Senate Bill sb1276c1

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    Florida Senate - 2004                           CS for SB 1276

    By the Committee on Appropriations; and Senator Peaden





    309-2356-04

  1                      A bill to be entitled

  2         An act relating to health care; amending s.

  3         216.341, F.S.; clarifying that certain

  4         provisions relate to the disbursement of trust

  5         funds of the Department of Health, not county

  6         health department trust funds; providing that

  7         certain limitations on the number of authorized

  8         positions do not apply to positions in the

  9         Department of Health funded by specified

10         sources; amending s. 400.23, F.S.; reducing the

11         nursing home staffing requirement for certified

12         nursing assistants; amending s. 409.814, F.S.,

13         as amended, relating to eligibility for the

14         Florida KidCare program; providing that a child

15         who is otherwise disqualified based on a

16         preexisting medical condition shall be eligible

17         when enrollment is possible; amending s.

18         409.903, F.S.; amending income levels that

19         determine the eligibility of pregnant women and

20         children under 1 year of age for mandatory

21         medical assistance; amending s. 409.904, F.S.;

22         clarifying Medicaid recipients' responsibility

23         for the cost of nursing home care; providing

24         limitations on the care available to certain

25         persons under "medically needy" coverage;

26         amending income levels that determine the

27         eligibility of children under 1 year of age for

28         optional medical assistance; amending s.

29         409.905, F.S.; deleting an obsolete reference;

30         establishing a utilization-management program

31         for private duty nursing for children and

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    Florida Senate - 2004                           CS for SB 1276
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 1         hospital neonatal intensive-care stays;

 2         establishing a hospitalist program; eliminating

 3         transportation services for nondisabled

 4         beneficiaries; authorizing the Agency for

 5         Health Care Administration to contract for

 6         transportation services; amending s. 409.906,

 7         F.S.; allowing the consolidation of certain

 8         services; authorizing the implementation of a

 9         home-based and community-based services

10         utilization-management program; specifying the

11         income standard for hospice care; amending s.

12         409.9065, F.S.; allowing the Agency for Health

13         Care Administration to operate a limited

14         pharmaceutical expense assistance program under

15         specified conditions; providing limitations on

16         benefits under the program; providing for

17         copayments; amending s. 409.907, F.S.;

18         clarifying that Medicaid provider network

19         status is not an entitlement; amending s.

20         409.911, F.S.; establishing the Medicaid

21         Disproportionate Share Council; amending s.

22         409.912, F.S.; reducing payment for

23         pharmaceutical ingredient prices; expanding the

24         existing pharmaceutical supplemental rebate

25         threshold to a minimum of 27 percent;

26         authorizing a return and reuse prescription

27         drug program; allowing for utilization

28         management and prior authorization for certain

29         categories of drugs; limiting allowable monthly

30         dosing of drugs that enhance or enable sexual

31         performance; modifying Medicaid prescribed drug

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    Florida Senate - 2004                           CS for SB 1276
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 1         coverage to allow for preferred daily dosages

 2         of certain select pharmaceuticals; authorizing

 3         a prior-authorization program for the off-label

 4         use of Medicaid prescribed pharmaceuticals;

 5         adopting an algorithm-based treatment protocol

 6         for select mental health disorders; requiring

 7         the agency to implement a behavioral health

 8         drug management program financed through an

 9         agreement with pharmaceutical manufacturers;

10         providing contract requirements and program

11         requirements; providing for application of

12         certain drug limits and prior-authorization

13         requirements if the agency is unable to

14         negotiate a contract; allowing for limitation

15         of the Medicaid provider networks; amending s.

16         409.9122, F.S.; revising prerequisites to

17         mandatory assignment; specifying managed care

18         enrollment in certain areas of the state;

19         requiring certain Medicaid applicants to select

20         a managed care plan at the time of application;

21         eliminating the exclusion of special hospital

22         payments from rates for health maintenance

23         organizations; providing technical updates;

24         amending ss. 430.204 and 430.205, F.S.;

25         rescinding the expiration of certain funding

26         provisions relating to

27         community-care-for-the-elderly core services

28         and to the community care service system;

29         amending s. 624.91, F.S., the Florida Healthy

30         Kids Corporation Act; deleting certain

31         eligibility requirements for state-funded

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    Florida Senate - 2004                           CS for SB 1276
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 1         assistance in paying premiums for the Florida

 2         Healthy Kids program; requiring purchases to be

 3         made in a manner consistent with delivering

 4         accessible medical care; providing an effective

 5         date.

 6  

 7  Be It Enacted by the Legislature of the State of Florida:

 8  

 9         Section 1.  Section 216.341, Florida Statutes, is

10  amended to read:

11         216.341  Disbursement of Department of Health county

12  health department trust funds; appropriation of authorized

13  positions.--

14         (1)  County health department trust funds may be

15  expended by the Department of Health for the respective county

16  health departments in accordance with budgets and plans agreed

17  upon by the county authorities of each county and the

18  Department of Health.

19         (2)  The requirement limitations on appropriations

20  provided in s. 216.262(1) shall not apply to Department of

21  Health positions funded by:

22         (a)  County health department trust funds; or.

23         (b)  The United States Trust Fund.

24         Section 2.  Effective May 1, 2004, paragraph (a) of

25  subsection (3) of section 400.23, Florida Statutes, is amended

26  to read:

27         400.23  Rules; evaluation and deficiencies; licensure

28  status.--

29         (3)(a)  The agency shall adopt rules providing for the

30  minimum staffing standards requirements for nursing homes.

31  These standards requirements shall require include, in for

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    Florida Senate - 2004                           CS for SB 1276
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 1  each nursing home facility, a minimum certified nursing

 2  assistant staffing of 2.3 hours of direct care per resident

 3  per day beginning January 1, 2002, and increasing to 2.6 hours

 4  of direct care per resident per day beginning January 1, 2003,

 5  and increasing to 2.9 hours of direct care per resident per

 6  day beginning May 1, 2004. Beginning January 1, 2002, no

 7  facility shall staff below one certified nursing assistant per

 8  20 residents, and a minimum licensed nursing staffing of 1.0

 9  hour of direct resident care per resident per day but never

10  below one licensed nurse per 40 residents. Nursing assistants

11  employed never below one licensed nurse per 40 residents.

12  Nursing assistants employed under s. 400.211(2) may be

13  included in computing the staffing ratio for certified nursing

14  assistants only if they provide nursing assistance services to

15  residents on a full-time basis. Each nursing home must

16  document compliance with staffing standards as required under

17  this paragraph and post daily the names of staff on duty for

18  the benefit of facility residents and the public. The agency

19  shall recognize the use of licensed nurses for compliance with

20  minimum staffing requirements for certified nursing

21  assistants, provided that the facility otherwise meets the

22  minimum staffing requirements for licensed nurses and that the

23  licensed nurses so recognized are performing the duties of a

24  certified nursing assistant. Unless otherwise approved by the

25  agency, licensed nurses counted towards the minimum staffing

26  requirements for certified nursing assistants must exclusively

27  perform the duties of a certified nursing assistant for the

28  entire shift and shall not also be counted towards the minimum

29  staffing requirements for licensed nurses. If the agency

30  approved a facility's request to use a licensed nurse to

31  perform both licensed nursing and certified nursing assistant

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    Florida Senate - 2004                           CS for SB 1276
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 1  duties, the facility must allocate the amount of staff time

 2  specifically spent on each set of certified nursing assistant

 3  duties for the purpose of documenting compliance with minimum

 4  staffing requirements for certified and licensed nursing

 5  staff. In no event may the hours of a licensed nurse with dual

 6  job responsibilities be counted twice.

 7         Section 3.  Section 409.814, Florida Statutes, as

 8  amended by CS for SB 2000, 1st engrossed, is amended to read:

 9         409.814  Eligibility.--A child who has not reached 19

10  years of age whose family income is equal to or below 200

11  percent of the federal poverty level is eligible for the

12  Florida KidCare program as provided in this section. A child

13  who is otherwise eligible for KidCare and who has a

14  preexisting condition that prevents coverage under another

15  insurance plan as described in subsection (4) which would have

16  disqualified the child for KidCare if the child were able to

17  enroll in the plan shall be eligible for KidCare coverage when

18  enrollment is possible. For enrollment in the Children's

19  Medical Services network, a complete application includes the

20  medical or behavioral health screening. If, subsequently, an

21  individual is determined to be ineligible for coverage, he or

22  she must immediately be disenrolled from the respective

23  Florida KidCare program component.

24         (1)  A child who is eligible for Medicaid coverage

25  under s. 409.903 or s. 409.904 must be enrolled in Medicaid

26  and is not eligible to receive health benefits under any other

27  health benefits coverage authorized under the Florida KidCare

28  program.

29         (2)  A child who is not eligible for Medicaid, but who

30  is eligible for the Florida KidCare program, may obtain health

31  benefits coverage under any of the other components listed in

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    Florida Senate - 2004                           CS for SB 1276
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 1  s. 409.813 if such coverage is approved and available in the

 2  county in which the child resides. However, a child who is

 3  eligible for Medikids may participate in the Florida Healthy

 4  Kids program only if the child has a sibling participating in

 5  the Florida Healthy Kids program and the child's county of

 6  residence permits such enrollment.

 7         (3)  A child who is eligible for the Florida KidCare

 8  program who is a child with special health care needs, as

 9  determined through a medical or behavioral screening

10  instrument, is eligible for health benefits coverage from and

11  shall be referred to the Children's Medical Services network.

12         (4)  The following children are not eligible to receive

13  premium assistance for health benefits coverage under the

14  Florida KidCare program, except under Medicaid if the child

15  would have been eligible for Medicaid under s. 409.903 or s.

16  409.904 as of June 1, 1997:

17         (a)  A child who is eligible for coverage under a state

18  health benefit plan on the basis of a family member's

19  employment with a public agency in the state.

20         (b)  A child who is currently eligible for or covered

21  under a family member's group health benefit plan or under

22  other employer health insurance coverage, excluding coverage

23  provided under the Florida Healthy Kids Corporation as

24  established under s. 624.91, provided that the cost of the

25  child's participation is not greater than 5 percent of the

26  family's income. This provision shall be applied during

27  redetermination for children who were enrolled prior to July

28  1, 2004. These enrollees shall have 6 months of eligibility

29  following redetermination to allow for a transition to the

30  other health benefit plan.

31  

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    Florida Senate - 2004                           CS for SB 1276
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 1         (c)  A child who is seeking premium assistance for the

 2  Florida KidCare program through employer-sponsored group

 3  coverage, if the child has been covered by the same employer's

 4  group coverage during the 6 months prior to the family's

 5  submitting an application for determination of eligibility

 6  under the program.

 7         (d)  A child who is an alien, but who does not meet the

 8  definition of qualified alien, in the United States.

 9         (e)  A child who is an inmate of a public institution

10  or a patient in an institution for mental diseases.

11         (f)  A child who has had his or her coverage in an

12  employer-sponsored health benefit plan voluntarily canceled in

13  the last 6 months, except those children who were on the

14  waiting list prior to January 31, 2004.

15         (5)  A child whose family income is above 200 percent

16  of the federal poverty level or a child who is excluded under

17  the provisions of subsection (4) may participate in the

18  Florida KidCare program, excluding the Medicaid program, but

19  is subject to the following provisions:

20         (a)  The family is not eligible for premium assistance

21  payments and must pay the full cost of the premium, including

22  any administrative costs.

23         (b)  The agency is authorized to place limits on

24  enrollment in Medikids by these children in order to avoid

25  adverse selection. The number of children participating in

26  Medikids whose family income exceeds 200 percent of the

27  federal poverty level must not exceed 10 percent of total

28  enrollees in the Medikids program.

29         (c)  The board of directors of the Florida Healthy Kids

30  Corporation is authorized to place limits on enrollment of

31  these children in order to avoid adverse selection. In

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    Florida Senate - 2004                           CS for SB 1276
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 1  addition, the board is authorized to offer a reduced benefit

 2  package to these children in order to limit program costs for

 3  such families. The number of children participating in the

 4  Florida Healthy Kids program whose family income exceeds 200

 5  percent of the federal poverty level must not exceed 10

 6  percent of total enrollees in the Florida Healthy Kids

 7  program.

 8         (d)  Children described in this subsection are not

 9  counted in the annual enrollment ceiling for the Florida

10  KidCare program.

11         (6)  Once a child is enrolled in the Florida KidCare

12  program, the child is eligible for coverage under the program

13  for 6 months without a redetermination or reverification of

14  eligibility, if the family continues to pay the applicable

15  premium. Eligibility for program components funded through

16  Title XXI of the Social Security Act shall terminate when a

17  child attains the age of 19. Effective January 1, 1999, a

18  child who has not attained the age of 5 and who has been

19  determined eligible for the Medicaid program is eligible for

20  coverage for 12 months without a redetermination or

21  reverification of eligibility.

22         (7)  When determining or reviewing a child's

23  eligibility under the Florida KidCare program, the applicant

24  shall be provided with reasonable notice of changes in

25  eligibility which may affect enrollment in one or more of the

26  program components. When a transition from one program

27  component to another is authorized, there shall be cooperation

28  between the program components and the affected family which

29  promotes continuity of health care coverage. Any authorized

30  transfers must be managed within the program's overall

31  appropriated or authorized levels of funding. Each component

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    Florida Senate - 2004                           CS for SB 1276
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 1  of the program shall establish a reserve to ensure that

 2  transfers between components will be accomplished within

 3  current year appropriations. These reserves shall be reviewed

 4  by each convening of the Social Services Estimating Conference

 5  to determine the adequacy of such reserves to meet actual

 6  experience.

 7         (8)  In determining the eligibility of a child, an

 8  assets test is not required. Each applicant shall provide

 9  written documentation during the application process and the

10  redetermination process, including, but not limited to, the

11  following:

12         (a)  Proof of family income.

13         (b)  A statement from all family members that:

14         1.  Their employer does not sponsor a health benefit

15  plan for employees; or

16         2.  The potential enrollee is not covered by the

17  employer-sponsored health benefit plan because the potential

18  enrollee is not eligible for coverage, or, if the potential

19  enrollee is eligible but not covered, a statement of the cost

20  to enroll the potential enrollee in the employer-sponsored

21  health benefit plan.

22         (9)  Subject to paragraph (4)(b) and s. 624.91(3), the

23  Florida KidCare program shall withhold benefits from an

24  enrollee if the program obtains evidence that the enrollee is

25  no longer eligible, submitted incorrect or fraudulent

26  information in order to establish eligibility, or failed to

27  provide verification of eligibility. The applicant or enrollee

28  shall be notified that because of such evidence program

29  benefits will be withheld unless the applicant or enrollee

30  contacts a designated representative of the program by a

31  specified date, which must be within 10 days after the date of

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    Florida Senate - 2004                           CS for SB 1276
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 1  notice, to discuss and resolve the matter. The program shall

 2  make every effort to resolve the matter within a timeframe

 3  that will not cause benefits to be withheld from an eligible

 4  enrollee.

 5         (10)  The following individuals may be subject to

 6  prosecution in accordance with s. 414.39:

 7         (a)  An applicant obtaining or attempting to obtain

 8  benefits for a potential enrollee under the Florida KidCare

 9  program when the applicant knows or should have known the

10  potential enrollee does not qualify for the Florida KidCare

11  program.

12         (b)  An individual who assists an applicant in

13  obtaining or attempting to obtain benefits for a potential

14  enrollee under the Florida KidCare program when the individual

15  knows or should have known the potential enrollee does not

16  qualify for the Florida KidCare program.

17         Section 4.  Subsection (5) of section 409.903, Florida

18  Statutes, is amended to read:

19         409.903  Mandatory payments for eligible persons.--The

20  agency shall make payments for medical assistance and related

21  services on behalf of the following persons who the

22  department, or the Social Security Administration by contract

23  with the Department of Children and Family Services,

24  determines to be eligible, subject to the income, assets, and

25  categorical eligibility tests set forth in federal and state

26  law.  Payment on behalf of these Medicaid eligible persons is

27  subject to the availability of moneys and any limitations

28  established by the General Appropriations Act or chapter 216.

29         (5)  Effective October 1, 2004, a pregnant woman for

30  the duration of her pregnancy and for the postpartum period as

31  defined in federal law and rule, or a child under age 1, if

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    Florida Senate - 2004                           CS for SB 1276
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 1  either is living in a family that has an income which is at or

 2  below 150 percent of the most current federal poverty level,

 3  or, effective January 1, 1992, that has an income which is at

 4  or below 185 percent of the most current federal poverty

 5  level. Such a person is not subject to an assets test.

 6  Further, a pregnant woman who applies for eligibility for the

 7  Medicaid program through a qualified Medicaid provider must be

 8  offered the opportunity, subject to federal rules, to be made

 9  presumptively eligible for the Medicaid program.

10         Section 5.  Subsections (2), (3), and (8) of section

11  409.904, Florida Statutes, are amended to read:

12         409.904  Optional payments for eligible persons.--The

13  agency may make payments for medical assistance and related

14  services on behalf of the following persons who are determined

15  to be eligible subject to the income, assets, and categorical

16  eligibility tests set forth in federal and state law.  Payment

17  on behalf of these Medicaid eligible persons is subject to the

18  availability of moneys and any limitations established by the

19  General Appropriations Act or chapter 216.

20         (2)  A family, a pregnant woman, a child under age 21,

21  a person age 65 or over, or a blind or disabled person, who

22  would be eligible under any group listed in s. 409.903(1),

23  (2), or (3), except that the income or assets of such family

24  or person exceed established limitations. For a family or

25  person in one of these coverage groups, medical expenses are

26  deductible from income in accordance with federal requirements

27  in order to make a determination of eligibility. Children and

28  pregnant women A family or person eligible under the coverage

29  known as the "medically needy," are is eligible to receive the

30  same services as other Medicaid recipients, with the exception

31  of services in skilled nursing facilities and intermediate

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    Florida Senate - 2004                           CS for SB 1276
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 1  care facilities for the developmentally disabled. Effective

 2  January 1, 2005, parents or caretaker relatives of children

 3  eligible under the coverage known as "medically needy" and

 4  aged, blind, or disabled persons eligible under such coverage

 5  are limited to pharmacy services only.

 6         (3)  A person who is in need of the services of a

 7  licensed nursing facility, a licensed intermediate care

 8  facility for the developmentally disabled, or a state mental

 9  hospital, whose income does not exceed 300 percent of the SSI

10  income standard, and who meets the assets standards

11  established under federal and state law. In determining the

12  person's responsibility for the cost of care, the following

13  amounts must be deducted from the person's income:

14         (a)  The monthly personal allowance for residents as

15  set based on appropriations.

16         (b)  The reasonable costs of medically necessary

17  services and supplies that are not reimbursable by the

18  Medicaid program.

19         (c)  The cost of premiums, copayments, coinsurance, and

20  deductibles for supplemental health insurance.

21         (8)  Effective October 1, 2004, a child under 1 year of

22  age who lives in a family that has an income above 150 185

23  percent of the most recently published federal poverty level,

24  but which is at or below 200 percent of such poverty level. In

25  determining the eligibility of such child, an assets test is

26  not required. A child who is eligible for Medicaid under this

27  subsection must be offered the opportunity, subject to federal

28  rules, to be made presumptively eligible.

29         Section 6.  Section 409.905, Florida Statutes, is

30  amended to read:

31  

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    Florida Senate - 2004                           CS for SB 1276
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 1         409.905  Mandatory Medicaid services.--The agency may

 2  make payments for the following services, which are required

 3  of the state by Title XIX of the Social Security Act,

 4  furnished by Medicaid providers to recipients who are

 5  determined to be eligible on the dates on which the services

 6  were provided. Any service under this section shall be

 7  provided only when medically necessary and in accordance with

 8  state and federal law. Mandatory services rendered by

 9  providers in mobile units to Medicaid recipients may be

10  restricted by the agency. Nothing in this section shall be

11  construed to prevent or limit the agency from adjusting fees,

12  reimbursement rates, lengths of stay, number of visits, number

13  of services, or any other adjustments necessary to comply with

14  the availability of moneys and any limitations or directions

15  provided for in the General Appropriations Act or chapter 216.

16         (1)  ADVANCED REGISTERED NURSE PRACTITIONER

17  SERVICES.--The agency shall pay for services provided to a

18  recipient by a licensed advanced registered nurse practitioner

19  who has a valid collaboration agreement with a licensed

20  physician on file with the Department of Health or who

21  provides anesthesia services in accordance with established

22  protocol required by state law and approved by the medical

23  staff of the facility in which the anesthetic service is

24  performed. Reimbursement for such services must be provided in

25  an amount that equals not less than 80 percent of the

26  reimbursement to a physician who provides the same services,

27  unless otherwise provided for in the General Appropriations

28  Act.

29         (2)  EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND

30  TREATMENT SERVICES.--The agency shall pay for early and

31  periodic screening and diagnosis of a recipient under age 21

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 1  to ascertain physical and mental problems and conditions and

 2  provide treatment to correct or ameliorate these problems and

 3  conditions.  These services include all services determined by

 4  the agency to be medically necessary for the treatment,

 5  correction, or amelioration of these problems, including

 6  personal care, private duty nursing, durable medical

 7  equipment, physical therapy, occupational therapy, speech

 8  therapy, respiratory therapy, and immunizations.

 9         (3)  FAMILY PLANNING SERVICES.--The agency shall pay

10  for services necessary to enable a recipient voluntarily to

11  plan family size or to space children. These services include

12  information; education; counseling regarding the availability,

13  benefits, and risks of each method of pregnancy prevention;

14  drugs and supplies; and necessary medical care and followup.

15  Each recipient participating in the family planning portion of

16  the Medicaid program must be provided freedom to choose any

17  alternative method of family planning, as required by federal

18  law.

19         (4)  HOME HEALTH CARE SERVICES.--The agency shall pay

20  for nursing and home health aide services, supplies,

21  appliances, and durable medical equipment, necessary to assist

22  a recipient living at home. An entity that provides services

23  pursuant to this subsection shall be licensed under part IV of

24  chapter 400 or part II of chapter 499, if appropriate.  These

25  services, equipment, and supplies, or reimbursement therefor,

26  may be limited as provided in the General Appropriations Act

27  and do not include services, equipment, or supplies provided

28  to a person residing in a hospital or nursing facility.

29         (a)  In providing home health care services, the agency

30  may require prior authorization of care based on diagnosis.

31  

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 1         (b)  Effective November 1, 2004, the agency shall

 2  implement a comprehensive utilization program that requires

 3  prior authorization of all private duty nursing services for

 4  children, including children served by the Department of

 5  Health's Children's Medical Services program. The agency may

 6  competitively bid a contract to select a qualified

 7  organization to provide such services. The agency may seek

 8  federal waiver approval as necessary to implement this policy.

 9         (5)  HOSPITAL INPATIENT SERVICES.--The agency shall pay

10  for all covered services provided for the medical care and

11  treatment of a recipient who is admitted as an inpatient by a

12  licensed physician or dentist to a hospital licensed under

13  part I of chapter 395.  However, the agency shall limit the

14  payment for inpatient hospital services for a Medicaid

15  recipient 21 years of age or older to 45 days or the number of

16  days specified in the annual necessary to comply with the

17  General Appropriations Act.

18         (a)  The agency is authorized to implement

19  reimbursement and utilization management reforms in order to

20  comply with any limitations or directions in the General

21  Appropriations Act, which may include, but are not limited to:

22  prior authorization for inpatient psychiatric days; prior

23  authorization for nonemergency hospital inpatient admissions

24  for individuals 21 years of age and older; authorization of

25  emergency and urgent-care admissions within 24 hours after

26  admission; enhanced utilization and concurrent review programs

27  for highly utilized services; reduction or elimination of

28  covered days of service; adjusting reimbursement ceilings for

29  variable costs; adjusting reimbursement ceilings for fixed and

30  property costs; and implementing target rates of increase. The

31  agency may limit prior authorization for hospital inpatient

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 1  services to selected diagnosis-related groups, based on an

 2  analysis of the cost and potential for unnecessary

 3  hospitalizations represented by certain diagnoses. Admissions

 4  for normal delivery and newborns are exempt from requirements

 5  for prior authorization. In implementing the provisions of

 6  this section related to prior authorization, the agency shall

 7  ensure that the process for authorization is accessible 24

 8  hours per day, 7 days per week and authorization is

 9  automatically granted when not denied within 4 hours after the

10  request. Authorization procedures must include steps for

11  review of denials. Upon implementing the prior authorization

12  program for hospital inpatient services, the agency shall

13  discontinue its hospital retrospective review program.

14         (b)  A licensed hospital maintained primarily for the

15  care and treatment of patients having mental disorders or

16  mental diseases is not eligible to participate in the hospital

17  inpatient portion of the Medicaid program except as provided

18  in federal law.  However, subject to federal Medicaid waiver

19  approval, the agency may pay for the department shall apply

20  for a waiver, within 9 months after June 5, 1991, designed to

21  provide hospitalization services for mental health reasons to

22  children and adults in the most cost-effective and lowest cost

23  setting possible.  Such waiver shall include a request for the

24  opportunity to pay for care in hospitals known under federal

25  law as "institutions for mental disease" or "IMD's."  The

26  waiver proposal shall propose no additional aggregate cost to

27  the state or Federal Government, and shall be conducted in

28  Hillsborough County, Highlands County, Hardee County, Manatee

29  County, and Polk County.  The waiver proposal may incorporate

30  competitive bidding for hospital services, comprehensive

31  brokering, prepaid capitated arrangements, or other mechanisms

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 1  deemed by the agency department to show promise in reducing

 2  the cost of acute care and increasing the effectiveness of

 3  preventive care.  When developing The waiver proposal, the

 4  department shall take into account price, quality,

 5  accessibility, linkages of the hospital to community services

 6  and family support programs, plans of the hospital to ensure

 7  the earliest discharge possible, and the comprehensiveness of

 8  the mental health and other health care services offered by

 9  participating providers.

10         (c)  The agency for Health Care Administration shall

11  adjust a hospital's current inpatient per diem rate to reflect

12  the cost of serving the Medicaid population at that

13  institution if:

14         1.  The hospital experiences an increase in Medicaid

15  caseload by more than 25 percent in any year, primarily

16  resulting from the closure of a hospital in the same service

17  area occurring after July 1, 1995;

18         2.  The hospital's Medicaid per diem rate is at least

19  25 percent below the Medicaid per patient cost for that year;

20  or

21         3.  The hospital is located in a county that has five

22  or fewer hospitals, began offering obstetrical services on or

23  after September 1999, and has submitted a request in writing

24  to the agency for a rate adjustment after July 1, 2000, but

25  before September 30, 2000, in which case such hospital's

26  Medicaid inpatient per diem rate shall be adjusted to cost,

27  effective July 1, 2002.

28  

29  No later than October 1 of each year, the agency must provide

30  estimated costs for any adjustment in a hospital inpatient per

31  diem pursuant to this paragraph to the Executive Office of the

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 1  Governor, the House of Representatives General Appropriations

 2  Committee, and the Senate Appropriations Committee. Before the

 3  agency implements a change in a hospital's inpatient per diem

 4  rate pursuant to this paragraph, the Legislature must have

 5  specifically appropriated sufficient funds in the General

 6  Appropriations Act to support the increase in cost as

 7  estimated by the agency.

 8         (d)  Effective September 1, 2004, the agency shall

 9  implement a hospitalist program in certain high-volume

10  participating hospitals, in select counties or statewide.  The

11  program shall require hospitalists to authorize and manage

12  Medicaid recipients' hospital admissions and lengths of stay.

13  Individuals who are dually eligible for Medicare and Medicaid

14  are exempted from this requirement.  Medicaid participating

15  physicians and other practitioners with hospital admitting

16  privileges shall coordinate and review admissions of Medicaid

17  beneficiaries with the hospitalist.  The agency may

18  competitively bid a contract for selection of a qualified

19  organization to provide hospitalist services.  The agency may

20  seek federal waiver approval as necessary to implement this

21  policy.

22         (e)  Effective November 1, 2004, the agency shall

23  implement a comprehensive utilization management program for

24  hospital neonatal intensive care stays in certain high-volume

25  Medicaid participating hospitals, in select counties or

26  statewide, and shall replace existing hospital inpatient

27  utilization management programs.  The program shall be

28  designed to manage the lengths of stay for children being

29  treated in neonatal intensive care units and must seek the

30  earliest medically appropriate discharge to the child's home

31  or other less costly treatment setting.  The agency may

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 1  competitively bid a contract for selection of a qualified

 2  organization to provide neonatal intensive care utilization

 3  management services.  The agency may seek federal waiver

 4  approval as necessary to implement this policy.

 5         (6)  HOSPITAL OUTPATIENT SERVICES.--The agency shall

 6  pay for preventive, diagnostic, therapeutic, or palliative

 7  care and other services provided to a recipient in the

 8  outpatient portion of a hospital licensed under part I of

 9  chapter 395, and provided under the direction of a licensed

10  physician or licensed dentist, except that payment for such

11  care and services is limited to $1,500 per state fiscal year

12  per recipient, unless an exception has been made by the

13  agency, and with the exception of a Medicaid recipient under

14  age 21, in which case the only limitation is medical

15  necessity.

16         (7)  INDEPENDENT LABORATORY SERVICES.--The agency shall

17  pay for medically necessary diagnostic laboratory procedures

18  ordered by a licensed physician or other licensed practitioner

19  of the healing arts which are provided for a recipient in a

20  laboratory that meets the requirements for Medicare

21  participation and is licensed under chapter 483, if required.

22         (8)  NURSING FACILITY SERVICES.--The agency shall pay

23  for 24-hour-a-day nursing and rehabilitative services for a

24  recipient in a nursing facility licensed under part II of

25  chapter 400 or in a rural hospital, as defined in s. 395.602,

26  or in a Medicare certified skilled nursing facility operated

27  by a hospital, as defined by s. 395.002(11), that is licensed

28  under part I of chapter 395, and in accordance with provisions

29  set forth in s. 409.908(2)(a), which services are ordered by

30  and provided under the direction of a licensed physician.

31  However, if a nursing facility has been destroyed or otherwise

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 1  made uninhabitable by natural disaster or other emergency and

 2  another nursing facility is not available, the agency must pay

 3  for similar services temporarily in a hospital licensed under

 4  part I of chapter 395 provided federal funding is approved and

 5  available.

 6         (9)  PHYSICIAN SERVICES.--The agency shall pay for

 7  covered services and procedures rendered to a recipient by, or

 8  under the personal supervision of, a person licensed under

 9  state law to practice medicine or osteopathic medicine.  These

10  services may be furnished in the physician's office, the

11  Medicaid recipient's home, a hospital, a nursing facility, or

12  elsewhere, but shall be medically necessary for the treatment

13  of an injury, illness, or disease within the scope of the

14  practice of medicine or osteopathic medicine as defined by

15  state law.  The agency shall not pay for services that are

16  clinically unproven, experimental, or for purely cosmetic

17  purposes.

18         (10)  PORTABLE X-RAY SERVICES.--The agency shall pay

19  for professional and technical portable radiological services

20  ordered by a licensed physician or other licensed practitioner

21  of the healing arts which are provided by a licensed

22  professional in a setting other than a hospital, clinic, or

23  office of a physician or practitioner of the healing arts, on

24  behalf of a recipient.

25         (11)  RURAL HEALTH CLINIC SERVICES.--The agency shall

26  pay for outpatient primary health care services for a

27  recipient provided by a clinic certified by and participating

28  in the Medicare program which is located in a federally

29  designated, rural, medically underserved area and has on its

30  staff one or more licensed primary care nurse practitioners or

31  

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 1  physician assistants, and a licensed staff supervising

 2  physician or a consulting supervising physician.

 3         (12)  TRANSPORTATION SERVICES.--The agency shall ensure

 4  that appropriate transportation services are available for a

 5  Medicaid recipient in need of transport to a qualified

 6  Medicaid provider for medically necessary and

 7  Medicaid-compensable services, provided a recipient's client's

 8  ability to choose a specific transportation provider is shall

 9  be limited to those options resulting from policies

10  established by the agency to meet the fiscal limitations of

11  the General Appropriations Act. Effective January 1, 2005,

12  except for persons who meet Medicaid disability standards

13  adopted by rule, nonemergency transportation services may not

14  be offered to nondisabled recipients if public transportation

15  is generally available in the beneficiary's community. The

16  agency may pay for transportation and other related travel

17  expenses as necessary only if these services are not otherwise

18  available. The agency may competitively bid and contract with

19  a statewide vendor on a capitated basis for the provision of

20  nonemergency transportation services.  The agency may seek

21  federal waiver approval as necessary to implement this

22  subsection.

23         Section 7.  Subsections (13), (14), and (15) of section

24  409.906, Florida Statutes, are amended to read:

25         409.906  Optional Medicaid services.--Subject to

26  specific appropriations, the agency may make payments for

27  services which are optional to the state under Title XIX of

28  the Social Security Act and are furnished by Medicaid

29  providers to recipients who are determined to be eligible on

30  the dates on which the services were provided.  Any optional

31  service that is provided shall be provided only when medically

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 1  necessary and in accordance with state and federal law.

 2  Optional services rendered by providers in mobile units to

 3  Medicaid recipients may be restricted or prohibited by the

 4  agency. Nothing in this section shall be construed to prevent

 5  or limit the agency from adjusting fees, reimbursement rates,

 6  lengths of stay, number of visits, or number of services, or

 7  making any other adjustments necessary to comply with the

 8  availability of moneys and any limitations or directions

 9  provided for in the General Appropriations Act or chapter 216.

10  If necessary to safeguard the state's systems of providing

11  services to elderly and disabled persons and subject to the

12  notice and review provisions of s. 216.177, the Governor may

13  direct the Agency for Health Care Administration to amend the

14  Medicaid state plan to delete the optional Medicaid service

15  known as "Intermediate Care Facilities for the Developmentally

16  Disabled."  Optional services may include:

17         (13)  HOME AND COMMUNITY-BASED SERVICES.--The agency

18  may pay for home-based or community-based services that are

19  rendered to a recipient in accordance with a federally

20  approved waiver program.

21         (a)  The agency may limit or eliminate coverage for

22  certain Project AIDS Care Waiver services, preauthorize

23  high-cost or highly utilized services, or make any other

24  adjustments necessary to comply with any limitations or

25  directions provided for in the General Appropriations Act.

26         (b)  The agency may consolidate types of services

27  offered in the Aged and Disabled Waiver, the Channeling

28  Waiver, Project AIDS Care Waiver, and the Traumatic Brain and

29  Spinal Cord Injury Waiver programs in order to group similar

30  services under a single service, or upon evidence of the need

31  for including a particular service type in a particular

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 1  waiver.  The agency may seek federal waiver approval as

 2  necessary to implement this policy.

 3         (c)  The agency may implement a utilization management

 4  program designed to preauthorize home-and-community-based

 5  service plans, including, but not limited to, proposed

 6  quantity and duration of services, and to monitor ongoing

 7  service use by participants in the program.  The agency may

 8  competitively procure a qualified organization to provide

 9  utilization management of home-and-community-based services.

10  The agency may seek federal waiver approval as necessary to

11  implement this policy.

12         (14)  HOSPICE CARE SERVICES.--The agency may pay for

13  all reasonable and necessary services for the palliation or

14  management of a recipient's terminal illness, if the services

15  are provided by a hospice that is licensed under part VI of

16  chapter 400 and meets Medicare certification requirements.

17  Effective October 1, 2004, subject to federal approval, the

18  community hospice income standard would be equal to the level

19  set in s. 409.904(1).

20         (15)  INTERMEDIATE CARE FACILITY FOR THE

21  DEVELOPMENTALLY DISABLED SERVICES.--The agency may pay for

22  health-related care and services provided on a 24-hour-a-day

23  basis by a facility licensed and certified as a Medicaid

24  Intermediate Care Facility for the Developmentally Disabled,

25  for a recipient who needs such care because of a developmental

26  disability.

27         Section 8.  Present subsection (8) of section 409.9065,

28  Florida Statutes, is redesignated as subsection (9), and a new

29  subsection (8) is added to that section, to read:

30         409.9065  Pharmaceutical expense assistance.--

31  

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 1         (8)  In the absence of state appropriations for the

 2  expansion of the Lifesaver Rx Program to provide benefits to

 3  higher income groups and additional discounts as described in

 4  subsections (2) and (3), the Agency for Health Care

 5  Administration may, subject to federal approval and continuing

 6  state appropriations, operate a pharmaceutical expense

 7  assistance program that limits eligibility and benefits to

 8  Medicaid beneficiaries who do not normally receive Medicaid

 9  benefits, are Florida residents age 65 and older, have an

10  income less than or equal to 120 percent of the federal

11  poverty level, are eligible for Medicare, and request to be

12  enrolled in the program. Benefits under the limited

13  pharmaceutical expense assistance program shall include

14  Medicaid payment for up to $160 per month for prescribed

15  drugs, subject to benefit utilization controls applied to

16  other Medicaid prescribed drug benefits and the following

17  copayments: $2 per generic product, $5 for a product that is

18  on the Medicaid Preferred Drug List, and $15 for a product

19  that is not on the Preferred Drug List.

20         Section 9.  Subsection (12) is added to section

21  409.907, Florida Statutes, to read:

22         409.907  Medicaid provider agreements.--The agency may

23  make payments for medical assistance and related services

24  rendered to Medicaid recipients only to an individual or

25  entity who has a provider agreement in effect with the agency,

26  who is performing services or supplying goods in accordance

27  with federal, state, and local law, and who agrees that no

28  person shall, on the grounds of handicap, race, color, or

29  national origin, or for any other reason, be subjected to

30  discrimination under any program or activity for which the

31  provider receives payment from the agency.

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 1         (12)  Licensed, certified, or otherwise qualified

 2  providers are not entitled to enrollment in a Medicaid

 3  provider network.

 4         Section 10.  Subsection (9) is added to section

 5  409.911, Florida Statutes, to read:

 6         409.911  Disproportionate share program.--Subject to

 7  specific allocations established within the General

 8  Appropriations Act and any limitations established pursuant to

 9  chapter 216, the agency shall distribute, pursuant to this

10  section, moneys to hospitals providing a disproportionate

11  share of Medicaid or charity care services by making quarterly

12  Medicaid payments as required. Notwithstanding the provisions

13  of s. 409.915, counties are exempt from contributing toward

14  the cost of this special reimbursement for hospitals serving a

15  disproportionate share of low-income patients.

16         (9)  The Agency for Health Care Administration shall

17  convene a Medicaid Disproportionate Share Council.

18         (a)  The purpose of the council is to study and make

19  recommendations regarding:

20         1.  The formula for the regular disproportionate share

21  program and alternative financing options;

22         2.  Enhanced Medicaid funding through the Special

23  Medicaid Payment program; and

24         3.  The federal status of the upper-payment-limit

25  funding option and how this option may be used to promote

26  health care initiatives determined by the council to be state

27  health care priorities.

28         (b)  The council shall include representatives of the

29  Executive Office of the Governor and of the agency,

30  representatives from teaching, public, private nonprofit,

31  

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 1  private for-profit, and family practice teaching hospitals,

 2  and representatives from other groups as needed.

 3         (c)  The council shall submit its findings and

 4  recommendations to the Governor and the Legislature no later

 5  than February 1 of each year.

 6         Section 11.  Subsection (40) of section 409.912,

 7  Florida Statutes, is amended, and subsection (45) is added to

 8  that section, to read:

 9         409.912  Cost-effective purchasing of health care.--The

10  agency shall purchase goods and services for Medicaid

11  recipients in the most cost-effective manner consistent with

12  the delivery of quality medical care.  The agency shall

13  maximize the use of prepaid per capita and prepaid aggregate

14  fixed-sum basis services when appropriate and other

15  alternative service delivery and reimbursement methodologies,

16  including competitive bidding pursuant to s. 287.057, designed

17  to facilitate the cost-effective purchase of a case-managed

18  continuum of care. The agency shall also require providers to

19  minimize the exposure of recipients to the need for acute

20  inpatient, custodial, and other institutional care and the

21  inappropriate or unnecessary use of high-cost services. The

22  agency may establish prior authorization requirements for

23  certain populations of Medicaid beneficiaries, certain drug

24  classes, or particular drugs to prevent fraud, abuse, overuse,

25  and possible dangerous drug interactions. The Pharmaceutical

26  and Therapeutics Committee shall make recommendations to the

27  agency on drugs for which prior authorization is required. The

28  agency shall inform the Pharmaceutical and Therapeutics

29  Committee of its decisions regarding drugs subject to prior

30  authorization.

31  

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 1         (40)(a)  The agency shall implement a Medicaid

 2  prescribed-drug spending-control program that includes the

 3  following components:

 4         1.  Medicaid prescribed-drug coverage for brand-name

 5  drugs for adult Medicaid recipients is limited to the

 6  dispensing of four brand-name drugs per month per recipient.

 7  Children are exempt from this restriction. Antiretroviral

 8  agents are excluded from this limitation. No requirements for

 9  prior authorization or other restrictions on medications used

10  to treat mental illnesses such as schizophrenia, severe

11  depression, or bipolar disorder may be imposed on Medicaid

12  recipients. Medications that will be available without

13  restriction for persons with mental illnesses include atypical

14  antipsychotic medications, conventional antipsychotic

15  medications, selective serotonin reuptake inhibitors, and

16  other medications used for the treatment of serious mental

17  illnesses. The agency shall also limit the amount of a

18  prescribed drug dispensed to no more than a 34-day supply. The

19  agency shall continue to provide unlimited generic drugs,

20  contraceptive drugs and items, and diabetic supplies. Although

21  a drug may be included on the preferred drug formulary, it

22  would not be exempt from the four-brand limit. The agency may

23  authorize exceptions to the brand-name-drug restriction based

24  upon the treatment needs of the patients, only when such

25  exceptions are based on prior consultation provided by the

26  agency or an agency contractor, but the agency must establish

27  procedures to ensure that:

28         a.  There will be a response to a request for prior

29  consultation by telephone or other telecommunication device

30  within 24 hours after receipt of a request for prior

31  consultation;

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 1         b.  A 72-hour supply of the drug prescribed will be

 2  provided in an emergency or when the agency does not provide a

 3  response within 24 hours as required by sub-subparagraph a.;

 4  and

 5         c.  Except for the exception for nursing home residents

 6  and other institutionalized adults and except for drugs on the

 7  restricted formulary for which prior authorization may be

 8  sought by an institutional or community pharmacy, prior

 9  authorization for an exception to the brand-name-drug

10  restriction is sought by the prescriber and not by the

11  pharmacy. When prior authorization is granted for a patient in

12  an institutional setting beyond the brand-name-drug

13  restriction, such approval is authorized for 12 months and

14  monthly prior authorization is not required for that patient.

15         2.  Reimbursement to pharmacies for Medicaid prescribed

16  drugs shall be set at the average wholesale price less 14.25

17  13.25 percent or wholesale acquisition cost plus 5 percent,

18  whichever is less.

19         3.  The agency shall develop and implement a process

20  for managing the drug therapies of Medicaid recipients who are

21  using significant numbers of prescribed drugs each month. The

22  management process may include, but is not limited to,

23  comprehensive, physician-directed medical-record reviews,

24  claims analyses, and case evaluations to determine the medical

25  necessity and appropriateness of a patient's treatment plan

26  and drug therapies. The agency may contract with a private

27  organization to provide drug-program-management services. The

28  Medicaid drug benefit management program shall include

29  initiatives to manage drug therapies for HIV/AIDS patients,

30  patients using 20 or more unique prescriptions in a 180-day

31  period, and the top 1,000 patients in annual spending.

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 1         4.  The agency may limit the size of its pharmacy

 2  network based on need, competitive bidding, price

 3  negotiations, credentialing, or similar criteria. The agency

 4  shall give special consideration to rural areas in determining

 5  the size and location of pharmacies included in the Medicaid

 6  pharmacy network. A pharmacy credentialing process may include

 7  criteria such as a pharmacy's full-service status, location,

 8  size, patient educational programs, patient consultation,

 9  disease-management services, and other characteristics. The

10  agency may impose a moratorium on Medicaid pharmacy enrollment

11  when it is determined that it has a sufficient number of

12  Medicaid-participating providers.

13         5.  The agency shall develop and implement a program

14  that requires Medicaid practitioners who prescribe drugs to

15  use a counterfeit-proof prescription pad for Medicaid

16  prescriptions. The agency shall require the use of

17  standardized counterfeit-proof prescription pads by

18  Medicaid-participating prescribers or prescribers who write

19  prescriptions for Medicaid recipients. The agency may

20  implement the program in targeted geographic areas or

21  statewide.

22         6.  The agency may enter into arrangements that require

23  manufacturers of generic drugs prescribed to Medicaid

24  recipients to provide rebates of at least 15.1 percent of the

25  average manufacturer price for the manufacturer's generic

26  products. These arrangements shall require that if a

27  generic-drug manufacturer pays federal rebates for

28  Medicaid-reimbursed drugs at a level below 15.1 percent, the

29  manufacturer must provide a supplemental rebate to the state

30  in an amount necessary to achieve a 15.1-percent rebate level.

31  

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 1         7.  The agency may establish a preferred drug formulary

 2  in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the

 3  establishment of such formulary, it is authorized to negotiate

 4  supplemental rebates from manufacturers that are in addition

 5  to those required by Title XIX of the Social Security Act and

 6  at no less than 12 10 percent of the average manufacturer

 7  price as defined in 42 U.S.C. s. 1936 on the last day of a

 8  quarter unless the federal or supplemental rebate, or both,

 9  equals or exceeds 27 25 percent. There is no upper limit on

10  the supplemental rebates the agency may negotiate. The agency

11  may determine that specific products, brand-name or generic,

12  are competitive at lower rebate percentages. Agreement to pay

13  the minimum supplemental rebate percentage will guarantee a

14  manufacturer that the Medicaid Pharmaceutical and Therapeutics

15  Committee will consider a product for inclusion on the

16  preferred drug formulary. However, a pharmaceutical

17  manufacturer is not guaranteed placement on the formulary by

18  simply paying the minimum supplemental rebate. Agency

19  decisions will be made on the clinical efficacy of a drug and

20  recommendations of the Medicaid Pharmaceutical and

21  Therapeutics Committee, as well as the price of competing

22  products minus federal and state rebates. The agency is

23  authorized to contract with an outside agency or contractor to

24  conduct negotiations for supplemental rebates. For the

25  purposes of this section, the term "supplemental rebates" may

26  include, at the agency's discretion, cash rebates and other

27  program benefits that offset a Medicaid expenditure. Such

28  other program benefits may include, but are not limited to,

29  disease management programs, drug product donation programs,

30  drug utilization control programs, prescriber and beneficiary

31  counseling and education, fraud and abuse initiatives, and

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 1  other services or administrative investments with guaranteed

 2  savings to the Medicaid program in the same year the rebate

 3  reduction is included in the General Appropriations Act. The

 4  agency is authorized to seek any federal waivers necessary to

 5  implement this initiative.

 6         8.  The agency shall implement a return and reuse

 7  program for drugs dispensed by pharmacies to institutional

 8  recipients, which includes payment of a $5 restocking fee for

 9  the implementation and operation of the program.  The return

10  and reuse program shall be implemented electronically and in a

11  manner that promotes efficiency.  The program must permit a

12  pharmacy to exclude drugs from the program if it is not

13  practical or cost-effective for the drug to be included and

14  must provide for the return to inventory of drugs that cannot

15  be credited or returned in a cost-effective manner. The agency

16  shall establish an advisory committee for the purposes of

17  studying the feasibility of using a restricted drug formulary

18  for nursing home residents and other institutionalized adults.

19  The committee shall be comprised of seven members appointed by

20  the Secretary of Health Care Administration. The committee

21  members shall include two physicians licensed under chapter

22  458 or chapter 459; three pharmacists licensed under chapter

23  465 and appointed from a list of recommendations provided by

24  the Florida Long-Term Care Pharmacy Alliance; and two

25  pharmacists licensed under chapter 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         10.  The agency shall implement a

 7  utilization-management and prior-authorization program for

 8  COX-II selective inhibitor products.  The program shall use

 9  evidence-based therapy management guidelines to ensure medical

10  necessity and appropriate prescribing of COX-II products

11  versus conventional nonsteroidal anti-inflammatory agents

12  (NSAIDS) in the absence of contraindications regardless of

13  preferred drug list status.  The agency may seek federal

14  waiver approval as necessary to implement this policy.

15         11.  The agency shall limit to one dose per month any

16  drug prescribed for the purpose of enhancing or enabling

17  sexual performance. The agency may seek federal waiver

18  approval as necessary to implement this policy.

19         12.  The agency may specify the preferred daily dosing

20  form or strength for the purpose of promoting best practices

21  with regard to the prescribing of certain drugs and ensuring

22  cost-effective prescribing practices.

23         13.  The agency may require prior authorization for the

24  off-label use of Medicaid-covered prescribed drugs.  The

25  agency may, but is not required to, preauthorize the use of a

26  product for an indication not in the approved labeling. Prior

27  authorization may require the prescribing professional to

28  provide information about the rationale and supporting medical

29  evidence for the off-label use of a drug.

30         14.  The agency may adopt an algorithm-driven treatment

31  protocol for major psychiatric disorders, including, at a

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 1  minimum, schizophrenia, major depressive disorders, and

 2  bipolar disorder.  The purpose of the algorithms is to improve

 3  the quality of care, achieve the best possible patient

 4  outcomes, and ensure cost-effective management of the use of

 5  medications.  The medication program shall use evidence-based,

 6  consensus medication treatment algorithms, clinical and

 7  technical support necessary to aid clinician implementation of

 8  the algorithm, patient and family education programs to ensure

 9  that the patient is an active partner in care, and the uniform

10  documentation of care provided and patient outcomes achieved.

11  The agency shall coordinate the development and adoption of

12  medication algorithms with the Department of Children and

13  Family Services. The agency may seek any federal waivers

14  necessary to implement this program.

15         15.  The agency shall implement a Medicaid behavioral

16  health drug management program financed through a value-added

17  agreement with pharmaceutical manufacturers that provide

18  financing for program startup and operational costs and

19  guarantee Medicaid budget savings. The agency shall contract

20  for the implementation of this program with vendors that have

21  an established relationship with pharmaceutical manufacturers

22  providing grant funds and experience in operating behavioral

23  health drug management programs. The agency, in conjunction

24  with the Department of Children and Family Services, shall

25  implement the Medicaid behavioral health drug management

26  system that is designed to improve the quality of care and

27  behavioral health prescribing practices based on best-practice

28  guidelines, improve patient adherence to medication plans,

29  reduce clinical risk, and lower prescribed drug costs and the

30  rate of inappropriate spending on Medicaid behavioral drugs.

31  The program must:

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 1         a.  Provide for the development and adoption of

 2  best-practice guidelines for behavioral-health-related drugs,

 3  such as antipsychotics, antidepressants, and medications for

 4  treating bipolar disorders and other behavioral conditions,

 5  and translate them into practice; review behavioral health

 6  prescribers and compare their prescribing patterns to a number

 7  of indicators that are based on national standards; and

 8  determine deviations from best-practice guidelines;

 9         b.  Implement processes for providing feedback to and

10  educating prescribers using best-practice educational

11  materials and peer-to-peer consultation;

12         c.  Assess Medicaid beneficiaries who are outliers in

13  their use of behavioral health drugs with regard to the

14  numbers and types of drugs taken, drug dosages, combination

15  drug therapies, and other indicators of improper use of

16  behavioral health drugs;

17         d.  Alert prescribers to patients who fail to refill

18  prescriptions in a timely fashion, are prescribed multiple

19  same-class behavioral health drugs, and may have other

20  potential medication problems;

21         e.  Track spending trends for behavioral health drugs

22  and deviation from best-practice guidelines;

23         f.  Use educational and technological approaches to

24  promote best practices; educate consumers; and train

25  prescribers in the use of practice guidelines;

26         g.  Disseminate electronic and published materials;

27         h.  Hold statewide and regional conferences; and

28         i.  Implement a disease-management program with a model

29  quality-based medication component for severely mentally ill

30  individuals and emotionally disturbed children who are high

31  users of care.

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 1  

 2  If the agency is unable to negotiate a contract with one or

 3  more manufacturers to finance and guarantee savings associated

 4  with a behavioral health drug management program by July 30,

 5  2004, the four-brand drug limit and preferred drug list

 6  prior-authorization requirements shall apply to

 7  mental-health-related drugs, notwithstanding any provision in

 8  subparagraph 1.

 9         (b)  The agency shall implement this subsection to the

10  extent that funds are appropriated to administer the Medicaid

11  prescribed-drug spending-control program. The agency may

12  contract all or any part or all of this program, including the

13  overall management of the drug program, to private

14  organizations.

15         (c)  The agency shall submit quarterly reports to the

16  Governor, the President of the Senate, and the Speaker of the

17  House of Representatives which must include, but need not be

18  limited to, the progress made in implementing this subsection

19  and its effect on Medicaid prescribed-drug expenditures.

20         (45)  The agency may implement Medicaid fee-for-service

21  provider network controls, including, but not limited to,

22  provider credentialing.  If a credentialing process is used,

23  the agency may limit its network based upon the following

24  considerations:

25         (a)  Beneficiary access to care;

26         (b)  Provider availability;

27         (c)  Provider quality standards;

28         (d)  Cultural competency;

29         (e)  Demographic characteristics of beneficiaries;

30         (f)  Practice standards;

31         (g)  Service wait times;

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 1         (h)  Usage criteria;

 2         (i)  Provider turnover;

 3         (j)  Provider profiling;

 4         (k)  Provider license history;

 5         (l)  History of fraud and abuse findings;

 6         (m)  Peer review;

 7         (n)  Policy and billing infractions;

 8         (o)  Clinical and medical record audit findings; and

 9         (p)  Such other findings as the agency considers

10  necessary to ensure the integrity of the program.

11         Section 12.  Subsection (2) of section 409.9122,

12  Florida Statutes, is amended, and subsection (14) is added to

13  that section, to read:

14         409.9122  Mandatory Medicaid managed care enrollment;

15  programs and procedures.--

16         (2)(a)  The agency shall enroll in a managed care plan

17  or MediPass all Medicaid recipients, except those Medicaid

18  recipients who are: in an institution; enrolled in the

19  Medicaid medically needy program; or eligible for both

20  Medicaid and Medicare.  However, to the extent permitted by

21  federal law, the agency may enroll in a managed care plan or

22  MediPass a Medicaid recipient who is exempt from mandatory

23  managed care enrollment, provided that:

24         1.  The recipient's decision to enroll in a managed

25  care plan or MediPass is voluntary;

26         2.  If the recipient chooses to enroll in a managed

27  care plan, the agency has determined that the managed care

28  plan provides specific programs and services which address the

29  special health needs of the recipient; and

30         3.  The agency receives any necessary waivers from the

31  federal Health Care Financing Administration.

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 1  

 2  The agency shall develop rules to establish policies by which

 3  exceptions to the mandatory managed care enrollment

 4  requirement may be made on a case-by-case basis. The rules

 5  shall include the specific criteria to be applied when making

 6  a determination as to whether to exempt a recipient from

 7  mandatory enrollment in a managed care plan or MediPass.

 8  School districts participating in the certified school match

 9  program pursuant to ss. 409.908(21) and 1011.70 shall be

10  reimbursed by Medicaid, subject to the limitations of s.

11  1011.70(1), for a Medicaid-eligible child participating in the

12  services as authorized in s. 1011.70, as provided for in s.

13  409.9071, regardless of whether the child is enrolled in

14  MediPass or a managed care plan. Managed care plans shall make

15  a good faith effort to execute agreements with school

16  districts regarding the coordinated provision of services

17  authorized under s. 1011.70. County health departments

18  delivering school-based services pursuant to ss. 381.0056 and

19  381.0057 shall be reimbursed by Medicaid for the federal share

20  for a Medicaid-eligible child who receives Medicaid-covered

21  services in a school setting, regardless of whether the child

22  is enrolled in MediPass or a managed care plan.  Managed care

23  plans shall make a good faith effort to execute agreements

24  with county health departments regarding the coordinated

25  provision of services to a Medicaid-eligible child. To ensure

26  continuity of care for Medicaid patients, the agency, the

27  Department of Health, and the Department of Education shall

28  develop procedures for ensuring that a student's managed care

29  plan or MediPass provider receives information relating to

30  services provided in accordance with ss. 381.0056, 381.0057,

31  409.9071, and 1011.70.

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 1         (b)  A Medicaid recipient shall not be enrolled in or

 2  assigned to a managed care plan or MediPass unless the managed

 3  care plan or MediPass has complied with the quality-of-care

 4  standards specified in paragraphs (3)(a) and (b),

 5  respectively.

 6         (c)  Medicaid recipients shall have a choice of managed

 7  care plans or MediPass.  The Agency for Health Care

 8  Administration, the Department of Health, the Department of

 9  Children and Family Services, and the Department of Elderly

10  Affairs shall cooperate to ensure that each Medicaid recipient

11  receives clear and easily understandable information that

12  meets the following requirements:

13         1.  Explains the concept of managed care, including

14  MediPass.

15         2.  Provides information on the comparative performance

16  of managed care plans and MediPass in the areas of quality,

17  credentialing, preventive health programs, network size and

18  availability, and patient satisfaction.

19         3.  Explains where additional information on each

20  managed care plan and MediPass in the recipient's area can be

21  obtained.

22         4.  Explains that recipients have the right to choose

23  their own managed care plans or MediPass.  However, if a

24  recipient does not choose a managed care plan or MediPass, the

25  agency will assign the recipient to a managed care plan or

26  MediPass according to the criteria specified in this section.

27         5.  Explains the recipient's right to complain, file a

28  grievance, or change managed care plans or MediPass providers

29  if the recipient is not satisfied with the managed care plan

30  or MediPass.

31  

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 1         (d)  The agency shall develop a mechanism for providing

 2  information to Medicaid recipients for the purpose of making a

 3  managed care plan or MediPass selection.  Examples of such

 4  mechanisms may include, but not be limited to, interactive

 5  information systems, mailings, and mass marketing materials.

 6  Managed care plans and MediPass providers are prohibited from

 7  providing inducements to Medicaid recipients to select their

 8  plans or from prejudicing Medicaid recipients against other

 9  managed care plans or MediPass providers.

10         (e)  Medicaid recipients who are already enrolled in a

11  managed care plan or MediPass shall be offered the opportunity

12  to change managed care plans or MediPass providers on a

13  staggered basis, as defined by the agency. All Medicaid

14  recipients shall have 90 days in which to make a choice of

15  managed care plans or MediPass providers. Those Medicaid

16  recipients who do not make a choice shall be assigned to a

17  managed care plan or MediPass in accordance with paragraph

18  (f). To facilitate continuity of care, for a Medicaid

19  recipient who is also a recipient of Supplemental Security

20  Income (SSI), prior to assigning the SSI recipient to a

21  managed care plan or MediPass, the agency shall determine

22  whether the SSI recipient has an ongoing relationship with a

23  MediPass provider or managed care plan, and if so, the agency

24  shall assign the SSI recipient to that MediPass provider or

25  managed care plan. Those SSI recipients who do not have such a

26  provider relationship shall be assigned to a managed care plan

27  or MediPass provider in accordance with paragraph (f).

28         (f)  When a Medicaid recipient does not choose a

29  managed care plan or MediPass provider, the agency shall

30  assign the Medicaid recipient to a managed care plan or

31  MediPass provider. Medicaid recipients who are subject to

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 1  mandatory assignment but who fail to make a choice shall be

 2  assigned to managed care plans until an enrollment of 39 40

 3  percent in MediPass and 61 60 percent in managed care plans is

 4  achieved. Once this enrollment is achieved, the assignments of

 5  recipients who fail to make a choice shall be divided in order

 6  to maintain an enrollment in MediPass and managed care plans

 7  which is in a 39 40 percent and 61 60 percent proportion,

 8  respectively. Thereafter, assignment of Medicaid recipients

 9  who fail to make a choice shall be based proportionally on the

10  preferences of recipients who have made a choice in the

11  previous period. Such proportions shall be revised at least

12  quarterly to reflect an update of the preferences of Medicaid

13  recipients. The agency shall disproportionately assign

14  Medicaid-eligible recipients who are required to but have

15  failed to make a choice of managed care plan or MediPass,

16  including children, and who are to be assigned to the MediPass

17  program to children's networks as described in s.

18  409.912(3)(g), Children's Medical Services network as defined

19  in s. 391.021, exclusive provider organizations, provider

20  service networks, minority physician networks, and pediatric

21  emergency department diversion programs authorized by this

22  chapter or the General Appropriations Act, in such manner as

23  the agency deems appropriate, until the agency has determined

24  that the networks and programs have sufficient numbers to be

25  economically operated. For purposes of this paragraph, when

26  referring to assignment, the term "managed care plans"

27  includes health maintenance organizations, exclusive provider

28  organizations, provider service networks, minority physician

29  networks, Children's Medical Services network, and pediatric

30  emergency department diversion programs authorized by this

31  chapter or the General Appropriations Act. When making

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 1  assignments, the agency shall take into account the following

 2  criteria and considerations:

 3         1.  A managed care plan has sufficient network capacity

 4  to meet the need of members.

 5         2.  The managed care plan or MediPass has previously

 6  enrolled the recipient as a member, or one of the managed care

 7  plan's primary care providers or MediPass providers has

 8  previously provided health care to the recipient.

 9         3.  The agency has knowledge that the member has

10  previously expressed a preference for a particular managed

11  care plan or MediPass provider as indicated by Medicaid

12  fee-for-service claims data, but has failed to make a choice.

13         4.  The managed care plan's or MediPass primary care

14  providers are geographically accessible to the recipient's

15  residence.

16  

17  (g)  When more than one managed care plan or MediPass provider

18  meets the criteria specified in this paragraph (f), the agency

19  shall make recipient assignments consecutively by family unit.

20         (g)(h)  The agency may not engage in practices that are

21  designed to favor one managed care plan over another or that

22  are designed to influence Medicaid recipients to enroll in

23  MediPass rather than in a managed care plan or to enroll in a

24  managed care plan rather than in MediPass. This subsection

25  does not prohibit the agency from reporting on the performance

26  of MediPass or any managed care plan, as measured by

27  performance criteria developed by the agency.

28         (h)  Effective January 1, 2005, the agency and the

29  Department of Children and Family Services shall ensure that

30  applicants for Medicaid for categories of assistance that

31  require eligible applicants to enroll in managed care shall

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 1  choose or be assigned to a managed care plan prior to an

 2  eligibility start date so that enrollment in a managed care

 3  plan begins on the same day as the eligibility start date.

 4         (i)  After a recipient has made a selection or has been

 5  enrolled in a managed care plan or MediPass, the recipient

 6  shall have 90 days in which to voluntarily disenroll and

 7  select another managed care plan or MediPass provider.  After

 8  90 days, no further changes may be made except for cause.

 9  Cause shall include, but not be limited to, poor quality of

10  care, lack of access to necessary specialty services, an

11  unreasonable delay or denial of service, or fraudulent

12  enrollment.  The agency shall develop criteria for good cause

13  disenrollment for chronically ill and disabled populations who

14  are assigned to managed care plans if more appropriate care is

15  available through the MediPass program.  The agency must make

16  a determination as to whether cause exists.  However, the

17  agency may require a recipient to use the managed care plan's

18  or MediPass grievance process prior to the agency's

19  determination of cause, except in cases in which immediate

20  risk of permanent damage to the recipient's health is alleged.

21  The grievance process, when utilized, must be completed in

22  time to permit the recipient to disenroll no later than the

23  first day of the second month after the month the

24  disenrollment request was made. If the managed care plan or

25  MediPass, as a result of the grievance process, approves an

26  enrollee's request to disenroll, the agency is not required to

27  make a determination in the case.  The agency must make a

28  determination and take final action on a recipient's request

29  so that disenrollment occurs no later than the first day of

30  the second month after the month the request was made.  If the

31  agency fails to act within the specified timeframe, the

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 1  recipient's request to disenroll is deemed to be approved as

 2  of the date agency action was required.  Recipients who

 3  disagree with the agency's finding that cause does not exist

 4  for disenrollment shall be advised of their right to pursue a

 5  Medicaid fair hearing to dispute the agency's finding.

 6         (j)  The agency shall apply for a federal waiver from

 7  the Health Care Financing Administration to lock eligible

 8  Medicaid recipients into a managed care plan or MediPass for

 9  12 months after an open enrollment period. After 12 months'

10  enrollment, a recipient may select another managed care plan

11  or MediPass provider.  However, nothing shall prevent a

12  Medicaid recipient from changing primary care providers within

13  the managed care plan or MediPass program during the 12-month

14  period.

15         (k)  When a Medicaid recipient does not choose a

16  managed care plan or MediPass provider, the agency shall

17  assign the Medicaid recipient to a managed care plan, except

18  in those counties in which there are fewer than two managed

19  care plans accepting Medicaid enrollees, in which case

20  assignment shall be to a managed care plan or a MediPass

21  provider. Medicaid recipients in counties with fewer than two

22  managed care plans accepting Medicaid enrollees who are

23  subject to mandatory assignment but who fail to make a choice

24  shall be assigned to managed care plans until an enrollment of

25  39 40 percent in MediPass and 61 60 percent in managed care

26  plans is achieved. Once that enrollment is achieved, the

27  assignments shall be divided in order to maintain an

28  enrollment in MediPass and managed care plans which is in a 39

29  40 percent and 61 60 percent proportion, respectively. In

30  geographic areas where the agency is contracting for the

31  provision of comprehensive behavioral health services through

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 1  a capitated prepaid arrangement, recipients who fail to make a

 2  choice shall be assigned equally to MediPass or a managed care

 3  plan. For purposes of this paragraph, when referring to

 4  assignment, the term "managed care plans" includes exclusive

 5  provider organizations, provider service networks, Children's

 6  Medical Services network, minority physician networks, and

 7  pediatric emergency department diversion programs authorized

 8  by this chapter or the General Appropriations Act. When making

 9  assignments, the agency shall take into account the following

10  criteria:

11         1.  A managed care plan has sufficient network capacity

12  to meet the need of members.

13         2.  The managed care plan or MediPass has previously

14  enrolled the recipient as a member, or one of the managed care

15  plan's primary care providers or MediPass providers has

16  previously provided health care to the recipient.

17         3.  The agency has knowledge that the member has

18  previously expressed a preference for a particular managed

19  care plan or MediPass provider as indicated by Medicaid

20  fee-for-service claims data, but has failed to make a choice.

21         4.  The managed care plan's or MediPass primary care

22  providers are geographically accessible to the recipient's

23  residence.

24         5.  The agency has authority to make mandatory

25  assignments based on quality of service and performance of

26  managed care plans.

27         (l)  Notwithstanding the provisions of chapter 287, the

28  agency may, at its discretion, renew cost-effective contracts

29  for choice counseling services once or more for such periods

30  as the agency may decide. However, all such renewals may not

31  

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 1  combine to exceed a total period longer than the term of the

 2  original contract.

 3         (14)  The agency shall include in its calculation of

 4  the hospital inpatient component of a Medicaid health

 5  maintenance organization's capitation rate any special

 6  payments, including, but not limited to, upper payment limit

 7  or disproportionate share hospital payments, made to

 8  qualifying hospitals through the fee-for-service program. The

 9  agency may seek federal waiver approval as needed to implement

10  this adjustment.

11         Section 13.  Paragraph (b) of subsection (1) of section

12  430.204, Florida Statutes, is amended to read:

13         430.204  Community-care-for-the-elderly core services;

14  departmental powers and duties.--

15         (1)

16         (b)  For fiscal year 2003-2004 only, The department

17  shall fund, through each area agency on aging in each county

18  as defined in s. 125.011(1), more than one community care

19  service system the primary purpose of which is the prevention

20  of unnecessary institutionalization of functionally impaired

21  elderly persons through the provision of community-based core

22  services. This paragraph expires July 1, 2004.

23         Section 14.  Paragraph (b) of subsection (1) of section

24  430.205, Florida Statutes, is amended to read:

25         430.205  Community care service system.--

26         (1)

27         (b)  For fiscal year 2003-2004 only, The department

28  shall fund, through the area agency on aging in each county as

29  defined in s. 125.011(1), more than one community care service

30  system that provides case management and other in-home and

31  community services as needed to help elderly persons maintain

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 1  independence and prevent or delay more costly institutional

 2  care. This paragraph expires July 1, 2004.

 3         Section 15.  Subsection (3) and paragraph (b) of

 4  subsection (5) of section 624.91, Florida Statutes, as amended

 5  by CS for SB 2000, 1st Engrossed, are amended to read:

 6         624.91  The Florida Healthy Kids Corporation Act.--

 7         (3)  ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.--Only the

 8  following individuals are eligible for state-funded assistance

 9  in paying Florida Healthy Kids premiums:

10         (a)  Residents of this state who are eligible for the

11  Florida KidCare program pursuant to s. 409.814.

12         (b)  Notwithstanding s. 409.814, legal aliens who are

13  enrolled in the Florida Healthy Kids program as of January 31,

14  2004, who do not qualify for Title XXI federal funds because

15  they are not qualified aliens as defined in s. 409.811.

16         (c)  Notwithstanding s. 409.814, individuals who have

17  attained the age of 19 as of March 31, 2004, who were

18  receiving Florida Healthy Kids benefits prior to the enactment

19  of the Florida KidCare program. This paragraph shall be

20  repealed March 31, 2005.

21         (d)  Notwithstanding s. 409.814, state employee

22  dependents who were enrolled in the Florida Healthy Kids

23  program as of January 31, 2004. Such individuals shall remain

24  eligible until January 1, 2005.

25         (4)(5)  CORPORATION AUTHORIZATION, DUTIES, POWERS.--

26         (b)  The Florida Healthy Kids Corporation shall:

27         1.  Arrange for the collection of any family, local

28  contributions, or employer payment or premium, in an amount to

29  be determined by the board of directors, to provide for

30  payment of premiums for comprehensive insurance coverage and

31  for the actual or estimated administrative expenses.

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 1         2.  Arrange for the collection of any voluntary

 2  contributions to provide for payment of premiums for children

 3  who are not eligible for medical assistance under Title XXI of

 4  the Social Security Act. Each fiscal year, the corporation

 5  shall establish a local match policy for the enrollment of

 6  non-Title-XXI-eligible children in the Healthy Kids program.

 7  By May 1 of each year, the corporation shall provide written

 8  notification of the amount to be remitted to the corporation

 9  for the following fiscal year under that policy. Local match

10  sources may include, but are not limited to, funds provided by

11  municipalities, counties, school boards, hospitals, health

12  care providers, charitable organizations, special taxing

13  districts, and private organizations. The minimum local match

14  cash contributions required each fiscal year and local match

15  credits shall be determined by the General Appropriations Act.

16  The corporation shall calculate a county's local match rate

17  based upon that county's percentage of the state's total

18  non-Title-XXI expenditures as reported in the corporation's

19  most recently audited financial statement. In awarding the

20  local match credits, the corporation may consider factors

21  including, but not limited to, population density, per capita

22  income, and existing child-health-related expenditures and

23  services.

24         3.  Subject to the provisions of s. 409.8134, accept

25  voluntary supplemental local match contributions that comply

26  with the requirements of Title XXI of the Social Security Act

27  for the purpose of providing additional coverage in

28  contributing counties under Title XXI.

29         4.  Establish the administrative and accounting

30  procedures for the operation of the corporation.

31  

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 1         5.  Establish, with consultation from appropriate

 2  professional organizations, standards for preventive health

 3  services and providers and comprehensive insurance benefits

 4  appropriate to children, provided that such standards for

 5  rural areas shall not limit primary care providers to

 6  board-certified pediatricians.

 7         6.  Determine eligibility for children seeking to

 8  participate in the Title XXI-funded components of the Florida

 9  KidCare program consistent with the requirements specified in

10  s. 409.814, as well as the non-Title-XXI-eligible children as

11  provided in subsection (3).

12         7.  Establish procedures under which providers of local

13  match to, applicants to and participants in the program may

14  have grievances reviewed by an impartial body and reported to

15  the board of directors of the corporation.

16         8.  Establish participation criteria and, if

17  appropriate, contract with an authorized insurer, health

18  maintenance organization, or third-party administrator to

19  provide administrative services to the corporation.

20         9.  Establish enrollment criteria which shall include

21  penalties or waiting periods of not fewer than 60 days for

22  reinstatement of coverage upon voluntary cancellation for

23  nonpayment of family premiums.

24         10.  Contract with authorized insurers or any provider

25  of health care services, meeting standards established by the

26  corporation, for the provision of comprehensive insurance

27  coverage to participants. Such standards shall include

28  criteria under which the corporation may contract with more

29  than one provider of health care services in program sites.

30  Health plans shall be selected through a competitive bid

31  process. The Florida Healthy Kids Corporation shall purchase

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 1  goods and services in the most cost-effective manner

 2  consistent with the delivery of quality and accessible medical

 3  care. The maximum administrative cost for a Florida Healthy

 4  Kids Corporation contract shall be 15 percent. The minimum

 5  medical loss ratio for a Florida Healthy Kids Corporation

 6  contract shall be 85 percent. The health plan selection

 7  criteria and scoring system, and the scoring results, shall be

 8  available upon request for inspection after the bids have been

 9  awarded.

10         11.  Establish disenrollment criteria in the event

11  local matching funds are insufficient to cover enrollments.

12         12.  Develop and implement a plan to publicize the

13  Florida Healthy Kids Corporation, the eligibility requirements

14  of the program, and the procedures for enrollment in the

15  program and to maintain public awareness of the corporation

16  and the program.

17         13.  Secure staff necessary to properly administer the

18  corporation. Staff costs shall be funded from state and local

19  matching funds and such other private or public funds as

20  become available. The board of directors shall determine the

21  number of staff members necessary to administer the

22  corporation.

23         14.  Provide a report annually to the Governor, Chief

24  Financial Officer, Commissioner of Education, Senate

25  President, Speaker of the House of Representatives, and

26  Minority Leaders of the Senate and the House of

27  Representatives.

28         15.  Establish benefit packages that which conform to

29  the provisions of the Florida KidCare program, as created in

30  ss. 409.810-409.820.

31  

                                  50

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    Florida Senate - 2004                           CS for SB 1276
    309-2356-04




 1         Section 16.  This act shall take effect July 1, 2004,

 2  except that this section and section 2 of this act shall take

 3  effect May 1, 2004, or upon becoming a law, whichever occurs

 4  later, in which case section 2 of this act shall operate

 5  retroactive to May 1, 2004.

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                                  51

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    Florida Senate - 2004                           CS for SB 1276
    309-2356-04




 1          STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
                       COMMITTEE SUBSTITUTE FOR
 2                         Senate Bill 1276

 3                                 

 4  Provides that certain limitations on the number of authorized
    positions in the Department of Health do not apply to
 5  positions funded by the United States Trust Fund.

 6  Eliminates the scheduled increase in minimum staffing
    standards for nursing homes from 2.6 hours to 2.9 hours of
 7  direct care per resident per day, effective May 1, 2004.

 8  Clarifies that a child who has a preexisting condition that
    prevents coverage under another family member's group health
 9  benefit plan or under other employer health insurance
    coverage, who is otherwise eligible for the KidCare program,
10  is eligible for KidCare coverage when enrollment is possible.

11  Allows children with family incomes below 200 percent of the
    federal poverty level who are not eligible for premium
12  assistance payments under the KidCare program to participate
    in the program by paying the full cost of the premium.
13  
    Reduces Medicaid coverage of pregnant women from 185 percent
14  to 150 percent of the federal poverty level, effective October
    1, 2004.
15  
    Limits the Medically Needy program for adults to a pharmacy
16  services benefit only, effective January 1, 2005.

17  
    Clarifies a recipient's responsibility for the cost of nursing
18  home care and specifies allowable costs that are to be
    deducted from income in determining Medicaid eligibility.
19  
    Allows implementation of a comprehensive utilization program
20  that requires prior authorization of all private duty nursing
    services for children, effective November 1, 2004.
21  
    Requires implementation of a hospitalist program in certain
22  high-volume participating hospitals, effective September 1,
    2004.
23  
    Requires implementation of a comprehensive utilization
24  management program for hospital neonatal intensive care stays
    in certain high-volume Medicaid participating hospitals,
25  effective November 1, 2004.

26  Requires that nonemergency transportation services may not be
    offered to nondisabled recipients if public transportation is
27  generally available in the beneficiary's community, effective
    January 1, 2005.
28  
    Authorizes implementation of utilization management programs
29  and consolidation of Medicaid home and community-based
    services programs.
30  
    Requires the community hospice income standard to be equal to
31  88 percent of the federal poverty level, effective October 1,
    2004.
                                  52

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    Florida Senate - 2004                           CS for SB 1276
    309-2356-04




 1  Makes the LifeSaver Rx prescription drug program for seniors
    contingent on an appropriation and, in the absence of a state
 2  appropriation, authorizes operation of the Silver Saver
    program.
 3  
    Clarifies that licensed, certified, or otherwise qualified
 4  providers are not entitled to enrollment in the Medicaid
    provider network.
 5  
    Establishes the Medicaid Disproportionate Share Council for
 6  the purpose of studying and making recommendations on the
    formula for the regular disproportionate share program and
 7  alternative financing options, special Medicaid payments, and
    upper payment limit options.
 8  
    Provides for reimbursement to pharmacies at the average
 9  wholesale price less 14.25 percent or wholesale acquisition
    cost plus 5 percent, whichever is less.
10  
    Revises the threshold for supplemental rebates from
11  manufacturers to a minimum of 27 percent.

12  Requires implementation of a return and reuse program for
    drugs dispensed by pharmacies to institutional recipients and
13  includes payment of a $5 restocking fee for operation of the
    program.
14  
    Requires implementation of a utilization management and prior
15  authorization program for the COX-II selective inhibitor
    products.
16  
    Requires a limitation to one dose per month for any drug
17  prescribed for the purpose of enhancing or enabling sexual
    performance.
18  
    Allows for the specifications of the preferred daily dosing
19  form or strength of certain drugs.

20  Allows prior authorization for the off-label use of
    Medicaid-covered prescribed drugs.
21  
    Authorizes adoption of algorithm-driven treatment protocols
22  for major psychiatric disorders.

23  Requires implementation of a Medicaid behavioral health drug
    management program financed through value-added agreements
24  with pharmaceutical manufacturers that provide guaranteed
    savings.
25  
    Authorizes implementation of Medicaid fee-for-service provider
26  network controls, including provider credentialing.

27  Revises the Medicaid program enrollment goal for managed care
    to 61 percent managed care and 39 percent MediPass.
28  
    Requires applicants required to enroll in managed care to
29  choose or be assigned to a managed care plan so that
    enrollment begins on the same day as the eligibility start
30  date, effective January 1, 2005.

31  Requires the Agency for Health Care Administration to include
    in its calculation of the hospital inpatient component of a
                                  53

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    Florida Senate - 2004                           CS for SB 1276
    309-2356-04




 1  Medicaid health maintenance organization's capitation rate any
    special payments, including the upper payment limit or
 2  disproportionate share hospital payments made to qualifying
    hospitals through the fee-for-service program.
 3  
    Requires the Department of Elder Affairs to fund, through each
 4  area agency on aging in each county defined in s. 125.011(1),
    F.S., more than one community care service system.
 5  
    Requires the Department of Elder Affairs to fund, through each
 6  area agency on aging in each county as defined in s.
    125.011(1), F.S., more than one community care system that
 7  provides case management and other in-home and community
    services.
 8  
    Eliminates state-funded assistance for paying premiums for
 9  non-Title XXI eligibles in the Florida Healthy Kids program
    and requires purchases made by the Florida Healthy Kids
10  Corporation to be made in a manner consistent with delivering
    accessible medical care.
11  

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                                  54

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