Amendment

Bill No. 1843

Amendment No. 341997

CHAMBER ACTION
Senate		House
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1	The Conference Committee on HB 1843 offered the following:
2
3	Conference Committee Amendment (with title amendment)
4	Remove everything after the enacting clause and insert:
5	Section 1.  Effective upon this act becoming a law and
6	applying retroactively to May 1, 2004, paragraph (a) of
7	subsection (3) of section 400.23, Florida Statutes, is amended
8	to read:
9	400.23  Rules; evaluation and deficiencies; licensure
10	status.--
11	(3)(a)  The agency shall adopt rules providing for the
12	minimum staffing requirements for nursing homes. These
13	requirements shall include, for each nursing home facility, a
14	minimum certified nursing assistant staffing of 2.3 hours of
15	direct care per resident per day beginning January 1, 2002,
16	increasing to 2.6 hours of direct care per resident per day
17	beginning January 1, 2003, and increasing to 2.9 hours of direct
18	care per resident per day beginning July May 1, 2005 2004.
19	Beginning January 1, 2002, no facility shall staff below one
20	certified nursing assistant per 20 residents, and a minimum
21	licensed nursing staffing of 1.0 hour of direct resident care
22	per resident per day but never below one licensed nurse per 40
23	residents. Nursing assistants employed never below one licensed
24	nurse per 40 residents. Nursing assistants employed under s.
25	400.211(2) may be included in computing the staffing ratio for
26	certified nursing assistants only if they provide nursing
27	assistance services to residents on a full-time basis. Each
28	nursing home must document compliance with staffing standards as
29	required under this paragraph and post daily the names of staff
30	on duty for the benefit of facility residents and the public.
31	The agency shall recognize the use of licensed nurses for
32	compliance with minimum staffing requirements for certified
33	nursing assistants, provided that the facility otherwise meets
34	the minimum staffing requirements for licensed nurses and that
35	the licensed nurses so recognized are performing the duties of a
36	certified nursing assistant. Unless otherwise approved by the
37	agency, licensed nurses counted towards the minimum staffing
38	requirements for certified nursing assistants must exclusively
39	perform the duties of a certified nursing assistant for the
40	entire shift and shall not also be counted towards the minimum
41	staffing requirements for licensed nurses. If the agency
42	approved a facility's request to use a licensed nurse to perform
43	both licensed nursing and certified nursing assistant duties,
44	the facility must allocate the amount of staff time specifically
45	spent on certified nursing assistant duties for the purpose of
46	documenting compliance with minimum staffing requirements for
47	certified and licensed nursing staff. In no event may the hours
48	of a licensed nurse with dual job responsibilities be counted
49	twice.
50	Section 2.  Paragraphs (c) and (d) of subsection (5) of
51	section 408.909, Florida Statutes, are redesignated as
52	paragraphs (d) and (e), respectively, present paragraph (c) of
53	subsection (5) of said section is amended, and a new paragraph
54	(c) is added to said subsection, to read:
55	408.909  Health flex plans.--
56	(5)  ELIGIBILITY.--Eligibility to enroll in an approved
57	health flex plan is limited to residents of this state who:
58	(c)  Are eligible under a federally approved Medicaid
59	demonstration waiver and reside in Palm Beach County or Miami-
60	Dade County;
61	(d)(c)  Are not covered by a private insurance policy and
62	are not eligible for coverage through a public health insurance
63	program, such as Medicare or Medicaid, unless specifically
64	authorized under paragraph (c), or another public health care
65	program, such as KidCare, and have not been covered at any time
66	during the past 6 months; and
67	Section 3.  Subsection (2) of section 409.8134, Florida
68	Statutes, as amended by chapter 2004-1, Laws of Florida, is
69	amended to read:
70	409.8134  Program enrollment and expenditure ceilings.--
71	(2)  Upon a unanimous recommendation by representatives
72	from each of the four Florida KidCare administrators, the
73	Florida KidCare program may conduct an open enrollment period
74	for the purpose of enrolling children eligible for all program
75	components listed in s. 409.813 except Medicaid. The four
76	Florida KidCare administrators shall work together to ensure
77	that the open enrollment period is announced statewide at least
78	1 month before the open enrollment is to begin. Eligible
79	children shall be enrolled on a first-come, first-served basis
80	using the date the open enrollment application is received. The
81	potential open enrollment periods shall be January 1st through
82	January 30th and September 1st through September 30th. Open
83	enrollment shall immediately cease when the enrollment ceiling
84	is reached reaches. An open enrollment shall only be held if the
85	Social Services Estimating Conference determines that sufficient
86	federal and state funds will be available to finance the
87	increased enrollment through federal fiscal year 2007. Any
88	individual who is not enrolled, including those added to the
89	waiting list after March 11 January 30, 2004, must reapply by
90	submitting a new application during the next open enrollment
91	period. However, the Children's Medical Services Network may
92	annually enroll up to 120 additional children based on emergency
93	disability criteria outside of the open enrollment periods and
94	the cost of serving these children must be managed within the
95	KidCare program's appropriated or authorized levels of funding.
96	Except for the Medicaid program, whenever the Social Services
97	Estimating Conference determines that there is presently, or
98	will be by the end of the current fiscal year, insufficient
99	funds to finance the current or projected enrollment in the
100	Florida KidCare program, all additional enrollment must cease
101	and additional enrollment may not resume until sufficient funds
102	are available to finance such enrollment.
103
104	Section 4.  Paragraph (f) of subsection (4) and paragraph
105	(a) of subsection (8) of section 409.814, Florida Statutes, as
106	amended by chapter 2004-1, Laws of Florida, are amended, and
107	paragraph (g) is added to subsection (4) of said section, to
108	read:
109	409.814  Eligibility.--A child who has not reached 19 years
110	of age whose family income is equal to or below 200 percent of
111	the federal poverty level is eligible for the Florida KidCare
112	program as provided in this section. For enrollment in the
113	Children's Medical Services network, a complete application
114	includes the medical or behavioral health screening. If,
115	subsequently, an individual is determined to be ineligible for
116	coverage, he or she must immediately be disenrolled from the
117	respective Florida KidCare program component.
118	(4)  The following children are not eligible to receive
119	premium assistance for health benefits coverage under the
120	Florida KidCare program, except under Medicaid if the child
121	would have been eligible for Medicaid under s. 409.903 or s.
122	409.904 as of June 1, 1997:
123	(f)  A child who has had his or her coverage in an
124	employer-sponsored health benefit plan voluntarily canceled in
125	the last 6 months, except those children who were on the waiting
126	list prior to March 12 January 31, 2004.
127	(g)  A child who is otherwise eligible for KidCare and who
128	has a preexisting condition that prevents coverage under another
129	insurance plan as described in paragraph (b) which would have
130	disqualified the child for KidCare if the child were able to
131	enroll in the plan shall be eligible for KidCare coverage when
132	enrollment is possible.
133	(8)  In determining the eligibility of a child, an assets
134	test is not required. Each applicant shall provide written
135	documentation during the application process and the
136	redetermination process, including, but not limited to, the
137	following:
138	(a)  Proof of family income supported by copies of any
139	federal income tax return for the prior year, any wages and
140	earnings statements (W-2 forms), and any other appropriate
141	document.
142	Section 5.  Effective January 1, 2005, subsection (6) of
143	section 409.814, Florida Statutes, as amended by chapter 2004-1,
144	Laws of Florida, is amended to read:
145	409.814  Eligibility.--A child who has not reached 19 years
146	of age whose family income is equal to or below 200 percent of
147	the federal poverty level is eligible for the Florida KidCare
148	program as provided in this section. For enrollment in the
149	Children's Medical Services network, a complete application
150	includes the medical or behavioral health screening. If,
151	subsequently, an individual is determined to be ineligible for
152	coverage, he or she must immediately be disenrolled from the
153	respective Florida KidCare program component.
154	(6)  Once a child is enrolled in the Florida KidCare
155	program, the child is eligible for coverage under the program
156	for 12 6 months without a redetermination or reverification of
157	eligibility, if the family continues to pay the applicable
158	premium. Eligibility for program components funded through Title
159	XXI of the Social Security Act shall terminate when a child
160	attains the age of 19. Effective January 1, 1999, a child who
161	has not attained the age of 5 and who has been determined
162	eligible for the Medicaid program is eligible for coverage for
163	12 months without a redetermination or reverification of
164	eligibility.
165	Section 6.  Subsection (5) of section 409.903, Florida
166	Statutes, is amended to read:
167	409.903  Mandatory payments for eligible persons.--The
168	agency shall make payments for medical assistance and related
169	services on behalf of the following persons who the department,
170	or the Social Security Administration by contract with the
171	Department of Children and Family Services, determines to be
172	eligible, subject to the income, assets, and categorical
173	eligibility tests set forth in federal and state law. Payment on
174	behalf of these Medicaid eligible persons is subject to the
175	availability of moneys and any limitations established by the
176	General Appropriations Act or chapter 216.
177	(5)  A pregnant woman for the duration of her pregnancy and
178	for the postpartum period as defined in federal law and rule, or
179	a child under age 1, if either is living in a family that has an
180	income which is at or below 150 percent of the most current
181	federal poverty level, or, effective January 1, 1992, that has
182	an income which is at or below 185 percent of the most current
183	federal poverty level. Such a person is not subject to an assets
184	test. Further, a pregnant woman who applies for eligibility for
185	the Medicaid program through a qualified Medicaid provider must
186	be offered the opportunity, subject to federal rules, to be made
187	presumptively eligible for the Medicaid program. Effective July
188	1, 2005, eligibility for Medicaid services is eliminated for
189	women who have incomes above 150 percent of the most current
190	federal poverty level.
191	Section 7.  Subsections (2) and (3) of section 409.904,
192	Florida Statutes, are amended to read:
193	409.904  Optional payments for eligible persons.--The
194	agency may make payments for medical assistance and related
195	services on behalf of the following persons who are determined
196	to be eligible subject to the income, assets, and categorical
197	eligibility tests set forth in federal and state law. Payment on
198	behalf of these Medicaid eligible persons is subject to the
199	availability of moneys and any limitations established by the
200	General Appropriations Act or chapter 216.
201	(2)  A family, a pregnant woman, a child under age 21, a
202	person age 65 or over, or a blind or disabled person, who would
203	be eligible under any group listed in s. 409.903(1), (2), or
204	(3), except that the income or assets of such family or person
205	exceed established limitations. For a family or person in one of
206	these coverage groups, medical expenses are deductible from
207	income in accordance with federal requirements in order to make
208	a determination of eligibility. A family or person eligible
209	under the coverage known as the "medically needy," is eligible
210	to receive the same services as other Medicaid recipients, with
211	the exception of services in skilled nursing facilities and
212	intermediate care facilities for the developmentally disabled.
213	Effective July 1, 2005, the medically needy are eligible for
214	prescribed drug services only.
215	(3)  A person who is in need of the services of a licensed
216	nursing facility, a licensed intermediate care facility for the
217	developmentally disabled, or a state mental hospital, whose
218	income does not exceed 300 percent of the SSI income standard,
219	and who meets the assets standards established under federal and
220	state law. In determining the person's responsibility for the
221	cost of care, the following amounts must be deducted from the
222	person's income:
223	(a)  The monthly personal allowance for residents as set
224	based on appropriations.
225	(b)  The reasonable costs of medically necessary services
226	and supplies that are not reimbursable by the Medicaid program.
227	(c)  The cost of premiums, copayments, coinsurance, and
228	deductibles for supplemental health insurance.
229	Section 8.  Subsections (4), (5), and (8) of section
230	409.905, Florida Statutes, are amended to read:
231	409.905  Mandatory Medicaid services.--The agency may make
232	payments for the following services, which are required of the
233	state by Title XIX of the Social Security Act, furnished by
234	Medicaid providers to recipients who are determined to be
235	eligible on the dates on which the services were provided. Any
236	service under this section shall be provided only when medically
237	necessary and in accordance with state and federal law.
238	Mandatory services rendered by providers in mobile units to
239	Medicaid recipients may be restricted by the agency. Nothing in
240	this section shall be construed to prevent or limit the agency
241	from adjusting fees, reimbursement rates, lengths of stay,
242	number of visits, number of services, or any other adjustments
243	necessary to comply with the availability of moneys and any
244	limitations or directions provided for in the General
245	Appropriations Act or chapter 216.
246	(4)  HOME HEALTH CARE SERVICES.--The agency shall pay for
247	nursing and home health aide services, supplies, appliances, and
248	durable medical equipment, necessary to assist a recipient
249	living at home. An entity that provides services pursuant to
250	this subsection shall be licensed under part IV of chapter 400
251	or part II of chapter 499, if appropriate. These services,
252	equipment, and supplies, or reimbursement therefor, may be
253	limited as provided in the General Appropriations Act and do not
254	include services, equipment, or supplies provided to a person
255	residing in a hospital or nursing facility.
256	(a)  In providing home health care services, the agency may
257	require prior authorization of care based on diagnosis.
258	(b)  The agency shall implement a comprehensive utilization
259	management program that requires prior authorization of all
260	private duty nursing services, an individualized treatment plan
261	that includes information about medication and treatment orders,
262	treatment goals, methods of care to be used, and plans for care
263	coordination by nurses and other health professionals. The
264	utilization management program shall also include a process for
265	periodically reviewing the ongoing use of private duty nursing
266	services. The assessment of need shall be based on a child's
267	condition, family support and care supplements, a family's
268	ability to provide care, and a family's and child's schedule
269	regarding work, school, sleep, and care for other family
270	dependents. When implemented, the private duty nursing
271	utilization management program shall replace the current
272	authorization program used by the Agency for Health Care
273	Administration and the Children's Medical Services program of
274	the Department of Health. The agency may competitively bid on a
275	contract to select a qualified organization to provide
276	utilization management of private duty nursing services. The
277	agency is authorized to seek federal waivers to implement this
278	initiative.
279	(5)  HOSPITAL INPATIENT SERVICES.--The agency shall pay for
280	all covered services provided for the medical care and treatment
281	of a recipient who is admitted as an inpatient by a licensed
282	physician or dentist to a hospital licensed under part I of
283	chapter 395. However, the agency shall limit the payment for
284	inpatient hospital services for a Medicaid recipient 21 years of
285	age or older to 45 days or the number of days necessary to
286	comply with the General Appropriations Act.
287	(a)  The agency is authorized to implement reimbursement
288	and utilization management reforms in order to comply with any
289	limitations or directions in the General Appropriations Act,
290	which may include, but are not limited to: prior authorization
291	for inpatient psychiatric days; prior authorization for
292	nonemergency hospital inpatient admissions for individuals 21
293	years of age and older; authorization of emergency and urgent-
294	care admissions within 24 hours after admission; enhanced
295	utilization and concurrent review programs for highly utilized
296	services; reduction or elimination of covered days of service;
297	adjusting reimbursement ceilings for variable costs; adjusting
298	reimbursement ceilings for fixed and property costs; and
299	implementing target rates of increase. The agency may limit
300	prior authorization for hospital inpatient services to selected
301	diagnosis-related groups, based on an analysis of the cost and
302	potential for unnecessary hospitalizations represented by
303	certain diagnoses. Admissions for normal delivery and newborns
304	are exempt from requirements for prior authorization. In
305	implementing the provisions of this section related to prior
306	authorization, the agency shall ensure that the process for
307	authorization is accessible 24 hours per day, 7 days per week
308	and authorization is automatically granted when not denied
309	within 4 hours after the request. Authorization procedures must
310	include steps for review of denials. Upon implementing the prior
311	authorization program for hospital inpatient services, the
312	agency shall discontinue its hospital retrospective review
313	program.
314	(b)  A licensed hospital maintained primarily for the care
315	and treatment of patients having mental disorders or mental
316	diseases is not eligible to participate in the hospital
317	inpatient portion of the Medicaid program except as provided in
318	federal law. However, the department shall apply for a waiver,
319	within 9 months after June 5, 1991, designed to provide
320	hospitalization services for mental health reasons to children
321	and adults in the most cost-effective and lowest cost setting
322	possible. Such waiver shall include a request for the
323	opportunity to pay for care in hospitals known under federal law
324	as "institutions for mental disease" or "IMD's." The waiver
325	proposal shall propose no additional aggregate cost to the state
326	or Federal Government, and shall be conducted in Hillsborough
327	County, Highlands County, Hardee County, Manatee County, and
328	Polk County. The waiver proposal may incorporate competitive
329	bidding for hospital services, comprehensive brokering, prepaid
330	capitated arrangements, or other mechanisms deemed by the
331	department to show promise in reducing the cost of acute care
332	and increasing the effectiveness of preventive care. When
333	developing the waiver proposal, the department shall take into
334	account price, quality, accessibility, linkages of the hospital
335	to community services and family support programs, plans of the
336	hospital to ensure the earliest discharge possible, and the
337	comprehensiveness of the mental health and other health care
338	services offered by participating providers.
339	(c)  The Agency for Health Care Administration shall adjust
340	a hospital's current inpatient per diem rate to reflect the cost
341	of serving the Medicaid population at that institution if:
342	1.  The hospital experiences an increase in Medicaid
343	caseload by more than 25 percent in any year, primarily
344	resulting from the closure of a hospital in the same service
345	area occurring after July 1, 1995;
346	2.  The hospital's Medicaid per diem rate is at least 25
347	percent below the Medicaid per patient cost for that year; or
348	3.  The hospital is located in a county that has five or
349	fewer hospitals, began offering obstetrical services on or after
350	September 1999, and has submitted a request in writing to the
351	agency for a rate adjustment after July 1, 2000, but before
352	September 30, 2000, in which case such hospital's Medicaid
353	inpatient per diem rate shall be adjusted to cost, effective
354	July 1, 2002.
355
356	No later than October 1 of each year, the agency must provide
357	estimated costs for any adjustment in a hospital inpatient per
358	diem pursuant to this paragraph to the Executive Office of the
359	Governor, the House of Representatives General Appropriations
360	Committee, and the Senate Appropriations Committee. Before the
361	agency implements a change in a hospital's inpatient per diem
362	rate pursuant to this paragraph, the Legislature must have
363	specifically appropriated sufficient funds in the General
364	Appropriations Act to support the increase in cost as estimated
365	by the agency.
366	(d)  The agency shall implement a hospitalist program in
367	certain high-volume participating hospitals, select counties, or
368	statewide. The program shall require hospitalists to authorize
369	and manage Medicaid recipients' hospital admissions and lengths
370	of stay. Individuals who are dually eligible for Medicare and
371	Medicaid are exempted from this requirement. Medicaid
372	participating physicians and other practitioners with hospital
373	admitting privileges shall coordinate and review admissions of
374	Medicaid recipients with the hospitalist. The agency may
375	competitively bid a contract for selection of a qualified
376	organization to provide hospitalist services. The qualified
377	organization shall employ board certified physicians who are
378	full-time dedicated employees of the contractor and have no
379	outside practice. Where used, the hospitalist program shall
380	replace the existing hospital utilization review program. The
381	agency is authorized to seek federal waivers to implement this
382	program.
383	(e)  The agency shall implement a comprehensive utilization
384	management program for hospital neonatal intensive care stays in
385	certain high-volume participating hospitals, select counties, or
386	statewide, and shall replace existing hospital inpatient
387	utilization management programs for neonatal intensive care
388	admissions. The program shall be designed to manage the lengths
389	of stay for children being treated in neonatal intensive care
390	units and must seek the earliest medically appropriate discharge
391	to the child's home or other less costly treatment setting. The
392	agency may competitively bid a contract for selection of a
393	qualified organization to provide neonatal intensive care
394	utilization management services. The agency is authorized to
395	seek any federal waivers to implement this initiative.
396	(8)  NURSING FACILITY SERVICES.--The agency shall pay for
397	24-hour-a-day nursing and rehabilitative services for a
398	recipient in a nursing facility licensed under part II of
399	chapter 400 or in a rural hospital, as defined in s. 395.602, or
400	in a Medicare certified skilled nursing facility operated by a
401	hospital, as defined by s. 395.002(11), that is licensed under
402	part I of chapter 395, and in accordance with provisions set
403	forth in s. 409.908(2)(a), which services are ordered by and
404	provided under the direction of a licensed physician. However,
405	if a nursing facility has been destroyed or otherwise made
406	uninhabitable by natural disaster or other emergency and another
407	nursing facility is not available, the agency must pay for
408	similar services temporarily in a hospital licensed under part I
409	of chapter 395 provided federal funding is approved and
410	available. The agency shall pay only for bed hold days if the
411	facility has an occupancy rate of 95 percent or greater. The
412	agency is authorized to seek any federal waivers to implement
413	this policy.
414	Section 9.  Subsections (1), (13), and (15) of section
415	409.906, Florida Statutes, are amended to read:
416	409.906  Optional Medicaid services.--Subject to specific
417	appropriations, the agency may make payments for services which
418	are optional to the state under Title XIX of the Social Security
419	Act and are furnished by Medicaid providers to recipients who
420	are determined to be eligible on the dates on which the services
421	were provided. Any optional service that is provided shall be
422	provided only when medically necessary and in accordance with
423	state and federal law. Optional services rendered by providers
424	in mobile units to Medicaid recipients may be restricted or
425	prohibited by the agency. Nothing in this section shall be
426	construed to prevent or limit the agency from adjusting fees,
427	reimbursement rates, lengths of stay, number of visits, or
428	number of services, or making any other adjustments necessary to
429	comply with the availability of moneys and any limitations or
430	directions provided for in the General Appropriations Act or
431	chapter 216. If necessary to safeguard the state's systems of
432	providing services to elderly and disabled persons and subject
433	to the notice and review provisions of s. 216.177, the Governor
434	may direct the Agency for Health Care Administration to amend
435	the Medicaid state plan to delete the optional Medicaid service
436	known as "Intermediate Care Facilities for the Developmentally
437	Disabled." Optional services may include:
438	(1)  ADULT DENTAL SERVICES.--
439	(a)  The agency may pay for medically necessary, emergency
440	dental procedures to alleviate pain or infection. Emergency
441	dental care shall be limited to emergency oral examinations,
442	necessary radiographs, extractions, and incision and drainage of
443	abscess, for a recipient who is age 21 years of age or older.
444	(b)  Beginning January 1, 2005, the agency may pay for
445	dentures, the procedures required to seat dentures, and the
446	repair and reline of dentures, provided by or under the
447	direction of a licensed dentist, for a recipient who is 21 years
448	of age or older. This paragraph is repealed effective July 1,
449	2005.
450	(c)  However, Medicaid will not provide reimbursement for
451	dental services provided in a mobile dental unit, except for a
452	mobile dental unit:
453	1.(a)  Owned by, operated by, or having a contractual
454	agreement with the Department of Health and complying with
455	Medicaid's county health department clinic services program
456	specifications as a county health department clinic services
457	provider.
458	2.(b)  Owned by, operated by, or having a contractual
459	arrangement with a federally qualified health center and
460	complying with Medicaid's federally qualified health center
461	specifications as a federally qualified health center provider.
462	3.(c)  Rendering dental services to Medicaid recipients, 21
463	years of age and older, at nursing facilities.
464	4.(d)  Owned by, operated by, or having a contractual
465	agreement with a state-approved dental educational institution.
466	(13)  HOME AND COMMUNITY-BASED SERVICES.--
467	(a)  The agency may pay for home-based or community-based
468	services that are rendered to a recipient in accordance with a
469	federally approved waiver program. The agency may limit or
470	eliminate coverage for certain Project AIDS Care Waiver
471	services, preauthorize high-cost or highly utilized services, or
472	make any other adjustments necessary to comply with any
473	limitations or directions provided for in the General
474	Appropriations Act.
475	(b)  The agency may consolidate types of services offered
476	in the Aged and Disabled Waiver, the Channeling Waiver, the
477	Project AIDS Care Waiver, and the Traumatic Brain and Spinal
478	Cord Injury Waiver programs in order to group similar services
479	under a single service, or continue a service upon evidence of
480	the need for including a particular service type in a particular
481	waiver. The agency is authorized to seek a Medicaid state plan
482	amendment or federal waiver approval to implement this policy.
483	(c)  The agency may implement a utilization management
484	program designed to prior authorize home and community-based
485	service plans and includes, but is not limited to, assessing
486	proposed quantity and duration of services and monitoring
487	ongoing service use by participants in the program. The agency
488	is authorized to competitively procure a qualified organization
489	to provide utilization management of home and community-based
490	services. The agency is authorized to seek any federal waivers
491	to implement this initiative.
492	(15)  INTERMEDIATE CARE FACILITY FOR THE DEVELOPMENTALLY
493	DISABLED SERVICES.--The agency may pay for health-related care
494	and services provided on a 24-hour-a-day basis by a facility
495	licensed and certified as a Medicaid Intermediate Care Facility
496	for the Developmentally Disabled, for a recipient who needs such
497	care because of a developmental disability. Payment shall not
498	include bed-hold days except in facilities with occupancy rates
499	of 95 percent or greater. The agency is authorized to seek any
500	federal waiver approvals to implement this policy.
501	Section 10.  Subsection (8) of section 409.9065, Florida
502	Statutes, is renumbered as subsection (9), and a new subsection
503	(8) is added to said section, to read:
504	409.9065  Pharmaceutical expense assistance.--
505	(8)  PHARMACEUTICAL EXPENSE ASSISTANCE PROGRAM.--In the
506	absence of federal approval for the Lifesaver Rx Program to
507	provide benefits to higher income groups and additional
508	discounts as described in subsections (2) and (3), the Agency
509	for Health Care Administration may, subject to federal approval
510	and continuing state appropriations, operate a pharmaceutical
511	expense assistance program that limits eligibility and benefits
512	to Medicaid beneficiaries who do not normally receive Medicaid
513	benefits, are Florida residents age 65 and older, have an income
514	less than or equal to 120 percent of the federal poverty level,
515	are eligible for Medicare, and request to be enrolled in the
516	program. Benefits under the limited pharmaceutical expense
517	assistance program shall include Medicaid payment for up to $160
518	per month for prescribed drugs, subject to benefit utilization
519	controls applied to other Medicaid prescribed drug benefits and
520	the following copayments: $2 per generic product, $5 for a
521	product that is on the Medicaid Preferred Drug List, and $15 for
522	a product that is not on the preferred drug list.
523	Section 11.  Subsection (12) is added to section 409.907,
524	Florida Statutes, to read:
525	409.907  Medicaid provider agreements.--The agency may make
526	payments for medical assistance and related services rendered to
527	Medicaid recipients only to an individual or entity who has a
528	provider agreement in effect with the agency, who is performing
529	services or supplying goods in accordance with federal, state,
530	and local law, and who agrees that no person shall, on the
531	grounds of handicap, race, color, or national origin, or for any
532	other reason, be subjected to discrimination under any program
533	or activity for which the provider receives payment from the
534	agency.
535	(12)  Licensed, certified, or otherwise qualified providers
536	are not entitled to enrollment in a Medicaid provider network.
537	Section 12.  Subsections (4), (14), and (19) of section
538	409.908, Florida Statutes, are amended to read:
539	409.908  Reimbursement of Medicaid providers.--Subject to
540	specific appropriations, the agency shall reimburse Medicaid
541	providers, in accordance with state and federal law, according
542	to methodologies set forth in the rules of the agency and in
543	policy manuals and handbooks incorporated by reference therein.
544	These methodologies may include fee schedules, reimbursement
545	methods based on cost reporting, negotiated fees, competitive
546	bidding pursuant to s. 287.057, and other mechanisms the agency
547	considers efficient and effective for purchasing services or
548	goods on behalf of recipients. If a provider is reimbursed based
549	on cost reporting and submits a cost report late and that cost
550	report would have been used to set a lower reimbursement rate
551	for a rate semester, then the provider's rate for that semester
552	shall be retroactively calculated using the new cost report, and
553	full payment at the recalculated rate shall be affected
554	retroactively. Medicare-granted extensions for filing cost
555	reports, if applicable, shall also apply to Medicaid cost
556	reports. Payment for Medicaid compensable services made on
557	behalf of Medicaid eligible persons is subject to the
558	availability of moneys and any limitations or directions
559	provided for in the General Appropriations Act or chapter 216.
560	Further, nothing in this section shall be construed to prevent
561	or limit the agency from adjusting fees, reimbursement rates,
562	lengths of stay, number of visits, or number of services, or
563	making any other adjustments necessary to comply with the
564	availability of moneys and any limitations or directions
565	provided for in the General Appropriations Act, provided the
566	adjustment is consistent with legislative intent.
567	(4)  Subject to any limitations or directions provided for
568	in the General Appropriations Act, alternative health plans,
569	health maintenance organizations, and prepaid health plans shall
570	be reimbursed a fixed, prepaid amount negotiated, or
571	competitively bid pursuant to s. 287.057, by the agency and
572	prospectively paid to the provider monthly for each Medicaid
573	recipient enrolled. The amount may not exceed the average amount
574	the agency determines it would have paid, based on claims
575	experience, for recipients in the same or similar category of
576	eligibility. The agency shall calculate capitation rates on a
577	regional basis and, beginning September 1, 1995, shall include
578	age-band differentials in such calculations. Effective July 1,
579	2001, the cost of exempting statutory teaching hospitals,
580	specialty hospitals, and community hospital education program
581	hospitals from reimbursement ceilings and the cost of special
582	Medicaid payments shall not be included in premiums paid to
583	health maintenance organizations or prepaid health care plans.
584	Each rate semester, the agency shall calculate and publish a
585	Medicaid hospital rate schedule that does not reflect either
586	special Medicaid payments or the elimination of rate
587	reimbursement ceilings, to be used by hospitals and Medicaid
588	health maintenance organizations, in order to determine the
589	Medicaid rate referred to in ss. 409.912(17), 409.9128(5), and
590	641.513(6).
591	(14)  A provider of prescribed drugs shall be reimbursed
592	the least of the amount billed by the provider, the provider's
593	usual and customary charge, or the Medicaid maximum allowable
594	fee established by the agency, plus a dispensing fee. The
595	Medicaid maximum allowable fee for ingredient cost will be based
596	on the lower of: average wholesale price (AWP) minus 15.4
597	percent, wholesaler acquisition cost (WAC) plus 5.75 percent,
598	the federal upper limit (FUL), the state maximum allowable cost
599	(SMAC), or the usual and customary (UAC) charge billed by the
600	provider. Medicaid providers are required to dispense generic
601	drugs if available at lower cost and the agency has not
602	determined that the branded product is more cost-effective,
603	unless the prescriber has requested and received approval to
604	require the branded product. The agency is directed to implement
605	a variable dispensing fee for payments for prescribed medicines
606	while ensuring continued access for Medicaid recipients. The
607	variable dispensing fee may be based upon, but not limited to,
608	either or both the volume of prescriptions dispensed by a
609	specific pharmacy provider, the volume of prescriptions
610	dispensed to an individual recipient, and dispensing of
611	preferred-drug-list products. The agency may increase the
612	pharmacy dispensing fee authorized by statute and in the annual
613	General Appropriations Act by $0.50 for the dispensing of a
614	Medicaid preferred-drug-list product and reduce the pharmacy
615	dispensing fee by $0.50 for the dispensing of a Medicaid product
616	that is not included on the preferred-drug list. The agency may
617	establish a supplemental pharmaceutical dispensing fee to be
618	paid to providers returning unused unit-dose packaged
619	medications to stock and crediting the Medicaid program for the
620	ingredient cost of those medications if the ingredient costs to
621	be credited exceed the value of the supplemental dispensing fee.
622	The agency is authorized to limit reimbursement for prescribed
623	medicine in order to comply with any limitations or directions
624	provided for in the General Appropriations Act, which may
625	include implementing a prospective or concurrent utilization
626	review program.
627	(19)  County health department services shall may be
628	reimbursed a rate per visit based on total reasonable costs of
629	the clinic, as determined by the agency in accordance with
630	federal regulations under the authority of 42 C.F.R. s. 431.615.
631	Section 13.  Section 409.911, Florida Statutes, is amended
632	to read:
633	409.911  Disproportionate share program.--Subject to
634	specific allocations established within the General
635	Appropriations Act and any limitations established pursuant to
636	chapter 216, the agency shall distribute, pursuant to this
637	section, moneys to hospitals providing a disproportionate share
638	of Medicaid or charity care services by making quarterly
639	Medicaid payments as required. Notwithstanding the provisions of
640	s. 409.915, counties are exempt from contributing toward the
641	cost of this special reimbursement for hospitals serving a
642	disproportionate share of low-income patients.
643	(1)  Definitions.--As used in this section, s. 409.9112,
644	and the Florida Hospital Uniform Reporting System manual:
645	(a)  "Adjusted patient days" means the sum of acute care
646	patient days and intensive care patient days as reported to the
647	Agency for Health Care Administration, divided by the ratio of
648	inpatient revenues generated from acute, intensive, ambulatory,
649	and ancillary patient services to gross revenues.
650	(b)  "Actual audited data" or "actual audited experience"
651	means data reported to the Agency for Health Care Administration
652	which has been audited in accordance with generally accepted
653	auditing standards by the agency or representatives under
654	contract with the agency.
655	(c)  "Charity care" or "uncompensated charity care" means
656	that portion of hospital charges reported to the Agency for
657	Health Care Administration for which there is no compensation,
658	other than restricted or unrestricted revenues provided to a
659	hospital by local governments or tax districts regardless of the
660	method of payment, for care provided to a patient whose family
661	income for the 12 months preceding the determination is less
662	than or equal to 200 percent of the federal poverty level,
663	unless the amount of hospital charges due from the patient
664	exceeds 25 percent of the annual family income. However, in no
665	case shall the hospital charges for a patient whose family
666	income exceeds four times the federal poverty level for a family
667	of four be considered charity.
668	(d)  "Charity care days" means the sum of the deductions
669	from revenues for charity care minus 50 percent of restricted
670	and unrestricted revenues provided to a hospital by local
671	governments or tax districts, divided by gross revenues per
672	adjusted patient day.
673	(e)  "Hospital" means a health care institution licensed as
674	a hospital pursuant to chapter 395, but does not include
675	ambulatory surgical centers.
676	(f)  "Medicaid days" means the number of actual days
677	attributable to Medicaid patients as determined by the Agency
678	for Health Care Administration.
679	(2)  The Agency for Health Care Administration shall use
680	the following actual audited data to determine the Medicaid days
681	and charity care to be used in calculating the disproportionate
682	share payment:
683	(a)  The average of the 1997, 1998, and 1999, and 2000
684	audited data to determine each hospital's Medicaid days and
685	charity care.
686	(b)  The average of the audited disproportionate share data
687	for the years available if the Agency for Health Care
688	Administration does not have the prescribed 3 years of audited
689	disproportionate share data for a hospital.
690	(c)  In accordance with s. 1923(b) of the Social Security
691	Act, a hospital with a Medicaid inpatient utilization rate
692	greater than one standard deviation above the statewide mean or
693	a hospital with a low-income utilization rate of 25 percent or
694	greater shall qualify for reimbursement.
695	(3)  Hospitals that qualify for a disproportionate share
696	payment solely under paragraph (2)(c) shall have their payment
697	calculated in accordance with the following formulas:
698
699	DSHP = (HMD/TMSD) x $1 million
700
701	Where:
702	DSHP = disproportionate share hospital payment.
703	HMD = hospital Medicaid days.
704	TSD = total state Medicaid days.
705
706	Any funds not allocated to hospitals qualifying under this
707	section shall be redistributed to the non-state government owned
708	or operated hospitals with greater than 3,300 Medicaid days.
709	(4)  The following formulas shall be used to pay
710	disproportionate share dollars to public hospitals:
711	(a)  For state mental health hospitals:
712
713	DSHP = (HMD/TMDMH) x TAAMH
714
715	shall be the difference between the federal cap for
716	Institutions for Mental Diseases and the amounts paid under the
717	mental health disproportionate share program.
718
719	Where:
720	DSHP = disproportionate share hospital payment.
721	HMD = hospital Medicaid days.
722	TMDHH = total Medicaid days for state mental health
723	hospitals.
724	TAAMH = total amount available for mental health hospitals.
725
726	(b)  For non-state government owned or operated hospitals
727	with 3,300 or more Medicaid days:
728
729	DSHP = [(.82 x HCCD/TCCD) + (.18 x HMD/TMD)]
730	x TAAPH
731	TAAPH = TAA - TAAMH
732
733	Where:
734	TAA = total available appropriation.
735	TAAPH = total amount available for public hospitals.
736	DSHP = disproportionate share hospital payments.
737	HMD = hospital Medicaid days.
738	TMD = total state Medicaid days for public hospitals.
739	HCCD = hospital charity care dollars.
740	TCCD = total state charity care dollars for public non-
741	state hospitals.
742
743	The TAAPH shall be reduced by $6,365,257 before computing the
744	DSHP for each public hospital. The $6,365,257 shall be
745	distributed equally between the public hospitals that are also
746	designated statutory teaching hospitals.
747	(c)  For non-state government owned or operated hospitals
748	with less than 3,300 Medicaid days, a total of $750,000 $400,000
749	shall be distributed equally among these hospitals.
750	(5)  In no case shall total payments to a hospital under
751	this section, with the exception of public non-state facilities
752	or state facilities, exceed the total amount of uncompensated
753	charity care of the hospital, as determined by the agency
754	according to the most recent calendar year audited data
755	available at the beginning of each state fiscal year.
756	(6)  The agency is authorized to receive funds from local
757	governments and other local political subdivisions for the
758	purpose of making payments, including federal matching funds,
759	through the Medicaid disproportionate share program. Funds
760	received from local governments for this purpose shall be
761	separately accounted for and shall not be commingled with other
762	state or local funds in any manner.
763	(7)  Payments made by the agency to hospitals eligible to
764	participate in this program shall be made in accordance with
765	federal rules and regulations.
766	(a)  If the Federal Government prohibits, restricts, or
767	changes in any manner the methods by which funds are distributed
768	for this program, the agency shall not distribute any additional
769	funds and shall return all funds to the local government from
770	which the funds were received, except as provided in paragraph
771	(b).
772	(b)  If the Federal Government imposes a restriction that
773	still permits a partial or different distribution, the agency
774	may continue to disburse funds to hospitals participating in the
775	disproportionate share program in a federally approved manner,
776	provided:
777	1.  Each local government which contributes to the
778	disproportionate share program agrees to the new manner of
779	distribution as shown by a written document signed by the
780	governing authority of each local government; and
781	2.  The Executive Office of the Governor, the Office of
782	Planning and Budgeting, the House of Representatives, and the
783	Senate are provided at least 7 days' prior notice of the
784	proposed change in the distribution, and do not disapprove such
785	change.
786	(c)  No distribution shall be made under the alternative
787	method specified in paragraph (b) unless all parties agree or
788	unless all funds of those parties that disagree which are not
789	yet disbursed have been returned to those parties.
790	(8)  Notwithstanding the provisions of chapter 216, the
791	Executive Office of the Governor is hereby authorized to
792	establish sufficient trust fund authority to implement the
793	disproportionate share program.
794	(9)  The Agency for Health Care Administration shall create
795	a Medicaid Disproportionate Share Council.
796	(a)  The purpose of the council is to study and make
797	recommendations regarding:
798	1.  The formula for the regular disproportionate share
799	program and alternative financing options.
800	2.  Enhanced Medicaid funding through the Special Medicaid
801	Payment program.
802	3.  The federal status of the upper-payment-limit funding
803	option and how this option may be used to promote health care
804	initiatives determined by the council to be state health care
805	priorities.
806	(b)  The council shall include representatives of the
807	Executive Office of the Governor and of the agency;
808	representatives from teaching, public, private nonprofit,
809	private for-profit and family practice teaching hospitals; and
810	representatives from other groups as needed.
811	(c)  The council shall submit its findings and
812	recommendations to the Governor and the Legislature no later
813	than February 1 of each year.
814	Section 14.  Section 409.9112, Florida Statutes, is amended
815	to read:
816	409.9112  Disproportionate share program for regional
817	perinatal intensive care centers.--In addition to the payments
818	made under s. 409.911, the Agency for Health Care Administration
819	shall design and implement a system of making disproportionate
820	share payments to those hospitals that participate in the
821	regional perinatal intensive care center program established
822	pursuant to chapter 383. This system of payments shall conform
823	with federal requirements and shall distribute funds in each
824	fiscal year for which an appropriation is made by making
825	quarterly Medicaid payments. Notwithstanding the provisions of
826	s. 409.915, counties are exempt from contributing toward the
827	cost of this special reimbursement for hospitals serving a
828	disproportionate share of low-income patients. For the state
829	fiscal year 2004-2005, the agency shall not distribute moneys
830	under the regional perinatal intensive care centers
831	disproportionate share program, except as noted in subsection
832	(2). In the event the Centers for Medicare and Medicaid Services
833	do not approve Florida's inpatient hospital state plan amendment
834	for the public disproportionate share program by January 1,
835	2005, the agency may make payments to hospitals under the
836	regional perinatal intensive care centers disproportionate share
837	program.
838	(1)  The following formula shall be used by the agency to
839	calculate the total amount earned for hospitals that participate
840	in the regional perinatal intensive care center program:
841
842	TAE = HDSP/THDSP
843
844	Where:
845	TAE = total amount earned by a regional perinatal intensive
846	care center.
847	HDSP = the prior state fiscal year regional perinatal
848	intensive care center disproportionate share payment to the
849	individual hospital.
850	THDSP = the prior state fiscal year total regional
851	perinatal intensive care center disproportionate share payments
852	to all hospitals.
853
854	(2)  The total additional payment for hospitals that
855	participate in the regional perinatal intensive care center
856	program shall be calculated by the agency as follows:
857
858	TAP = TAE x TA
859
860	Where:
861	TAP = total additional payment for a regional perinatal
862	intensive care center.
863	TAE = total amount earned by a regional perinatal intensive
864	care center.
865	TA = total appropriation for the regional perinatal
866	intensive care center disproportionate share program.
867
868	(3)  In order to receive payments under this section, a
869	hospital must be participating in the regional perinatal
870	intensive care center program pursuant to chapter 383 and must
871	meet the following additional requirements:
872	(a)  Agree to conform to all departmental and agency
873	requirements to ensure high quality in the provision of
874	services, including criteria adopted by departmental and agency
875	rule concerning staffing ratios, medical records, standards of
876	care, equipment, space, and such other standards and criteria as
877	the department and agency deem appropriate as specified by rule.
878	(b)  Agree to provide information to the department and
879	agency, in a form and manner to be prescribed by rule of the
880	department and agency, concerning the care provided to all
881	patients in neonatal intensive care centers and high-risk
882	maternity care.
883	(c)  Agree to accept all patients for neonatal intensive
884	care and high-risk maternity care, regardless of ability to pay,
885	on a functional space-available basis.
886	(d)  Agree to develop arrangements with other maternity and
887	neonatal care providers in the hospital's region for the
888	appropriate receipt and transfer of patients in need of
889	specialized maternity and neonatal intensive care services.
890	(e)  Agree to establish and provide a developmental
891	evaluation and services program for certain high-risk neonates,
892	as prescribed and defined by rule of the department.
893	(f)  Agree to sponsor a program of continuing education in
894	perinatal care for health care professionals within the region
895	of the hospital, as specified by rule.
896	(g)  Agree to provide backup and referral services to the
897	department's county health departments and other low-income
898	perinatal providers within the hospital's region, including the
899	development of written agreements between these organizations
900	and the hospital.
901	(h)  Agree to arrange for transportation for high-risk
902	obstetrical patients and neonates in need of transfer from the
903	community to the hospital or from the hospital to another more
904	appropriate facility.
905	(4)  Hospitals which fail to comply with any of the
906	conditions in subsection (3) or the applicable rules of the
907	department and agency shall not receive any payments under this
908	section until full compliance is achieved. A hospital which is
909	not in compliance in two or more consecutive quarters shall not
910	receive its share of the funds. Any forfeited funds shall be
911	distributed by the remaining participating regional perinatal
912	intensive care center program hospitals.
913	Section 15.  Section 409.9113, Florida Statutes, is amended
914	to read:
915	409.9113  Disproportionate share program for teaching
916	hospitals.--In addition to the payments made under ss. 409.911
917	and 409.9112, the Agency for Health Care Administration shall
918	make disproportionate share payments to statutorily defined
919	teaching hospitals for their increased costs associated with
920	medical education programs and for tertiary health care services
921	provided to the indigent. This system of payments shall conform
922	with federal requirements and shall distribute funds in each
923	fiscal year for which an appropriation is made by making
924	quarterly Medicaid payments. Notwithstanding s. 409.915,
925	counties are exempt from contributing toward the cost of this
926	special reimbursement for hospitals serving a disproportionate
927	share of low-income patients. For the state fiscal year 2004-
928	2005, the agency shall not distribute moneys under the teaching
929	hospital disproportionate share program, except as noted in
930	subsection (2). In the event the Centers for Medicare and
931	Medicaid Services do not approve Florida's inpatient hospital
932	state plan amendment for the public disproportionate share
933	program by January 1, 2005, the agency may make payments to
934	hospitals under the teaching hospital disproportionate share
935	program.
936	(1)  On or before September 15 of each year, the Agency for
937	Health Care Administration shall calculate an allocation
938	fraction to be used for distributing funds to state statutory
939	teaching hospitals. Subsequent to the end of each quarter of the
940	state fiscal year, the agency shall distribute to each statutory
941	teaching hospital, as defined in s. 408.07, an amount determined
942	by multiplying one-fourth of the funds appropriated for this
943	purpose by the Legislature times such hospital's allocation
944	fraction. The allocation fraction for each such hospital shall
945	be determined by the sum of three primary factors, divided by
946	three. The primary factors are:
947	(a)  The number of nationally accredited graduate medical
948	education programs offered by the hospital, including programs
949	accredited by the Accreditation Council for Graduate Medical
950	Education and the combined Internal Medicine and Pediatrics
951	programs acceptable to both the American Board of Internal
952	Medicine and the American Board of Pediatrics at the beginning
953	of the state fiscal year preceding the date on which the
954	allocation fraction is calculated. The numerical value of this
955	factor is the fraction that the hospital represents of the total
956	number of programs, where the total is computed for all state
957	statutory teaching hospitals.
958	(b)  The number of full-time equivalent trainees in the
959	hospital, which comprises two components:
960	1.  The number of trainees enrolled in nationally
961	accredited graduate medical education programs, as defined in
962	paragraph (a). Full-time equivalents are computed using the
963	fraction of the year during which each trainee is primarily
964	assigned to the given institution, over the state fiscal year
965	preceding the date on which the allocation fraction is
966	calculated. The numerical value of this factor is the fraction
967	that the hospital represents of the total number of full-time
968	equivalent trainees enrolled in accredited graduate programs,
969	where the total is computed for all state statutory teaching
970	hospitals.
971	2.  The number of medical students enrolled in accredited
972	colleges of medicine and engaged in clinical activities,
973	including required clinical clerkships and clinical electives.
974	Full-time equivalents are computed using the fraction of the
975	year during which each trainee is primarily assigned to the
976	given institution, over the course of the state fiscal year
977	preceding the date on which the allocation fraction is
978	calculated. The numerical value of this factor is the fraction
979	that the given hospital represents of the total number of full-
980	time equivalent students enrolled in accredited colleges of
981	medicine, where the total is computed for all state statutory
982	teaching hospitals.
983
984	The primary factor for full-time equivalent trainees is computed
985	as the sum of these two components, divided by two.
986	(c)  A service index that comprises three components:
987	1.  The Agency for Health Care Administration Service
988	Index, computed by applying the standard Service Inventory
989	Scores established by the Agency for Health Care Administration
990	to services offered by the given hospital, as reported on
991	Worksheet A-2 for the last fiscal year reported to the agency
992	before the date on which the allocation fraction is calculated.
993	The numerical value of this factor is the fraction that the
994	given hospital represents of the total Agency for Health Care
995	Administration Service Index values, where the total is computed
996	for all state statutory teaching hospitals.
997	2.  A volume-weighted service index, computed by applying
998	the standard Service Inventory Scores established by the Agency
999	for Health Care Administration to the volume of each service,
1000	expressed in terms of the standard units of measure reported on
1001	Worksheet A-2 for the last fiscal year reported to the agency
1002	before the date on which the allocation factor is calculated.
1003	The numerical value of this factor is the fraction that the
1004	given hospital represents of the total volume-weighted service
1005	index values, where the total is computed for all state
1006	statutory teaching hospitals.
1007	3.  Total Medicaid payments to each hospital for direct
1008	inpatient and outpatient services during the fiscal year
1009	preceding the date on which the allocation factor is calculated.
1010	This includes payments made to each hospital for such services
1011	by Medicaid prepaid health plans, whether the plan was
1012	administered by the hospital or not. The numerical value of this
1013	factor is the fraction that each hospital represents of the
1014	total of such Medicaid payments, where the total is computed for
1015	all state statutory teaching hospitals.
1016
1017	The primary factor for the service index is computed as the sum
1018	of these three components, divided by three.
1019	(2)  By October 1 of each year, the agency shall use the
1020	following formula to calculate the maximum additional
1021	disproportionate share payment for statutorily defined teaching
1022	hospitals:
1023
1024	TAP = THAF x A
1025
1026	Where:
1027	TAP = total additional payment.
1028	THAF = teaching hospital allocation factor.
1029	A = amount appropriated for a teaching hospital
1030	disproportionate share program.
1031	Section 16.  Section 409.9117, Florida Statutes, is amended
1032	to read:
1033	409.9117  Primary care disproportionate share program.--
1034	For the state fiscal year 2004-2005, the agency shall not
1035	distribute moneys under the primary care disproportionate share
1036	program, except as noted in subsection (2). In the event the
1037	Centers for Medicare and Medicaid Services do not approve
1038	Florida's inpatient hospital state plan amendment for the public
1039	disproportionate share program by January 1, 2005, the agency
1040	may make payments to hospitals under the primary care
1041	disproportionate share program.
1042	(1)  If federal funds are available for disproportionate
1043	share programs in addition to those otherwise provided by law,
1044	there shall be created a primary care disproportionate share
1045	program.
1046	(2)  The following formula shall be used by the agency to
1047	calculate the total amount earned for hospitals that participate
1048	in the primary care disproportionate share program:
1049
1050	TAE = HDSP/THDSP
1051
1052	Where:
1053	TAE = total amount earned by a hospital participating in
1054	the primary care disproportionate share program.
1055	HDSP = the prior state fiscal year primary care
1056	disproportionate share payment to the individual hospital.
1057	THDSP = the prior state fiscal year total primary care
1058	disproportionate share payments to all hospitals.
1059
1060	(3)  The total additional payment for hospitals that
1061	participate in the primary care disproportionate share program
1062	shall be calculated by the agency as follows:
1063
1064	TAP = TAE x TA
1065
1066	Where:
1067	TAP = total additional payment for a primary care hospital.
1068	TAE = total amount earned by a primary care hospital.
1069	TA = total appropriation for the primary care
1070	disproportionate share program.
1071
1072	(4)  In the establishment and funding of this program, the
1073	agency shall use the following criteria in addition to those
1074	specified in s. 409.911, payments may not be made to a hospital
1075	unless the hospital agrees to:
1076	(a)  Cooperate with a Medicaid prepaid health plan, if one
1077	exists in the community.
1078	(b)  Ensure the availability of primary and specialty care
1079	physicians to Medicaid recipients who are not enrolled in a
1080	prepaid capitated arrangement and who are in need of access to
1081	such physicians.
1082	(c)  Coordinate and provide primary care services free of
1083	charge, except copayments, to all persons with incomes up to 100
1084	percent of the federal poverty level who are not otherwise
1085	covered by Medicaid or another program administered by a
1086	governmental entity, and to provide such services based on a
1087	sliding fee scale to all persons with incomes up to 200 percent
1088	of the federal poverty level who are not otherwise covered by
1089	Medicaid or another program administered by a governmental
1090	entity, except that eligibility may be limited to persons who
1091	reside within a more limited area, as agreed to by the agency
1092	and the hospital.
1093	(d)  Contract with any federally qualified health center,
1094	if one exists within the agreed geopolitical boundaries,
1095	concerning the provision of primary care services, in order to
1096	guarantee delivery of services in a nonduplicative fashion, and
1097	to provide for referral arrangements, privileges, and
1098	admissions, as appropriate. The hospital shall agree to provide
1099	at an onsite or offsite facility primary care services within 24
1100	hours to which all Medicaid recipients and persons eligible
1101	under this paragraph who do not require emergency room services
1102	are referred during normal daylight hours.
1103	(e)  Cooperate with the agency, the county, and other
1104	entities to ensure the provision of certain public health
1105	services, case management, referral and acceptance of patients,
1106	and sharing of epidemiological data, as the agency and the
1107	hospital find mutually necessary and desirable to promote and
1108	protect the public health within the agreed geopolitical
1109	boundaries.
1110	(f)  In cooperation with the county in which the hospital
1111	resides, develop a low-cost, outpatient, prepaid health care
1112	program to persons who are not eligible for the Medicaid
1113	program, and who reside within the area.
1114	(g)  Provide inpatient services to residents within the
1115	area who are not eligible for Medicaid or Medicare, and who do
1116	not have private health insurance, regardless of ability to pay,
1117	on the basis of available space, except that nothing shall
1118	prevent the hospital from establishing bill collection programs
1119	based on ability to pay.
1120	(h)  Work with the Florida Healthy Kids Corporation, the
1121	Florida Health Care Purchasing Cooperative, and business health
1122	coalitions, as appropriate, to develop a feasibility study and
1123	plan to provide a low-cost comprehensive health insurance plan
1124	to persons who reside within the area and who do not have access
1125	to such a plan.
1126	(i)  Work with public health officials and other experts to
1127	provide community health education and prevention activities
1128	designed to promote healthy lifestyles and appropriate use of
1129	health services.
1130	(j)  Work with the local health council to develop a plan
1131	for promoting access to affordable health care services for all
1132	persons who reside within the area, including, but not limited
1133	to, public health services, primary care services, inpatient
1134	services, and affordable health insurance generally.
1135
1136	Any hospital that fails to comply with any of the provisions of
1137	this subsection, or any other contractual condition, may not
1138	receive payments under this section until full compliance is
1139	achieved.
1140	Section 17.  Section 409.912, Florida Statutes, is amended
1141	to read:
1142	409.912  Cost-effective purchasing of health care.--The
1143	agency shall purchase goods and services for Medicaid recipients
1144	in the most cost-effective manner consistent with the delivery
1145	of quality medical care. The agency shall maximize the use of
1146	prepaid per capita and prepaid aggregate fixed-sum basis
1147	services when appropriate and other alternative service delivery
1148	and reimbursement methodologies, including competitive bidding
1149	pursuant to s. 287.057, designed to facilitate the cost-
1150	effective purchase of a case-managed continuum of care. The
1151	agency shall also require providers to minimize the exposure of
1152	recipients to the need for acute inpatient, custodial, and other
1153	institutional care and the inappropriate or unnecessary use of
1154	high-cost services. The agency may establish prior authorization
1155	requirements for certain populations of Medicaid beneficiaries,
1156	certain drug classes, or particular drugs to prevent fraud,
1157	abuse, overuse, and possible dangerous drug interactions. The
1158	Pharmaceutical and Therapeutics Committee shall make
1159	recommendations to the agency on drugs for which prior
1160	authorization is required. The agency shall inform the
1161	Pharmaceutical and Therapeutics Committee of its decisions
1162	regarding drugs subject to prior authorization. The agency is
1163	authorized to limit the entities it contracts with or enrolls as
1164	Medicaid providers by developing a provider network through
1165	provider credentialing. The agency may limit its network based
1166	on the assessment of beneficiary access to care, provider
1167	availability, provider quality standards, time and distance
1168	standards for access to care, the cultural competence of the
1169	provider network, demographic characteristics of Medicaid
1170	beneficiaries, practice and provider-to-beneficiary standards,
1171	appointment wait times, beneficiary use of services, provider
1172	turnover, provider profiling, provider licensure history,
1173	previous program integrity investigations and findings, peer
1174	review, provider Medicaid policy and billing compliance record,
1175	clinical and medical record audits, and other factors. Providers
1176	shall not be entitled to enrollment in the Medicaid provider
1177	network. The agency is authorized to seek federal waivers
1178	necessary to implement this policy.
1179	(1)  The agency shall work with the Department of Children
1180	and Family Services to ensure access of children and families in
1181	the child protection system to needed and appropriate mental
1182	health and substance abuse services.
1183	(2)  The agency may enter into agreements with appropriate
1184	agents of other state agencies or of any agency of the Federal
1185	Government and accept such duties in respect to social welfare
1186	or public aid as may be necessary to implement the provisions of
1187	Title XIX of the Social Security Act and ss. 409.901-409.920.
1188	(3)  The agency may contract with health maintenance
1189	organizations certified pursuant to part I of chapter 641 for
1190	the provision of services to recipients.
1191	(4)  The agency may contract with:
1192	(a)  An entity that provides no prepaid health care
1193	services other than Medicaid services under contract with the
1194	agency and which is owned and operated by a county, county
1195	health department, or county-owned and operated hospital to
1196	provide health care services on a prepaid or fixed-sum basis to
1197	recipients, which entity may provide such prepaid services
1198	either directly or through arrangements with other providers.
1199	Such prepaid health care services entities must be licensed
1200	under parts I and III by January 1, 1998, and until then are
1201	exempt from the provisions of part I of chapter 641. An entity
1202	recognized under this paragraph which demonstrates to the
1203	satisfaction of the Office of Insurance Regulation of the
1204	Financial Services Commission that it is backed by the full
1205	faith and credit of the county in which it is located may be
1206	exempted from s. 641.225.
1207	(b)  An entity that is providing comprehensive behavioral
1208	health care services to certain Medicaid recipients through a
1209	capitated, prepaid arrangement pursuant to the federal waiver
1210	provided for by s. 409.905(5). Such an entity must be licensed
1211	under chapter 624, chapter 636, or chapter 641 and must possess
1212	the clinical systems and operational competence to manage risk
1213	and provide comprehensive behavioral health care to Medicaid
1214	recipients. As used in this paragraph, the term "comprehensive
1215	behavioral health care services" means covered mental health and
1216	substance abuse treatment services that are available to
1217	Medicaid recipients. The secretary of the Department of Children
1218	and Family Services shall approve provisions of procurements
1219	related to children in the department's care or custody prior to
1220	enrolling such children in a prepaid behavioral health plan. Any
1221	contract awarded under this paragraph must be competitively
1222	procured. In developing the behavioral health care prepaid plan
1223	procurement document, the agency shall ensure that the
1224	procurement document requires the contractor to develop and
1225	implement a plan to ensure compliance with s. 394.4574 related
1226	to services provided to residents of licensed assisted living
1227	facilities that hold a limited mental health license. Except as
1228	provided in subparagraph 8., the agency shall seek federal
1229	approval to contract with a single entity meeting these
1230	requirements to provide comprehensive behavioral health care
1231	services to all Medicaid recipients not enrolled in a managed
1232	care plan in an AHCA area. Each entity must offer sufficient
1233	choice of providers in its network to ensure recipient access to
1234	care and the opportunity to select a provider with whom they are
1235	satisfied. The network shall include all public mental health
1236	hospitals. To ensure unimpaired access to behavioral health care
1237	services by Medicaid recipients, all contracts issued pursuant
1238	to this paragraph shall require 80 percent of the capitation
1239	paid to the managed care plan, including health maintenance
1240	organizations, to be expended for the provision of behavioral
1241	health care services. In the event the managed care plan expends
1242	less than 80 percent of the capitation paid pursuant to this
1243	paragraph for the provision of behavioral health care services,
1244	the difference shall be returned to the agency. The agency shall
1245	provide the managed care plan with a certification letter
1246	indicating the amount of capitation paid during each calendar
1247	year for the provision of behavioral health care services
1248	pursuant to this section. The agency may reimburse for substance
1249	abuse treatment services on a fee-for-service basis until the
1250	agency finds that adequate funds are available for capitated,
1251	prepaid arrangements.
1252	1.  By January 1, 2001, the agency shall modify the
1253	contracts with the entities providing comprehensive inpatient
1254	and outpatient mental health care services to Medicaid
1255	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
1256	Counties, to include substance abuse treatment services.
1257	2.  By July 1, 2003, the agency and the Department of
1258	Children and Family Services shall execute a written agreement
1259	that requires collaboration and joint development of all policy,
1260	budgets, procurement documents, contracts, and monitoring plans
1261	that have an impact on the state and Medicaid community mental
1262	health and targeted case management programs.
1263	3.  Except as provided in subparagraph 8., by July 1, 2006,
1264	the agency and the Department of Children and Family Services
1265	shall contract with managed care entities in each AHCA area
1266	except area 6 or arrange to provide comprehensive inpatient and
1267	outpatient mental health and substance abuse services through
1268	capitated prepaid arrangements to all Medicaid recipients who
1269	are eligible to participate in such plans under federal law and
1270	regulation. In AHCA areas where eligible individuals number less
1271	than 150,000, the agency shall contract with a single managed
1272	care plan to provide comprehensive behavioral health services to
1273	all recipients who are not enrolled in a Medicaid health
1274	maintenance organization. The agency may contract with more than
1275	one comprehensive behavioral health provider to provide care to
1276	recipients who are not enrolled in a Medicaid health maintenance
1277	organization plan in AHCA areas where the eligible population
1278	exceeds 150,000. Contracts for comprehensive behavioral health
1279	providers awarded pursuant to this section shall be
1280	competitively procured. Both for-profit and not-for-profit
1281	corporations shall be eligible to compete. Managed care plans
1282	contracting with the agency under subsection (3) shall provide
1283	and receive payment for the same comprehensive behavioral health
1284	benefits as provided in AHCA rules, including handbooks
1285	incorporated by reference.
1286	4.  By October 1, 2003, the agency and the department shall
1287	submit a plan to the Governor, the President of the Senate, and
1288	the Speaker of the House of Representatives which provides for
1289	the full implementation of capitated prepaid behavioral health
1290	care in all areas of the state. The plan shall include
1291	provisions which ensure that children and families receiving
1292	foster care and other related services are appropriately served
1293	and that these services assist the community-based care lead
1294	agencies in meeting the goals and outcomes of the child welfare
1295	system. The plan will be developed with the participation of
1296	community-based lead agencies, community alliances, sheriffs,
1297	and community providers serving dependent children.
1298	a.  Implementation shall begin in 2003 in those AHCA areas
1299	of the state where the agency is able to establish sufficient
1300	capitation rates.
1301	b.  If the agency determines that the proposed capitation
1302	rate in any area is insufficient to provide appropriate
1303	services, the agency may adjust the capitation rate to ensure
1304	that care will be available. The agency and the department may
1305	use existing general revenue to address any additional required
1306	match but may not over-obligate existing funds on an annualized
1307	basis.
1308	c.  Subject to any limitations provided for in the General
1309	Appropriations Act, the agency, in compliance with appropriate
1310	federal authorization, shall develop policies and procedures
1311	that allow for certification of local and state funds.
1312	5.  Children residing in a statewide inpatient psychiatric
1313	program, or in a Department of Juvenile Justice or a Department
1314	of Children and Family Services residential program approved as
1315	a Medicaid behavioral health overlay services provider shall not
1316	be included in a behavioral health care prepaid health plan or
1317	any other Medicaid managed care plan pursuant to this paragraph.
1318	6.  In converting to a prepaid system of delivery, the
1319	agency shall in its procurement document require an entity
1320	providing only comprehensive behavioral health care services to
1321	prevent the displacement of indigent care patients by enrollees
1322	in the Medicaid prepaid health plan providing behavioral health
1323	care services from facilities receiving state funding to provide
1324	indigent behavioral health care, to facilities licensed under
1325	chapter 395 which do not receive state funding for indigent
1326	behavioral health care, or reimburse the unsubsidized facility
1327	for the cost of behavioral health care provided to the displaced
1328	indigent care patient.
1329	7.  Traditional community mental health providers under
1330	contract with the Department of Children and Family Services
1331	pursuant to part IV of chapter 394, child welfare providers
1332	under contract with the Department of Children and Family
1333	Services in areas 1 and 6, and inpatient mental health providers
1334	licensed pursuant to chapter 395 must be offered an opportunity
1335	to accept or decline a contract to participate in any provider
1336	network for prepaid behavioral health services.
1337	8.  For fiscal year 2004-2005, all Medicaid eligible
1338	children, except children in areas 1 and 6, whose cases are open
1339	for child welfare services in the HomeSafeNet system, shall be
1340	enrolled in MediPass or in Medicaid fee-for-service and all
1341	their behavioral health care services including inpatient,
1342	outpatient psychiatric, community mental health, and case
1343	management shall be reimbursed on a fee-for-service basis.
1344	Beginning July 1, 2005, such children, who are open for child
1345	welfare services in the HomeSafeNet system, shall receive their
1346	behavioral health care services through a specialty prepaid plan
1347	operated by community-based lead agencies either through a
1348	single agency or formal agreements among several agencies. The
1349	specialty prepaid plan must result in savings to the state
1350	comparable to savings achieved in other Medicaid managed care
1351	and prepaid programs. Such plan must provide mechanisms to
1352	maximize state and local revenues. The specialty prepaid plan
1353	shall be developed by the agency and The Department of Children
1354	and Family Services. The agency is authorized to seek any
1355	federal waivers to implement this initiative.
1356	(c)  A federally qualified health center or an entity owned
1357	by one or more federally qualified health centers or an entity
1358	owned by other migrant and community health centers receiving
1359	non-Medicaid financial support from the Federal Government to
1360	provide health care services on a prepaid or fixed-sum basis to
1361	recipients. Such prepaid health care services entity must be
1362	licensed under parts I and III of chapter 641, but shall be
1363	prohibited from serving Medicaid recipients on a prepaid basis,
1364	until such licensure has been obtained. However, such an entity
1365	is exempt from s. 641.225 if the entity meets the requirements
1366	specified in subsections (17) (15) and (18) (16).
1367	(d)  A provider service network may be reimbursed on a fee-
1368	for-service or prepaid basis. A provider service network which
1369	is reimbursed by the agency on a prepaid basis shall be exempt
1370	from parts I and III of chapter 641, but must meet appropriate
1371	financial reserve, quality assurance, and patient rights
1372	requirements as established by the agency. The agency shall
1373	award contracts on a competitive bid basis and shall select
1374	bidders based upon price and quality of care. Medicaid
1375	recipients assigned to a demonstration project shall be chosen
1376	equally from those who would otherwise have been assigned to
1377	prepaid plans and MediPass. The agency is authorized to seek
1378	federal Medicaid waivers as necessary to implement the
1379	provisions of this section.
1380	(e)  An entity that provides only comprehensive behavioral
1381	health care services to certain Medicaid recipients through an
1382	administrative services organization agreement. Such an entity
1383	must possess the clinical systems and operational competence to
1384	provide comprehensive health care to Medicaid recipients. As
1385	used in this paragraph, the term "comprehensive behavioral
1386	health care services" means covered mental health and substance
1387	abuse treatment services that are available to Medicaid
1388	recipients. Any contract awarded under this paragraph must be
1389	competitively procured. The agency must ensure that Medicaid
1390	recipients have available the choice of at least two managed
1391	care plans for their behavioral health care services.
1392	(f)  An entity that provides in-home physician services to
1393	test the cost-effectiveness of enhanced home-based medical care
1394	to Medicaid recipients with degenerative neurological diseases
1395	and other diseases or disabling conditions associated with high
1396	costs to Medicaid. The program shall be designed to serve very
1397	disabled persons and to reduce Medicaid reimbursed costs for
1398	inpatient, outpatient, and emergency department services. The
1399	agency shall contract with vendors on a risk-sharing basis.
1400	(g)  Children's provider networks that provide care
1401	coordination and care management for Medicaid-eligible pediatric
1402	patients, primary care, authorization of specialty care, and
1403	other urgent and emergency care through organized providers
1404	designed to service Medicaid eligibles under age 18 and
1405	pediatric emergency departments' diversion programs. The
1406	networks shall provide after-hour operations, including evening
1407	and weekend hours, to promote, when appropriate, the use of the
1408	children's networks rather than hospital emergency departments.
1409	(h)  An entity authorized in s. 430.205 to contract with
1410	the agency and the Department of Elderly Affairs to provide
1411	health care and social services on a prepaid or fixed-sum basis
1412	to elderly recipients. Such prepaid health care services
1413	entities are exempt from the provisions of part I of chapter 641
1414	for the first 3 years of operation. An entity recognized under
1415	this paragraph that demonstrates to the satisfaction of the
1416	Office of Insurance Regulation that it is backed by the full
1417	faith and credit of one or more counties in which it operates
1418	may be exempted from s. 641.225.
1419	(i)  A Children's Medical Services network, as defined in
1420	s. 391.021.
1421	(5)  By October 1, 2003, the agency and the department
1422	shall, to the extent feasible, develop a plan for implementing
1423	new Medicaid procedure codes for emergency and crisis care,
1424	supportive residential services, and other services designed to
1425	maximize the use of Medicaid funds for Medicaid-eligible
1426	recipients. The agency shall include in the agreement developed
1427	pursuant to subsection (4) a provision that ensures that the
1428	match requirements for these new procedure codes are met by
1429	certifying eligible general revenue or local funds that are
1430	currently expended on these services by the department with
1431	contracted alcohol, drug abuse, and mental health providers. The
1432	plan must describe specific procedure codes to be implemented, a
1433	projection of the number of procedures to be delivered during
1434	fiscal year 2003-2004, and a financial analysis that describes
1435	the certified match procedures, and accountability mechanisms,
1436	projects the earnings associated with these procedures, and
1437	describes the sources of state match. This plan may not be
1438	implemented in any part until approved by the Legislative Budget
1439	Commission. If such approval has not occurred by December 31,
1440	2003, the plan shall be submitted for consideration by the 2004
1441	Legislature.
1442	(6)  The agency may contract with any public or private
1443	entity otherwise authorized by this section on a prepaid or
1444	fixed-sum basis for the provision of health care services to
1445	recipients. An entity may provide prepaid services to
1446	recipients, either directly or through arrangements with other
1447	entities, if each entity involved in providing services:
1448	(a)  Is organized primarily for the purpose of providing
1449	health care or other services of the type regularly offered to
1450	Medicaid recipients;
1451	(b)  Ensures that services meet the standards set by the
1452	agency for quality, appropriateness, and timeliness;
1453	(c)  Makes provisions satisfactory to the agency for
1454	insolvency protection and ensures that neither enrolled Medicaid
1455	recipients nor the agency will be liable for the debts of the
1456	entity;
1457	(d)  Submits to the agency, if a private entity, a
1458	financial plan that the agency finds to be fiscally sound and
1459	that provides for working capital in the form of cash or
1460	equivalent liquid assets excluding revenues from Medicaid
1461	premium payments equal to at least the first 3 months of
1462	operating expenses or $200,000, whichever is greater;
1463	(e)  Furnishes evidence satisfactory to the agency of
1464	adequate liability insurance coverage or an adequate plan of
1465	self-insurance to respond to claims for injuries arising out of
1466	the furnishing of health care;
1467	(f)  Provides, through contract or otherwise, for periodic
1468	review of its medical facilities and services, as required by
1469	the agency; and
1470	(g)  Provides organizational, operational, financial, and
1471	other information required by the agency.
1472	(7)  The agency may contract on a prepaid or fixed-sum
1473	basis with any health insurer that:
1474	(a)  Pays for health care services provided to enrolled
1475	Medicaid recipients in exchange for a premium payment paid by
1476	the agency;
1477	(b)  Assumes the underwriting risk; and
1478	(c)  Is organized and licensed under applicable provisions
1479	of the Florida Insurance Code and is currently in good standing
1480	with the Office of Insurance Regulation.
1481	(8)  The agency may contract on a prepaid or fixed-sum
1482	basis with an exclusive provider organization to provide health
1483	care services to Medicaid recipients provided that the exclusive
1484	provider organization meets applicable managed care plan
1485	requirements in this section, ss. 409.9122, 409.9123, 409.9128,
1486	and 627.6472, and other applicable provisions of law.
1487	(9)  The Agency for Health Care Administration may provide
1488	cost-effective purchasing of chiropractic services on a fee-for-
1489	service basis to Medicaid recipients through arrangements with a
1490	statewide chiropractic preferred provider organization
1491	incorporated in this state as a not-for-profit corporation. The
1492	agency shall ensure that the benefit limits and prior
1493	authorization requirements in the current Medicaid program shall
1494	apply to the services provided by the chiropractic preferred
1495	provider organization.
1496	(10)  The agency shall not contract on a prepaid or fixed-
1497	sum basis for Medicaid services with an entity which knows or
1498	reasonably should know that any officer, director, agent,
1499	managing employee, or owner of stock or beneficial interest in
1500	excess of 5 percent common or preferred stock, or the entity
1501	itself, has been found guilty of, regardless of adjudication, or
1502	entered a plea of nolo contendere, or guilty, to:
1503	(a)  Fraud;
1504	(b)  Violation of federal or state antitrust statutes,
1505	including those proscribing price fixing between competitors and
1506	the allocation of customers among competitors;
1507	(c)  Commission of a felony involving embezzlement, theft,
1508	forgery, income tax evasion, bribery, falsification or
1509	destruction of records, making false statements, receiving
1510	stolen property, making false claims, or obstruction of justice;
1511	or
1512	(d)  Any crime in any jurisdiction which directly relates
1513	to the provision of health services on a prepaid or fixed-sum
1514	basis.
1515	(11)  The agency, after notifying the Legislature, may
1516	apply for waivers of applicable federal laws and regulations as
1517	necessary to implement more appropriate systems of health care
1518	for Medicaid recipients and reduce the cost of the Medicaid
1519	program to the state and federal governments and shall implement
1520	such programs, after legislative approval, within a reasonable
1521	period of time after federal approval. These programs must be
1522	designed primarily to reduce the need for inpatient care,
1523	custodial care and other long-term or institutional care, and
1524	other high-cost services.
1525	(a)  Prior to seeking legislative approval of such a waiver
1526	as authorized by this subsection, the agency shall provide
1527	notice and an opportunity for public comment. Notice shall be
1528	provided to all persons who have made requests of the agency for
1529	advance notice and shall be published in the Florida
1530	Administrative Weekly not less than 28 days prior to the
1531	intended action.
1532	(b)  Notwithstanding s. 216.292, funds that are
1533	appropriated to the Department of Elderly Affairs for the
1534	Assisted Living for the Elderly Medicaid waiver and are not
1535	expended shall be transferred to the agency to fund Medicaid-
1536	reimbursed nursing home care.
1537	(12)  The agency shall establish a postpayment utilization
1538	control program designed to identify recipients who may
1539	inappropriately overuse or underuse Medicaid services and shall
1540	provide methods to correct such misuse.
1541	(13)  The agency shall develop and provide coordinated
1542	systems of care for Medicaid recipients and may contract with
1543	public or private entities to develop and administer such
1544	systems of care among public and private health care providers
1545	in a given geographic area.
1546	(14)  The agency shall operate or contract for the
1547	operation of utilization management and incentive systems
1548	designed to encourage cost-effective use services.
1549	(15)(a)  The agency shall operate the Comprehensive
1550	Assessment and Review (CARES) nursing facility preadmission
1551	screening program to ensure that Medicaid payment for nursing
1552	facility care is made only for individuals whose conditions
1553	require such care and to ensure that long-term care services are
1554	provided in the setting most appropriate to the needs of the
1555	person and in the most economical manner possible. The CARES
1556	program shall also ensure that individuals participating in
1557	Medicaid home and community-based waiver programs meet criteria
1558	for those programs, consistent with approved federal waivers.
1559	(b)  The agency shall operate the CARES program through an
1560	interagency agreement with the Department of Elderly Affairs.
1561	(c)  Prior to making payment for nursing facility services
1562	for a Medicaid recipient, the agency must verify that the
1563	nursing facility preadmission screening program has determined
1564	that the individual requires nursing facility care and that the
1565	individual cannot be safely served in community-based programs.
1566	The nursing facility preadmission screening program shall refer
1567	a Medicaid recipient to a community-based program if the
1568	individual could be safely served at a lower cost and the
1569	recipient chooses to participate in such program.
1570	(d)  By January 1 of each year, the agency shall submit a
1571	report to the Legislature and the Office of Long-Term-Care
1572	Policy describing the operations of the CARES program. The
1573	report must describe:
1574	1.  Rate of diversion to community alternative programs;
1575	2.  CARES program staffing needs to achieve additional
1576	diversions;
1577	3.  Reasons the program is unable to place individuals in
1578	less restrictive settings when such individuals desired such
1579	services and could have been served in such settings;
1580	4.  Barriers to appropriate placement, including barriers
1581	due to policies or operations of other agencies or state-funded
1582	programs; and
1583	5.  Statutory changes necessary to ensure that individuals
1584	in need of long-term care services receive care in the least
1585	restrictive environment.
1586	(16)(a)  The agency shall identify health care utilization
1587	and price patterns within the Medicaid program which are not
1588	cost-effective or medically appropriate and assess the
1589	effectiveness of new or alternate methods of providing and
1590	monitoring service, and may implement such methods as it
1591	considers appropriate. Such methods may include disease
1592	management initiatives, an integrated and systematic approach
1593	for managing the health care needs of recipients who are at risk
1594	of or diagnosed with a specific disease by using best practices,
1595	prevention strategies, clinical-practice improvement, clinical
1596	interventions and protocols, outcomes research, information
1597	technology, and other tools and resources to reduce overall
1598	costs and improve measurable outcomes.
1599	(b)  The responsibility of the agency under this subsection
1600	shall include the development of capabilities to identify actual
1601	and optimal practice patterns; patient and provider educational
1602	initiatives; methods for determining patient compliance with
1603	prescribed treatments; fraud, waste, and abuse prevention and
1604	detection programs; and beneficiary case management programs.
1605	1.  The practice pattern identification program shall
1606	evaluate practitioner prescribing patterns based on national and
1607	regional practice guidelines, comparing practitioners to their
1608	peer groups. The agency and its Drug Utilization Review Board
1609	shall consult with a panel of practicing health care
1610	professionals consisting of the following: the Speaker of the
1611	House of Representatives and the President of the Senate shall
1612	each appoint three physicians licensed under chapter 458 or
1613	chapter 459; and the Governor shall appoint two pharmacists
1614	licensed under chapter 465 and one dentist licensed under
1615	chapter 466 who is an oral surgeon. Terms of the panel members
1616	shall expire at the discretion of the appointing official. The
1617	panel shall begin its work by August 1, 1999, regardless of the
1618	number of appointments made by that date. The advisory panel
1619	shall be responsible for evaluating treatment guidelines and
1620	recommending ways to incorporate their use in the practice
1621	pattern identification program. Practitioners who are
1622	prescribing inappropriately or inefficiently, as determined by
1623	the agency, may have their prescribing of certain drugs subject
1624	to prior authorization.
1625	2.  The agency shall also develop educational interventions
1626	designed to promote the proper use of medications by providers
1627	and beneficiaries.
1628	3.  The agency shall implement a pharmacy fraud, waste, and
1629	abuse initiative that may include a surety bond or letter of
1630	credit requirement for participating pharmacies, enhanced
1631	provider auditing practices, the use of additional fraud and
1632	abuse software, recipient management programs for beneficiaries
1633	inappropriately using their benefits, and other steps that will
1634	eliminate provider and recipient fraud, waste, and abuse. The
1635	initiative shall address enforcement efforts to reduce the
1636	number and use of counterfeit prescriptions.
1637	4.  By September 30, 2002, the agency shall contract with
1638	an entity in the state to implement a wireless handheld clinical
1639	pharmacology drug information database for practitioners. The
1640	initiative shall be designed to enhance the agency's efforts to
1641	reduce fraud, abuse, and errors in the prescription drug benefit
1642	program and to otherwise further the intent of this paragraph.
1643	5.  The agency may apply for any federal waivers needed to
1644	implement this paragraph.
1645	(17)  An entity contracting on a prepaid or fixed-sum basis
1646	shall, in addition to meeting any applicable statutory surplus
1647	requirements, also maintain at all times in the form of cash,
1648	investments that mature in less than 180 days allowable as
1649	admitted assets by the Office of Insurance Regulation, and
1650	restricted funds or deposits controlled by the agency or the
1651	Office of Insurance Regulation, a surplus amount equal to one-
1652	and-one-half times the entity's monthly Medicaid prepaid
1653	revenues. As used in this subsection, the term "surplus" means
1654	the entity's total assets minus total liabilities. If an
1655	entity's surplus falls below an amount equal to one-and-one-half
1656	times the entity's monthly Medicaid prepaid revenues, the agency
1657	shall prohibit the entity from engaging in marketing and
1658	preenrollment activities, shall cease to process new
1659	enrollments, and shall not renew the entity's contract until the
1660	required balance is achieved. The requirements of this
1661	subsection do not apply:
1662	(a)  Where a public entity agrees to fund any deficit
1663	incurred by the contracting entity; or
1664	(b)  Where the entity's performance and obligations are
1665	guaranteed in writing by a guaranteeing organization which:
1666	1.  Has been in operation for at least 5 years and has
1667	assets in excess of $50 million; or
1668	2.  Submits a written guarantee acceptable to the agency
1669	which is irrevocable during the term of the contracting entity's
1670	contract with the agency and, upon termination of the contract,
1671	until the agency receives proof of satisfaction of all
1672	outstanding obligations incurred under the contract.
1673	(18)(a)  The agency may require an entity contracting on a
1674	prepaid or fixed-sum basis to establish a restricted insolvency
1675	protection account with a federally guaranteed financial
1676	institution licensed to do business in this state. The entity
1677	shall deposit into that account 5 percent of the capitation
1678	payments made by the agency each month until a maximum total of
1679	2 percent of the total current contract amount is reached. The
1680	restricted insolvency protection account may be drawn upon with
1681	the authorized signatures of two persons designated by the
1682	entity and two representatives of the agency. If the agency
1683	finds that the entity is insolvent, the agency may draw upon the
1684	account solely with the two authorized signatures of
1685	representatives of the agency, and the funds may be disbursed to
1686	meet financial obligations incurred by the entity under the
1687	prepaid contract. If the contract is terminated, expired, or not
1688	continued, the account balance must be released by the agency to
1689	the entity upon receipt of proof of satisfaction of all
1690	outstanding obligations incurred under this contract.
1691	(b)  The agency may waive the insolvency protection account
1692	requirement in writing when evidence is on file with the agency
1693	of adequate insolvency insurance and reinsurance that will
1694	protect enrollees if the entity becomes unable to meet its
1695	obligations.
1696	(19)  An entity that contracts with the agency on a prepaid
1697	or fixed-sum basis for the provision of Medicaid services shall
1698	reimburse any hospital or physician that is outside the entity's
1699	authorized geographic service area as specified in its contract
1700	with the agency, and that provides services authorized by the
1701	entity to its members, at a rate negotiated with the hospital or
1702	physician for the provision of services or according to the
1703	lesser of the following:
1704	(a)  The usual and customary charges made to the general
1705	public by the hospital or physician; or
1706	(b)  The Florida Medicaid reimbursement rate established
1707	for the hospital or physician.
1708	(20)  When a merger or acquisition of a Medicaid prepaid
1709	contractor has been approved by the Office of Insurance
1710	Regulation pursuant to s. 628.4615, the agency shall approve the
1711	assignment or transfer of the appropriate Medicaid prepaid
1712	contract upon request of the surviving entity of the merger or
1713	acquisition if the contractor and the other entity have been in
1714	good standing with the agency for the most recent 12-month
1715	period, unless the agency determines that the assignment or
1716	transfer would be detrimental to the Medicaid recipients or the
1717	Medicaid program. To be in good standing, an entity must not
1718	have failed accreditation or committed any material violation of
1719	the requirements of s. 641.52 and must meet the Medicaid
1720	contract requirements. For purposes of this section, a merger or
1721	acquisition means a change in controlling interest of an entity,
1722	including an asset or stock purchase.
1723	(21)  Any entity contracting with the agency pursuant to
1724	this section to provide health care services to Medicaid
1725	recipients is prohibited from engaging in any of the following
1726	practices or activities:
1727	(a)  Practices that are discriminatory, including, but not
1728	limited to, attempts to discourage participation on the basis of
1729	actual or perceived health status.
1730	(b)  Activities that could mislead or confuse recipients,
1731	or misrepresent the organization, its marketing representatives,
1732	or the agency. Violations of this paragraph include, but are not
1733	limited to:
1734	1.  False or misleading claims that marketing
1735	representatives are employees or representatives of the state or
1736	county, or of anyone other than the entity or the organization
1737	by whom they are reimbursed.
1738	2.  False or misleading claims that the entity is
1739	recommended or endorsed by any state or county agency, or by any
1740	other organization which has not certified its endorsement in
1741	writing to the entity.
1742	3.  False or misleading claims that the state or county
1743	recommends that a Medicaid recipient enroll with an entity.
1744	4.  Claims that a Medicaid recipient will lose benefits
1745	under the Medicaid program, or any other health or welfare
1746	benefits to which the recipient is legally entitled, if the
1747	recipient does not enroll with the entity.
1748	(c)  Granting or offering of any monetary or other valuable
1749	consideration for enrollment, except as authorized by subsection
1750	(24) (22).
1751	(d)  Door-to-door solicitation of recipients who have not
1752	contacted the entity or who have not invited the entity to make
1753	a presentation.
1754	(e)  Solicitation of Medicaid recipients by marketing
1755	representatives stationed in state offices unless approved and
1756	supervised by the agency or its agent and approved by the
1757	affected state agency when solicitation occurs in an office of
1758	the state agency. The agency shall ensure that marketing
1759	representatives stationed in state offices shall market their
1760	managed care plans to Medicaid recipients only in designated
1761	areas and in such a way as to not interfere with the recipients'
1762	activities in the state office.
1763	(f)  Enrollment of Medicaid recipients.
1764	(22)  The agency may impose a fine for a violation of this
1765	section or the contract with the agency by a person or entity
1766	that is under contract with the agency. With respect to any
1767	nonwillful violation, such fine shall not exceed $2,500 per
1768	violation. In no event shall such fine exceed an aggregate
1769	amount of $10,000 for all nonwillful violations arising out of
1770	the same action. With respect to any knowing and willful
1771	violation of this section or the contract with the agency, the
1772	agency may impose a fine upon the entity in an amount not to
1773	exceed $20,000 for each such violation. In no event shall such
1774	fine exceed an aggregate amount of $100,000 for all knowing and
1775	willful violations arising out of the same action.
1776	(23)  A health maintenance organization or a person or
1777	entity exempt from chapter 641 that is under contract with the
1778	agency for the provision of health care services to Medicaid
1779	recipients may not use or distribute marketing materials used to
1780	solicit Medicaid recipients, unless such materials have been
1781	approved by the agency. The provisions of this subsection do not
1782	apply to general advertising and marketing materials used by a
1783	health maintenance organization to solicit both non-Medicaid
1784	subscribers and Medicaid recipients.
1785	(24)  Upon approval by the agency, health maintenance
1786	organizations and persons or entities exempt from chapter 641
1787	that are under contract with the agency for the provision of
1788	health care services to Medicaid recipients may be permitted
1789	within the capitation rate to provide additional health benefits
1790	that the agency has found are of high quality, are practicably
1791	available, provide reasonable value to the recipient, and are
1792	provided at no additional cost to the state.
1793	(25)  The agency shall utilize the statewide health
1794	maintenance organization complaint hotline for the purpose of
1795	investigating and resolving Medicaid and prepaid health plan
1796	complaints, maintaining a record of complaints and confirmed
1797	problems, and receiving disenrollment requests made by
1798	recipients.
1799	(26)  The agency shall require the publication of the
1800	health maintenance organization's and the prepaid health plan's
1801	consumer services telephone numbers and the "800" telephone
1802	number of the statewide health maintenance organization
1803	complaint hotline on each Medicaid identification card issued by
1804	a health maintenance organization or prepaid health plan
1805	contracting with the agency to serve Medicaid recipients and on
1806	each subscriber handbook issued to a Medicaid recipient.
1807	(27)  The agency shall establish a health care quality
1808	improvement system for those entities contracting with the
1809	agency pursuant to this section, incorporating all the standards
1810	and guidelines developed by the Medicaid Bureau of the Health
1811	Care Financing Administration as a part of the quality assurance
1812	reform initiative. The system shall include, but need not be
1813	limited to, the following:
1814	(a)  Guidelines for internal quality assurance programs,
1815	including standards for:
1816	1.  Written quality assurance program descriptions.
1817	2.  Responsibilities of the governing body for monitoring,
1818	evaluating, and making improvements to care.
1819	3.  An active quality assurance committee.
1820	4.  Quality assurance program supervision.
1821	5.  Requiring the program to have adequate resources to
1822	effectively carry out its specified activities.
1823	6.  Provider participation in the quality assurance
1824	program.
1825	7.  Delegation of quality assurance program activities.
1826	8.  Credentialing and recredentialing.
1827	9.  Enrollee rights and responsibilities.
1828	10.  Availability and accessibility to services and care.
1829	11.  Ambulatory care facilities.
1830	12.  Accessibility and availability of medical records, as
1831	well as proper recordkeeping and process for record review.
1832	13.  Utilization review.
1833	14.  A continuity of care system.
1834	15.  Quality assurance program documentation.
1835	16.  Coordination of quality assurance activity with other
1836	management activity.
1837	17.  Delivering care to pregnant women and infants; to
1838	elderly and disabled recipients, especially those who are at
1839	risk of institutional placement; to persons with developmental
1840	disabilities; and to adults who have chronic, high-cost medical
1841	conditions.
1842	(b)  Guidelines which require the entities to conduct
1843	quality-of-care studies which:
1844	1.  Target specific conditions and specific health service
1845	delivery issues for focused monitoring and evaluation.
1846	2.  Use clinical care standards or practice guidelines to
1847	objectively evaluate the care the entity delivers or fails to
1848	deliver for the targeted clinical conditions and health services
1849	delivery issues.
1850	3.  Use quality indicators derived from the clinical care
1851	standards or practice guidelines to screen and monitor care and
1852	services delivered.
1853	(c)  Guidelines for external quality review of each
1854	contractor which require: focused studies of patterns of care;
1855	individual care review in specific situations; and followup
1856	activities on previous pattern-of-care study findings and
1857	individual-care-review findings. In designing the external
1858	quality review function and determining how it is to operate as
1859	part of the state's overall quality improvement system, the
1860	agency shall construct its external quality review organization
1861	and entity contracts to address each of the following:
1862	1.  Delineating the role of the external quality review
1863	organization.
1864	2.  Length of the external quality review organization
1865	contract with the state.
1866	3.  Participation of the contracting entities in designing
1867	external quality review organization review activities.
1868	4.  Potential variation in the type of clinical conditions
1869	and health services delivery issues to be studied at each plan.
1870	5.  Determining the number of focused pattern-of-care
1871	studies to be conducted for each plan.
1872	6.  Methods for implementing focused studies.
1873	7.  Individual care review.
1874	8.  Followup activities.
1875	(28)  In order to ensure that children receive health care
1876	services for which an entity has already been compensated, an
1877	entity contracting with the agency pursuant to this section
1878	shall achieve an annual Early and Periodic Screening, Diagnosis,
1879	and Treatment (EPSDT) Service screening rate of at least 60
1880	percent for those recipients continuously enrolled for at least
1881	8 months. The agency shall develop a method by which the EPSDT
1882	screening rate shall be calculated. For any entity which does
1883	not achieve the annual 60 percent rate, the entity must submit a
1884	corrective action plan for the agency's approval. If the entity
1885	does not meet the standard established in the corrective action
1886	plan during the specified timeframe, the agency is authorized to
1887	impose appropriate contract sanctions. At least annually, the
1888	agency shall publicly release the EPSDT Services screening rates
1889	of each entity it has contracted with on a prepaid basis to
1890	serve Medicaid recipients.
1891	(29)  The agency shall perform enrollments and
1892	disenrollments for Medicaid recipients who are eligible for
1893	MediPass or managed care plans. Notwithstanding the prohibition
1894	contained in paragraph (21)(19)(f), managed care plans may
1895	perform preenrollments of Medicaid recipients under the
1896	supervision of the agency or its agents. For the purposes of
1897	this section, "preenrollment" means the provision of marketing
1898	and educational materials to a Medicaid recipient and assistance
1899	in completing the application forms, but shall not include
1900	actual enrollment into a managed care plan. An application for
1901	enrollment shall not be deemed complete until the agency or its
1902	agent verifies that the recipient made an informed, voluntary
1903	choice. The agency, in cooperation with the Department of
1904	Children and Family Services, may test new marketing initiatives
1905	to inform Medicaid recipients about their managed care options
1906	at selected sites. The agency shall report to the Legislature on
1907	the effectiveness of such initiatives. The agency may contract
1908	with a third party to perform managed care plan and MediPass
1909	enrollment and disenrollment services for Medicaid recipients
1910	and is authorized to adopt rules to implement such services. The
1911	agency may adjust the capitation rate only to cover the costs of
1912	a third-party enrollment and disenrollment contract, and for
1913	agency supervision and management of the managed care plan
1914	enrollment and disenrollment contract.
1915	(30)  Any lists of providers made available to Medicaid
1916	recipients, MediPass enrollees, or managed care plan enrollees
1917	shall be arranged alphabetically showing the provider's name and
1918	specialty and, separately, by specialty in alphabetical order.
1919	(31)  The agency shall establish an enhanced managed care
1920	quality assurance oversight function, to include at least the
1921	following components:
1922	(a)  At least quarterly analysis and followup, including
1923	sanctions as appropriate, of managed care participant
1924	utilization of services.
1925	(b)  At least quarterly analysis and followup, including
1926	sanctions as appropriate, of quality findings of the Medicaid
1927	peer review organization and other external quality assurance
1928	programs.
1929	(c)  At least quarterly analysis and followup, including
1930	sanctions as appropriate, of the fiscal viability of managed
1931	care plans.
1932	(d)  At least quarterly analysis and followup, including
1933	sanctions as appropriate, of managed care participant
1934	satisfaction and disenrollment surveys.
1935	(e)  The agency shall conduct regular and ongoing Medicaid
1936	recipient satisfaction surveys.
1937
1938	The analyses and followup activities conducted by the agency
1939	under its enhanced managed care quality assurance oversight
1940	function shall not duplicate the activities of accreditation
1941	reviewers for entities regulated under part III of chapter 641,
1942	but may include a review of the finding of such reviewers.
1943	(32)  Each managed care plan that is under contract with
1944	the agency to provide health care services to Medicaid
1945	recipients shall annually conduct a background check with the
1946	Florida Department of Law Enforcement of all persons with
1947	ownership interest of 5 percent or more or executive management
1948	responsibility for the managed care plan and shall submit to the
1949	agency information concerning any such person who has been found
1950	guilty of, regardless of adjudication, or has entered a plea of
1951	nolo contendere or guilty to, any of the offenses listed in s.
1952	435.03.
1953	(33)  The agency shall, by rule, develop a process whereby
1954	a Medicaid managed care plan enrollee who wishes to enter
1955	hospice care may be disenrolled from the managed care plan
1956	within 24 hours after contacting the agency regarding such
1957	request. The agency rule shall include a methodology for the
1958	agency to recoup managed care plan payments on a pro rata basis
1959	if payment has been made for the enrollment month when
1960	disenrollment occurs.
1961	(34)  The agency and entities which contract with the
1962	agency to provide health care services to Medicaid recipients
1963	under this section or s. 409.9122 must comply with the
1964	provisions of s. 641.513 in providing emergency services and
1965	care to Medicaid recipients and MediPass recipients.
1966	(35)  All entities providing health care services to
1967	Medicaid recipients shall make available, and encourage all
1968	pregnant women and mothers with infants to receive, and provide
1969	documentation in the medical records to reflect, the following:
1970	(a)  Healthy Start prenatal or infant screening.
1971	(b)  Healthy Start care coordination, when screening or
1972	other factors indicate need.
1973	(c)  Healthy Start enhanced services in accordance with the
1974	prenatal or infant screening results.
1975	(d)  Immunizations in accordance with recommendations of
1976	the Advisory Committee on Immunization Practices of the United
1977	States Public Health Service and the American Academy of
1978	Pediatrics, as appropriate.
1979	(e)  Counseling and services for family planning to all
1980	women and their partners.
1981	(f)  A scheduled postpartum visit for the purpose of
1982	voluntary family planning, to include discussion of all methods
1983	of contraception, as appropriate.
1984	(g)  Referral to the Special Supplemental Nutrition Program
1985	for Women, Infants, and Children (WIC).
1986	(36)  Any entity that provides Medicaid prepaid health plan
1987	services shall ensure the appropriate coordination of health
1988	care services with an assisted living facility in cases where a
1989	Medicaid recipient is both a member of the entity's prepaid
1990	health plan and a resident of the assisted living facility. If
1991	the entity is at risk for Medicaid targeted case management and
1992	behavioral health services, the entity shall inform the assisted
1993	living facility of the procedures to follow should an emergent
1994	condition arise.
1995	(37)  The agency may seek and implement federal waivers
1996	necessary to provide for cost-effective purchasing of home
1997	health services, private duty nursing services, transportation,
1998	independent laboratory services, and durable medical equipment
1999	and supplies through competitive bidding pursuant to s. 287.057.
2000	The agency may request appropriate waivers from the federal
2001	Health Care Financing Administration in order to competitively
2002	bid such services. The agency may exclude providers not selected
2003	through the bidding process from the Medicaid provider network.
2004	(38)  The Agency for Health Care Administration is directed
2005	to issue a request for proposal or intent to negotiate to
2006	implement on a demonstration basis an outpatient specialty
2007	services pilot project in a rural and urban county in the state.
2008	As used in this subsection, the term "outpatient specialty
2009	services" means clinical laboratory, diagnostic imaging, and
2010	specified home medical services to include durable medical
2011	equipment, prosthetics and orthotics, and infusion therapy.
2012	(a)  The entity that is awarded the contract to provide
2013	Medicaid managed care outpatient specialty services must, at a
2014	minimum, meet the following criteria:
2015	1.  The entity must be licensed by the Office of Insurance
2016	Regulation under part II of chapter 641.
2017	2.  The entity must be experienced in providing outpatient
2018	specialty services.
2019	3.  The entity must demonstrate to the satisfaction of the
2020	agency that it provides high-quality services to its patients.
2021	4.  The entity must demonstrate that it has in place a
2022	complaints and grievance process to assist Medicaid recipients
2023	enrolled in the pilot managed care program to resolve complaints
2024	and grievances.
2025	(b)  The pilot managed care program shall operate for a
2026	period of 3 years. The objective of the pilot program shall be
2027	to determine the cost-effectiveness and effects on utilization,
2028	access, and quality of providing outpatient specialty services
2029	to Medicaid recipients on a prepaid, capitated basis.
2030	(c)  The agency shall conduct a quality assurance review of
2031	the prepaid health clinic each year that the demonstration
2032	program is in effect. The prepaid health clinic is responsible
2033	for all expenses incurred by the agency in conducting a quality
2034	assurance review.
2035	(d)  The entity that is awarded the contract to provide
2036	outpatient specialty services to Medicaid recipients shall
2037	report data required by the agency in a format specified by the
2038	agency, for the purpose of conducting the evaluation required in
2039	paragraph (e).
2040	(e)  The agency shall conduct an evaluation of the pilot
2041	managed care program and report its findings to the Governor and
2042	the Legislature by no later than January 1, 2001.
2043	(39)  The agency shall enter into agreements with not-for-
2044	profit organizations based in this state for the purpose of
2045	providing vision screening.
2046	(40)(a)  The agency shall implement a Medicaid prescribed-
2047	drug spending-control program that includes the following
2048	components:
2049	1.  Medicaid prescribed-drug coverage for brand-name drugs
2050	for adult Medicaid recipients is limited to the dispensing of
2051	four brand-name drugs per month per recipient. Children are
2052	exempt from this restriction. Antiretroviral agents are excluded
2053	from this limitation. No requirements for prior authorization or
2054	other restrictions on medications used to treat mental illnesses
2055	such as schizophrenia, severe depression, or bipolar disorder
2056	may be imposed on Medicaid recipients. Medications that will be
2057	available without restriction for persons with mental illnesses
2058	include atypical antipsychotic medications, conventional
2059	antipsychotic medications, selective serotonin reuptake
2060	inhibitors, and other medications used for the treatment of
2061	serious mental illnesses. The agency shall also limit the amount
2062	of a prescribed drug dispensed to no more than a 34-day supply.
2063	The agency shall continue to provide unlimited generic drugs,
2064	contraceptive drugs and items, and diabetic supplies. Although a
2065	drug may be included on the preferred drug formulary, it would
2066	not be exempt from the four-brand limit. The agency may
2067	authorize exceptions to the brand-name-drug restriction based
2068	upon the treatment needs of the patients, only when such
2069	exceptions are based on prior consultation provided by the
2070	agency or an agency contractor, but the agency must establish
2071	procedures to ensure that:
2072	a.  There will be a response to a request for prior
2073	consultation by telephone or other telecommunication device
2074	within 24 hours after receipt of a request for prior
2075	consultation;
2076	b.  A 72-hour supply of the drug prescribed will be
2077	provided in an emergency or when the agency does not provide a
2078	response within 24 hours as required by sub-subparagraph a.; and
2079	c.  Except for the exception for nursing home residents and
2080	other institutionalized adults and except for drugs on the
2081	restricted formulary for which prior authorization may be sought
2082	by an institutional or community pharmacy, prior authorization
2083	for an exception to the brand-name-drug restriction is sought by
2084	the prescriber and not by the pharmacy. When prior authorization
2085	is granted for a patient in an institutional setting beyond the
2086	brand-name-drug restriction, such approval is authorized for 12
2087	months and monthly prior authorization is not required for that
2088	patient.
2089	2.  Reimbursement to pharmacies for Medicaid prescribed
2090	drugs shall be set at the lesser of: the average wholesale price
2091	(AWP) minus 15.4 percent, the wholesaler acquisition cost (WAC)
2092	plus 5.75 percent, the federal upper limit (FUL), the state
2093	maximum allowable cost (SMAC), or the usual and customary (UAC)
2094	charge billed by the provider the average wholesale price less
2095	13.25 percent.
2096	3.  The agency shall develop and implement a process for
2097	managing the drug therapies of Medicaid recipients who are using
2098	significant numbers of prescribed drugs each month. The
2099	management process may include, but is not limited to,
2100	comprehensive, physician-directed medical-record reviews, claims
2101	analyses, and case evaluations to determine the medical
2102	necessity and appropriateness of a patient's treatment plan and
2103	drug therapies. The agency may contract with a private
2104	organization to provide drug-program-management services. The
2105	Medicaid drug benefit management program shall include
2106	initiatives to manage drug therapies for HIV/AIDS patients,
2107	patients using 20 or more unique prescriptions in a 180-day
2108	period, and the top 1,000 patients in annual spending.
2109	4.  The agency may limit the size of its pharmacy network
2110	based on need, competitive bidding, price negotiations,
2111	credentialing, or similar criteria. The agency shall give
2112	special consideration to rural areas in determining the size and
2113	location of pharmacies included in the Medicaid pharmacy
2114	network. A pharmacy credentialing process may include criteria
2115	such as a pharmacy's full-service status, location, size,
2116	patient educational programs, patient consultation, disease-
2117	management services, and other characteristics. The agency may
2118	impose a moratorium on Medicaid pharmacy enrollment when it is
2119	determined that it has a sufficient number of Medicaid-
2120	participating providers.
2121	5.  The agency shall develop and implement a program that
2122	requires Medicaid practitioners who prescribe drugs to use a
2123	counterfeit-proof prescription pad for Medicaid prescriptions.
2124	The agency shall require the use of standardized counterfeit-
2125	proof prescription pads by Medicaid-participating prescribers or
2126	prescribers who write prescriptions for Medicaid recipients. The
2127	agency may implement the program in targeted geographic areas or
2128	statewide.
2129	6.  The agency may enter into arrangements that require
2130	manufacturers of generic drugs prescribed to Medicaid recipients
2131	to provide rebates of at least 15.1 percent of the average
2132	manufacturer price for the manufacturer's generic products.
2133	These arrangements shall require that if a generic-drug
2134	manufacturer pays federal rebates for Medicaid-reimbursed drugs
2135	at a level below 15.1 percent, the manufacturer must provide a
2136	supplemental rebate to the state in an amount necessary to
2137	achieve a 15.1-percent rebate level.
2138	7.  The agency may establish a preferred drug formulary in
2139	accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
2140	establishment of such formulary, it is authorized to negotiate
2141	supplemental rebates from manufacturers that are in addition to
2142	those required by Title XIX of the Social Security Act and at no
2143	less than 14 10 percent of the average manufacturer price as
2144	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2145	the federal or supplemental rebate, or both, equals or exceeds
2146	29 25 percent. There is no upper limit on the supplemental
2147	rebates the agency may negotiate. The agency may determine that
2148	specific products, brand-name or generic, are competitive at
2149	lower rebate percentages. Agreement to pay the minimum
2150	supplemental rebate percentage will guarantee a manufacturer
2151	that the Medicaid Pharmaceutical and Therapeutics Committee will
2152	consider a product for inclusion on the preferred drug
2153	formulary. However, a pharmaceutical manufacturer is not
2154	guaranteed placement on the formulary by simply paying the
2155	minimum supplemental rebate. Agency decisions will be made on
2156	the clinical efficacy of a drug and recommendations of the
2157	Medicaid Pharmaceutical and Therapeutics Committee, as well as
2158	the price of competing products minus federal and state rebates.
2159	The agency is authorized to contract with an outside agency or
2160	contractor to conduct negotiations for supplemental rebates. For
2161	the purposes of this section, the term "supplemental rebates"
2162	means may include, at the agency's discretion, cash rebates and
2163	other program benefits that offset a Medicaid expenditure.
2164	Effective July 1, 2004, value-added programs as a substitution
2165	for supplemental rebates are prohibited. Such other program
2166	benefits may include, but are not limited to, disease management
2167	programs, drug product donation programs, drug utilization
2168	control programs, prescriber and beneficiary counseling and
2169	education, fraud and abuse initiatives, and other services or
2170	administrative investments with guaranteed savings to the
2171	Medicaid program in the same year the rebate reduction is
2172	included in the General Appropriations Act. The agency is
2173	authorized to seek any federal waivers to implement this
2174	initiative.
2175	8.  The agency shall establish an advisory committee for
2176	the purposes of studying the feasibility of using a restricted
2177	drug formulary for nursing home residents and other
2178	institutionalized adults. The committee shall be comprised of
2179	seven members appointed by the Secretary of Health Care
2180	Administration. The committee members shall include two
2181	physicians licensed under chapter 458 or chapter 459; three
2182	pharmacists licensed under chapter 465 and appointed from a list
2183	of recommendations provided by the Florida Long-Term Care
2184	Pharmacy Alliance; and two pharmacists licensed under chapter
2185	465.
2186	9.  The Agency for Health Care Administration shall expand
2187	home delivery of pharmacy products. To assist Medicaid patients
2188	in securing their prescriptions and reduce program costs, the
2189	agency shall expand its current mail-order-pharmacy diabetes-
2190	supply program to include all generic and brand-name drugs used
2191	by Medicaid patients with diabetes. Medicaid recipients in the
2192	current program may obtain nondiabetes drugs on a voluntary
2193	basis. This initiative is limited to the geographic area covered
2194	by the current contract. The agency may seek and implement any
2195	federal waivers necessary to implement this subparagraph.
2196	10.  The agency shall limit to one dose per month any drug
2197	prescribed to treat erectile dysfunction.
2198	11.a.  The agency shall implement a Medicaid behavioral
2199	drug management system. The agency may contract with a vendor
2200	that has experience in operating behavioral drug management
2201	systems to implement this program. The agency is authorized to
2202	seek federal waivers to implement this program.
2203	b.  The agency, in conjunction with the Department of
2204	Children and Family Services, may implement the Medicaid
2205	behavioral drug management system that is designed to improve
2206	the quality of care and behavioral health prescribing practices
2207	based on best practice guidelines, improve patient adherence to
2208	medication plans, reduce clinical risk, and lower prescribed
2209	drug costs and the rate of inappropriate spending on Medicaid
2210	behavioral drugs. The program shall include the following
2211	elements:
2212	(I)  Provide for the development and adoption of best
2213	practice guidelines for behavioral health-related drugs such as
2214	antipsychotics, antidepressants, and medications for treating
2215	bipolar disorders and other behavioral conditions; translate
2216	them into practice; review behavioral health prescribers and
2217	compare their prescribing patterns to a number of indicators
2218	that are based on national standards; and determine deviations
2219	from best practice guidelines.
2220	(II)  Implement processes for providing feedback to and
2221	educating prescribers using best practice educational materials
2222	and peer-to-peer consultation.
2223	(III)  Assess Medicaid beneficiaries who are outliers in
2224	their use of behavioral health drugs with regard to the numbers
2225	and types of drugs taken, drug dosages, combination drug
2226	therapies, and other indicators of improper use of behavioral
2227	health drugs.
2228	(IV)  Alert prescribers to patients who fail to refill
2229	prescriptions in a timely fashion, are prescribed multiple same-
2230	class behavioral health drugs, and may have other potential
2231	medication problems.
2232	(V)  Track spending trends for behavioral health drugs and
2233	deviation from best practice guidelines.
2234	(VI)  Use educational and technological approaches to
2235	promote best practices, educate consumers, and train prescribers
2236	in the use of practice guidelines.
2237	(VII)  Disseminate electronic and published materials.
2238	(VIII)  Hold statewide and regional conferences.
2239	(IX)  Implement a disease management program with a model
2240	quality-based medication component for severely mentally ill
2241	individuals and emotionally disturbed children who are high
2242	users of care.
2243	c.  If the agency is unable to negotiate a contract with
2244	one or more manufacturers to finance and guarantee savings
2245	associated with a behavioral drug management program by
2246	September 1, 2004, the four-brand drug limit and preferred drug
2247	list prior-authorization requirements shall apply to mental-
2248	health-related drugs, notwithstanding any provision in
2249	subparagraph 1. The agency is authorized to seek federal waivers
2250	to implement this policy.
2251	12.  The agency is authorized to contract for drug rebate
2252	administration, including, but not limited to, calculating
2253	rebate amounts, invoicing manufacturers, negotiating disputes
2254	with manufacturers, and maintaining a database of rebate
2255	collections.
2256	13.  The agency may specify the preferred daily dosing form
2257	or strength for the purpose of promoting best practices with
2258	regard to the prescribing of certain drugs as specified in the
2259	General Appropriations Act and ensuring cost-effective
2260	prescribing practices.
2261	14.  The agency may require prior authorization for the
2262	off-label use of Medicaid-covered prescribed drugs as specified
2263	in the General Appropriations Act. The agency may, but is not
2264	required to, preauthorize the use of a product for an indication
2265	not in the approved labeling. Prior authorization may require
2266	the prescribing professional to provide information about the
2267	rationale and supporting medical evidence for the off-label use
2268	of a drug.
2269	15.  The agency shall implement a return and reuse program
2270	for drugs dispensed by pharmacies to institutional recipients,
2271	which includes payment of a $5 restocking fee for the
2272	implementation and operation of the program. The return and
2273	reuse program shall be implemented electronically and in a
2274	manner that promotes efficiency. The program must permit a
2275	pharmacy to exclude drugs from the program if it is not
2276	practical or cost-effective for the drug to be included and must
2277	provide for the return to inventory of drugs that cannot be
2278	credited or returned in a cost-effective manner.
2279	(b)  The agency shall implement this subsection to the
2280	extent that funds are appropriated to administer the Medicaid
2281	prescribed-drug spending-control program. The agency may
2282	contract all or any part of this program to private
2283	organizations.
2284	(c)  The agency shall submit quarterly reports to the
2285	Governor, the President of the Senate, and the Speaker of the
2286	House of Representatives which must include, but need not be
2287	limited to, the progress made in implementing this subsection
2288	and its effect on Medicaid prescribed-drug expenditures.
2289	(41)  Notwithstanding the provisions of chapter 287, the
2290	agency may, at its discretion, renew a contract or contracts for
2291	fiscal intermediary services one or more times for such periods
2292	as the agency may decide; however, all such renewals may not
2293	combine to exceed a total period longer than the term of the
2294	original contract.
2295	(42)  The agency shall provide for the development of a
2296	demonstration project by establishment in Miami-Dade County of a
2297	long-term-care facility licensed pursuant to chapter 395 to
2298	improve access to health care for a predominantly minority,
2299	medically underserved, and medically complex population and to
2300	evaluate alternatives to nursing home care and general acute
2301	care for such population. Such project is to be located in a
2302	health care condominium and colocated with licensed facilities
2303	providing a continuum of care. The establishment of this project
2304	is not subject to the provisions of s. 408.036 or s. 408.039.
2305	The agency shall report its findings to the Governor, the
2306	President of the Senate, and the Speaker of the House of
2307	Representatives by January 1, 2003.
2308	(43)  The agency shall develop and implement a utilization
2309	management program for Medicaid-eligible recipients for the
2310	management of occupational, physical, respiratory, and speech
2311	therapies. The agency shall establish a utilization program that
2312	may require prior authorization in order to ensure medically
2313	necessary and cost-effective treatments. The program shall be
2314	operated in accordance with a federally approved waiver program
2315	or state plan amendment. The agency may seek a federal waiver or
2316	state plan amendment to implement this program. The agency may
2317	also competitively procure these services from an outside vendor
2318	on a regional or statewide basis.
2319	(44)  The agency may contract on a prepaid or fixed-sum
2320	basis with appropriately licensed prepaid dental health plans to
2321	provide dental services.
2322	(45)  The Agency for Health Care Administration shall
2323	ensure that any Medicaid managed care plan as defined in s.
2324	409.9122(2)(h), whether paid on a capitated basis or a shared
2325	savings basis, is cost-effective. For purposes of this
2326	subsection, the term "cost-effective" means that a network's
2327	per-member, per-month costs to the state, including, but not
2328	limited to, fee-for-service costs, administrative costs, and
2329	case-management fees, must be no greater than the state's costs
2330	associated with contracts for Medicaid services established
2331	under subsection (3), which shall be actuarially adjusted for
2332	case mix, model, and service area. The agency shall conduct
2333	actuarially sound audits adjusted for case mix and model in
2334	order to ensure such cost-effectiveness and shall publish the
2335	audit results on its Internet website and submit the audit
2336	results annually to the Governor, the President of the Senate,
2337	and the Speaker of the House of Representatives no later than
2338	December 31 of each year. Contracts established pursuant to this
2339	subsection which are not cost-effective may not be renewed.
2340	Section 18.  Paragraphs (a) and (e) of subsection (2) of
2341	section 409.9122, Florida Statutes, are amended, and subsection
2342	(14) is added to said section, to read:
2343	409.9122  Mandatory Medicaid managed care enrollment;
2344	programs and procedures.--
2345	(2)(a)  The agency shall enroll in a managed care plan or
2346	MediPass all Medicaid recipients, except those Medicaid
2347	recipients who are: in an institution; enrolled in the Medicaid
2348	medically needy program; or eligible for both Medicaid and
2349	Medicare. Upon enrollment, individuals will be able to change
2350	their managed care option during the 90-day opt out period
2351	required by federal Medicaid regulations. The agency is
2352	authorized to seek the necessary Medicaid state plan amendment
2353	to implement this policy. However, to the extent permitted by
2354	federal law, the agency may enroll in a managed care plan or
2355	MediPass a Medicaid recipient who is exempt from mandatory
2356	managed care enrollment, provided that:
2357	1.  The recipient's decision to enroll in a managed care
2358	plan or MediPass is voluntary;
2359	2.  If the recipient chooses to enroll in a managed care
2360	plan, the agency has determined that the managed care plan
2361	provides specific programs and services which address the
2362	special health needs of the recipient; and
2363	3.  The agency receives any necessary waivers from the
2364	federal Health Care Financing Administration.
2365
2366	The agency shall develop rules to establish policies by which
2367	exceptions to the mandatory managed care enrollment requirement
2368	may be made on a case-by-case basis. The rules shall include the
2369	specific criteria to be applied when making a determination as
2370	to whether to exempt a recipient from mandatory enrollment in a
2371	managed care plan or MediPass. School districts participating in
2372	the certified school match program pursuant to ss. 409.908(21)
2373	and 1011.70 shall be reimbursed by Medicaid, subject to the
2374	limitations of s. 1011.70(1), for a Medicaid-eligible child
2375	participating in the services as authorized in s. 1011.70, as
2376	provided for in s. 409.9071, regardless of whether the child is
2377	enrolled in MediPass or a managed care plan. Managed care plans
2378	shall make a good faith effort to execute agreements with school
2379	districts regarding the coordinated provision of services
2380	authorized under s. 1011.70. County health departments
2381	delivering school-based services pursuant to ss. 381.0056 and
2382	381.0057 shall be reimbursed by Medicaid for the federal share
2383	for a Medicaid-eligible child who receives Medicaid-covered
2384	services in a school setting, regardless of whether the child is
2385	enrolled in MediPass or a managed care plan. Managed care plans
2386	shall make a good faith effort to execute agreements with county
2387	health departments regarding the coordinated provision of
2388	services to a Medicaid-eligible child. To ensure continuity of
2389	care for Medicaid patients, the agency, the Department of
2390	Health, and the Department of Education shall develop procedures
2391	for ensuring that a student's managed care plan or MediPass
2392	provider receives information relating to services provided in
2393	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2394	(e)  Medicaid recipients who are already enrolled in a
2395	managed care plan or MediPass shall be offered the opportunity
2396	to change managed care plans or MediPass providers on a
2397	staggered basis, as defined by the agency. All Medicaid
2398	recipients shall have 30 90 days in which to make a choice of
2399	managed care plans or MediPass providers. Those Medicaid
2400	recipients who do not make a choice shall be assigned to a
2401	managed care plan or MediPass in accordance with paragraph (f).
2402	To facilitate continuity of care, for a Medicaid recipient who
2403	is also a recipient of Supplemental Security Income (SSI), prior
2404	to assigning the SSI recipient to a managed care plan or
2405	MediPass, the agency shall determine whether the SSI recipient
2406	has an ongoing relationship with a MediPass provider or managed
2407	care plan, and if so, the agency shall assign the SSI recipient
2408	to that MediPass provider or managed care plan. Those SSI
2409	recipients who do not have such a provider relationship shall be
2410	assigned to a managed care plan or MediPass provider in
2411	accordance with paragraph (f).
2412	(14)  The agency shall include in its calculation of the
2413	hospital inpatient component of a Medicaid health maintenance
2414	organization's capitation rate any special payments, including,
2415	but not limited to, upper payment limit or disproportionate
2416	share hospital payments, made to qualifying hospitals through
2417	the fee-for-service program. The agency may seek federal waiver
2418	approval or state plan amendment as needed to implement this
2419	adjustment.
2420	Section 19.  Section 409.9124, Florida Statutes, is amended
2421	to read:
2422	409.9124  Managed care reimbursement.--
2423	(1)  The agency shall develop and adopt by rule a
2424	methodology for reimbursing managed care plans.
2425	(2)  Final rates shall be published annually prior to
2426	September 1 of each year, based on methodology that:
2427	(a)  Uses Medicaid's fee-for-service expenditures.
2428	(b)  Is certified as an actuarially sound computation of
2429	Medicaid fee-for-service expenditures for comparable groups of
2430	Medicaid recipients and includes all fee-for-service
2431	expenditures, including those fee-for-service expenditures
2432	attributable to recipients who are enrolled for a portion of a
2433	year in a managed care plan or waiver program.
2434	(c)  Is compliant with applicable federal laws and
2435	regulations, including, but not limited to, the requirements to
2436	include an allowance for administrative expenses and to account
2437	for all fee-for service expenditures, including fee-for-service
2438	expenditures for those groups enrolled for part of a year.
2439	(3)  Each year prior to establishing new managed care
2440	rates, the agency shall review all prior year adjustments for
2441	changes in trend, and shall reduce or eliminate those
2442	adjustments which are not reasonable and which reflect policies
2443	or programs which are not in effect.
2444	(4)(2)  The agency shall by rule prescribe those items of
2445	financial information which each managed care plan shall report
2446	to the agency, in the time periods prescribed by rule. In
2447	prescribing items for reporting and definitions of terms, the
2448	agency shall consult with the Office of Insurance Regulation of
2449	the Financial Services Commission wherever possible.
2450	(5)(3)  The agency shall quarterly examine the financial
2451	condition of each managed care plan, and its performance in
2452	serving Medicaid patients, and shall utilize examinations
2453	performed by the Office of Insurance Regulation wherever
2454	possible.
2455	Section 20.  Paragraph (b) of subsection (5) of section
2456	624.91, Florida Statutes, as amended by chapter 2004-1, Laws of
2457	Florida, is amended to read:
2458	624.91  The Florida Healthy Kids Corporation Act.--
2459	(5)  CORPORATION AUTHORIZATION, DUTIES, POWERS.--
2460	(b)  The Florida Healthy Kids Corporation shall:
2461	1.  Arrange for the collection of any family, local
2462	contributions, or employer payment or premium, in an amount to
2463	be determined by the board of directors, to provide for payment
2464	of premiums for comprehensive insurance coverage and for the
2465	actual or estimated administrative expenses.
2466	2.  Arrange for the collection of any voluntary
2467	contributions to provide for payment of premiums for children
2468	who are not eligible for medical assistance under Title XXI of
2469	the Social Security Act. Each fiscal year, the corporation shall
2470	establish a local match policy for the enrollment of non-Title-
2471	XXI-eligible children in the Healthy Kids program. By May 1 of
2472	each year, the corporation shall provide written notification of
2473	the amount to be remitted to the corporation for the following
2474	fiscal year under that policy. Local match sources may include,
2475	but are not limited to, funds provided by municipalities,
2476	counties, school boards, hospitals, health care providers,
2477	charitable organizations, special taxing districts, and private
2478	organizations. The minimum local match cash contributions
2479	required each fiscal year and local match credits shall be
2480	determined by the General Appropriations Act. The corporation
2481	shall calculate a county's local match rate based upon that
2482	county's percentage of the state's total non-Title-XXI
2483	expenditures as reported in the corporation's most recently
2484	audited financial statement. In awarding the local match
2485	credits, the corporation may consider factors including, but not
2486	limited to, population density, per capita income, and existing
2487	child-health-related expenditures and services.
2488	3.  Subject to the provisions of s. 409.8134, accept
2489	voluntary supplemental local match contributions that comply
2490	with the requirements of Title XXI of the Social Security Act
2491	for the purpose of providing additional coverage in contributing
2492	counties under Title XXI.
2493	4.  Establish the administrative and accounting procedures
2494	for the operation of the corporation.
2495	5.  Establish, with consultation from appropriate
2496	professional organizations, standards for preventive health
2497	services and providers and comprehensive insurance benefits
2498	appropriate to children, provided that such standards for rural
2499	areas shall not limit primary care providers to board-certified
2500	pediatricians.
2501	6.  Determine eligibility for children seeking to
2502	participate in the Title XXI-funded components of the Florida
2503	KidCare program consistent with the requirements specified in s.
2504	409.814, as well as the non-Title-XXI-eligible children as
2505	provided in subsection (3).
2506	7.  Establish procedures under which providers of local
2507	match to, applicants to and participants in the program may have
2508	grievances reviewed by an impartial body and reported to the
2509	board of directors of the corporation.
2510	8.  Establish participation criteria and, if appropriate,
2511	contract with an authorized insurer, health maintenance
2512	organization, or third-party administrator to provide
2513	administrative services to the corporation.
2514	9.  Establish enrollment criteria which shall include
2515	penalties or waiting periods of not fewer than 60 days for
2516	reinstatement of coverage upon voluntary cancellation for
2517	nonpayment of family premiums.
2518	10.  Contract with authorized insurers or any provider of
2519	health care services, meeting standards established by the
2520	corporation, for the provision of comprehensive insurance
2521	coverage to participants. Such standards shall include criteria
2522	under which the corporation may contract with more than one
2523	provider of health care services in program sites. Health plans
2524	shall be selected through a competitive bid process. The Florida
2525	Healthy Kids Corporation shall purchase goods and services in
2526	the most cost-effective manner consistent with the delivery of
2527	quality medical care. The maximum administrative cost for a
2528	Florida Healthy Kids Corporation contract shall be 15 percent.
2529	For health care contracts, the minimum medical loss ratio for a
2530	Florida Healthy Kids Corporation contract shall be 85 percent.
2531	For dental contracts, the remaining compensation to be paid to
2532	the authorized insurer or provider under a Florida Healthy Kids
2533	Corporation contract shall be no less than an amount which is 85
2534	percent of premium; to the extent any contract provision does
2535	not provide for this minimum compensation, this section shall
2536	prevail. The health plan selection criteria and scoring system,
2537	and the scoring results, shall be available upon request for
2538	inspection after the bids have been awarded.
2539	11.  Establish disenrollment criteria in the event local
2540	matching funds are insufficient to cover enrollments.
2541	12.  Develop and implement a plan to publicize the Florida
2542	Healthy Kids Corporation, the eligibility requirements of the
2543	program, and the procedures for enrollment in the program and to
2544	maintain public awareness of the corporation and the program.
2545	13.  Secure staff necessary to properly administer the
2546	corporation. Staff costs shall be funded from state and local
2547	matching funds and such other private or public funds as become
2548	available. The board of directors shall determine the number of
2549	staff members necessary to administer the corporation.
2550	14.  Provide a report annually to the Governor, Chief
2551	Financial Officer, Commissioner of Education, Senate President,
2552	Speaker of the House of Representatives, and Minority Leaders of
2553	the Senate and the House of Representatives.
2554	15.  Establish benefit packages which conform to the
2555	provisions of the Florida KidCare program, as created in ss.
2556	409.810-409.820.
2557	Section 21.  Notwithstanding s. 430.707, Florida Statutes,
2558	no later than September 1, 2005, subject to federal approval of
2559	the application to be a Program of All-inclusive Care for the
2560	Elderly site, the agency shall contract with one private, not-
2561	for-profit hospice organization located in Lee County and one
2562	such organization in Martin County, such an entity shall be
2563	exempt from the requirements of chapter 641 Florida Statutes,
2564	each of which provides comprehensive services, including hospice
2565	care for frail and elderly persons. The agency shall approve 100
2566	initial enrollees in the Program of All-inclusive Care for the
2567	Elderly in Lee and Martin counties. There shall be 50 initial
2568	enrollees in each county.
2569	Section 22.  In order to improve affordability and provide
2570	coverage for more facilities for residents of the state, the
2571	agency shall renegotiate the terms, conditions, and duration of
2572	its loan to the Long Term Care Risk Retention Group to provide
2573	that participating skilled nursing facilities be required to pay
2574	no more than $65 per bed for capitalization costs and
2575	participating adult living facilities will be required to pay no
2576	more than $33 per bed for capitalization costs.
2577	Section 23.  The Office of Program Policy Analysis and
2578	Government Accountability shall perform a review of optional
2579	Medicaid coverage for pregnant women, adult dentures, and the
2580	medically needy. The review shall determine the cost benefit to
2581	the state of providing these optional Medicaid items to Medicaid
2582	recipients. A report on the findings of the review shall be
2583	provided to the Executive Office of the Governor, the President
2584	of the Senate, and the Speaker of the House of Representatives
2585	by February 1, 2005.
2586	Section 24.  The Agency for Health Care Administration may
2587	contract on a capitated, prepaid, or fixed-sum basis with a
2588	laboratory service provider to provide statewide laboratory
2589	services for Medicaid recipients. The contract is not subject to
2590	any requirement of the Florida Insurance Code. Whether or not
2591	the agency procures statewide laboratory services, the agency
2592	shall ensure that it secures laboratory values from Medicaid-
2593	enrolled laboratories for all tests provided to Medicaid
2594	recipients. Such data shall be included in the Medicaid real-
2595	time web-based reporting system that interfaces with a real-time
2596	web-based prescription ordering and tracking system as required
2597	by the 2003-2004 General Appropriations Act.
2598	Section 25.  Except as otherwise provided herein, this act
2599	shall take effect July 1, 2004.
2600
2601	================= T I T L E  A M E N D M E N T =================
2602	Remove the entire title and insert:
2603	A bill to be entitled
2604	An act relating to health care; amending s. 400.23, F.S.;
2605	delaying a nursing home staffing increase; providing for
2606	retroactive application; amending s. 408.909, F.S.;
2607	providing additional eligibility; amending s. 409.8134,
2608	F.S.; revising a date for eligibility to be exempt from
2609	reapplying; amending s. 409.814, F.S.; providing
2610	additional eligibility for KidCare; requiring proof of
2611	family income with supporting documents; amending s.
2612	409.903, F.S.; eliminating services for certain persons;
2613	providing income deductions; amending s. 409.905, F.S.,
2614	relating to mandatory Medicaid services; requiring
2615	utilization management of private duty nursing services;
2616	establishing a hospitalist program; limiting payment for
2617	bed hold days for nursing facilities; amending s. 409.906,
2618	F.S., relating to optional Medicaid services; providing
2619	for adult denture and adult hearing and visual services;
2620	eliminating vacancy interim rates for intermediate care
2621	facility for the developmentally disabled services;
2622	requiring utilization management for home and community-
2623	based services; consolidating home and community-based
2624	services; amending s. 409.9065, F.S.; authorizing the
2625	agency to operate a pharmaceutical expense assistance
2626	program under certain circumstances; amending s. 409.907,
2627	F.S.; revising Medicaid provider agreement requirements;
2628	amending s. 409.908, F.S.; revising guidelines relating to
2629	reimbursement of Medicaid providers; mandating the payment
2630	method of county health departments; amending s. 409.911,
2631	F.S.; requiring the convening of the Medicaid
2632	Disproportionate Share Council and providing duties
2633	thereof; amending ss. 409.9112, 409.9113, and 409.9117,
2634	F.S.; restricting the agency from distributing certain
2635	funds; amending s. 409.912, F.S.; granting Medicaid
2636	provider network management; providing limits on certain
2637	drugs; providing for management of mental health drugs;
2638	reducing payment for pharmaceutical ingredient prices;
2639	expanding the existing pharmaceutical supplemental rebate
2640	threshold; correcting cross references; amending s.
2641	409.9124, F.S.; requiring the agency to publish managed
2642	care rates annually; amending s. 624.91, F.S.; revising
2643	Healthy Kids contract requirements; requiring certain
2644	programs be provided in certain counties; requiring the
2645	agency to negotiate to reduce costs; requiring a review by
2646	the Office of Program Policy Analysis and Government
2647	Accountability; requiring a report; authorizing the Agency
2648	for Health Care Administration to contract on a capitated,
2649	prepaid, or fixed-sum basis with a laboratory service
2650	provider to provide statewide laboratory services for
2651	Medicaid recipients; requiring the agency to ensure that
2652	it secures laboratory values from Medicaid-enrolled
2653	laboratories for all tests provided to Medicaid recipients
2654	and to include such data in the Medicaid real-time web-
2655	based reporting system that interfaces with a real time
2656	web-based prescription ordering and tracking system;
2657	providing effective dates.

CODING: Words stricken are deletions; words underlined are additions.