HB 0035A 2003
1	CHAMBER ACTION
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6	The Committee on Appropriations recommends the following:
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8	Committee Substitute
9	Remove the entire bill and insert:
10	A bill to be entitled
11	An act relating to health care; amending s. 400.179, F.S.;
12	retaining a fee against leasehold licensees to meet
13	bonding requirements to cover Medicaid underpayments and
14	overpayments; amending s. 409.811, F.S.; defining "Florida
15	Healthy Kids" and "Managed care plan" for purposes of the
16	Florida Kidcare Act; amending s. 409.813, F.S.; revising
17	provisions for components of the Florida Kidcare program;
18	amending s. 409.8132, F.S.; providing a cross reference;
19	creating s. 409.8133, F.S.; creating the Florida Healthy
20	Kids program component of the Florida Kidcare program;
21	providing for administration; providing an exemption from
22	insurance licensure; providing for benefits, eligibility,
23	and enrollment; amending s. 409.814, F.S.; revising
24	Florida Kidcare program eligibility provisions; amending
25	s. 409.818, F.S.; revising provisions for administration
26	of the Florida Kidcare Act; providing for the Florida
27	Healthy Kids program; revising premium assistance payment
28	requirements; amending s. 409.901, F.S.; revising the
29	definition of "third party"; amending s. 409.904, F.S.;
30	revising eligibility requirements for certain optional
31	payments for medical assistance and related services;
32	amending s. 409.906, F.S.; revising requirements for
33	payment of optional Medicaid services; limiting provision
34	of dental, hearing, and visual services; amending s.
35	409.9081, F.S.; providing coinsurance requirements for
36	prescription drugs; providing copayment requirements for
37	hospital outpatient emergency department services;
38	amending s. 409.911, F.S.; revising formulas for payment
39	under the disproportionate share program; revising
40	definitions; providing for use of audited data; amending
41	s. 409.9112, F.S.; revising formulas for payment under the
42	disproportionate share program for regional perinatal
43	intensive care centers; amending s. 409.9117, F.S.;
44	revising formulas for payment under the primary care
45	disproportionate share program; revising criteria for such
46	payments; amending s. 409.9119, F.S.; revising criteria
47	for payment under the disproportionate share program for
48	specialty hospitals for children; amending s. 409.912,
49	F.S.; providing for the Agency for Health Care
50	Administration to contract with a service network;
51	deleting provisions for service network demonstration
52	projects; providing for contracting to provide Medicaid
53	covered dental services; amending s. 409.9122, F.S.;
54	revising provisions for assignment to a managed care plan
55	by the agency; amending s. 409.913, F.S.; providing for
56	oversight of Medicaid by authorized agents of the Agency
57	for Health Care Administration; amending s. 430.502, F.S.;
58	requiring the Agency for Health Care Administration and
59	the Department of Health to seek and implement a Medicaid
60	home and community-based waiver for persons with
61	Alzheimer's disease; requiring the development of waiver
62	program standards; providing for consultation with the
63	presiding officers of the Legislature; providing for a
64	contingent future repeal of such waiver program; amending
65	s. 624.91, F.S.; revising duties of the Florida Healthy
66	Kids Corporation; removing a provision for coordination of
67	benefits; removing provisions for contracting for
68	administrative services and insurance coverage; revising
69	membership of the board of directors of the corporation;
70	amending s. 624.915, F.S.; providing that excess funds of
71	the Florida Healthy Kids Corporation be remitted to the
72	agency to be used for the Florida Kidcare program;
73	repealing s. 57, ch. 98-288, Laws of Florida, relating to
74	future review and repeal of the "Florida Kidcare Act"
75	based on specified changes in federal policy; providing
76	for construction of the act in pari materia with laws
77	enacted during the Regular Session of the Legislature;
78	providing effective dates.
79
80	Be It Enacted by the Legislature of the State of Florida:
81
82	Section 1. Effective upon this act becoming a law,
83	paragraph (d) of subsection (5) of section 400.179, Florida
84	Statutes, is amended to read:
85	400.179 Sale or transfer of ownership of a nursing
86	facility; liability for Medicaid underpayments and
87	overpayments.--
88	(5) Because any transfer of a nursing facility may expose
89	the fact that Medicaid may have underpaid or overpaid the
90	transferor, and because in most instances, any such underpayment
91	or overpayment can only be determined following a formal field
92	audit, the liabilities for any such underpayments or
93	overpayments shall be as follows:
94	(d) Where the transfer involves a facility that has been
95	leased by the transferor:
96	1. The transferee shall, as a condition to being issued a
97	license by the agency, acquire, maintain, and provide proof to
98	the agency of a bond with a term of 30 months, renewable
99	annually, in an amount not less than the total of 3 months
100	Medicaid payments to the facility computed on the basis of the
101	preceding 12-month average Medicaid payments to the facility.
102	2. A leasehold licensee may meet the requirements of
103	subparagraph 1. by payment of a nonrefundable fee, paid at
104	initial licensure, paid at the time of any subsequent change of
105	ownership, and paid at the time of any subsequent annual license
106	renewal, in the amount of 2 percent of the total of 3 months'
107	Medicaid payments to the facility computed on the basis of the
108	preceding 12-month average Medicaid payments to the facility. If
109	a preceding 12-month average is not available, projected
110	Medicaid payments may be used. The fee shall be deposited into
111	the Health Care Trust Fund and shall be accounted for separately
112	as a Medicaid nursing home overpayment account. These fees shall
113	be used at the sole discretion of the agency to repay nursing
114	home Medicaid overpayments. Payment of this fee shall not
115	release the licensee from any liability for any Medicaid
116	overpayments, nor shall payment bar the agency from seeking to
117	recoup overpayments from the licensee and any other liable
118	party. As a condition of exercising this lease bond alternative,
119	licensees paying this fee must maintain an existing lease bond
120	through the end of the 30-month term period of that bond. The
121	agency is herein granted specific authority to promulgate all
122	rules pertaining to the administration and management of this
123	account, including withdrawals from the account, subject to
124	federal review and approval. This subparagraph is repealed on
125	June 30, 2003.This provision shall take effect upon becoming
126	law and shall apply to any leasehold license application.
127	a. The financial viability of the Medicaid nursing home
128	overpayment account shall be determined by the agency through
129	annual review of the account balance and the amount of total
130	outstanding, unpaid Medicaid overpayments owing from leasehold
131	licensees to the agency as determined by final agency audits.
132	b. The agency, in consultation with the Florida Health
133	Care Association and the Florida Association of Homes for the
134	Aging, shall study and make recommendations on the minimum
135	amount to be held in reserve to protect against Medicaid
136	overpayments to leasehold licensees and on the issue of
137	successor liability for Medicaid overpayments upon sale or
138	transfer of ownership of a nursing facility. The agency shall
139	submit the findings and recommendations of the study to the
140	Governor, the President of the Senate, and the Speaker of the
141	House of Representatives by January 1, 2003.
142	3. The leasehold licensee may meet the bond requirement
143	through other arrangements acceptable to the agency. The agency
144	is herein granted specific authority to promulgate rules
145	pertaining to lease bond arrangements.
146	4. All existing nursing facility licensees, operating the
147	facility as a leasehold, shall acquire, maintain, and provide
148	proof to the agency of the 30-month bond required in
149	subparagraph 1., above, on and after July 1, 1993, for each
150	license renewal.
151	5. It shall be the responsibility of all nursing facility
152	operators, operating the facility as a leasehold, to renew the
153	30-month bond and to provide proof of such renewal to the agency
154	annually at the time of application for license renewal.
155	6. Any failure of the nursing facility operator to
156	acquire, maintain, renew annually, or provide proof to the
157	agency shall be grounds for the agency to deny, cancel, revoke,
158	or suspend the facility license to operate such facility and to
159	take any further action, including, but not limited to,
160	enjoining the facility, asserting a moratorium, or applying for
161	a receiver, deemed necessary to ensure compliance with this
162	section and to safeguard and protect the health, safety, and
163	welfare of the facility's residents. A lease agreement required
164	as a condition of bond financing or refinancing under s. 154.213
165	by a health facilities authority or required under s. 159.30 by
166	a county or municipality is not a leasehold for purposes of this
167	paragraph and is not subject to the bond requirement of this
168	paragraph.
169	Section 2. Subsections (14), (15), (16), (17), (18), (19),
170	(20), (21), (22), (23), (24), (25), (26), and (27) of section
171	409.811, Florida Statutes, are renumbered as subsections (15),
172	(16), (17), (19), (20), (21), (22), (23), (24), (25), (26),
173	(27), (28), and (29), respectively, and new subsections (14) and
174	(18) are added to said section to read:
175	409.811 Definitions relating to Florida Kidcare Act.--As
176	used in ss. 409.810-409.820, the term:
177	(14) "Florida Healthy Kids" means a component of the
178	Florida Kidcare program of medical assistance for children from
179	5 through 18 years of age with incomes or assets too high to
180	qualify for Medicaid.
181	(18) "Managed care plan" means a health maintenance
182	organization authorized pursuant to chapter 641 or a prepaid
183	health plan authorized pursuant to s. 409.912.
184	Section 3. Subsection (3) of section 409.813, Florida
185	Statutes, is amended to read:
186	409.813 Program components; entitlement and
187	nonentitlement.--The Florida Kidcare program includes health
188	benefits coverage provided to children through:
189	(3) The Florida Healthy Kids programCorporationas
190	created in s. 409.8133624.91;
191
192	Except for coverage under the Medicaid program, coverage under
193	the Florida Kidcare program is not an entitlement. No cause of
194	action shall arise against the state, the department, the
195	Department of Children and Family Services, or the agency for
196	failure to make health services available to any person under
197	ss. 409.810-409.820.
198	Section 4. Subsection (7) of section 409.8132, Florida
199	Statutes, is amended to read:
200	409.8132 Medikids program component.--
201	(7) ENROLLMENT.--Enrollment in the Medikids program
202	component may only occur during periodic open enrollment periods
203	as specified by the agency. An applicant may apply for
204	enrollment in the Medikids program component and proceed through
205	the eligibility determination process at any time throughout the
206	year. However, enrollment in Medikids shall not begin until the
207	next open enrollment period; and a child may not receive
208	services under the Medikids program until the child is enrolled
209	in a managed care plan as defined in s. 409.811 or inMediPass.
210	In addition, once determined eligible, an applicant may receive
211	choice counseling and select a managed care plan or MediPass.
212	The agency may initiate mandatory assignment for a Medikids
213	applicant who has not chosen a managed care plan or MediPass
214	provider after the applicant's voluntary choice period ends. An
215	applicant may select MediPass under the Medikids program
216	component only in counties that have fewer than two managed care
217	plans available to serve Medicaid recipients and only if the
218	federal Health Care Financing Administration determines that
219	MediPass constitutes "health insurance coverage" as defined in
220	Title XXI of the Social Security Act.
221	Section 5. Section 409.8133, Florida Statutes, is created
222	to read:
223	409.8133 Florida Healthy Kids program component.--
224	(1) PROGRAM COMPONENT CREATED; PURPOSE.--The Florida
225	Healthy Kids program component is created in the Agency for
226	Health Care Administration to provide health care services under
227	the Florida Kidcare program to eligible children using the
228	administrative structure and provider network of the Medicaid
229	program.
230	(2) ADMINISTRATION.--The Florida Healthy Kids program
231	shall be administered by the Agency for Health Care
232	Administration and the Florida Healthy Kids Corporation.
233	(a) The agency is designated as the state agency
234	authorized to make payments and contract for medical assistance
235	and related services for the Florida Healthy Kids program
236	component of the Florida Kidcare program. Payments shall be
237	made, subject to any limitations or directions in the General
238	Appropriations Act, only for covered services provided to
239	eligible children by qualified health care providers under the
240	Florida Kidcare program.
241	(b) The Florida Healthy Kids Corporation shall perform its
242	functions as authorized in s. 624.91, including eligibility
243	determinations for participation in the Florida Healthy Kids
244	program.
245	(3) INSURANCE LICENSURE NOT REQUIRED.--The Florida Healthy
246	Kids program component shall not be subject to the licensing
247	requirements of the Florida Insurance Code or rules of the
248	Office of Insurance Regulation.
249	(4) BENEFITS.--Benefits provided under the Florida Healthy
250	Kids program component shall be established by the board of
251	directors of the Florida Healthy Kids Corporation. The benefits
252	shall comply with s. 409.815.
253	(5) ELIGIBILITY.--
254	(a) A child who has attained the age of 5 years but who is
255	under the age of 19 years is eligible to enroll in the Florida
256	Healthy Kids program component of the Florida Kidcare program if
257	the child is a member of a family that has a family income which
258	exceeds the Medicaid applicable income level as specified in s.
259	409.903. A child who is eligible for the Florida Healthy Kids
260	program may elect to enroll in employer-sponsored group
261	coverage.
262	(b) The provisions of s. 409.814 shall be applicable to
263	the Florida Healthy Kids program.
264	(6) ENROLLMENT.--Enrollment in the Florida Healthy Kids
265	program component shall be done by the Florida Healthy Kids
266	Corporation in accordance with s. 624.91.
267	Section 6. Paragraph (b) of subsection (4) and paragraph
268	(c) of subsection (5) of section 409.814, Florida Statutes, are
269	amended to read:
270	409.814 Eligibility.--A child whose family income is equal
271	to or below 200 percent of the federal poverty level is eligible
272	for the Florida Kidcare program as provided in this section. In
273	determining the eligibility of such a child, an assets test is
274	not required. An applicant under 19 years of age who, based on a
275	complete application, appears to be eligible for the Medicaid
276	component of the Florida Kidcare program is presumed eligible
277	for coverage under Medicaid, subject to federal rules. A child
278	who has been deemed presumptively eligible for Medicaid shall
279	not be enrolled in a managed care plan until the child's full
280	eligibility determination for Medicaid has been completed. The
281	Florida Healthy Kids Corporation may, subject to compliance with
282	applicable requirements of the Agency for Health Care
283	Administration and the Department of Children and Family
284	Services, be designated as an entity to conduct presumptive
285	eligibility determinations. An applicant under 19 years of age
286	who, based on a complete application, appears to be eligible for
287	the Medikids, Florida Healthy Kids, or Children's Medical
288	Services network program component, who is screened as
289	ineligible for Medicaid and prior to the monthly verification of
290	the applicant's enrollment in Medicaid or of eligibility for
291	coverage under the state employee health benefit plan, may be
292	enrolled in and begin receiving coverage from the appropriate
293	program component on the first day of the month following the
294	receipt of a completed application. For enrollment in the
295	Children's Medical Services network, a complete application
296	includes the medical or behavioral health screening. If, after
297	verification, an individual is determined to be ineligible for
298	coverage, he or she must be disenrolled from the respective
299	Title XXI-funded Kidcare program component.
300	(4) The following children are not eligible to receive
301	premium assistance for health benefits coverage under ss.
302	409.810-409.820, except under Medicaid if the child would have
303	been eligible for Medicaid under s. 409.903 or s. 409.904 as of
304	June 1, 1997:
305	(b) A child who is covered under a group health benefit
306	plan or under other health insurance coverage, excluding
307	coverage provided under the Florida Healthy Kids program
308	Corporation as established under s. 409.8133624.91.
309	(5) A child whose family income is above 200 percent of
310	the federal poverty level or a child who is excluded under the
311	provisions of subsection (4) may participate in the Florida
312	Kidcare program, excluding the Medicaid program, but is subject
313	to the following provisions:
314	(c) The board of directors of the Florida Healthy Kids
315	Corporation is authorized to place limits on enrollment in the
316	Florida Healthy Kids program byofthese children in order to
317	avoid adverse selection. In addition, the board is authorized to
318	offer a reduced benefit package to these children in order to
319	limit program costs for such families. The number of children
320	participating in the Florida Healthy Kids program whose family
321	income exceeds 200 percent of the federal poverty level must not
322	exceed 10 percent of total enrollees in the Florida Healthy Kids
323	program.
324	Section 7. Paragraph (c) of subsection (1), paragraphs
325	(a), (c), and (g) of subsection (3), and subsections (4) and (5)
326	of section 409.818, Florida Statutes, are amended to read:
327	409.818 Administration.--In order to implement ss.
328	409.810-409.820, the following agencies shall have the following
329	duties:
330	(1) The Department of Children and Family Services shall:
331	(c) Inform program applicants about eligibility
332	determinations and provide information about eligibility of
333	applicants to Medicaid, Medikids, the Children's Medical
334	Services network, and the Florida Healthy Kids program
335	Corporation, and to insurers and their agents, through a
336	centralized coordinating office.
337	(3) The Agency for Health Care Administration, under the
338	authority granted in s. 409.914(1), shall:
339	(a) Calculate the premium assistance payment necessary to
340	comply with the premium and cost-sharing limitations specified
341	in s. 409.816. The premium assistance payment for each enrollee
342	in a health insurance plan participating in the Florida Healthy
343	Kids Corporation shall equal the premium agreed to by the agency
344	and the provider of servicesapproved by the Florida Healthy
345	Kids Corporation and the Department of Insurance pursuant to ss.
346	627.410 and 641.31, less any enrollee's share of the premium
347	established within the limitations specified in s. 409.816. The
348	premium assistance payment for each enrollee in an employer-
349	sponsored health insurance plan approved under ss. 409.810-
350	409.820 shall equal the premium for the plan adjusted for any
351	benchmark benefit plan actuarial equivalent benefit rider
352	approved by the Department of Insurance pursuant to ss. 627.410
353	and 641.31, less any enrollee's share of the premium established
354	within the limitations specified in s. 409.816. In calculating
355	the premium assistance payment levels for children with family
356	coverage, the agency shall set the premium assistance payment
357	levels for each child proportionately to the total cost of
358	family coverage.
359	(c) Make premium assistance payments to health insurance
360	plans on a periodic basis. The agency may use its Medicaid
361	fiscal agent or a contracted third-party administrator in making
362	these payments. The agency may require health insurance plans
363	that participate in the Medikids program, the Florida Healthy
364	Kids program,or employer-sponsored group health insurance to
365	collect premium payments from an enrollee's family.
366	Participating health insurance plans shall report premium
367	payments collected on behalf of enrollees in the program to the
368	agency in accordance with a schedule established by the agency.
369	(g) Adopt rules necessary for calculating premium
370	assistance payment levels, calculating the program enrollment
371	ceiling, making premium assistance payments, monitoring access
372	and quality assurance standards, investigating and resolving
373	complaints and grievances, administering the Medikids program
374	and the Florida Healthy Kids program, and approving health
375	benefits coverage.
376
377	The agency is designated the lead state agency for Title XXI of
378	the Social Security Act for purposes of receipt of federal
379	funds, for reporting purposes, and for ensuring compliance with
380	federal and state regulations and rules.
381	(4) The Department of Insurance shall certify that health
382	benefits coverage plans that seek to provide services under the
383	Florida Kidcare program, except those offered through the
384	Florida Healthy Kids Corporation or theChildren's Medical
385	Services network, meet, exceed, or are actuarially equivalent to
386	the benchmark benefit plan and that health insurance plans will
387	be offered at an approved rate. In determining actuarial
388	equivalence of benefits coverage, the Department of Insurance
389	and health insurance plans must comply with the requirements of
390	s. 2103 of Title XXI of the Social Security Act. The department
391	shall adopt rules necessary for certifying health benefits
392	coverage plans.
393	(5) The Florida Healthy Kids Corporation shall perform
394	retain itsfunctions as authorized in s. 624.91, including
395	eligibility determination for participation in the Florida
396	Healthy Kids program.
397	Section 8. Subsection (25) of section 409.901, Florida
398	Statutes, is amended to read:
399	409.901 Definitions; ss. 409.901-409.920.--As used in ss.
400	409.901-409.920, except as otherwise specifically provided, the
401	term:
402	(25) "Third party" means an individual, entity, or
403	program, excluding Medicaid, that is, may be, could be, should
404	be, or has been liable for all or part of the cost of medical
405	services related to any medical assistance providedcovered by
406	Medicaid. Third party includes a third-party administrator or
407	TPA and a pharmacy benefits manager or PBM.
408	Section 9. Subsection (2) of section 409.904, Florida
409	Statutes, is amended to read:
410	409.904 Optional payments for eligible persons.--The
411	agency may make payments for medical assistance and related
412	services on behalf of the following persons who are determined
413	to be eligible subject to the income, assets, and categorical
414	eligibility tests set forth in federal and state law. Payment on
415	behalf of these Medicaid eligible persons is subject to the
416	availability of moneys and any limitations established by the
417	General Appropriations Act or chapter 216.
418	(2) A caretaker relative or parent, a pregnant woman, a
419	child under age 19 who would otherwise qualify for Florida
420	Kidcare Medicaid, a child up to age 21 who would otherwise
421	qualify under s. 409.903(1), a person age 65 or over, or a blind
422	or disabled person, who would otherwise be eligible for Florida
423	Medicaid, except that the income or assets of such family or
424	person exceed established limitations. For a family or person in
425	one of these coverage groups, medical expenses are deductible
426	from income in accordance with federal requirements in order to
427	make a determination of eligibility. Expenses used to meet
428	spend-down liability are not reimbursable by Medicaid. Effective
429	May 1, 2003, When determining the eligibility of a pregnant
430	woman, a child, or an aged, blind, or disabled individual, $270
431	shall be deducted from the countable income of the filing unit.
432	When determining the eligibility of the parent or caretaker
433	relative as defined by Title XIX of the Social Security Act, the
434	additional income disregard of $270 does not apply.A family or
435	person eligible under the coverage known as the "medically
436	needy," is eligible to receive the same services as other
437	Medicaid recipients, with the exception of services in skilled
438	nursing facilities and intermediate care facilities for the
439	developmentally disabled.
440	Section 10. Subsections (1), (12), and (23) of section
441	409.906, Florida Statutes, are amended to read:
442	409.906 Optional Medicaid services.--Subject to specific
443	appropriations, the agency may make payments for services which
444	are optional to the state under Title XIX of the Social Security
445	Act and are furnished by Medicaid providers to recipients who
446	are determined to be eligible on the dates on which the services
447	were provided. Any optional service that is provided shall be
448	provided only when medically necessary and in accordance with
449	state and federal law. Optional services rendered by providers
450	in mobile units to Medicaid recipients may be restricted or
451	prohibited by the agency. Nothing in this section shall be
452	construed to prevent or limit the agency from adjusting fees,
453	reimbursement rates, lengths of stay, number of visits, or
454	number of services, or making any other adjustments necessary to
455	comply with the availability of moneys and any limitations or
456	directions provided for in the General Appropriations Act or
457	chapter 216. If necessary to safeguard the state's systems of
458	providing services to elderly and disabled persons and subject
459	to the notice and review provisions of s. 216.177, the Governor
460	may direct the Agency for Health Care Administration to amend
461	the Medicaid state plan to delete the optional Medicaid service
462	known as "Intermediate Care Facilities for the Developmentally
463	Disabled." Optional services may include:
464	(1) ADULT DENTAL SERVICES.--The agency may pay for
465	dentures, the procedures required to seat dentures, the repair
466	and reline of dentures, emergency dental procedures necessary to
467	alleviate pain or infection, and basic dental preventive
468	procedures provided by or under the direction of a licensed
469	dentist for a recipient who is age 65 or oldermedically
470	necessary, emergency dental procedures to alleviate pain or
471	infection. Emergency dental care shall be limited to emergency
472	oral examinations, necessary radiographs, extractions, and
473	incision and drainage of abscess, for a recipient who is age 21
474	or older. However, Medicaid will not provide reimbursement for
475	dental services provided in a mobile dental unit, except for a
476	mobile dental unit:
477	(a) Owned by, operated by, or having a contractual
478	agreement with the Department of Health and complying with
479	Medicaid's county health department clinic services program
480	specifications as a county health department clinic services
481	provider.
482	(b) Owned by, operated by, or having a contractual
483	arrangement with a federally qualified health center and
484	complying with Medicaid's federally qualified health center
485	specifications as a federally qualified health center provider.
486	(c) Rendering dental services to Medicaid recipients, 21
487	years of age and older, at nursing facilities.
488	(d) Owned by, operated by, or having a contractual
489	agreement with a state-approved dental educational institution.
490	(12) CHILDREN'SHEARING SERVICES.--The agency may pay for
491	hearing and related services, including hearing evaluations,
492	hearing aid devices, dispensing of the hearing aid, and related
493	repairs, if provided to a recipient younger than 21 years of age
494	by a licensed hearing aid specialist, otolaryngologist,
495	otologist, audiologist, or physician.
496	(23) CHILDREN'SVISUAL SERVICES.--The agency may pay for
497	visual examinations, eyeglasses, and eyeglass repairs for a
498	recipient younger than 21 years of age, if they are prescribed
499	by a licensed physician specializing in diseases of the eye or
500	by a licensed optometrist.
501	Section 11. Paragraphs (c) and (d) are added to subsection
502	(1) of section 409.9081, Florida Statutes, to read:
503	409.9081 Copayments.--
504	(1) The agency shall require, subject to federal
505	regulations and limitations, each Medicaid recipient to pay at
506	the time of service a nominal copayment for the following
507	Medicaid services:
508	(c) Prescription drugs: a coinsurance equal to 5 percent
509	of the Medicaid cost of the prescription drug at the time of
510	purchase. The maximum coinsurance shall be $15 per prescription
511	drug purchased.
512	(d) Hospital outpatient services, emergency department: up
513	to $15 for each hospital outpatient emergency department
514	encounter that is for nonemergency purposes.
515	Section 12. Section 409.911, Florida Statutes, is amended
516	to read:
517	409.911 Disproportionate share program.--Subject to
518	specific allocations established within the General
519	Appropriations Act and any limitations established pursuant to
520	chapter 216, the agency shall distribute, pursuant to this
521	section, moneys to hospitals providing a disproportionate share
522	of Medicaid or charity care services by making quarterly
523	Medicaid payments as required. Notwithstanding the provisions of
524	s. 409.915, counties are exempt from contributing toward the
525	cost of this special reimbursement for hospitals serving a
526	disproportionate share of low-income patients.
527	(1) Definitions.--As used in this section, s. 409.9112,
528	and the Florida Hospital Uniform Reporting System manual:
529	(a) "Adjusted patient days" means the sum of acute care
530	patient days and intensive care patient days as reported to the
531	Agency for Health Care Administration, divided by the ratio of
532	inpatient revenues generated from acute, intensive, ambulatory,
533	and ancillary patient services to gross revenues.
534	(b) "Actual audited data" or "actual audited experience"
535	means data reported to the Agency for Health Care Administration
536	which has been audited in accordance with generally accepted
537	auditing standards by the agency or representatives under
538	contract with the agency.
539	(c) "Base Medicaid per diem" means the hospital's Medicaid
540	per diem rate initially established by the Agency for Health
541	Care Administration on January 1, 1999. The base Medicaid per
542	diem rate shall not include any additional per diem increases
543	received as a result of the disproportionate share distribution.
544	(c)(d)"Charity care" or "uncompensated charity care"
545	means that portion of hospital charges reported to the Agency
546	for Health Care Administration for which there is no
547	compensation, other than restricted or unrestricted revenues
548	provided to a hospital by local governments or tax districts
549	regardless of the method of payment, for care provided to a
550	patient whose family income for the 12 months preceding the
551	determination is less than or equal to 200 percent of the
552	federal poverty level, unless the amount of hospital charges due
553	from the patient exceeds 25 percent of the annual family income.
554	However, in no case shall the hospital charges for a patient
555	whose family income exceeds four times the federal poverty level
556	for a family of four be considered charity.
557	(d)(e)"Charity care days" means the sum of the deductions
558	from revenues for charity care minus 50 percent of restricted
559	and unrestricted revenues provided to a hospital by local
560	governments or tax districts, divided by gross revenues per
561	adjusted patient day.
562	(f) "Disproportionate share percentage" means a rate of
563	increase in the Medicaid per diem rate as calculated under this
564	section.
565	(e)(g)"Hospital" means a health care institution licensed
566	as a hospital pursuant to chapter 395, but does not include
567	ambulatory surgical centers.
568	(f)(h)"Medicaid days" means the number of actual days
569	attributable to Medicaid patients as determined by the Agency
570	for Health Care Administration.
571	(2) The Agency for Health Care Administration shall
572	utilize the following actual audited datacriteria to determine
573	the Medicaid days and charity care to be used in the calculation
574	of theif a hospital qualifies for adisproportionate share
575	payment:
576	(a) The Agency for Health Care Administration shall use
577	the average of the 1997, 1998, and 1999 audited data to
578	determine each hospital's Medicaid days and charity careA
579	hospital's total Medicaid days when combined with its total
580	charity care days must equal or exceed 7 percent of its total
581	adjusted patient days.
582	(b) In the event the Agency for Health Care Administration
583	does not have the prescribed 3 years of audited disproportionate
584	share data for a hospital, the Agency for Health Care
585	Administration shall use the average of the audited
586	disproportionate share data for the years availableA hospital's
587	total charity care days weighted by a factor of 4.5, plus its
588	total Medicaid days weighted by a factor of 1, shall be equal to
589	or greater than 10 percent of its total adjusted patient days.
590	(c) Additionally, In accordance with s. 1923(b) of the
591	Social Security Actthe seventh federal Omnibus Budget
592	Reconciliation Act, a hospital with a Medicaid inpatient
593	utilization rate greater than one standard deviation above the
594	statewide mean or a hospital with a low-income utilization rate
595	of 25 percent or greater shall qualify for reimbursement.
596	(3) In computing the disproportionate share rate:
597	(a) Per diem increases earned from disproportionate share
598	shall be applied to each hospital's base Medicaid per diem rate
599	and shall be capped at 170 percent.
600	(b) The agency shall use 1994 audited financial data for
601	the calculation of disproportionate share payments under this
602	section.
603	(c) If the total amount earned by all hospitals under this
604	section exceeds the amount appropriated, each hospital's share
605	shall be reduced on a pro rata basis so that the total dollars
606	distributed from the trust fund do not exceed the total amount
607	appropriated.
608	(d) The total amount calculated to be distributed under
609	this section shall be made in quarterly payments subsequent to
610	each quarter during the fiscal year.
611	(3)(4)Hospitals that qualify for a disproportionate share
612	payment solely under paragraph (2)(c) shall have their payment
613	calculated in accordance with the following formulas:
614
615	DSHP = (HMD/TSMD) x $1 million
616	TAA = TA x (1/5.5)
617	DSHP = (HMD/TSMD) x TAA
618
619	Where:
620	TAA = total amount available.
621	TA = total appropriation.
622	DSHP = disproportionate share hospital payment.
623	HMD = hospital Medicaid days.
624	TSMD = total state Medicaid days.
625
626	(4) The following formulas shall be used to pay
627	disproportionate share dollars to public hospitals:
628	(a) For state mental health hospitals:
629
630	DSHP = (HMD/TMDMH) x TAAMH
631
632	The total amount available for the state mental health hospitals
633	shall be the difference between the federal cap for Institutions
634	for Mental Diseases and the amounts paid under the mental health
635	disproportionate share program.
636
637	Where:
638	DSHP = disproportionate share hospital payment.
639	HMD = hospital Medicaid days.
640	TMDMH = total Medicaid days for state mental health
641	hospitals.
642	TAAMH = total amount available for mental health hospitals.
643
644	(b) For nonstate government owned or operated hospitals
645	with 3,200 or more Medicaid days:
646
647	DSHP = [(.82 x HCCD/TCCD) + (.18 x HMD/TMD)] x TAAPH
648	TAAPH = TAA – TAAMH – 1,400,000
649
650	Where:
651	DSHP = disproportionate share hospital payments.
652	HCCD = hospital charity care dollars.
653	TCCD = total charity care dollars for public nonstate
654	hospitals.
655	HMD = hospital Medicaid days.
656	TMD = total Medicaid days for public nonstate hospitals.
657	TAAPH = total amount available for public hospitals.
658	TAA = total available appropriation.
659	TAAMH = total amount available for mental health hospitals.
660
661	(c) For nonstate government owned or operated hospitals
662	with less than 3,200 Medicaid days, a total of $400,000 shall be
663	distributed equally among these hospitals.
664	(5) The following formula shall be utilized by the agency
665	to determine the maximum disproportionate share rate to be used
666	to increase the Medicaid per diem rate for hospitals that
667	qualify pursuant to paragraphs (2)(a) and (b):
668	DSR = CCD MD
669	((---------) x 4.5) + (---------)
670	@_@2@_@
671	Where:
672	APD = adjusted patient days.
673	CCD = charity care days.
674	DSR = disproportionate share rate.
675	MD = Medicaid days.
676
677	(6)(a) To calculate the total amount earned by all
678	hospitals under this section, hospitals with a disproportionate
679	share rate less than 50 percent shall divide their Medicaid days
680	by four, and hospitals with a disproportionate share rate
681	greater than or equal to 50 percent and with greater than 40,000
682	Medicaid days shall multiply their Medicaid days by 1.5, and the
683	following formula shall be used by the agency to calculate the
684	total amount earned by all hospitals under this section:
685
686	TAE = BMPD x MD x DSP
687
688	Where:
689	TAE = total amount earned.
690	BMPD = base Medicaid per diem.
691	MD = Medicaid days.
692	DSP = disproportionate share percentage.
693
694	(5)(b)In no case shall total payments to a hospital under
695	this section, with the exception of public nonstate facilities
696	orstate facilities, exceed the total amount of uncompensated
697	charity care of the hospital, as determined by the agency
698	according to the most recent calendar year audited data
699	available at the beginning of each state fiscal year.
700	(7) The following criteria shall be used in determining
701	the disproportionate share percentage:
702	(a) If the disproportionate share rate is less than 10
703	percent, the disproportionate share percentage is zero and there
704	is no additional payment.
705	(b) If the disproportionate share rate is greater than or
706	equal to 10 percent, but less than 20 percent, then the
707	disproportionate share percentage is 1.8478498.
708	(c) If the disproportionate share rate is greater than or
709	equal to 20 percent, but less than 30 percent, then the
710	disproportionate share percentage is 3.4145488.
711	(d) If the disproportionate share rate is greater than or
712	equal to 30 percent, but less than 40 percent, then the
713	disproportionate share percentage is 6.3095734.
714	(e) If the disproportionate share rate is greater than or
715	equal to 40 percent, but less than 50 percent, then the
716	disproportionate share percentage is 11.6591440.
717	(f) If the disproportionate share rate is greater than or
718	equal to 50 percent, but less than 60 percent, then the
719	disproportionate share percentage is 73.5642254.
720	(g) If the disproportionate share rate is greater than or
721	equal to 60 percent but less than 72.5 percent, then the
722	disproportionate share percentage is 135.9356391.
723	(h) If the disproportionate share rate is greater than or
724	equal to 72.5 percent, then the disproportionate share
725	percentage is 170.
726	(8) The following formula shall be used by the agency to
727	calculate the total amount earned by all hospitals under this
728	section:
729
730	TAE = BMPD x MD x DSP
731
732	Where:
733	TAE = total amount earned.
734	BMPD = base Medicaid per diem.
735	MD = Medicaid days.
736	DSP = disproportionate share percentage.
737
738	(6)(9)The agency is authorized to receive funds from
739	local governments and other local political subdivisions for the
740	purpose of making payments, including federal matching funds,
741	through the Medicaid disproportionate share program. Funds
742	received from local governments for this purpose shall be
743	separately accounted for and shall not be commingled with other
744	state or local funds in any manner.
745	(7)(10)Payments made by the agency to hospitals eligible
746	to participate in this program shall be made in accordance with
747	federal rules and regulations.
748	(a) If the Federal Government prohibits, restricts, or
749	changes in any manner the methods by which funds are distributed
750	for this program, the agency shall not distribute any additional
751	funds and shall return all funds to the local government from
752	which the funds were received, except as provided in paragraph
753	(b).
754	(b) If the Federal Government imposes a restriction that
755	still permits a partial or different distribution, the agency
756	may continue to disburse funds to hospitals participating in the
757	disproportionate share program in a federally approved manner,
758	provided:
759	1. Each local government which contributes to the
760	disproportionate share program agrees to the new manner of
761	distribution as shown by a written document signed by the
762	governing authority of each local government; and
763	2. The Executive Office of the Governor, the Office of
764	Planning and Budgeting, the House of Representatives, and the
765	Senate are provided at least 7 days' prior notice of the
766	proposed change in the distribution, and do not disapprove such
767	change.
768	(c) No distribution shall be made under the alternative
769	method specified in paragraph (b) unless all parties agree or
770	unless all funds of those parties that disagree which are not
771	yet disbursed have been returned to those parties.
772	(8)(11)Notwithstanding the provisions of chapter 216, the
773	Executive Office of the Governor is hereby authorized to
774	establish sufficient trust fund authority to implement the
775	disproportionate share program.
776	Section 13. Subsections (1) and (2) of section 409.9112,
777	Florida Statutes, are amended to read:
778	409.9112 Disproportionate share program for regional
779	perinatal intensive care centers.--In addition to the payments
780	made under s. 409.911, the Agency for Health Care Administration
781	shall design and implement a system of making disproportionate
782	share payments to those hospitals that participate in the
783	regional perinatal intensive care center program established
784	pursuant to chapter 383. This system of payments shall conform
785	with federal requirements and shall distribute funds in each
786	fiscal year for which an appropriation is made by making
787	quarterly Medicaid payments. Notwithstanding the provisions of
788	s. 409.915, counties are exempt from contributing toward the
789	cost of this special reimbursement for hospitals serving a
790	disproportionate share of low-income patients.
791	(1) The following formula shall be used by the agency to
792	calculate the total amount earned for hospitals that participate
793	in the regional perinatal intensive care center program:
794
795	TAE = HDSP/THDSP
796
797	Where:
798	TAE = total amount earned by a regional perinatal intensive
799	care center.
800	HDSP = the prior state fiscal year regional perinatal
801	intensive care center disproportionate share payment to the
802	individual hospital.
803	THDSP = the prior state fiscal year total regional
804	perinatal intensive care center disproportionate share payments
805	to all hospitals.
806	(2) The total additional payment for hospitals that
807	participate in the regional perinatal intensive care center
808	program shall be calculated by the agency as follows:
809
810	TAP = TAE x TA
811
812	Where:
813	TAP = total additional payment for a regional perinatal
814	intensive care center.
815	TAE = total amount earned by a regional perinatal intensive
816	care center.
817	TA = total appropriation for the regional perinatal
818	intensive care center disproportionate share program.
819
820	TAE = DSR x BMPD x MD
821
822	Where:
823	TAE = total amount earned by a regional perinatal intensive
824	care center.
825	DSR = disproportionate share rate.
826	BMPD = base Medicaid per diem.
827	MD = Medicaid days.
828
829	(2) The total additional payment for hospitals that
830	participate in the regional perinatal intensive care center
831	program shall be calculated by the agency as follows:
832	TAP = TAE x TA
833	(---------------)
834	@_@5@_@
835	Where:
836	TAP = total additional payment for a regional perinatal
837	intensive care center.
838	TAE = total amount earned by a regional perinatal intensive
839	care center.
840	STAE = sum of total amount earned by each hospital that
841	participates in the regional perinatal intensive care center
842	program.
843	TA = total appropriation for the regional perinatal
844	intensive care disproportionate share program.
845	Section 14. Section 409.9117, Florida Statutes, is amended
846	to read:
847	409.9117 Primary care disproportionate share program.--
848	(1) If federal funds are available for disproportionate
849	share programs in addition to those otherwise provided by law,
850	there shall be created a primary care disproportionate share
851	program.
852	(2) The following formula shall be used by the agency to
853	calculate the total amount earned for hospitals that participate
854	in the primary care disproportionate share program:
855
856	TAE = HDSP/THDSP
857
858	Where:
859	TAE = total amount earned by a hospital participating in
860	the primary care disproportionate share program.
861	HDSP = the prior state fiscal year primary care
862	disproportionate share payment to the individual hospital.
863	THDSP = the prior state fiscal year to primary care
864	disproportionate share payments to all hospitals.
865	(3) The total additional payment for hospitals that
866	participate in the primary care disproportionate share program
867	shall be calculated by the agency as follows:
868
869	TAP = TAE x TA
870
871	Where:
872	TAP = total additional payment for a primary care hospital.
873	TAE = total amount earned by a primary care hospital.
874	TA = total appropriation for the primary care
875	disproportionate share program.
876	(4)(2)In the establishment and funding of this program,
877	the agency shall use the following criteria in addition to those
878	specified in s. 409.911.,Payments may not be made to a hospital
879	unless the hospital agrees to:
880	(a) Cooperate with a Medicaid prepaid health plan, if one
881	exists in the community.
882	(b) Ensure the availability of primary and specialty care
883	physicians to Medicaid recipients who are not enrolled in a
884	prepaid capitated arrangement and who are in need of access to
885	such physicians.
886	(c) Coordinate and provide primary care services free of
887	charge, except copayments, to all persons with incomes up to 100
888	percent of the federal poverty level who are not otherwise
889	covered by Medicaid or another program administered by a
890	governmental entity, and to provide such services based on a
891	sliding fee scale to all persons with incomes up to 200 percent
892	of the federal poverty level who are not otherwise covered by
893	Medicaid or another program administered by a governmental
894	entity, except that eligibility may be limited to persons who
895	reside within a more limited area, as agreed to by the agency
896	and the hospital.
897	(d) Contract with any federally qualified health center,
898	if one exists within the agreed geopolitical boundaries,
899	concerning the provision of primary care services, in order to
900	guarantee delivery of services in a nonduplicative fashion, and
901	to provide for referral arrangements, privileges, and
902	admissions, as appropriate. The hospital shall agree to provide
903	at an onsite or offsite facility primary care services within 24
904	hours to which all Medicaid recipients and persons eligible
905	under this paragraph who do not require emergency room services
906	are referred during normal daylight hours.
907	(e) Cooperate with the agency, the county, and other
908	entities to ensure the provision of certain public health
909	services, case management, referral and acceptance of patients,
910	and sharing of epidemiological data, as the agency and the
911	hospital find mutually necessary and desirable to promote and
912	protect the public health within the agreed geopolitical
913	boundaries.
914	(f) In cooperation with the county in which the hospital
915	resides, develop a low-cost, outpatient, prepaid health care
916	program to persons who are not eligible for the Medicaid
917	program, and who reside within the area.
918	(g) Provide inpatient services to residents within the
919	area who are not eligible for Medicaid or Medicare, and who do
920	not have private health insurance, regardless of ability to pay,
921	on the basis of available space, except that nothing shall
922	prevent the hospital from establishing bill collection programs
923	based on ability to pay.
924	(h) Work with the Florida Healthy Kids Corporation, the
925	Florida Health Care Purchasing Cooperative,and business health
926	coalitions, as appropriate, to develop a feasibility study and
927	plan to provide a low-cost comprehensive health insurance plan
928	to persons who reside within the area and who do not have access
929	to such a plan.
930	(i) Work with public health officials and other experts to
931	provide community health education and prevention activities
932	designed to promote healthy lifestyles and appropriate use of
933	health services.
934	(j) Work with the local health council to develop a plan
935	for promoting access to affordable health care services for all
936	persons who reside within the area, including, but not limited
937	to, public health services, primary care services, inpatient
938	services, and affordable health insurance generally.
939
940	Any hospital that fails to comply with any of the provisions of
941	this subsection, or any other contractual condition, may not
942	receive payments under this section until full compliance is
943	achieved.
944	Section 15. Section 409.9119, Florida Statutes, is amended
945	to read:
946	409.9119 Disproportionate share program for specialty
947	hospitals for children.--In addition to the payments made under
948	s. 409.911, the Agency for Health Care Administration shall
949	develop and implement a system under which disproportionate
950	share payments are made to those hospitals that are licensed by
951	the state as specialty hospitals for children and were licensed
952	on January 1, 2000, as specialty hospitals for children. This
953	system of payments must conform to federal requirements and must
954	distribute funds in each fiscal year for which an appropriation
955	is made by making quarterly Medicaid payments. Notwithstanding
956	s. 409.915, counties are exempt from contributing toward the
957	cost of this special reimbursement for hospitals that serve a
958	disproportionate share of low-income patients. Payments are
959	subject to specific appropriations in the General Appropriations
960	Act.
961	(1) The agency shall use the following formula to
962	calculate the total amount earned for hospitals that participate
963	in the specialty hospital for children disproportionate share
964	program:
965
966	TAE = DSR x BMPD x MD
967
968	Where:
969	TAE = total amount earned by a specialty hospital for
970	children.
971	DSR = disproportionate share rate.
972	BMPD = base Medicaid per diem.
973	MD = Medicaid days.
974	(2) The agency shall calculate the total additional
975	payment for hospitals that participate in the specialty hospital
976	for children disproportionate share program as follows:
977	TAP = TAE x TA
978	(---------------)
979	STAE
980	Where:
981	TAP = total additional payment for a specialty hospital for
982	children.
983	TAE = total amount earned by a specialty hospital for
984	children.
985	TA = total appropriation for the specialty hospital for
986	children disproportionate share program.
987	STAE = sum of total amount earned by each hospital that
988	participates in the specialty hospital for children
989	disproportionate share program.
990
991	(3) A hospital may not receive any payments under this
992	section until it achieves full compliance with the applicable
993	rules of the agency. A hospital that is not in compliance for
994	two or more consecutive quarters may not receive its share of
995	the funds. Any forfeited funds must be distributed to the
996	remaining participating specialty hospitals for children that
997	are in compliance.
998	Section 16. Paragraph (d) of subsection (3) of section
999	409.912, Florida Statutes, is amended, and subsection (41) is
1000	added to said section, to read:
1001	409.912 Cost-effective purchasing of health care.--The
1002	agency shall purchase goods and services for Medicaid recipients
1003	in the most cost-effective manner consistent with the delivery
1004	of quality medical care. The agency shall maximize the use of
1005	prepaid per capita and prepaid aggregate fixed-sum basis
1006	services when appropriate and other alternative service delivery
1007	and reimbursement methodologies, including competitive bidding
1008	pursuant to s. 287.057, designed to facilitate the cost-
1009	effective purchase of a case-managed continuum of care. The
1010	agency shall also require providers to minimize the exposure of
1011	recipients to the need for acute inpatient, custodial, and other
1012	institutional care and the inappropriate or unnecessary use of
1013	high-cost services. The agency may establish prior authorization
1014	requirements for certain populations of Medicaid beneficiaries,
1015	certain drug classes, or particular drugs to prevent fraud,
1016	abuse, overuse, and possible dangerous drug interactions. The
1017	Pharmaceutical and Therapeutics Committee shall make
1018	recommendations to the agency on drugs for which prior
1019	authorization is required. The agency shall inform the
1020	Pharmaceutical and Therapeutics Committee of its decisions
1021	regarding drugs subject to prior authorization.
1022	(3) The agency may contract with:
1023	(d) A provider networkNo more than four provider service
1024	networks for demonstration projects to test Medicaid direct
1025	contracting. The demonstration projectsmay be reimbursed on a
1026	fee-for-service or prepaid basis. A provider service network
1027	which is reimbursed by the agency on a prepaid basis shall be
1028	exempt from parts I and III of chapter 641, but must meet
1029	appropriate financial reserve, quality assurance, and patient
1030	rights requirements as established by the agency. The agency
1031	shall award contracts on a competitive bid basis and shall
1032	select bidders based upon price and quality of care. Medicaid
1033	recipients assigned to a demonstration project shall be chosen
1034	equally from those who would otherwise have been assigned to
1035	prepaid plans and MediPass.The agency is authorized to seek
1036	federal Medicaid waivers as necessary to implement the
1037	provisions of this section. A demonstration project awarded
1038	pursuant to this paragraph shall be for 4 years from the date of
1039	implementation.
1040	(41) The agency may contract on a prepaid or fixed-sum
1041	basis with an appropriately licensed prepaid dental health plan
1042	to provide Medicaid covered dental services to child or adult
1043	Medicaid recipients.
1044	Section 17. Paragraphs (f), (k), and (l) of subsection (2)
1045	of section 409.9122, Florida Statutes, are amended to read:
1046	409.9122 Mandatory Medicaid managed care enrollment;
1047	programs and procedures.--
1048	(2)
1049	(f) When a Medicaid recipient does not choose a managed
1050	care plan or MediPass provider, the agency shall assign the
1051	Medicaid recipient to a managed care plan or MediPass provider.
1052	Medicaid recipients who are subject to mandatory assignment but
1053	who fail to make a choice shall be assigned to managed care
1054	plans until an enrollment of 4045 percent in MediPass and 6055
1055	percent in managed care plans is achieved. Once this enrollment
1056	is achieved, the assignments shall be divided in order to
1057	maintain an enrollment in MediPass and managed care plans which
1058	is in a 4045 percent and 6055percent proportion,
1059	respectively. Thereafter, assignment of Medicaid recipients who
1060	fail to make a choice shall be based proportionally on the
1061	preferences of recipients who have made a choice in the previous
1062	period. Such proportions shall be revised at least quarterly to
1063	reflect an update of the preferences of Medicaid recipients. The
1064	agency shall disproportionately assign Medicaid-eligible
1065	recipients who are required to but have failed to make a choice
1066	of managed care plan or MediPass, including children, and who
1067	are to be assigned to the MediPass program to children's
1068	networks as described in s. 409.912(3)(g), Children's Medical
1069	Services network as defined in s. 391.021, exclusive provider
1070	organizations, provider service networks, minority physician
1071	networks, and pediatric emergency department diversion programs
1072	authorized by this chapter or the General Appropriations Act, in
1073	such manner as the agency deems appropriate, until the agency
1074	has determined that the networks and programs have sufficient
1075	numbers to be economically operated. For purposes of this
1076	paragraph, when referring to assignment, the term "managed care
1077	plans" includes health maintenance organizations, exclusive
1078	provider organizations, provider service networks, minority
1079	physician networks, Children's Medical Services network, and
1080	pediatric emergency department diversion programs authorized by
1081	this chapter or the General Appropriations Act. Beginning July
1082	1, 2002, the agency shall assign all children in families who
1083	have not made a choice of a managed care plan or MediPass in the
1084	required timeframe to a pediatric emergency room diversion
1085	program described in s. 409.912(3)(g) that, as of July 1, 2002,
1086	has executed a contract with the agency, until such network or
1087	program has reached an enrollment of 15,000 children. Once that
1088	minimum enrollment level has been reached, the agency shall
1089	assign children who have not chosen a managed care plan or
1090	MediPass to the network or program in a manner that maintains
1091	the minimum enrollment in the network or program at not less
1092	than 15,000 children. To the extent practicable, the agency
1093	shall also assign all eligible children in the same family to
1094	such network or program. When making assignments, the agency
1095	shall take into account the following criteria:
1096	1. A managed care plan has sufficient network capacity to
1097	meet the need of members.
1098	2. The managed care plan or MediPass has previously
1099	enrolled the recipient as a member, or one of the managed care
1100	plan's primary care providers or MediPass providers has
1101	previously provided health care to the recipient.
1102	3. The agency has knowledge that the member has previously
1103	expressed a preference for a particular managed care plan or
1104	MediPass provider as indicated by Medicaid fee-for-service
1105	claims data, but has failed to make a choice.
1106	4. The managed care plan's or MediPass primary care
1107	providers are geographically accessible to the recipient's
1108	residence.
1109	5. The agency has authority to make mandatory assignments
1110	based on quality of service and performance of managed care
1111	plans.
1112	(k) When a Medicaid recipient does not choose a managed
1113	care plan or MediPass provider, the agency shall assign the
1114	Medicaid recipient to a managed care plan, except in those
1115	counties in which there are fewer than two managed care plans
1116	accepting Medicaid enrollees, in which case assignment shall be
1117	to a managed care plan or a MediPass provider. Medicaid
1118	recipients in counties with fewer than two managed care plans
1119	accepting Medicaid enrollees who are subject to mandatory
1120	assignment but who fail to make a choice shall be assigned to
1121	managed care plans until an enrollment of 45 percent in MediPass
1122	and 55 percent in managed care plans is achieved. Once that
1123	enrollment is achieved, the assignments shall be divided in
1124	order to maintain an enrollment in MediPass and managed care
1125	plans which is in a 45 percent and 55 percent proportion,
1126	respectively. In geographic areas where the agency is
1127	contracting for the provision of comprehensive behavioral health
1128	services through a capitated prepaid arrangement, recipients who
1129	fail to make a choice shall be assigned equally to MediPass or a
1130	managed care plan. For purposes of this paragraph, when
1131	referring to assignment, the term "managed care plans" includes
1132	exclusive provider organizations, provider service networks,
1133	Children's Medical Services network, minority physician
1134	networks, and pediatric emergency department diversion programs
1135	authorized by this chapter or the General Appropriations Act.
1136	When making assignments, the agency shall take into account the
1137	following criteria:
1138	1. A managed care plan has sufficient network capacity to
1139	meet the need of members.
1140	2. The managed care plan or MediPass has previously
1141	enrolled the recipient as a member, or one of the managed care
1142	plan's primary care providers or MediPass providers has
1143	previously provided health care to the recipient.
1144	3. The agency has knowledge that the member has previously
1145	expressed a preference for a particular managed care plan or
1146	MediPass provider as indicated by Medicaid fee-for-service
1147	claims data, but has failed to make a choice.
1148	4. The managed care plan's or MediPass primary care
1149	providers are geographically accessible to the recipient's
1150	residence.
1151	5. The agency has authority to make mandatory assignments
1152	based on quality of service and performance of managed care
1153	plans.
1154	(k)(l)Notwithstanding the provisions of chapter 287, the
1155	agency may, at its discretion, renew cost-effective contracts
1156	for choice counseling services once or more for such periods as
1157	the agency may decide. However, all such renewals may not
1158	combine to exceed a total period longer than the term of the
1159	original contract.
1160	Section 18. Subsections (8) and (28) of section 409.913,
1161	Florida Statutes, are amended to read:
1162	409.913 Oversight of the integrity of the Medicaid
1163	program.--The agency shall operate a program to oversee the
1164	activities of Florida Medicaid recipients, and providers and
1165	their representatives, to ensure that fraudulent and abusive
1166	behavior and neglect of recipients occur to the minimum extent
1167	possible, and to recover overpayments and impose sanctions as
1168	appropriate. Beginning January 1, 2003, and each year
1169	thereafter, the agency and the Medicaid Fraud Control Unit of
1170	the Department of Legal Affairs shall submit a joint report to
1171	the Legislature documenting the effectiveness of the state's
1172	efforts to control Medicaid fraud and abuse and to recover
1173	Medicaid overpayments during the previous fiscal year. The
1174	report must describe the number of cases opened and investigated
1175	each year; the sources of the cases opened; the disposition of
1176	the cases closed each year; the amount of overpayments alleged
1177	in preliminary and final audit letters; the number and amount of
1178	fines or penalties imposed; any reductions in overpayment
1179	amounts negotiated in settlement agreements or by other means;
1180	the amount of final agency determinations of overpayments; the
1181	amount deducted from federal claiming as a result of
1182	overpayments; the amount of overpayments recovered each year;
1183	the amount of cost of investigation recovered each year; the
1184	average length of time to collect from the time the case was
1185	opened until the overpayment is paid in full; the amount
1186	determined as uncollectible and the portion of the uncollectible
1187	amount subsequently reclaimed from the Federal Government; the
1188	number of providers, by type, that are terminated from
1189	participation in the Medicaid program as a result of fraud and
1190	abuse; and all costs associated with discovering and prosecuting
1191	cases of Medicaid overpayments and making recoveries in such
1192	cases. The report must also document actions taken to prevent
1193	overpayments and the number of providers prevented from
1194	enrolling in or reenrolling in the Medicaid program as a result
1195	of documented Medicaid fraud and abuse and must recommend
1196	changes necessary to prevent or recover overpayments. For the
1197	2001-2002 fiscal year, the agency shall prepare a report that
1198	contains as much of this information as is available to it.
1199	(8) A Medicaid provider shall retain medical,
1200	professional, financial, and business records pertaining to
1201	services and goods furnished to a Medicaid recipient and billed
1202	to Medicaid for a period of 5 years after the date of furnishing
1203	such services or goods. The agency and its duly authorized
1204	agentsmay investigate, review, or analyze such records, which
1205	must be made available during normal business hours. However,
1206	24-hour notice must be provided if patient treatment would be
1207	disrupted. The provider is responsible for furnishing to the
1208	agency and its duly authorized agents, and keeping the agency
1209	and its duly authorized agentsinformed of the location of, the
1210	provider's Medicaid-related records. The authority of the agency
1211	and its duly authorized agentsto obtain Medicaid-related
1212	records from a provider is neither curtailed nor limited during
1213	a period of litigation between the agency and the provider.
1214	(28) Notwithstanding other provisions of law, the agency
1215	and its duly authorized agentsand the Medicaid Fraud Control
1216	Unit of the Department of Legal Affairs may review a provider's
1217	Medicaid-related records in order to determine the total output
1218	of a provider's practice to reconcile quantities of goods or
1219	services billed to Medicaid against quantities of goods or
1220	services used in the provider's total practice.
1221	Section 19. Subsections (7), (8), and (9) are added to
1222	section 430.502, Florida Statutes, to read:
1223	430.502 Alzheimer's disease; memory disorder clinics and
1224	day care and respite care programs.--
1225	(7) The Agency for Health Care Administration and the
1226	department shall seek a federal waiver to implement a Medicaid
1227	home and community-based waiver targeted to persons with
1228	Alzheimer's disease to test the effectiveness of Alzheimer's
1229	specific interventions to delay or to avoid institutional
1230	placement.
1231	(8) The department shall implement the waiver program
1232	specified in subsection (7). The agency and the department shall
1233	ensure that providers are selected that have a history of
1234	successfully serving persons with Alzheimer's disease. The
1235	department and the agency shall develop specialized standards
1236	for providers and services tailored to persons in the early,
1237	middle, and late stages of Alzheimer's disease and designate a
1238	level of care determination process and standard that is most
1239	appropriate to this population. The department and the agency
1240	shall include in the waiver services designed to assist the
1241	caregiver in continuing to provide in-home care. The department
1242	shall implement this waiver program subject to a specific
1243	appropriation or as provided in the General Appropriations Act.
1244	The department and the agency shall submit their program design
1245	to the President of the Senate and the Speaker of the House of
1246	Representatives for consultation during the development process.
1247	(9) Authority to continue the waiver program specified in
1248	subsection (7) shall be automatically eliminated at the close of
1249	the 2008 Regular Session of the Legislature unless further
1250	legislative action is taken to continue it prior to such time.
1251	Section 20. Subsections (2) and (4) and paragraph (a) of
1252	subsection (5) of section 624.91, Florida Statutes, are amended
1253	to read:
1254	624.91 The Florida Healthy Kids Corporation Act.--
1255	(2) LEGISLATIVE INTENT.--
1256	(a) The Legislature finds that increased access to health
1257	care services could improve children's health and reduce the
1258	incidence and costs of childhood illness and disabilities among
1259	children in this state. Many children do not have comprehensive,
1260	affordable health care services available. It is the intent of
1261	the Legislature that the Florida Healthy Kids Corporation
1262	provide comprehensive health insurance coverage to such
1263	children. The corporation is encouraged to cooperate with any
1264	existing health service programs funded by the public or the
1265	private sector and to work cooperatively with the Florida
1266	Partnership for School Readiness.
1267	(b) It is the intent of the Legislature that the Florida
1268	Healthy Kids Corporation serve as an administrator forone of
1269	several providers of services to children eligible for medical
1270	assistance under Title XXI of the Social Security Act. Although
1271	the corporation may serve other children, the Legislature
1272	intends the primary recipients of services provided through the
1273	corporation be school-age children with a family income below
1274	200 percent of the federal poverty level, who do not qualify for
1275	Medicaid. It is also the intent of the Legislature that state
1276	and local government Florida Healthy Kids funds be used to
1277	continue and expand coverage, subject to specific appropriations
1278	in the General Appropriations Actwithin available
1279	appropriations, to children not eligible for federal matching
1280	funds under Title XXI.
1281	(4) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
1282	(a) There is created the Florida Healthy Kids Corporation,
1283	a not-for-profit corporation.
1284	(b) The Florida Healthy Kids Corporation shall:
1285	1. Organize school children groups to facilitate the
1286	provision of comprehensive health insurance coverage to
1287	children.;
1288	2. Arrange for the collection for the Agency for Health
1289	Care Administrationof any family, local contributions, or
1290	employer payment or premium, in an amount to be determined by
1291	the board of directors, to provide for payment of premiums for
1292	comprehensive insurance coverage and for the actual or estimated
1293	administrative expenses.;
1294	3. Arrange for the collection of any voluntary
1295	contributions to provide for payment of premiums for coverage
1296	under the Florida Kidcare program forchildren who are not
1297	eligible for medical assistance under Title XXI of the Social
1298	Security Act for the Agency for Health Care Administration. Each
1299	fiscal year, the corporation shall establish a local match
1300	policy for the enrollment of non-Title-XXI-eligible children in
1301	the Healthy Kids program. By May 1 of each year, the corporation
1302	shall provide written notification of the amount to be remitted
1303	to the Agency for Health Care Administrationcorporationfor the
1304	following fiscal year under that policy. Local match sources may
1305	include, but are not limited to, funds provided by
1306	municipalities, counties, school boards, hospitals, health care
1307	providers, charitable organizations, special taxing districts,
1308	and private organizations. The minimum local match cash
1309	contributions required each fiscal year and local match credits
1310	shall be determined by the General Appropriations Act. The
1311	corporation shall calculate a county's local match rate based
1312	upon that county's percentage of the state's total non-Title-XXI
1313	expenditures as reported in the corporation's most recently
1314	audited financial statement. In awarding the local match
1315	credits, the corporation may consider factors including, but not
1316	limited to, population density, per capita income, and existing
1317	child-health-related expenditures and services.;
1318	4. Accept for the Agency for Health Care Administration
1319	voluntary supplemental local match contributions that comply
1320	with the requirements of Title XXI of the Social Security Act
1321	for the purpose of providing additional coverage in contributing
1322	counties under Title XXI that shall be remitted to the Agency
1323	for Health Care Administration within 1 week after receipt.;
1324	5. Establish the administrative and accounting procedures
1325	for the operation of the corporation.;
1326	6. Establish, with consultation from appropriate
1327	professional organizations, standards for preventive health
1328	services and providers and comprehensive insurance benefits
1329	appropriate to children; provided that such standards for rural
1330	areas shall not limit primary care providers to board-certified
1331	pediatricians.;
1332	7. Establish eligibility criteria which children must meet
1333	in order to participate in the program.;
1334	8. Establish procedures under which providers of local
1335	match to, applicants to and participants in the program may have
1336	grievances reviewed by an impartial body and reported to the
1337	board of directors of the corporation.;
1338	9. Establish participation criteria and, if appropriate,
1339	contract with an authorized insurer, health maintenance
1340	organization, or insurance administrator to provide
1341	administrative services to the corporation;
1342	9.10.Establish enrollment criteria which shall include
1343	penalties or waiting periods of not fewer than 60 days for
1344	reinstatement of coverage upon voluntary cancellation for
1345	nonpayment of family premiums.;
1346	10.11.If a space is available, establish a special open
1347	enrollment period of 30 days' duration for any child who is
1348	enrolled in Medicaid or Medikids if such child loses Medicaid or
1349	Medikids eligibility and becomes eligible for the Florida
1350	Healthy Kids program.;
1351	12. Contract with authorized insurers or any provider of
1352	health care services, meeting standards established by the
1353	corporation, for the provision of comprehensive insurance
1354	coverage to participants. Such standards shall include criteria
1355	under which the corporation may contract with more than one
1356	provider of health care services in program sites. Health plans
1357	shall be selected through a competitive bid process. The
1358	selection of health plans shall be based primarily on quality
1359	criteria established by the board. The health plan selection
1360	criteria and scoring system, and the scoring results, shall be
1361	available upon request for inspection after the bids have been
1362	awarded;
1363	11.13.Establish disenrollment criteria in the event local
1364	matching funds are insufficient to cover enrollments.;
1365	12.14.Develop and implement a plan to publicize the
1366	Florida Healthy Kids Corporation, the eligibility requirements
1367	of the program, and the procedures for enrollment in the program
1368	and to maintain public awareness of the corporation and the
1369	program.;
1370	13.15.Secure staff necessary to properly administer the
1371	corporation. Staff costs shall be funded from state and local
1372	matching funds and such other private or public funds as become
1373	available. The board of directors shall determine the number of
1374	staff members necessary to administer the corporation.;
1375	14.16.As appropriate, enter into contracts with local
1376	school boards or other agencies to provide onsite information,
1377	enrollment, and other services necessary to the operation of the
1378	corporation.;
1379	15.17.Provide a report annually to the Governor, Chief
1380	Financial Officer, Commissioner of Education, Senate President,
1381	Speaker of the House of Representatives, and Minority Leaders of
1382	the Senate and the House of Representatives.;
1383	16.18.Each fiscal year, establish a maximum number of
1384	participants, on a statewide basis, who may enroll in the
1385	program.; and
1386	17.19.Establish eligibility criteria, premium and cost-
1387	sharing requirements, and benefit packages which conform to the
1388	provisions of the Florida Kidcare program, as created in ss.
1389	409.810-409.820.
1390	(c) Coverage under the corporation's program is secondary
1391	to any other available private coverage held by the participant
1392	child or family member. The corporation may establish procedures
1393	for coordinating benefits under this program with benefits under
1394	other public and private coverage.
1395	(c)(d)The Florida Healthy Kids Corporation shall be a
1396	private corporation not for profit, organized pursuant to
1397	chapter 617, and shall have all powers necessary to carry out
1398	the purposes of this act, including, but not limited to, the
1399	power to receive and accept grants, loans, or advances of funds
1400	from any public or private agency and to receive and accept from
1401	any source contributions of money, property, labor, or any other
1402	thing of value, to be held, used, and applied for the purposes
1403	of this act.
1404	(5) BOARD OF DIRECTORS.--
1405	(a) The Florida Healthy Kids Corporation shall operate
1406	subject to the supervision and approval of a board of directors
1407	chaired by the Chief Financial Officer or her or his designee,
1408	and composed of 1014other members selected for 3-year terms of
1409	office as follows:
1410	1. The secretary of the Agency for Health Care
1411	Administration or her or his designee.One member appointed by
1412	the Commissioner of Education from among three persons nominated
1413	by the Florida Association of School Administrators;
1414	2. One member appointed by the Commissioner of Education
1415	from among three persons nominated by the Florida Association of
1416	School Boards;
1417	2.3.One member appointed by the Commissioner of Education
1418	from the Office of School Health Programs of the Florida
1419	Department of Education.;
1420	3.4.One member appointed by the Governor from among three
1421	members nominated by the Florida Pediatric Society.;
1422	4.5.One member, appointed by the Governor, who represents
1423	the Children's Medical Services Program.;
1424	5.6. One member appointed by the GovernorChief Financial
1425	Officerfrom among three members nominated by the Florida
1426	Hospital Association.;
1427	7. Two members, appointed by the Chief Financial Officer,
1428	who are representatives of authorized health care insurers or
1429	health maintenance organizations;
1430	6.8. One member, appointed by the Board of GovernorsChief
1431	Financial Officer, who is knowledgeable aboutrepresents the
1432	Institute for child health policy.;
1433	7.9.One member, appointed by the Governor, from among
1434	three members nominated by the Florida Academy of Family
1435	Physicians.;
1436	8.10.One member, appointed by the Governor, who
1437	represents the state Medicaid program.Agency for Health Care
1438	Administration;
1439	11. One member, appointed by the Chief Financial Officer,
1440	from among three members nominated by the Florida Association of
1441	Counties, representing rural counties;
1442	9.12.One member, appointed by the Governor, from among
1443	three members nominated by the Florida Association of Counties.,
1444	representing urban counties; and
1445	10.13.The State Health Officer or her or his designee.
1446	Section 21. Section 624.915, Florida Statutes, is amended
1447	to read:
1448	624.915 Florida Healthy Kids Corporation; operating
1449	fund.--The Florida Healthy Kids Corporation may establish and
1450	manage an operating fund for the purposes of addressing the
1451	corporation's unique cash-flow needs and facilitating the fiscal
1452	management of the corporation. The corporation may accumulate
1453	and maintain in the operating fund at any given time a cash
1454	balance reserve equal to no more than 25 percent of its
1455	annualized operating expenses. Excess funds shall be remitted to
1456	the Agency for Health Care Administration for use in funding the
1457	Florida Kidcare program.Upon dissolution of the corporation,
1458	any remaining cash balances of state funds shall revert to the
1459	General Revenue Fund, or such other state funds consistent with
1460	the appropriated funding, as provided by law.
1461	Section 22. Section 57 of chapter 98-288, Laws of Florida,
1462	is repealed.
1463	Section 23. If any law amended by this act was also
1464	amended by a law enacted at the 2003 Regular Session of the
1465	Legislature, such laws shall be construed as if they had been
1466	enacted at the same session of the Legislature, and full effect
1467	shall be given to each if possible.
1468	Section 24. Except as otherwise provided herein, this act
1469	shall take effect July 1, 2003.