as well as treatment of disease, injury, or impairment
22 that may affect the oral or general health of the individual.
23 However, Medicaid will not provide reimbursement for dental
24 services provided in a mobile dental unit, except for a mobile
25 dental unit:
26 (a) Owned by, operated by, or having a contractual
27 agreement with the Department of Health and complying with
28 Medicaid's county health department clinic services program
29 specifications as a county health department clinic services
30 provider.
31
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1 (b) Owned by, operated by, or having a contractual
2 arrangement with a federally qualified health center and
3 complying with Medicaid's federally qualified health center
4 specifications as a federally qualified health center
5 provider.
6 (c) Rendering dental services to Medicaid recipients,
7 21 years of age and older, at nursing facilities.
8 (d) Owned by, operated by, or having a contractual
9 agreement with a state-approved dental educational
10 institution.
11 (6)(7) CHIROPRACTIC SERVICES.--The agency may pay for
12 manual manipulation of the spine and initial services,
13 screening, and X rays provided to a recipient by a licensed
14 chiropractic physician.
15 (7)(8) COMMUNITY MENTAL HEALTH SERVICES.--
16 (a) The agency may pay for rehabilitative services
17 provided to a recipient by a mental health or substance abuse
18 provider under contract with the agency or the Department of
19 Children and Family Services to provide such services. Those
20 services which are psychiatric in nature shall be rendered or
21 recommended by a psychiatrist, and those services which are
22 medical in nature shall be rendered or recommended by a
23 physician or psychiatrist. The agency must develop a provider
24 enrollment process for community mental health providers which
25 bases provider enrollment on an assessment of service need.
26 The provider enrollment process shall be designed to control
27 costs, prevent fraud and abuse, consider provider expertise
28 and capacity, and assess provider success in managing
29 utilization of care and measuring treatment outcomes.
30 Providers will be selected through a competitive procurement
31 or selective contracting process. In addition to other
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1 community mental health providers, the agency shall consider
2 for enrollment mental health programs licensed under chapter
3 395 and group practices licensed under chapter 458, chapter
4 459, chapter 490, or chapter 491. The agency is also
5 authorized to continue operation of its behavioral health
6 utilization management program and may develop new services if
7 these actions are necessary to ensure savings from the
8 implementation of the utilization management system. The
9 agency shall coordinate the implementation of this enrollment
10 process with the Department of Children and Family Services
11 and the Department of Juvenile Justice. The agency is
12 authorized to utilize diagnostic criteria in setting
13 reimbursement rates, to preauthorize certain high-cost or
14 highly utilized services, to limit or eliminate coverage for
15 certain services, or to make any other adjustments necessary
16 to comply with any limitations or directions provided for in
17 the General Appropriations Act.
18 (b) The agency is authorized to implement
19 reimbursement and use management reforms in order to comply
20 with any limitations or directions in the General
21 Appropriations Act, which may include, but are not limited to:
22 prior authorization of treatment and service plans; prior
23 authorization of services; enhanced use review programs for
24 highly used services; and limits on services for those
25 determined to be abusing their benefit coverages.
26 (8)(9) DIALYSIS FACILITY SERVICES.--Subject to
27 specific appropriations being provided for this purpose, the
28 agency may pay a dialysis facility that is approved as a
29 dialysis facility in accordance with Title XVIII of the Social
30 Security Act, for dialysis services that are provided to a
31 Medicaid recipient under the direction of a physician licensed
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1 to practice medicine or osteopathic medicine in this state,
2 including dialysis services provided in the recipient's home
3 by a hospital-based or freestanding dialysis facility.
4 (9)(10) DURABLE MEDICAL EQUIPMENT.--The agency may
5 authorize and pay for certain durable medical equipment and
6 supplies provided to a Medicaid recipient as medically
7 necessary.
8 (10)(11) HEALTHY START SERVICES.--The agency may pay
9 for a continuum of risk-appropriate medical and psychosocial
10 services for the Healthy Start program in accordance with a
11 federal waiver. The agency may not implement the federal
12 waiver unless the waiver permits the state to limit enrollment
13 or the amount, duration, and scope of services to ensure that
14 expenditures will not exceed funds appropriated by the
15 Legislature or available from local sources. If the Health
16 Care Financing Administration does not approve a federal
17 waiver for Healthy Start services, the agency, in consultation
18 with the Department of Health and the Florida Association of
19 Healthy Start Coalitions, is authorized to establish a
20 Medicaid certified-match program for Healthy Start services.
21 Participation in the Healthy Start certified-match program
22 shall be voluntary, and reimbursement shall be limited to the
23 federal Medicaid share to Medicaid-enrolled Healthy Start
24 coalitions for services provided to Medicaid recipients. The
25 agency shall take no action to implement a certified-match
26 program without ensuring that the amendment and review
27 requirements of ss. 216.177 and 216.181 have been met.
28 (11)(12) CHILDREN'S HEARING SERVICES.--The agency may
29 pay for hearing and related services, including hearing
30 evaluations, hearing aid devices, dispensing of the hearing
31 aid, and related repairs, if provided to a recipient younger
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1 than 21 years of age by a licensed hearing aid specialist,
2 otolaryngologist, otologist, audiologist, or physician.
3 (12)(13) HOME AND COMMUNITY-BASED SERVICES.--The
4 agency may pay for home-based or community-based services that
5 are rendered to a recipient in accordance with a federally
6 approved waiver program. The agency may limit or eliminate
7 coverage for certain Project AIDS Care Waiver services,
8 preauthorize high-cost or highly utilized services, or make
9 any other adjustments necessary to comply with any limitations
10 or directions provided for in the General Appropriations Act.
11 (13)(14) HOSPICE CARE SERVICES.--The agency may pay
12 for all reasonable and necessary services for the palliation
13 or management of a recipient's terminal illness, if the
14 services are provided by a hospice that is licensed under part
15 VI of chapter 400 and meets Medicare certification
16 requirements.
17 (14)(15) INTERMEDIATE CARE FACILITY FOR THE
18 DEVELOPMENTALLY DISABLED SERVICES.--The agency may pay for
19 health-related care and services provided on a 24-hour-a-day
20 basis by a facility licensed and certified as a Medicaid
21 Intermediate Care Facility for the Developmentally Disabled,
22 for a recipient who needs such care because of a developmental
23 disability.
24 (15)(16) INTERMEDIATE CARE SERVICES.--The agency may
25 pay for 24-hour-a-day intermediate care nursing and
26 rehabilitation services rendered to a recipient in a nursing
27 facility licensed under part II of chapter 400, if the
28 services are ordered by and provided under the direction of a
29 physician.
30 (16)(17) OPTOMETRIC SERVICES.--The agency may pay for
31 services provided to a recipient, including examination,
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1 diagnosis, treatment, and management, related to ocular
2 pathology, if the services are provided by a licensed
3 optometrist or physician.
4 (17)(18) PHYSICIAN ASSISTANT SERVICES.--The agency may
5 pay for all services provided to a recipient by a physician
6 assistant licensed under s. 458.347 or s. 459.022.
7 Reimbursement for such services must be not less than 80
8 percent of the reimbursement that would be paid to a physician
9 who provided the same services.
10 (18)(19) PODIATRIC SERVICES.--The agency may pay for
11 services, including diagnosis and medical, surgical,
12 palliative, and mechanical treatment, related to ailments of
13 the human foot and lower leg, if provided to a recipient by a
14 podiatric physician licensed under state law.
15 (19)(20) PRESCRIBED DRUG SERVICES.--The agency may pay
16 for medications that are prescribed for a recipient by a
17 physician or other licensed practitioner of the healing arts
18 authorized to prescribe medications and that are dispensed to
19 the recipient by a licensed pharmacist or physician in
20 accordance with applicable state and federal law.
21 (20)(21) REGISTERED NURSE FIRST ASSISTANT
22 SERVICES.--The agency may pay for all services provided to a
23 recipient by a registered nurse first assistant as described
24 in s. 464.027. Reimbursement for such services may not be
25 less than 80 percent of the reimbursement that would be paid
26 to a physician providing the same services.
27 (21)(22) STATE HOSPITAL SERVICES.--The agency may pay
28 for all-inclusive psychiatric inpatient hospital care provided
29 to a recipient age 65 or older in a state mental hospital.
30 (22)(23) CHILDREN'S VISUAL SERVICES.--The agency may
31 pay for visual examinations, eyeglasses, and eyeglass repairs
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1 for a recipient younger than 21 years of age, if they are
2 prescribed by a licensed physician specializing in diseases of
3 the eye or by a licensed optometrist.
4 (23)(24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.--The
5 Agency for Health Care Administration, in consultation with
6 the Department of Children and Family Services, may establish
7 a targeted case-management project in those counties
8 identified by the Department of Children and Family Services
9 and for all counties with a community-based child welfare
10 project, as authorized under s. 409.1671, which have been
11 specifically approved by the department. Results of targeted
12 case management projects shall be reported to the Social
13 Services Estimating Conference established under s. 216.136.
14 The covered group of individuals who are eligible to receive
15 targeted case management include children who are eligible for
16 Medicaid; who are between the ages of birth through 21; and
17 who are under protective supervision or postplacement
18 supervision, under foster-care supervision, or in shelter care
19 or foster care. The number of individuals who are eligible to
20 receive targeted case management shall be limited to the
21 number for whom the Department of Children and Family Services
22 has available matching funds to cover the costs. The general
23 revenue funds required to match the funds for services
24 provided by the community-based child welfare projects are
25 limited to funds available for services described under s.
26 409.1671. The Department of Children and Family Services may
27 transfer the general revenue matching funds as billed by the
28 Agency for Health Care Administration.
29 (24)(25) ASSISTIVE-CARE SERVICES.--The agency may pay
30 for assistive-care services provided to recipients with
31 functional or cognitive impairments residing in assisted
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1 living facilities, adult family-care homes, or residential
2 treatment facilities. These services may include health
3 support, assistance with the activities of daily living and
4 the instrumental acts of daily living, assistance with
5 medication administration, and arrangements for health care.
6 Section 6. Subsections (14) and (20) of section
7 409.908, Florida Statutes, are amended to read:
8 409.908 Reimbursement of Medicaid providers.--Subject
9 to specific appropriations, the agency shall reimburse
10 Medicaid providers, in accordance with state and federal law,
11 according to methodologies set forth in the rules of the
12 agency and in policy manuals and handbooks incorporated by
13 reference therein. These methodologies may include fee
14 schedules, reimbursement methods based on cost reporting,
15 negotiated fees, competitive bidding pursuant to s. 287.057,
16 and other mechanisms the agency considers efficient and
17 effective for purchasing services or goods on behalf of
18 recipients. If a provider is reimbursed based on cost
19 reporting and submits a cost report late and that cost report
20 would have been used to set a lower reimbursement rate for a
21 rate semester, then the provider's rate for that semester
22 shall be retroactively calculated using the new cost report,
23 and full payment at the recalculated rate shall be affected
24 retroactively. Medicare-granted extensions for filing cost
25 reports, if applicable, shall also apply to Medicaid cost
26 reports. Payment for Medicaid compensable services made on
27 behalf of Medicaid eligible persons is subject to the
28 availability of moneys and any limitations or directions
29 provided for in the General Appropriations Act or chapter 216.
30 Further, nothing in this section shall be construed to prevent
31 or limit the agency from adjusting fees, reimbursement rates,
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1 lengths of stay, number of visits, or number of services, or
2 making any other adjustments necessary to comply with the
3 availability of moneys and any limitations or directions
4 provided for in the General Appropriations Act, provided the
5 adjustment is consistent with legislative intent.
6 (14) A provider of prescribed drugs shall be
7 reimbursed the least of the amount billed by the provider, the
8 provider's usual and customary charge, or the Medicaid maximum
9 allowable fee established by the agency, plus a dispensing
10 fee. The agency is directed to implement a variable dispensing
11 fee for payments for prescribed medicines while ensuring
12 continued access for Medicaid recipients. The variable
13 dispensing fee may be based upon, but not limited to, either
14 or both the volume of prescriptions dispensed by a specific
15 pharmacy provider, the volume of prescriptions dispensed to an
16 individual recipient, and dispensing of preferred-drug-list
17 products. The agency may shall increase the pharmacy
18 dispensing fee authorized by statute and in the annual General
19 Appropriations Act by $0.50 for the dispensing of a Medicaid
20 preferred-drug-list product and reduce the pharmacy dispensing
21 fee by $0.50 for the dispensing of a Medicaid product that is
22 not included on the preferred-drug list. The agency may
23 establish a supplemental pharmaceutical dispensing fee to be
24 paid to providers returning unused unit-dose packaged
25 medications to stock and crediting the Medicaid program for
26 the ingredient cost of those medications if the ingredient
27 costs to be credited exceed the value of the supplemental
28 dispensing fee. The agency is authorized to limit
29 reimbursement for prescribed medicine in order to comply with
30 any limitations or directions provided for in the General
31
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1 Appropriations Act, which may include implementing a
2 prospective or concurrent utilization review program.
3 (20) A renal dialysis facility that provides dialysis
4 services under s. 409.906(8) s. 409.906(9) must be reimbursed
5 the lesser of the amount billed by the provider, the
6 provider's usual and customary charge, or the maximum
7 allowable fee established by the agency, whichever amount is
8 less.
9 Section 7. Subsection (1) of section 409.9081, Florida
10 Statutes, is amended to read:
11 409.9081 Copayments.--
12 (1) The agency shall require, subject to federal
13 regulations and limitations, each Medicaid recipient to pay at
14 the time of service a nominal copayment for the following
15 Medicaid services:
16 (a) Hospital outpatient services: up to $3 for each
17 hospital outpatient visit.
18 (b) Physician services: up to $2 copayment for each
19 visit with a physician licensed under chapter 458, chapter
20 459, chapter 460, chapter 461, or chapter 463.
21 (c) Hospital emergency department visits for
22 nonemergency care: $15 for each emergency department visit.
23 Section 8. Section 409.911, Florida Statutes, is
24 amended to read:
25 409.911 Disproportionate share program.--Subject to
26 specific allocations established within the General
27 Appropriations Act and any limitations established pursuant to
28 chapter 216, the agency shall distribute, pursuant to this
29 section, moneys to hospitals providing a disproportionate
30 share of Medicaid or charity care services by making quarterly
31 Medicaid payments as required. Notwithstanding the provisions
20
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1 of s. 409.915, counties are exempt from contributing toward
2 the cost of this special reimbursement for hospitals serving a
3 disproportionate share of low-income patients.
4 (1) Definitions.--As used in this section, s.
5 409.9112, and the Florida Hospital Uniform Reporting System
6 manual:
7 (a) "Adjusted patient days" means the sum of acute
8 care patient days and intensive care patient days as reported
9 to the Agency for Health Care Administration, divided by the
10 ratio of inpatient revenues generated from acute, intensive,
11 ambulatory, and ancillary patient services to gross revenues.
12 (b) "Actual audited data" or "actual audited
13 experience" means data reported to the Agency for Health Care
14 Administration which has been audited in accordance with
15 generally accepted auditing standards by the agency or
16 representatives under contract with the agency.
17 (c) "Base Medicaid per diem" means the hospital's
18 Medicaid per diem rate initially established by the Agency for
19 Health Care Administration on January 1, 1999. The base
20 Medicaid per diem rate shall not include any additional per
21 diem increases received as a result of the disproportionate
22 share distribution.
23 (c)(d) "Charity care" or "uncompensated charity care"
24 means that portion of hospital charges reported to the Agency
25 for Health Care Administration for which there is no
26 compensation, other than restricted or unrestricted revenues
27 provided to a hospital by local governments or tax districts
28 regardless of the method of payment, for care provided to a
29 patient whose family income for the 12 months preceding the
30 determination is less than or equal to 200 percent of the
31 federal poverty level, unless the amount of hospital charges
21
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1 due from the patient exceeds 25 percent of the annual family
2 income. However, in no case shall the hospital charges for a
3 patient whose family income exceeds four times the federal
4 poverty level for a family of four be considered charity.
5 (d)(e) "Charity care days" means the sum of the
6 deductions from revenues for charity care minus 50 percent of
7 restricted and unrestricted revenues provided to a hospital by
8 local governments or tax districts, divided by gross revenues
9 per adjusted patient day.
10 (f) "Disproportionate share percentage" means a rate
11 of increase in the Medicaid per diem rate as calculated under
12 this section.
13 (e)(g) "Hospital" means a health care institution
14 licensed as a hospital pursuant to chapter 395, but does not
15 include ambulatory surgical centers.
16 (f)(h) "Medicaid days" means the number of actual days
17 attributable to Medicaid patients as determined by the Agency
18 for Health Care Administration.
19 (2) The Agency for Health Care Administration shall
20 use utilize the following actual audited data criteria to
21 determine the Medicaid days and charity care to be used in
22 calculating the if a hospital qualifies for a disproportionate
23 share payment:
24 (a) The average of the 1997, 1998, and 1999 audited
25 data to determine each hospital's Medicaid days and charity
26 care.
27 (b) The average of the audited disproportionate share
28 data for the years available if the Agency for Health Care
29 Administration does not have the prescribed 3 years of audited
30 disproportionate share data for a hospital.
31
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1 (a) A hospital's total Medicaid days when combined
2 with its total charity care days must equal or exceed 7
3 percent of its total adjusted patient days.
4 (b) A hospital's total charity care days weighted by a
5 factor of 4.5, plus its total Medicaid days weighted by a
6 factor of 1, shall be equal to or greater than 10 percent of
7 its total adjusted patient days.
8 (c) Additionally, In accordance with s. 1923(b) of the
9 Social Security Act the seventh federal Omnibus Budget
10 Reconciliation Act, a hospital with a Medicaid inpatient
11 utilization rate greater than one standard deviation above the
12 statewide mean or a hospital with a low-income utilization
13 rate of 25 percent or greater shall qualify for reimbursement.
14 (3) In computing the disproportionate share rate:
15 (a) Per diem increases earned from disproportionate
16 share shall be applied to each hospital's base Medicaid per
17 diem rate and shall be capped at 170 percent.
18 (b) The agency shall use 1994 audited financial data
19 for the calculation of disproportionate share payments under
20 this section.
21 (c) If the total amount earned by all hospitals under
22 this section exceeds the amount appropriated, each hospital's
23 share shall be reduced on a pro rata basis so that the total
24 dollars distributed from the trust fund do not exceed the
25 total amount appropriated.
26 (d) The total amount calculated to be distributed
27 under this section shall be made in quarterly payments
28 subsequent to each quarter during the fiscal year.
29 (3)(4) Hospitals that qualify for a disproportionate
30 share payment solely under paragraph (2)(c) shall have their
31 payment calculated in accordance with the following formulas:
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1 DSHP = (HMD/TMSD)*$1 million
2
3 Where:
4
5 DSHP = disproportionate share hospital payment.
6 HMD = hospital Medicaid days.
7 TSD = total state Medicaid days.
8
9
10 TAA = TA x (1/5.5)
11 DSHP = (HMD/TSMD) x TAA
12
13 Where:
14 TAA = total amount available.
15 TA = total appropriation.
16 DSHP = disproportionate share hospital payment.
17 HMD = hospital Medicaid days.
18 TSMD = total state Medicaid days.
19
20 (4) The following formulas shall be used to pay
21 disproportionate share dollars to public hospitals:
22 (a) For state mental health hospitals:
23
24 DSHP = (HMD/TMDMH) * TAAMH
25
26 shall be the difference between the federal cap
27 for Institutions for Mental Diseases and the
28 amounts paid under the mental health
29 disproportionate share program.
30
31 Where:
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1
2 DSHP = disproportionate share hospital payment.
3 HMD = hospital Medicaid days.
4 TMDHH = total Medicaid days for state mental health
5 hospitals.
6 TAAMH = total amount available for mental health
7 hospitals.
8
9 (b) For non-state government owned or operated
10 hospitals with 3,300 or more Medicaid days:
11
12 DSHP = [(.82*HCCD/TCCD) + (.18*HMD/TMD)] * TAAPH
13 TAAPH = TAA - TAAMH
14
15 Where:
16
17 TAA = total available appropriation.
18 TAAPH = total amount available for public hospitals.
19 DSHP = disproportionate share hospital payments.
20 HMD = hospital Medicaid days.
21 TMD = total state Medicaid days for public hospitals.
22 HCCD = hospital charity care dollars.
23 TCCD = total state charity care dollars for public
24 non-state hospitals.
25
26 (c) For non-state government owned or operated
27 hospitals with less than 3,300 Medicaid days, a total of
28 $400,000 shall be distributed equally among these hospitals.
29 (5) The following formula shall be utilized by the
30 agency to determine the maximum disproportionate share rate to
31
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1 be used to increase the Medicaid per diem rate for hospitals
2 that qualify pursuant to paragraphs (2)(a) and (b):al>
3
4 CCD MD
5 DSR = ( (........) x 4.5) + (........)
6 APD APD
7 Where:
8 APD = adjusted patient days.
9 CCD = charity care days.
10 DSR = disproportionate share rate.
11 MD = Medicaid days.
12
13 (6)(a) To calculate the total amount earned by all
14 hospitals under this section, hospitals with a
15 disproportionate share rate less than 50 percent shall divide
16 their Medicaid days by four, and hospitals with a
17 disproportionate share rate greater than or equal to 50
18 percent and with greater than 40,000 Medicaid days shall
19 multiply their Medicaid days by 1.5, and the following formula
20 shall be used by the agency to calculate the total amount
21 earned by all hospitals under this section:
22
23 TAE = BMPD x MD x DSP
24
25 Where:
26 TAE = total amount earned.
27 BMPD = base Medicaid per diem.
28 MD = Medicaid days.
29 DSP = disproportionate share percentage.
30
31
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1 (5)(b) In no case shall total payments to a hospital
2 under this section, with the exception of public non-state
3 facilities or state facilities, exceed the total amount of
4 uncompensated charity care of the hospital, as determined by
5 the agency according to the most recent calendar year audited
6 data available at the beginning of each state fiscal year.
7 (7) The following criteria shall be used in
8 determining the disproportionate share percentage:
9 (a) If the disproportionate share rate is less than 10
10 percent, the disproportionate share percentage is zero and
11 there is no additional payment.
12 (b) If the disproportionate share rate is greater than
13 or equal to 10 percent, but less than 20 percent, then the
14 disproportionate share percentage is 1.8478498.
15 (c) If the disproportionate share rate is greater than
16 or equal to 20 percent, but less than 30 percent, then the
17 disproportionate share percentage is 3.4145488.
18 (d) If the disproportionate share rate is greater than
19 or equal to 30 percent, but less than 40 percent, then the
20 disproportionate share percentage is 6.3095734.
21 (e) If the disproportionate share rate is greater than
22 or equal to 40 percent, but less than 50 percent, then the
23 disproportionate share percentage is 11.6591440.
24 (f) If the disproportionate share rate is greater than
25 or equal to 50 percent, but less than 60 percent, then the
26 disproportionate share percentage is 73.5642254.
27 (g) If the disproportionate share rate is greater than
28 or equal to 60 percent but less than 72.5 percent, then the
29 disproportionate share percentage is 135.9356391.
30
31
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1 (h) If the disproportionate share rate is greater than
2 or equal to 72.5 percent, then the disproportionate share
3 percentage is 170.
4 (8) The following formula shall be used by the agency
5 to calculate the total amount earned by all hospitals under
6 this section:
7
8 TAE = BMPD x MD x DSP
9
10 Where:
11 TAE = total amount earned.
12 BMPD = base Medicaid per diem.
13 MD = Medicaid days.
14 DSP = disproportionate share percentage.
15
16 (6)(9) The agency is authorized to receive funds from
17 local governments and other local political subdivisions for
18 the purpose of making payments, including federal matching
19 funds, through the Medicaid disproportionate share program.
20 Funds received from local governments for this purpose shall
21 be separately accounted for and shall not be commingled with
22 other state or local funds in any manner.
23 (7)(10) Payments made by the agency to hospitals
24 eligible to participate in this program shall be made in
25 accordance with federal rules and regulations.
26 (a) If the Federal Government prohibits, restricts, or
27 changes in any manner the methods by which funds are
28 distributed for this program, the agency shall not distribute
29 any additional funds and shall return all funds to the local
30 government from which the funds were received, except as
31 provided in paragraph (b).
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1 (b) If the Federal Government imposes a restriction
2 that still permits a partial or different distribution, the
3 agency may continue to disburse funds to hospitals
4 participating in the disproportionate share program in a
5 federally approved manner, provided:
6 1. Each local government which contributes to the
7 disproportionate share program agrees to the new manner of
8 distribution as shown by a written document signed by the
9 governing authority of each local government; and
10 2. The Executive Office of the Governor, the Office of
11 Planning and Budgeting, the House of Representatives, and the
12 Senate are provided at least 7 days' prior notice of the
13 proposed change in the distribution, and do not disapprove
14 such change.
15 (c) No distribution shall be made under the
16 alternative method specified in paragraph (b) unless all
17 parties agree or unless all funds of those parties that
18 disagree which are not yet disbursed have been returned to
19 those parties.
20 (8)(11) Notwithstanding the provisions of chapter 216,
21 the Executive Office of the Governor is hereby authorized to
22 establish sufficient trust fund authority to implement the
23 disproportionate share program.
24 Section 9. Section 409.9112, Florida Statutes, is
25 amended to read:
26 409.9112 Disproportionate share program for regional
27 perinatal intensive care centers.--In addition to the payments
28 made under s. 409.911, the Agency for Health Care
29 Administration shall design and implement a system of making
30 disproportionate share payments to those hospitals that
31 participate in the regional perinatal intensive care center
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1 program established pursuant to chapter 383. This system of
2 payments shall conform with federal requirements and shall
3 distribute funds in each fiscal year for which an
4 appropriation is made by making quarterly Medicaid payments.
5 Notwithstanding the provisions of s. 409.915, counties are
6 exempt from contributing toward the cost of this special
7 reimbursement for hospitals serving a disproportionate share
8 of low-income patients.
9 (1) The following formula shall be used by the agency
10 to calculate the total amount earned for hospitals that
11 participate in the regional perinatal intensive care center
12 program:
13
14 TAE = HDSP/THDSP
15
16 Where:
17
18 TAE = total amount earned by a regional perinatal
19 intensive care center.
20 HDSP = the prior state fiscal year regional perinatal
21 intensive care center disproportionate share payment to the
22 individual hospital.
23 THDSP = the prior state fiscal year total regional
24 perinatal intensive care center disproportionate share
25 payments to all hospitals.
26
27 (2) The total additional payment for hospitals that
28 participate in the regional perinatal intensive care center
29 program shall be calculated by the agency as follows:
30
31 TAP = TAE * TA
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1
2 Where:
3
4 TAP = total additional payment for a regional perinatal
5 intensive care center.
6 TAE = total amount earned by a regional perinatal
7 intensive care center.
8 TA = total appropriation for the regional perinatal
9 intensive care center disproportionate share program.
10
11 TAE = DSR x BMPD x MD
12
13 Where:
14 TAE = total amount earned by a regional perinatal
15 intensive care center.
16 DSR = disproportionate share rate.
17 BMPD = base Medicaid per diem.
18 MD = Medicaid days.
19
20 (2) The total additional payment for hospitals that
21 participate in the regional perinatal intensive care center
22 program shall be calculated by the agency as follows:
23
24
25 TAE x TA
26 TAP = (............)
27 STAE
28
29 Where:
30 TAP = total additional payment for a regional perinatal
31 intensive care center.
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1 TAE = total amount earned by a regional perinatal
2 intensive care center.
3 STAE = sum of total amount earned by each hospital that
4 participates in the regional perinatal intensive care center
5 program.
6 TA = total appropriation for the regional perinatal
7 intensive care disproportionate share program.
8
9 (3) In order to receive payments under this section, a
10 hospital must be participating in the regional perinatal
11 intensive care center program pursuant to chapter 383 and must
12 meet the following additional requirements:
13 (a) Agree to conform to all departmental and agency
14 requirements to ensure high quality in the provision of
15 services, including criteria adopted by departmental and
16 agency rule concerning staffing ratios, medical records,
17 standards of care, equipment, space, and such other standards
18 and criteria as the department and agency deem appropriate as
19 specified by rule.
20 (b) Agree to provide information to the department and
21 agency, in a form and manner to be prescribed by rule of the
22 department and agency, concerning the care provided to all
23 patients in neonatal intensive care centers and high-risk
24 maternity care.
25 (c) Agree to accept all patients for neonatal
26 intensive care and high-risk maternity care, regardless of
27 ability to pay, on a functional space-available basis.
28 (d) Agree to develop arrangements with other maternity
29 and neonatal care providers in the hospital's region for the
30 appropriate receipt and transfer of patients in need of
31 specialized maternity and neonatal intensive care services.
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1 (e) Agree to establish and provide a developmental
2 evaluation and services program for certain high-risk
3 neonates, as prescribed and defined by rule of the department.
4 (f) Agree to sponsor a program of continuing education
5 in perinatal care for health care professionals within the
6 region of the hospital, as specified by rule.
7 (g) Agree to provide backup and referral services to
8 the department's county health departments and other
9 low-income perinatal providers within the hospital's region,
10 including the development of written agreements between these
11 organizations and the hospital.
12 (h) Agree to arrange for transportation for high-risk
13 obstetrical patients and neonates in need of transfer from the
14 community to the hospital or from the hospital to another more
15 appropriate facility.
16 (4) Hospitals which fail to comply with any of the
17 conditions in subsection (3) or the applicable rules of the
18 department and agency shall not receive any payments under
19 this section until full compliance is achieved. A hospital
20 which is not in compliance in two or more consecutive quarters
21 shall not receive its share of the funds. Any forfeited funds
22 shall be distributed by the remaining participating regional
23 perinatal intensive care center program hospitals.
24 Section 10. Subsection (1) of section 409.9116,
25 Florida Statutes, is amended to read:
26 409.9116 Disproportionate share/financial assistance
27 program for rural hospitals.--In addition to the payments made
28 under s. 409.911, the Agency for Health Care Administration
29 shall administer a federally matched disproportionate share
30 program and a state-funded financial assistance program for
31 statutory rural hospitals. The agency shall make
33
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1 disproportionate share payments to statutory rural hospitals
2 that qualify for such payments and financial assistance
3 payments to statutory rural hospitals that do not qualify for
4 disproportionate share payments. The disproportionate share
5 program payments shall be limited by and conform with federal
6 requirements. Funds shall be distributed quarterly in each
7 fiscal year for which an appropriation is made.
8 Notwithstanding the provisions of s. 409.915, counties are
9 exempt from contributing toward the cost of this special
10 reimbursement for hospitals serving a disproportionate share
11 of low-income patients.
12 (1) The following formula shall be used by the agency
13 to calculate the total amount earned for hospitals that
14 participate in the rural hospital disproportionate share
15 program or the financial assistance program:
16
17 TAERH = (CCD + MDD)/TPD
18
19 Where:
20 CCD = total charity care-other, plus charity
21 care-Hill-Burton, minus 50 percent of unrestricted tax revenue
22 from local governments, and restricted funds for indigent
23 care, divided by gross revenue per adjusted patient day;
24 however, if CCD is less than zero, then zero shall be used for
25 CCD.
26 MDD = Medicaid inpatient days plus Medicaid HMO
27 inpatient days.
28 TPD = total inpatient days.
29 TAERH = total amount earned by each rural hospital.
30
31
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1 In computing the total amount earned by each rural hospital,
2 the agency must use the average of the 3 most recent years of
3 actual data reported in accordance with s. 408.061(4)(a). The
4 agency shall provide a preliminary estimate of the payments
5 under the rural disproportionate share and financial
6 assistance programs to the rural hospitals by August 31 of
7 each state fiscal year for review. Each rural hospital shall
8 have 30 days to review the preliminary estimates of payments
9 and report any errors to the agency. The agency shall make any
10 corrections deemed necessary and compute the rural
11 disproportionate share and financial assistance program
12 payments.
13 Section 11. Section 409.9117, Florida Statutes, is
14 amended to read:
15 409.9117 Primary care disproportionate share
16 program.--
17 (1) If federal funds are available for
18 disproportionate share programs in addition to those otherwise
19 provided by law, there shall be created a primary care
20 disproportionate share program.
21 (2) The following formula shall be used by the agency
22 to calculate the total amount earned for hospitals that
23 participate in the primary care disproportionate share
24 program:
25
26 TAE = HDSP/THDSP
27
28 Where:
29
30 TAE = total amount earned by a hospital participating
31 in the primary care disproportionate share program.
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1 HDSP = the prior state fiscal year primary care
2 disproportionate share payment to the individual hospital.
3 THDSP = the prior state fiscal year total primary care
4 disproportionate share payments to all hospitals.
5
6 (3) The total additional payment for hospitals that
7 participate in the primary care disproportionate share program
8 shall be calculated by the agency as follows:
9
10 TAP = TAE * TA
11
12 Where:
13
14 TAP = total additional payment for a primary care
15 hospital.
16 TAE = total amount earned by a primary care hospital.
17 TA = total appropriation for the primary care
18 disproportionate share program.
19 (4)(2) In the establishment and funding of this
20 program, the agency shall use the following criteria in
21 addition to those specified in s. 409.911, payments may not be
22 made to a hospital unless the hospital agrees to:
23 (a) Cooperate with a Medicaid prepaid health plan, if
24 one exists in the community.
25 (b) Ensure the availability of primary and specialty
26 care physicians to Medicaid recipients who are not enrolled in
27 a prepaid capitated arrangement and who are in need of access
28 to such physicians.
29 (c) Coordinate and provide primary care services free
30 of charge, except copayments, to all persons with incomes up
31 to 100 percent of the federal poverty level who are not
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1 otherwise covered by Medicaid or another program administered
2 by a governmental entity, and to provide such services based
3 on a sliding fee scale to all persons with incomes up to 200
4 percent of the federal poverty level who are not otherwise
5 covered by Medicaid or another program administered by a
6 governmental entity, except that eligibility may be limited to
7 persons who reside within a more limited area, as agreed to by
8 the agency and the hospital.
9 (d) Contract with any federally qualified health
10 center, if one exists within the agreed geopolitical
11 boundaries, concerning the provision of primary care services,
12 in order to guarantee delivery of services in a nonduplicative
13 fashion, and to provide for referral arrangements, privileges,
14 and admissions, as appropriate. The hospital shall agree to
15 provide at an onsite or offsite facility primary care services
16 within 24 hours to which all Medicaid recipients and persons
17 eligible under this paragraph who do not require emergency
18 room services are referred during normal daylight hours.
19 (e) Cooperate with the agency, the county, and other
20 entities to ensure the provision of certain public health
21 services, case management, referral and acceptance of
22 patients, and sharing of epidemiological data, as the agency
23 and the hospital find mutually necessary and desirable to
24 promote and protect the public health within the agreed
25 geopolitical boundaries.
26 (f) In cooperation with the county in which the
27 hospital resides, develop a low-cost, outpatient, prepaid
28 health care program to persons who are not eligible for the
29 Medicaid program, and who reside within the area.
30 (g) Provide inpatient services to residents within the
31 area who are not eligible for Medicaid or Medicare, and who do
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1 not have private health insurance, regardless of ability to
2 pay, on the basis of available space, except that nothing
3 shall prevent the hospital from establishing bill collection
4 programs based on ability to pay.
5 (h) Work with the Florida Healthy Kids Corporation,
6 the Florida Health Care Purchasing Cooperative, and business
7 health coalitions, as appropriate, to develop a feasibility
8 study and plan to provide a low-cost comprehensive health
9 insurance plan to persons who reside within the area and who
10 do not have access to such a plan.
11 (i) Work with public health officials and other
12 experts to provide community health education and prevention
13 activities designed to promote healthy lifestyles and
14 appropriate use of health services.
15 (j) Work with the local health council to develop a
16 plan for promoting access to affordable health care services
17 for all persons who reside within the area, including, but not
18 limited to, public health services, primary care services,
19 inpatient services, and affordable health insurance generally.
20
21 Any hospital that fails to comply with any of the provisions
22 of this subsection, or any other contractual condition, may
23 not receive payments under this section until full compliance
24 is achieved.
25 Section 12. Section 409.9119, Florida Statutes, is
26 repealed.
27 Section 13. Paragraph (d) of subsection (3) and
28 paragraph (a) of subsection (38) of section 409.912, Florida
29 Statutes, are amended, and subsection (41) is added to that
30 section, to read:
31
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1 409.912 Cost-effective purchasing of health care.--The
2 agency shall purchase goods and services for Medicaid
3 recipients in the most cost-effective manner consistent with
4 the delivery of quality medical care. The agency shall
5 maximize the use of prepaid per capita and prepaid aggregate
6 fixed-sum basis services when appropriate and other
7 alternative service delivery and reimbursement methodologies,
8 including competitive bidding pursuant to s. 287.057, designed
9 to facilitate the cost-effective purchase of a case-managed
10 continuum of care. The agency shall also require providers to
11 minimize the exposure of recipients to the need for acute
12 inpatient, custodial, and other institutional care and the
13 inappropriate or unnecessary use of high-cost services. The
14 agency may establish prior authorization requirements for
15 certain populations of Medicaid beneficiaries, certain drug
16 classes, or particular drugs to prevent fraud, abuse, overuse,
17 and possible dangerous drug interactions. The Pharmaceutical
18 and Therapeutics Committee shall make recommendations to the
19 agency on drugs for which prior authorization is required. The
20 agency shall inform the Pharmaceutical and Therapeutics
21 Committee of its decisions regarding drugs subject to prior
22 authorization.
23 (3) The agency may contract with:
24 (d) A provider service network No more than four
25 provider service networks for demonstration projects to test
26 Medicaid direct contracting. The demonstration projects may be
27 reimbursed on a fee-for-service or prepaid basis. A provider
28 service network which is reimbursed by the agency on a prepaid
29 basis shall be exempt from parts I and III of chapter 641, but
30 must meet appropriate financial reserve, quality assurance,
31 and patient rights requirements as established by the agency.
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1 The agency shall award contracts on a competitive bid basis
2 and shall select bidders based upon price and quality of care.
3 Medicaid recipients assigned to a demonstration project shall
4 be chosen equally from those who would otherwise have been
5 assigned to prepaid plans and MediPass. The agency is
6 authorized to seek federal Medicaid waivers as necessary to
7 implement the provisions of this section. A demonstration
8 project awarded pursuant to this paragraph shall be for 4
9 years from the date of implementation.
10 (38)(a) The agency shall implement a Medicaid
11 prescribed-drug spending-control program that includes the
12 following components:
13 1. Medicaid prescribed-drug coverage for brand-name
14 drugs for adult Medicaid recipients is limited to the
15 dispensing of four brand-name drugs per month per recipient.
16 Children are exempt from this restriction. Antiretroviral
17 agents are excluded from this limitation. No requirements for
18 prior authorization or other restrictions on medications used
19 to treat mental illnesses such as schizophrenia, severe
20 depression, or bipolar disorder may be imposed on Medicaid
21 recipients. Medications that will be available without
22 restriction for persons with mental illnesses include atypical
23 antipsychotic medications, conventional antipsychotic
24 medications, selective serotonin reuptake inhibitors, and
25 other medications used for the treatment of serious mental
26 illnesses. The agency shall also limit the amount of a
27 prescribed drug dispensed to no more than a 34-day supply. The
28 agency shall continue to provide unlimited generic drugs,
29 contraceptive drugs and items, and diabetic supplies. Although
30 a drug may be included on the preferred drug formulary, it
31 would not be exempt from the four-brand limit. The agency may
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1 authorize exceptions to the brand-name-drug restriction based
2 upon the treatment needs of the patients, only when such
3 exceptions are based on prior consultation provided by the
4 agency or an agency contractor, but the agency must establish
5 procedures to ensure that:
6 a. There will be a response to a request for prior
7 consultation by telephone or other telecommunication device
8 within 24 hours after receipt of a request for prior
9 consultation;
10 b. A 72-hour supply of the drug prescribed will be
11 provided in an emergency or when the agency does not provide a
12 response within 24 hours as required by sub-subparagraph a.;
13 and
14 c. Except for the exception for nursing home residents
15 and other institutionalized adults and Except for drugs on the
16 restricted formulary for which prior authorization may be
17 sought by an institutional or community pharmacy, prior
18 authorization for an exception to the brand-name-drug
19 restriction is sought by the prescriber and not by the
20 pharmacy. When prior authorization is granted for a patient in
21 an institutional setting beyond the brand-name-drug
22 restriction, such approval is authorized for 12 months and
23 monthly prior authorization is not required for that patient.
24 2. Reimbursement to pharmacies for Medicaid prescribed
25 drugs shall be set at the average wholesale price less 13.25
26 percent.
27 3. The agency shall develop and implement a process
28 for managing the drug therapies of Medicaid recipients who are
29 using significant numbers of prescribed drugs each month. The
30 management process may include, but is not limited to,
31 comprehensive, physician-directed medical-record reviews,
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1 claims analyses, and case evaluations to determine the medical
2 necessity and appropriateness of a patient's treatment plan
3 and drug therapies. The agency may contract with a private
4 organization to provide drug-program-management services. The
5 Medicaid drug benefit management program shall include
6 initiatives to manage drug therapies for HIV/AIDS patients,
7 patients using 20 or more unique prescriptions in a 180-day
8 period, and the top 1,000 patients in annual spending.
9 4. The agency may limit the size of its pharmacy
10 network based on need, competitive bidding, price
11 negotiations, credentialing, or similar criteria. The agency
12 shall give special consideration to rural areas in determining
13 the size and location of pharmacies included in the Medicaid
14 pharmacy network. A pharmacy credentialing process may include
15 criteria such as a pharmacy's full-service status, location,
16 size, patient educational programs, patient consultation,
17 disease-management services, and other characteristics. The
18 agency may impose a moratorium on Medicaid pharmacy enrollment
19 when it is determined that it has a sufficient number of
20 Medicaid-participating providers.
21 5. The agency shall develop and implement a program
22 that requires Medicaid practitioners who prescribe drugs to
23 use a counterfeit-proof prescription pad for Medicaid
24 prescriptions. The agency shall require the use of
25 standardized counterfeit-proof prescription pads by
26 Medicaid-participating prescribers or prescribers who write
27 prescriptions for Medicaid recipients. The agency may
28 implement the program in targeted geographic areas or
29 statewide.
30 6. The agency may enter into arrangements that require
31 manufacturers of generic drugs prescribed to Medicaid
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1 recipients to provide rebates of at least 15.1 percent of the
2 average manufacturer price for the manufacturer's generic
3 products. These arrangements shall require that if a
4 generic-drug manufacturer pays federal rebates for
5 Medicaid-reimbursed drugs at a level below 15.1 percent, the
6 manufacturer must provide a supplemental rebate to the state
7 in an amount necessary to achieve a 15.1-percent rebate level.
8 7. The agency may establish a preferred drug formulary
9 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
10 establishment of such formulary, it is authorized to negotiate
11 supplemental rebates from manufacturers that are in addition
12 to those required by Title XIX of the Social Security Act and
13 at no less than 10 percent of the average manufacturer price
14 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
15 unless the federal or supplemental rebate, or both, equals or
16 exceeds 25 percent. There is no upper limit on the
17 supplemental rebates the agency may negotiate. The agency may
18 determine that specific products, brand-name or generic, are
19 competitive at lower rebate percentages. Agreement to pay the
20 minimum supplemental rebate percentage will guarantee a
21 manufacturer that the Medicaid Pharmaceutical and Therapeutics
22 Committee will consider a product for inclusion on the
23 preferred drug formulary. However, a pharmaceutical
24 manufacturer is not guaranteed placement on the formulary by
25 simply paying the minimum supplemental rebate. Agency
26 decisions will be made on the clinical efficacy of a drug and
27 recommendations of the Medicaid Pharmaceutical and
28 Therapeutics Committee, as well as the price of competing
29 products minus federal and state rebates. The agency is
30 authorized to contract with an outside agency or contractor to
31 conduct negotiations for supplemental rebates. For the
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1 purposes of this section, the term "supplemental rebates" may
2 include, at the agency's discretion, cash rebates and other
3 program benefits that offset a Medicaid expenditure. Effective
4 July 1, 2003, value-added programs as a substitution for
5 supplemental rebates are prohibited. Such other program
6 benefits may include, but are not limited to, disease
7 management programs, drug product donation programs, drug
8 utilization control programs, prescriber and beneficiary
9 counseling and education, fraud and abuse initiatives, and
10 other services or administrative investments with guaranteed
11 savings to the Medicaid program in the same year the rebate
12 reduction is included in the General Appropriations Act. The
13 agency is authorized to seek any federal waivers to implement
14 this initiative.
15 8. The agency shall establish an advisory committee
16 for the purposes of studying the feasibility of using a
17 restricted drug formulary for nursing home residents and other
18 institutionalized adults. The committee shall be comprised of
19 seven members appointed by the Secretary of Health Care
20 Administration. The committee members shall include two
21 physicians licensed under chapter 458 or chapter 459; three
22 pharmacists licensed under chapter 465 and appointed from a
23 list of recommendations provided by the Florida Long-Term Care
24 Pharmacy Alliance; and two pharmacists licensed under chapter
25 465.
26 9. The Agency for Health Care Administration shall
27 expand home delivery of pharmacy products. To assist Medicaid
28 patients in securing their prescriptions and reduce program
29 costs, the agency shall expand its current mail-order-pharmacy
30 diabetes-supply program to include all generic and brand-name
31 drugs used by Medicaid patients with diabetes. Medicaid
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1 recipients in the current program may obtain nondiabetes drugs
2 on a voluntary basis. This initiative is limited to the
3 geographic area covered by the current contract. The agency
4 may seek and implement any federal waivers necessary to
5 implement this subparagraph.
6 (41) The agency shall develop and implement a
7 utilization management program for Medicaid-eligible
8 recipients younger than 21 years of age for the management of
9 occupational, physical, respiratory, and speech therapies. The
10 agency shall establish a utilization program that may require
11 prior authorization in order to ensure medically necessary and
12 cost-effective treatments. The program shall be operated in
13 accordance with a federally approved waiver program or state
14 plan amendment. The agency may seek a federal waiver or state
15 plan amendment to implement this program. The agency may also
16 competitively procure these services from an outside vendor on
17 a regional or statewide basis.
18 Section 14. Paragraphs (f) and (k) of subsection (2)
19 of section 409.9122, Florida Statutes, are amended to read:
20 409.9122 Mandatory Medicaid managed care enrollment;
21 programs and procedures.--
22 (2)
23 (f) When a Medicaid recipient does not choose a
24 managed care plan or MediPass provider, the agency shall
25 assign the Medicaid recipient to a managed care plan or
26 MediPass provider. Medicaid recipients who are subject to
27 mandatory assignment but who fail to make a choice shall be
28 assigned to managed care plans until an enrollment of 40 45
29 percent in MediPass and 60 55 percent in managed care plans is
30 achieved. Once this enrollment is achieved, the assignments
31 shall be divided in order to maintain an enrollment in
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1 MediPass and managed care plans which is in a 40 45 percent
2 and 60 55 percent proportion, respectively. Thereafter,
3 assignment of Medicaid recipients who fail to make a choice
4 shall be based proportionally on the preferences of recipients
5 who have made a choice in the previous period. Such
6 proportions shall be revised at least quarterly to reflect an
7 update of the preferences of Medicaid recipients. The agency
8 shall disproportionately assign Medicaid-eligible recipients
9 who are required to but have failed to make a choice of
10 managed care plan or MediPass, including children, and who are
11 to be assigned to the MediPass program to children's networks
12 as described in s. 409.912(3)(g), Children's Medical Services
13 network as defined in s. 391.021, exclusive provider
14 organizations, provider service networks, minority physician
15 networks, and pediatric emergency department diversion
16 programs authorized by this chapter or the General
17 Appropriations Act, in such manner as the agency deems
18 appropriate, until the agency has determined that the networks
19 and programs have sufficient numbers to be economically
20 operated. For purposes of this paragraph, when referring to
21 assignment, the term "managed care plans" includes health
22 maintenance organizations, exclusive provider organizations,
23 provider service networks, minority physician networks,
24 Children's Medical Services network, and pediatric emergency
25 department diversion programs authorized by this chapter or
26 the General Appropriations Act. Beginning July 1, 2002, the
27 agency shall assign all children in families who have not made
28 a choice of a managed care plan or MediPass in the required
29 timeframe to a pediatric emergency room diversion program
30 described in s. 409.912(3)(g) that, as of July 1, 2002, has
31 executed a contract with the agency, until such network or
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1 program has reached an enrollment of 15,000 children. Once
2 that minimum enrollment level has been reached, the agency
3 shall assign children who have not chosen a managed care plan
4 or MediPass to the network or program in a manner that
5 maintains the minimum enrollment in the network or program at
6 not less than 15,000 children. To the extent practicable, the
7 agency shall also assign all eligible children in the same
8 family to such network or program. When making assignments,
9 the agency shall take into account the following criteria:
10 1. A managed care plan has sufficient network capacity
11 to meet the need of members.
12 2. The managed care plan or MediPass has previously
13 enrolled the recipient as a member, or one of the managed care
14 plan's primary care providers or MediPass providers has
15 previously provided health care to the recipient.
16 3. The agency has knowledge that the member has
17 previously expressed a preference for a particular managed
18 care plan or MediPass provider as indicated by Medicaid
19 fee-for-service claims data, but has failed to make a choice.
20 4. The managed care plan's or MediPass primary care
21 providers are geographically accessible to the recipient's
22 residence.
23 (k) When a Medicaid recipient does not choose a
24 managed care plan or MediPass provider, the agency shall
25 assign the Medicaid recipient to a managed care plan, except
26 in those counties in which there are fewer than two managed
27 care plans accepting Medicaid enrollees, in which case
28 assignment shall be to a managed care plan or a MediPass
29 provider. Medicaid recipients in counties with fewer than two
30 managed care plans accepting Medicaid enrollees who are
31 subject to mandatory assignment but who fail to make a choice
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1 shall be assigned to managed care plans until an enrollment of
2 40 45 percent in MediPass and 60 55 percent in managed care
3 plans is achieved. Once that enrollment is achieved, the
4 assignments shall be divided in order to maintain an
5 enrollment in MediPass and managed care plans which is in a 40
6 45 percent and 60 55 percent proportion, respectively. In
7 geographic areas where the agency is contracting for the
8 provision of comprehensive behavioral health services through
9 a capitated prepaid arrangement, recipients who fail to make a
10 choice shall be assigned equally to MediPass or a managed care
11 plan. For purposes of this paragraph, when referring to
12 assignment, the term "managed care plans" includes exclusive
13 provider organizations, provider service networks, Children's
14 Medical Services network, minority physician networks, and
15 pediatric emergency department diversion programs authorized
16 by this chapter or the General Appropriations Act. When making
17 assignments, the agency shall take into account the following
18 criteria:
19 1. A managed care plan has sufficient network capacity
20 to meet the need of members.
21 2. The managed care plan or MediPass has previously
22 enrolled the recipient as a member, or one of the managed care
23 plan's primary care providers or MediPass providers has
24 previously provided health care to the recipient.
25 3. The agency has knowledge that the member has
26 previously expressed a preference for a particular managed
27 care plan or MediPass provider as indicated by Medicaid
28 fee-for-service claims data, but has failed to make a choice.
29 4. The managed care plan's or MediPass primary care
30 providers are geographically accessible to the recipient's
31 residence.
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1 5. The agency has authority to make mandatory
2 assignments based on quality of service and performance of
3 managed care plans.
4 Section 15. Paragraph (q) of subsection (2) of section
5 409.815, Florida Statutes, is amended to read:
6 409.815 Health benefits coverage; limitations.--
7 (2) BENCHMARK BENEFITS.--In order for health benefits
8 coverage to qualify for premium assistance payments for an
9 eligible child under ss. 409.810-409.820, the health benefits
10 coverage, except for coverage under Medicaid and Medikids,
11 must include the following minimum benefits, as medically
12 necessary.
13 (q) Dental services.--Subject to a specific
14 appropriation for this benefit, Covered services include those
15 dental services provided to children by the Florida Medicaid
16 program under s. 409.906(5), up to a maximum benefit of $500
17 per enrollee per year.
18 Section 16. If any law that is amended by this act was
19 also amended by a law enacted at the 2003 Regular Session of
20 the Legislature, such laws shall be construed as if they had
21 been enacted during the same session of the Legislature, and
22 full effect should be given to each if that is possible.
23 Section 17. Except as otherwise expressly provided in
24 this act, this act shall take effect July 1, 2003.
25
26 *****************************************
27 SENATE SUMMARY
28 Revises various provisions of the Medicaid program.
Revises requirements for dental, hearing, and visual
29 services. Deletes certain requirements for prior
authorization. Prohibits value-added rebates. Revises the
30 formulas used to calculate payments under the
disproportionate share program. (See bill for details.)
31
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