Senate Bill sb1064c2
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By the Committees on Appropriations; Health, Aging, and
Long-Term Care; and Senators Saunders, Aronberg, Fasano and
Lynn
309-2388-04
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 16.56,
3 F.S.; adding criminal violations of s. 409.920
4 or s. 409.9201, F.S., to the list of specified
5 crimes within the jurisdiction of the Office of
6 Statewide Prosecution; amending s. 400.408,
7 F.S.; including the Medicaid Fraud Control Unit
8 of the Department of Legal Affairs in the
9 Agency for Health Care Administration's local
10 coordinating workgroups for identifying
11 unlicensed assisted living facilities; amending
12 s. 400.434, F.S.; giving the Medicaid Fraud
13 Control Unit of the Department of Legal Affairs
14 the authority to enter and inspect facilities
15 licensed under part III of ch. 400, F.S.;
16 creating s. 409.9021, F.S.; requiring a
17 Medicaid applicant to agree to forfeiture of
18 all entitlements under the Medicaid program
19 upon a judicial or administrative finding of
20 fraud within a specified period; amending s.
21 409.912, F.S.; authorizing the Agency for
22 Health Care Administration to require a
23 confirmation or second physician's opinion of
24 the correct diagnosis for purposes of
25 authorizing future services under the Medicaid
26 program; authorizing the Agency for Health Care
27 Administration to impose mandatory enrollment
28 in drug-therapy-management or
29 disease-management programs for certain
30 categories of recipients; requiring that the
31 Agency for Health Care Administration and the
1
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1 Drug Utilization Review Board consult with the
2 Department of Health; allowing termination of
3 certain practitioners from the Medicaid
4 program; providing that Medicaid recipients may
5 be required to participate in a provider
6 lock-in program for not less than 1 year and up
7 to the duration of the time the recipient
8 participates in the program; requiring the
9 agency to seek a federal waiver to terminate
10 eligibility; requiring the agency to conduct a
11 study of electronic verification systems;
12 authorizing the agency to use credentialing
13 criteria for the purpose of including providers
14 in the Medicaid program; amending s. 409.913,
15 F.S.; providing specified conditions for
16 providers to meet in order to submit claims to
17 the Medicaid program; providing that claims may
18 be denied if not properly submitted; providing
19 that the agency may seek any remedy under law
20 if a provider submits specified false or
21 erroneous claims; providing that suspension or
22 termination precludes participation in the
23 Medicaid program; providing that the agency is
24 required to report administrative sanctions to
25 licensing authorities for certain violations;
26 providing that the agency may withhold payment
27 to a provider under certain circumstances;
28 providing that the agency may deny payments to
29 terminated or suspended providers; authorizing
30 the agency to implement amnesty programs for
31 providers to voluntarily repay overpayments;
2
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1 authorizing the agency to adopt rules;
2 providing for limiting, restricting, or
3 suspending Medicaid eligibility of Medicaid
4 recipients convicted of certain crimes or
5 offenses; authorizing the agency and the
6 Medicaid Fraud Control Unit of the Department
7 of Legal Affairs to review non-Medicaid-related
8 records in order to determine reconciliation of
9 a provider's records; authorizing the agency
10 head or designee to limit, restrict, or suspend
11 Medicaid eligibility for a period not to exceed
12 1 year if a recipient is convicted of a federal
13 health care crime; authorizing the Agency for
14 Health Care Administration to limit the number
15 of certain types of prescription claims
16 submitted by pharmacy providers; requiring the
17 agency to limit the allowable amount of certain
18 types of prescriptions under specified
19 circumstances; amending s. 409.9131, F.S.;
20 requiring that the Office of Program Policy
21 Analysis and Government Accountability report
22 to the Legislature on the agency's fraud and
23 abuse prevention, deterrence, detection, and
24 recovery efforts; redefining the term "peer
25 review"; providing for peer review for purposes
26 of determining a potential overpayment if the
27 medical necessity or quality of care is
28 evaluated; requiring an additional statement on
29 Medicaid cost reports certifying that Medicaid
30 providers are familiar with the laws and
31 regulations regarding the provision of health
3
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1 care services under the Medicaid program;
2 amending s. 409.920, F.S.; redefining the term
3 "knowingly" to include "willfully" or
4 "willful"; making it unlawful to knowingly use
5 or endeavor to use a Medicaid provider's or a
6 Medicaid recipient's identification number or
7 cause to be made, or aid and abet in the making
8 of, a claim for items or services that are not
9 authorized to be reimbursed under the Medicaid
10 program; defining the term "paid for"; creating
11 s. 409.9201, F.S.; providing definitions;
12 providing that a person who knowingly sells or
13 attempts to sell legend drugs obtained through
14 the Medicaid program commits a felony;
15 providing that a person who knowingly purchases
16 or attempts to purchase legend drugs obtained
17 through the Medicaid program and intended for
18 the use of another commits a felony; providing
19 that a person who knowingly makes or conspires
20 to make false representations for the purpose
21 of obtaining goods or services from the
22 Medicaid program commits a felony; providing
23 specified criminal penalties depending on the
24 value of the legend drugs or goods or services
25 obtained from the Medicaid program; amending s.
26 456.072, F.S.; providing an additional ground
27 under which a health care practitioner who
28 prescribes medicinal drugs or controlled
29 substances may be subject to discipline by the
30 Department of Health or the appropriate board
31 having jurisdiction over the health care
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1 practitioner; authorizing the Department of
2 Health to initiate a disciplinary investigation
3 of prescribing practitioners under specified
4 circumstances; amending s. 465.188, F.S.;
5 deleting the requirement that the Agency for
6 Health Care Administration give pharmacists at
7 least 1 week's notice prior to an audit;
8 specifying an effective date for certain audit
9 criteria; creating s. 812.0191, F.S.; providing
10 definitions; providing that a person who
11 traffics in property paid for in whole or in
12 part by the Medicaid program, or who knowingly
13 finances, directs, or traffics in such
14 property, commits a felony; providing specified
15 criminal penalties depending on the value of
16 the property; amending s. 895.02, F.S.; adding
17 Medicaid recipient fraud to the definition of
18 the term "racketeering activity"; amending s.
19 905.34, F.S.; adding any criminal violation of
20 s. 409.920 or s. 409.9201, F.S., to the list of
21 crimes within the jurisdiction of the statewide
22 grand jury; amending s. 932.701, F.S.;
23 expanding the definition of "contraband
24 article"; amending s. 932.7055, F.S.; requiring
25 that proceeds collected under the Florida
26 Contraband Forfeiture Act be deposited in the
27 Department of Legal Affairs' Grants and
28 Donations Trust Fund; amending ss. 394.9082,
29 400.0077, 409.9065, 409.9071, 409.908,
30 409.91196, 409.9122, 409.9131, 430.608,
31 636.0145, 641.225, and 641.386, F.S.;
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1 correcting cross-references; reenacting s.
2 921.0022(3)(g), F.S., relating to the offense
3 severity ranking chart of the Criminal
4 Punishment Code, to incorporate the amendment
5 to s. 409.920, F.S., in a reference thereto;
6 reenacting s. 705.101(6), F.S., relating to
7 unclaimed evidence, to incorporate the
8 amendment to s. 932.701, F.S., in a reference
9 thereto; reenacting s. 932.703(4), F.S.,
10 relating to forfeiture of contraband articles,
11 to incorporate the amendment to s. 932.701,
12 F.S., in a reference thereto; providing an
13 appropriation and authorizing positions;
14 providing an effective date.
15
16 Be It Enacted by the Legislature of the State of Florida:
17
18 Section 1. Subsection (1) of section 16.56, Florida
19 Statutes, is amended to read:
20 16.56 Office of Statewide Prosecution.--
21 (1) There is created in the Department of Legal
22 Affairs an Office of Statewide Prosecution. The office shall
23 be a separate "budget entity" as that term is defined in
24 chapter 216. The office may:
25 (a) Investigate and prosecute the offenses of:
26 1. Bribery, burglary, criminal usury, extortion,
27 gambling, kidnapping, larceny, murder, prostitution, perjury,
28 robbery, carjacking, and home-invasion robbery;
29 2. Any crime involving narcotic or other dangerous
30 drugs;
31
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1 3. Any violation of the provisions of the Florida RICO
2 (Racketeer Influenced and Corrupt Organization) Act, including
3 any offense listed in the definition of racketeering activity
4 in s. 895.02(1)(a), providing such listed offense is
5 investigated in connection with a violation of s. 895.03 and
6 is charged in a separate count of an information or indictment
7 containing a count charging a violation of s. 895.03, the
8 prosecution of which listed offense may continue independently
9 if the prosecution of the violation of s. 895.03 is terminated
10 for any reason;
11 4. Any violation of the provisions of the Florida
12 Anti-Fencing Act;
13 5. Any violation of the provisions of the Florida
14 Antitrust Act of 1980, as amended;
15 6. Any crime involving, or resulting in, fraud or
16 deceit upon any person;
17 7. Any violation of s. 847.0135, relating to computer
18 pornography and child exploitation prevention, or any offense
19 related to a violation of s. 847.0135;
20 8. Any violation of the provisions of chapter 815; or
21 9. Any criminal violation of part I of chapter 499; or
22 10. Any criminal violation of s. 409.920 or s.
23 409.9201.
24
25 or any attempt, solicitation, or conspiracy to commit any of
26 the crimes specifically enumerated above. The office shall
27 have such power only when any such offense is occurring, or
28 has occurred, in two or more judicial circuits as part of a
29 related transaction, or when any such offense is connected
30 with an organized criminal conspiracy affecting two or more
31 judicial circuits.
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1 (b) Upon request, cooperate with and assist state
2 attorneys and state and local law enforcement officials in
3 their efforts against organized crimes.
4 (c) Request and receive from any department, division,
5 board, bureau, commission, or other agency of the state, or of
6 any political subdivision thereof, cooperation and assistance
7 in the performance of its duties.
8 Section 2. Paragraph (i) of subsection (1) of section
9 400.408, Florida Statutes, is amended to read:
10 400.408 Unlicensed facilities; referral of person for
11 residency to unlicensed facility; penalties; verification of
12 licensure status.--
13 (1)
14 (i) Each field office of the Agency for Health Care
15 Administration shall establish a local coordinating workgroup
16 which includes representatives of local law enforcement
17 agencies, state attorneys, the Medicaid Fraud Control Unit of
18 the Department of Legal Affairs, local fire authorities, the
19 Department of Children and Family Services, the district
20 long-term care ombudsman council, and the district human
21 rights advocacy committee to assist in identifying the
22 operation of unlicensed facilities and to develop and
23 implement a plan to ensure effective enforcement of state laws
24 relating to such facilities. The workgroup shall report its
25 findings, actions, and recommendations semiannually to the
26 Director of Health Facility Regulation of the agency.
27 Section 3. Section 400.434, Florida Statutes, is
28 amended to read:
29 400.434 Right of entry and inspection.--Any duly
30 designated officer or employee of the department, the
31 Department of Children and Family Services, the agency, the
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1 Medicaid Fraud Control Unit of the Department of Legal
2 Affairs, the state or local fire marshal, or a member of the
3 state or local long-term care ombudsman council shall have the
4 right to enter unannounced upon and into the premises of any
5 facility licensed pursuant to this part in order to determine
6 the state of compliance with the provisions of this part and
7 of rules or standards in force pursuant thereto. The right of
8 entry and inspection shall also extend to any premises which
9 the agency has reason to believe is being operated or
10 maintained as a facility without a license; but no such entry
11 or inspection of any premises may be made without the
12 permission of the owner or person in charge thereof, unless a
13 warrant is first obtained from the circuit court authorizing
14 such entry. The warrant requirement shall extend only to a
15 facility which the agency has reason to believe is being
16 operated or maintained as a facility without a license. Any
17 application for a license or renewal thereof made pursuant to
18 this part shall constitute permission for, and complete
19 acquiescence in, any entry or inspection of the premises for
20 which the license is sought, in order to facilitate
21 verification of the information submitted on or in connection
22 with the application; to discover, investigate, and determine
23 the existence of abuse or neglect; or to elicit, receive,
24 respond to, and resolve complaints. Any current valid license
25 shall constitute unconditional permission for, and complete
26 acquiescence in, any entry or inspection of the premises by
27 authorized personnel. The agency shall retain the right of
28 entry and inspection of facilities that have had a license
29 revoked or suspended within the previous 24 months, to ensure
30 that the facility is not operating unlawfully. However, before
31 entering the facility, a statement of probable cause must be
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1 filed with the director of the agency, who must approve or
2 disapprove the action within 48 hours. Probable cause shall
3 include, but is not limited to, evidence that the facility
4 holds itself out to the public as a provider of personal care
5 services or the receipt of a complaint by the long-term care
6 ombudsman council about the facility. Data collected by the
7 state or local long-term care ombudsman councils or the state
8 or local advocacy councils may be used by the agency in
9 investigations involving violations of regulatory standards.
10 Section 4. Section 409.9021, Florida Statutes, is
11 created to read:
12 409.9021 Forfeiture of eligibility agreement.--As a
13 condition of Medicaid eligibility, subject to federal
14 approval, a Medicaid applicant shall agree in writing to
15 forfeit all entitlements to any goods or services provided
16 through the Medicaid program if he or she has been found to
17 have committed fraud, through judicial or administrative
18 proceedings, three times in a period of less than 36 months.
19 This provision applies only to the Medicaid recipient found to
20 have committed or participated in the fraud and does not apply
21 to any family member of the recipient who was not involved in
22 the fraud.
23 Section 5. Section 409.912, Florida Statutes, is
24 amended to read:
25 409.912 Cost-effective purchasing of health care.--The
26 agency shall purchase goods and services for Medicaid
27 recipients in the most cost-effective manner consistent with
28 the delivery of quality medical care. To ensure that medical
29 services are effectively utilized, the agency may, in any
30 case, require a confirmation or second physician's opinion of
31 the correct diagnosis for purposes of authorizing future
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1 services under the Medicaid program. This section does not
2 restrict access to emergency services or poststabilization
3 care services as defined in 42 C.F.R. part 438.114. Such
4 confirmation or second opinion shall be rendered in a manner
5 approved by the agency. The agency shall maximize the use of
6 prepaid per capita and prepaid aggregate fixed-sum basis
7 services when appropriate and other alternative service
8 delivery and reimbursement methodologies, including
9 competitive bidding pursuant to s. 287.057, designed to
10 facilitate the cost-effective purchase of a case-managed
11 continuum of care. The agency shall also require providers to
12 minimize the exposure of recipients to the need for acute
13 inpatient, custodial, and other institutional care and the
14 inappropriate or unnecessary use of high-cost services. The
15 agency may mandate establish prior authorization, drug therapy
16 management, or disease management participation requirements
17 for certain populations of Medicaid beneficiaries, certain
18 drug classes, or particular drugs to prevent fraud, abuse,
19 overuse, and possible dangerous drug interactions. The
20 Pharmaceutical and Therapeutics Committee shall make
21 recommendations to the agency on drugs for which prior
22 authorization is required. The agency shall inform the
23 Pharmaceutical and Therapeutics Committee of its decisions
24 regarding drugs subject to prior authorization.
25 (1) The agency shall work with the Department of
26 Children and Family Services to ensure access of children and
27 families in the child protection system to needed and
28 appropriate mental health and substance abuse services.
29 (2) The agency may enter into agreements with
30 appropriate agents of other state agencies or of any agency of
31 the Federal Government and accept such duties in respect to
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1 social welfare or public aid as may be necessary to implement
2 the provisions of Title XIX of the Social Security Act and ss.
3 409.901-409.920.
4 (3) The agency may contract with health maintenance
5 organizations certified pursuant to part I of chapter 641 for
6 the provision of services to recipients.
7 (4) The agency may contract with:
8 (a) An entity that provides no prepaid health care
9 services other than Medicaid services under contract with the
10 agency and which is owned and operated by a county, county
11 health department, or county-owned and operated hospital to
12 provide health care services on a prepaid or fixed-sum basis
13 to recipients, which entity may provide such prepaid services
14 either directly or through arrangements with other providers.
15 Such prepaid health care services entities must be licensed
16 under parts I and III by January 1, 1998, and until then are
17 exempt from the provisions of part I of chapter 641. An entity
18 recognized under this paragraph which demonstrates to the
19 satisfaction of the Office of Insurance Regulation of the
20 Financial Services Commission that it is backed by the full
21 faith and credit of the county in which it is located may be
22 exempted from s. 641.225.
23 (b) An entity that is providing comprehensive
24 behavioral health care services to certain Medicaid recipients
25 through a capitated, prepaid arrangement pursuant to the
26 federal waiver provided for by s. 409.905(5). Such an entity
27 must be licensed under chapter 624, chapter 636, or chapter
28 641 and must possess the clinical systems and operational
29 competence to manage risk and provide comprehensive behavioral
30 health care to Medicaid recipients. As used in this paragraph,
31 the term "comprehensive behavioral health care services" means
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1 covered mental health and substance abuse treatment services
2 that are available to Medicaid recipients. The secretary of
3 the Department of Children and Family Services shall approve
4 provisions of procurements related to children in the
5 department's care or custody prior to enrolling such children
6 in a prepaid behavioral health plan. Any contract awarded
7 under this paragraph must be competitively procured. In
8 developing the behavioral health care prepaid plan procurement
9 document, the agency shall ensure that the procurement
10 document requires the contractor to develop and implement a
11 plan to ensure compliance with s. 394.4574 related to services
12 provided to residents of licensed assisted living facilities
13 that hold a limited mental health license. The agency shall
14 seek federal approval to contract with a single entity meeting
15 these requirements to provide comprehensive behavioral health
16 care services to all Medicaid recipients in an AHCA area. Each
17 entity must offer sufficient choice of providers in its
18 network to ensure recipient access to care and the opportunity
19 to select a provider with whom they are satisfied. The network
20 shall include all public mental health hospitals. To ensure
21 unimpaired access to behavioral health care services by
22 Medicaid recipients, all contracts issued pursuant to this
23 paragraph shall require 80 percent of the capitation paid to
24 the managed care plan, including health maintenance
25 organizations, to be expended for the provision of behavioral
26 health care services. In the event the managed care plan
27 expends less than 80 percent of the capitation paid pursuant
28 to this paragraph for the provision of behavioral health care
29 services, the difference shall be returned to the agency. The
30 agency shall provide the managed care plan with a
31 certification letter indicating the amount of capitation paid
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1 during each calendar year for the provision of behavioral
2 health care services pursuant to this section. The agency may
3 reimburse for substance abuse treatment services on a
4 fee-for-service basis until the agency finds that adequate
5 funds are available for capitated, prepaid arrangements.
6 1. By January 1, 2001, the agency shall modify the
7 contracts with the entities providing comprehensive inpatient
8 and outpatient mental health care services to Medicaid
9 recipients in Hillsborough, Highlands, Hardee, Manatee, and
10 Polk Counties, to include substance abuse treatment services.
11 2. By July 1, 2003, the agency and the Department of
12 Children and Family Services shall execute a written agreement
13 that requires collaboration and joint development of all
14 policy, budgets, procurement documents, contracts, and
15 monitoring plans that have an impact on the state and Medicaid
16 community mental health and targeted case management programs.
17 3. By July 1, 2006, the agency and the Department of
18 Children and Family Services shall contract with managed care
19 entities in each AHCA area except area 6 or arrange to provide
20 comprehensive inpatient and outpatient mental health and
21 substance abuse services through capitated prepaid
22 arrangements to all Medicaid recipients who are eligible to
23 participate in such plans under federal law and regulation. In
24 AHCA areas where eligible individuals number less than
25 150,000, the agency shall contract with a single managed care
26 plan. The agency may contract with more than one plan in AHCA
27 areas where the eligible population exceeds 150,000. Contracts
28 awarded pursuant to this section shall be competitively
29 procured. Both for-profit and not-for-profit corporations
30 shall be eligible to compete.
31
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1 4. By October 1, 2003, the agency and the department
2 shall submit a plan to the Governor, the President of the
3 Senate, and the Speaker of the House of Representatives which
4 provides for the full implementation of capitated prepaid
5 behavioral health care in all areas of the state. The plan
6 shall include provisions which ensure that children and
7 families receiving foster care and other related services are
8 appropriately served and that these services assist the
9 community-based care lead agencies in meeting the goals and
10 outcomes of the child welfare system. The plan will be
11 developed with the participation of community-based lead
12 agencies, community alliances, sheriffs, and community
13 providers serving dependent children.
14 a. Implementation shall begin in 2003 in those AHCA
15 areas of the state where the agency is able to establish
16 sufficient capitation rates.
17 b. If the agency determines that the proposed
18 capitation rate in any area is insufficient to provide
19 appropriate services, the agency may adjust the capitation
20 rate to ensure that care will be available. The agency and the
21 department may use existing general revenue to address any
22 additional required match but may not over-obligate existing
23 funds on an annualized basis.
24 c. Subject to any limitations provided for in the
25 General Appropriations Act, the agency, in compliance with
26 appropriate federal authorization, shall develop policies and
27 procedures that allow for certification of local and state
28 funds.
29 5. Children residing in a statewide inpatient
30 psychiatric program, or in a Department of Juvenile Justice or
31 a Department of Children and Family Services residential
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1 program approved as a Medicaid behavioral health overlay
2 services provider shall not be included in a behavioral health
3 care prepaid health plan pursuant to this paragraph.
4 6. In converting to a prepaid system of delivery, the
5 agency shall in its procurement document require an entity
6 providing comprehensive behavioral health care services to
7 prevent the displacement of indigent care patients by
8 enrollees in the Medicaid prepaid health plan providing
9 behavioral health care services from facilities receiving
10 state funding to provide indigent behavioral health care, to
11 facilities licensed under chapter 395 which do not receive
12 state funding for indigent behavioral health care, or
13 reimburse the unsubsidized facility for the cost of behavioral
14 health care provided to the displaced indigent care patient.
15 7. Traditional community mental health providers under
16 contract with the Department of Children and Family Services
17 pursuant to part IV of chapter 394, child welfare providers
18 under contract with the Department of Children and Family
19 Services, and inpatient mental health providers licensed
20 pursuant to chapter 395 must be offered an opportunity to
21 accept or decline a contract to participate in any provider
22 network for prepaid behavioral health services.
23 (c) A federally qualified health center or an entity
24 owned by one or more federally qualified health centers or an
25 entity owned by other migrant and community health centers
26 receiving non-Medicaid financial support from the Federal
27 Government to provide health care services on a prepaid or
28 fixed-sum basis to recipients. Such prepaid health care
29 services entity must be licensed under parts I and III of
30 chapter 641, but shall be prohibited from serving Medicaid
31 recipients on a prepaid basis, until such licensure has been
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1 obtained. However, such an entity is exempt from s. 641.225
2 if the entity meets the requirements specified in subsections
3 (15) and (16).
4 (d) A provider service network may be reimbursed on a
5 fee-for-service or prepaid basis. A provider service network
6 which is reimbursed by the agency on a prepaid basis shall be
7 exempt from parts I and III of chapter 641, but must meet
8 appropriate financial reserve, quality assurance, and patient
9 rights requirements as established by the agency. The agency
10 shall award contracts on a competitive bid basis and shall
11 select bidders based upon price and quality of care. Medicaid
12 recipients assigned to a demonstration project shall be chosen
13 equally from those who would otherwise have been assigned to
14 prepaid plans and MediPass. The agency is authorized to seek
15 federal Medicaid waivers as necessary to implement the
16 provisions of this section.
17 (e) An entity that provides comprehensive behavioral
18 health care services to certain Medicaid recipients through an
19 administrative services organization agreement. Such an entity
20 must possess the clinical systems and operational competence
21 to provide comprehensive health care to Medicaid recipients.
22 As used in this paragraph, the term "comprehensive behavioral
23 health care services" means covered mental health and
24 substance abuse treatment services that are available to
25 Medicaid recipients. Any contract awarded under this paragraph
26 must be competitively procured. The agency must ensure that
27 Medicaid recipients have available the choice of at least two
28 managed care plans for their behavioral health care services.
29 (f) An entity that provides in-home physician services
30 to test the cost-effectiveness of enhanced home-based medical
31 care to Medicaid recipients with degenerative neurological
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1 diseases and other diseases or disabling conditions associated
2 with high costs to Medicaid. The program shall be designed to
3 serve very disabled persons and to reduce Medicaid reimbursed
4 costs for inpatient, outpatient, and emergency department
5 services. The agency shall contract with vendors on a
6 risk-sharing basis.
7 (g) Children's provider networks that provide care
8 coordination and care management for Medicaid-eligible
9 pediatric patients, primary care, authorization of specialty
10 care, and other urgent and emergency care through organized
11 providers designed to service Medicaid eligibles under age 18
12 and pediatric emergency departments' diversion programs. The
13 networks shall provide after-hour operations, including
14 evening and weekend hours, to promote, when appropriate, the
15 use of the children's networks rather than hospital emergency
16 departments.
17 (h) An entity authorized in s. 430.205 to contract
18 with the agency and the Department of Elderly Affairs to
19 provide health care and social services on a prepaid or
20 fixed-sum basis to elderly recipients. Such prepaid health
21 care services entities are exempt from the provisions of part
22 I of chapter 641 for the first 3 years of operation. An entity
23 recognized under this paragraph that demonstrates to the
24 satisfaction of the Office of Insurance Regulation that it is
25 backed by the full faith and credit of one or more counties in
26 which it operates may be exempted from s. 641.225.
27 (i) A Children's Medical Services network, as defined
28 in s. 391.021.
29 (5) By October 1, 2003, the agency and the department
30 shall, to the extent feasible, develop a plan for implementing
31 new Medicaid procedure codes for emergency and crisis care,
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1 supportive residential services, and other services designed
2 to maximize the use of Medicaid funds for Medicaid-eligible
3 recipients. The agency shall include in the agreement
4 developed pursuant to subsection (4) a provision that ensures
5 that the match requirements for these new procedure codes are
6 met by certifying eligible general revenue or local funds that
7 are currently expended on these services by the department
8 with contracted alcohol, drug abuse, and mental health
9 providers. The plan must describe specific procedure codes to
10 be implemented, a projection of the number of procedures to be
11 delivered during fiscal year 2003-2004, and a financial
12 analysis that describes the certified match procedures, and
13 accountability mechanisms, projects the earnings associated
14 with these procedures, and describes the sources of state
15 match. This plan may not be implemented in any part until
16 approved by the Legislative Budget Commission. If such
17 approval has not occurred by December 31, 2003, the plan shall
18 be submitted for consideration by the 2004 Legislature.
19 (6) The agency may contract with any public or private
20 entity otherwise authorized by this section on a prepaid or
21 fixed-sum basis for the provision of health care services to
22 recipients. An entity may provide prepaid services to
23 recipients, either directly or through arrangements with other
24 entities, if each entity involved in providing services:
25 (a) Is organized primarily for the purpose of
26 providing health care or other services of the type regularly
27 offered to Medicaid recipients;
28 (b) Ensures that services meet the standards set by
29 the agency for quality, appropriateness, and timeliness;
30 (c) Makes provisions satisfactory to the agency for
31 insolvency protection and ensures that neither enrolled
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1 Medicaid recipients nor the agency will be liable for the
2 debts of the entity;
3 (d) Submits to the agency, if a private entity, a
4 financial plan that the agency finds to be fiscally sound and
5 that provides for working capital in the form of cash or
6 equivalent liquid assets excluding revenues from Medicaid
7 premium payments equal to at least the first 3 months of
8 operating expenses or $200,000, whichever is greater;
9 (e) Furnishes evidence satisfactory to the agency of
10 adequate liability insurance coverage or an adequate plan of
11 self-insurance to respond to claims for injuries arising out
12 of the furnishing of health care;
13 (f) Provides, through contract or otherwise, for
14 periodic review of its medical facilities and services, as
15 required by the agency; and
16 (g) Provides organizational, operational, financial,
17 and other information required by the agency.
18 (7) The agency may contract on a prepaid or fixed-sum
19 basis with any health insurer that:
20 (a) Pays for health care services provided to enrolled
21 Medicaid recipients in exchange for a premium payment paid by
22 the agency;
23 (b) Assumes the underwriting risk; and
24 (c) Is organized and licensed under applicable
25 provisions of the Florida Insurance Code and is currently in
26 good standing with the Office of Insurance Regulation.
27 (8) The agency may contract on a prepaid or fixed-sum
28 basis with an exclusive provider organization to provide
29 health care services to Medicaid recipients provided that the
30 exclusive provider organization meets applicable managed care
31 plan requirements in this section, ss. 409.9122, 409.9123,
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1 409.9128, and 627.6472, and other applicable provisions of
2 law.
3 (9) The Agency for Health Care Administration may
4 provide cost-effective purchasing of chiropractic services on
5 a fee-for-service basis to Medicaid recipients through
6 arrangements with a statewide chiropractic preferred provider
7 organization incorporated in this state as a not-for-profit
8 corporation. The agency shall ensure that the benefit limits
9 and prior authorization requirements in the current Medicaid
10 program shall apply to the services provided by the
11 chiropractic preferred provider organization.
12 (10) The agency shall not contract on a prepaid or
13 fixed-sum basis for Medicaid services with an entity which
14 knows or reasonably should know that any officer, director,
15 agent, managing employee, or owner of stock or beneficial
16 interest in excess of 5 percent common or preferred stock, or
17 the entity itself, has been found guilty of, regardless of
18 adjudication, or entered a plea of nolo contendere, or guilty,
19 to:
20 (a) Fraud;
21 (b) Violation of federal or state antitrust statutes,
22 including those proscribing price fixing between competitors
23 and the allocation of customers among competitors;
24 (c) Commission of a felony involving embezzlement,
25 theft, forgery, income tax evasion, bribery, falsification or
26 destruction of records, making false statements, receiving
27 stolen property, making false claims, or obstruction of
28 justice; or
29 (d) Any crime in any jurisdiction which directly
30 relates to the provision of health services on a prepaid or
31 fixed-sum basis.
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1 (11) The agency, after notifying the Legislature, may
2 apply for waivers of applicable federal laws and regulations
3 as necessary to implement more appropriate systems of health
4 care for Medicaid recipients and reduce the cost of the
5 Medicaid program to the state and federal governments and
6 shall implement such programs, after legislative approval,
7 within a reasonable period of time after federal approval.
8 These programs must be designed primarily to reduce the need
9 for inpatient care, custodial care and other long-term or
10 institutional care, and other high-cost services.
11 (a) Prior to seeking legislative approval of such a
12 waiver as authorized by this subsection, the agency shall
13 provide notice and an opportunity for public comment. Notice
14 shall be provided to all persons who have made requests of the
15 agency for advance notice and shall be published in the
16 Florida Administrative Weekly not less than 28 days prior to
17 the intended action.
18 (b) Notwithstanding s. 216.292, funds that are
19 appropriated to the Department of Elderly Affairs for the
20 Assisted Living for the Elderly Medicaid waiver and are not
21 expended shall be transferred to the agency to fund
22 Medicaid-reimbursed nursing home care.
23 (12) The agency shall establish a postpayment
24 utilization control program designed to identify recipients
25 who may inappropriately overuse or underuse Medicaid services
26 and shall provide methods to correct such misuse.
27 (13) The agency shall develop and provide coordinated
28 systems of care for Medicaid recipients and may contract with
29 public or private entities to develop and administer such
30 systems of care among public and private health care providers
31 in a given geographic area.
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1 (14) The agency shall operate or contract for the
2 operation of utilization management and incentive systems
3 designed to encourage cost-effective use services.
4 (15)(a) The agency shall operate the Comprehensive
5 Assessment and Review (CARES) nursing facility preadmission
6 screening program to ensure that Medicaid payment for nursing
7 facility care is made only for individuals whose conditions
8 require such care and to ensure that long-term care services
9 are provided in the setting most appropriate to the needs of
10 the person and in the most economical manner possible. The
11 CARES program shall also ensure that individuals participating
12 in Medicaid home and community-based waiver programs meet
13 criteria for those programs, consistent with approved federal
14 waivers.
15 (b) The agency shall operate the CARES program through
16 an interagency agreement with the Department of Elderly
17 Affairs.
18 (c) Prior to making payment for nursing facility
19 services for a Medicaid recipient, the agency must verify that
20 the nursing facility preadmission screening program has
21 determined that the individual requires nursing facility care
22 and that the individual cannot be safely served in
23 community-based programs. The nursing facility preadmission
24 screening program shall refer a Medicaid recipient to a
25 community-based program if the individual could be safely
26 served at a lower cost and the recipient chooses to
27 participate in such program.
28 (d) By January 1 of each year, the agency shall submit
29 a report to the Legislature and the Office of Long-Term-Care
30 Policy describing the operations of the CARES program. The
31 report must describe:
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1 1. Rate of diversion to community alternative
2 programs;
3 2. CARES program staffing needs to achieve additional
4 diversions;
5 3. Reasons the program is unable to place individuals
6 in less restrictive settings when such individuals desired
7 such services and could have been served in such settings;
8 4. Barriers to appropriate placement, including
9 barriers due to policies or operations of other agencies or
10 state-funded programs; and
11 5. Statutory changes necessary to ensure that
12 individuals in need of long-term care services receive care in
13 the least restrictive environment.
14 (16)(a) The agency shall identify health care
15 utilization and price patterns within the Medicaid program
16 which are not cost-effective or medically appropriate and
17 assess the effectiveness of new or alternate methods of
18 providing and monitoring service, and may implement such
19 methods as it considers appropriate. Such methods may include
20 disease management initiatives, an integrated and systematic
21 approach for managing the health care needs of recipients who
22 are at risk of or diagnosed with a specific disease by using
23 best practices, prevention strategies, clinical-practice
24 improvement, clinical interventions and protocols, outcomes
25 research, information technology, and other tools and
26 resources to reduce overall costs and improve measurable
27 outcomes.
28 (b) The responsibility of the agency under this
29 subsection shall include the development of capabilities to
30 identify actual and optimal practice patterns; patient and
31 provider educational initiatives; methods for determining
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1 patient compliance with prescribed treatments; fraud, waste,
2 and abuse prevention and detection programs; and beneficiary
3 case management programs.
4 1. The practice pattern identification program shall
5 evaluate practitioner prescribing patterns based on national
6 and regional practice guidelines, comparing practitioners to
7 their peer groups. The agency and its Drug Utilization Review
8 Board shall consult with the Department of Health and a panel
9 of practicing health care professionals consisting of the
10 following: the Speaker of the House of Representatives and the
11 President of the Senate shall each appoint three physicians
12 licensed under chapter 458 or chapter 459; and the Governor
13 shall appoint two pharmacists licensed under chapter 465 and
14 one dentist licensed under chapter 466 who is an oral surgeon.
15 Terms of the panel members shall expire at the discretion of
16 the appointing official. The panel shall begin its work by
17 August 1, 1999, regardless of the number of appointments made
18 by that date. The advisory panel shall be responsible for
19 evaluating treatment guidelines and recommending ways to
20 incorporate their use in the practice pattern identification
21 program. Practitioners who are prescribing inappropriately or
22 inefficiently, as determined by the agency, may have their
23 prescribing of certain drugs subject to prior authorization or
24 may be terminated from all participation in the Medicaid
25 program.
26 2. The agency shall also develop educational
27 interventions designed to promote the proper use of
28 medications by providers and beneficiaries.
29 3. The agency shall implement a pharmacy fraud, waste,
30 and abuse initiative that may include a surety bond or letter
31 of credit requirement for participating pharmacies, enhanced
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1 provider auditing practices, the use of additional fraud and
2 abuse software, recipient management programs for
3 beneficiaries inappropriately using their benefits, and other
4 steps that will eliminate provider and recipient fraud, waste,
5 and abuse. The initiative shall address enforcement efforts to
6 reduce the number and use of counterfeit prescriptions.
7 4. By September 30, 2002, the agency shall contract
8 with an entity in the state to implement a wireless handheld
9 clinical pharmacology drug information database for
10 practitioners. The initiative shall be designed to enhance the
11 agency's efforts to reduce fraud, abuse, and errors in the
12 prescription drug benefit program and to otherwise further the
13 intent of this paragraph.
14 5. The agency may apply for any federal waivers needed
15 to implement this paragraph.
16 (17) An entity contracting on a prepaid or fixed-sum
17 basis shall, in addition to meeting any applicable statutory
18 surplus requirements, also maintain at all times in the form
19 of cash, investments that mature in less than 180 days
20 allowable as admitted assets by the Office of Insurance
21 Regulation, and restricted funds or deposits controlled by the
22 agency or the Office of Insurance Regulation, a surplus amount
23 equal to one-and-one-half times the entity's monthly Medicaid
24 prepaid revenues. As used in this subsection, the term
25 "surplus" means the entity's total assets minus total
26 liabilities. If an entity's surplus falls below an amount
27 equal to one-and-one-half times the entity's monthly Medicaid
28 prepaid revenues, the agency shall prohibit the entity from
29 engaging in marketing and preenrollment activities, shall
30 cease to process new enrollments, and shall not renew the
31
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1 entity's contract until the required balance is achieved. The
2 requirements of this subsection do not apply:
3 (a) Where a public entity agrees to fund any deficit
4 incurred by the contracting entity; or
5 (b) Where the entity's performance and obligations are
6 guaranteed in writing by a guaranteeing organization which:
7 1. Has been in operation for at least 5 years and has
8 assets in excess of $50 million; or
9 2. Submits a written guarantee acceptable to the
10 agency which is irrevocable during the term of the contracting
11 entity's contract with the agency and, upon termination of the
12 contract, until the agency receives proof of satisfaction of
13 all outstanding obligations incurred under the contract.
14 (18)(a) The agency may require an entity contracting
15 on a prepaid or fixed-sum basis to establish a restricted
16 insolvency protection account with a federally guaranteed
17 financial institution licensed to do business in this state.
18 The entity shall deposit into that account 5 percent of the
19 capitation payments made by the agency each month until a
20 maximum total of 2 percent of the total current contract
21 amount is reached. The restricted insolvency protection
22 account may be drawn upon with the authorized signatures of
23 two persons designated by the entity and two representatives
24 of the agency. If the agency finds that the entity is
25 insolvent, the agency may draw upon the account solely with
26 the two authorized signatures of representatives of the
27 agency, and the funds may be disbursed to meet financial
28 obligations incurred by the entity under the prepaid contract.
29 If the contract is terminated, expired, or not continued, the
30 account balance must be released by the agency to the entity
31
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1 upon receipt of proof of satisfaction of all outstanding
2 obligations incurred under this contract.
3 (b) The agency may waive the insolvency protection
4 account requirement in writing when evidence is on file with
5 the agency of adequate insolvency insurance and reinsurance
6 that will protect enrollees if the entity becomes unable to
7 meet its obligations.
8 (19) An entity that contracts with the agency on a
9 prepaid or fixed-sum basis for the provision of Medicaid
10 services shall reimburse any hospital or physician that is
11 outside the entity's authorized geographic service area as
12 specified in its contract with the agency, and that provides
13 services authorized by the entity to its members, at a rate
14 negotiated with the hospital or physician for the provision of
15 services or according to the lesser of the following:
16 (a) The usual and customary charges made to the
17 general public by the hospital or physician; or
18 (b) The Florida Medicaid reimbursement rate
19 established for the hospital or physician.
20 (20) When a merger or acquisition of a Medicaid
21 prepaid contractor has been approved by the Office of
22 Insurance Regulation pursuant to s. 628.4615, the agency shall
23 approve the assignment or transfer of the appropriate Medicaid
24 prepaid contract upon request of the surviving entity of the
25 merger or acquisition if the contractor and the other entity
26 have been in good standing with the agency for the most recent
27 12-month period, unless the agency determines that the
28 assignment or transfer would be detrimental to the Medicaid
29 recipients or the Medicaid program. To be in good standing,
30 an entity must not have failed accreditation or committed any
31 material violation of the requirements of s. 641.52 and must
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1 meet the Medicaid contract requirements. For purposes of this
2 section, a merger or acquisition means a change in controlling
3 interest of an entity, including an asset or stock purchase.
4 (21) Any entity contracting with the agency pursuant
5 to this section to provide health care services to Medicaid
6 recipients is prohibited from engaging in any of the following
7 practices or activities:
8 (a) Practices that are discriminatory, including, but
9 not limited to, attempts to discourage participation on the
10 basis of actual or perceived health status.
11 (b) Activities that could mislead or confuse
12 recipients, or misrepresent the organization, its marketing
13 representatives, or the agency. Violations of this paragraph
14 include, but are not limited to:
15 1. False or misleading claims that marketing
16 representatives are employees or representatives of the state
17 or county, or of anyone other than the entity or the
18 organization by whom they are reimbursed.
19 2. False or misleading claims that the entity is
20 recommended or endorsed by any state or county agency, or by
21 any other organization which has not certified its endorsement
22 in writing to the entity.
23 3. False or misleading claims that the state or county
24 recommends that a Medicaid recipient enroll with an entity.
25 4. Claims that a Medicaid recipient will lose benefits
26 under the Medicaid program, or any other health or welfare
27 benefits to which the recipient is legally entitled, if the
28 recipient does not enroll with the entity.
29 (c) Granting or offering of any monetary or other
30 valuable consideration for enrollment, except as authorized by
31 subsection (22).
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1 (d) Door-to-door solicitation of recipients who have
2 not contacted the entity or who have not invited the entity to
3 make a presentation.
4 (e) Solicitation of Medicaid recipients by marketing
5 representatives stationed in state offices unless approved and
6 supervised by the agency or its agent and approved by the
7 affected state agency when solicitation occurs in an office of
8 the state agency. The agency shall ensure that marketing
9 representatives stationed in state offices shall market their
10 managed care plans to Medicaid recipients only in designated
11 areas and in such a way as to not interfere with the
12 recipients' activities in the state office.
13 (f) Enrollment of Medicaid recipients.
14 (22) The agency may impose a fine for a violation of
15 this section or the contract with the agency by a person or
16 entity that is under contract with the agency. With respect
17 to any nonwillful violation, such fine shall not exceed $2,500
18 per violation. In no event shall such fine exceed an
19 aggregate amount of $10,000 for all nonwillful violations
20 arising out of the same action. With respect to any knowing
21 and willful violation of this section or the contract with the
22 agency, the agency may impose a fine upon the entity in an
23 amount not to exceed $20,000 for each such violation. In no
24 event shall such fine exceed an aggregate amount of $100,000
25 for all knowing and willful violations arising out of the same
26 action.
27 (23) A health maintenance organization or a person or
28 entity exempt from chapter 641 that is under contract with the
29 agency for the provision of health care services to Medicaid
30 recipients may not use or distribute marketing materials used
31 to solicit Medicaid recipients, unless such materials have
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1 been approved by the agency. The provisions of this subsection
2 do not apply to general advertising and marketing materials
3 used by a health maintenance organization to solicit both
4 non-Medicaid subscribers and Medicaid recipients.
5 (24) Upon approval by the agency, health maintenance
6 organizations and persons or entities exempt from chapter 641
7 that are under contract with the agency for the provision of
8 health care services to Medicaid recipients may be permitted
9 within the capitation rate to provide additional health
10 benefits that the agency has found are of high quality, are
11 practicably available, provide reasonable value to the
12 recipient, and are provided at no additional cost to the
13 state.
14 (25) The agency shall utilize the statewide health
15 maintenance organization complaint hotline for the purpose of
16 investigating and resolving Medicaid and prepaid health plan
17 complaints, maintaining a record of complaints and confirmed
18 problems, and receiving disenrollment requests made by
19 recipients.
20 (26) The agency shall require the publication of the
21 health maintenance organization's and the prepaid health
22 plan's consumer services telephone numbers and the "800"
23 telephone number of the statewide health maintenance
24 organization complaint hotline on each Medicaid identification
25 card issued by a health maintenance organization or prepaid
26 health plan contracting with the agency to serve Medicaid
27 recipients and on each subscriber handbook issued to a
28 Medicaid recipient.
29 (27) The agency shall establish a health care quality
30 improvement system for those entities contracting with the
31 agency pursuant to this section, incorporating all the
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1 standards and guidelines developed by the Medicaid Bureau of
2 the Health Care Financing Administration as a part of the
3 quality assurance reform initiative. The system shall
4 include, but need not be limited to, the following:
5 (a) Guidelines for internal quality assurance
6 programs, including standards for:
7 1. Written quality assurance program descriptions.
8 2. Responsibilities of the governing body for
9 monitoring, evaluating, and making improvements to care.
10 3. An active quality assurance committee.
11 4. Quality assurance program supervision.
12 5. Requiring the program to have adequate resources to
13 effectively carry out its specified activities.
14 6. Provider participation in the quality assurance
15 program.
16 7. Delegation of quality assurance program activities.
17 8. Credentialing and recredentialing.
18 9. Enrollee rights and responsibilities.
19 10. Availability and accessibility to services and
20 care.
21 11. Ambulatory care facilities.
22 12. Accessibility and availability of medical records,
23 as well as proper recordkeeping and process for record review.
24 13. Utilization review.
25 14. A continuity of care system.
26 15. Quality assurance program documentation.
27 16. Coordination of quality assurance activity with
28 other management activity.
29 17. Delivering care to pregnant women and infants; to
30 elderly and disabled recipients, especially those who are at
31 risk of institutional placement; to persons with developmental
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1 disabilities; and to adults who have chronic, high-cost
2 medical conditions.
3 (b) Guidelines which require the entities to conduct
4 quality-of-care studies which:
5 1. Target specific conditions and specific health
6 service delivery issues for focused monitoring and evaluation.
7 2. Use clinical care standards or practice guidelines
8 to objectively evaluate the care the entity delivers or fails
9 to deliver for the targeted clinical conditions and health
10 services delivery issues.
11 3. Use quality indicators derived from the clinical
12 care standards or practice guidelines to screen and monitor
13 care and services delivered.
14 (c) Guidelines for external quality review of each
15 contractor which require: focused studies of patterns of care;
16 individual care review in specific situations; and followup
17 activities on previous pattern-of-care study findings and
18 individual-care-review findings. In designing the external
19 quality review function and determining how it is to operate
20 as part of the state's overall quality improvement system, the
21 agency shall construct its external quality review
22 organization and entity contracts to address each of the
23 following:
24 1. Delineating the role of the external quality review
25 organization.
26 2. Length of the external quality review organization
27 contract with the state.
28 3. Participation of the contracting entities in
29 designing external quality review organization review
30 activities.
31
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1 4. Potential variation in the type of clinical
2 conditions and health services delivery issues to be studied
3 at each plan.
4 5. Determining the number of focused pattern-of-care
5 studies to be conducted for each plan.
6 6. Methods for implementing focused studies.
7 7. Individual care review.
8 8. Followup activities.
9 (28) In order to ensure that children receive health
10 care services for which an entity has already been
11 compensated, an entity contracting with the agency pursuant to
12 this section shall achieve an annual Early and Periodic
13 Screening, Diagnosis, and Treatment (EPSDT) Service screening
14 rate of at least 60 percent for those recipients continuously
15 enrolled for at least 8 months. The agency shall develop a
16 method by which the EPSDT screening rate shall be calculated.
17 For any entity which does not achieve the annual 60 percent
18 rate, the entity must submit a corrective action plan for the
19 agency's approval. If the entity does not meet the standard
20 established in the corrective action plan during the specified
21 timeframe, the agency is authorized to impose appropriate
22 contract sanctions. At least annually, the agency shall
23 publicly release the EPSDT Services screening rates of each
24 entity it has contracted with on a prepaid basis to serve
25 Medicaid recipients.
26 (29) The agency shall perform enrollments and
27 disenrollments for Medicaid recipients who are eligible for
28 MediPass or managed care plans. Notwithstanding the
29 prohibition contained in paragraph (19)(f), managed care plans
30 may perform preenrollments of Medicaid recipients under the
31 supervision of the agency or its agents. For the purposes of
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1 this section, "preenrollment" means the provision of marketing
2 and educational materials to a Medicaid recipient and
3 assistance in completing the application forms, but shall not
4 include actual enrollment into a managed care plan. An
5 application for enrollment shall not be deemed complete until
6 the agency or its agent verifies that the recipient made an
7 informed, voluntary choice. The agency, in cooperation with
8 the Department of Children and Family Services, may test new
9 marketing initiatives to inform Medicaid recipients about
10 their managed care options at selected sites. The agency shall
11 report to the Legislature on the effectiveness of such
12 initiatives. The agency may contract with a third party to
13 perform managed care plan and MediPass enrollment and
14 disenrollment services for Medicaid recipients and is
15 authorized to adopt rules to implement such services. The
16 agency may adjust the capitation rate only to cover the costs
17 of a third-party enrollment and disenrollment contract, and
18 for agency supervision and management of the managed care plan
19 enrollment and disenrollment contract.
20 (30) Any lists of providers made available to Medicaid
21 recipients, MediPass enrollees, or managed care plan enrollees
22 shall be arranged alphabetically showing the provider's name
23 and specialty and, separately, by specialty in alphabetical
24 order.
25 (31) The agency shall establish an enhanced managed
26 care quality assurance oversight function, to include at least
27 the following components:
28 (a) At least quarterly analysis and followup,
29 including sanctions as appropriate, of managed care
30 participant utilization of services.
31
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1 (b) At least quarterly analysis and followup,
2 including sanctions as appropriate, of quality findings of the
3 Medicaid peer review organization and other external quality
4 assurance programs.
5 (c) At least quarterly analysis and followup,
6 including sanctions as appropriate, of the fiscal viability of
7 managed care plans.
8 (d) At least quarterly analysis and followup,
9 including sanctions as appropriate, of managed care
10 participant satisfaction and disenrollment surveys.
11 (e) The agency shall conduct regular and ongoing
12 Medicaid recipient satisfaction surveys.
13
14 The analyses and followup activities conducted by the agency
15 under its enhanced managed care quality assurance oversight
16 function shall not duplicate the activities of accreditation
17 reviewers for entities regulated under part III of chapter
18 641, but may include a review of the finding of such
19 reviewers.
20 (32) Each managed care plan that is under contract
21 with the agency to provide health care services to Medicaid
22 recipients shall annually conduct a background check with the
23 Florida Department of Law Enforcement of all persons with
24 ownership interest of 5 percent or more or executive
25 management responsibility for the managed care plan and shall
26 submit to the agency information concerning any such person
27 who has been found guilty of, regardless of adjudication, or
28 has entered a plea of nolo contendere or guilty to, any of the
29 offenses listed in s. 435.03.
30 (33) The agency shall, by rule, develop a process
31 whereby a Medicaid managed care plan enrollee who wishes to
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1 enter hospice care may be disenrolled from the managed care
2 plan within 24 hours after contacting the agency regarding
3 such request. The agency rule shall include a methodology for
4 the agency to recoup managed care plan payments on a pro rata
5 basis if payment has been made for the enrollment month when
6 disenrollment occurs.
7 (34) The agency and entities which contract with the
8 agency to provide health care services to Medicaid recipients
9 under this section or s. 409.9122 must comply with the
10 provisions of s. 641.513 in providing emergency services and
11 care to Medicaid recipients and MediPass recipients.
12 (35) All entities providing health care services to
13 Medicaid recipients shall make available, and encourage all
14 pregnant women and mothers with infants to receive, and
15 provide documentation in the medical records to reflect, the
16 following:
17 (a) Healthy Start prenatal or infant screening.
18 (b) Healthy Start care coordination, when screening or
19 other factors indicate need.
20 (c) Healthy Start enhanced services in accordance with
21 the prenatal or infant screening results.
22 (d) Immunizations in accordance with recommendations
23 of the Advisory Committee on Immunization Practices of the
24 United States Public Health Service and the American Academy
25 of Pediatrics, as appropriate.
26 (e) Counseling and services for family planning to all
27 women and their partners.
28 (f) A scheduled postpartum visit for the purpose of
29 voluntary family planning, to include discussion of all
30 methods of contraception, as appropriate.
31
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1 (g) Referral to the Special Supplemental Nutrition
2 Program for Women, Infants, and Children (WIC).
3 (36) Any entity that provides Medicaid prepaid health
4 plan services shall ensure the appropriate coordination of
5 health care services with an assisted living facility in cases
6 where a Medicaid recipient is both a member of the entity's
7 prepaid health plan and a resident of the assisted living
8 facility. If the entity is at risk for Medicaid targeted case
9 management and behavioral health services, the entity shall
10 inform the assisted living facility of the procedures to
11 follow should an emergent condition arise.
12 (37) The agency may seek and implement federal waivers
13 necessary to provide for cost-effective purchasing of home
14 health services, private duty nursing services,
15 transportation, independent laboratory services, and durable
16 medical equipment and supplies through competitive bidding
17 pursuant to s. 287.057. The agency may request appropriate
18 waivers from the federal Health Care Financing Administration
19 in order to competitively bid such services. The agency may
20 exclude providers not selected through the bidding process
21 from the Medicaid provider network.
22 (38) The Agency for Health Care Administration is
23 directed to issue a request for proposal or intent to
24 negotiate to implement on a demonstration basis an outpatient
25 specialty services pilot project in a rural and urban county
26 in the state. As used in this subsection, the term
27 "outpatient specialty services" means clinical laboratory,
28 diagnostic imaging, and specified home medical services to
29 include durable medical equipment, prosthetics and orthotics,
30 and infusion therapy.
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1 (a) The entity that is awarded the contract to provide
2 Medicaid managed care outpatient specialty services must, at a
3 minimum, meet the following criteria:
4 1. The entity must be licensed by the Office of
5 Insurance Regulation under part II of chapter 641.
6 2. The entity must be experienced in providing
7 outpatient specialty services.
8 3. The entity must demonstrate to the satisfaction of
9 the agency that it provides high-quality services to its
10 patients.
11 4. The entity must demonstrate that it has in place a
12 complaints and grievance process to assist Medicaid recipients
13 enrolled in the pilot managed care program to resolve
14 complaints and grievances.
15 (b) The pilot managed care program shall operate for a
16 period of 3 years. The objective of the pilot program shall
17 be to determine the cost-effectiveness and effects on
18 utilization, access, and quality of providing outpatient
19 specialty services to Medicaid recipients on a prepaid,
20 capitated basis.
21 (c) The agency shall conduct a quality assurance
22 review of the prepaid health clinic each year that the
23 demonstration program is in effect. The prepaid health clinic
24 is responsible for all expenses incurred by the agency in
25 conducting a quality assurance review.
26 (d) The entity that is awarded the contract to provide
27 outpatient specialty services to Medicaid recipients shall
28 report data required by the agency in a format specified by
29 the agency, for the purpose of conducting the evaluation
30 required in paragraph (e).
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1 (e) The agency shall conduct an evaluation of the
2 pilot managed care program and report its findings to the
3 Governor and the Legislature by no later than January 1, 2001.
4 (39) The agency shall enter into agreements with
5 not-for-profit organizations based in this state for the
6 purpose of providing vision screening.
7 (40)(a) The agency shall implement a Medicaid
8 prescribed-drug spending-control program that includes the
9 following components:
10 1. Medicaid prescribed-drug coverage for brand-name
11 drugs for adult Medicaid recipients is limited to the
12 dispensing of four brand-name drugs per month per recipient.
13 Children are exempt from this restriction. Antiretroviral
14 agents are excluded from this limitation. No requirements for
15 prior authorization or other restrictions on medications used
16 to treat mental illnesses such as schizophrenia, severe
17 depression, or bipolar disorder may be imposed on Medicaid
18 recipients. Medications that will be available without
19 restriction for persons with mental illnesses include atypical
20 antipsychotic medications, conventional antipsychotic
21 medications, selective serotonin reuptake inhibitors, and
22 other medications used for the treatment of serious mental
23 illnesses. The agency shall also limit the amount of a
24 prescribed drug dispensed to no more than a 34-day supply. The
25 agency shall continue to provide unlimited generic drugs,
26 contraceptive drugs and items, and diabetic supplies. Although
27 a drug may be included on the preferred drug formulary, it
28 would not be exempt from the four-brand limit. The agency may
29 authorize exceptions to the brand-name-drug restriction based
30 upon the treatment needs of the patients, only when such
31 exceptions are based on prior consultation provided by the
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1 agency or an agency contractor, but the agency must establish
2 procedures to ensure that:
3 a. There will be a response to a request for prior
4 consultation by telephone or other telecommunication device
5 within 24 hours after receipt of a request for prior
6 consultation;
7 b. A 72-hour supply of the drug prescribed will be
8 provided in an emergency or when the agency does not provide a
9 response within 24 hours as required by sub-subparagraph a.;
10 and
11 c. Except for the exception for nursing home residents
12 and other institutionalized adults and except for drugs on the
13 restricted formulary for which prior authorization may be
14 sought by an institutional or community pharmacy, prior
15 authorization for an exception to the brand-name-drug
16 restriction is sought by the prescriber and not by the
17 pharmacy. When prior authorization is granted for a patient in
18 an institutional setting beyond the brand-name-drug
19 restriction, such approval is authorized for 12 months and
20 monthly prior authorization is not required for that patient.
21 2. Reimbursement to pharmacies for Medicaid prescribed
22 drugs shall be set at the average wholesale price less 13.25
23 percent.
24 3. The agency shall develop and implement a process
25 for managing the drug therapies of Medicaid recipients who are
26 using significant numbers of prescribed drugs each month. The
27 management process may include, but is not limited to,
28 comprehensive, physician-directed medical-record reviews,
29 claims analyses, and case evaluations to determine the medical
30 necessity and appropriateness of a patient's treatment plan
31 and drug therapies. The agency may contract with a private
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1 organization to provide drug-program-management services. The
2 Medicaid drug benefit management program shall include
3 initiatives to manage drug therapies for HIV/AIDS patients,
4 patients using 20 or more unique prescriptions in a 180-day
5 period, and the top 1,000 patients in annual spending. The
6 agency shall enroll any Medicaid recipient in the drug benefit
7 management program if he or she meets the specifications of
8 this provision and is not enrolled in a Medicaid health
9 maintenance organization.
10 4. The agency may limit the size of its pharmacy
11 network based on need, competitive bidding, price
12 negotiations, credentialing, or similar criteria. The agency
13 shall give special consideration to rural areas in determining
14 the size and location of pharmacies included in the Medicaid
15 pharmacy network. A pharmacy credentialing process may include
16 criteria such as a pharmacy's full-service status, location,
17 size, patient educational programs, patient consultation,
18 disease-management services, and other characteristics. The
19 agency may impose a moratorium on Medicaid pharmacy enrollment
20 when it is determined that it has a sufficient number of
21 Medicaid-participating providers.
22 5. The agency shall develop and implement a program
23 that requires Medicaid practitioners who prescribe drugs to
24 use a counterfeit-proof prescription pad for Medicaid
25 prescriptions. The agency shall require the use of
26 standardized counterfeit-proof prescription pads by
27 Medicaid-participating prescribers or prescribers who write
28 prescriptions for Medicaid recipients. The agency may
29 implement the program in targeted geographic areas or
30 statewide.
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1 6. The agency may enter into arrangements that require
2 manufacturers of generic drugs prescribed to Medicaid
3 recipients to provide rebates of at least 15.1 percent of the
4 average manufacturer price for the manufacturer's generic
5 products. These arrangements shall require that if a
6 generic-drug manufacturer pays federal rebates for
7 Medicaid-reimbursed drugs at a level below 15.1 percent, the
8 manufacturer must provide a supplemental rebate to the state
9 in an amount necessary to achieve a 15.1-percent rebate level.
10 7. The agency may establish a preferred drug formulary
11 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
12 establishment of such formulary, it is authorized to negotiate
13 supplemental rebates from manufacturers that are in addition
14 to those required by Title XIX of the Social Security Act and
15 at no less than 10 percent of the average manufacturer price
16 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
17 unless the federal or supplemental rebate, or both, equals or
18 exceeds 25 percent. There is no upper limit on the
19 supplemental rebates the agency may negotiate. The agency may
20 determine that specific products, brand-name or generic, are
21 competitive at lower rebate percentages. Agreement to pay the
22 minimum supplemental rebate percentage will guarantee a
23 manufacturer that the Medicaid Pharmaceutical and Therapeutics
24 Committee will consider a product for inclusion on the
25 preferred drug formulary. However, a pharmaceutical
26 manufacturer is not guaranteed placement on the formulary by
27 simply paying the minimum supplemental rebate. Agency
28 decisions will be made on the clinical efficacy of a drug and
29 recommendations of the Medicaid Pharmaceutical and
30 Therapeutics Committee, as well as the price of competing
31 products minus federal and state rebates. The agency is
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1 authorized to contract with an outside agency or contractor to
2 conduct negotiations for supplemental rebates. For the
3 purposes of this section, the term "supplemental rebates" may
4 include, at the agency's discretion, cash rebates and other
5 program benefits that offset a Medicaid expenditure. Such
6 other program benefits may include, but are not limited to,
7 disease management programs, drug product donation programs,
8 drug utilization control programs, prescriber and beneficiary
9 counseling and education, fraud and abuse initiatives, and
10 other services or administrative investments with guaranteed
11 savings to the Medicaid program in the same year the rebate
12 reduction is included in the General Appropriations Act. The
13 agency is authorized to seek any federal waivers to implement
14 this initiative.
15 8. The agency shall establish an advisory committee
16 for the purposes of studying the feasibility of using a
17 restricted drug formulary for nursing home residents and other
18 institutionalized adults. The committee shall be comprised of
19 seven members appointed by the Secretary of Health Care
20 Administration. The committee members shall include two
21 physicians licensed under chapter 458 or chapter 459; three
22 pharmacists licensed under chapter 465 and appointed from a
23 list of recommendations provided by the Florida Long-Term Care
24 Pharmacy Alliance; and two pharmacists licensed under chapter
25 465.
26 9. The Agency for Health Care Administration shall
27 expand home delivery of pharmacy products. To assist Medicaid
28 patients in securing their prescriptions and reduce program
29 costs, the agency shall expand its current mail-order-pharmacy
30 diabetes-supply program to include all generic and brand-name
31 drugs used by Medicaid patients with diabetes. Medicaid
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1 recipients in the current program may obtain nondiabetes drugs
2 on a voluntary basis. This initiative is limited to the
3 geographic area covered by the current contract. The agency
4 may seek and implement any federal waivers necessary to
5 implement this subparagraph.
6 (b) The agency shall implement this subsection to the
7 extent that funds are appropriated to administer the Medicaid
8 prescribed-drug spending-control program. The agency may
9 contract all or any part of this program to private
10 organizations.
11 (c) The agency shall submit quarterly reports to the
12 Governor, the President of the Senate, and the Speaker of the
13 House of Representatives which must include, but need not be
14 limited to, the progress made in implementing this subsection
15 and its effect on Medicaid prescribed-drug expenditures.
16 (41) Notwithstanding the provisions of chapter 287,
17 the agency may, at its discretion, renew a contract or
18 contracts for fiscal intermediary services one or more times
19 for such periods as the agency may decide; however, all such
20 renewals may not combine to exceed a total period longer than
21 the term of the original contract.
22 (42) The agency shall provide for the development of a
23 demonstration project by establishment in Miami-Dade County of
24 a long-term-care facility licensed pursuant to chapter 395 to
25 improve access to health care for a predominantly minority,
26 medically underserved, and medically complex population and to
27 evaluate alternatives to nursing home care and general acute
28 care for such population. Such project is to be located in a
29 health care condominium and colocated with licensed facilities
30 providing a continuum of care. The establishment of this
31 project is not subject to the provisions of s. 408.036 or s.
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1 408.039. The agency shall report its findings to the
2 Governor, the President of the Senate, and the Speaker of the
3 House of Representatives by January 1, 2003.
4 (43) The agency shall develop and implement a
5 utilization management program for Medicaid-eligible
6 recipients for the management of occupational, physical,
7 respiratory, and speech therapies. The agency shall establish
8 a utilization program that may require prior authorization in
9 order to ensure medically necessary and cost-effective
10 treatments. The program shall be operated in accordance with a
11 federally approved waiver program or state plan amendment. The
12 agency may seek a federal waiver or state plan amendment to
13 implement this program. The agency may also competitively
14 procure these services from an outside vendor on a regional or
15 statewide basis.
16 (44) The agency may contract on a prepaid or fixed-sum
17 basis with appropriately licensed prepaid dental health plans
18 to provide dental services.
19 (45) The agency shall mandate a recipient's
20 participation in a provider lock-in program, subject to the
21 availability of funds, if a recipient is found to have
22 committed fraud or abuse, limiting the receipt of goods or
23 services to a single specified provider after the 21-day
24 appeal process has ended for a period of not less than 1 year.
25 If the Medicaid recipient in a lock-in program is found to
26 have committed fraud or abuse in the Medicaid program on a
27 second occasion, the Medicaid recipient shall remain in the
28 lock-in program for the duration of his or her participation
29 in the Medicaid program. The lock-in programs shall include,
30 but are not limited to, pharmacies, medical doctors, and
31 infusion clinics. The limitation does not apply to emergency
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1 services and care provided to the recipient in a hospital
2 emergency department. The agency shall seek any federal
3 waivers necessary to implement this subsection.
4 (46) The agency shall seek a federal waiver for
5 permission to terminate the eligibility of a Medicaid
6 recipient who has been found to have committed fraud, through
7 judicial or administrative proceedings, for a third time in a
8 period of less than 36 months.
9 (47) The agency shall conduct a study of available
10 electronic systems for the purpose of verifying the identity
11 and eligibility of a Medicaid recipient. The agency shall
12 recommend to the Legislature a plan to implement an electronic
13 verification system for Medicaid recipients by January 31,
14 2005.
15 (48) A provider is not entitled to enrollment in the
16 Medicaid provider network. The agency may implement a Medicaid
17 fee for service provider network controls, including, but not
18 limited to, competitive procurement and provider
19 credentialing. If a credentialing process is used, the agency
20 may limit its provider network based upon the following
21 considerations: beneficiary access to care, provider
22 availability, provider quality standards and quality assurance
23 processes, cultural competency, demographic characteristics of
24 beneficiaries, practice standards, service wait times,
25 provider turnover, provider licensure and accreditation
26 history, program integrity history, peer review, Medicaid
27 policy and billing compliance records, clinical and medical
28 record audit findings, and such other areas that are
29 considered necessary by the agency to ensure the integrity of
30 the program.
31
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1 Section 6. Section 409.913, Florida Statutes, is
2 amended to read:
3 409.913 Oversight of the integrity of the Medicaid
4 program.--The agency shall operate a program to oversee the
5 activities of Florida Medicaid recipients, and providers and
6 their representatives, to ensure that fraudulent and abusive
7 behavior and neglect of recipients occur to the minimum extent
8 possible, and to recover overpayments and impose sanctions as
9 appropriate. Beginning January 1, 2003, and each year
10 thereafter, the agency and the Medicaid Fraud Control Unit of
11 the Department of Legal Affairs shall submit a joint report to
12 the Legislature documenting the effectiveness of the state's
13 efforts to control Medicaid fraud and abuse and to recover
14 Medicaid overpayments during the previous fiscal year. The
15 report must describe the number of cases opened and
16 investigated each year; the sources of the cases opened; the
17 disposition of the cases closed each year; the amount of
18 overpayments alleged in preliminary and final audit letters;
19 the number and amount of fines or penalties imposed; any
20 reductions in overpayment amounts negotiated in settlement
21 agreements or by other means; the amount of final agency
22 determinations of overpayments; the amount deducted from
23 federal claiming as a result of overpayments; the amount of
24 overpayments recovered each year; the amount of cost of
25 investigation recovered each year; the average length of time
26 to collect from the time the case was opened until the
27 overpayment is paid in full; the amount determined as
28 uncollectible and the portion of the uncollectible amount
29 subsequently reclaimed from the Federal Government; the number
30 of providers, by type, that are terminated from participation
31 in the Medicaid program as a result of fraud and abuse; and
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1 all costs associated with discovering and prosecuting cases of
2 Medicaid overpayments and making recoveries in such cases. The
3 report must also document actions taken to prevent
4 overpayments and the number of providers prevented from
5 enrolling in or reenrolling in the Medicaid program as a
6 result of documented Medicaid fraud and abuse and must
7 recommend changes necessary to prevent or recover
8 overpayments. For the 2001-2002 fiscal year, the agency shall
9 prepare a report that contains as much of this information as
10 is available to it.
11 (1) For the purposes of this section, the term:
12 (a) "Abuse" means:
13 1. Provider practices that are inconsistent with
14 generally accepted business or medical practices and that
15 result in an unnecessary cost to the Medicaid program or in
16 reimbursement for goods or services that are not medically
17 necessary or that fail to meet professionally recognized
18 standards for health care.
19 2. Recipient practices that result in unnecessary cost
20 to the Medicaid program.
21 (b) "Complaint" means an allegation that fraud, abuse,
22 or an overpayment has occurred.
23 (c) "Fraud" means an intentional deception or
24 misrepresentation made by a person with the knowledge that the
25 deception results in unauthorized benefit to herself or
26 himself or another person. The term includes any act that
27 constitutes fraud under applicable federal or state law.
28 (d) "Medical necessity" or "medically necessary" means
29 any goods or services necessary to palliate the effects of a
30 terminal condition, or to prevent, diagnose, correct, cure,
31 alleviate, or preclude deterioration of a condition that
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1 threatens life, causes pain or suffering, or results in
2 illness or infirmity, which goods or services are provided in
3 accordance with generally accepted standards of medical
4 practice. For purposes of determining Medicaid reimbursement,
5 the agency is the final arbiter of medical necessity.
6 Determinations of medical necessity must be made by a licensed
7 physician employed by or under contract with the agency and
8 must be based upon information available at the time the goods
9 or services are provided.
10 (e) "Overpayment" includes any amount that is not
11 authorized to be paid by the Medicaid program whether paid as
12 a result of inaccurate or improper cost reporting, improper
13 claiming, unacceptable practices, fraud, abuse, or mistake.
14 (f) "Person" means any natural person, corporation,
15 partnership, association, clinic, group, or other entity,
16 whether or not such person is enrolled in the Medicaid program
17 or is a provider of health care.
18 (2) The agency shall conduct, or cause to be conducted
19 by contract or otherwise, reviews, investigations, analyses,
20 audits, or any combination thereof, to determine possible
21 fraud, abuse, overpayment, or recipient neglect in the
22 Medicaid program and shall report the findings of any
23 overpayments in audit reports as appropriate.
24 (3) The agency may conduct, or may contract for,
25 prepayment review of provider claims to ensure cost-effective
26 purchasing; to ensure that, billing by a provider to the
27 agency is in accordance with applicable provisions of all
28 Medicaid rules, regulations, handbooks, and policies and in
29 accordance with federal, state, and local law;, and to ensure
30 that appropriate provision of care is rendered to Medicaid
31 recipients. Such prepayment reviews may be conducted as
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1 determined appropriate by the agency, without any suspicion or
2 allegation of fraud, abuse, or neglect, and may last for up to
3 1 year. Unless the agency has reliable evidence of fraud,
4 misrepresentation, abuse, or neglect, claims shall be
5 adjudicated for denial or payment within 90 days after the
6 date complete documentation is received by the agency for
7 review. If there is reliable evidence of fraud,
8 misrepresentation, abuse, or neglect, claims shall be
9 adjudicated for denial or payment within 180 days after the
10 date complete documentation is received by the agency for
11 review.
12 (4) Any suspected criminal violation identified by the
13 agency must be referred to the Medicaid Fraud Control Unit of
14 the Office of the Attorney General for investigation. The
15 agency and the Attorney General shall enter into a memorandum
16 of understanding, which must include, but need not be limited
17 to, a protocol for regularly sharing information and
18 coordinating casework. The protocol must establish a
19 procedure for the referral by the agency of cases involving
20 suspected Medicaid fraud to the Medicaid Fraud Control Unit
21 for investigation, and the return to the agency of those cases
22 where investigation determines that administrative action by
23 the agency is appropriate. Offices of the Medicaid program
24 integrity program and the Medicaid Fraud Control Unit of the
25 Department of Legal Affairs, shall, to the extent possible, be
26 collocated. The agency and the Department of Legal Affairs
27 shall periodically conduct joint training and other joint
28 activities designed to increase communication and coordination
29 in recovering overpayments.
30 (5) A Medicaid provider is subject to having goods and
31 services that are paid for by the Medicaid program reviewed by
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1 an appropriate peer-review organization designated by the
2 agency. The written findings of the applicable peer-review
3 organization are admissible in any court or administrative
4 proceeding as evidence of medical necessity or the lack
5 thereof.
6 (6) Any notice required to be given to a provider
7 under this section is presumed to be sufficient notice if sent
8 to the address last shown on the provider enrollment file. It
9 is the responsibility of the provider to furnish and keep the
10 agency informed of the provider's current address. United
11 States Postal Service proof of mailing or certified or
12 registered mailing of such notice to the provider at the
13 address shown on the provider enrollment file constitutes
14 sufficient proof of notice. Any notice required to be given to
15 the agency by this section must be sent to the agency at an
16 address designated by rule.
17 (7) When presenting a claim for payment under the
18 Medicaid program, a provider has an affirmative duty to
19 supervise the provision of, and be responsible for, goods and
20 services claimed to have been provided, to supervise and be
21 responsible for preparation and submission of the claim, and
22 to present a claim that is true and accurate and that is for
23 goods and services that:
24 (a) Have actually been furnished to the recipient by
25 the provider prior to submitting the claim.
26 (b) Are Medicaid-covered goods or services that are
27 medically necessary.
28 (c) Are of a quality comparable to those furnished to
29 the general public by the provider's peers.
30 (d) Have not been billed in whole or in part to a
31 recipient or a recipient's responsible party, except for such
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1 copayments, coinsurance, or deductibles as are authorized by
2 the agency.
3 (e) Are provided in accord with applicable provisions
4 of all Medicaid rules, regulations, handbooks, and policies
5 and in accordance with federal, state, and local law.
6 (f) Are documented by records made at the time the
7 goods or services were provided, demonstrating the medical
8 necessity for the goods or services rendered. Medicaid goods
9 or services are excessive or not medically necessary unless
10 both the medical basis and the specific need for them are
11 fully and properly documented in the recipient's medical
12 record.
13
14 The agency may deny payment or require repayment for goods or
15 services that are not presented as required in this
16 subsection.
17 (8) The agency shall not reimburse any person or
18 entity for any prescription for medications, medical supplies,
19 or medical services if the prescription was written by a
20 physician or other prescribing practitioner who is not
21 enrolled in the Medicaid program. This section does not apply:
22 (a) In instances involving bona fide emergency medical
23 conditions as determined by the agency;
24 (b) To a provider of medical services to a patient in
25 a hospital emergency department, hospital inpatient, or
26 hospital outpatient setting;
27 (c) To bono fide pro bono services by preapproved
28 non-Medicaid providers as determined by the agency;
29 (d) To prescribing physicians who are board-certified
30 specialists treating Medicaid recipients referred for
31
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1 treatment by a treating physician who is enrolled in the
2 Medicaid program;
3 (e) To prescriptions written for dually eligible
4 Medicare beneficiaries by an authorized Medicare provider who
5 is not enrolled in the Medicaid program;
6 (f) To other physicians who are not enrolled in the
7 Medicaid program but who provide a medically necessary service
8 or prescription not otherwise reasonably available from a
9 Medicaid-enrolled physician; or
10 (g) In instances where the agency cannot practically
11 notify a pharmacy at the point of sale that a prescription
12 will be approved for processing under paragraphs (a)-(f).
13 (9)(8) A Medicaid provider shall retain medical,
14 professional, financial, and business records pertaining to
15 services and goods furnished to a Medicaid recipient and
16 billed to Medicaid for a period of 5 years after the date of
17 furnishing such services or goods. The agency may investigate,
18 review, or analyze such records, which must be made available
19 during normal business hours. However, 24-hour notice must be
20 provided if patient treatment would be disrupted. The provider
21 is responsible for furnishing to the agency, and keeping the
22 agency informed of the location of, the provider's
23 Medicaid-related records. The authority of the agency to
24 obtain Medicaid-related records from a provider is neither
25 curtailed nor limited during a period of litigation between
26 the agency and the provider.
27 (10)(9) Payments for the services of billing agents or
28 persons participating in the preparation of a Medicaid claim
29 shall not be based on amounts for which they bill nor based on
30 the amount a provider receives from the Medicaid program.
31
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1 (11)(10) The agency may deny payment or require
2 repayment for inappropriate, medically unnecessary, or
3 excessive goods or services from the person furnishing them,
4 the person under whose supervision they were furnished, or the
5 person causing them to be furnished.
6 (12)(11) The complaint and all information obtained
7 pursuant to an investigation of a Medicaid provider, or the
8 authorized representative or agent of a provider, relating to
9 an allegation of fraud, abuse, or neglect are confidential and
10 exempt from the provisions of s. 119.07(1):
11 (a) Until the agency takes final agency action with
12 respect to the provider and requires repayment of any
13 overpayment, or imposes an administrative sanction;
14 (b) Until the Attorney General refers the case for
15 criminal prosecution;
16 (c) Until 10 days after the complaint is determined
17 without merit; or
18 (d) At all times if the complaint or information is
19 otherwise protected by law.
20 (13)(12) The agency may terminate participation of a
21 Medicaid provider in the Medicaid program and may seek civil
22 remedies or impose other administrative sanctions against a
23 Medicaid provider, if the provider has been:
24 (a) Convicted of a criminal offense related to the
25 delivery of any health care goods or services, including the
26 performance of management or administrative functions relating
27 to the delivery of health care goods or services;
28 (b) Convicted of a criminal offense under federal law
29 or the law of any state relating to the practice of the
30 provider's profession; or
31
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1 (c) Found by a court of competent jurisdiction to have
2 neglected or physically abused a patient in connection with
3 the delivery of health care goods or services.
4 (14)(13) If the provider has been suspended or
5 terminated from participation in the Medicaid program or the
6 Medicare program by the Federal Government or any state, the
7 agency must immediately suspend or terminate, as appropriate,
8 the provider's participation in the Florida Medicaid program
9 for a period no less than that imposed by the Federal
10 Government or any other state, and may not enroll such
11 provider in the Florida Medicaid program while such foreign
12 suspension or termination remains in effect. This sanction is
13 in addition to all other remedies provided by law.
14 (15)(14) The agency may seek any remedy provided by
15 law, including, but not limited to, the remedies provided in
16 subsections (13) (12) and (16) (15) and s. 812.035, if:
17 (a) The provider's license has not been renewed, or
18 has been revoked, suspended, or terminated, for cause, by the
19 licensing agency of any state;
20 (b) The provider has failed to make available or has
21 refused access to Medicaid-related records to an auditor,
22 investigator, or other authorized employee or agent of the
23 agency, the Attorney General, a state attorney, or the Federal
24 Government;
25 (c) The provider has not furnished or has failed to
26 make available such Medicaid-related records as the agency has
27 found necessary to determine whether Medicaid payments are or
28 were due and the amounts thereof;
29 (d) The provider has failed to maintain medical
30 records made at the time of service, or prior to service if
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1 prior authorization is required, demonstrating the necessity
2 and appropriateness of the goods or services rendered;
3 (e) The provider is not in compliance with provisions
4 of Medicaid provider publications that have been adopted by
5 reference as rules in the Florida Administrative Code; with
6 provisions of state or federal laws, rules, or regulations;
7 with provisions of the provider agreement between the agency
8 and the provider; or with certifications found on claim forms
9 or on transmittal forms for electronically submitted claims
10 that are submitted by the provider or authorized
11 representative, as such provisions apply to the Medicaid
12 program;
13 (f) The provider or person who ordered or prescribed
14 the care, services, or supplies has furnished, or ordered the
15 furnishing of, goods or services to a recipient which are
16 inappropriate, unnecessary, excessive, or harmful to the
17 recipient or are of inferior quality;
18 (g) The provider has demonstrated a pattern of failure
19 to provide goods or services that are medically necessary;
20 (h) The provider or an authorized representative of
21 the provider, or a person who ordered or prescribed the goods
22 or services, has submitted or caused to be submitted false or
23 a pattern of erroneous Medicaid claims that have resulted in
24 overpayments to a provider or that exceed those to which the
25 provider was entitled under the Medicaid program;
26 (i) The provider or an authorized representative of
27 the provider, or a person who has ordered or prescribed the
28 goods or services, has submitted or caused to be submitted a
29 Medicaid provider enrollment application, a request for prior
30 authorization for Medicaid services, a drug exception request,
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1 or a Medicaid cost report that contains materially false or
2 incorrect information;
3 (j) The provider or an authorized representative of
4 the provider has collected from or billed a recipient or a
5 recipient's responsible party improperly for amounts that
6 should not have been so collected or billed by reason of the
7 provider's billing the Medicaid program for the same service;
8 (k) The provider or an authorized representative of
9 the provider has included in a cost report costs that are not
10 allowable under a Florida Title XIX reimbursement plan, after
11 the provider or authorized representative had been advised in
12 an audit exit conference or audit report that the costs were
13 not allowable;
14 (l) The provider is charged by information or
15 indictment with fraudulent billing practices. The sanction
16 applied for this reason is limited to suspension of the
17 provider's participation in the Medicaid program for the
18 duration of the indictment unless the provider is found guilty
19 pursuant to the information or indictment;
20 (m) The provider or a person who has ordered, or
21 prescribed the goods or services is found liable for negligent
22 practice resulting in death or injury to the provider's
23 patient;
24 (n) The provider fails to demonstrate that it had
25 available during a specific audit or review period sufficient
26 quantities of goods, or sufficient time in the case of
27 services, to support the provider's billings to the Medicaid
28 program;
29 (o) The provider has failed to comply with the notice
30 and reporting requirements of s. 409.907;
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1 (p) The agency has received reliable information of
2 patient abuse or neglect or of any act prohibited by s.
3 409.920; or
4 (q) The provider has failed to comply with an
5 agreed-upon repayment schedule.
6 (16)(15) The agency shall impose any of the following
7 sanctions or disincentives on a provider or a person for any
8 of the acts described in subsection (15) (14):
9 (a) Suspension for a specific period of time of not
10 more than 1 year. Suspension shall preclude participation in
11 the Medicaid program, which includes any action that results
12 in a claim for payment to the Medicaid program as a result of
13 furnishing, supervising a person who is furnishing, or causing
14 a person to furnish goods or services.
15 (b) Termination for a specific period of time of from
16 more than 1 year to 20 years. Termination shall preclude
17 participation in the Medicaid program, which includes any
18 action that results in a claim for payment to the Medicaid
19 program as a result of furnishing, supervising a person who is
20 furnishing, or causing a person to furnish goods or services.
21 (c) Imposition of a fine of up to $5,000 for each
22 violation. Each day that an ongoing violation continues, such
23 as refusing to furnish Medicaid-related records or refusing
24 access to records, is considered, for the purposes of this
25 section, to be a separate violation. Each instance of
26 improper billing of a Medicaid recipient; each instance of
27 including an unallowable cost on a hospital or nursing home
28 Medicaid cost report after the provider or authorized
29 representative has been advised in an audit exit conference or
30 previous audit report of the cost unallowability; each
31 instance of furnishing a Medicaid recipient goods or
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1 professional services that are inappropriate or of inferior
2 quality as determined by competent peer judgment; each
3 instance of knowingly submitting a materially false or
4 erroneous Medicaid provider enrollment application, request
5 for prior authorization for Medicaid services, drug exception
6 request, or cost report; each instance of inappropriate
7 prescribing of drugs for a Medicaid recipient as determined by
8 competent peer judgment; and each false or erroneous Medicaid
9 claim leading to an overpayment to a provider is considered,
10 for the purposes of this section, to be a separate violation.
11 (d) Immediate suspension, if the agency has received
12 information of patient abuse or neglect or of any act
13 prohibited by s. 409.920. Upon suspension, the agency must
14 issue an immediate final order under s. 120.569(2)(n).
15 (e) A fine, not to exceed $10,000, for a violation of
16 paragraph (15)(i) (14)(i).
17 (f) Imposition of liens against provider assets,
18 including, but not limited to, financial assets and real
19 property, not to exceed the amount of fines or recoveries
20 sought, upon entry of an order determining that such moneys
21 are due or recoverable.
22 (g) Prepayment reviews of claims for a specified
23 period of time.
24 (h) Comprehensive followup reviews of providers every
25 6 months to ensure that they are billing Medicaid correctly.
26 (i) Corrective-action plans that would remain in
27 effect for providers for up to 3 years and that would be
28 monitored by the agency every 6 months while in effect.
29 (j) Other remedies as permitted by law to effect the
30 recovery of a fine or overpayment.
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1 The Secretary of Health Care Administration may make a
2 determination that imposition of a sanction or disincentive is
3 not in the best interest of the Medicaid program, in which
4 case a sanction or disincentive shall not be imposed.
5 (17)(16) In determining the appropriate administrative
6 sanction to be applied, or the duration of any suspension or
7 termination, the agency shall consider:
8 (a) The seriousness and extent of the violation or
9 violations.
10 (b) Any prior history of violations by the provider
11 relating to the delivery of health care programs which
12 resulted in either a criminal conviction or in administrative
13 sanction or penalty.
14 (c) Evidence of continued violation within the
15 provider's management control of Medicaid statutes, rules,
16 regulations, or policies after written notification to the
17 provider of improper practice or instance of violation.
18 (d) The effect, if any, on the quality of medical care
19 provided to Medicaid recipients as a result of the acts of the
20 provider.
21 (e) Any action by a licensing agency respecting the
22 provider in any state in which the provider operates or has
23 operated.
24 (f) The apparent impact on access by recipients to
25 Medicaid services if the provider is suspended or terminated,
26 in the best judgment of the agency.
27
28 The agency shall document the basis for all sanctioning
29 actions and recommendations.
30 (18)(17) The agency may take action to sanction,
31 suspend, or terminate a particular provider working for a
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1 group provider, and may suspend or terminate Medicaid
2 participation at a specific location, rather than or in
3 addition to taking action against an entire group.
4 (19)(18) The agency shall establish a process for
5 conducting followup reviews of a sampling of providers who
6 have a history of overpayment under the Medicaid program.
7 This process must consider the magnitude of previous fraud or
8 abuse and the potential effect of continued fraud or abuse on
9 Medicaid costs.
10 (20)(19) In making a determination of overpayment to a
11 provider, the agency must use accepted and valid auditing,
12 accounting, analytical, statistical, or peer-review methods,
13 or combinations thereof. Appropriate statistical methods may
14 include, but are not limited to, sampling and extension to the
15 population, parametric and nonparametric statistics, tests of
16 hypotheses, and other generally accepted statistical methods.
17 Appropriate analytical methods may include, but are not
18 limited to, reviews to determine variances between the
19 quantities of products that a provider had on hand and
20 available to be purveyed to Medicaid recipients during the
21 review period and the quantities of the same products paid for
22 by the Medicaid program for the same period, taking into
23 appropriate consideration sales of the same products to
24 non-Medicaid customers during the same period. In meeting its
25 burden of proof in any administrative or court proceeding, the
26 agency may introduce the results of such statistical methods
27 as evidence of overpayment.
28 (21)(20) When making a determination that an
29 overpayment has occurred, the agency shall prepare and issue
30 an audit report to the provider showing the calculation of
31 overpayments.
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1 (22)(21) The audit report, supported by agency work
2 papers, showing an overpayment to a provider constitutes
3 evidence of the overpayment. A provider may not present or
4 elicit testimony, either on direct examination or
5 cross-examination in any court or administrative proceeding,
6 regarding the purchase or acquisition by any means of drugs,
7 goods, or supplies; sales or divestment by any means of drugs,
8 goods, or supplies; or inventory of drugs, goods, or supplies,
9 unless such acquisition, sales, divestment, or inventory is
10 documented by written invoices, written inventory records, or
11 other competent written documentary evidence maintained in the
12 normal course of the provider's business. Notwithstanding the
13 applicable rules of discovery, all documentation that will be
14 offered as evidence at an administrative hearing on a Medicaid
15 overpayment must be exchanged by all parties at least 14 days
16 before the administrative hearing or must be excluded from
17 consideration.
18 (23)(22)(a) In an audit or investigation of a
19 violation committed by a provider which is conducted pursuant
20 to this section, the agency is entitled to recover all
21 investigative, legal, and expert witness costs if the agency's
22 findings were not contested by the provider or, if contested,
23 the agency ultimately prevailed.
24 (b) The agency has the burden of documenting the
25 costs, which include salaries and employee benefits and
26 out-of-pocket expenses. The amount of costs that may be
27 recovered must be reasonable in relation to the seriousness of
28 the violation and must be set taking into consideration the
29 financial resources, earning ability, and needs of the
30 provider, who has the burden of demonstrating such factors.
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1 (c) The provider may pay the costs over a period to be
2 determined by the agency if the agency determines that an
3 extreme hardship would result to the provider from immediate
4 full payment. Any default in payment of costs may be
5 collected by any means authorized by law.
6 (24)(23) If the agency imposes an administrative
7 sanction pursuant to subsection (13), subsection (14), or
8 subsection (15), except paragraphs (15)(e) and (o), under this
9 section upon any provider or other person who is regulated by
10 another state entity, the agency shall notify that other
11 entity of the imposition of the sanction. Such notification
12 must include the provider's or person's name and license
13 number and the specific reasons for sanction.
14 (25)(24)(a) The agency may withhold Medicaid payments,
15 in whole or in part, to a provider upon receipt of reliable
16 evidence that the circumstances giving rise to the need for a
17 withholding of payments involve fraud, willful
18 misrepresentation, or abuse under the Medicaid program, or a
19 crime committed while rendering goods or services to Medicaid
20 recipients, pending completion of legal proceedings. If it is
21 determined that fraud, willful misrepresentation, abuse, or a
22 crime did not occur, the payments withheld must be paid to the
23 provider within 14 days after such determination with interest
24 at the rate of 10 percent a year. Any money withheld in
25 accordance with this paragraph shall be placed in a suspended
26 account, readily accessible to the agency, so that any payment
27 ultimately due the provider shall be made within 14 days.
28 (b) The agency may deny payment, or require repayment,
29 if the goods or services were furnished, supervised, or caused
30 to be furnished by a person who has been suspended or
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1 terminated from the Medicaid program or Medicare program by
2 the Federal Government or any state.
3 (c)(b) Overpayments owed to the agency bear interest
4 at the rate of 10 percent per year from the date of
5 determination of the overpayment by the agency, and payment
6 arrangements must be made at the conclusion of legal
7 proceedings. A provider who does not enter into or adhere to
8 an agreed-upon repayment schedule may be terminated by the
9 agency for nonpayment or partial payment.
10 (d)(c) The agency, upon entry of a final agency order,
11 a judgment or order of a court of competent jurisdiction, or a
12 stipulation or settlement, may collect the moneys owed by all
13 means allowable by law, including, but not limited to,
14 notifying any fiscal intermediary of Medicare benefits that
15 the state has a superior right of payment. Upon receipt of
16 such written notification, the Medicare fiscal intermediary
17 shall remit to the state the sum claimed.
18 (e) The agency may institute amnesty programs to allow
19 Medicaid providers the opportunity to voluntarily repay
20 overpayments. The agency may adopt rules to administer such
21 programs.
22 (26)(25) The agency may impose administrative
23 sanctions against a Medicaid recipient, or the agency may seek
24 any other remedy provided by law, including, but not limited
25 to, the remedies provided in s. 812.035, if the agency finds
26 that a recipient has engaged in solicitation in violation of
27 s. 409.920 or that the recipient has otherwise abused the
28 Medicaid program.
29 (27)(26) When the Agency for Health Care
30 Administration has made a probable cause determination and
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1 alleged that an overpayment to a Medicaid provider has
2 occurred, the agency, after notice to the provider, may:
3 (a) Withhold, and continue to withhold during the
4 pendency of an administrative hearing pursuant to chapter 120,
5 any medical assistance reimbursement payments until such time
6 as the overpayment is recovered, unless within 30 days after
7 receiving notice thereof the provider:
8 1. Makes repayment in full; or
9 2. Establishes a repayment plan that is satisfactory
10 to the Agency for Health Care Administration.
11 (b) Withhold, and continue to withhold during the
12 pendency of an administrative hearing pursuant to chapter 120,
13 medical assistance reimbursement payments if the terms of a
14 repayment plan are not adhered to by the provider.
15 (28)(27) Venue for all Medicaid program integrity
16 overpayment cases shall lie in Leon County, at the discretion
17 of the agency.
18 (29)(28) Notwithstanding other provisions of law, the
19 agency and the Medicaid Fraud Control Unit of the Department
20 of Legal Affairs may review a provider's Medicaid-related and
21 non-Medicaid-related records in order to determine the total
22 output of a provider's practice to reconcile quantities of
23 goods or services billed to Medicaid with against quantities
24 of goods or services used in the provider's total practice.
25 (30)(29) The agency may terminate a provider's
26 participation in the Medicaid program if the provider fails to
27 reimburse an overpayment that has been determined by final
28 order, not subject to further appeal, within 35 days after the
29 date of the final order, unless the provider and the agency
30 have entered into a repayment agreement.
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1 (31)(30) If a provider requests an administrative
2 hearing pursuant to chapter 120, such hearing must be
3 conducted within 90 days following assignment of an
4 administrative law judge, absent exceptionally good cause
5 shown as determined by the administrative law judge or hearing
6 officer. Upon issuance of a final order, the outstanding
7 balance of the amount determined to constitute the overpayment
8 shall become due. If a provider fails to make payments in
9 full, fails to enter into a satisfactory repayment plan, or
10 fails to comply with the terms of a repayment plan or
11 settlement agreement, the agency may withhold medical
12 assistance reimbursement payments until the amount due is paid
13 in full.
14 (32)(31) Duly authorized agents and employees of the
15 agency shall have the power to inspect, during normal business
16 hours, the records of any pharmacy, wholesale establishment,
17 or manufacturer, or any other place in which drugs and medical
18 supplies are manufactured, packed, packaged, made, stored,
19 sold, or kept for sale, for the purpose of verifying the
20 amount of drugs and medical supplies ordered, delivered, or
21 purchased by a provider. The agency shall provide at least 2
22 business days' prior notice of any such inspection. The notice
23 must identify the provider whose records will be inspected,
24 and the inspection shall include only records specifically
25 related to that provider.
26 (33) In accordance with federal law, Medicaid
27 recipients convicted of a crime pursuant to 42 U.S.C. 1320a-7b
28 may be limited, restricted, or suspended from Medicaid
29 eligibility for a period not to exceed 1 year, as determined
30 by the agency head or designee.
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1 (34) To deter fraud and abuse in the Medicaid program,
2 the agency may limit the number of Schedule II and Schedule
3 III refill prescription claims submitted from a pharmacy
4 provider. The agency shall limit the allowable amount of
5 reimbursement of prescription refill claims for Schedule II
6 and Schedule III pharmaceuticals if the agency or the Medicaid
7 Fraud Control Unit determines that the specific prescription
8 refill was not requested by the Medicaid recipient or
9 authorized representative for whom the refill claim is
10 submitted or was not prescribed by the recipient's medical
11 provider or physician. Any such refill request must be
12 consistent with the original prescription.
13 (35) The Office of Program Policy Analysis and
14 Government Accountability shall provide a report to the
15 President of the Senate and the Speaker of the House of
16 Representatives on a biennial basis, beginning January 31,
17 2006, on the agency's efforts to prevent, detect, and deter,
18 as well as recover funds lost to, fraud and abuse in the
19 Medicaid program.
20 Section 7. Paragraph (d) of subsection (2) and
21 paragraph (b) of subsection (5) of section 409.9131, Florida
22 Statutes, are amended, and subsection (6) is added to that
23 section, to read:
24 409.9131 Special provisions relating to integrity of
25 the Medicaid program.--
26 (2) DEFINITIONS.--For purposes of this section, the
27 term:
28 (d) "Peer review" means an evaluation of the
29 professional practices of a Medicaid physician provider by a
30 peer or peers in order to assess the medical necessity,
31 appropriateness, and quality of care provided, as such care is
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1 compared to that customarily furnished by the physician's
2 peers and to recognized health care standards, and, in cases
3 involving determination of medical necessity, to determine
4 whether the documentation in the physician's records is
5 adequate.
6 (5) DETERMINATIONS OF OVERPAYMENT.--In making a
7 determination of overpayment to a physician, the agency must:
8 (b) Refer all physician service claims for peer review
9 when the agency's preliminary analysis indicates that an
10 evaluation of the medical necessity, appropriateness, and
11 quality of care needs to be undertaken to determine a
12 potential overpayment, and before any formal proceedings are
13 initiated against the physician, except as required by s.
14 409.913.
15 (6) COST REPORTS.--For any Medicaid provider
16 submitting a cost report to the agency by any method, and in
17 addition to any other certification, the following statement
18 must immediately precede the dated signature of the provider's
19 administrator or chief financial officer on such cost report:
20 "I certify that I am familiar with the laws and
21 regulations regarding the provision of health
22 care services under the Florida Medicaid
23 program, including the laws and regulations
24 relating to claims for Medicaid reimbursements
25 and payments, and that the services identified
26 in this cost report were provided in compliance
27 with such laws and regulations."
28 Section 8. Section 409.920, Florida Statutes, is
29 amended to read:
30 409.920 Medicaid provider fraud.--
31 (1) For the purposes of this section, the term:
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1 (a) "Agency" means the Agency for Health Care
2 Administration.
3 (b) "Fiscal agent" means any individual, firm,
4 corporation, partnership, organization, or other legal entity
5 that has contracted with the agency to receive, process, and
6 adjudicate claims under the Medicaid program.
7 (c) "Item or service" includes:
8 1. Any particular item, device, medical supply, or
9 service claimed to have been provided to a recipient and
10 listed in an itemized claim for payment; or
11 2. In the case of a claim based on costs, any entry in
12 the cost report, books of account, or other documents
13 supporting such claim.
14 (d) "Knowingly" means that the act was done
15 voluntarily and intentionally and not because of mistake or
16 accident. As used in this section, the term "knowingly" also
17 includes the word "willfully" or "willful" which, as used in
18 this section, means that an act was committed voluntarily and
19 purposely, with the specific intent to do something that the
20 law forbids, and that the act was committed with bad purpose,
21 either to disobey or disregard the law done by a person who is
22 aware or should be aware of the nature of his or her conduct
23 and that his or her conduct is substantially certain to cause
24 the intended result.
25 (2) It is unlawful to:
26 (a) Knowingly make, cause to be made, or aid and abet
27 in the making of any false statement or false representation
28 of a material fact, by commission or omission, in any claim
29 submitted to the agency or its fiscal agent for payment.
30
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1 (b) Knowingly make, cause to be made, or aid and abet
2 in the making of a claim for items or services that are not
3 authorized to be reimbursed by the Medicaid program.
4 (c) Knowingly charge, solicit, accept, or receive
5 anything of value, other than an authorized copayment from a
6 Medicaid recipient, from any source in addition to the amount
7 legally payable for an item or service provided to a Medicaid
8 recipient under the Medicaid program or knowingly fail to
9 credit the agency or its fiscal agent for any payment received
10 from a third-party source.
11 (d) Knowingly make or in any way cause to be made any
12 false statement or false representation of a material fact, by
13 commission or omission, in any document containing items of
14 income and expense that is or may be used by the agency to
15 determine a general or specific rate of payment for an item or
16 service provided by a provider.
17 (e) Knowingly solicit, offer, pay, or receive any
18 remuneration, including any kickback, bribe, or rebate,
19 directly or indirectly, overtly or covertly, in cash or in
20 kind, in return for referring an individual to a person for
21 the furnishing or arranging for the furnishing of any item or
22 service for which payment may be made, in whole or in part,
23 under the Medicaid program, or in return for obtaining,
24 purchasing, leasing, ordering, or arranging for or
25 recommending, obtaining, purchasing, leasing, or ordering any
26 goods, facility, item, or service, for which payment may be
27 made, in whole or in part, under the Medicaid program.
28 (f) Knowingly submit false or misleading information
29 or statements to the Medicaid program for the purpose of being
30 accepted as a Medicaid provider.
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1 (g) Knowingly use or endeavor to use a Medicaid
2 provider's identification number or a Medicaid recipient's
3 identification number to make, cause to be made, or aid and
4 abet in the making of a claim for items or services that are
5 not authorized to be reimbursed by the Medicaid program.
6
7 A person who violates this subsection commits a felony of the
8 third degree, punishable as provided in s. 775.082, s.
9 775.083, or s. 775.084.
10 (3) The repayment of Medicaid payments wrongfully
11 obtained, or the offer or endeavor to repay Medicaid funds
12 wrongfully obtained, does not constitute a defense to, or a
13 ground for dismissal of, criminal charges brought under this
14 section.
15 (4) Property "paid for" includes all property
16 furnished to or intended to be furnished to any recipient of
17 benefits under the Medicaid program, regardless of whether
18 reimbursement is ever actually made by the program.
19 (5)(4) All records in the custody of the agency or its
20 fiscal agent which relate to Medicaid provider fraud are
21 business records within the meaning of s. 90.803(6).
22 (6)(5) Proof that a claim was submitted to the agency
23 or its fiscal agent which contained a false statement or a
24 false representation of a material fact, by commission or
25 omission, unless satisfactorily explained, gives rise to an
26 inference that the person whose signature appears as the
27 provider's authorizing signature on the claim form, or whose
28 signature appears on an agency electronic claim submission
29 agreement submitted for claims made to the fiscal agent by
30 electronic means, had knowledge of the false statement or
31 false representation. This subsection applies whether the
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1 signature appears on the claim form or the electronic claim
2 submission agreement by means of handwriting, typewriting,
3 facsimile signature stamp, computer impulse, initials, or
4 otherwise.
5 (7)(6) Proof of submission to the agency or its fiscal
6 agent of a document containing items of income and expense,
7 which document is used or that may be used by the agency or
8 its fiscal agent to determine a general or specific rate of
9 payment and which document contains a false statement or a
10 false representation of a material fact, by commission or
11 omission, unless satisfactorily explained, gives rise to the
12 inference that the person who signed the certification of the
13 document had knowledge of the false statement or
14 representation. This subsection applies whether the signature
15 appears on the document by means of handwriting, typewriting,
16 facsimile signature stamp, electronic transmission, initials,
17 or otherwise.
18 (8)(7) The Attorney General shall conduct a statewide
19 program of Medicaid fraud control. To accomplish this purpose,
20 the Attorney General shall:
21 (a) Investigate the possible criminal violation of any
22 applicable state law pertaining to fraud in the administration
23 of the Medicaid program, in the provision of medical
24 assistance, or in the activities of providers of health care
25 under the Medicaid program.
26 (b) Investigate the alleged abuse or neglect of
27 patients in health care facilities receiving payments under
28 the Medicaid program, in coordination with the agency.
29 (c) Investigate the alleged misappropriation of
30 patients' private funds in health care facilities receiving
31 payments under the Medicaid program.
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1 (d) Refer to the Office of Statewide Prosecution or
2 the appropriate state attorney all violations indicating a
3 substantial potential for criminal prosecution.
4 (e) Refer to the agency all suspected abusive
5 activities not of a criminal or fraudulent nature.
6 (f) Safeguard the privacy rights of all individuals
7 and provide safeguards to prevent the use of patient medical
8 records for any reason beyond the scope of a specific
9 investigation for fraud or abuse, or both, without the
10 patient's written consent.
11 (g) Publicize to state employees and the public the
12 ability of persons to bring suit under the provisions of the
13 Florida False Claims Act and the potential for the persons
14 bringing a civil action under the Florida False Claims Act to
15 obtain a monetary award.
16 (9)(8) In carrying out the duties and responsibilities
17 under this section, the Attorney General may:
18 (a) Enter upon the premises of any health care
19 provider, excluding a physician, participating in the Medicaid
20 program to examine all accounts and records that may, in any
21 manner, be relevant in determining the existence of fraud in
22 the Medicaid program, to investigate alleged abuse or neglect
23 of patients, or to investigate alleged misappropriation of
24 patients' private funds. A participating physician is required
25 to make available any accounts or records that may, in any
26 manner, be relevant in determining the existence of fraud in
27 the Medicaid program, alleged abuse or neglect of patients, or
28 alleged misappropriation of patients' private funds. The
29 accounts or records of a non-Medicaid patient may not be
30 reviewed by, or turned over to, the Attorney General without
31 the patient's written consent.
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1 (b) Subpoena witnesses or materials, including medical
2 records relating to Medicaid recipients, within or outside the
3 state and, through any duly designated employee, administer
4 oaths and affirmations and collect evidence for possible use
5 in either civil or criminal judicial proceedings.
6 (c) Request and receive the assistance of any state
7 attorney or law enforcement agency in the investigation and
8 prosecution of any violation of this section.
9 (d) Seek any civil remedy provided by law, including,
10 but not limited to, the remedies provided in ss. 68.081-68.092
11 and 812.035 and this chapter.
12 (e) Refer to the agency for collection each instance
13 of overpayment to a provider of health care under the Medicaid
14 program which is discovered during the course of an
15 investigation.
16 Section 9. Section 409.9201, Florida Statutes, is
17 created to read:
18 409.9201 Medicaid fraud.--
19 (1) As used in this section, the term:
20 (a) "Legend drug" means any drug, including, but not
21 limited to, finished dosage forms or active ingredients that
22 are subject to, defined by, or described by s. 503(b) of the
23 Federal Food, Drug, and Cosmetic Act or by s. 465.003(8), s.
24 499.007(12), or s. 499.0122(1)(b) or (c).
25 (b) "Value" means the amount billed to the Medicaid
26 program for the property dispensed or the market value of a
27 legend drug or goods or services at the time and place of the
28 offense. If the market value cannot be determined, the term
29 means the replacement cost of the legend drug or goods or
30 services within a reasonable time after the offense.
31
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1 (2) Any person who knowingly sells, who knowingly
2 attempts or conspires to sell, or who knowingly causes any
3 other person to sell or attempt or conspire to sell a legend
4 drug that was paid for by the Medicaid program commits a
5 felony.
6 (a) If the value of the legend drug involved is less
7 than $20,000, the crime is a felony of the third degree,
8 punishable as provided in s. 775.082, s. 775.083, or s.
9 775.084.
10 (b) If the value of the legend drug involved is
11 $20,000 or more but less than $100,000, the crime is a felony
12 of the second degree, punishable as provided in s. 775.082, s.
13 775.083, or s. 775.084.
14 (c) If the value of the legend drug involved is
15 $100,000 or more, the crime is a felony of the first degree,
16 punishable as provided in s. 775.082, s. 775.083, or s.
17 775.084.
18 (3) Any person who knowingly purchases, or who
19 knowingly attempts or conspires to purchase, a legend drug
20 that was paid for by the Medicaid program and intended for use
21 by another person commits a felony.
22 (a) If the value of the legend drug is less than
23 $20,000, the crime is a felony of the third degree, punishable
24 as provided in s. 775.082, s. 775.083, or s. 775.084.
25 (b) If the value of the legend drug is $20,000 or more
26 but less than $100,000, the crime is a felony of the second
27 degree, punishable as provided in s. 775.082, s. 775.083, or
28 s. 775.084.
29 (c) If the value of the legend drug is $100,000 or
30 more, the crime is a felony of the first degree, punishable as
31 provided in s. 775.082, s. 775.083, or s. 775.084.
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1 (4) Any person who knowingly makes or knowingly causes
2 to be made, or who attempts or conspires to make, any false
3 statement or representation to any person for the purpose of
4 obtaining goods or services from the Medicaid program commits
5 a felony.
6 (a) If the value of the goods or services is less than
7 $20,000, the crime is a felony of the third degree, punishable
8 as provided in s. 775.082, s. 775.083, or s. 775.084.
9 (b) If the value of the goods or services is $20,000
10 or more but less than $100,000, the crime is a felony of the
11 second degree, punishable as provided in s. 775.082, s.
12 775.083, or s. 775.084.
13 (c) If the value of the goods or services involved is
14 $100,000 or more, the crime is a felony of the first degree,
15 punishable as provided in s. 775.082, s. 775.083, or s.
16 775.084.
17
18 The value of individual items of the legend drugs or goods or
19 services involved in distinct transactions committed during a
20 single scheme or course of conduct, whether involving a single
21 person or several persons, may be aggregated when determining
22 the punishment for the offense.
23 Section 10. Paragraph (ff) is added to subsection (1)
24 of section 456.072, Florida Statutes, to read:
25 456.072 Grounds for discipline; penalties;
26 enforcement.--
27 (1) The following acts shall constitute grounds for
28 which the disciplinary actions specified in subsection (2) may
29 be taken:
30 (ff) Engaging in a pattern of practice when
31 prescribing medicinal drugs or controlled substances which
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1 demonstrates a lack of reasonable skill or safety to patients,
2 a violation of any provision of this chapter, a violation of
3 the applicable practice act, or a violation of any rules
4 adopted pursuant to this chapter or the applicable practice
5 act of the prescribing practitioner. Notwithstanding s.
6 456.073(13), the department may initiate an investigation and
7 establish such a pattern from billing records, data, or any
8 other information obtained by the department.
9 Section 11. Subsection (1) of section 465.188, Florida
10 Statutes, is amended to read:
11 465.188 Medicaid audits of pharmacies.--
12 (1) Notwithstanding any other law, when an audit of
13 the Medicaid-related records of a pharmacy licensed under
14 chapter 465 is conducted, such audit must be conducted as
15 provided in this section.
16 (a) The agency conducting the audit must give the
17 pharmacist at least 1 week's prior notice of the initial audit
18 for each audit cycle.
19 (b) An audit must be conducted by a pharmacist
20 licensed in this state.
21 (c) Any clerical or recordkeeping error, such as a
22 typographical error, scrivener's error, or computer error
23 regarding a document or record required under the Medicaid
24 program does not constitute a willful violation and is not
25 subject to criminal penalties without proof of intent to
26 commit fraud.
27 (d) A pharmacist may use the physician's record or
28 other order for drugs or medicinal supplies written or
29 transmitted by any means of communication for purposes of
30 validating the pharmacy record with respect to orders or
31 refills of a legend or narcotic drug.
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1 (e) A finding of an overpayment or underpayment must
2 be based on the actual overpayment or underpayment and may not
3 be a projection based on the number of patients served having
4 a similar diagnosis or on the number of similar orders or
5 refills for similar drugs.
6 (f) Each pharmacy shall be audited under the same
7 standards and parameters.
8 (g) A pharmacist must be allowed at least 10 days in
9 which to produce documentation to address any discrepancy
10 found during an audit.
11 (h) The period covered by an audit may not exceed 1
12 calendar year.
13 (i) An audit may not be scheduled during the first 5
14 days of any month due to the high volume of prescriptions
15 filled during that time.
16 (j) The audit report must be delivered to the
17 pharmacist within 90 days after conclusion of the audit. A
18 final audit report shall be delivered to the pharmacist within
19 6 months after receipt of the preliminary audit report or
20 final appeal, as provided for in subsection (2), whichever is
21 later.
22 (k) The audit criteria set forth in this section
23 applies only to audits of claims submitted for payment
24 subsequent to July 11, 2003.
25 Section 12. Section 812.0191, Florida Statutes, is
26 created to read:
27 812.0191 Dealing in property paid for in whole or in
28 part by the Medicaid program.--
29 (1) As used in this section, the term:
30 (a) "Property paid for in whole or in part by the
31 Medicaid program" means any devices, goods, services, drugs,
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1 or any other property furnished or intended to be furnished to
2 a recipient of benefits under the Medicaid program.
3 (b) "Value" means the amount billed to Medicaid for
4 the property dispensed or the market value of the devices,
5 goods, services, or drugs at the time and place of the
6 offense. If the market value cannot be determined, the term
7 means the replacement cost of the devices, goods, services, or
8 drugs within a reasonable time after the offense.
9 (2) Any person who traffics in, or endeavors to
10 traffic in, property that he or she knows or should have known
11 was paid for in whole or in part by the Medicaid program
12 commits a felony.
13 (a) If the value of the property involved is less than
14 $20,000, the crime is a felony of the third degree, punishable
15 as provided in s. 775.082, s. 775.083, or s. 775.084.
16 (b) If the value of the property involved is $20,000
17 or more but less than $100,000, the crime is a felony of the
18 second degree, punishable as provided in s. 775.082, s.
19 775.083, or s. 775.084.
20 (c) If the value of the property involved is $100,000
21 or more, the crime is a felony of the first degree, punishable
22 as provided in s. 775.082, s. 775.083, or s. 775.084.
23
24 The value of individual items of the devices, goods, services,
25 drugs, or other property involved in distinct transactions
26 committed during a single scheme or course of conduct, whether
27 involving a single person or several persons, may be
28 aggregated when determining the punishment for the offense.
29 (3) Any person who knowingly initiates, organizes,
30 plans, finances, directs, manages, or supervises the obtaining
31 of property paid for in whole or in part by the Medicaid
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1 program and who traffics in, or endeavors to traffic in, such
2 property commits a felony of the first degree, punishable as
3 provided in s. 775.082, s. 775.083, or s. 775.084.
4 Section 13. Paragraph (a) of subsection (1) of section
5 895.02, Florida Statutes, is amended to read:
6 895.02 Definitions.--As used in ss. 895.01-895.08, the
7 term:
8 (1) "Racketeering activity" means to commit, to
9 attempt to commit, to conspire to commit, or to solicit,
10 coerce, or intimidate another person to commit:
11 (a) Any crime which is chargeable by indictment or
12 information under the following provisions of the Florida
13 Statutes:
14 1. Section 210.18, relating to evasion of payment of
15 cigarette taxes.
16 2. Section 403.727(3)(b), relating to environmental
17 control.
18 3. Section 414.39, relating to public assistance
19 fraud.
20 4. Section 409.920 or s. 409.9201, relating to
21 Medicaid provider fraud.
22 5. Section 440.105 or s. 440.106, relating to workers'
23 compensation.
24 6. Sections 499.0051, 499.0052, 499.0053, 499.0054,
25 and 499.0691, relating to crimes involving contraband and
26 adulterated drugs.
27 7. Part IV of chapter 501, relating to telemarketing.
28 8. Chapter 517, relating to sale of securities and
29 investor protection.
30 9. Section 550.235, s. 550.3551, or s. 550.3605,
31 relating to dogracing and horseracing.
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1 10. Chapter 550, relating to jai alai frontons.
2 11. Chapter 552, relating to the manufacture,
3 distribution, and use of explosives.
4 12. Chapter 560, relating to money transmitters, if
5 the violation is punishable as a felony.
6 13. Chapter 562, relating to beverage law enforcement.
7 14. Section 624.401, relating to transacting insurance
8 without a certificate of authority, s. 624.437(4)(c)1.,
9 relating to operating an unauthorized multiple-employer
10 welfare arrangement, or s. 626.902(1)(b), relating to
11 representing or aiding an unauthorized insurer.
12 15. Section 655.50, relating to reports of currency
13 transactions, when such violation is punishable as a felony.
14 16. Chapter 687, relating to interest and usurious
15 practices.
16 17. Section 721.08, s. 721.09, or s. 721.13, relating
17 to real estate timeshare plans.
18 18. Chapter 782, relating to homicide.
19 19. Chapter 784, relating to assault and battery.
20 20. Chapter 787, relating to kidnapping.
21 21. Chapter 790, relating to weapons and firearms.
22 22. Section 796.03, s. 796.04, s. 796.05, or s.
23 796.07, relating to prostitution.
24 23. Chapter 806, relating to arson.
25 24. Section 810.02(2)(c), relating to specified
26 burglary of a dwelling or structure.
27 25. Chapter 812, relating to theft, robbery, and
28 related crimes.
29 26. Chapter 815, relating to computer-related crimes.
30 27. Chapter 817, relating to fraudulent practices,
31 false pretenses, fraud generally, and credit card crimes.
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1 28. Chapter 825, relating to abuse, neglect, or
2 exploitation of an elderly person or disabled adult.
3 29. Section 827.071, relating to commercial sexual
4 exploitation of children.
5 30. Chapter 831, relating to forgery and
6 counterfeiting.
7 31. Chapter 832, relating to issuance of worthless
8 checks and drafts.
9 32. Section 836.05, relating to extortion.
10 33. Chapter 837, relating to perjury.
11 34. Chapter 838, relating to bribery and misuse of
12 public office.
13 35. Chapter 843, relating to obstruction of justice.
14 36. Section 847.011, s. 847.012, s. 847.013, s.
15 847.06, or s. 847.07, relating to obscene literature and
16 profanity.
17 37. Section 849.09, s. 849.14, s. 849.15, s. 849.23,
18 or s. 849.25, relating to gambling.
19 38. Chapter 874, relating to criminal street gangs.
20 39. Chapter 893, relating to drug abuse prevention and
21 control.
22 40. Chapter 896, relating to offenses related to
23 financial transactions.
24 41. Sections 914.22 and 914.23, relating to tampering
25 with a witness, victim, or informant, and retaliation against
26 a witness, victim, or informant.
27 42. Sections 918.12 and 918.13, relating to tampering
28 with jurors and evidence.
29 Section 14. Section 905.34, Florida Statutes, is
30 amended to read:
31
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1 905.34 Powers and duties; law applicable.--The
2 jurisdiction of a statewide grand jury impaneled under this
3 chapter shall extend throughout the state. The subject matter
4 jurisdiction of the statewide grand jury shall be limited to
5 the offenses of:
6 (1) Bribery, burglary, carjacking, home-invasion
7 robbery, criminal usury, extortion, gambling, kidnapping,
8 larceny, murder, prostitution, perjury, and robbery;
9 (2) Crimes involving narcotic or other dangerous
10 drugs;
11 (3) Any violation of the provisions of the Florida
12 RICO (Racketeer Influenced and Corrupt Organization) Act,
13 including any offense listed in the definition of racketeering
14 activity in s. 895.02(1)(a), providing such listed offense is
15 investigated in connection with a violation of s. 895.03 and
16 is charged in a separate count of an information or indictment
17 containing a count charging a violation of s. 895.03, the
18 prosecution of which listed offense may continue independently
19 if the prosecution of the violation of s. 895.03 is terminated
20 for any reason;
21 (4) Any violation of the provisions of the Florida
22 Anti-Fencing Act;
23 (5) Any violation of the provisions of the Florida
24 Antitrust Act of 1980, as amended;
25 (6) Any violation of the provisions of chapter 815;
26 (7) Any crime involving, or resulting in, fraud or
27 deceit upon any person;
28 (8) Any violation of s. 847.0135, s. 847.0137, or s.
29 847.0138 relating to computer pornography and child
30 exploitation prevention, or any offense related to a violation
31 of s. 847.0135, s. 847.0137, or s. 847.0138; or
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1 (9) Any criminal violation of part I of chapter 499;
2 or
3 (10) Any criminal violation of s. 409.920 or s.
4 409.9201;
5
6 or any attempt, solicitation, or conspiracy to commit any
7 violation of the crimes specifically enumerated above, when
8 any such offense is occurring, or has occurred, in two or more
9 judicial circuits as part of a related transaction or when any
10 such offense is connected with an organized criminal
11 conspiracy affecting two or more judicial circuits. The
12 statewide grand jury may return indictments and presentments
13 irrespective of the county or judicial circuit where the
14 offense is committed or triable. If an indictment is
15 returned, it shall be certified and transferred for trial to
16 the county where the offense was committed. The powers and
17 duties of, and law applicable to, county grand juries shall
18 apply to a statewide grand jury except when such powers,
19 duties, and law are inconsistent with the provisions of ss.
20 905.31-905.40.
21 Section 15. Paragraph (a) of subsection (2) of section
22 932.701, Florida Statutes, is amended to read:
23 932.701 Short title; definitions.--
24 (2) As used in the Florida Contraband Forfeiture Act:
25 (a) "Contraband article" means:
26 1. Any controlled substance as defined in chapter 893
27 or any substance, device, paraphernalia, or currency or other
28 means of exchange that was used, was attempted to be used, or
29 was intended to be used in violation of any provision of
30 chapter 893, if the totality of the facts presented by the
31 state is clearly sufficient to meet the state's burden of
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1 establishing probable cause to believe that a nexus exists
2 between the article seized and the narcotics activity, whether
3 or not the use of the contraband article can be traced to a
4 specific narcotics transaction.
5 2. Any gambling paraphernalia, lottery tickets, money,
6 currency, or other means of exchange which was used, was
7 attempted, or intended to be used in violation of the gambling
8 laws of the state.
9 3. Any equipment, liquid or solid, which was being
10 used, is being used, was attempted to be used, or intended to
11 be used in violation of the beverage or tobacco laws of the
12 state.
13 4. Any motor fuel upon which the motor fuel tax has
14 not been paid as required by law.
15 5. Any personal property, including, but not limited
16 to, any vessel, aircraft, item, object, tool, substance,
17 device, weapon, machine, vehicle of any kind, money,
18 securities, books, records, research, negotiable instruments,
19 or currency, which was used or was attempted to be used as an
20 instrumentality in the commission of, or in aiding or abetting
21 in the commission of, any felony, whether or not comprising an
22 element of the felony, or which is acquired by proceeds
23 obtained as a result of a violation of the Florida Contraband
24 Forfeiture Act.
25 6. Any real property, including any right, title,
26 leasehold, or other interest in the whole of any lot or tract
27 of land, which was used, is being used, or was attempted to be
28 used as an instrumentality in the commission of, or in aiding
29 or abetting in the commission of, any felony, or which is
30 acquired by proceeds obtained as a result of a violation of
31 the Florida Contraband Forfeiture Act.
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1 7. Any personal property, including, but not limited
2 to, equipment, money, securities, books, records, research,
3 negotiable instruments, currency, or any vessel, aircraft,
4 item, object, tool, substance, device, weapon, machine, or
5 vehicle of any kind in the possession of or belonging to any
6 person who takes aquaculture products in violation of s.
7 812.014(2)(c).
8 8. Any motor vehicle offered for sale in violation of
9 s. 320.28.
10 9. Any motor vehicle used during the course of
11 committing an offense in violation of s. 322.34(9)(a).
12 10. Any real property, including any right, title,
13 leasehold, or other interest in the whole of any lot or tract
14 of land, which is acquired by proceeds obtained as a result of
15 Medicaid fraud under s. 409.920 or s. 409.9201; any personal
16 property, including, but not limited to, equipment, money,
17 securities, books, records, research, negotiable instruments,
18 or currency; or any vessel, aircraft, item, object, tool,
19 substance, device, weapon, machine, or vehicle of any kind in
20 the possession of or belonging to any person which is acquired
21 by proceeds obtained as a result of Medicaid fraud under s.
22 409.920 or s. 409.9201.
23 Section 16. Paragraph (l) is added to subsection (5)
24 of section 932.7055, Florida Statutes, to read:
25 932.7055 Disposition of liens and forfeited
26 property.--
27 (5) If the seizing agency is a state agency, all
28 remaining proceeds shall be deposited into the General Revenue
29 Fund. However, if the seizing agency is:
30 (l) The Medicaid Fraud Control Unit of the Department
31 of Legal Affairs, the proceeds accrued pursuant to the
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1 provisions of the Florida Contraband Forfeiture Act shall be
2 deposited into the Department of Legal Affairs Grants and
3 Donations Trust Fund to be used for investigation and
4 prosecution of Medicaid fraud, abuse, neglect, and other
5 related cases by the Medicaid Fraud Control Unit.
6 Section 17. Paragraphs (a), (b), and (e) of subsection
7 (4) of section 394.9082, Florida Statutes, are amended to
8 read:
9 394.9082 Behavioral health service delivery
10 strategies.--
11 (4) CONTRACT FOR SERVICES.--
12 (a) The Department of Children and Family Services and
13 the Agency for Health Care Administration may contract for the
14 provision or management of behavioral health services with a
15 managing entity in at least two geographic areas. Both the
16 Department of Children and Family Services and the Agency for
17 Health Care Administration must contract with the same
18 managing entity in any distinct geographic area where the
19 strategy operates. This managing entity shall be accountable
20 at a minimum for the delivery of behavioral health services
21 specified and funded by the department and the agency. The
22 geographic area must be of sufficient size in population and
23 have enough public funds for behavioral health services to
24 allow for flexibility and maximum efficiency. Notwithstanding
25 the provisions of s. 409.912(4)(3)(b)1. and 2., at least one
26 service delivery strategy must be in one of the service
27 districts in the catchment area of G. Pierce Wood Memorial
28 Hospital.
29 (b) Under one of the service delivery strategies, the
30 Department of Children and Family Services may contract with a
31 prepaid mental health plan that operates under s. 409.912 to
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1 be the managing entity. Under this strategy, the Department of
2 Children and Family Services is not required to competitively
3 procure those services and, notwithstanding other provisions
4 of law, may employ prospective payment methodologies that the
5 department finds are necessary to improve client care or
6 institute more efficient practices. The Department of Children
7 and Family Services may employ in its contract any provision
8 of the current prepaid behavioral health care plan authorized
9 under s. 409.912(4)(3)(a) and (b), or any other provision
10 necessary to improve quality, access, continuity, and price.
11 Any contracts under this strategy in Area 6 of the Agency for
12 Health Care Administration or in the prototype region under s.
13 20.19(7) of the Department of Children and Family Services may
14 be entered with the existing substance abuse treatment
15 provider network if an administrative services organization is
16 part of its network. In Area 6 of the Agency for Health Care
17 Administration or in the prototype region of the Department of
18 Children and Family Services, the Department of Children and
19 Family Services and the Agency for Health Care Administration
20 may employ alternative service delivery and financing
21 methodologies, which may include prospective payment for
22 certain population groups. The population groups that are to
23 be provided these substance abuse services would include at a
24 minimum: individuals and families receiving family safety
25 services; Medicaid-eligible children, adolescents, and adults
26 who are substance-abuse-impaired; or current recipients and
27 persons at risk of needing cash assistance under Florida's
28 welfare reform initiatives.
29 (e) The cost of the managing entity contract shall be
30 funded through a combination of funds from the Department of
31 Children and Family Services and the Agency for Health Care
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1 Administration. To operate the managing entity, the Department
2 of Children and Family Services and the Agency for Health Care
3 Administration may not expend more than 10 percent of the
4 annual appropriations for mental health and substance abuse
5 treatment services prorated to the geographic areas and must
6 include all behavioral health Medicaid funds, including
7 psychiatric inpatient funds. This restriction does not apply
8 to a prepaid behavioral health plan that is authorized under
9 s. 409.912(4)(3)(a) and (b).
10 Section 18. Subsection (6) of section 400.0077,
11 Florida Statutes, is amended to read:
12 400.0077 Confidentiality.--
13 (6) This section does not limit the subpoena power of
14 the Attorney General pursuant to s. 409.920(9)(8)(b).
15 Section 19. Paragraph (a) of subsection (4) of section
16 409.9065, Florida Statutes, is amended to read:
17 409.9065 Pharmaceutical expense assistance.--
18 (4) ADMINISTRATION.--The pharmaceutical expense
19 assistance program shall be administered by the agency, in
20 collaboration with the Department of Elderly Affairs and the
21 Department of Children and Family Services.
22 (a) The agency shall, by rule, establish for the
23 pharmaceutical expense assistance program eligibility
24 requirements; limits on participation; benefit limitations,
25 including copayments; a requirement for generic drug
26 substitution; and other program parameters comparable to those
27 of the Medicaid program. Individuals eligible to participate
28 in this program are not subject to the limit of four brand
29 name drugs per month per recipient as specified in s.
30 409.912(40)(38)(a). There shall be no monetary limit on
31 prescription drugs purchased with discounts of less than 51
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1 percent unless the agency determines there is a risk of a
2 funding shortfall in the program. If the agency determines
3 there is a risk of a funding shortfall, the agency may
4 establish monetary limits on prescription drugs which shall
5 not be less than $160 worth of prescription drugs per month.
6 Section 20. Subsection (1) of section 409.9071,
7 Florida Statutes, is amended to read:
8 409.9071 Medicaid provider agreements for school
9 districts certifying state match.--
10 (1) The agency shall submit a state plan amendment by
11 September 1, 1997, for the purpose of obtaining federal
12 authorization to reimburse school-based services as provided
13 in former s. 236.0812 pursuant to the rehabilitative services
14 option provided under 42 U.S.C. s. 1396d(a)(13). For purposes
15 of this section, billing agent consulting services shall be
16 considered billing agent services, as that term is used in s.
17 409.913(10)(9), and, as such, payments to such persons shall
18 not be based on amounts for which they bill nor based on the
19 amount a provider receives from the Medicaid program. This
20 provision shall not restrict privatization of Medicaid
21 school-based services. Subject to any limitations provided for
22 in the General Appropriations Act, the agency, in compliance
23 with appropriate federal authorization, shall develop policies
24 and procedures and shall allow for certification of state and
25 local education funds which have been provided for
26 school-based services as specified in s. 1011.70 and
27 authorized by a physician's order where required by federal
28 Medicaid law. Any state or local funds certified pursuant to
29 this section shall be for children with specified disabilities
30 who are eligible for both Medicaid and part B or part H of the
31 Individuals with Disabilities Education Act (IDEA), or the
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1 exceptional student education program, or who have an
2 individualized educational plan.
3 Section 21. Subsection (4) of section 409.908, Florida
4 Statutes, is amended to read:
5 409.908 Reimbursement of Medicaid providers.--Subject
6 to specific appropriations, the agency shall reimburse
7 Medicaid providers, in accordance with state and federal law,
8 according to methodologies set forth in the rules of the
9 agency and in policy manuals and handbooks incorporated by
10 reference therein. These methodologies may include fee
11 schedules, reimbursement methods based on cost reporting,
12 negotiated fees, competitive bidding pursuant to s. 287.057,
13 and other mechanisms the agency considers efficient and
14 effective for purchasing services or goods on behalf of
15 recipients. If a provider is reimbursed based on cost
16 reporting and submits a cost report late and that cost report
17 would have been used to set a lower reimbursement rate for a
18 rate semester, then the provider's rate for that semester
19 shall be retroactively calculated using the new cost report,
20 and full payment at the recalculated rate shall be affected
21 retroactively. Medicare-granted extensions for filing cost
22 reports, if applicable, shall also apply to Medicaid cost
23 reports. Payment for Medicaid compensable services made on
24 behalf of Medicaid eligible persons is subject to the
25 availability of moneys and any limitations or directions
26 provided for in the General Appropriations Act or chapter 216.
27 Further, nothing in this section shall be construed to prevent
28 or limit the agency from adjusting fees, reimbursement rates,
29 lengths of stay, number of visits, or number of services, or
30 making any other adjustments necessary to comply with the
31 availability of moneys and any limitations or directions
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1 provided for in the General Appropriations Act, provided the
2 adjustment is consistent with legislative intent.
3 (4) Subject to any limitations or directions provided
4 for in the General Appropriations Act, alternative health
5 plans, health maintenance organizations, and prepaid health
6 plans shall be reimbursed a fixed, prepaid amount negotiated,
7 or competitively bid pursuant to s. 287.057, by the agency and
8 prospectively paid to the provider monthly for each Medicaid
9 recipient enrolled. The amount may not exceed the average
10 amount the agency determines it would have paid, based on
11 claims experience, for recipients in the same or similar
12 category of eligibility. The agency shall calculate capitation
13 rates on a regional basis and, beginning September 1, 1995,
14 shall include age-band differentials in such calculations.
15 Effective July 1, 2001, the cost of exempting statutory
16 teaching hospitals, specialty hospitals, and community
17 hospital education program hospitals from reimbursement
18 ceilings and the cost of special Medicaid payments shall not
19 be included in premiums paid to health maintenance
20 organizations or prepaid health care plans. Each rate
21 semester, the agency shall calculate and publish a Medicaid
22 hospital rate schedule that does not reflect either special
23 Medicaid payments or the elimination of rate reimbursement
24 ceilings, to be used by hospitals and Medicaid health
25 maintenance organizations, in order to determine the Medicaid
26 rate referred to in ss. 409.912(19)(17), 409.9128(5), and
27 641.513(6).
28 Section 22. Subsections (1) and (2) of section
29 409.91196, Florida Statutes, are amended to read:
30 409.91196 Supplemental rebate agreements;
31 confidentiality of records and meetings.--
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1 (1) Trade secrets, rebate amount, percent of rebate,
2 manufacturer's pricing, and supplemental rebates which are
3 contained in records of the Agency for Health Care
4 Administration and its agents with respect to supplemental
5 rebate negotiations and which are prepared pursuant to a
6 supplemental rebate agreement under s. 409.912(40)(38)(a)7.
7 are confidential and exempt from s. 119.07 and s. 24(a), Art.
8 I of the State Constitution.
9 (2) Those portions of meetings of the Medicaid
10 Pharmaceutical and Therapeutics Committee at which trade
11 secrets, rebate amount, percent of rebate, manufacturer's
12 pricing, and supplemental rebates are disclosed for discussion
13 or negotiation of a supplemental rebate agreement under s.
14 409.912(40)(38)(a)7. are exempt from s. 286.011 and s. 24(b),
15 Art. I of the State Constitution.
16 Section 23. Paragraph (f) of subsection (2) of section
17 409.9122, Florida Statutes, is amended to read:
18 409.9122 Mandatory Medicaid managed care enrollment;
19 programs and procedures.--
20 (2)
21 (f) When a Medicaid recipient does not choose a
22 managed care plan or MediPass provider, the agency shall
23 assign the Medicaid recipient to a managed care plan or
24 MediPass provider. Medicaid recipients who are subject to
25 mandatory assignment but who fail to make a choice shall be
26 assigned to managed care plans until an enrollment of 40
27 percent in MediPass and 60 percent in managed care plans is
28 achieved. Once this enrollment is achieved, the assignments
29 shall be divided in order to maintain an enrollment in
30 MediPass and managed care plans which is in a 40 percent and
31 60 percent proportion, respectively. Thereafter, assignment of
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1 Medicaid recipients who fail to make a choice shall be based
2 proportionally on the preferences of recipients who have made
3 a choice in the previous period. Such proportions shall be
4 revised at least quarterly to reflect an update of the
5 preferences of Medicaid recipients. The agency shall
6 disproportionately assign Medicaid-eligible recipients who are
7 required to but have failed to make a choice of managed care
8 plan or MediPass, including children, and who are to be
9 assigned to the MediPass program to children's networks as
10 described in s. 409.912(4)(3)(g), Children's Medical Services
11 network as defined in s. 391.021, exclusive provider
12 organizations, provider service networks, minority physician
13 networks, and pediatric emergency department diversion
14 programs authorized by this chapter or the General
15 Appropriations Act, in such manner as the agency deems
16 appropriate, until the agency has determined that the networks
17 and programs have sufficient numbers to be economically
18 operated. For purposes of this paragraph, when referring to
19 assignment, the term "managed care plans" includes health
20 maintenance organizations, exclusive provider organizations,
21 provider service networks, minority physician networks,
22 Children's Medical Services network, and pediatric emergency
23 department diversion programs authorized by this chapter or
24 the General Appropriations Act. When making assignments, the
25 agency shall take into account the following criteria:
26 1. A managed care plan has sufficient network capacity
27 to meet the need of members.
28 2. The managed care plan or MediPass has previously
29 enrolled the recipient as a member, or one of the managed care
30 plan's primary care providers or MediPass providers has
31 previously provided health care to the recipient.
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1 3. The agency has knowledge that the member has
2 previously expressed a preference for a particular managed
3 care plan or MediPass provider as indicated by Medicaid
4 fee-for-service claims data, but has failed to make a choice.
5 4. The managed care plan's or MediPass primary care
6 providers are geographically accessible to the recipient's
7 residence.
8 Section 24. Subsection (3) of section 409.9131,
9 Florida Statutes, is amended to read:
10 409.9131 Special provisions relating to integrity of
11 the Medicaid program.--
12 (3) ONSITE RECORDS REVIEW.--As specified in s.
13 409.913(9)(8), the agency may investigate, review, or analyze
14 a physician's medical records concerning Medicaid patients.
15 The physician must make such records available to the agency
16 during normal business hours. The agency must provide notice
17 to the physician at least 24 hours before such visit. The
18 agency and physician shall make every effort to set a mutually
19 agreeable time for the agency's visit during normal business
20 hours and within the 24-hour period. If such a time cannot be
21 agreed upon, the agency may set the time.
22 Section 25. Subsection (2) of section 430.608, Florida
23 Statutes, is amended to read:
24 430.608 Confidentiality of information.--
25 (2) This section does not, however, limit the subpoena
26 authority of the Medicaid Fraud Control Unit of the Department
27 of Legal Affairs pursuant to s. 409.920(9)(8)(b).
28 Section 26. Section 636.0145, Florida Statutes, is
29 amended to read:
30 636.0145 Certain entities contracting with
31 Medicaid.--Notwithstanding the requirements of s.
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1 409.912(4)(3)(b), an entity that is providing comprehensive
2 inpatient and outpatient mental health care services to
3 certain Medicaid recipients in Hillsborough, Highlands,
4 Hardee, Manatee, and Polk Counties through a capitated,
5 prepaid arrangement pursuant to the federal waiver provided
6 for in s. 409.905(5) must become licensed under chapter 636 by
7 December 31, 1998. Any entity licensed under this chapter
8 which provides services solely to Medicaid recipients under a
9 contract with Medicaid shall be exempt from ss. 636.017,
10 636.018, 636.022, 636.028, and 636.034.
11 Section 27. Subsection (3) of section 641.225, Florida
12 Statutes, is amended to read:
13 641.225 Surplus requirements.--
14 (3)(a) An entity providing prepaid capitated services
15 which is authorized under s. 409.912(4)(3)(a) and which
16 applies for a certificate of authority is subject to the
17 minimum surplus requirements set forth in subsection (1),
18 unless the entity is backed by the full faith and credit of
19 the county in which it is located.
20 (b) An entity providing prepaid capitated services
21 which is authorized under s. 409.912(4)(3)(b) or (c), and
22 which applies for a certificate of authority is subject to the
23 minimum surplus requirements set forth in s. 409.912.
24 Section 28. Subsection (4) of section 641.386, Florida
25 Statutes, is amended to read:
26 641.386 Agent licensing and appointment required;
27 exceptions.--
28 (4) All agents and health maintenance organizations
29 shall comply with and be subject to the applicable provisions
30 of ss. 641.309 and 409.912(21)(19), and all companies and
31 entities appointing agents shall comply with s. 626.451, when
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1 marketing for any health maintenance organization licensed
2 pursuant to this part, including those organizations under
3 contract with the Agency for Health Care Administration to
4 provide health care services to Medicaid recipients or any
5 private entity providing health care services to Medicaid
6 recipients pursuant to a prepaid health plan contract with the
7 Agency for Health Care Administration.
8 Section 29. For the purposes of incorporating the
9 amendment to section 409.920, Florida Statutes, in a reference
10 thereto, paragraph (g) of subsection (3) of section 921.0022,
11 Florida Statutes, is reenacted to read:
12 921.0022 Criminal Punishment Code; offense severity
13 ranking chart.--
14 (3) OFFENSE SEVERITY RANKING CHART
15
16 Florida Felony
17 Statute Degree Description
18
19
20 (g) LEVEL 7
21 316.027(1)(b) 2nd Accident involving death, failure
22 to stop; leaving scene.
23 316.193(3)(c)2. 3rd DUI resulting in serious bodily
24 injury.
25 327.35(3)(c)2. 3rd Vessel BUI resulting in serious
26 bodily injury.
27 402.319(2) 2nd Misrepresentation and negligence
28 or intentional act resulting in
29 great bodily harm, permanent
30 disfiguration, permanent
31 disability, or death.
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1 409.920(2) 3rd Medicaid provider fraud.
2 456.065(2) 3rd Practicing a health care
3 profession without a license.
4 456.065(2) 2nd Practicing a health care
5 profession without a license
6 which results in serious bodily
7 injury.
8 458.327(1) 3rd Practicing medicine without a
9 license.
10 459.013(1) 3rd Practicing osteopathic medicine
11 without a license.
12 460.411(1) 3rd Practicing chiropractic medicine
13 without a license.
14 461.012(1) 3rd Practicing podiatric medicine
15 without a license.
16 462.17 3rd Practicing naturopathy without a
17 license.
18 463.015(1) 3rd Practicing optometry without a
19 license.
20 464.016(1) 3rd Practicing nursing without a
21 license.
22 465.015(2) 3rd Practicing pharmacy without a
23 license.
24 466.026(1) 3rd Practicing dentistry or dental
25 hygiene without a license.
26 467.201 3rd Practicing midwifery without a
27 license.
28 468.366 3rd Delivering respiratory care
29 services without a license.
30 483.828(1) 3rd Practicing as clinical laboratory
31 personnel without a license.
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1 483.901(9) 3rd Practicing medical physics
2 without a license.
3 484.013(1)(c) 3rd Preparing or dispensing optical
4 devices without a prescription.
5 484.053 3rd Dispensing hearing aids without a
6 license.
7 494.0018(2) 1st Conviction of any violation of
8 ss. 494.001-494.0077 in which the
9 total money and property
10 unlawfully obtained exceeded
11 $50,000 and there were five or
12 more victims.
13 560.123(8)(b)1. 3rd Failure to report currency or
14 payment instruments exceeding
15 $300 but less than $20,000 by
16 money transmitter.
17 560.125(5)(a) 3rd Money transmitter business by
18 unauthorized person, currency or
19 payment instruments exceeding
20 $300 but less than $20,000.
21 655.50(10)(b)1. 3rd Failure to report financial
22 transactions exceeding $300 but
23 less than $20,000 by financial
24 institution.
25 782.051(3) 2nd Attempted felony murder of a
26 person by a person other than the
27 perpetrator or the perpetrator of
28 an attempted felony.
29
30
31
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1 782.07(1) 2nd Killing of a human being by the
2 act, procurement, or culpable
3 negligence of another
4 (manslaughter).
5 782.071 2nd Killing of human being or viable
6 fetus by the operation of a motor
7 vehicle in a reckless manner
8 (vehicular homicide).
9 782.072 2nd Killing of a human being by the
10 operation of a vessel in a
11 reckless manner (vessel
12 homicide).
13 784.045(1)(a)1. 2nd Aggravated battery; intentionally
14 causing great bodily harm or
15 disfigurement.
16 784.045(1)(a)2. 2nd Aggravated battery; using deadly
17 weapon.
18 784.045(1)(b) 2nd Aggravated battery; perpetrator
19 aware victim pregnant.
20 784.048(4) 3rd Aggravated stalking; violation of
21 injunction or court order.
22 784.07(2)(d) 1st Aggravated battery on law
23 enforcement officer.
24 784.074(1)(a) 1st Aggravated battery on sexually
25 violent predators facility staff.
26 784.08(2)(a) 1st Aggravated battery on a person 65
27 years of age or older.
28 784.081(1) 1st Aggravated battery on specified
29 official or employee.
30
31
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1 784.082(1) 1st Aggravated battery by detained
2 person on visitor or other
3 detainee.
4 784.083(1) 1st Aggravated battery on code
5 inspector.
6 790.07(4) 1st Specified weapons violation
7 subsequent to previous conviction
8 of s. 790.07(1) or (2).
9 790.16(1) 1st Discharge of a machine gun under
10 specified circumstances.
11 790.165(2) 2nd Manufacture, sell, possess, or
12 deliver hoax bomb.
13 790.165(3) 2nd Possessing, displaying, or
14 threatening to use any hoax bomb
15 while committing or attempting to
16 commit a felony.
17 790.166(3) 2nd Possessing, selling, using, or
18 attempting to use a hoax weapon
19 of mass destruction.
20 790.166(4) 2nd Possessing, displaying, or
21 threatening to use a hoax weapon
22 of mass destruction while
23 committing or attempting to
24 commit a felony.
25 796.03 2nd Procuring any person under 16
26 years for prostitution.
27 800.04(5)(c)1. 2nd Lewd or lascivious molestation;
28 victim less than 12 years of age;
29 offender less than 18 years.
30
31
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1 800.04(5)(c)2. 2nd Lewd or lascivious molestation;
2 victim 12 years of age or older
3 but less than 16 years; offender
4 18 years or older.
5 806.01(2) 2nd Maliciously damage structure by
6 fire or explosive.
7 810.02(3)(a) 2nd Burglary of occupied dwelling;
8 unarmed; no assault or battery.
9 810.02(3)(b) 2nd Burglary of unoccupied dwelling;
10 unarmed; no assault or battery.
11 810.02(3)(d) 2nd Burglary of occupied conveyance;
12 unarmed; no assault or battery.
13 812.014(2)(a) 1st Property stolen, valued at
14 $100,000 or more; cargo stolen
15 valued at $50,000 or more;
16 property stolen while causing
17 other property damage; 1st degree
18 grand theft.
19 812.014(2)(b)3. 2nd Property stolen, emergency
20 medical equipment; 2nd degree
21 grand theft.
22 812.0145(2)(a) 1st Theft from person 65 years of age
23 or older; $50,000 or more.
24 812.019(2) 1st Stolen property; initiates,
25 organizes, plans, etc., the theft
26 of property and traffics in
27 stolen property.
28 812.131(2)(a) 2nd Robbery by sudden snatching.
29 812.133(2)(b) 1st Carjacking; no firearm, deadly
30 weapon, or other weapon.
31
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1 817.234(8)(a) 2nd Solicitation of motor vehicle
2 accident victims with intent to
3 defraud.
4 817.234(9) 2nd Organizing, planning, or
5 participating in an intentional
6 motor vehicle collision.
7 817.234(11)(c) 1st Insurance fraud; property value
8 $100,000 or more.
9 817.2341(2)(b)&
10 (3)(b) 1st Making false entries of material
11 fact or false statements
12 regarding property values
13 relating to the solvency of an
14 insuring entity which are a
15 significant cause of the
16 insolvency of that entity.
17 825.102(3)(b) 2nd Neglecting an elderly person or
18 disabled adult causing great
19 bodily harm, disability, or
20 disfigurement.
21 825.103(2)(b) 2nd Exploiting an elderly person or
22 disabled adult and property is
23 valued at $20,000 or more, but
24 less than $100,000.
25 827.03(3)(b) 2nd Neglect of a child causing great
26 bodily harm, disability, or
27 disfigurement.
28 827.04(3) 3rd Impregnation of a child under 16
29 years of age by person 21 years
30 of age or older.
31
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1 837.05(2) 3rd Giving false information about
2 alleged capital felony to a law
3 enforcement officer.
4 838.015 2nd Bribery.
5 838.016 2nd Unlawful compensation or reward
6 for official behavior.
7 838.021(3)(a) 2nd Unlawful harm to a public
8 servant.
9 838.22 2nd Bid tampering.
10 872.06 2nd Abuse of a dead human body.
11 893.13(1)(c)1. 1st Sell, manufacture, or deliver
12 cocaine (or other drug prohibited
13 under s. 893.03(1)(a), (1)(b),
14 (1)(d), (2)(a), (2)(b), or
15 (2)(c)4.) within 1,000 feet of a
16 child care facility, school, or
17 state, county, or municipal park
18 or publicly owned recreational
19 facility or community center.
20 893.13(1)(e)1. 1st Sell, manufacture, or deliver
21 cocaine or other drug prohibited
22 under s. 893.03(1)(a), (1)(b),
23 (1)(d), (2)(a), (2)(b), or
24 (2)(c)4., within 1,000 feet of
25 property used for religious
26 services or a specified business
27 site.
28 893.13(4)(a) 1st Deliver to minor cocaine (or
29 other s. 893.03(1)(a), (1)(b),
30 (1)(d), (2)(a), (2)(b), or
31 (2)(c)4. drugs).
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1 893.135(1)(a)1. 1st Trafficking in cannabis, more
2 than 25 lbs., less than 2,000
3 lbs.
4 893.135
5 (1)(b)1.a. 1st Trafficking in cocaine, more than
6 28 grams, less than 200 grams.
7 893.135
8 (1)(c)1.a. 1st Trafficking in illegal drugs,
9 more than 4 grams, less than 14
10 grams.
11 893.135
12 (1)(d)1. 1st Trafficking in phencyclidine,
13 more than 28 grams, less than 200
14 grams.
15 893.135(1)(e)1. 1st Trafficking in methaqualone, more
16 than 200 grams, less than 5
17 kilograms.
18 893.135(1)(f)1. 1st Trafficking in amphetamine, more
19 than 14 grams, less than 28
20 grams.
21 893.135
22 (1)(g)1.a. 1st Trafficking in flunitrazepam, 4
23 grams or more, less than 14
24 grams.
25 893.135
26 (1)(h)1.a. 1st Trafficking in
27 gamma-hydroxybutyric acid (GHB),
28 1 kilogram or more, less than 5
29 kilograms.
30
31
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1 893.135
2 (1)(j)1.a. 1st Trafficking in 1,4-Butanediol, 1
3 kilogram or more, less than 5
4 kilograms.
5 893.135
6 (1)(k)2.a. 1st Trafficking in Phenethylamines,
7 10 grams or more, less than 200
8 grams.
9 896.101(5)(a) 3rd Money laundering, financial
10 transactions exceeding $300 but
11 less than $20,000.
12 896.104(4)(a)1. 3rd Structuring transactions to evade
13 reporting or registration
14 requirements, financial
15 transactions exceeding $300 but
16 less than $20,000.
17 Section 30. For the purpose of incorporating the
18 amendment to section 932.701, Florida Statutes, in a reference
19 thereto, subsection (6) of section 705.101, Florida Statutes,
20 is reenacted to read:
21 705.101 Definitions.--As used in this chapter:
22 (6) "Unclaimed evidence" means any tangible personal
23 property, including cash, not included within the definition
24 of "contraband article," as provided in s. 932.701(2), which
25 was seized by a law enforcement agency, was intended for use
26 in a criminal or quasi-criminal proceeding, and is retained by
27 the law enforcement agency or the clerk of the county or
28 circuit court for 60 days after the final disposition of the
29 proceeding and to which no claim of ownership has been made.
30 Section 31. For the purpose of incorporating the
31 amendment to section 932.701, Florida Statutes, in references
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1 thereto, subsection (4) of section 932.703, Florida Statutes,
2 is reenacted to read:
3 932.703 Forfeiture of contraband article;
4 exceptions.--
5 (4) In any incident in which possession of any
6 contraband article defined in s. 932.701(2)(a) constitutes a
7 felony, the vessel, motor vehicle, aircraft, other personal
8 property, or real property in or on which such contraband
9 article is located at the time of seizure shall be contraband
10 subject to forfeiture. It shall be presumed in the manner
11 provided in s. 90.302(2) that the vessel, motor vehicle,
12 aircraft, other personal property, or real property in which
13 or on which such contraband article is located at the time of
14 seizure is being used or was attempted or intended to be used
15 in a manner to facilitate the transportation, carriage,
16 conveyance, concealment, receipt, possession, purchase, sale,
17 barter, exchange, or giving away of a contraband article
18 defined in s. 932.701(2).
19 Section 32. The sum of $262,087 is appropriated from
20 the Medical Quality Assurance Trust Fund to the Department of
21 Health, and four full-time equivalent positions are
22 authorized, for the purpose of implementing the provisions of
23 this act during the 2004-2005 fiscal year.
24 Section 33. This act shall take effect July 1, 2004.
25
26
27
28
29
30
31
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS/SB 1064
3
4 Requires the Agency for Health Care Administration (AHCA) to
enroll Medicaid recipients in the drug benefit management
5 program if they are using significant numbers of prescribed
drugs each month and are not enrolled in a health maintenance
6 organization.
7 Deletes language that gave the Medicaid Fraud Control Unit
authorization to review non-Medicaid patient records without
8 the patient's consent when the unit is investigating suspected
Medicaid fraud.
9
Requires a Medicaid applicant to forfeit his or her
10 entitlement to goods and services in the Medicaid program if
found, through administrative or judicial proceedings, to have
11 committed fraud three times in a period of less than 36
months. Requires AHCA to seek a federal waiver to terminate
12 the eligibility of the recipient from the Medicaid program.
13 Gives AHCA the authority to require a confirmation, or second
physician's opinion of the correct diagnosis, for the purpose
14 of authorizing future services under the Medicaid program.
15 Requires AHCA to mandate a Medicaid recipient's participation
in a provider lock-in program, limiting the receipt of goods
16 or services to a single provider for a period of no less than
one year, and for the duration of the recipient's
17 participation in the program if he or she commits a second
offense of fraud or abuse. The lock-in programs include, but
18 are not limited to, pharmacies, medical doctors, and infusion
clinics.
19
Requires AHCA to conduct a study and recommend a plan to
20 implement an electronic verification system in the Medicaid
program.
21
Authorizes AHCA to implement provider network controls,
22 including but not limited to, competitive bidding and provider
credentialing.
23
Clarifies that AHCA may reimburse a person or entity for a
24 prescription for medication or medical supplies under the
Medicaid program if the prescriber is a physician who is not
25 enrolled in the Medicaid program but has provided a medically
necessary service or prescription not otherwise reasonably
26 available from a Medicaid-enrolled physician, or in instances
where AHCA cannot practically notify a pharmacy at the point
27 of sale that a prescription will be approved for processing
under the specified instances.
28
Provides that the Office of Program Policy and Governmental
29 Accountability must report on AHCA's efforts to deter fraud
and abuse in the Medicaid program.
30
Clarifies that Medicaid fraud committed under s. 409.920,
31 F.S., and s. 409.9201, F.S., applies to individuals other than
Medicaid providers and recipients.
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1 Provides that proceeds accrued pursuant to the Contraband
Forfeiture Act through fraud and abuse efforts by the Medicaid
2 Fraud Control Unit in the Department of Legal Affairs are to
be deposited in the Department of Legal Affairs Trust Fund.
3
Appropriates $262,087 from the Medical Quality Assurance Trust
4 Fund to the Department of Health and authorizes four full-time
equivalent positions for the purpose of implementing the
5 provisions of this act.
6 Requires AHCA to give pharmacies at least one week prior
notice of the initial audit for each audit cycle.
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
110
CODING: Words stricken are deletions; words underlined are additions.