HB 1843

1	A bill to be entitled
2	An act relating to health care; amending s. 395.701, F.S.;
3	revising, providing, and deleting definitions relating to
4	assessments on certain net operating revenues; amending s.
5	400.23, F.S.; delaying a nursing home staffing increase;
6	amending s. 408.07, F.S.; revising a definition relating
7	to revenue deductions; amending s. 409.814, F.S.; revising
8	a redetermination review period for the Florida KidCare
9	Program; amending s. 409.905, F.S., relating to mandatory
10	Medicaid services; requiring utilization management of
11	private duty nursing services; establishing a hospitalist
12	program; limiting payment for bed hold days for nursing
13	facilities; amending s. 409.906, F.S., relating to
14	optional Medicaid services; providing for adult denture
15	and adult hearing and visual services; eliminating vacancy
16	interim rates for intermediate care facility for the
17	developmentally disabled services; requiring utilization
18	management for home and community-based services;
19	consolidating home and community-based services; amending
20	s. 409.908, F.S.; mandating the payment method of county
21	health departments; amending s. 409.911, F.S.; authorizing
22	the convening of the Medicaid Disproportionate Share Task
23	Force and providing duties thereof; amending s. 409.912,
24	F.S.; granting Medicaid provider network management;
25	providing limits on certain drugs; providing for
26	management of mental health drugs; expanding the existing
27	pharmaceutical supplemental rebate threshold; correcting
28	cross references; amending s. 409.9122, F.S.; revising
29	enrollment policies with respect to the selection of a
30	managed care plan at the time of Medicaid application;
31	amending s. 409.915, F.S.; providing a new calculation
32	method for county nursing home contributions to Medicaid;
33	authorizing the Agency for Health Care Administration to
34	seek federal waivers necessary to implement Medicaid
35	reform; providing effective dates.
36
37	Be It Enacted by the Legislature of the State of Florida:
38
39	Section 1.  Subsection (1) of section 395.701, Florida
40	Statutes, is amended to read:
41	395.701  Annual assessments on net operating revenues for
42	inpatient and outpatient services to fund public medical
43	assistance; administrative fines for failure to pay assessments
44	when due; exemption.--
45	(1)  For the purposes of this section, the term:
46	(a)  "Agency" means the Agency for Health Care
47	Administration.
48	(b)  "Deductions from revenue" means those items that can
49	be deducted from gross revenue in order to calculate net revenue
50	and includes bad debts; contractual adjustments; uncompensated
51	care; administrative, courtesy, and policy discounts and
52	adjustments; and other such revenue deductions, as well as the
53	offset of restricted donations and grants for indigent care.
54	Items to be deducted from gross revenue shall be reduced by the
55	amounts received for special Medicaid payments made pursuant to
56	s. 409.908(1), and disproportionate share payments made pursuant
57	to s. 409.911, s. 409.9112, s. 409.9113, s. 409.9115, s.
58	409.9116, s. 409.9117, s. 409.9118, or s. 409.9119.
59	(c)(b)  "Gross operating revenue" or "gross revenue" means
60	the sum of daily hospital service charges, ambulatory service
61	charges, ancillary service charges, and other operating revenue.
62	(d)(c)  "Hospital" means a health care institution as
63	defined in s. 395.002(13), but does not include any hospital
64	operated by the agency or the state Department of Corrections.
65	(e)(d)  "Net operating revenue" or "net revenue" means
66	gross revenue less deductions from revenue.
67	(e)  "Total deductions from gross revenue" or "deductions
68	from revenue" means reductions from gross revenue resulting from
69	inability to collect payment of charges. Such reductions include
70	bad debts; contractual adjustments; uncompensated care;
71	administrative, courtesy, and policy discounts and adjustments;
72	and other such revenue deductions, but also includes the offset
73	of restricted donations and grants for indigent care.
74	Section 2.  Paragraph (a) of subsection (3) of section
75	400.23, Florida Statutes, is amended to read:
76	400.23  Rules; evaluation and deficiencies; licensure
77	status.--
78	(3)(a)  The agency shall adopt rules providing for the
79	minimum staffing requirements for nursing homes. These
80	requirements shall include, for each nursing home facility, a
81	minimum certified nursing assistant staffing of 2.3 hours of
82	direct care per resident per day beginning January 1, 2002,
83	increasing to 2.6 hours of direct care per resident per day
84	beginning January 1, 2003, and increasing to 2.9 hours of direct
85	care per resident per day beginning July May 1, 2004. Beginning
86	January 1, 2002, no facility shall staff below one certified
87	nursing assistant per 20 residents, and a minimum licensed
88	nursing staffing of 1.0 hour of direct resident care per
89	resident per day but never below one licensed nurse per 40
90	residents. Nursing assistants employed never below one licensed
91	nurse per 40 residents. Nursing assistants employed under s.
92	400.211(2) may be included in computing the staffing ratio for
93	certified nursing assistants only if they provide nursing
94	assistance services to residents on a full-time basis. Each
95	nursing home must document compliance with staffing standards as
96	required under this paragraph and post daily the names of staff
97	on duty for the benefit of facility residents and the public.
98	The agency shall recognize the use of licensed nurses for
99	compliance with minimum staffing requirements for certified
100	nursing assistants, provided that the facility otherwise meets
101	the minimum staffing requirements for licensed nurses and that
102	the licensed nurses so recognized are performing the duties of a
103	certified nursing assistant. Unless otherwise approved by the
104	agency, licensed nurses counted towards the minimum staffing
105	requirements for certified nursing assistants must exclusively
106	perform the duties of a certified nursing assistant for the
107	entire shift and shall not also be counted towards the minimum
108	staffing requirements for licensed nurses. If the agency
109	approved a facility's request to use a licensed nurse to perform
110	both licensed nursing and certified nursing assistant duties,
111	the facility must allocate the amount of staff time specifically
112	spent on certified nursing assistant duties for the purpose of
113	documenting compliance with minimum staffing requirements for
114	certified and licensed nursing staff. In no event may the hours
115	of a licensed nurse with dual job responsibilities be counted
116	twice.
117	Section 3.  Subsection (16) of section 408.07, Florida
118	Statutes, is amended to read:
119	408.07  Definitions.--As used in this chapter, with the
120	exception of ss. 408.031-408.045, the term:
121	(16)  "Deductions from gross revenue" or "deductions from
122	revenue" means reductions from gross revenue resulting from
123	inability to collect payment of charges. For hospitals, such
124	reductions include contractual adjustments; uncompensated care;
125	administrative, courtesy, and policy discounts and adjustments;
126	and other such revenue deductions, but also includes the offset
127	of restricted donations and grants for indigent care. Items to
128	be deducted from gross revenue shall be reduced by any amounts
129	received for special Medicaid payments made pursuant to s.
130	409.908(1), and disproportionate share payments made pursuant to
131	s. 409.911, s. 409.9112, s. 409.9113, s. 409.9115, s. 409.9116,
132	s. 409.9117, s. 409.9118, or s. 409.9119.
133	Section 4.  Effective January 1, 2005, subsection (6) of
134	section 409.814, Florida Statutes, is amended to read:
135	409.814  Eligibility.--A child whose family income is equal
136	to or below 200 percent of the federal poverty level is eligible
137	for the Florida Kidcare program as provided in this section. In
138	determining the eligibility of such a child, an assets test is
139	not required. An applicant under 19 years of age who, based on a
140	complete application, appears to be eligible for the Medicaid
141	component of the Florida Kidcare program is presumed eligible
142	for coverage under Medicaid, subject to federal rules. A child
143	who has been deemed presumptively eligible for Medicaid shall
144	not be enrolled in a managed care plan until the child's full
145	eligibility determination for Medicaid has been completed. The
146	Florida Healthy Kids Corporation may, subject to compliance with
147	applicable requirements of the Agency for Health Care
148	Administration and the Department of Children and Family
149	Services, be designated as an entity to conduct presumptive
150	eligibility determinations. An applicant under 19 years of age
151	who, based on a complete application, appears to be eligible for
152	the Medikids, Florida Healthy Kids, or Children's Medical
153	Services network program component, who is screened as
154	ineligible for Medicaid and prior to the monthly verification of
155	the applicant's enrollment in Medicaid or of eligibility for
156	coverage under the state employee health benefit plan, may be
157	enrolled in and begin receiving coverage from the appropriate
158	program component on the first day of the month following the
159	receipt of a completed application. For enrollment in the
160	Children's Medical Services network, a complete application
161	includes the medical or behavioral health screening. If, after
162	verification, an individual is determined to be ineligible for
163	coverage, he or she must be disenrolled from the respective
164	Title XXI-funded Kidcare program component.
165	(6)  Once a child is enrolled in the Florida Kidcare
166	program, the child is eligible for coverage under the program
167	for 12 6 months without a redetermination or reverification of
168	eligibility, if the family continues to pay the applicable
169	premium. Effective January 1, 1999, a child who has not attained
170	the age of 5 and who has been determined eligible for the
171	Medicaid program is eligible for coverage for 12 months without
172	a redetermination or reverification of eligibility.
173	Section 5.  Subsections (4), (5), and (8) of section
174	409.905, Florida Statutes, are amended to read:
175	409.905  Mandatory Medicaid services.--The agency may make
176	payments for the following services, which are required of the
177	state by Title XIX of the Social Security Act, furnished by
178	Medicaid providers to recipients who are determined to be
179	eligible on the dates on which the services were provided. Any
180	service under this section shall be provided only when medically
181	necessary and in accordance with state and federal law.
182	Mandatory services rendered by providers in mobile units to
183	Medicaid recipients may be restricted by the agency. Nothing in
184	this section shall be construed to prevent or limit the agency
185	from adjusting fees, reimbursement rates, lengths of stay,
186	number of visits, number of services, or any other adjustments
187	necessary to comply with the availability of moneys and any
188	limitations or directions provided for in the General
189	Appropriations Act or chapter 216.
190	(4)  HOME HEALTH CARE SERVICES.--The agency shall pay for
191	nursing and home health aide services, supplies, appliances, and
192	durable medical equipment, necessary to assist a recipient
193	living at home. An entity that provides services pursuant to
194	this subsection shall be licensed under part IV of chapter 400
195	or part II of chapter 499, if appropriate. These services,
196	equipment, and supplies, or reimbursement therefor, may be
197	limited as provided in the General Appropriations Act and do not
198	include services, equipment, or supplies provided to a person
199	residing in a hospital or nursing facility.
200	(a)  In providing home health care services, the agency may
201	require prior authorization of care based on diagnosis.
202	(b)  The agency shall implement a comprehensive utilization
203	management program that requires prior authorization of all
204	private duty nursing services, an individualized treatment plan
205	that includes information about medication and treatment orders,
206	treatment goals, methods of care to be used, and plans for care
207	coordination by nurses and other health professionals. The
208	utilization management program shall also include a process for
209	periodically reviewing the ongoing use of private duty nursing
210	services. The assessment of need shall be based on a child's
211	condition, family support and care supplements, a family's
212	ability to provide care, and a family's and child's schedule
213	regarding work, school, sleep, and care for other family
214	dependents. When implemented, the private duty nursing
215	utilization management program shall replace the current
216	authorization program used by the Agency for Health Care
217	Administration and the Children's Medical Services program of
218	the Department of Health. The agency may competitively bid on a
219	contract to select a qualified organization to provide
220	utilization management of private duty nursing services. The
221	agency is authorized to seek federal waivers or any state plan
222	amendment necessary to implement this program.
223	(5)  HOSPITAL INPATIENT SERVICES.--The agency shall pay for
224	all covered services provided for the medical care and treatment
225	of a recipient who is admitted as an inpatient by a licensed
226	physician or dentist to a hospital licensed under part I of
227	chapter 395. However, the agency shall limit the payment for
228	inpatient hospital services for a Medicaid recipient 21 years of
229	age or older to 45 days or the number of days necessary to
230	comply with the General Appropriations Act.
231	(a)  The agency is authorized to implement reimbursement
232	and utilization management reforms in order to comply with any
233	limitations or directions in the General Appropriations Act,
234	which may include, but are not limited to: prior authorization
235	for inpatient psychiatric days; prior authorization for
236	nonemergency hospital inpatient admissions for individuals 21
237	years of age and older; authorization of emergency and urgent-
238	care admissions within 24 hours after admission; enhanced
239	utilization and concurrent review programs for highly utilized
240	services; reduction or elimination of covered days of service;
241	adjusting reimbursement ceilings for variable costs; adjusting
242	reimbursement ceilings for fixed and property costs; and
243	implementing target rates of increase. The agency may limit
244	prior authorization for hospital inpatient services to selected
245	diagnosis-related groups, based on an analysis of the cost and
246	potential for unnecessary hospitalizations represented by
247	certain diagnoses. Admissions for normal delivery and newborns
248	are exempt from requirements for prior authorization. In
249	implementing the provisions of this section related to prior
250	authorization, the agency shall ensure that the process for
251	authorization is accessible 24 hours per day, 7 days per week
252	and authorization is automatically granted when not denied
253	within 4 hours after the request. Authorization procedures must
254	include steps for review of denials. Upon implementing the prior
255	authorization program for hospital inpatient services, the
256	agency shall discontinue its hospital retrospective review
257	program.
258	(b)  A licensed hospital maintained primarily for the care
259	and treatment of patients having mental disorders or mental
260	diseases is not eligible to participate in the hospital
261	inpatient portion of the Medicaid program except as provided in
262	federal law. However, the department shall apply for a waiver,
263	within 9 months after June 5, 1991, designed to provide
264	hospitalization services for mental health reasons to children
265	and adults in the most cost-effective and lowest cost setting
266	possible. Such waiver shall include a request for the
267	opportunity to pay for care in hospitals known under federal law
268	as "institutions for mental disease" or "IMD's." The waiver
269	proposal shall propose no additional aggregate cost to the state
270	or Federal Government, and shall be conducted in Hillsborough
271	County, Highlands County, Hardee County, Manatee County, and
272	Polk County. The waiver proposal may incorporate competitive
273	bidding for hospital services, comprehensive brokering, prepaid
274	capitated arrangements, or other mechanisms deemed by the
275	department to show promise in reducing the cost of acute care
276	and increasing the effectiveness of preventive care. When
277	developing the waiver proposal, the department shall take into
278	account price, quality, accessibility, linkages of the hospital
279	to community services and family support programs, plans of the
280	hospital to ensure the earliest discharge possible, and the
281	comprehensiveness of the mental health and other health care
282	services offered by participating providers.
283	(c)  The Agency for Health Care Administration shall adjust
284	a hospital's current inpatient per diem rate to reflect the cost
285	of serving the Medicaid population at that institution if:
286	1.  The hospital experiences an increase in Medicaid
287	caseload by more than 25 percent in any year, primarily
288	resulting from the closure of a hospital in the same service
289	area occurring after July 1, 1995;
290	2.  The hospital's Medicaid per diem rate is at least 25
291	percent below the Medicaid per patient cost for that year; or
292	3.  The hospital is located in a county that has five or
293	fewer hospitals, began offering obstetrical services on or after
294	September 1999, and has submitted a request in writing to the
295	agency for a rate adjustment after July 1, 2000, but before
296	September 30, 2000, in which case such hospital's Medicaid
297	inpatient per diem rate shall be adjusted to cost, effective
298	July 1, 2002.
299
300	No later than October 1 of each year, the agency must provide
301	estimated costs for any adjustment in a hospital inpatient per
302	diem pursuant to this paragraph to the Executive Office of the
303	Governor, the House of Representatives General Appropriations
304	Committee, and the Senate Appropriations Committee. Before the
305	agency implements a change in a hospital's inpatient per diem
306	rate pursuant to this paragraph, the Legislature must have
307	specifically appropriated sufficient funds in the General
308	Appropriations Act to support the increase in cost as estimated
309	by the agency.
310	(d)  The agency shall implement a hospitalist program in
311	certain high volume Medicaid participating hospitals, in select
312	counties, or statewide. The program shall require hospitalists
313	to authorize and manage Medicaid recipients' hospital admissions
314	and lengths of stay. Individuals dually eligible for Medicare
315	and Medicaid are exempted from this requirement. Medicaid
316	participating physicians and other practitioners with hospital
317	admitting privileges shall coordinate and review admissions of
318	Medicaid beneficiaries with the hospitalist. The agency may
319	competitively bid for the selection of a qualified organization
320	to provide hospitalist services. Where used, the hospitalist
321	program shall replace the existing hospital utilization review
322	program. The agency is authorized to seek a Medicaid federal
323	waiver or state plan amendment to implement this program.
324	(8)  NURSING FACILITY SERVICES.--The agency shall pay for
325	24-hour-a-day nursing and rehabilitative services for a
326	recipient in a nursing facility licensed under part II of
327	chapter 400 or in a rural hospital, as defined in s. 395.602, or
328	in a Medicare certified skilled nursing facility operated by a
329	hospital, as defined by s. 395.002(11), that is licensed under
330	part I of chapter 395, and in accordance with provisions set
331	forth in s. 409.908(2)(a), which services are ordered by and
332	provided under the direction of a licensed physician. However,
333	if a nursing facility has been destroyed or otherwise made
334	uninhabitable by natural disaster or other emergency and another
335	nursing facility is not available, the agency must pay for
336	similar services temporarily in a hospital licensed under part I
337	of chapter 395 provided federal funding is approved and
338	available. The agency shall only pay for bed hold days if the
339	facility has an occupancy rate of 90 percent or greater. The
340	agency is authorized to seek a Medicaid state plan amendment to
341	implement this policy.
342	Section 6.  Subsections (1), (5), (8), (12), (13), (15),
343	and (23) of section 409.906, Florida Statutes, are amended to
344	read:
345	409.906  Optional Medicaid services.--Subject to specific
346	appropriations, the agency may make payments for services which
347	are optional to the state under Title XIX of the Social Security
348	Act and are furnished by Medicaid providers to recipients who
349	are determined to be eligible on the dates on which the services
350	were provided. Any optional service that is provided shall be
351	provided only when medically necessary and in accordance with
352	state and federal law. Optional services rendered by providers
353	in mobile units to Medicaid recipients may be restricted or
354	prohibited by the agency. Nothing in this section shall be
355	construed to prevent or limit the agency from adjusting fees,
356	reimbursement rates, lengths of stay, number of visits, or
357	number of services, or making any other adjustments necessary to
358	comply with the availability of moneys and any limitations or
359	directions provided for in the General Appropriations Act or
360	chapter 216. If necessary to safeguard the state's systems of
361	providing services to elderly and disabled persons and subject
362	to the notice and review provisions of s. 216.177, the Governor
363	may direct the Agency for Health Care Administration to amend
364	the Medicaid state plan to delete the optional Medicaid service
365	known as "Intermediate Care Facilities for the Developmentally
366	Disabled." Optional services may include:
367	(1)  ADULT DENTAL SERVICES.--
368	(a)  The agency may pay for medically necessary, emergency
369	dental procedures to alleviate pain or infection. Emergency
370	dental care shall be limited to emergency oral examinations,
371	necessary radiographs, extractions, and incision and drainage of
372	abscess, for a recipient who is age 21 years of age or older.
373	(b)  Beginning January 1, 2005, the agency may pay for
374	dentures, the procedures required to seat dentures, and the
375	repair and reline of dentures, provided by or under the
376	direction of a licensed dentist, for a recipient who is 21 years
377	of age or older.
378	(c)  However, Medicaid will not provide reimbursement for
379	dental services provided in a mobile dental unit, except for a
380	mobile dental unit:
381	1.(a)  Owned by, operated by, or having a contractual
382	agreement with the Department of Health and complying with
383	Medicaid's county health department clinic services program
384	specifications as a county health department clinic services
385	provider.
386	2.(b)  Owned by, operated by, or having a contractual
387	arrangement with a federally qualified health center and
388	complying with Medicaid's federally qualified health center
389	specifications as a federally qualified health center provider.
390	3.(c)  Rendering dental services to Medicaid recipients, 21
391	years of age and older, at nursing facilities.
392	4.(d)  Owned by, operated by, or having a contractual
393	agreement with a state-approved dental educational institution.
394	(5)  CASE MANAGEMENT SERVICES.--
395	(a)  The agency may pay for primary care case management
396	services rendered to a recipient pursuant to a federally
397	approved waiver, and targeted case management services for
398	specific groups of targeted recipients, for which funding has
399	been provided and which are rendered pursuant to federal
400	guidelines. The agency is authorized to limit reimbursement for
401	targeted case management services in order to comply with any
402	limitations or directions provided for in the General
403	Appropriations Act. Notwithstanding s. 216.292, the Department
404	of Children and Family Services may transfer general funds to
405	the Agency for Health Care Administration to fund state match
406	requirements exceeding the amount specified in the General
407	Appropriations Act for targeted case management services.
408	(b)  The agency is authorized to work with the Department
409	of Children and Family Services and the local children's
410	services councils to develop a targeted case management program
411	for at-risk children in the counties where participating
412	children's boards or councils or participating local governments
413	are located. The covered group of individuals who are eligible
414	to receive at-risk targeted case management include children who
415	are eligible for Medicaid; who are between the ages of birth and
416	21 years; who are not being served by dependency, delinquency,
417	alcohol, drug abuse, and mental health programs, or other case
418	management services; who are the children of parents who have a
419	history of or are currently suffering from substance abuse,
420	mental illness, postpartum depression, or domestic violence
421	problems and are determined to be having, or at risk of having,
422	significant behavioral and/or performance problems in the home,
423	school, or community; who are siblings of a child in state
424	custody; or who are refused entry into their home by their
425	parents. The number of individuals who are eligible to receive
426	this targeted case management program shall be limited to the
427	number for whom there is sufficient local public tax revenue
428	provided as matching funds to cover the costs. The public
429	revenue funds required to match the funds for these targeted
430	case management services are limited to those funds that are
431	local public tax revenues and made available to the state for
432	this purpose.
433	(8)  COMMUNITY MENTAL HEALTH SERVICES.--
434	(a)  The agency may pay for rehabilitative services
435	provided to a recipient by a mental health or substance abuse
436	provider under contract with the agency or the Department of
437	Children and Family Services to provide such services. Those
438	services which are psychiatric in nature shall be rendered or
439	recommended by a psychiatrist, and those services which are
440	medical in nature shall be rendered or recommended by a
441	physician or psychiatrist. The agency must develop a provider
442	enrollment process for community mental health providers which
443	bases provider enrollment on an assessment of service need. The
444	provider enrollment process shall be designed to control costs,
445	prevent fraud and abuse, consider provider expertise and
446	capacity, and assess provider success in managing utilization of
447	care and measuring treatment outcomes. Providers will be
448	selected through a competitive procurement or selective
449	contracting process. In addition to other community mental
450	health providers, the agency shall consider for enrollment
451	mental health programs licensed under chapter 395 and group
452	practices licensed under chapter 458, chapter 459, chapter 490,
453	or chapter 491. The agency is also authorized to continue
454	operation of its behavioral health utilization management
455	program and may develop new services if these actions are
456	necessary to ensure savings from the implementation of the
457	utilization management system. The agency shall coordinate the
458	implementation of this enrollment process with the Department of
459	Children and Family Services and the Department of Juvenile
460	Justice. The agency is authorized to utilize diagnostic criteria
461	in setting reimbursement rates, to preauthorize certain high-
462	cost or highly utilized services, to limit or eliminate coverage
463	for certain services, or to make any other adjustments necessary
464	to comply with any limitations or directions provided for in the
465	General Appropriations Act.
466	(b)  The agency is authorized to implement reimbursement
467	and use management reforms in order to comply with any
468	limitations or directions in the General Appropriations Act,
469	which may include, but are not limited to: prior authorization
470	of treatment and service plans; prior authorization of services;
471	enhanced use review programs for highly used services; and
472	limits on services for those determined to be abusing their
473	benefit coverages.
474	(c)  The agency, in conjunction with the Department of
475	Children and Family Services and Medicaid community mental
476	health and targeted case management providers, shall use a
477	targeted utilization management approach rather than an across-
478	the-board prior authorization process focusing on prior
479	authorization activity for providers that have been determined
480	to exceed specified parameters with regard to service and claims
481	patterns, audit findings or other reasonable indicators of
482	potential fraud, abuse, or over billing.
483	(d)  The agency is authorized to seek a Medicaid state plan
484	amendment or federal waiver approval as necessary to modify the
485	community mental health prior authorization program. The
486	utilization management plan shall accomplish the following:
487	control costs and encourage appropriate service utilization;
488	describe a proposed reconfiguring of procedure codes and rates
489	which is responsive to the needs of Medicaid recipients and
490	consistent with the requirements of the Health Insurance
491	Portability and Accountability Act of 1996; encourage and
492	facilitate the use of best practices; use, to the extent
493	possible, community mental health and targeted case management
494	providers' internal utilization management systems to control
495	costs and ensure appropriate service utilization; and anticipate
496	and prepare the community mental health system for risk-based
497	contracting as required by s. 394.9082. The agency may curtail
498	the use of prior authorization programs in areas of the state
499	where capitated mental health managed care plans are
500	operational.
501	(12)  CHILDREN'S HEARING SERVICES.--The agency may pay for
502	hearing and related services, including hearing evaluations,
503	hearing aid devices, dispensing of the hearing aid, and related
504	repairs, if provided to a recipient younger than 21 years of age
505	by a licensed hearing aid specialist, otolaryngologist,
506	otologist, audiologist, or physician. Effective January 1, 2005,
507	hearing services shall be provided to recipients 21 years of age
508	or older.
509	(13)  HOME AND COMMUNITY-BASED SERVICES.--
510	(a)  The agency may pay for home-based or community-based
511	services that are rendered to a recipient in accordance with a
512	federally approved waiver program. The agency may limit or
513	eliminate coverage for certain Project AIDS Care Waiver
514	services, preauthorize high-cost or highly utilized services, or
515	make any other adjustments necessary to comply with any
516	limitations or directions provided for in the General
517	Appropriations Act.
518	(b)  The agency may consolidate types of services offered
519	in the Aged and Disabled Waiver, the Channeling Waiver, the
520	Project AIDS Care Waiver, and the Traumatic Brain and Spinal
521	Cord Injury Waiver programs in order to group similar services
522	under a single service, or upon evidence of the need for
523	including a particular service type in a particular waiver. The
524	agency is authorized to seek a Medicaid state plan amendment or
525	federal waiver approval as necessary to implement this policy.
526	(c)  The agency may implement a utilization management
527	program designed to prior authorize home and community-based
528	service plans, including, but not limited to, proposed quantity
529	and duration of services and monitoring ongoing service use by
530	participants in the program. The agency is authorized to
531	competitively procure a qualified organization to provide
532	utilization management of home and community-based services. The
533	agency is authorized to seek a Medicaid state plan amendment or
534	federal waiver approval as necessary to implement this policy.
535	(15)  INTERMEDIATE CARE FACILITY FOR THE DEVELOPMENTALLY
536	DISABLED SERVICES.--The agency may pay for health-related care
537	and services provided on a 24-hour-a-day basis by a facility
538	licensed and certified as a Medicaid Intermediate Care Facility
539	for the Developmentally Disabled, for a recipient who needs such
540	care because of a developmental disability. Payment shall not
541	include vacancy interim rates. The agency is authorized to seek
542	a Medicaid state plan amendment or federal waiver approval as
543	necessary to implement this policy.
544	(23)  CHILDREN'S VISUAL SERVICES.--The agency may pay for
545	visual examinations, eyeglasses, and eyeglass repairs for a
546	recipient younger than 21 years of age, if they are prescribed
547	by a licensed physician specializing in diseases of the eye or
548	by a licensed optometrist. Effective January 1, 2005, visual
549	services shall be provided to recipients 21 years of age or
550	older.
551	Section 7.  Subsection (19) of section 409.908, Florida
552	Statutes, is amended to read:
553	409.908  Reimbursement of Medicaid providers.--Subject to
554	specific appropriations, the agency shall reimburse Medicaid
555	providers, in accordance with state and federal law, according
556	to methodologies set forth in the rules of the agency and in
557	policy manuals and handbooks incorporated by reference therein.
558	These methodologies may include fee schedules, reimbursement
559	methods based on cost reporting, negotiated fees, competitive
560	bidding pursuant to s. 287.057, and other mechanisms the agency
561	considers efficient and effective for purchasing services or
562	goods on behalf of recipients. If a provider is reimbursed based
563	on cost reporting and submits a cost report late and that cost
564	report would have been used to set a lower reimbursement rate
565	for a rate semester, then the provider's rate for that semester
566	shall be retroactively calculated using the new cost report, and
567	full payment at the recalculated rate shall be affected
568	retroactively. Medicare-granted extensions for filing cost
569	reports, if applicable, shall also apply to Medicaid cost
570	reports. Payment for Medicaid compensable services made on
571	behalf of Medicaid eligible persons is subject to the
572	availability of moneys and any limitations or directions
573	provided for in the General Appropriations Act or chapter 216.
574	Further, nothing in this section shall be construed to prevent
575	or limit the agency from adjusting fees, reimbursement rates,
576	lengths of stay, number of visits, or number of services, or
577	making any other adjustments necessary to comply with the
578	availability of moneys and any limitations or directions
579	provided for in the General Appropriations Act, provided the
580	adjustment is consistent with legislative intent.
581	(19)  County health department services shall may be
582	reimbursed a rate per visit based on total reasonable costs of
583	the clinic, as determined by the agency in accordance with
584	federal regulations under the authority of 42 C.F.R. s. 431.615.
585	Section 8.  Subsection (9) is added to section 409.911,
586	Florida Statutes, to read:
587	409.911  Disproportionate share program.--Subject to
588	specific allocations established within the General
589	Appropriations Act and any limitations established pursuant to
590	chapter 216, the agency shall distribute, pursuant to this
591	section, moneys to hospitals providing a disproportionate share
592	of Medicaid or charity care services by making quarterly
593	Medicaid payments as required. Notwithstanding the provisions of
594	s. 409.915, counties are exempt from contributing toward the
595	cost of this special reimbursement for hospitals serving a
596	disproportionate share of low-income patients.
597	(9)  The Medicaid Disproportionate Share Task Force is
598	authorized to convene each fiscal year for the purpose of
599	monitoring the implementation of enhanced Medicaid funding
600	through the Special Medicaid Payment program. In addition, the
601	task force shall review the federal status of the Upper Payment
602	Limit funding option and recommend how this option may be
603	further used to promote local primary care networks to uninsured
604	citizens in the state, to increase the accessibility of trauma
605	centers to residents of the state, and to ensure the financial
606	viability of the state's graduate medical education programs and
607	other health care policies determined by the task force to be
608	state health care priorities. The task force shall annually
609	present its findings and recommendations in the last week of
610	January to the Executive Office of the Governor and the
611	Legislature.
612	Section 9.  Section 409.912, Florida Statutes, is amended
613	to read:
614	409.912  Cost-effective purchasing of health care.--The
615	agency shall purchase goods and services for Medicaid recipients
616	in the most cost-effective manner consistent with the delivery
617	of quality medical care. The agency shall maximize the use of
618	prepaid per capita and prepaid aggregate fixed-sum basis
619	services when appropriate and other alternative service delivery
620	and reimbursement methodologies, including competitive bidding
621	pursuant to s. 287.057, designed to facilitate the cost-
622	effective purchase of a case-managed continuum of care. The
623	agency shall also require providers to minimize the exposure of
624	recipients to the need for acute inpatient, custodial, and other
625	institutional care and the inappropriate or unnecessary use of
626	high-cost services. The agency may establish prior authorization
627	requirements for certain populations of Medicaid beneficiaries,
628	certain drug classes, or particular drugs to prevent fraud,
629	abuse, overuse, and possible dangerous drug interactions. The
630	Pharmaceutical and Therapeutics Committee shall make
631	recommendations to the agency on drugs for which prior
632	authorization is required. The agency shall inform the
633	Pharmaceutical and Therapeutics Committee of its decisions
634	regarding drugs subject to prior authorization. The agency is
635	authorized to limit the entities it contracts with by developing
636	a provider network through competitive bidding or provider
637	credentialing. If a credentialing process is used, the agency
638	may limit its network based on the assessment of beneficiary
639	access to care, provider availability, provider quality
640	standards, time and distance standards for access to care, the
641	cultural competence of the provider network, demographic
642	characteristics of Medicaid beneficiaries, practice and
643	provider-to-beneficiary standards, appointment wait times,
644	beneficiary use of services, provider turnover, provider
645	profiling, provider licensure history, previous program
646	integrity investigations and findings, peer review, provider
647	Medicaid policy and billing compliance record, clinical and
648	medical record audits, and other factors. Providers shall not be
649	entitled to enrollment in the Medicaid provider network. The
650	agency is authorized to seek the Medicaid state plan amendments
651	and federal waivers necessary to implement this policy.
652	(1)  The agency shall work with the Department of Children
653	and Family Services to ensure access of children and families in
654	the child protection system to needed and appropriate mental
655	health and substance abuse services.
656	(2)  The agency may enter into agreements with appropriate
657	agents of other state agencies or of any agency of the Federal
658	Government and accept such duties in respect to social welfare
659	or public aid as may be necessary to implement the provisions of
660	Title XIX of the Social Security Act and ss. 409.901-409.920.
661	(3)  The agency may contract with health maintenance
662	organizations certified pursuant to part I of chapter 641 for
663	the provision of services to recipients.
664	(4)  The agency may contract with:
665	(a)  An entity that provides no prepaid health care
666	services other than Medicaid services under contract with the
667	agency and which is owned and operated by a county, county
668	health department, or county-owned and operated hospital to
669	provide health care services on a prepaid or fixed-sum basis to
670	recipients, which entity may provide such prepaid services
671	either directly or through arrangements with other providers.
672	Such prepaid health care services entities must be licensed
673	under parts I and III by January 1, 1998, and until then are
674	exempt from the provisions of part I of chapter 641. An entity
675	recognized under this paragraph which demonstrates to the
676	satisfaction of the Office of Insurance Regulation of the
677	Financial Services Commission that it is backed by the full
678	faith and credit of the county in which it is located may be
679	exempted from s. 641.225.
680	(b)  An entity that is providing comprehensive behavioral
681	health care services to certain Medicaid recipients through a
682	capitated, prepaid arrangement pursuant to the federal waiver
683	provided for by s. 409.905(5). Such an entity must be licensed
684	under chapter 624, chapter 636, or chapter 641 and must possess
685	the clinical systems and operational competence to manage risk
686	and provide comprehensive behavioral health care to Medicaid
687	recipients. As used in this paragraph, the term "comprehensive
688	behavioral health care services" means covered mental health and
689	substance abuse treatment services that are available to
690	Medicaid recipients. The secretary of the Department of Children
691	and Family Services shall approve provisions of procurements
692	related to children in the department's care or custody prior to
693	enrolling such children in a prepaid behavioral health plan. Any
694	contract awarded under this paragraph must be competitively
695	procured. In developing the behavioral health care prepaid plan
696	procurement document, the agency shall ensure that the
697	procurement document requires the contractor to develop and
698	implement a plan to ensure compliance with s. 394.4574 related
699	to services provided to residents of licensed assisted living
700	facilities that hold a limited mental health license. The agency
701	shall seek federal approval to contract with a single entity
702	meeting these requirements to provide comprehensive behavioral
703	health care services to all Medicaid recipients not enrolled in
704	a managed care plan in an AHCA area. Each entity must offer
705	sufficient choice of providers in its network to ensure
706	recipient access to care and the opportunity to select a
707	provider with whom they are satisfied. The network shall include
708	all public mental health hospitals. To ensure unimpaired access
709	to behavioral health care services by Medicaid recipients, all
710	contracts issued pursuant to this paragraph shall require 80
711	percent of the capitation paid to the managed care plan,
712	including health maintenance organizations, to be expended for
713	the provision of behavioral health care services. In the event
714	the managed care plan expends less than 80 percent of the
715	capitation paid pursuant to this paragraph for the provision of
716	behavioral health care services, the difference shall be
717	returned to the agency. The agency shall provide the managed
718	care plan with a certification letter indicating the amount of
719	capitation paid during each calendar year for the provision of
720	behavioral health care services pursuant to this section. The
721	agency may reimburse for substance abuse treatment services on a
722	fee-for-service basis until the agency finds that adequate funds
723	are available for capitated, prepaid arrangements.
724	1.  By January 1, 2001, the agency shall modify the
725	contracts with the entities providing comprehensive inpatient
726	and outpatient mental health care services to Medicaid
727	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
728	Counties, to include substance abuse treatment services.
729	2.  By July 1, 2003, the agency and the Department of
730	Children and Family Services shall execute a written agreement
731	that requires collaboration and joint development of all policy,
732	budgets, procurement documents, contracts, and monitoring plans
733	that have an impact on the state and Medicaid community mental
734	health and targeted case management programs.
735	3.  By July 1, 2006, the agency and the Department of
736	Children and Family Services shall contract with managed care
737	entities in each AHCA area except area 6 or arrange to provide
738	comprehensive inpatient and outpatient mental health and
739	substance abuse services through capitated prepaid arrangements
740	to all Medicaid recipients who are eligible to participate in
741	such plans under federal law and regulation. In AHCA areas where
742	eligible individuals number less than 150,000, the agency shall
743	contract with a single managed care plan to provide
744	comprehensive behavioral health services to all recipients who
745	are not enrolled in a Medicaid health maintenance organization.
746	The agency may contract with more than one comprehensive
747	behavioral health provider to provide care to recipients who are
748	not enrolled in a Medicaid health maintenance organization plan
749	in AHCA areas where the eligible population exceeds 150,000.
750	Contracts for comprehensive behavioral health providers awarded
751	pursuant to this section shall be competitively procured. Both
752	for-profit and not-for-profit corporations shall be eligible to
753	compete. Managed care plans contracting with the agency under
754	subsection (3) shall provide and receive payment for the same
755	comprehensive behavioral health benefits as provided in AHCA
756	rules, including handbooks incorporated by reference.
757	4.  By October 1, 2003, the agency and the department shall
758	submit a plan to the Governor, the President of the Senate, and
759	the Speaker of the House of Representatives which provides for
760	the full implementation of capitated prepaid behavioral health
761	care in all areas of the state. The plan shall include
762	provisions which ensure that children and families receiving
763	foster care and other related services are appropriately served
764	and that these services assist the community-based care lead
765	agencies in meeting the goals and outcomes of the child welfare
766	system. The plan will be developed with the participation of
767	community-based lead agencies, community alliances, sheriffs,
768	and community providers serving dependent children.
769	a.  Implementation shall begin in 2003 in those AHCA areas
770	of the state where the agency is able to establish sufficient
771	capitation rates.
772	b.  If the agency determines that the proposed capitation
773	rate in any area is insufficient to provide appropriate
774	services, the agency may adjust the capitation rate to ensure
775	that care will be available. The agency and the department may
776	use existing general revenue to address any additional required
777	match but may not over-obligate existing funds on an annualized
778	basis.
779	c.  Subject to any limitations provided for in the General
780	Appropriations Act, the agency, in compliance with appropriate
781	federal authorization, shall develop policies and procedures
782	that allow for certification of local and state funds.
783	5.  Children residing in a statewide inpatient psychiatric
784	program, or in a Department of Juvenile Justice or a Department
785	of Children and Family Services residential program approved as
786	a Medicaid behavioral health overlay services provider shall not
787	be included in a behavioral health care prepaid health plan
788	pursuant to this paragraph.
789	6.  In converting to a prepaid system of delivery, the
790	agency shall in its procurement document require an entity
791	providing only comprehensive behavioral health care services to
792	prevent the displacement of indigent care patients by enrollees
793	in the Medicaid prepaid health plan providing behavioral health
794	care services from facilities receiving state funding to provide
795	indigent behavioral health care, to facilities licensed under
796	chapter 395 which do not receive state funding for indigent
797	behavioral health care, or reimburse the unsubsidized facility
798	for the cost of behavioral health care provided to the displaced
799	indigent care patient.
800	7.  Traditional community mental health providers under
801	contract with the Department of Children and Family Services
802	pursuant to part IV of chapter 394, child welfare providers
803	under contract with the Department of Children and Family
804	Services, and inpatient mental health providers licensed
805	pursuant to chapter 395 must be offered an opportunity to accept
806	or decline a contract to participate in any provider network for
807	prepaid behavioral health services.
808	(c)  A federally qualified health center or an entity owned
809	by one or more federally qualified health centers or an entity
810	owned by other migrant and community health centers receiving
811	non-Medicaid financial support from the Federal Government to
812	provide health care services on a prepaid or fixed-sum basis to
813	recipients. Such prepaid health care services entity must be
814	licensed under parts I and III of chapter 641, but shall be
815	prohibited from serving Medicaid recipients on a prepaid basis,
816	until such licensure has been obtained. However, such an entity
817	is exempt from s. 641.225 if the entity meets the requirements
818	specified in subsections (17) (15) and (18) (16).
819	(d)  A provider service network may be reimbursed on a fee-
820	for-service or prepaid basis. A provider service network which
821	is reimbursed by the agency on a prepaid basis shall be exempt
822	from parts I and III of chapter 641, but must meet appropriate
823	financial reserve, quality assurance, and patient rights
824	requirements as established by the agency. The agency shall
825	award contracts on a competitive bid basis and shall select
826	bidders based upon price and quality of care. Medicaid
827	recipients assigned to a demonstration project shall be chosen
828	equally from those who would otherwise have been assigned to
829	prepaid plans and MediPass. The agency is authorized to seek
830	federal Medicaid waivers as necessary to implement the
831	provisions of this section.
832	(e)  An entity that provides only comprehensive behavioral
833	health care services to certain Medicaid recipients through an
834	administrative services organization agreement. Such an entity
835	must possess the clinical systems and operational competence to
836	provide comprehensive health care to Medicaid recipients. As
837	used in this paragraph, the term "comprehensive behavioral
838	health care services" means covered mental health and substance
839	abuse treatment services that are available to Medicaid
840	recipients. Any contract awarded under this paragraph must be
841	competitively procured. The agency must ensure that Medicaid
842	recipients have available the choice of at least two managed
843	care plans for their behavioral health care services.
844	(f)  An entity that provides in-home physician services to
845	test the cost-effectiveness of enhanced home-based medical care
846	to Medicaid recipients with degenerative neurological diseases
847	and other diseases or disabling conditions associated with high
848	costs to Medicaid. The program shall be designed to serve very
849	disabled persons and to reduce Medicaid reimbursed costs for
850	inpatient, outpatient, and emergency department services. The
851	agency shall contract with vendors on a risk-sharing basis.
852	(g)  Children's provider networks that provide care
853	coordination and care management for Medicaid-eligible pediatric
854	patients, primary care, authorization of specialty care, and
855	other urgent and emergency care through organized providers
856	designed to service Medicaid eligibles under age 18 and
857	pediatric emergency departments' diversion programs. The
858	networks shall provide after-hour operations, including evening
859	and weekend hours, to promote, when appropriate, the use of the
860	children's networks rather than hospital emergency departments.
861	(h)  An entity authorized in s. 430.205 to contract with
862	the agency and the Department of Elderly Affairs to provide
863	health care and social services on a prepaid or fixed-sum basis
864	to elderly recipients. Such prepaid health care services
865	entities are exempt from the provisions of part I of chapter 641
866	for the first 3 years of operation. An entity recognized under
867	this paragraph that demonstrates to the satisfaction of the
868	Office of Insurance Regulation that it is backed by the full
869	faith and credit of one or more counties in which it operates
870	may be exempted from s. 641.225.
871	(i)  A Children's Medical Services network, as defined in
872	s. 391.021.
873	(5)  By October 1, 2003, the agency and the department
874	shall, to the extent feasible, develop a plan for implementing
875	new Medicaid procedure codes for emergency and crisis care,
876	supportive residential services, and other services designed to
877	maximize the use of Medicaid funds for Medicaid-eligible
878	recipients. The agency shall include in the agreement developed
879	pursuant to subsection (4) a provision that ensures that the
880	match requirements for these new procedure codes are met by
881	certifying eligible general revenue or local funds that are
882	currently expended on these services by the department with
883	contracted alcohol, drug abuse, and mental health providers. The
884	plan must describe specific procedure codes to be implemented, a
885	projection of the number of procedures to be delivered during
886	fiscal year 2003-2004, and a financial analysis that describes
887	the certified match procedures, and accountability mechanisms,
888	projects the earnings associated with these procedures, and
889	describes the sources of state match. This plan may not be
890	implemented in any part until approved by the Legislative Budget
891	Commission. If such approval has not occurred by December 31,
892	2003, the plan shall be submitted for consideration by the 2004
893	Legislature.
894	(6)  The agency may contract with any public or private
895	entity otherwise authorized by this section on a prepaid or
896	fixed-sum basis for the provision of health care services to
897	recipients. An entity may provide prepaid services to
898	recipients, either directly or through arrangements with other
899	entities, if each entity involved in providing services:
900	(a)  Is organized primarily for the purpose of providing
901	health care or other services of the type regularly offered to
902	Medicaid recipients;
903	(b)  Ensures that services meet the standards set by the
904	agency for quality, appropriateness, and timeliness;
905	(c)  Makes provisions satisfactory to the agency for
906	insolvency protection and ensures that neither enrolled Medicaid
907	recipients nor the agency will be liable for the debts of the
908	entity;
909	(d)  Submits to the agency, if a private entity, a
910	financial plan that the agency finds to be fiscally sound and
911	that provides for working capital in the form of cash or
912	equivalent liquid assets excluding revenues from Medicaid
913	premium payments equal to at least the first 3 months of
914	operating expenses or $200,000, whichever is greater;
915	(e)  Furnishes evidence satisfactory to the agency of
916	adequate liability insurance coverage or an adequate plan of
917	self-insurance to respond to claims for injuries arising out of
918	the furnishing of health care;
919	(f)  Provides, through contract or otherwise, for periodic
920	review of its medical facilities and services, as required by
921	the agency; and
922	(g)  Provides organizational, operational, financial, and
923	other information required by the agency.
924	(7)  The agency may contract on a prepaid or fixed-sum
925	basis with any health insurer that:
926	(a)  Pays for health care services provided to enrolled
927	Medicaid recipients in exchange for a premium payment paid by
928	the agency;
929	(b)  Assumes the underwriting risk; and
930	(c)  Is organized and licensed under applicable provisions
931	of the Florida Insurance Code and is currently in good standing
932	with the Office of Insurance Regulation.
933	(8)  The agency may contract on a prepaid or fixed-sum
934	basis with an exclusive provider organization to provide health
935	care services to Medicaid recipients provided that the exclusive
936	provider organization meets applicable managed care plan
937	requirements in this section, ss. 409.9122, 409.9123, 409.9128,
938	and 627.6472, and other applicable provisions of law.
939	(9)  The Agency for Health Care Administration may provide
940	cost-effective purchasing of chiropractic services on a fee-for-
941	service basis to Medicaid recipients through arrangements with a
942	statewide chiropractic preferred provider organization
943	incorporated in this state as a not-for-profit corporation. The
944	agency shall ensure that the benefit limits and prior
945	authorization requirements in the current Medicaid program shall
946	apply to the services provided by the chiropractic preferred
947	provider organization.
948	(10)  The agency shall not contract on a prepaid or fixed-
949	sum basis for Medicaid services with an entity which knows or
950	reasonably should know that any officer, director, agent,
951	managing employee, or owner of stock or beneficial interest in
952	excess of 5 percent common or preferred stock, or the entity
953	itself, has been found guilty of, regardless of adjudication, or
954	entered a plea of nolo contendere, or guilty, to:
955	(a)  Fraud;
956	(b)  Violation of federal or state antitrust statutes,
957	including those proscribing price fixing between competitors and
958	the allocation of customers among competitors;
959	(c)  Commission of a felony involving embezzlement, theft,
960	forgery, income tax evasion, bribery, falsification or
961	destruction of records, making false statements, receiving
962	stolen property, making false claims, or obstruction of justice;
963	or
964	(d)  Any crime in any jurisdiction which directly relates
965	to the provision of health services on a prepaid or fixed-sum
966	basis.
967	(11)  The agency, after notifying the Legislature, may
968	apply for waivers of applicable federal laws and regulations as
969	necessary to implement more appropriate systems of health care
970	for Medicaid recipients and reduce the cost of the Medicaid
971	program to the state and federal governments and shall implement
972	such programs, after legislative approval, within a reasonable
973	period of time after federal approval. These programs must be
974	designed primarily to reduce the need for inpatient care,
975	custodial care and other long-term or institutional care, and
976	other high-cost services.
977	(a)  Prior to seeking legislative approval of such a waiver
978	as authorized by this subsection, the agency shall provide
979	notice and an opportunity for public comment. Notice shall be
980	provided to all persons who have made requests of the agency for
981	advance notice and shall be published in the Florida
982	Administrative Weekly not less than 28 days prior to the
983	intended action.
984	(b)  Notwithstanding s. 216.292, funds that are
985	appropriated to the Department of Elderly Affairs for the
986	Assisted Living for the Elderly Medicaid waiver and are not
987	expended shall be transferred to the agency to fund Medicaid-
988	reimbursed nursing home care.
989	(12)  The agency shall establish a postpayment utilization
990	control program designed to identify recipients who may
991	inappropriately overuse or underuse Medicaid services and shall
992	provide methods to correct such misuse.
993	(13)  The agency shall develop and provide coordinated
994	systems of care for Medicaid recipients and may contract with
995	public or private entities to develop and administer such
996	systems of care among public and private health care providers
997	in a given geographic area.
998	(14)  The agency shall operate or contract for the
999	operation of utilization management and incentive systems
1000	designed to encourage cost-effective use services.
1001	(15)(a)  The agency shall operate the Comprehensive
1002	Assessment and Review (CARES) nursing facility preadmission
1003	screening program to ensure that Medicaid payment for nursing
1004	facility care is made only for individuals whose conditions
1005	require such care and to ensure that long-term care services are
1006	provided in the setting most appropriate to the needs of the
1007	person and in the most economical manner possible. The CARES
1008	program shall also ensure that individuals participating in
1009	Medicaid home and community-based waiver programs meet criteria
1010	for those programs, consistent with approved federal waivers.
1011	(b)  The agency shall operate the CARES program through an
1012	interagency agreement with the Department of Elderly Affairs.
1013	(c)  Prior to making payment for nursing facility services
1014	for a Medicaid recipient, the agency must verify that the
1015	nursing facility preadmission screening program has determined
1016	that the individual requires nursing facility care and that the
1017	individual cannot be safely served in community-based programs.
1018	The nursing facility preadmission screening program shall refer
1019	a Medicaid recipient to a community-based program if the
1020	individual could be safely served at a lower cost and the
1021	recipient chooses to participate in such program.
1022	(d)  By January 1 of each year, the agency shall submit a
1023	report to the Legislature and the Office of Long-Term-Care
1024	Policy describing the operations of the CARES program. The
1025	report must describe:
1026	1.  Rate of diversion to community alternative programs;
1027	2.  CARES program staffing needs to achieve additional
1028	diversions;
1029	3.  Reasons the program is unable to place individuals in
1030	less restrictive settings when such individuals desired such
1031	services and could have been served in such settings;
1032	4.  Barriers to appropriate placement, including barriers
1033	due to policies or operations of other agencies or state-funded
1034	programs; and
1035	5.  Statutory changes necessary to ensure that individuals
1036	in need of long-term care services receive care in the least
1037	restrictive environment.
1038	(16)(a)  The agency shall identify health care utilization
1039	and price patterns within the Medicaid program which are not
1040	cost-effective or medically appropriate and assess the
1041	effectiveness of new or alternate methods of providing and
1042	monitoring service, and may implement such methods as it
1043	considers appropriate. Such methods may include disease
1044	management initiatives, an integrated and systematic approach
1045	for managing the health care needs of recipients who are at risk
1046	of or diagnosed with a specific disease by using best practices,
1047	prevention strategies, clinical-practice improvement, clinical
1048	interventions and protocols, outcomes research, information
1049	technology, and other tools and resources to reduce overall
1050	costs and improve measurable outcomes.
1051	(b)  The responsibility of the agency under this subsection
1052	shall include the development of capabilities to identify actual
1053	and optimal practice patterns; patient and provider educational
1054	initiatives; methods for determining patient compliance with
1055	prescribed treatments; fraud, waste, and abuse prevention and
1056	detection programs; and beneficiary case management programs.
1057	1.  The practice pattern identification program shall
1058	evaluate practitioner prescribing patterns based on national and
1059	regional practice guidelines, comparing practitioners to their
1060	peer groups. The agency and its Drug Utilization Review Board
1061	shall consult with a panel of practicing health care
1062	professionals consisting of the following: the Speaker of the
1063	House of Representatives and the President of the Senate shall
1064	each appoint three physicians licensed under chapter 458 or
1065	chapter 459; and the Governor shall appoint two pharmacists
1066	licensed under chapter 465 and one dentist licensed under
1067	chapter 466 who is an oral surgeon. Terms of the panel members
1068	shall expire at the discretion of the appointing official. The
1069	panel shall begin its work by August 1, 1999, regardless of the
1070	number of appointments made by that date. The advisory panel
1071	shall be responsible for evaluating treatment guidelines and
1072	recommending ways to incorporate their use in the practice
1073	pattern identification program. Practitioners who are
1074	prescribing inappropriately or inefficiently, as determined by
1075	the agency, may have their prescribing of certain drugs subject
1076	to prior authorization.
1077	2.  The agency shall also develop educational interventions
1078	designed to promote the proper use of medications by providers
1079	and beneficiaries.
1080	3.  The agency shall implement a pharmacy fraud, waste, and
1081	abuse initiative that may include a surety bond or letter of
1082	credit requirement for participating pharmacies, enhanced
1083	provider auditing practices, the use of additional fraud and
1084	abuse software, recipient management programs for beneficiaries
1085	inappropriately using their benefits, and other steps that will
1086	eliminate provider and recipient fraud, waste, and abuse. The
1087	initiative shall address enforcement efforts to reduce the
1088	number and use of counterfeit prescriptions.
1089	4.  By September 30, 2002, the agency shall contract with
1090	an entity in the state to implement a wireless handheld clinical
1091	pharmacology drug information database for practitioners. The
1092	initiative shall be designed to enhance the agency's efforts to
1093	reduce fraud, abuse, and errors in the prescription drug benefit
1094	program and to otherwise further the intent of this paragraph.
1095	5.  The agency may apply for any federal waivers needed to
1096	implement this paragraph.
1097	(17)  An entity contracting on a prepaid or fixed-sum basis
1098	shall, in addition to meeting any applicable statutory surplus
1099	requirements, also maintain at all times in the form of cash,
1100	investments that mature in less than 180 days allowable as
1101	admitted assets by the Office of Insurance Regulation, and
1102	restricted funds or deposits controlled by the agency or the
1103	Office of Insurance Regulation, a surplus amount equal to one-
1104	and-one-half times the entity's monthly Medicaid prepaid
1105	revenues. As used in this subsection, the term "surplus" means
1106	the entity's total assets minus total liabilities. If an
1107	entity's surplus falls below an amount equal to one-and-one-half
1108	times the entity's monthly Medicaid prepaid revenues, the agency
1109	shall prohibit the entity from engaging in marketing and
1110	preenrollment activities, shall cease to process new
1111	enrollments, and shall not renew the entity's contract until the
1112	required balance is achieved. The requirements of this
1113	subsection do not apply:
1114	(a)  Where a public entity agrees to fund any deficit
1115	incurred by the contracting entity; or
1116	(b)  Where the entity's performance and obligations are
1117	guaranteed in writing by a guaranteeing organization which:
1118	1.  Has been in operation for at least 5 years and has
1119	assets in excess of $50 million; or
1120	2.  Submits a written guarantee acceptable to the agency
1121	which is irrevocable during the term of the contracting entity's
1122	contract with the agency and, upon termination of the contract,
1123	until the agency receives proof of satisfaction of all
1124	outstanding obligations incurred under the contract.
1125	(18)(a)  The agency may require an entity contracting on a
1126	prepaid or fixed-sum basis to establish a restricted insolvency
1127	protection account with a federally guaranteed financial
1128	institution licensed to do business in this state. The entity
1129	shall deposit into that account 5 percent of the capitation
1130	payments made by the agency each month until a maximum total of
1131	2 percent of the total current contract amount is reached. The
1132	restricted insolvency protection account may be drawn upon with
1133	the authorized signatures of two persons designated by the
1134	entity and two representatives of the agency. If the agency
1135	finds that the entity is insolvent, the agency may draw upon the
1136	account solely with the two authorized signatures of
1137	representatives of the agency, and the funds may be disbursed to
1138	meet financial obligations incurred by the entity under the
1139	prepaid contract. If the contract is terminated, expired, or not
1140	continued, the account balance must be released by the agency to
1141	the entity upon receipt of proof of satisfaction of all
1142	outstanding obligations incurred under this contract.
1143	(b)  The agency may waive the insolvency protection account
1144	requirement in writing when evidence is on file with the agency
1145	of adequate insolvency insurance and reinsurance that will
1146	protect enrollees if the entity becomes unable to meet its
1147	obligations.
1148	(19)  An entity that contracts with the agency on a prepaid
1149	or fixed-sum basis for the provision of Medicaid services shall
1150	reimburse any hospital or physician that is outside the entity's
1151	authorized geographic service area as specified in its contract
1152	with the agency, and that provides services authorized by the
1153	entity to its members, at a rate negotiated with the hospital or
1154	physician for the provision of services or according to the
1155	lesser of the following:
1156	(a)  The usual and customary charges made to the general
1157	public by the hospital or physician; or
1158	(b)  The Florida Medicaid reimbursement rate established
1159	for the hospital or physician.
1160	(20)  When a merger or acquisition of a Medicaid prepaid
1161	contractor has been approved by the Office of Insurance
1162	Regulation pursuant to s. 628.4615, the agency shall approve the
1163	assignment or transfer of the appropriate Medicaid prepaid
1164	contract upon request of the surviving entity of the merger or
1165	acquisition if the contractor and the other entity have been in
1166	good standing with the agency for the most recent 12-month
1167	period, unless the agency determines that the assignment or
1168	transfer would be detrimental to the Medicaid recipients or the
1169	Medicaid program. To be in good standing, an entity must not
1170	have failed accreditation or committed any material violation of
1171	the requirements of s. 641.52 and must meet the Medicaid
1172	contract requirements. For purposes of this section, a merger or
1173	acquisition means a change in controlling interest of an entity,
1174	including an asset or stock purchase.
1175	(21)  Any entity contracting with the agency pursuant to
1176	this section to provide health care services to Medicaid
1177	recipients is prohibited from engaging in any of the following
1178	practices or activities:
1179	(a)  Practices that are discriminatory, including, but not
1180	limited to, attempts to discourage participation on the basis of
1181	actual or perceived health status.
1182	(b)  Activities that could mislead or confuse recipients,
1183	or misrepresent the organization, its marketing representatives,
1184	or the agency. Violations of this paragraph include, but are not
1185	limited to:
1186	1.  False or misleading claims that marketing
1187	representatives are employees or representatives of the state or
1188	county, or of anyone other than the entity or the organization
1189	by whom they are reimbursed.
1190	2.  False or misleading claims that the entity is
1191	recommended or endorsed by any state or county agency, or by any
1192	other organization which has not certified its endorsement in
1193	writing to the entity.
1194	3.  False or misleading claims that the state or county
1195	recommends that a Medicaid recipient enroll with an entity.
1196	4.  Claims that a Medicaid recipient will lose benefits
1197	under the Medicaid program, or any other health or welfare
1198	benefits to which the recipient is legally entitled, if the
1199	recipient does not enroll with the entity.
1200	(c)  Granting or offering of any monetary or other valuable
1201	consideration for enrollment, except as authorized by subsection
1202	(24) (22).
1203	(d)  Door-to-door solicitation of recipients who have not
1204	contacted the entity or who have not invited the entity to make
1205	a presentation.
1206	(e)  Solicitation of Medicaid recipients by marketing
1207	representatives stationed in state offices unless approved and
1208	supervised by the agency or its agent and approved by the
1209	affected state agency when solicitation occurs in an office of
1210	the state agency. The agency shall ensure that marketing
1211	representatives stationed in state offices shall market their
1212	managed care plans to Medicaid recipients only in designated
1213	areas and in such a way as to not interfere with the recipients'
1214	activities in the state office.
1215	(f)  Enrollment of Medicaid recipients.
1216	(22)  The agency may impose a fine for a violation of this
1217	section or the contract with the agency by a person or entity
1218	that is under contract with the agency. With respect to any
1219	nonwillful violation, such fine shall not exceed $2,500 per
1220	violation. In no event shall such fine exceed an aggregate
1221	amount of $10,000 for all nonwillful violations arising out of
1222	the same action. With respect to any knowing and willful
1223	violation of this section or the contract with the agency, the
1224	agency may impose a fine upon the entity in an amount not to
1225	exceed $20,000 for each such violation. In no event shall such
1226	fine exceed an aggregate amount of $100,000 for all knowing and
1227	willful violations arising out of the same action.
1228	(23)  A health maintenance organization or a person or
1229	entity exempt from chapter 641 that is under contract with the
1230	agency for the provision of health care services to Medicaid
1231	recipients may not use or distribute marketing materials used to
1232	solicit Medicaid recipients, unless such materials have been
1233	approved by the agency. The provisions of this subsection do not
1234	apply to general advertising and marketing materials used by a
1235	health maintenance organization to solicit both non-Medicaid
1236	subscribers and Medicaid recipients.
1237	(24)  Upon approval by the agency, health maintenance
1238	organizations and persons or entities exempt from chapter 641
1239	that are under contract with the agency for the provision of
1240	health care services to Medicaid recipients may be permitted
1241	within the capitation rate to provide additional health benefits
1242	that the agency has found are of high quality, are practicably
1243	available, provide reasonable value to the recipient, and are
1244	provided at no additional cost to the state.
1245	(25)  The agency shall utilize the statewide health
1246	maintenance organization complaint hotline for the purpose of
1247	investigating and resolving Medicaid and prepaid health plan
1248	complaints, maintaining a record of complaints and confirmed
1249	problems, and receiving disenrollment requests made by
1250	recipients.
1251	(26)  The agency shall require the publication of the
1252	health maintenance organization's and the prepaid health plan's
1253	consumer services telephone numbers and the "800" telephone
1254	number of the statewide health maintenance organization
1255	complaint hotline on each Medicaid identification card issued by
1256	a health maintenance organization or prepaid health plan
1257	contracting with the agency to serve Medicaid recipients and on
1258	each subscriber handbook issued to a Medicaid recipient.
1259	(27)  The agency shall establish a health care quality
1260	improvement system for those entities contracting with the
1261	agency pursuant to this section, incorporating all the standards
1262	and guidelines developed by the Medicaid Bureau of the Health
1263	Care Financing Administration as a part of the quality assurance
1264	reform initiative. The system shall include, but need not be
1265	limited to, the following:
1266	(a)  Guidelines for internal quality assurance programs,
1267	including standards for:
1268	1.  Written quality assurance program descriptions.
1269	2.  Responsibilities of the governing body for monitoring,
1270	evaluating, and making improvements to care.
1271	3.  An active quality assurance committee.
1272	4.  Quality assurance program supervision.
1273	5.  Requiring the program to have adequate resources to
1274	effectively carry out its specified activities.
1275	6.  Provider participation in the quality assurance
1276	program.
1277	7.  Delegation of quality assurance program activities.
1278	8.  Credentialing and recredentialing.
1279	9.  Enrollee rights and responsibilities.
1280	10.  Availability and accessibility to services and care.
1281	11.  Ambulatory care facilities.
1282	12.  Accessibility and availability of medical records, as
1283	well as proper recordkeeping and process for record review.
1284	13.  Utilization review.
1285	14.  A continuity of care system.
1286	15.  Quality assurance program documentation.
1287	16.  Coordination of quality assurance activity with other
1288	management activity.
1289	17.  Delivering care to pregnant women and infants; to
1290	elderly and disabled recipients, especially those who are at
1291	risk of institutional placement; to persons with developmental
1292	disabilities; and to adults who have chronic, high-cost medical
1293	conditions.
1294	(b)  Guidelines which require the entities to conduct
1295	quality-of-care studies which:
1296	1.  Target specific conditions and specific health service
1297	delivery issues for focused monitoring and evaluation.
1298	2.  Use clinical care standards or practice guidelines to
1299	objectively evaluate the care the entity delivers or fails to
1300	deliver for the targeted clinical conditions and health services
1301	delivery issues.
1302	3.  Use quality indicators derived from the clinical care
1303	standards or practice guidelines to screen and monitor care and
1304	services delivered.
1305	(c)  Guidelines for external quality review of each
1306	contractor which require: focused studies of patterns of care;
1307	individual care review in specific situations; and followup
1308	activities on previous pattern-of-care study findings and
1309	individual-care-review findings. In designing the external
1310	quality review function and determining how it is to operate as
1311	part of the state's overall quality improvement system, the
1312	agency shall construct its external quality review organization
1313	and entity contracts to address each of the following:
1314	1.  Delineating the role of the external quality review
1315	organization.
1316	2.  Length of the external quality review organization
1317	contract with the state.
1318	3.  Participation of the contracting entities in designing
1319	external quality review organization review activities.
1320	4.  Potential variation in the type of clinical conditions
1321	and health services delivery issues to be studied at each plan.
1322	5.  Determining the number of focused pattern-of-care
1323	studies to be conducted for each plan.
1324	6.  Methods for implementing focused studies.
1325	7.  Individual care review.
1326	8.  Followup activities.
1327	(28)  In order to ensure that children receive health care
1328	services for which an entity has already been compensated, an
1329	entity contracting with the agency pursuant to this section
1330	shall achieve an annual Early and Periodic Screening, Diagnosis,
1331	and Treatment (EPSDT) Service screening rate of at least 60
1332	percent for those recipients continuously enrolled for at least
1333	8 months. The agency shall develop a method by which the EPSDT
1334	screening rate shall be calculated. For any entity which does
1335	not achieve the annual 60 percent rate, the entity must submit a
1336	corrective action plan for the agency's approval. If the entity
1337	does not meet the standard established in the corrective action
1338	plan during the specified timeframe, the agency is authorized to
1339	impose appropriate contract sanctions. At least annually, the
1340	agency shall publicly release the EPSDT Services screening rates
1341	of each entity it has contracted with on a prepaid basis to
1342	serve Medicaid recipients.
1343	(29)  The agency shall perform enrollments and
1344	disenrollments for Medicaid recipients who are eligible for
1345	MediPass or managed care plans. Notwithstanding the prohibition
1346	contained in paragraph (21)(19)(f), managed care plans may
1347	perform preenrollments of Medicaid recipients under the
1348	supervision of the agency or its agents. For the purposes of
1349	this section, "preenrollment" means the provision of marketing
1350	and educational materials to a Medicaid recipient and assistance
1351	in completing the application forms, but shall not include
1352	actual enrollment into a managed care plan. An application for
1353	enrollment shall not be deemed complete until the agency or its
1354	agent verifies that the recipient made an informed, voluntary
1355	choice. The agency, in cooperation with the Department of
1356	Children and Family Services, may test new marketing initiatives
1357	to inform Medicaid recipients about their managed care options
1358	at selected sites. The agency shall report to the Legislature on
1359	the effectiveness of such initiatives. The agency may contract
1360	with a third party to perform managed care plan and MediPass
1361	enrollment and disenrollment services for Medicaid recipients
1362	and is authorized to adopt rules to implement such services. The
1363	agency may adjust the capitation rate only to cover the costs of
1364	a third-party enrollment and disenrollment contract, and for
1365	agency supervision and management of the managed care plan
1366	enrollment and disenrollment contract.
1367	(30)  Any lists of providers made available to Medicaid
1368	recipients, MediPass enrollees, or managed care plan enrollees
1369	shall be arranged alphabetically showing the provider's name and
1370	specialty and, separately, by specialty in alphabetical order.
1371	(31)  The agency shall establish an enhanced managed care
1372	quality assurance oversight function, to include at least the
1373	following components:
1374	(a)  At least quarterly analysis and followup, including
1375	sanctions as appropriate, of managed care participant
1376	utilization of services.
1377	(b)  At least quarterly analysis and followup, including
1378	sanctions as appropriate, of quality findings of the Medicaid
1379	peer review organization and other external quality assurance
1380	programs.
1381	(c)  At least quarterly analysis and followup, including
1382	sanctions as appropriate, of the fiscal viability of managed
1383	care plans.
1384	(d)  At least quarterly analysis and followup, including
1385	sanctions as appropriate, of managed care participant
1386	satisfaction and disenrollment surveys.
1387	(e)  The agency shall conduct regular and ongoing Medicaid
1388	recipient satisfaction surveys.
1389
1390	The analyses and followup activities conducted by the agency
1391	under its enhanced managed care quality assurance oversight
1392	function shall not duplicate the activities of accreditation
1393	reviewers for entities regulated under part III of chapter 641,
1394	but may include a review of the finding of such reviewers.
1395	(32)  Each managed care plan that is under contract with
1396	the agency to provide health care services to Medicaid
1397	recipients shall annually conduct a background check with the
1398	Florida Department of Law Enforcement of all persons with
1399	ownership interest of 5 percent or more or executive management
1400	responsibility for the managed care plan and shall submit to the
1401	agency information concerning any such person who has been found
1402	guilty of, regardless of adjudication, or has entered a plea of
1403	nolo contendere or guilty to, any of the offenses listed in s.
1404	435.03.
1405	(33)  The agency shall, by rule, develop a process whereby
1406	a Medicaid managed care plan enrollee who wishes to enter
1407	hospice care may be disenrolled from the managed care plan
1408	within 24 hours after contacting the agency regarding such
1409	request. The agency rule shall include a methodology for the
1410	agency to recoup managed care plan payments on a pro rata basis
1411	if payment has been made for the enrollment month when
1412	disenrollment occurs.
1413	(34)  The agency and entities which contract with the
1414	agency to provide health care services to Medicaid recipients
1415	under this section or s. 409.9122 must comply with the
1416	provisions of s. 641.513 in providing emergency services and
1417	care to Medicaid recipients and MediPass recipients.
1418	(35)  All entities providing health care services to
1419	Medicaid recipients shall make available, and encourage all
1420	pregnant women and mothers with infants to receive, and provide
1421	documentation in the medical records to reflect, the following:
1422	(a)  Healthy Start prenatal or infant screening.
1423	(b)  Healthy Start care coordination, when screening or
1424	other factors indicate need.
1425	(c)  Healthy Start enhanced services in accordance with the
1426	prenatal or infant screening results.
1427	(d)  Immunizations in accordance with recommendations of
1428	the Advisory Committee on Immunization Practices of the United
1429	States Public Health Service and the American Academy of
1430	Pediatrics, as appropriate.
1431	(e)  Counseling and services for family planning to all
1432	women and their partners.
1433	(f)  A scheduled postpartum visit for the purpose of
1434	voluntary family planning, to include discussion of all methods
1435	of contraception, as appropriate.
1436	(g)  Referral to the Special Supplemental Nutrition Program
1437	for Women, Infants, and Children (WIC).
1438	(36)  Any entity that provides Medicaid prepaid health plan
1439	services shall ensure the appropriate coordination of health
1440	care services with an assisted living facility in cases where a
1441	Medicaid recipient is both a member of the entity's prepaid
1442	health plan and a resident of the assisted living facility. If
1443	the entity is at risk for Medicaid targeted case management and
1444	behavioral health services, the entity shall inform the assisted
1445	living facility of the procedures to follow should an emergent
1446	condition arise.
1447	(37)  The agency may seek and implement federal waivers
1448	necessary to provide for cost-effective purchasing of home
1449	health services, private duty nursing services, transportation,
1450	independent laboratory services, and durable medical equipment
1451	and supplies through competitive bidding pursuant to s. 287.057.
1452	The agency may request appropriate waivers from the federal
1453	Health Care Financing Administration in order to competitively
1454	bid such services. The agency may exclude providers not selected
1455	through the bidding process from the Medicaid provider network.
1456	(38)  The Agency for Health Care Administration is directed
1457	to issue a request for proposal or intent to negotiate to
1458	implement on a demonstration basis an outpatient specialty
1459	services pilot project in a rural and urban county in the state.
1460	As used in this subsection, the term "outpatient specialty
1461	services" means clinical laboratory, diagnostic imaging, and
1462	specified home medical services to include durable medical
1463	equipment, prosthetics and orthotics, and infusion therapy.
1464	(a)  The entity that is awarded the contract to provide
1465	Medicaid managed care outpatient specialty services must, at a
1466	minimum, meet the following criteria:
1467	1.  The entity must be licensed by the Office of Insurance
1468	Regulation under part II of chapter 641.
1469	2.  The entity must be experienced in providing outpatient
1470	specialty services.
1471	3.  The entity must demonstrate to the satisfaction of the
1472	agency that it provides high-quality services to its patients.
1473	4.  The entity must demonstrate that it has in place a
1474	complaints and grievance process to assist Medicaid recipients
1475	enrolled in the pilot managed care program to resolve complaints
1476	and grievances.
1477	(b)  The pilot managed care program shall operate for a
1478	period of 3 years. The objective of the pilot program shall be
1479	to determine the cost-effectiveness and effects on utilization,
1480	access, and quality of providing outpatient specialty services
1481	to Medicaid recipients on a prepaid, capitated basis.
1482	(c)  The agency shall conduct a quality assurance review of
1483	the prepaid health clinic each year that the demonstration
1484	program is in effect. The prepaid health clinic is responsible
1485	for all expenses incurred by the agency in conducting a quality
1486	assurance review.
1487	(d)  The entity that is awarded the contract to provide
1488	outpatient specialty services to Medicaid recipients shall
1489	report data required by the agency in a format specified by the
1490	agency, for the purpose of conducting the evaluation required in
1491	paragraph (e).
1492	(e)  The agency shall conduct an evaluation of the pilot
1493	managed care program and report its findings to the Governor and
1494	the Legislature by no later than January 1, 2001.
1495	(39)  The agency shall enter into agreements with not-for-
1496	profit organizations based in this state for the purpose of
1497	providing vision screening.
1498	(40)(a)  The agency shall implement a Medicaid prescribed-
1499	drug spending-control program that includes the following
1500	components:
1501	1.  Medicaid prescribed-drug coverage for brand-name drugs
1502	for adult Medicaid recipients is limited to the dispensing of
1503	four brand-name drugs per month per recipient. Children are
1504	exempt from this restriction. Antiretroviral agents are excluded
1505	from this limitation. No requirements for prior authorization or
1506	other restrictions on medications used to treat mental illnesses
1507	such as schizophrenia, severe depression, or bipolar disorder
1508	may be imposed on Medicaid recipients. Medications that will be
1509	available without restriction for persons with mental illnesses
1510	include atypical antipsychotic medications, conventional
1511	antipsychotic medications, selective serotonin reuptake
1512	inhibitors, and other medications used for the treatment of
1513	serious mental illnesses. The agency shall also limit the amount
1514	of a prescribed drug dispensed to no more than a 34-day supply.
1515	The agency shall continue to provide unlimited generic drugs,
1516	contraceptive drugs and items, and diabetic supplies. Although a
1517	drug may be included on the preferred drug formulary, it would
1518	not be exempt from the four-brand limit. The agency may
1519	authorize exceptions to the brand-name-drug restriction based
1520	upon the treatment needs of the patients, only when such
1521	exceptions are based on prior consultation provided by the
1522	agency or an agency contractor, but the agency must establish
1523	procedures to ensure that:
1524	a.  There will be a response to a request for prior
1525	consultation by telephone or other telecommunication device
1526	within 24 hours after receipt of a request for prior
1527	consultation;
1528	b.  A 72-hour supply of the drug prescribed will be
1529	provided in an emergency or when the agency does not provide a
1530	response within 24 hours as required by sub-subparagraph a.; and
1531	c.  Except for the exception for nursing home residents and
1532	other institutionalized adults and except for drugs on the
1533	restricted formulary for which prior authorization may be sought
1534	by an institutional or community pharmacy, prior authorization
1535	for an exception to the brand-name-drug restriction is sought by
1536	the prescriber and not by the pharmacy. When prior authorization
1537	is granted for a patient in an institutional setting beyond the
1538	brand-name-drug restriction, such approval is authorized for 12
1539	months and monthly prior authorization is not required for that
1540	patient.
1541	2.  Reimbursement to pharmacies for Medicaid prescribed
1542	drugs shall be set at the average wholesale price less 13.25
1543	percent.
1544	3.  The agency shall develop and implement a process for
1545	managing the drug therapies of Medicaid recipients who are using
1546	significant numbers of prescribed drugs each month. The
1547	management process may include, but is not limited to,
1548	comprehensive, physician-directed medical-record reviews, claims
1549	analyses, and case evaluations to determine the medical
1550	necessity and appropriateness of a patient's treatment plan and
1551	drug therapies. The agency may contract with a private
1552	organization to provide drug-program-management services. The
1553	Medicaid drug benefit management program shall include
1554	initiatives to manage drug therapies for HIV/AIDS patients,
1555	patients using 20 or more unique prescriptions in a 180-day
1556	period, and the top 1,000 patients in annual spending.
1557	4.  The agency may limit the size of its pharmacy network
1558	based on need, competitive bidding, price negotiations,
1559	credentialing, or similar criteria. The agency shall give
1560	special consideration to rural areas in determining the size and
1561	location of pharmacies included in the Medicaid pharmacy
1562	network. A pharmacy credentialing process may include criteria
1563	such as a pharmacy's full-service status, location, size,
1564	patient educational programs, patient consultation, disease-
1565	management services, and other characteristics. The agency may
1566	impose a moratorium on Medicaid pharmacy enrollment when it is
1567	determined that it has a sufficient number of Medicaid-
1568	participating providers.
1569	5.  The agency shall develop and implement a program that
1570	requires Medicaid practitioners who prescribe drugs to use a
1571	counterfeit-proof prescription pad for Medicaid prescriptions.
1572	The agency shall require the use of standardized counterfeit-
1573	proof prescription pads by Medicaid-participating prescribers or
1574	prescribers who write prescriptions for Medicaid recipients. The
1575	agency may implement the program in targeted geographic areas or
1576	statewide.
1577	6.  The agency may enter into arrangements that require
1578	manufacturers of generic drugs prescribed to Medicaid recipients
1579	to provide rebates of at least 15.1 percent of the average
1580	manufacturer price for the manufacturer's generic products.
1581	These arrangements shall require that if a generic-drug
1582	manufacturer pays federal rebates for Medicaid-reimbursed drugs
1583	at a level below 15.1 percent, the manufacturer must provide a
1584	supplemental rebate to the state in an amount necessary to
1585	achieve a 15.1-percent rebate level.
1586	7.  The agency may establish a preferred drug formulary in
1587	accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
1588	establishment of such formulary, it is authorized to negotiate
1589	supplemental rebates from manufacturers that are in addition to
1590	those required by Title XIX of the Social Security Act and at no
1591	less than 12 10 percent of the average manufacturer price as
1592	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
1593	the federal or supplemental rebate, or both, equals or exceeds
1594	27 25 percent. There is no upper limit on the supplemental
1595	rebates the agency may negotiate. The agency may determine that
1596	specific products, brand-name or generic, are competitive at
1597	lower rebate percentages. Agreement to pay the minimum
1598	supplemental rebate percentage will guarantee a manufacturer
1599	that the Medicaid Pharmaceutical and Therapeutics Committee will
1600	consider a product for inclusion on the preferred drug
1601	formulary. However, a pharmaceutical manufacturer is not
1602	guaranteed placement on the formulary by simply paying the
1603	minimum supplemental rebate. Agency decisions will be made on
1604	the clinical efficacy of a drug and recommendations of the
1605	Medicaid Pharmaceutical and Therapeutics Committee, as well as
1606	the price of competing products minus federal and state rebates.
1607	The agency is authorized to contract with an outside agency or
1608	contractor to conduct negotiations for supplemental rebates. For
1609	the purposes of this section, the term "supplemental rebates"
1610	may include, at the agency's discretion, cash rebates and other
1611	program benefits that offset a Medicaid expenditure. Effective
1612	July 1, 2004, value-added programs as a substitution for
1613	supplemental rebates are prohibited. Such other program benefits
1614	may include, but are not limited to, disease management
1615	programs, drug product donation programs, drug utilization
1616	control programs, prescriber and beneficiary counseling and
1617	education, fraud and abuse initiatives, and other services or
1618	administrative investments with guaranteed savings to the
1619	Medicaid program in the same year the rebate reduction is
1620	included in the General Appropriations Act. The agency is
1621	authorized to seek any federal waivers to implement this
1622	initiative.
1623	8.  The agency shall establish an advisory committee for
1624	the purposes of studying the feasibility of using a restricted
1625	drug formulary for nursing home residents and other
1626	institutionalized adults. The committee shall be comprised of
1627	seven members appointed by the Secretary of Health Care
1628	Administration. The committee members shall include two
1629	physicians licensed under chapter 458 or chapter 459; three
1630	pharmacists licensed under chapter 465 and appointed from a list
1631	of recommendations provided by the Florida Long-Term Care
1632	Pharmacy Alliance; and two pharmacists licensed under chapter
1633	465.
1634	9.  The Agency for Health Care Administration shall expand
1635	home delivery of pharmacy products. To assist Medicaid patients
1636	in securing their prescriptions and reduce program costs, the
1637	agency shall expand its current mail-order-pharmacy diabetes-
1638	supply program to include all generic and brand-name drugs used
1639	by Medicaid patients with diabetes. Medicaid recipients in the
1640	current program may obtain nondiabetes drugs on a voluntary
1641	basis. This initiative is limited to the geographic area covered
1642	by the current contract. The agency may seek and implement any
1643	federal waivers necessary to implement this subparagraph.
1644	10.  The agency shall limit to one dose per month any drug
1645	prescribed to treat erectile dysfunction. The agency is
1646	authorized to seek a Medicaid state plan amendment to implement
1647	this limitation.
1648	11.a.  The agency shall implement a Medicaid behavioral
1649	pharmacy management system. The agency may contract with a
1650	vendor that has experience in operating behavioral pharmacy
1651	management systems to implement this program. The agency is
1652	authorized to seek a Medicaid waiver or state plan amendment to
1653	implement this program.
1654	b.  The agency, in conjunction with the Department of
1655	Children and Family Services, shall implement the Medicaid
1656	behavioral pharmacy management system that is designed to
1657	improve the quality of care and behavioral health prescribing
1658	practices based on best practice guidelines, improve patient
1659	adherence to medication plans, reduce clinical risk, and lower
1660	prescribed drug costs and the rate of inappropriate spending on
1661	Medicaid behavioral drugs. The program shall include the
1662	following elements:
1663	(I)  Provide for the development and adoption of best
1664	practice guidelines for behavioral health-related drugs such as
1665	antipsychotics, antidepressants, and medications for treating
1666	bipolar disorders and other behavioral conditions; translate
1667	them into practice; review behavioral health prescribers and
1668	compare their prescribing patterns to a number of indicators
1669	that are based on national standards; and determine deviations
1670	from best practice guidelines.
1671	(II)  Implement processes for providing feedback to and
1672	educating prescribers using best practice educational materials
1673	and peer-to-peer consultation.
1674	(III)  Assess Medicaid beneficiaries who are outliers in
1675	their use of behavioral health drugs with regard to the numbers
1676	and types of drugs taken, drug dosages, combination drug
1677	therapies, and other indicators of improper use of behavioral
1678	health drugs.
1679	(IV)  Alert prescribers to patients who fail to refill
1680	prescriptions in a timely fashion, are prescribed multiple same-
1681	class behavioral health drugs, and may have other potential
1682	medication problems.
1683	(V)  Track spending trends for behavioral health drugs and
1684	deviation from best practice guidelines.
1685	(VI)  Use educational and technological approaches to
1686	promote best practices, educate consumers, and train prescribers
1687	in the use of practice guidelines.
1688	(VII)  Disseminate electronic and published materials.
1689	(VIII)  Hold statewide and regional conferences.
1690	(IX)  Implement a disease management program with a model
1691	quality-based medication component for severely mentally ill
1692	individuals and emotionally disturbed children who are high
1693	users of care.
1694	12.  The agency is authorized to contract for drug rebate
1695	administration, including, but not limited to, calculating
1696	rebate amounts, invoicing manufacturers, negotiating disputes
1697	with manufacturers, and maintaining a database of rebate
1698	collections.
1699	(b)  The agency shall implement this subsection to the
1700	extent that funds are appropriated to administer the Medicaid
1701	prescribed-drug spending-control program. The agency may
1702	contract all or any part of this program to private
1703	organizations.
1704	(c)  The agency shall submit quarterly reports to the
1705	Governor, the President of the Senate, and the Speaker of the
1706	House of Representatives which must include, but need not be
1707	limited to, the progress made in implementing this subsection
1708	and its effect on Medicaid prescribed-drug expenditures.
1709	(41)  Notwithstanding the provisions of chapter 287, the
1710	agency may, at its discretion, renew a contract or contracts for
1711	fiscal intermediary services one or more times for such periods
1712	as the agency may decide; however, all such renewals may not
1713	combine to exceed a total period longer than the term of the
1714	original contract.
1715	(42)  The agency shall provide for the development of a
1716	demonstration project by establishment in Miami-Dade County of a
1717	long-term-care facility licensed pursuant to chapter 395 to
1718	improve access to health care for a predominantly minority,
1719	medically underserved, and medically complex population and to
1720	evaluate alternatives to nursing home care and general acute
1721	care for such population. Such project is to be located in a
1722	health care condominium and colocated with licensed facilities
1723	providing a continuum of care. The establishment of this project
1724	is not subject to the provisions of s. 408.036 or s. 408.039.
1725	The agency shall report its findings to the Governor, the
1726	President of the Senate, and the Speaker of the House of
1727	Representatives by January 1, 2003.
1728	(43)  The agency shall develop and implement a utilization
1729	management program for Medicaid-eligible recipients for the
1730	management of occupational, physical, respiratory, and speech
1731	therapies. The agency shall establish a utilization program that
1732	may require prior authorization in order to ensure medically
1733	necessary and cost-effective treatments. The program shall be
1734	operated in accordance with a federally approved waiver program
1735	or state plan amendment. The agency may seek a federal waiver or
1736	state plan amendment to implement this program. The agency may
1737	also competitively procure these services from an outside vendor
1738	on a regional or statewide basis.
1739	(44)  The agency may contract on a prepaid or fixed-sum
1740	basis with appropriately licensed prepaid dental health plans to
1741	provide dental services.
1742	Section 10.  Paragraph (a) of subsection (2) of section
1743	409.9122, Florida Statutes, is amended to read:
1744	409.9122  Mandatory Medicaid managed care enrollment;
1745	programs and procedures.--
1746	(2)(a)  The agency shall enroll in a managed care plan or
1747	MediPass all Medicaid recipients on the effective date of their
1748	eligibility, except those Medicaid recipients who are: in an
1749	institution; enrolled in the Medicaid medically needy program;
1750	or eligible for both Medicaid and Medicare. Upon enrollment,
1751	individuals will be able to change their managed care option
1752	during the 90-day opt out period required by federal Medicaid
1753	regulations. The agency is authorized to seek the necessary
1754	Medicaid state plan amendment to implement this policy. However,
1755	to the extent permitted by federal law, the agency may enroll in
1756	a managed care plan or MediPass a Medicaid recipient who is
1757	exempt from mandatory managed care enrollment, provided that:
1758	1.  The recipient's decision to enroll in a managed care
1759	plan or MediPass is voluntary;
1760	2.  If the recipient chooses to enroll in a managed care
1761	plan, the agency has determined that the managed care plan
1762	provides specific programs and services which address the
1763	special health needs of the recipient; and
1764	3.  The agency receives any necessary waivers from the
1765	federal Health Care Financing Administration.
1766
1767	The agency shall develop rules to establish policies by which
1768	exceptions to the mandatory managed care enrollment requirement
1769	may be made on a case-by-case basis. The rules shall include the
1770	specific criteria to be applied when making a determination as
1771	to whether to exempt a recipient from mandatory enrollment in a
1772	managed care plan or MediPass. School districts participating in
1773	the certified school match program pursuant to ss. 409.908(21)
1774	and 1011.70 shall be reimbursed by Medicaid, subject to the
1775	limitations of s. 1011.70(1), for a Medicaid-eligible child
1776	participating in the services as authorized in s. 1011.70, as
1777	provided for in s. 409.9071, regardless of whether the child is
1778	enrolled in MediPass or a managed care plan. Managed care plans
1779	shall make a good faith effort to execute agreements with school
1780	districts regarding the coordinated provision of services
1781	authorized under s. 1011.70. County health departments
1782	delivering school-based services pursuant to ss. 381.0056 and
1783	381.0057 shall be reimbursed by Medicaid for the federal share
1784	for a Medicaid-eligible child who receives Medicaid-covered
1785	services in a school setting, regardless of whether the child is
1786	enrolled in MediPass or a managed care plan. Managed care plans
1787	shall make a good faith effort to execute agreements with county
1788	health departments regarding the coordinated provision of
1789	services to a Medicaid-eligible child. To ensure continuity of
1790	care for Medicaid patients, the agency, the Department of
1791	Health, and the Department of Education shall develop procedures
1792	for ensuring that a student's managed care plan or MediPass
1793	provider receives information relating to services provided in
1794	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
1795	Section 11.  Subsections (1) and (3) of section 409.915,
1796	Florida Statutes, are amended to read:
1797	409.915  County contributions to Medicaid.--Although the
1798	state is responsible for the full portion of the state share of
1799	the matching funds required for the Medicaid program, in order
1800	to acquire a certain portion of these funds, the state shall
1801	charge the counties for certain items of care and service as
1802	provided in this section.
1803	(1)  Each county shall participate in the following items
1804	of care and service:
1805	(a)  For both health maintenance members and fee-for-
1806	service beneficiaries, payments for inpatient hospitalization in
1807	excess of 10 days, but not in excess of 45 days, with the
1808	exception of pregnant women and children whose income is in
1809	excess of the federal poverty level and who do not participate
1810	in the Medicaid medically needy program, and for adult lung
1811	transplant services. Counties shall pay for items of care and
1812	service provided to the county's eligible recipients regardless
1813	of where in the state the care or service is rendered.
1814	(b)  Payments for nursing home or intermediate facilities
1815	care in excess of $170 per month, with the exception of skilled
1816	nursing care for children under age 21. Beginning on July 1,
1817	2004, county contributions shall be based on each county's
1818	percentage of the total county contribution for fiscal year
1819	2003-2004 adjusted for increases in Medicaid financed nursing
1820	facility residents. The Office of Program Policy Analysis and
1821	Government Accountability shall recommend to the Legislature
1822	each county's share of the total cost every 5 years beginning in
1823	February of 2009. The recommendation shall be based on the
1824	projected number of county residents who will use nursing home
1825	services funded by Medicaid for the subsequent 5-year period.
1826	(3)  Each county shall set aside sufficient funds to pay
1827	for its required county contributions items of care and service
1828	provided to the county's eligible recipients for which county
1829	contributions are required, regardless of where in the state the
1830	care or service is rendered.
1831	Section 12.  Notwithstanding s. 409.912(11), Florida
1832	Statutes, the Agency for Health Care Administration is
1833	authorized to seek federal waivers necessary to implement
1834	Medicaid reform.
1835	Section 13.  Except as otherwise provided herein, this act
1836	shall take effect July 1, 2004.

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