Senate Bill sb0022Ae1
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SB 22-A First Engrossed
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
1
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SB 22-A First Engrossed
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; amending s.
29 409.815, F.S., relating to benefits coverage;
30 specifying a maximum annual benefit for
31 children's dental services; providing for
2
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SB 22-A First Engrossed
1 construction of the act in pari materia with
2 laws enacted during the Regular Session of the
3 Legislature; providing an effective date.
4
5 Be It Enacted by the Legislature of the State of Florida:
6
7 Section 1. Effective upon this act becoming a law,
8 paragraph (d) of subsection (5) of section 400.179, Florida
9 Statutes, is amended to read:
10 400.179 Sale or transfer of ownership of a nursing
11 facility; liability for Medicaid underpayments and
12 overpayments.--
13 (5) Because any transfer of a nursing facility may
14 expose the fact that Medicaid may have underpaid or overpaid
15 the transferor, and because in most instances, any such
16 underpayment or overpayment can only be determined following a
17 formal field audit, the liabilities for any such underpayments
18 or overpayments shall be as follows:
19 (d) Where the transfer involves a facility that has
20 been leased by the transferor:
21 1. The transferee shall, as a condition to being
22 issued a license by the agency, acquire, maintain, and provide
23 proof to the agency of a bond with a term of 30 months,
24 renewable annually, in an amount not less than the total of 3
25 months Medicaid payments to the facility computed on the basis
26 of the preceding 12-month average Medicaid payments to the
27 facility.
28 2. A leasehold licensee may meet the requirements of
29 subparagraph 1. by payment of a nonrefundable fee, paid at
30 initial licensure, paid at the time of any subsequent change
31 of ownership, and paid at the time of any subsequent annual
3
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SB 22-A First Engrossed
1 license renewal, in the amount of 2 percent of the total of 3
2 months' Medicaid payments to the facility computed on the
3 basis of the preceding 12-month average Medicaid payments to
4 the facility. If a preceding 12-month average is not
5 available, projected Medicaid payments may be used. The fee
6 shall be deposited into the Health Care Trust Fund and shall
7 be accounted for separately as a Medicaid nursing home
8 overpayment account. These fees shall be used at the sole
9 discretion of the agency to repay nursing home Medicaid
10 overpayments. Payment of this fee shall not release the
11 licensee from any liability for any Medicaid overpayments, nor
12 shall payment bar the agency from seeking to recoup
13 overpayments from the licensee and any other liable party. As
14 a condition of exercising this lease bond alternative,
15 licensees paying this fee must maintain an existing lease bond
16 through the end of the 30-month term period of that bond. The
17 agency is herein granted specific authority to promulgate all
18 rules pertaining to the administration and management of this
19 account, including withdrawals from the account, subject to
20 federal review and approval. This subparagraph is repealed on
21 June 30, 2003. This provision shall take effect upon becoming
22 law and shall apply to any leasehold license application.
23 a. The financial viability of the Medicaid nursing
24 home overpayment account shall be determined by the agency
25 through annual review of the account balance and the amount of
26 total outstanding, unpaid Medicaid overpayments owing from
27 leasehold licensees to the agency as determined by final
28 agency audits.
29 b. The agency, in consultation with the Florida Health
30 Care Association and the Florida Association of Homes for the
31 Aging, shall study and make recommendations on the minimum
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SB 22-A First Engrossed
1 amount to be held in reserve to protect against Medicaid
2 overpayments to leasehold licensees and on the issue of
3 successor liability for Medicaid overpayments upon sale or
4 transfer of ownership of a nursing facility. The agency shall
5 submit the findings and recommendations of the study to the
6 Governor, the President of the Senate, and the Speaker of the
7 House of Representatives by January 1, 2003.
8 3. The leasehold licensee may meet the bond
9 requirement through other arrangements acceptable to the
10 agency. The agency is herein granted specific authority to
11 promulgate rules pertaining to lease bond arrangements.
12 4. All existing nursing facility licensees, operating
13 the facility as a leasehold, shall acquire, maintain, and
14 provide proof to the agency of the 30-month bond required in
15 subparagraph 1., above, on and after July 1, 1993, for each
16 license renewal.
17 5. It shall be the responsibility of all nursing
18 facility operators, operating the facility as a leasehold, to
19 renew the 30-month bond and to provide proof of such renewal
20 to the agency annually at the time of application for license
21 renewal.
22 6. Any failure of the nursing facility operator to
23 acquire, maintain, renew annually, or provide proof to the
24 agency shall be grounds for the agency to deny, cancel,
25 revoke, or suspend the facility license to operate such
26 facility and to take any further action, including, but not
27 limited to, enjoining the facility, asserting a moratorium, or
28 applying for a receiver, deemed necessary to ensure compliance
29 with this section and to safeguard and protect the health,
30 safety, and welfare of the facility's residents. A lease
31 agreement required as a condition of bond financing or
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SB 22-A First Engrossed
1 refinancing under s. 154.213 by a health facilities authority
2 or required under s. 159.30 by a county or municipality is not
3 a leasehold for purposes of this paragraph and is not subject
4 to the bond requirement of this paragraph.
5 Section 2. Paragraph (a) of subsection (3) of section
6 400.23, Florida Statutes, is amended to read:
7 400.23 Rules; evaluation and deficiencies; licensure
8 status.--
9 (3)(a) The agency shall adopt rules providing for the
10 minimum staffing requirements for nursing homes. These
11 requirements shall include, for each nursing home facility, a
12 minimum certified nursing assistant staffing of 2.3 hours of
13 direct care per resident per day beginning January 1, 2002,
14 increasing to 2.6 hours of direct care per resident per day
15 beginning January 1, 2003, and increasing to 2.9 hours of
16 direct care per resident per day beginning July January 1,
17 2004. Beginning January 1, 2002, no facility shall staff below
18 one certified nursing assistant per 20 residents, and a
19 minimum licensed nursing staffing of 1.0 hour of direct
20 resident care per resident per day but never below one
21 licensed nurse per 40 residents. Nursing assistants employed
22 under s. 400.211(2) may be included in computing the staffing
23 ratio for certified nursing assistants only if they provide
24 nursing assistance services to residents on a full-time basis.
25 Each nursing home must document compliance with staffing
26 standards as required under this paragraph and post daily the
27 names of staff on duty for the benefit of facility residents
28 and the public. The agency shall recognize the use of licensed
29 nurses for compliance with minimum staffing requirements for
30 certified nursing assistants, provided that the facility
31 otherwise meets the minimum staffing requirements for licensed
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SB 22-A First Engrossed
1 nurses and that the licensed nurses so recognized are
2 performing the duties of a certified nursing assistant. Unless
3 otherwise approved by the agency, licensed nurses counted
4 towards the minimum staffing requirements for certified
5 nursing assistants must exclusively perform the duties of a
6 certified nursing assistant for the entire shift and shall not
7 also be counted towards the minimum staffing requirements for
8 licensed nurses. If the agency approved a facility's request
9 to use a licensed nurse to perform both licensed nursing and
10 certified nursing assistant duties, the facility must allocate
11 the amount of staff time specifically spent on certified
12 nursing assistant duties for the purpose of documenting
13 compliance with minimum staffing requirements for certified
14 and licensed nursing staff. In no event may the hours of a
15 licensed nurse with dual job responsibilities be counted
16 twice.
17 Section 3. Subsection (25) of section 409.901, Florida
18 Statutes, is amended to read:
19 409.901 Definitions; ss. 409.901-409.920.--As used in
20 ss. 409.901-409.920, except as otherwise specifically
21 provided, the term:
22 (25) "Third party" means an individual, entity, or
23 program, excluding Medicaid, that is, may be, could be, should
24 be, or has been liable for all or part of the cost of medical
25 services related to any medical assistance covered by
26 Medicaid. A third party includes a third-party administrator
27 or a pharmacy benefits manager.
28 Section 4. Subsection (2) of section 409.904, Florida
29 Statutes, as amended by section 1 of chapter 2003-9, Laws of
30 Florida, is amended to read:
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SB 22-A First Engrossed
1 409.904 Optional payments for eligible persons.--The
2 agency may make payments for medical assistance and related
3 services on behalf of the following persons who are determined
4 to be eligible subject to the income, assets, and categorical
5 eligibility tests set forth in federal and state law. Payment
6 on behalf of these Medicaid eligible persons is subject to the
7 availability of moneys and any limitations established by the
8 General Appropriations Act or chapter 216.
9 (2) A family caretaker relative or parent, a pregnant
10 woman, a child under age 21 19 who would otherwise qualify for
11 Florida Kidcare Medicaid, a child up to age 21 who would
12 otherwise qualify under s. 409.903(1), a person age 65 or
13 over, or a blind or disabled person, who would otherwise be
14 eligible under any group listed in s. 409.903(1), (2), or (3)
15 for Florida Medicaid, except that the income or assets of such
16 family or person exceed established limitations. For a family
17 or person in one of these coverage groups, medical expenses
18 are deductible from income in accordance with federal
19 requirements in order to make a determination of eligibility.
20 Expenses used to meet spend-down liability are not
21 reimbursable by Medicaid. Effective July 1, 2003, when
22 determining the eligibility of a pregnant woman, a child, or
23 an aged, blind, or disabled individual, $270 shall be deducted
24 from the countable income of the filing unit. When determining
25 the eligibility of the parent or caretaker relative as defined
26 by Title XIX of the Social Security Act, the additional income
27 disregard of $270 does not apply. A family or person eligible
28 under the coverage known as the "medically needy," is eligible
29 to receive the same services as other Medicaid recipients,
30 with the exception of services in skilled nursing facilities
31
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SB 22-A First Engrossed
1 and intermediate care facilities for the developmentally
2 disabled.
3 Section 5. Section 409.906, Florida Statutes, is
4 amended to read:
5 409.906 Optional Medicaid services.--Subject to
6 specific appropriations, the agency may make payments for
7 services which are optional to the state under Title XIX of
8 the Social Security Act and are furnished by Medicaid
9 providers to recipients who are determined to be eligible on
10 the dates on which the services were provided. Any optional
11 service that is provided shall be provided only when medically
12 necessary and in accordance with state and federal law.
13 Optional services rendered by providers in mobile units to
14 Medicaid recipients may be restricted or prohibited by the
15 agency. Nothing in this section shall be construed to prevent
16 or limit the agency from adjusting fees, reimbursement rates,
17 lengths of stay, number of visits, or number of services, or
18 making any other adjustments necessary to comply with the
19 availability of moneys and any limitations or directions
20 provided for in the General Appropriations Act or chapter 216.
21 If necessary to safeguard the state's systems of providing
22 services to elderly and disabled persons and subject to the
23 notice and review provisions of s. 216.177, the Governor may
24 direct the Agency for Health Care Administration to amend the
25 Medicaid state plan to delete the optional Medicaid service
26 known as "Intermediate Care Facilities for the Developmentally
27 Disabled." Optional services may include:
28 (1) ADULT DENTAL SERVICES.--The agency may pay for
29 medically necessary, emergency dental procedures to alleviate
30 pain or infection. Emergency dental care shall be limited to
31 emergency oral examinations, necessary radiographs,
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SB 22-A First Engrossed
1 extractions, and incision and drainage of abscess, for a
2 recipient who is age 21 or older. However, Medicaid will not
3 provide reimbursement for dental services provided in a mobile
4 dental unit, except for a mobile dental unit:
5 (a) Owned by, operated by, or having a contractual
6 agreement with the Department of Health and complying with
7 Medicaid's county health department clinic services program
8 specifications as a county health department clinic services
9 provider.
10 (b) Owned by, operated by, or having a contractual
11 arrangement with a federally qualified health center and
12 complying with Medicaid's federally qualified health center
13 specifications as a federally qualified health center
14 provider.
15 (c) Rendering dental services to Medicaid recipients,
16 21 years of age and older, at nursing facilities.
17 (d) Owned by, operated by, or having a contractual
18 agreement with a state-approved dental educational
19 institution.
20 (1)(2) ADULT HEALTH SCREENING SERVICES.--The agency
21 may pay for an annual routine physical examination, conducted
22 by or under the direction of a licensed physician, for a
23 recipient age 21 or older, without regard to medical
24 necessity, in order to detect and prevent disease, disability,
25 or other health condition or its progression.
26 (2)(3) AMBULATORY SURGICAL CENTER SERVICES.--The
27 agency may pay for services provided to a recipient in an
28 ambulatory surgical center licensed under part I of chapter
29 395, by or under the direction of a licensed physician or
30 dentist.
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SB 22-A First Engrossed
1 (3)(4) BIRTH CENTER SERVICES.--The agency may pay for
2 examinations and delivery, recovery, and newborn assessment,
3 and related services, provided in a licensed birth center
4 staffed with licensed physicians, certified nurse midwives,
5 and midwives licensed in accordance with chapter 467, to a
6 recipient expected to experience a low-risk pregnancy and
7 delivery.
8 (4)(5) CASE MANAGEMENT SERVICES.--The agency may pay
9 for primary care case management services rendered to a
10 recipient pursuant to a federally approved waiver, and
11 targeted case management services for specific groups of
12 targeted recipients, for which funding has been provided and
13 which are rendered pursuant to federal guidelines. The agency
14 is authorized to limit reimbursement for targeted case
15 management services in order to comply with any limitations or
16 directions provided for in the General Appropriations Act.
17 Notwithstanding s. 216.292, the Department of Children and
18 Family Services may transfer general funds to the Agency for
19 Health Care Administration to fund state match requirements
20 exceeding the amount specified in the General Appropriations
21 Act for targeted case management services.
22 (5)(6) CHILDREN'S DENTAL SERVICES.--The agency may pay
23 for diagnostic, preventive, or corrective procedures,
24 including orthodontia in severe cases, provided to a recipient
25 under age 21, by or under the supervision of a licensed
26 dentist. Services provided under this program include
27 treatment of the teeth and associated structures of the oral
28 cavity, as well as treatment of disease, injury, or impairment
29 that may affect the oral or general health of the individual.
30 However, Medicaid will not provide reimbursement for dental
31
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SB 22-A First Engrossed
1 services provided in a mobile dental unit, except for a mobile
2 dental unit:
3 (a) Owned by, operated by, or having a contractual
4 agreement with the Department of Health and complying with
5 Medicaid's county health department clinic services program
6 specifications as a county health department clinic services
7 provider.
8 (b) Owned by, operated by, or having a contractual
9 arrangement with a federally qualified health center and
10 complying with Medicaid's federally qualified health center
11 specifications as a federally qualified health center
12 provider.
13 (c) Rendering dental services to Medicaid recipients,
14 21 years of age and older, at nursing facilities.
15 (d) Owned by, operated by, or having a contractual
16 agreement with a state-approved dental educational
17 institution.
18 (6)(7) CHIROPRACTIC SERVICES.--The agency may pay for
19 manual manipulation of the spine and initial services,
20 screening, and X rays provided to a recipient by a licensed
21 chiropractic physician.
22 (7)(8) COMMUNITY MENTAL HEALTH SERVICES.--
23 (a) The agency may pay for rehabilitative services
24 provided to a recipient by a mental health or substance abuse
25 provider under contract with the agency or the Department of
26 Children and Family Services to provide such services. Those
27 services which are psychiatric in nature shall be rendered or
28 recommended by a psychiatrist, and those services which are
29 medical in nature shall be rendered or recommended by a
30 physician or psychiatrist. The agency must develop a provider
31 enrollment process for community mental health providers which
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SB 22-A First Engrossed
1 bases provider enrollment on an assessment of service need.
2 The provider enrollment process shall be designed to control
3 costs, prevent fraud and abuse, consider provider expertise
4 and capacity, and assess provider success in managing
5 utilization of care and measuring treatment outcomes.
6 Providers will be selected through a competitive procurement
7 or selective contracting process. In addition to other
8 community mental health providers, the agency shall consider
9 for enrollment mental health programs licensed under chapter
10 395 and group practices licensed under chapter 458, chapter
11 459, chapter 490, or chapter 491. The agency is also
12 authorized to continue operation of its behavioral health
13 utilization management program and may develop new services if
14 these actions are necessary to ensure savings from the
15 implementation of the utilization management system. The
16 agency shall coordinate the implementation of this enrollment
17 process with the Department of Children and Family Services
18 and the Department of Juvenile Justice. The agency is
19 authorized to utilize diagnostic criteria in setting
20 reimbursement rates, to preauthorize certain high-cost or
21 highly utilized services, to limit or eliminate coverage for
22 certain services, or to make any other adjustments necessary
23 to comply with any limitations or directions provided for in
24 the General Appropriations Act.
25 (b) The agency is authorized to implement
26 reimbursement and use management reforms in order to comply
27 with any limitations or directions in the General
28 Appropriations Act, which may include, but are not limited to:
29 prior authorization of treatment and service plans; prior
30 authorization of services; enhanced use review programs for
31
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SB 22-A First Engrossed
1 highly used services; and limits on services for those
2 determined to be abusing their benefit coverages.
3 (8)(9) DIALYSIS FACILITY SERVICES.--Subject to
4 specific appropriations being provided for this purpose, the
5 agency may pay a dialysis facility that is approved as a
6 dialysis facility in accordance with Title XVIII of the Social
7 Security Act, for dialysis services that are provided to a
8 Medicaid recipient under the direction of a physician licensed
9 to practice medicine or osteopathic medicine in this state,
10 including dialysis services provided in the recipient's home
11 by a hospital-based or freestanding dialysis facility.
12 (9)(10) DURABLE MEDICAL EQUIPMENT.--The agency may
13 authorize and pay for certain durable medical equipment and
14 supplies provided to a Medicaid recipient as medically
15 necessary.
16 (10)(11) HEALTHY START SERVICES.--The agency may pay
17 for a continuum of risk-appropriate medical and psychosocial
18 services for the Healthy Start program in accordance with a
19 federal waiver. The agency may not implement the federal
20 waiver unless the waiver permits the state to limit enrollment
21 or the amount, duration, and scope of services to ensure that
22 expenditures will not exceed funds appropriated by the
23 Legislature or available from local sources. If the Health
24 Care Financing Administration does not approve a federal
25 waiver for Healthy Start services, the agency, in consultation
26 with the Department of Health and the Florida Association of
27 Healthy Start Coalitions, is authorized to establish a
28 Medicaid certified-match program for Healthy Start services.
29 Participation in the Healthy Start certified-match program
30 shall be voluntary, and reimbursement shall be limited to the
31 federal Medicaid share to Medicaid-enrolled Healthy Start
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SB 22-A First Engrossed
1 coalitions for services provided to Medicaid recipients. The
2 agency shall take no action to implement a certified-match
3 program without ensuring that the amendment and review
4 requirements of ss. 216.177 and 216.181 have been met.
5 (11)(12) CHILDREN'S HEARING SERVICES.--The agency may
6 pay for hearing and related services, including hearing
7 evaluations, hearing aid devices, dispensing of the hearing
8 aid, and related repairs, if provided to a recipient younger
9 than 21 years of age by a licensed hearing aid specialist,
10 otolaryngologist, otologist, audiologist, or physician.
11 (12)(13) HOME AND COMMUNITY-BASED SERVICES.--The
12 agency may pay for home-based or community-based services that
13 are rendered to a recipient in accordance with a federally
14 approved waiver program. The agency may limit or eliminate
15 coverage for certain Project AIDS Care Waiver services,
16 preauthorize high-cost or highly utilized services, or make
17 any other adjustments necessary to comply with any limitations
18 or directions provided for in the General Appropriations Act.
19 (13)(14) HOSPICE CARE SERVICES.--The agency may pay
20 for all reasonable and necessary services for the palliation
21 or management of a recipient's terminal illness, if the
22 services are provided by a hospice that is licensed under part
23 VI of chapter 400 and meets Medicare certification
24 requirements.
25 (14)(15) INTERMEDIATE CARE FACILITY FOR THE
26 DEVELOPMENTALLY DISABLED SERVICES.--The agency may pay for
27 health-related care and services provided on a 24-hour-a-day
28 basis by a facility licensed and certified as a Medicaid
29 Intermediate Care Facility for the Developmentally Disabled,
30 for a recipient who needs such care because of a developmental
31 disability.
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SB 22-A First Engrossed
1 (15)(16) INTERMEDIATE CARE SERVICES.--The agency may
2 pay for 24-hour-a-day intermediate care nursing and
3 rehabilitation services rendered to a recipient in a nursing
4 facility licensed under part II of chapter 400, if the
5 services are ordered by and provided under the direction of a
6 physician.
7 (16)(17) OPTOMETRIC SERVICES.--The agency may pay for
8 services provided to a recipient, including examination,
9 diagnosis, treatment, and management, related to ocular
10 pathology, if the services are provided by a licensed
11 optometrist or physician.
12 (17)(18) PHYSICIAN ASSISTANT SERVICES.--The agency may
13 pay for all services provided to a recipient by a physician
14 assistant licensed under s. 458.347 or s. 459.022.
15 Reimbursement for such services must be not less than 80
16 percent of the reimbursement that would be paid to a physician
17 who provided the same services.
18 (18)(19) PODIATRIC SERVICES.--The agency may pay for
19 services, including diagnosis and medical, surgical,
20 palliative, and mechanical treatment, related to ailments of
21 the human foot and lower leg, if provided to a recipient by a
22 podiatric physician licensed under state law.
23 (19)(20) PRESCRIBED DRUG SERVICES.--The agency may pay
24 for medications that are prescribed for a recipient by a
25 physician or other licensed practitioner of the healing arts
26 authorized to prescribe medications and that are dispensed to
27 the recipient by a licensed pharmacist or physician in
28 accordance with applicable state and federal law.
29 (20)(21) REGISTERED NURSE FIRST ASSISTANT
30 SERVICES.--The agency may pay for all services provided to a
31 recipient by a registered nurse first assistant as described
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SB 22-A First Engrossed
1 in s. 464.027. Reimbursement for such services may not be
2 less than 80 percent of the reimbursement that would be paid
3 to a physician providing the same services.
4 (21)(22) STATE HOSPITAL SERVICES.--The agency may pay
5 for all-inclusive psychiatric inpatient hospital care provided
6 to a recipient age 65 or older in a state mental hospital.
7 (22)(23) CHILDREN'S VISUAL SERVICES.--The agency may
8 pay for visual examinations, eyeglasses, and eyeglass repairs
9 for a recipient younger than 21 years of age, if they are
10 prescribed by a licensed physician specializing in diseases of
11 the eye or by a licensed optometrist.
12 (23)(24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.--The
13 Agency for Health Care Administration, in consultation with
14 the Department of Children and Family Services, may establish
15 a targeted case-management project in those counties
16 identified by the Department of Children and Family Services
17 and for all counties with a community-based child welfare
18 project, as authorized under s. 409.1671, which have been
19 specifically approved by the department. Results of targeted
20 case management projects shall be reported to the Social
21 Services Estimating Conference established under s. 216.136.
22 The covered group of individuals who are eligible to receive
23 targeted case management include children who are eligible for
24 Medicaid; who are between the ages of birth through 21; and
25 who are under protective supervision or postplacement
26 supervision, under foster-care supervision, or in shelter care
27 or foster care. The number of individuals who are eligible to
28 receive targeted case management shall be limited to the
29 number for whom the Department of Children and Family Services
30 has available matching funds to cover the costs. The general
31 revenue funds required to match the funds for services
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SB 22-A First Engrossed
1 provided by the community-based child welfare projects are
2 limited to funds available for services described under s.
3 409.1671. The Department of Children and Family Services may
4 transfer the general revenue matching funds as billed by the
5 Agency for Health Care Administration.
6 (24)(25) ASSISTIVE-CARE SERVICES.--The agency may pay
7 for assistive-care services provided to recipients with
8 functional or cognitive impairments residing in assisted
9 living facilities, adult family-care homes, or residential
10 treatment facilities. These services may include health
11 support, assistance with the activities of daily living and
12 the instrumental acts of daily living, assistance with
13 medication administration, and arrangements for health care.
14 Section 6. Subsections (14) and (20) of section
15 409.908, Florida Statutes, are amended to read:
16 409.908 Reimbursement of Medicaid providers.--Subject
17 to specific appropriations, the agency shall reimburse
18 Medicaid providers, in accordance with state and federal law,
19 according to methodologies set forth in the rules of the
20 agency and in policy manuals and handbooks incorporated by
21 reference therein. These methodologies may include fee
22 schedules, reimbursement methods based on cost reporting,
23 negotiated fees, competitive bidding pursuant to s. 287.057,
24 and other mechanisms the agency considers efficient and
25 effective for purchasing services or goods on behalf of
26 recipients. If a provider is reimbursed based on cost
27 reporting and submits a cost report late and that cost report
28 would have been used to set a lower reimbursement rate for a
29 rate semester, then the provider's rate for that semester
30 shall be retroactively calculated using the new cost report,
31 and full payment at the recalculated rate shall be affected
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SB 22-A First Engrossed
1 retroactively. Medicare-granted extensions for filing cost
2 reports, if applicable, shall also apply to Medicaid cost
3 reports. Payment for Medicaid compensable services made on
4 behalf of Medicaid eligible persons is subject to the
5 availability of moneys and any limitations or directions
6 provided for in the General Appropriations Act or chapter 216.
7 Further, nothing in this section shall be construed to prevent
8 or limit the agency from adjusting fees, reimbursement rates,
9 lengths of stay, number of visits, or number of services, or
10 making any other adjustments necessary to comply with the
11 availability of moneys and any limitations or directions
12 provided for in the General Appropriations Act, provided the
13 adjustment is consistent with legislative intent.
14 (14) A provider of prescribed drugs shall be
15 reimbursed the least of the amount billed by the provider, the
16 provider's usual and customary charge, or the Medicaid maximum
17 allowable fee established by the agency, plus a dispensing
18 fee. The agency is directed to implement a variable dispensing
19 fee for payments for prescribed medicines while ensuring
20 continued access for Medicaid recipients. The variable
21 dispensing fee may be based upon, but not limited to, either
22 or both the volume of prescriptions dispensed by a specific
23 pharmacy provider, the volume of prescriptions dispensed to an
24 individual recipient, and dispensing of preferred-drug-list
25 products. The agency may shall increase the pharmacy
26 dispensing fee authorized by statute and in the annual General
27 Appropriations Act by $0.50 for the dispensing of a Medicaid
28 preferred-drug-list product and reduce the pharmacy dispensing
29 fee by $0.50 for the dispensing of a Medicaid product that is
30 not included on the preferred-drug list. The agency may
31 establish a supplemental pharmaceutical dispensing fee to be
19
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SB 22-A First Engrossed
1 paid to providers returning unused unit-dose packaged
2 medications to stock and crediting the Medicaid program for
3 the ingredient cost of those medications if the ingredient
4 costs to be credited exceed the value of the supplemental
5 dispensing fee. The agency is authorized to limit
6 reimbursement for prescribed medicine in order to comply with
7 any limitations or directions provided for in the General
8 Appropriations Act, which may include implementing a
9 prospective or concurrent utilization review program.
10 (20) A renal dialysis facility that provides dialysis
11 services under s. 409.906(8) s. 409.906(9) must be reimbursed
12 the lesser of the amount billed by the provider, the
13 provider's usual and customary charge, or the maximum
14 allowable fee established by the agency, whichever amount is
15 less.
16 Section 7. Subsection (1) of section 409.9081, Florida
17 Statutes, is amended to read:
18 409.9081 Copayments.--
19 (1) The agency shall require, subject to federal
20 regulations and limitations, each Medicaid recipient to pay at
21 the time of service a nominal copayment for the following
22 Medicaid services:
23 (a) Hospital outpatient services: up to $3 for each
24 hospital outpatient visit.
25 (b) Physician services: up to $2 copayment for each
26 visit with a physician licensed under chapter 458, chapter
27 459, chapter 460, chapter 461, or chapter 463.
28 (c) Hospital emergency department visits for
29 nonemergency care: $15 for each emergency department visit.
30 Section 8. Section 409.911, Florida Statutes, is
31 amended to read:
20
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SB 22-A First Engrossed
1 409.911 Disproportionate share program.--Subject to
2 specific allocations established within the General
3 Appropriations Act and any limitations established pursuant to
4 chapter 216, the agency shall distribute, pursuant to this
5 section, moneys to hospitals providing a disproportionate
6 share of Medicaid or charity care services by making quarterly
7 Medicaid payments as required. Notwithstanding the provisions
8 of s. 409.915, counties are exempt from contributing toward
9 the cost of this special reimbursement for hospitals serving a
10 disproportionate share of low-income patients.
11 (1) Definitions.--As used in this section, s.
12 409.9112, and the Florida Hospital Uniform Reporting System
13 manual:
14 (a) "Adjusted patient days" means the sum of acute
15 care patient days and intensive care patient days as reported
16 to the Agency for Health Care Administration, divided by the
17 ratio of inpatient revenues generated from acute, intensive,
18 ambulatory, and ancillary patient services to gross revenues.
19 (b) "Actual audited data" or "actual audited
20 experience" means data reported to the Agency for Health Care
21 Administration which has been audited in accordance with
22 generally accepted auditing standards by the agency or
23 representatives under contract with the agency.
24 (c) "Base Medicaid per diem" means the hospital's
25 Medicaid per diem rate initially established by the Agency for
26 Health Care Administration on January 1, 1999. The base
27 Medicaid per diem rate shall not include any additional per
28 diem increases received as a result of the disproportionate
29 share distribution.
30 (c)(d) "Charity care" or "uncompensated charity care"
31 means that portion of hospital charges reported to the Agency
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SB 22-A First Engrossed
1 for Health Care Administration for which there is no
2 compensation, other than restricted or unrestricted revenues
3 provided to a hospital by local governments or tax districts
4 regardless of the method of payment, for care provided to a
5 patient whose family income for the 12 months preceding the
6 determination is less than or equal to 200 percent of the
7 federal poverty level, unless the amount of hospital charges
8 due from the patient exceeds 25 percent of the annual family
9 income. However, in no case shall the hospital charges for a
10 patient whose family income exceeds four times the federal
11 poverty level for a family of four be considered charity.
12 (d)(e) "Charity care days" means the sum of the
13 deductions from revenues for charity care minus 50 percent of
14 restricted and unrestricted revenues provided to a hospital by
15 local governments or tax districts, divided by gross revenues
16 per adjusted patient day.
17 (f) "Disproportionate share percentage" means a rate
18 of increase in the Medicaid per diem rate as calculated under
19 this section.
20 (e)(g) "Hospital" means a health care institution
21 licensed as a hospital pursuant to chapter 395, but does not
22 include ambulatory surgical centers.
23 (f)(h) "Medicaid days" means the number of actual days
24 attributable to Medicaid patients as determined by the Agency
25 for Health Care Administration.
26 (2) The Agency for Health Care Administration shall
27 use utilize the following actual audited data criteria to
28 determine the Medicaid days and charity care to be used in
29 calculating the if a hospital qualifies for a disproportionate
30 share payment:
31
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SB 22-A First Engrossed
1 (a) The average of the 1997, 1998, and 1999 audited
2 data to determine each hospital's Medicaid days and charity
3 care.
4 (b) The average of the audited disproportionate share
5 data for the years available if the Agency for Health Care
6 Administration does not have the prescribed 3 years of audited
7 disproportionate share data for a hospital.
8 (a) A hospital's total Medicaid days when combined
9 with its total charity care days must equal or exceed 7
10 percent of its total adjusted patient days.
11 (b) A hospital's total charity care days weighted by a
12 factor of 4.5, plus its total Medicaid days weighted by a
13 factor of 1, shall be equal to or greater than 10 percent of
14 its total adjusted patient days.
15 (c) Additionally, In accordance with s. 1923(b) of the
16 Social Security Act the seventh federal Omnibus Budget
17 Reconciliation Act, a hospital with a Medicaid inpatient
18 utilization rate greater than one standard deviation above the
19 statewide mean or a hospital with a low-income utilization
20 rate of 25 percent or greater shall qualify for reimbursement.
21 (3) In computing the disproportionate share rate:
22 (a) Per diem increases earned from disproportionate
23 share shall be applied to each hospital's base Medicaid per
24 diem rate and shall be capped at 170 percent.
25 (b) The agency shall use 1994 audited financial data
26 for the calculation of disproportionate share payments under
27 this section.
28 (c) If the total amount earned by all hospitals under
29 this section exceeds the amount appropriated, each hospital's
30 share shall be reduced on a pro rata basis so that the total
31
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SB 22-A First Engrossed
1 dollars distributed from the trust fund do not exceed the
2 total amount appropriated.
3 (d) The total amount calculated to be distributed
4 under this section shall be made in quarterly payments
5 subsequent to each quarter during the fiscal year.
6 (3)(4) Hospitals that qualify for a disproportionate
7 share payment solely under paragraph (2)(c) shall have their
8 payment calculated in accordance with the following formulas:
9 DSHP = (HMD/TMSD)*$1 million
10
11 Where:
12
13 DSHP = disproportionate share hospital payment.
14 HMD = hospital Medicaid days.
15 TSD = total state Medicaid days.
16
17
18 TAA = TA x (1/5.5)
19 DSHP = (HMD/TSMD) x TAA
20
21 Where:
22 TAA = total amount available.
23 TA = total appropriation.
24 DSHP = disproportionate share hospital payment.
25 HMD = hospital Medicaid days.
26 TSMD = total state Medicaid days.
27
28 (4) The following formulas shall be used to pay
29 disproportionate share dollars to public hospitals:
30 (a) For state mental health hospitals:
31
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SB 22-A First Engrossed
1 DSHP = (HMD/TMDMH) * TAAMH
2
3 shall be the difference between the federal cap
4 for Institutions for Mental Diseases and the
5 amounts paid under the mental health
6 disproportionate share program.
7
8 Where:
9
10 DSHP = disproportionate share hospital payment.
11 HMD = hospital Medicaid days.
12 TMDHH = total Medicaid days for state mental health
13 hospitals.
14 TAAMH = total amount available for mental health
15 hospitals.
16
17 (b) For non-state government owned or operated
18 hospitals with 3,300 or more Medicaid days:
19
20 DSHP = [(.82*HCCD/TCCD) + (.18*HMD/TMD)] * TAAPH
21 TAAPH = TAA - TAAMH
22
23 Where:
24
25 TAA = total available appropriation.
26 TAAPH = total amount available for public hospitals.
27 DSHP = disproportionate share hospital payments.
28 HMD = hospital Medicaid days.
29 TMD = total state Medicaid days for public hospitals.
30 HCCD = hospital charity care dollars.
31
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SB 22-A First Engrossed
1 TCCD = total state charity care dollars for public
2 non-state hospitals.
3
4 (c) For non-state government owned or operated
5 hospitals with less than 3,300 Medicaid days, a total of
6 $400,000 shall be distributed equally among these hospitals.
7 (5) The following formula shall be utilized by the
8 agency to determine the maximum disproportionate share rate to
9 be used to increase the Medicaid per diem rate for hospitals
10 that qualify pursuant to paragraphs (2)(a) and (b):al>
11
12 CCD MD
13 DSR = ( (........) x 4.5) + (........)
14 APD APD
15 Where:
16 APD = adjusted patient days.
17 CCD = charity care days.
18 DSR = disproportionate share rate.
19 MD = Medicaid days.
20
21 (6)(a) To calculate the total amount earned by all
22 hospitals under this section, hospitals with a
23 disproportionate share rate less than 50 percent shall divide
24 their Medicaid days by four, and hospitals with a
25 disproportionate share rate greater than or equal to 50
26 percent and with greater than 40,000 Medicaid days shall
27 multiply their Medicaid days by 1.5, and the following formula
28 shall be used by the agency to calculate the total amount
29 earned by all hospitals under this section:
30
31 TAE = BMPD x MD x DSP
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SB 22-A First Engrossed
1
2 Where:
3 TAE = total amount earned.
4 BMPD = base Medicaid per diem.
5 MD = Medicaid days.
6 DSP = disproportionate share percentage.
7
8 (5)(b) In no case shall total payments to a hospital
9 under this section, with the exception of public non-state
10 facilities or state facilities, exceed the total amount of
11 uncompensated charity care of the hospital, as determined by
12 the agency according to the most recent calendar year audited
13 data available at the beginning of each state fiscal year.
14 (7) The following criteria shall be used in
15 determining the disproportionate share percentage:
16 (a) If the disproportionate share rate is less than 10
17 percent, the disproportionate share percentage is zero and
18 there is no additional payment.
19 (b) If the disproportionate share rate is greater than
20 or equal to 10 percent, but less than 20 percent, then the
21 disproportionate share percentage is 1.8478498.
22 (c) If the disproportionate share rate is greater than
23 or equal to 20 percent, but less than 30 percent, then the
24 disproportionate share percentage is 3.4145488.
25 (d) If the disproportionate share rate is greater than
26 or equal to 30 percent, but less than 40 percent, then the
27 disproportionate share percentage is 6.3095734.
28 (e) If the disproportionate share rate is greater than
29 or equal to 40 percent, but less than 50 percent, then the
30 disproportionate share percentage is 11.6591440.
31
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SB 22-A First Engrossed
1 (f) If the disproportionate share rate is greater than
2 or equal to 50 percent, but less than 60 percent, then the
3 disproportionate share percentage is 73.5642254.
4 (g) If the disproportionate share rate is greater than
5 or equal to 60 percent but less than 72.5 percent, then the
6 disproportionate share percentage is 135.9356391.
7 (h) If the disproportionate share rate is greater than
8 or equal to 72.5 percent, then the disproportionate share
9 percentage is 170.
10 (8) The following formula shall be used by the agency
11 to calculate the total amount earned by all hospitals under
12 this section:
13
14 TAE = BMPD x MD x DSP
15
16 Where:
17 TAE = total amount earned.
18 BMPD = base Medicaid per diem.
19 MD = Medicaid days.
20 DSP = disproportionate share percentage.
21
22 (6)(9) The agency is authorized to receive funds from
23 local governments and other local political subdivisions for
24 the purpose of making payments, including federal matching
25 funds, through the Medicaid disproportionate share program.
26 Funds received from local governments for this purpose shall
27 be separately accounted for and shall not be commingled with
28 other state or local funds in any manner.
29 (7)(10) Payments made by the agency to hospitals
30 eligible to participate in this program shall be made in
31 accordance with federal rules and regulations.
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SB 22-A First Engrossed
1 (a) If the Federal Government prohibits, restricts, or
2 changes in any manner the methods by which funds are
3 distributed for this program, the agency shall not distribute
4 any additional funds and shall return all funds to the local
5 government from which the funds were received, except as
6 provided in paragraph (b).
7 (b) If the Federal Government imposes a restriction
8 that still permits a partial or different distribution, the
9 agency may continue to disburse funds to hospitals
10 participating in the disproportionate share program in a
11 federally approved manner, provided:
12 1. Each local government which contributes to the
13 disproportionate share program agrees to the new manner of
14 distribution as shown by a written document signed by the
15 governing authority of each local government; and
16 2. The Executive Office of the Governor, the Office of
17 Planning and Budgeting, the House of Representatives, and the
18 Senate are provided at least 7 days' prior notice of the
19 proposed change in the distribution, and do not disapprove
20 such change.
21 (c) No distribution shall be made under the
22 alternative method specified in paragraph (b) unless all
23 parties agree or unless all funds of those parties that
24 disagree which are not yet disbursed have been returned to
25 those parties.
26 (8)(11) Notwithstanding the provisions of chapter 216,
27 the Executive Office of the Governor is hereby authorized to
28 establish sufficient trust fund authority to implement the
29 disproportionate share program.
30 Section 9. Section 409.9112, Florida Statutes, is
31 amended to read:
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SB 22-A First Engrossed
1 409.9112 Disproportionate share program for regional
2 perinatal intensive care centers.--In addition to the payments
3 made under s. 409.911, the Agency for Health Care
4 Administration shall design and implement a system of making
5 disproportionate share payments to those hospitals that
6 participate in the regional perinatal intensive care center
7 program established pursuant to chapter 383. This system of
8 payments shall conform with federal requirements and shall
9 distribute funds in each fiscal year for which an
10 appropriation is made by making quarterly Medicaid payments.
11 Notwithstanding the provisions of s. 409.915, counties are
12 exempt from contributing toward the cost of this special
13 reimbursement for hospitals serving a disproportionate share
14 of low-income patients.
15 (1) The following formula shall be used by the agency
16 to calculate the total amount earned for hospitals that
17 participate in the regional perinatal intensive care center
18 program:
19
20 TAE = HDSP/THDSP
21
22 Where:
23
24 TAE = total amount earned by a regional perinatal
25 intensive care center.
26 HDSP = the prior state fiscal year regional perinatal
27 intensive care center disproportionate share payment to the
28 individual hospital.
29 THDSP = the prior state fiscal year total regional
30 perinatal intensive care center disproportionate share
31 payments to all hospitals.
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SB 22-A First Engrossed
1
2 (2) The total additional payment for hospitals that
3 participate in the regional perinatal intensive care center
4 program shall be calculated by the agency as follows:
5
6 TAP = TAE * TA
7
8 Where:
9
10 TAP = total additional payment for a regional perinatal
11 intensive care center.
12 TAE = total amount earned by a regional perinatal
13 intensive care center.
14 TA = total appropriation for the regional perinatal
15 intensive care center disproportionate share program.
16
17 TAE = DSR x BMPD x MD
18
19 Where:
20 TAE = total amount earned by a regional perinatal
21 intensive care center.
22 DSR = disproportionate share rate.
23 BMPD = base Medicaid per diem.
24 MD = Medicaid days.
25
26 (2) The total additional payment for hospitals that
27 participate in the regional perinatal intensive care center
28 program shall be calculated by the agency as follows:
29
30
31 TAE x TA
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SB 22-A First Engrossed
1 TAP = (............)
2 STAE
3
4 Where:
5 TAP = total additional payment for a regional perinatal
6 intensive care center.
7 TAE = total amount earned by a regional perinatal
8 intensive care center.
9 STAE = sum of total amount earned by each hospital that
10 participates in the regional perinatal intensive care center
11 program.
12 TA = total appropriation for the regional perinatal
13 intensive care disproportionate share program.
14
15 (3) In order to receive payments under this section, a
16 hospital must be participating in the regional perinatal
17 intensive care center program pursuant to chapter 383 and must
18 meet the following additional requirements:
19 (a) Agree to conform to all departmental and agency
20 requirements to ensure high quality in the provision of
21 services, including criteria adopted by departmental and
22 agency rule concerning staffing ratios, medical records,
23 standards of care, equipment, space, and such other standards
24 and criteria as the department and agency deem appropriate as
25 specified by rule.
26 (b) Agree to provide information to the department and
27 agency, in a form and manner to be prescribed by rule of the
28 department and agency, concerning the care provided to all
29 patients in neonatal intensive care centers and high-risk
30 maternity care.
31
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SB 22-A First Engrossed
1 (c) Agree to accept all patients for neonatal
2 intensive care and high-risk maternity care, regardless of
3 ability to pay, on a functional space-available basis.
4 (d) Agree to develop arrangements with other maternity
5 and neonatal care providers in the hospital's region for the
6 appropriate receipt and transfer of patients in need of
7 specialized maternity and neonatal intensive care services.
8 (e) Agree to establish and provide a developmental
9 evaluation and services program for certain high-risk
10 neonates, as prescribed and defined by rule of the department.
11 (f) Agree to sponsor a program of continuing education
12 in perinatal care for health care professionals within the
13 region of the hospital, as specified by rule.
14 (g) Agree to provide backup and referral services to
15 the department's county health departments and other
16 low-income perinatal providers within the hospital's region,
17 including the development of written agreements between these
18 organizations and the hospital.
19 (h) Agree to arrange for transportation for high-risk
20 obstetrical patients and neonates in need of transfer from the
21 community to the hospital or from the hospital to another more
22 appropriate facility.
23 (4) Hospitals which fail to comply with any of the
24 conditions in subsection (3) or the applicable rules of the
25 department and agency shall not receive any payments under
26 this section until full compliance is achieved. A hospital
27 which is not in compliance in two or more consecutive quarters
28 shall not receive its share of the funds. Any forfeited funds
29 shall be distributed by the remaining participating regional
30 perinatal intensive care center program hospitals.
31
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SB 22-A First Engrossed
1 Section 10. Subsection (1) of section 409.9116,
2 Florida Statutes, is amended to read:
3 409.9116 Disproportionate share/financial assistance
4 program for rural hospitals.--In addition to the payments made
5 under s. 409.911, the Agency for Health Care Administration
6 shall administer a federally matched disproportionate share
7 program and a state-funded financial assistance program for
8 statutory rural hospitals. The agency shall make
9 disproportionate share payments to statutory rural hospitals
10 that qualify for such payments and financial assistance
11 payments to statutory rural hospitals that do not qualify for
12 disproportionate share payments. The disproportionate share
13 program payments shall be limited by and conform with federal
14 requirements. Funds shall be distributed quarterly in each
15 fiscal year for which an appropriation is made.
16 Notwithstanding the provisions of s. 409.915, counties are
17 exempt from contributing toward the cost of this special
18 reimbursement for hospitals serving a disproportionate share
19 of low-income patients.
20 (1) The following formula shall be used by the agency
21 to calculate the total amount earned for hospitals that
22 participate in the rural hospital disproportionate share
23 program or the financial assistance program:
24
25 TAERH = (CCD + MDD)/TPD
26
27 Where:
28 CCD = total charity care-other, plus charity
29 care-Hill-Burton, minus 50 percent of unrestricted tax revenue
30 from local governments, and restricted funds for indigent
31 care, divided by gross revenue per adjusted patient day;
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SB 22-A First Engrossed
1 however, if CCD is less than zero, then zero shall be used for
2 CCD.
3 MDD = Medicaid inpatient days plus Medicaid HMO
4 inpatient days.
5 TPD = total inpatient days.
6 TAERH = total amount earned by each rural hospital.
7
8 In computing the total amount earned by each rural hospital,
9 the agency must use the average of the 3 most recent years of
10 actual data reported in accordance with s. 408.061(4)(a). The
11 agency shall provide a preliminary estimate of the payments
12 under the rural disproportionate share and financial
13 assistance programs to the rural hospitals by August 31 of
14 each state fiscal year for review. Each rural hospital shall
15 have 30 days to review the preliminary estimates of payments
16 and report any errors to the agency. The agency shall make any
17 corrections deemed necessary and compute the rural
18 disproportionate share and financial assistance program
19 payments.
20 Section 11. Section 409.9117, Florida Statutes, is
21 amended to read:
22 409.9117 Primary care disproportionate share
23 program.--
24 (1) If federal funds are available for
25 disproportionate share programs in addition to those otherwise
26 provided by law, there shall be created a primary care
27 disproportionate share program.
28 (2) The following formula shall be used by the agency
29 to calculate the total amount earned for hospitals that
30 participate in the primary care disproportionate share
31 program:
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SB 22-A First Engrossed
1
2 TAE = HDSP/THDSP
3
4 Where:
5
6 TAE = total amount earned by a hospital participating
7 in the primary care disproportionate share program.
8 HDSP = the prior state fiscal year primary care
9 disproportionate share payment to the individual hospital.
10 THDSP = the prior state fiscal year total primary care
11 disproportionate share payments to all hospitals.
12
13 (3) The total additional payment for hospitals that
14 participate in the primary care disproportionate share program
15 shall be calculated by the agency as follows:
16
17 TAP = TAE * TA
18
19 Where:
20
21 TAP = total additional payment for a primary care
22 hospital.
23 TAE = total amount earned by a primary care hospital.
24 TA = total appropriation for the primary care
25 disproportionate share program.
26 (4)(2) In the establishment and funding of this
27 program, the agency shall use the following criteria in
28 addition to those specified in s. 409.911, payments may not be
29 made to a hospital unless the hospital agrees to:
30 (a) Cooperate with a Medicaid prepaid health plan, if
31 one exists in the community.
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SB 22-A First Engrossed
1 (b) Ensure the availability of primary and specialty
2 care physicians to Medicaid recipients who are not enrolled in
3 a prepaid capitated arrangement and who are in need of access
4 to such physicians.
5 (c) Coordinate and provide primary care services free
6 of charge, except copayments, to all persons with incomes up
7 to 100 percent of the federal poverty level who are not
8 otherwise covered by Medicaid or another program administered
9 by a governmental entity, and to provide such services based
10 on a sliding fee scale to all persons with incomes up to 200
11 percent of the federal poverty level who are not otherwise
12 covered by Medicaid or another program administered by a
13 governmental entity, except that eligibility may be limited to
14 persons who reside within a more limited area, as agreed to by
15 the agency and the hospital.
16 (d) Contract with any federally qualified health
17 center, if one exists within the agreed geopolitical
18 boundaries, concerning the provision of primary care services,
19 in order to guarantee delivery of services in a nonduplicative
20 fashion, and to provide for referral arrangements, privileges,
21 and admissions, as appropriate. The hospital shall agree to
22 provide at an onsite or offsite facility primary care services
23 within 24 hours to which all Medicaid recipients and persons
24 eligible under this paragraph who do not require emergency
25 room services are referred during normal daylight hours.
26 (e) Cooperate with the agency, the county, and other
27 entities to ensure the provision of certain public health
28 services, case management, referral and acceptance of
29 patients, and sharing of epidemiological data, as the agency
30 and the hospital find mutually necessary and desirable to
31
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SB 22-A First Engrossed
1 promote and protect the public health within the agreed
2 geopolitical boundaries.
3 (f) In cooperation with the county in which the
4 hospital resides, develop a low-cost, outpatient, prepaid
5 health care program to persons who are not eligible for the
6 Medicaid program, and who reside within the area.
7 (g) Provide inpatient services to residents within the
8 area who are not eligible for Medicaid or Medicare, and who do
9 not have private health insurance, regardless of ability to
10 pay, on the basis of available space, except that nothing
11 shall prevent the hospital from establishing bill collection
12 programs based on ability to pay.
13 (h) Work with the Florida Healthy Kids Corporation,
14 the Florida Health Care Purchasing Cooperative, and business
15 health coalitions, as appropriate, to develop a feasibility
16 study and plan to provide a low-cost comprehensive health
17 insurance plan to persons who reside within the area and who
18 do not have access to such a plan.
19 (i) Work with public health officials and other
20 experts to provide community health education and prevention
21 activities designed to promote healthy lifestyles and
22 appropriate use of health services.
23 (j) Work with the local health council to develop a
24 plan for promoting access to affordable health care services
25 for all persons who reside within the area, including, but not
26 limited to, public health services, primary care services,
27 inpatient services, and affordable health insurance generally.
28
29 Any hospital that fails to comply with any of the provisions
30 of this subsection, or any other contractual condition, may
31
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SB 22-A First Engrossed
1 not receive payments under this section until full compliance
2 is achieved.
3 Section 12. Section 409.9119, Florida Statutes, is
4 repealed.
5 Section 13. Paragraph (d) of subsection (3) and
6 paragraph (a) of subsection (38) of section 409.912, Florida
7 Statutes, are amended, and subsection (41) is added to that
8 section, to read:
9 409.912 Cost-effective purchasing of health care.--The
10 agency shall purchase goods and services for Medicaid
11 recipients in the most cost-effective manner consistent with
12 the delivery of quality medical care. The agency shall
13 maximize the use of prepaid per capita and prepaid aggregate
14 fixed-sum basis services when appropriate and other
15 alternative service delivery and reimbursement methodologies,
16 including competitive bidding pursuant to s. 287.057, designed
17 to facilitate the cost-effective purchase of a case-managed
18 continuum of care. The agency shall also require providers to
19 minimize the exposure of recipients to the need for acute
20 inpatient, custodial, and other institutional care and the
21 inappropriate or unnecessary use of high-cost services. The
22 agency may establish prior authorization requirements for
23 certain populations of Medicaid beneficiaries, certain drug
24 classes, or particular drugs to prevent fraud, abuse, overuse,
25 and possible dangerous drug interactions. The Pharmaceutical
26 and Therapeutics Committee shall make recommendations to the
27 agency on drugs for which prior authorization is required. The
28 agency shall inform the Pharmaceutical and Therapeutics
29 Committee of its decisions regarding drugs subject to prior
30 authorization.
31 (3) The agency may contract with:
39
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SB 22-A First Engrossed
1 (d) A provider service network No more than four
2 provider service networks for demonstration projects to test
3 Medicaid direct contracting. The demonstration projects may be
4 reimbursed on a fee-for-service or prepaid basis. A provider
5 service network which is reimbursed by the agency on a prepaid
6 basis shall be exempt from parts I and III of chapter 641, but
7 must meet appropriate financial reserve, quality assurance,
8 and patient rights requirements as established by the agency.
9 The agency shall award contracts on a competitive bid basis
10 and shall select bidders based upon price and quality of care.
11 Medicaid recipients assigned to a demonstration project shall
12 be chosen equally from those who would otherwise have been
13 assigned to prepaid plans and MediPass. The agency is
14 authorized to seek federal Medicaid waivers as necessary to
15 implement the provisions of this section. A demonstration
16 project awarded pursuant to this paragraph shall be for 4
17 years from the date of implementation.
18 (38)(a) The agency shall implement a Medicaid
19 prescribed-drug spending-control program that includes the
20 following components:
21 1. Medicaid prescribed-drug coverage for brand-name
22 drugs for adult Medicaid recipients is limited to the
23 dispensing of four brand-name drugs per month per recipient.
24 Children are exempt from this restriction. Antiretroviral
25 agents are excluded from this limitation. No requirements for
26 prior authorization or other restrictions on medications used
27 to treat mental illnesses such as schizophrenia, severe
28 depression, or bipolar disorder may be imposed on Medicaid
29 recipients. Medications that will be available without
30 restriction for persons with mental illnesses include atypical
31 antipsychotic medications, conventional antipsychotic
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1 medications, selective serotonin reuptake inhibitors, and
2 other medications used for the treatment of serious mental
3 illnesses. The agency shall also limit the amount of a
4 prescribed drug dispensed to no more than a 34-day supply. The
5 agency shall continue to provide unlimited generic drugs,
6 contraceptive drugs and items, and diabetic supplies. Although
7 a drug may be included on the preferred drug formulary, it
8 would not be exempt from the four-brand limit. The agency may
9 authorize exceptions to the brand-name-drug restriction based
10 upon the treatment needs of the patients, only when such
11 exceptions are based on prior consultation provided by the
12 agency or an agency contractor, but the agency must establish
13 procedures to ensure that:
14 a. There will be a response to a request for prior
15 consultation by telephone or other telecommunication device
16 within 24 hours after receipt of a request for prior
17 consultation;
18 b. A 72-hour supply of the drug prescribed will be
19 provided in an emergency or when the agency does not provide a
20 response within 24 hours as required by sub-subparagraph a.;
21 and
22 c. Except for the exception for nursing home residents
23 and other institutionalized adults and Except for drugs on the
24 restricted formulary for which prior authorization may be
25 sought by an institutional or community pharmacy, prior
26 authorization for an exception to the brand-name-drug
27 restriction is sought by the prescriber and not by the
28 pharmacy. When prior authorization is granted for a patient in
29 an institutional setting beyond the brand-name-drug
30 restriction, such approval is authorized for 12 months and
31 monthly prior authorization is not required for that patient.
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1 2. Reimbursement to pharmacies for Medicaid prescribed
2 drugs shall be set at the average wholesale price less 13.25
3 percent.
4 3. The agency shall develop and implement a process
5 for managing the drug therapies of Medicaid recipients who are
6 using significant numbers of prescribed drugs each month. The
7 management process may include, but is not limited to,
8 comprehensive, physician-directed medical-record reviews,
9 claims analyses, and case evaluations to determine the medical
10 necessity and appropriateness of a patient's treatment plan
11 and drug therapies. The agency may contract with a private
12 organization to provide drug-program-management services. The
13 Medicaid drug benefit management program shall include
14 initiatives to manage drug therapies for HIV/AIDS patients,
15 patients using 20 or more unique prescriptions in a 180-day
16 period, and the top 1,000 patients in annual spending.
17 4. The agency may limit the size of its pharmacy
18 network based on need, competitive bidding, price
19 negotiations, credentialing, or similar criteria. The agency
20 shall give special consideration to rural areas in determining
21 the size and location of pharmacies included in the Medicaid
22 pharmacy network. A pharmacy credentialing process may include
23 criteria such as a pharmacy's full-service status, location,
24 size, patient educational programs, patient consultation,
25 disease-management services, and other characteristics. The
26 agency may impose a moratorium on Medicaid pharmacy enrollment
27 when it is determined that it has a sufficient number of
28 Medicaid-participating providers.
29 5. The agency shall develop and implement a program
30 that requires Medicaid practitioners who prescribe drugs to
31 use a counterfeit-proof prescription pad for Medicaid
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1 prescriptions. The agency shall require the use of
2 standardized counterfeit-proof prescription pads by
3 Medicaid-participating prescribers or prescribers who write
4 prescriptions for Medicaid recipients. The agency may
5 implement the program in targeted geographic areas or
6 statewide.
7 6. The agency may enter into arrangements that require
8 manufacturers of generic drugs prescribed to Medicaid
9 recipients to provide rebates of at least 15.1 percent of the
10 average manufacturer price for the manufacturer's generic
11 products. These arrangements shall require that if a
12 generic-drug manufacturer pays federal rebates for
13 Medicaid-reimbursed drugs at a level below 15.1 percent, the
14 manufacturer must provide a supplemental rebate to the state
15 in an amount necessary to achieve a 15.1-percent rebate level.
16 7. The agency may establish a preferred drug formulary
17 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
18 establishment of such formulary, it is authorized to negotiate
19 supplemental rebates from manufacturers that are in addition
20 to those required by Title XIX of the Social Security Act and
21 at no less than 10 percent of the average manufacturer price
22 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
23 unless the federal or supplemental rebate, or both, equals or
24 exceeds 25 percent. There is no upper limit on the
25 supplemental rebates the agency may negotiate. The agency may
26 determine that specific products, brand-name or generic, are
27 competitive at lower rebate percentages. Agreement to pay the
28 minimum supplemental rebate percentage will guarantee a
29 manufacturer that the Medicaid Pharmaceutical and Therapeutics
30 Committee will consider a product for inclusion on the
31 preferred drug formulary. However, a pharmaceutical
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1 manufacturer is not guaranteed placement on the formulary by
2 simply paying the minimum supplemental rebate. Agency
3 decisions will be made on the clinical efficacy of a drug and
4 recommendations of the Medicaid Pharmaceutical and
5 Therapeutics Committee, as well as the price of competing
6 products minus federal and state rebates. The agency is
7 authorized to contract with an outside agency or contractor to
8 conduct negotiations for supplemental rebates. For the
9 purposes of this section, the term "supplemental rebates" may
10 include, at the agency's discretion, cash rebates and other
11 program benefits that offset a Medicaid expenditure. Effective
12 July 1, 2003, value-added programs as a substitution for
13 supplemental rebates are prohibited. Such other program
14 benefits may include, but are not limited to, disease
15 management programs, drug product donation programs, drug
16 utilization control programs, prescriber and beneficiary
17 counseling and education, fraud and abuse initiatives, and
18 other services or administrative investments with guaranteed
19 savings to the Medicaid program in the same year the rebate
20 reduction is included in the General Appropriations Act. The
21 agency is authorized to seek any federal waivers to implement
22 this initiative.
23 8. The agency shall establish an advisory committee
24 for the purposes of studying the feasibility of using a
25 restricted drug formulary for nursing home residents and other
26 institutionalized adults. The committee shall be comprised of
27 seven members appointed by the Secretary of Health Care
28 Administration. The committee members shall include two
29 physicians licensed under chapter 458 or chapter 459; three
30 pharmacists licensed under chapter 465 and appointed from a
31 list of recommendations provided by the Florida Long-Term Care
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1 Pharmacy Alliance; and two pharmacists licensed under chapter
2 465.
3 9. The Agency for Health Care Administration shall
4 expand home delivery of pharmacy products. To assist Medicaid
5 patients in securing their prescriptions and reduce program
6 costs, the agency shall expand its current mail-order-pharmacy
7 diabetes-supply program to include all generic and brand-name
8 drugs used by Medicaid patients with diabetes. Medicaid
9 recipients in the current program may obtain nondiabetes drugs
10 on a voluntary basis. This initiative is limited to the
11 geographic area covered by the current contract. The agency
12 may seek and implement any federal waivers necessary to
13 implement this subparagraph.
14 (41) The agency shall develop and implement a
15 utilization management program for Medicaid-eligible
16 recipients younger than 21 years of age for the management of
17 occupational, physical, respiratory, and speech therapies. The
18 agency shall establish a utilization program that may require
19 prior authorization in order to ensure medically necessary and
20 cost-effective treatments. The program shall be operated in
21 accordance with a federally approved waiver program or state
22 plan amendment. The agency may seek a federal waiver or state
23 plan amendment to implement this program. The agency may also
24 competitively procure these services from an outside vendor on
25 a regional or statewide basis.
26 Section 14. Paragraphs (f) and (k) of subsection (2)
27 of section 409.9122, Florida Statutes, are amended to read:
28 409.9122 Mandatory Medicaid managed care enrollment;
29 programs and procedures.--
30 (2)
31
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1 (f) When a Medicaid recipient does not choose a
2 managed care plan or MediPass provider, the agency shall
3 assign the Medicaid recipient to a managed care plan or
4 MediPass provider. Medicaid recipients who are subject to
5 mandatory assignment but who fail to make a choice shall be
6 assigned to managed care plans until an enrollment of 40 45
7 percent in MediPass and 60 55 percent in managed care plans is
8 achieved. Once this enrollment is achieved, the assignments
9 shall be divided in order to maintain an enrollment in
10 MediPass and managed care plans which is in a 40 45 percent
11 and 60 55 percent proportion, respectively. Thereafter,
12 assignment of Medicaid recipients who fail to make a choice
13 shall be based proportionally on the preferences of recipients
14 who have made a choice in the previous period. Such
15 proportions shall be revised at least quarterly to reflect an
16 update of the preferences of Medicaid recipients. The agency
17 shall disproportionately assign Medicaid-eligible recipients
18 who are required to but have failed to make a choice of
19 managed care plan or MediPass, including children, and who are
20 to be assigned to the MediPass program to children's networks
21 as described in s. 409.912(3)(g), Children's Medical Services
22 network as defined in s. 391.021, exclusive provider
23 organizations, provider service networks, minority physician
24 networks, and pediatric emergency department diversion
25 programs authorized by this chapter or the General
26 Appropriations Act, in such manner as the agency deems
27 appropriate, until the agency has determined that the networks
28 and programs have sufficient numbers to be economically
29 operated. For purposes of this paragraph, when referring to
30 assignment, the term "managed care plans" includes health
31 maintenance organizations, exclusive provider organizations,
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1 provider service networks, minority physician networks,
2 Children's Medical Services network, and pediatric emergency
3 department diversion programs authorized by this chapter or
4 the General Appropriations Act. Beginning July 1, 2002, the
5 agency shall assign all children in families who have not made
6 a choice of a managed care plan or MediPass in the required
7 timeframe to a pediatric emergency room diversion program
8 described in s. 409.912(3)(g) that, as of July 1, 2002, has
9 executed a contract with the agency, until such network or
10 program has reached an enrollment of 15,000 children. Once
11 that minimum enrollment level has been reached, the agency
12 shall assign children who have not chosen a managed care plan
13 or MediPass to the network or program in a manner that
14 maintains the minimum enrollment in the network or program at
15 not less than 15,000 children. To the extent practicable, the
16 agency shall also assign all eligible children in the same
17 family to such network or program. When making assignments,
18 the agency shall take into account the following 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 (k) When a Medicaid recipient does not choose a
2 managed care plan or MediPass provider, the agency shall
3 assign the Medicaid recipient to a managed care plan, except
4 in those counties in which there are fewer than two managed
5 care plans accepting Medicaid enrollees, in which case
6 assignment shall be to a managed care plan or a MediPass
7 provider. Medicaid recipients in counties with fewer than two
8 managed care plans accepting Medicaid enrollees who are
9 subject to mandatory assignment but who fail to make a choice
10 shall be assigned to managed care plans until an enrollment of
11 40 45 percent in MediPass and 60 55 percent in managed care
12 plans is achieved. Once that enrollment is achieved, the
13 assignments shall be divided in order to maintain an
14 enrollment in MediPass and managed care plans which is in a 40
15 45 percent and 60 55 percent proportion, respectively. In
16 geographic areas where the agency is contracting for the
17 provision of comprehensive behavioral health services through
18 a capitated prepaid arrangement, recipients who fail to make a
19 choice shall be assigned equally to MediPass or a managed care
20 plan. For purposes of this paragraph, when referring to
21 assignment, the term "managed care plans" includes exclusive
22 provider organizations, provider service networks, Children's
23 Medical Services network, minority physician networks, and
24 pediatric emergency department diversion programs authorized
25 by this chapter or the General Appropriations Act. When making
26 assignments, the agency shall take into account the following
27 criteria:
28 1. A managed care plan has sufficient network capacity
29 to meet the need of members.
30 2. The managed care plan or MediPass has previously
31 enrolled the recipient as a member, or one of the managed care
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1 plan's primary care providers or MediPass providers has
2 previously provided health care to the recipient.
3 3. The agency has knowledge that the member has
4 previously expressed a preference for a particular managed
5 care plan or MediPass provider as indicated by Medicaid
6 fee-for-service claims data, but has failed to make a choice.
7 4. The managed care plan's or MediPass primary care
8 providers are geographically accessible to the recipient's
9 residence.
10 5. The agency has authority to make mandatory
11 assignments based on quality of service and performance of
12 managed care plans.
13 Section 15. Paragraph (q) of subsection (2) of section
14 409.815, Florida Statutes, is amended to read:
15 409.815 Health benefits coverage; limitations.--
16 (2) BENCHMARK BENEFITS.--In order for health benefits
17 coverage to qualify for premium assistance payments for an
18 eligible child under ss. 409.810-409.820, the health benefits
19 coverage, except for coverage under Medicaid and Medikids,
20 must include the following minimum benefits, as medically
21 necessary.
22 (q) Dental services.--Subject to a specific
23 appropriation for this benefit, Covered services include those
24 dental services provided to children by the Florida Medicaid
25 program under s. 409.906(5), up to a maximum benefit of $500
26 per enrollee per year.
27 Section 16. If any law that is amended by this act was
28 also amended by a law enacted at the 2003 Regular Session of
29 the Legislature, such laws shall be construed as if they had
30 been enacted during the same session of the Legislature, and
31 full effect should be given to each if that is possible.
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1 Section 17. Except as otherwise expressly provided in
2 this act, this act shall take effect July 1, 2003.
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