Senate Bill sb1276e1
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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
1
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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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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
3
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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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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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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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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.
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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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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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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 supported by copies of any
13 federal income tax return for the prior year, any wages and
14 earnings statements (W-2 forms), and any other appropriate
15 document.
16 (b) A statement from all family members that:
17 1. Their employer does not sponsor a health benefit
18 plan for employees; or
19 2. The potential enrollee is not covered by the
20 employer-sponsored health benefit plan because the potential
21 enrollee is not eligible for coverage, or, if the potential
22 enrollee is eligible but not covered, a statement of the cost
23 to enroll the potential enrollee in the employer-sponsored
24 health benefit plan.
25 (9) Subject to paragraph (4)(b) and s. 624.91(3), the
26 Florida KidCare program shall withhold benefits from an
27 enrollee if the program obtains evidence that the enrollee is
28 no longer eligible, submitted incorrect or fraudulent
29 information in order to establish eligibility, or failed to
30 provide verification of eligibility. The applicant or enrollee
31 shall be notified that because of such evidence program
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1 benefits will be withheld unless the applicant or enrollee
2 contacts a designated representative of the program by a
3 specified date, which must be within 10 days after the date of
4 notice, to discuss and resolve the matter. The program shall
5 make every effort to resolve the matter within a timeframe
6 that will not cause benefits to be withheld from an eligible
7 enrollee.
8 (10) The following individuals may be subject to
9 prosecution in accordance with s. 414.39:
10 (a) An applicant obtaining or attempting to obtain
11 benefits for a potential enrollee under the Florida KidCare
12 program when the applicant knows or should have known the
13 potential enrollee does not qualify for the Florida KidCare
14 program.
15 (b) An individual who assists an applicant in
16 obtaining or attempting to obtain benefits for a potential
17 enrollee under the Florida KidCare program when the individual
18 knows or should have known the potential enrollee does not
19 qualify for the Florida KidCare program.
20 Section 4. Subsection (5) of section 409.903, Florida
21 Statutes, is amended to read:
22 409.903 Mandatory payments for eligible persons.--The
23 agency shall make payments for medical assistance and related
24 services on behalf of the following persons who the
25 department, or the Social Security Administration by contract
26 with the Department of Children and Family Services,
27 determines to be eligible, subject to the income, assets, and
28 categorical eligibility tests set forth in federal and state
29 law. Payment on behalf of these Medicaid eligible persons is
30 subject to the availability of moneys and any limitations
31 established by the General Appropriations Act or chapter 216.
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1 (5) Effective October 1, 2004, a pregnant woman for
2 the duration of her pregnancy and for the postpartum period as
3 defined in federal law and rule, or a child under age 1, if
4 either is living in a family that has an income which is at or
5 below 150 percent of the most current federal poverty level,
6 or, effective January 1, 1992, that has an income which is at
7 or below 185 percent of the most current federal poverty
8 level. Such a person is not subject to an assets test.
9 Further, a pregnant woman who applies for eligibility for the
10 Medicaid program through a qualified Medicaid provider must be
11 offered the opportunity, subject to federal rules, to be made
12 presumptively eligible for the Medicaid program.
13 Section 5. Subsections (2), (3), and (8) of section
14 409.904, Florida Statutes, are amended to read:
15 409.904 Optional payments for eligible persons.--The
16 agency may make payments for medical assistance and related
17 services on behalf of the following persons who are determined
18 to be eligible subject to the income, assets, and categorical
19 eligibility tests set forth in federal and state law. Payment
20 on behalf of these Medicaid eligible persons is subject to the
21 availability of moneys and any limitations established by the
22 General Appropriations Act or chapter 216.
23 (2) A family, a pregnant woman, a child under age 21,
24 a person age 65 or over, or a blind or disabled person, who
25 would be eligible under any group listed in s. 409.903(1),
26 (2), or (3), except that the income or assets of such family
27 or person exceed established limitations. For a family or
28 person in one of these coverage groups, medical expenses are
29 deductible from income in accordance with federal requirements
30 in order to make a determination of eligibility. Children and
31 pregnant women A family or person eligible under the coverage
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1 known as the "medically needy," are is eligible to receive the
2 same services as other Medicaid recipients, with the exception
3 of services in skilled nursing facilities and intermediate
4 care facilities for the developmentally disabled. Effective
5 January 1, 2005, parents or caretaker relatives of children
6 eligible under the coverage known as "medically needy" and
7 aged, blind, or disabled persons eligible under such coverage
8 are limited to pharmacy services only.
9 (3) A person who is in need of the services of a
10 licensed nursing facility, a licensed intermediate care
11 facility for the developmentally disabled, or a state mental
12 hospital, whose income does not exceed 300 percent of the SSI
13 income standard, and who meets the assets standards
14 established under federal and state law. In determining the
15 person's responsibility for the cost of care, the following
16 amounts must be deducted from the person's income:
17 (a) The monthly personal allowance for residents as
18 set based on appropriations.
19 (b) The reasonable costs of medically necessary
20 services and supplies that are not reimbursable by the
21 Medicaid program.
22 (c) The cost of premiums, copayments, coinsurance, and
23 deductibles for supplemental health insurance.
24 (8) Effective October 1, 2004, a child under 1 year of
25 age who lives in a family that has an income above 150 185
26 percent of the most recently published federal poverty level,
27 but which is at or below 200 percent of such poverty level. In
28 determining the eligibility of such child, an assets test is
29 not required. A child who is eligible for Medicaid under this
30 subsection must be offered the opportunity, subject to federal
31 rules, to be made presumptively eligible.
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1 Section 6. Section 409.905, Florida Statutes, is
2 amended to read:
3 409.905 Mandatory Medicaid services.--The agency may
4 make payments for the following services, which are required
5 of the state by Title XIX of the Social Security Act,
6 furnished by Medicaid providers to recipients who are
7 determined to be eligible on the dates on which the services
8 were provided. Any service under this section shall be
9 provided only when medically necessary and in accordance with
10 state and federal law. Mandatory services rendered by
11 providers in mobile units to Medicaid recipients may be
12 restricted by the agency. Nothing in this section shall be
13 construed to prevent or limit the agency from adjusting fees,
14 reimbursement rates, lengths of stay, number of visits, number
15 of services, or any other adjustments necessary to comply with
16 the availability of moneys and any limitations or directions
17 provided for in the General Appropriations Act or chapter 216.
18 (1) ADVANCED REGISTERED NURSE PRACTITIONER
19 SERVICES.--The agency shall pay for services provided to a
20 recipient by a licensed advanced registered nurse practitioner
21 who has a valid collaboration agreement with a licensed
22 physician on file with the Department of Health or who
23 provides anesthesia services in accordance with established
24 protocol required by state law and approved by the medical
25 staff of the facility in which the anesthetic service is
26 performed. Reimbursement for such services must be provided in
27 an amount that equals not less than 80 percent of the
28 reimbursement to a physician who provides the same services,
29 unless otherwise provided for in the General Appropriations
30 Act.
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1 (2) EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND
2 TREATMENT SERVICES.--The agency shall pay for early and
3 periodic screening and diagnosis of a recipient under age 21
4 to ascertain physical and mental problems and conditions and
5 provide treatment to correct or ameliorate these problems and
6 conditions. These services include all services determined by
7 the agency to be medically necessary for the treatment,
8 correction, or amelioration of these problems, including
9 personal care, private duty nursing, durable medical
10 equipment, physical therapy, occupational therapy, speech
11 therapy, respiratory therapy, and immunizations.
12 (3) FAMILY PLANNING SERVICES.--The agency shall pay
13 for services necessary to enable a recipient voluntarily to
14 plan family size or to space children. These services include
15 information; education; counseling regarding the availability,
16 benefits, and risks of each method of pregnancy prevention;
17 drugs and supplies; and necessary medical care and followup.
18 Each recipient participating in the family planning portion of
19 the Medicaid program must be provided freedom to choose any
20 alternative method of family planning, as required by federal
21 law.
22 (4) HOME HEALTH CARE SERVICES.--The agency shall pay
23 for nursing and home health aide services, supplies,
24 appliances, and durable medical equipment, necessary to assist
25 a recipient living at home. An entity that provides services
26 pursuant to this subsection shall be licensed under part IV of
27 chapter 400 or part II of chapter 499, if appropriate. These
28 services, equipment, and supplies, or reimbursement therefor,
29 may be limited as provided in the General Appropriations Act
30 and do not include services, equipment, or supplies provided
31 to a person residing in a hospital or nursing facility.
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1 (a) In providing home health care services, the agency
2 may require prior authorization of care based on diagnosis.
3 (b) Effective November 1, 2004, the agency shall
4 implement a comprehensive utilization program that requires
5 prior authorization of all private duty nursing services for
6 children, including children served by the Department of
7 Health's Children's Medical Services program. The agency may
8 competitively bid a contract to select a qualified
9 organization to provide such services. The agency may seek
10 federal waiver approval as necessary to implement this policy.
11 (5) HOSPITAL INPATIENT SERVICES.--The agency shall pay
12 for all covered services provided for the medical care and
13 treatment of a recipient who is admitted as an inpatient by a
14 licensed physician or dentist to a hospital licensed under
15 part I of chapter 395. However, the agency shall limit the
16 payment for inpatient hospital services for a Medicaid
17 recipient 21 years of age or older to 45 days or the number of
18 days specified in the annual necessary to comply with the
19 General Appropriations Act.
20 (a) The agency is authorized to implement
21 reimbursement and utilization management reforms in order to
22 comply with any limitations or directions in the General
23 Appropriations Act, which may include, but are not limited to:
24 prior authorization for inpatient psychiatric days; prior
25 authorization for nonemergency hospital inpatient admissions
26 for individuals 21 years of age and older; authorization of
27 emergency and urgent-care admissions within 24 hours after
28 admission; enhanced utilization and concurrent review programs
29 for highly utilized services; reduction or elimination of
30 covered days of service; adjusting reimbursement ceilings for
31 variable costs; adjusting reimbursement ceilings for fixed and
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1 property costs; and implementing target rates of increase. The
2 agency may limit prior authorization for hospital inpatient
3 services to selected diagnosis-related groups, based on an
4 analysis of the cost and potential for unnecessary
5 hospitalizations represented by certain diagnoses. Admissions
6 for normal delivery and newborns are exempt from requirements
7 for prior authorization. In implementing the provisions of
8 this section related to prior authorization, the agency shall
9 ensure that the process for authorization is accessible 24
10 hours per day, 7 days per week and authorization is
11 automatically granted when not denied within 4 hours after the
12 request. Authorization procedures must include steps for
13 review of denials. Upon implementing the prior authorization
14 program for hospital inpatient services, the agency shall
15 discontinue its hospital retrospective review program.
16 (b) A licensed hospital maintained primarily for the
17 care and treatment of patients having mental disorders or
18 mental diseases is not eligible to participate in the hospital
19 inpatient portion of the Medicaid program except as provided
20 in federal law. However, subject to federal Medicaid waiver
21 approval, the agency may pay for the department shall apply
22 for a waiver, within 9 months after June 5, 1991, designed to
23 provide hospitalization services for mental health reasons to
24 children and adults in the most cost-effective and lowest cost
25 setting possible. Such waiver shall include a request for the
26 opportunity to pay for care in hospitals known under federal
27 law as "institutions for mental disease" or "IMD's." The
28 waiver proposal shall propose no additional aggregate cost to
29 the state or Federal Government, and shall be conducted in
30 Hillsborough County, Highlands County, Hardee County, Manatee
31 County, and Polk County. The waiver proposal may incorporate
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1 competitive bidding for hospital services, comprehensive
2 brokering, prepaid capitated arrangements, or other mechanisms
3 deemed by the agency department to show promise in reducing
4 the cost of acute care and increasing the effectiveness of
5 preventive care. When developing The waiver proposal, the
6 department shall take into account price, quality,
7 accessibility, linkages of the hospital to community services
8 and family support programs, plans of the hospital to ensure
9 the earliest discharge possible, and the comprehensiveness of
10 the mental health and other health care services offered by
11 participating providers.
12 (c) The agency for Health Care Administration shall
13 adjust a hospital's current inpatient per diem rate to reflect
14 the cost of serving the Medicaid population at that
15 institution if:
16 1. The hospital experiences an increase in Medicaid
17 caseload by more than 25 percent in any year, primarily
18 resulting from the closure of a hospital in the same service
19 area occurring after July 1, 1995;
20 2. The hospital's Medicaid per diem rate is at least
21 25 percent below the Medicaid per patient cost for that year;
22 or
23 3. The hospital is located in a county that has five
24 or fewer hospitals, began offering obstetrical services on or
25 after September 1999, and has submitted a request in writing
26 to the agency for a rate adjustment after July 1, 2000, but
27 before September 30, 2000, in which case such hospital's
28 Medicaid inpatient per diem rate shall be adjusted to cost,
29 effective July 1, 2002.
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1 No later than October 1 of each year, the agency must provide
2 estimated costs for any adjustment in a hospital inpatient per
3 diem pursuant to this paragraph to the Executive Office of the
4 Governor, the House of Representatives General Appropriations
5 Committee, and the Senate Appropriations Committee. Before the
6 agency implements a change in a hospital's inpatient per diem
7 rate pursuant to this paragraph, the Legislature must have
8 specifically appropriated sufficient funds in the General
9 Appropriations Act to support the increase in cost as
10 estimated by the agency.
11 (d) Effective September 1, 2004, the agency shall
12 implement a hospitalist program in certain high-volume
13 participating hospitals, in select counties or statewide. The
14 program shall require hospitalists to authorize and manage
15 Medicaid recipients' hospital admissions and lengths of stay.
16 Individuals who are dually eligible for Medicare and Medicaid
17 are exempted from this requirement. Medicaid participating
18 physicians and other practitioners with hospital admitting
19 privileges shall coordinate and review admissions of Medicaid
20 beneficiaries with the hospitalist. The agency may
21 competitively bid a contract for selection of a qualified
22 organization to provide hospitalist services. The agency may
23 seek federal waiver approval as necessary to implement this
24 policy.
25 (e) Effective November 1, 2004, the agency shall
26 implement a comprehensive utilization management program for
27 hospital neonatal intensive care stays in certain high-volume
28 Medicaid participating hospitals, in select counties or
29 statewide, and shall replace existing hospital inpatient
30 utilization management programs. The program shall be
31 designed to manage the lengths of stay for children being
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1 treated in neonatal intensive care units and must seek the
2 earliest medically appropriate discharge to the child's home
3 or other less costly treatment setting. The agency may
4 competitively bid a contract for selection of a qualified
5 organization to provide neonatal intensive care utilization
6 management services. The agency may seek federal waiver
7 approval as necessary to implement this policy.
8 (6) HOSPITAL OUTPATIENT SERVICES.--The agency shall
9 pay for preventive, diagnostic, therapeutic, or palliative
10 care and other services provided to a recipient in the
11 outpatient portion of a hospital licensed under part I of
12 chapter 395, and provided under the direction of a licensed
13 physician or licensed dentist, except that payment for such
14 care and services is limited to $1,500 per state fiscal year
15 per recipient, unless an exception has been made by the
16 agency, and with the exception of a Medicaid recipient under
17 age 21, in which case the only limitation is medical
18 necessity.
19 (7) INDEPENDENT LABORATORY SERVICES.--The agency shall
20 pay for medically necessary diagnostic laboratory procedures
21 ordered by a licensed physician or other licensed practitioner
22 of the healing arts which are provided for a recipient in a
23 laboratory that meets the requirements for Medicare
24 participation and is licensed under chapter 483, if required.
25 (8) NURSING FACILITY SERVICES.--The agency shall pay
26 for 24-hour-a-day nursing and rehabilitative services for a
27 recipient in a nursing facility licensed under part II of
28 chapter 400 or in a rural hospital, as defined in s. 395.602,
29 or in a Medicare certified skilled nursing facility operated
30 by a hospital, as defined by s. 395.002(11), that is licensed
31 under part I of chapter 395, and in accordance with provisions
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1 set forth in s. 409.908(2)(a), which services are ordered by
2 and provided under the direction of a licensed physician.
3 However, if a nursing facility has been destroyed or otherwise
4 made uninhabitable by natural disaster or other emergency and
5 another nursing facility is not available, the agency must pay
6 for similar services temporarily in a hospital licensed under
7 part I of chapter 395 provided federal funding is approved and
8 available.
9 (9) PHYSICIAN SERVICES.--The agency shall pay for
10 covered services and procedures rendered to a recipient by, or
11 under the personal supervision of, a person licensed under
12 state law to practice medicine or osteopathic medicine. These
13 services may be furnished in the physician's office, the
14 Medicaid recipient's home, a hospital, a nursing facility, or
15 elsewhere, but shall be medically necessary for the treatment
16 of an injury, illness, or disease within the scope of the
17 practice of medicine or osteopathic medicine as defined by
18 state law. The agency shall not pay for services that are
19 clinically unproven, experimental, or for purely cosmetic
20 purposes.
21 (10) PORTABLE X-RAY SERVICES.--The agency shall pay
22 for professional and technical portable radiological services
23 ordered by a licensed physician or other licensed practitioner
24 of the healing arts which are provided by a licensed
25 professional in a setting other than a hospital, clinic, or
26 office of a physician or practitioner of the healing arts, on
27 behalf of a recipient.
28 (11) RURAL HEALTH CLINIC SERVICES.--The agency shall
29 pay for outpatient primary health care services for a
30 recipient provided by a clinic certified by and participating
31 in the Medicare program which is located in a federally
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1 designated, rural, medically underserved area and has on its
2 staff one or more licensed primary care nurse practitioners or
3 physician assistants, and a licensed staff supervising
4 physician or a consulting supervising physician.
5 (12) TRANSPORTATION SERVICES.--The agency shall ensure
6 that appropriate transportation services are available for a
7 Medicaid recipient in need of transport to a qualified
8 Medicaid provider for medically necessary and
9 Medicaid-compensable services, provided a recipient's client's
10 ability to choose a specific transportation provider is shall
11 be limited to those options resulting from policies
12 established by the agency to meet the fiscal limitations of
13 the General Appropriations Act. Effective January 1, 2005,
14 except for persons who meet Medicaid disability standards
15 adopted by rule, nonemergency transportation services may not
16 be offered to nondisabled recipients if public transportation
17 is generally available in the beneficiary's community. The
18 agency may pay for transportation and other related travel
19 expenses as necessary only if these services are not otherwise
20 available. The agency may competitively bid and contract with
21 a statewide vendor on a capitated basis for the provision of
22 nonemergency transportation services. The agency may seek
23 federal waiver approval as necessary to implement this
24 subsection.
25 Section 7. Subsections (13), (14), and (15) of section
26 409.906, Florida Statutes, are amended to read:
27 409.906 Optional Medicaid services.--Subject to
28 specific appropriations, the agency may make payments for
29 services which are optional to the state under Title XIX of
30 the Social Security Act and are furnished by Medicaid
31 providers to recipients who are determined to be eligible on
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1 the dates on which the services were provided. Any optional
2 service that is provided shall be provided only when medically
3 necessary and in accordance with state and federal law.
4 Optional services rendered by providers in mobile units to
5 Medicaid recipients may be restricted or prohibited by the
6 agency. Nothing in this section shall be construed to prevent
7 or limit the agency from adjusting fees, reimbursement rates,
8 lengths of stay, number of visits, or number of services, or
9 making any other adjustments necessary to comply with the
10 availability of moneys and any limitations or directions
11 provided for in the General Appropriations Act or chapter 216.
12 If necessary to safeguard the state's systems of providing
13 services to elderly and disabled persons and subject to the
14 notice and review provisions of s. 216.177, the Governor may
15 direct the Agency for Health Care Administration to amend the
16 Medicaid state plan to delete the optional Medicaid service
17 known as "Intermediate Care Facilities for the Developmentally
18 Disabled." Optional services may include:
19 (13) HOME AND COMMUNITY-BASED SERVICES.--The agency
20 may pay for home-based or community-based services that are
21 rendered to a recipient in accordance with a federally
22 approved waiver program.
23 (a) The agency may limit or eliminate coverage for
24 certain Project AIDS Care Waiver services, preauthorize
25 high-cost or highly utilized services, or make any other
26 adjustments necessary to comply with any limitations or
27 directions provided for in the General Appropriations Act.
28 (b) The agency may consolidate types of services
29 offered in the Aged and Disabled Waiver, the Channeling
30 Waiver, Project AIDS Care Waiver, and the Traumatic Brain and
31 Spinal Cord Injury Waiver programs in order to group similar
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1 services under a single service, or upon evidence of the need
2 for including a particular service type in a particular
3 waiver. The agency may seek federal waiver approval as
4 necessary to implement this policy.
5 (c) The agency may implement a utilization management
6 program designed to preauthorize home-and-community-based
7 service plans, including, but not limited to, proposed
8 quantity and duration of services, and to monitor ongoing
9 service use by participants in the program. The agency may
10 competitively procure a qualified organization to provide
11 utilization management of home-and-community-based services.
12 The agency may seek federal waiver approval as necessary to
13 implement this policy.
14 (14) HOSPICE CARE SERVICES.--The agency may pay for
15 all reasonable and necessary services for the palliation or
16 management of a recipient's terminal illness, if the services
17 are provided by a hospice that is licensed under part VI of
18 chapter 400 and meets Medicare certification requirements.
19 Effective October 1, 2004, subject to federal approval, the
20 community hospice income standard would be equal to the level
21 set in s. 409.904(1).
22 (15) INTERMEDIATE CARE FACILITY FOR THE
23 DEVELOPMENTALLY DISABLED SERVICES.--The agency may pay for
24 health-related care and services provided on a 24-hour-a-day
25 basis by a facility licensed and certified as a Medicaid
26 Intermediate Care Facility for the Developmentally Disabled,
27 for a recipient who needs such care because of a developmental
28 disability.
29 Section 8. Present subsection (8) of section 409.9065,
30 Florida Statutes, is redesignated as subsection (9), and a new
31 subsection (8) is added to that section, to read:
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1 409.9065 Pharmaceutical expense assistance.--
2 (8) In the absence of state appropriations for the
3 expansion of the Lifesaver Rx Program to provide benefits to
4 higher income groups and additional discounts as described in
5 subsections (2) and (3), the Agency for Health Care
6 Administration may, subject to federal approval and continuing
7 state appropriations, operate a pharmaceutical expense
8 assistance program that limits eligibility and benefits to
9 Medicaid beneficiaries who do not normally receive Medicaid
10 benefits, are Florida residents age 65 and older, have an
11 income less than or equal to 120 percent of the federal
12 poverty level, are eligible for Medicare, and request to be
13 enrolled in the program. Benefits under the limited
14 pharmaceutical expense assistance program shall include
15 Medicaid payment for up to $160 per month for prescribed
16 drugs, subject to benefit utilization controls applied to
17 other Medicaid prescribed drug benefits and the following
18 copayments: $2 per generic product, $5 for a product that is
19 on the Medicaid Preferred Drug List, and $15 for a product
20 that is not on the Preferred Drug List.
21 Section 9. Subsection (12) is added to section
22 409.907, Florida Statutes, to read:
23 409.907 Medicaid provider agreements.--The agency may
24 make payments for medical assistance and related services
25 rendered to Medicaid recipients only to an individual or
26 entity who has a provider agreement in effect with the agency,
27 who is performing services or supplying goods in accordance
28 with federal, state, and local law, and who agrees that no
29 person shall, on the grounds of handicap, race, color, or
30 national origin, or for any other reason, be subjected to
31
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1 discrimination under any program or activity for which the
2 provider receives payment from the agency.
3 (12) Licensed, certified, or otherwise qualified
4 providers are not entitled to enrollment in a Medicaid
5 provider network.
6 Section 10. Subsection (9) is added to section
7 409.911, Florida Statutes, to read:
8 409.911 Disproportionate share program.--Subject to
9 specific allocations established within the General
10 Appropriations Act and any limitations established pursuant to
11 chapter 216, the agency shall distribute, pursuant to this
12 section, moneys to hospitals providing a disproportionate
13 share of Medicaid or charity care services by making quarterly
14 Medicaid payments as required. Notwithstanding the provisions
15 of s. 409.915, counties are exempt from contributing toward
16 the cost of this special reimbursement for hospitals serving a
17 disproportionate share of low-income patients.
18 (9) The Agency for Health Care Administration shall
19 convene a Medicaid Disproportionate Share Council.
20 (a) The purpose of the council is to study and make
21 recommendations regarding:
22 1. The formula for the regular disproportionate share
23 program and alternative financing options;
24 2. Enhanced Medicaid funding through the Special
25 Medicaid Payment program; and
26 3. The federal status of the upper-payment-limit
27 funding option and how this option may be used to promote
28 health care initiatives determined by the council to be state
29 health care priorities.
30 (b) The council shall include representatives of the
31 Executive Office of the Governor and of the agency,
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1 representatives from teaching, public, private nonprofit,
2 private for-profit, and family practice teaching hospitals,
3 and representatives from other groups as needed.
4 (c) The council shall submit its findings and
5 recommendations to the Governor and the Legislature no later
6 than February 1 of each year.
7 Section 11. Subsection (40) of section 409.912,
8 Florida Statutes, is amended, and subsection (45) is added to
9 that section, to read:
10 409.912 Cost-effective purchasing of health care.--The
11 agency shall purchase goods and services for Medicaid
12 recipients in the most cost-effective manner consistent with
13 the delivery of quality medical care. The agency shall
14 maximize the use of prepaid per capita and prepaid aggregate
15 fixed-sum basis services when appropriate and other
16 alternative service delivery and reimbursement methodologies,
17 including competitive bidding pursuant to s. 287.057, designed
18 to facilitate the cost-effective purchase of a case-managed
19 continuum of care. The agency shall also require providers to
20 minimize the exposure of recipients to the need for acute
21 inpatient, custodial, and other institutional care and the
22 inappropriate or unnecessary use of high-cost services. The
23 agency may establish prior authorization requirements for
24 certain populations of Medicaid beneficiaries, certain drug
25 classes, or particular drugs to prevent fraud, abuse, overuse,
26 and possible dangerous drug interactions. The Pharmaceutical
27 and Therapeutics Committee shall make recommendations to the
28 agency on drugs for which prior authorization is required. The
29 agency shall inform the Pharmaceutical and Therapeutics
30 Committee of its decisions regarding drugs subject to prior
31 authorization.
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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
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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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