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 to
7	revenue deductions; amending s. 409.814, F.S.; revising a
8	redetermination review period for the Florida KidCare Program;
9	amending s. 409.905, F.S., relating to mandatory Medicaid
10	services; requiring utilization management of private duty
11	nursing services; establishing a hospitalist program; limiting
12	payment for bed hold days for nursing facilities; amending s.
13	409.906, F.S., relating to optional Medicaid services; providing
14	for adult denture and adult hearing and visual services;
15	eliminating vacancy interim rates for intermediate care facility
16	for the developmentally disabled services; requiring utilization
17	management for home and community-based services; consolidating
18	home and community-based services; amending s. 409.908, F.S.;
19	deleting certain guidelines relating to reimbursement of
20	Medicaid providers; mandating the payment method of county
21	health departments; amending s. 409.911, F.S.; authorizing the
22	convening of the Medicaid Disproportionate Share Task Force and
23	providing duties thereof; amending s. 409.912, F.S.; granting
24	Medicaid provider network management; providing limits on
25	certain drugs; providing for management of mental health drugs;
26	reducing payment for pharmaceutical ingredient prices; expanding
27	the existing pharmaceutical supplemental rebate threshold;
28	correcting cross references; amending s. 409.9122, F.S.;
29	revising enrollment policies with respect to the selection of a
30	managed care plan at the time of Medicaid application; revising
31	prerequisites to mandatory assignment; amending s. 409.915,
32	F.S.; providing a new calculation method for county nursing home
33	contributions to Medicaid; authorizing the Agency for Health
34	Care Administration to seek federal waivers necessary to
35	implement Medicaid 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.  Subsections (4) and (19) of section 409.908,
552	Florida Statutes, are 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	(4)  Subject to any limitations or directions provided for
582	in the General Appropriations Act, alternative health plans,
583	health maintenance organizations, and prepaid health plans shall
584	be reimbursed a fixed, prepaid amount negotiated, or
585	competitively bid pursuant to s. 287.057, by the agency and
586	prospectively paid to the provider monthly for each Medicaid
587	recipient enrolled. The amount may not exceed the average amount
588	the agency determines it would have paid, based on claims
589	experience, for recipients in the same or similar category of
590	eligibility. The agency shall calculate capitation rates on a
591	regional basis and, beginning September 1, 1995, shall include
592	age-band differentials in such calculations. Effective July 1,
593	2001, the cost of exempting statutory teaching hospitals,
594	specialty hospitals, and community hospital education program
595	hospitals from reimbursement ceilings and the cost of special
596	Medicaid payments shall not be included in premiums paid to
597	health maintenance organizations or prepaid health care plans.
598	Each rate semester, the agency shall calculate and publish a
599	Medicaid hospital rate schedule that does not reflect either
600	special Medicaid payments or the elimination of rate
601	reimbursement ceilings, to be used by hospitals and Medicaid
602	health maintenance organizations, in order to determine the
603	Medicaid rate referred to in ss. 409.912(17), 409.9128(5), and
604	641.513(6).
605	(19)  County health department services shall may be
606	reimbursed a rate per visit based on total reasonable costs of
607	the clinic, as determined by the agency in accordance with
608	federal regulations under the authority of 42 C.F.R. s. 431.615.
609	Section 8.  Subsection (9) is added to section 409.911,
610	Florida Statutes, to read:
611	409.911  Disproportionate share program.--Subject to
612	specific allocations established within the General
613	Appropriations Act and any limitations established pursuant to
614	chapter 216, the agency shall distribute, pursuant to this
615	section, moneys to hospitals providing a disproportionate share
616	of Medicaid or charity care services by making quarterly
617	Medicaid payments as required. Notwithstanding the provisions of
618	s. 409.915, counties are exempt from contributing toward the
619	cost of this special reimbursement for hospitals serving a
620	disproportionate share of low-income patients.
621	(9)  The Medicaid Disproportionate Share Task Force is
622	authorized to convene each fiscal year for the purpose of
623	monitoring the implementation of enhanced Medicaid funding
624	through the Special Medicaid Payment program. In addition, the
625	task force shall review the federal status of the Upper Payment
626	Limit funding option and recommend how this option may be
627	further used to promote local primary care networks to uninsured
628	citizens in the state, to increase the accessibility of trauma
629	centers to residents of the state, and to ensure the financial
630	viability of the state's graduate medical education programs and
631	other health care policies determined by the task force to be
632	state health care priorities. The task force shall annually
633	present its findings and recommendations in the last week of
634	January to the Executive Office of the Governor and the
635	Legislature.
636	Section 9.  Section 409.912, Florida Statutes, is amended
637	to read:
638	409.912  Cost-effective purchasing of health care.--The
639	agency shall purchase goods and services for Medicaid recipients
640	in the most cost-effective manner consistent with the delivery
641	of quality medical care. The agency shall maximize the use of
642	prepaid per capita and prepaid aggregate fixed-sum basis
643	services when appropriate and other alternative service delivery
644	and reimbursement methodologies, including competitive bidding
645	pursuant to s. 287.057, designed to facilitate the cost-
646	effective purchase of a case-managed continuum of care. The
647	agency shall also require providers to minimize the exposure of
648	recipients to the need for acute inpatient, custodial, and other
649	institutional care and the inappropriate or unnecessary use of
650	high-cost services. The agency may establish prior authorization
651	requirements for certain populations of Medicaid beneficiaries,
652	certain drug classes, or particular drugs to prevent fraud,
653	abuse, overuse, and possible dangerous drug interactions. The
654	Pharmaceutical and Therapeutics Committee shall make
655	recommendations to the agency on drugs for which prior
656	authorization is required. The agency shall inform the
657	Pharmaceutical and Therapeutics Committee of its decisions
658	regarding drugs subject to prior authorization. The agency is
659	authorized to limit the entities it contracts with by developing
660	a provider network through competitive bidding or provider
661	credentialing. If a credentialing process is used, the agency
662	may limit its network based on the assessment of beneficiary
663	access to care, provider availability, provider quality
664	standards, time and distance standards for access to care, the
665	cultural competence of the provider network, demographic
666	characteristics of Medicaid beneficiaries, practice and
667	provider-to-beneficiary standards, appointment wait times,
668	beneficiary use of services, provider turnover, provider
669	profiling, provider licensure history, previous program
670	integrity investigations and findings, peer review, provider
671	Medicaid policy and billing compliance record, clinical and
672	medical record audits, and other factors. Providers shall not be
673	entitled to enrollment in the Medicaid provider network. The
674	agency is authorized to seek the Medicaid state plan amendments
675	and federal waivers necessary to implement this policy.
676	(1)  The agency shall work with the Department of Children
677	and Family Services to ensure access of children and families in
678	the child protection system to needed and appropriate mental
679	health and substance abuse services.
680	(2)  The agency may enter into agreements with appropriate
681	agents of other state agencies or of any agency of the Federal
682	Government and accept such duties in respect to social welfare
683	or public aid as may be necessary to implement the provisions of
684	Title XIX of the Social Security Act and ss. 409.901-409.920.
685	(3)  The agency may contract with health maintenance
686	organizations certified pursuant to part I of chapter 641 for
687	the provision of services to recipients.
688	(4)  The agency may contract with:
689	(a)  An entity that provides no prepaid health care
690	services other than Medicaid services under contract with the
691	agency and which is owned and operated by a county, county
692	health department, or county-owned and operated hospital to
693	provide health care services on a prepaid or fixed-sum basis to
694	recipients, which entity may provide such prepaid services
695	either directly or through arrangements with other providers.
696	Such prepaid health care services entities must be licensed
697	under parts I and III by January 1, 1998, and until then are
698	exempt from the provisions of part I of chapter 641. An entity
699	recognized under this paragraph which demonstrates to the
700	satisfaction of the Office of Insurance Regulation of the
701	Financial Services Commission that it is backed by the full
702	faith and credit of the county in which it is located may be
703	exempted from s. 641.225.
704	(b)  An entity that is providing comprehensive behavioral
705	health care services to certain Medicaid recipients through a
706	capitated, prepaid arrangement pursuant to the federal waiver
707	provided for by s. 409.905(5). Such an entity must be licensed
708	under chapter 624, chapter 636, or chapter 641 and must possess
709	the clinical systems and operational competence to manage risk
710	and provide comprehensive behavioral health care to Medicaid
711	recipients. As used in this paragraph, the term "comprehensive
712	behavioral health care services" means covered mental health and
713	substance abuse treatment services that are available to
714	Medicaid recipients. The secretary of the Department of Children
715	and Family Services shall approve provisions of procurements
716	related to children in the department's care or custody prior to
717	enrolling such children in a prepaid behavioral health plan. Any
718	contract awarded under this paragraph must be competitively
719	procured. In developing the behavioral health care prepaid plan
720	procurement document, the agency shall ensure that the
721	procurement document requires the contractor to develop and
722	implement a plan to ensure compliance with s. 394.4574 related
723	to services provided to residents of licensed assisted living
724	facilities that hold a limited mental health license. The agency
725	shall seek federal approval to contract with a single entity
726	meeting these requirements to provide comprehensive behavioral
727	health care services to all Medicaid recipients not enrolled in
728	a managed care plan in an AHCA area. Each entity must offer
729	sufficient choice of providers in its network to ensure
730	recipient access to care and the opportunity to select a
731	provider with whom they are satisfied. The network shall include
732	all public mental health hospitals. To ensure unimpaired access
733	to behavioral health care services by Medicaid recipients, all
734	contracts issued pursuant to this paragraph shall require 80
735	percent of the capitation paid to the managed care plan,
736	including health maintenance organizations, to be expended for
737	the provision of behavioral health care services. In the event
738	the managed care plan expends less than 80 percent of the
739	capitation paid pursuant to this paragraph for the provision of
740	behavioral health care services, the difference shall be
741	returned to the agency. The agency shall provide the managed
742	care plan with a certification letter indicating the amount of
743	capitation paid during each calendar year for the provision of
744	behavioral health care services pursuant to this section. The
745	agency may reimburse for substance abuse treatment services on a
746	fee-for-service basis until the agency finds that adequate funds
747	are available for capitated, prepaid arrangements.
748	1.  By January 1, 2001, the agency shall modify the
749	contracts with the entities providing comprehensive inpatient
750	and outpatient mental health care services to Medicaid
751	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
752	Counties, to include substance abuse treatment services.
753	2.  By July 1, 2003, the agency and the Department of
754	Children and Family Services shall execute a written agreement
755	that requires collaboration and joint development of all policy,
756	budgets, procurement documents, contracts, and monitoring plans
757	that have an impact on the state and Medicaid community mental
758	health and targeted case management programs.
759	3.  By July 1, 2006, the agency and the Department of
760	Children and Family Services shall contract with managed care
761	entities in each AHCA area except area 6 or arrange to provide
762	comprehensive inpatient and outpatient mental health and
763	substance abuse services through capitated prepaid arrangements
764	to all Medicaid recipients who are eligible to participate in
765	such plans under federal law and regulation. In AHCA areas where
766	eligible individuals number less than 150,000, the agency shall
767	contract with a single managed care plan to provide
768	comprehensive behavioral health services to all recipients who
769	are not enrolled in a Medicaid health maintenance organization.
770	The agency may contract with more than one comprehensive
771	behavioral health provider to provide care to recipients who are
772	not enrolled in a Medicaid health maintenance organization plan
773	in AHCA areas where the eligible population exceeds 150,000.
774	Contracts for comprehensive behavioral health providers awarded
775	pursuant to this section shall be competitively procured. Both
776	for-profit and not-for-profit corporations shall be eligible to
777	compete. Managed care plans contracting with the agency under
778	subsection (3) shall provide and receive payment for the same
779	comprehensive behavioral health benefits as provided in AHCA
780	rules, including handbooks incorporated by reference.
781	4.  By October 1, 2003, the agency and the department shall
782	submit a plan to the Governor, the President of the Senate, and
783	the Speaker of the House of Representatives which provides for
784	the full implementation of capitated prepaid behavioral health
785	care in all areas of the state. The plan shall include
786	provisions which ensure that children and families receiving
787	foster care and other related services are appropriately served
788	and that these services assist the community-based care lead
789	agencies in meeting the goals and outcomes of the child welfare
790	system. The plan will be developed with the participation of
791	community-based lead agencies, community alliances, sheriffs,
792	and community providers serving dependent children.
793	a.  Implementation shall begin in 2003 in those AHCA areas
794	of the state where the agency is able to establish sufficient
795	capitation rates.
796	b.  If the agency determines that the proposed capitation
797	rate in any area is insufficient to provide appropriate
798	services, the agency may adjust the capitation rate to ensure
799	that care will be available. The agency and the department may
800	use existing general revenue to address any additional required
801	match but may not over-obligate existing funds on an annualized
802	basis.
803	c.  Subject to any limitations provided for in the General
804	Appropriations Act, the agency, in compliance with appropriate
805	federal authorization, shall develop policies and procedures
806	that allow for certification of local and state funds.
807	5.  Children residing in a statewide inpatient psychiatric
808	program, or in a Department of Juvenile Justice or a Department
809	of Children and Family Services residential program approved as
810	a Medicaid behavioral health overlay services provider shall not
811	be included in a behavioral health care prepaid health plan
812	pursuant to this paragraph.
813	6.  In converting to a prepaid system of delivery, the
814	agency shall in its procurement document require an entity
815	providing only comprehensive behavioral health care services to
816	prevent the displacement of indigent care patients by enrollees
817	in the Medicaid prepaid health plan providing behavioral health
818	care services from facilities receiving state funding to provide
819	indigent behavioral health care, to facilities licensed under
820	chapter 395 which do not receive state funding for indigent
821	behavioral health care, or reimburse the unsubsidized facility
822	for the cost of behavioral health care provided to the displaced
823	indigent care patient.
824	7.  Traditional community mental health providers under
825	contract with the Department of Children and Family Services
826	pursuant to part IV of chapter 394, child welfare providers
827	under contract with the Department of Children and Family
828	Services, and inpatient mental health providers licensed
829	pursuant to chapter 395 must be offered an opportunity to accept
830	or decline a contract to participate in any provider network for
831	prepaid behavioral health services.
832	(c)  A federally qualified health center or an entity owned
833	by one or more federally qualified health centers or an entity
834	owned by other migrant and community health centers receiving
835	non-Medicaid financial support from the Federal Government to
836	provide health care services on a prepaid or fixed-sum basis to
837	recipients. Such prepaid health care services entity must be
838	licensed under parts I and III of chapter 641, but shall be
839	prohibited from serving Medicaid recipients on a prepaid basis,
840	until such licensure has been obtained. However, such an entity
841	is exempt from s. 641.225 if the entity meets the requirements
842	specified in subsections (17) (15) and (18) (16).
843	(d)  A provider service network may be reimbursed on a fee-
844	for-service or prepaid basis. A provider service network which
845	is reimbursed by the agency on a prepaid basis shall be exempt
846	from parts I and III of chapter 641, but must meet appropriate
847	financial reserve, quality assurance, and patient rights
848	requirements as established by the agency. The agency shall
849	award contracts on a competitive bid basis and shall select
850	bidders based upon price and quality of care. Medicaid
851	recipients assigned to a demonstration project shall be chosen
852	equally from those who would otherwise have been assigned to
853	prepaid plans and MediPass. The agency is authorized to seek
854	federal Medicaid waivers as necessary to implement the
855	provisions of this section.
856	(e)  An entity that provides only comprehensive behavioral
857	health care services to certain Medicaid recipients through an
858	administrative services organization agreement. Such an entity
859	must possess the clinical systems and operational competence to
860	provide comprehensive health care to Medicaid recipients. As
861	used in this paragraph, the term "comprehensive behavioral
862	health care services" means covered mental health and substance
863	abuse treatment services that are available to Medicaid
864	recipients. Any contract awarded under this paragraph must be
865	competitively procured. The agency must ensure that Medicaid
866	recipients have available the choice of at least two managed
867	care plans for their behavioral health care services.
868	(f)  An entity that provides in-home physician services to
869	test the cost-effectiveness of enhanced home-based medical care
870	to Medicaid recipients with degenerative neurological diseases
871	and other diseases or disabling conditions associated with high
872	costs to Medicaid. The program shall be designed to serve very
873	disabled persons and to reduce Medicaid reimbursed costs for
874	inpatient, outpatient, and emergency department services. The
875	agency shall contract with vendors on a risk-sharing basis.
876	(g)  Children's provider networks that provide care
877	coordination and care management for Medicaid-eligible pediatric
878	patients, primary care, authorization of specialty care, and
879	other urgent and emergency care through organized providers
880	designed to service Medicaid eligibles under age 18 and
881	pediatric emergency departments' diversion programs. The
882	networks shall provide after-hour operations, including evening
883	and weekend hours, to promote, when appropriate, the use of the
884	children's networks rather than hospital emergency departments.
885	(h)  An entity authorized in s. 430.205 to contract with
886	the agency and the Department of Elderly Affairs to provide
887	health care and social services on a prepaid or fixed-sum basis
888	to elderly recipients. Such prepaid health care services
889	entities are exempt from the provisions of part I of chapter 641
890	for the first 3 years of operation. An entity recognized under
891	this paragraph that demonstrates to the satisfaction of the
892	Office of Insurance Regulation that it is backed by the full
893	faith and credit of one or more counties in which it operates
894	may be exempted from s. 641.225.
895	(i)  A Children's Medical Services network, as defined in
896	s. 391.021.
897	(5)  By October 1, 2003, the agency and the department
898	shall, to the extent feasible, develop a plan for implementing
899	new Medicaid procedure codes for emergency and crisis care,
900	supportive residential services, and other services designed to
901	maximize the use of Medicaid funds for Medicaid-eligible
902	recipients. The agency shall include in the agreement developed
903	pursuant to subsection (4) a provision that ensures that the
904	match requirements for these new procedure codes are met by
905	certifying eligible general revenue or local funds that are
906	currently expended on these services by the department with
907	contracted alcohol, drug abuse, and mental health providers. The
908	plan must describe specific procedure codes to be implemented, a
909	projection of the number of procedures to be delivered during
910	fiscal year 2003-2004, and a financial analysis that describes
911	the certified match procedures, and accountability mechanisms,
912	projects the earnings associated with these procedures, and
913	describes the sources of state match. This plan may not be
914	implemented in any part until approved by the Legislative Budget
915	Commission. If such approval has not occurred by December 31,
916	2003, the plan shall be submitted for consideration by the 2004
917	Legislature.
918	(6)  The agency may contract with any public or private
919	entity otherwise authorized by this section on a prepaid or
920	fixed-sum basis for the provision of health care services to
921	recipients. An entity may provide prepaid services to
922	recipients, either directly or through arrangements with other
923	entities, if each entity involved in providing services:
924	(a)  Is organized primarily for the purpose of providing
925	health care or other services of the type regularly offered to
926	Medicaid recipients;
927	(b)  Ensures that services meet the standards set by the
928	agency for quality, appropriateness, and timeliness;
929	(c)  Makes provisions satisfactory to the agency for
930	insolvency protection and ensures that neither enrolled Medicaid
931	recipients nor the agency will be liable for the debts of the
932	entity;
933	(d)  Submits to the agency, if a private entity, a
934	financial plan that the agency finds to be fiscally sound and
935	that provides for working capital in the form of cash or
936	equivalent liquid assets excluding revenues from Medicaid
937	premium payments equal to at least the first 3 months of
938	operating expenses or $200,000, whichever is greater;
939	(e)  Furnishes evidence satisfactory to the agency of
940	adequate liability insurance coverage or an adequate plan of
941	self-insurance to respond to claims for injuries arising out of
942	the furnishing of health care;
943	(f)  Provides, through contract or otherwise, for periodic
944	review of its medical facilities and services, as required by
945	the agency; and
946	(g)  Provides organizational, operational, financial, and
947	other information required by the agency.
948	(7)  The agency may contract on a prepaid or fixed-sum
949	basis with any health insurer that:
950	(a)  Pays for health care services provided to enrolled
951	Medicaid recipients in exchange for a premium payment paid by
952	the agency;
953	(b)  Assumes the underwriting risk; and
954	(c)  Is organized and licensed under applicable provisions
955	of the Florida Insurance Code and is currently in good standing
956	with the Office of Insurance Regulation.
957	(8)  The agency may contract on a prepaid or fixed-sum
958	basis with an exclusive provider organization to provide health
959	care services to Medicaid recipients provided that the exclusive
960	provider organization meets applicable managed care plan
961	requirements in this section, ss. 409.9122, 409.9123, 409.9128,
962	and 627.6472, and other applicable provisions of law.
963	(9)  The Agency for Health Care Administration may provide
964	cost-effective purchasing of chiropractic services on a fee-for-
965	service basis to Medicaid recipients through arrangements with a
966	statewide chiropractic preferred provider organization
967	incorporated in this state as a not-for-profit corporation. The
968	agency shall ensure that the benefit limits and prior
969	authorization requirements in the current Medicaid program shall
970	apply to the services provided by the chiropractic preferred
971	provider organization.
972	(10)  The agency shall not contract on a prepaid or fixed-
973	sum basis for Medicaid services with an entity which knows or
974	reasonably should know that any officer, director, agent,
975	managing employee, or owner of stock or beneficial interest in
976	excess of 5 percent common or preferred stock, or the entity
977	itself, has been found guilty of, regardless of adjudication, or
978	entered a plea of nolo contendere, or guilty, to:
979	(a)  Fraud;
980	(b)  Violation of federal or state antitrust statutes,
981	including those proscribing price fixing between competitors and
982	the allocation of customers among competitors;
983	(c)  Commission of a felony involving embezzlement, theft,
984	forgery, income tax evasion, bribery, falsification or
985	destruction of records, making false statements, receiving
986	stolen property, making false claims, or obstruction of justice;
987	or
988	(d)  Any crime in any jurisdiction which directly relates
989	to the provision of health services on a prepaid or fixed-sum
990	basis.
991	(11)  The agency, after notifying the Legislature, may
992	apply for waivers of applicable federal laws and regulations as
993	necessary to implement more appropriate systems of health care
994	for Medicaid recipients and reduce the cost of the Medicaid
995	program to the state and federal governments and shall implement
996	such programs, after legislative approval, within a reasonable
997	period of time after federal approval. These programs must be
998	designed primarily to reduce the need for inpatient care,
999	custodial care and other long-term or institutional care, and
1000	other high-cost services.
1001	(a)  Prior to seeking legislative approval of such a waiver
1002	as authorized by this subsection, the agency shall provide
1003	notice and an opportunity for public comment. Notice shall be
1004	provided to all persons who have made requests of the agency for
1005	advance notice and shall be published in the Florida
1006	Administrative Weekly not less than 28 days prior to the
1007	intended action.
1008	(b)  Notwithstanding s. 216.292, funds that are
1009	appropriated to the Department of Elderly Affairs for the
1010	Assisted Living for the Elderly Medicaid waiver and are not
1011	expended shall be transferred to the agency to fund Medicaid-
1012	reimbursed nursing home care.
1013	(12)  The agency shall establish a postpayment utilization
1014	control program designed to identify recipients who may
1015	inappropriately overuse or underuse Medicaid services and shall
1016	provide methods to correct such misuse.
1017	(13)  The agency shall develop and provide coordinated
1018	systems of care for Medicaid recipients and may contract with
1019	public or private entities to develop and administer such
1020	systems of care among public and private health care providers
1021	in a given geographic area.
1022	(14)  The agency shall operate or contract for the
1023	operation of utilization management and incentive systems
1024	designed to encourage cost-effective use services.
1025	(15)(a)  The agency shall operate the Comprehensive
1026	Assessment and Review (CARES) nursing facility preadmission
1027	screening program to ensure that Medicaid payment for nursing
1028	facility care is made only for individuals whose conditions
1029	require such care and to ensure that long-term care services are
1030	provided in the setting most appropriate to the needs of the
1031	person and in the most economical manner possible. The CARES
1032	program shall also ensure that individuals participating in
1033	Medicaid home and community-based waiver programs meet criteria
1034	for those programs, consistent with approved federal waivers.
1035	(b)  The agency shall operate the CARES program through an
1036	interagency agreement with the Department of Elderly Affairs.
1037	(c)  Prior to making payment for nursing facility services
1038	for a Medicaid recipient, the agency must verify that the
1039	nursing facility preadmission screening program has determined
1040	that the individual requires nursing facility care and that the
1041	individual cannot be safely served in community-based programs.
1042	The nursing facility preadmission screening program shall refer
1043	a Medicaid recipient to a community-based program if the
1044	individual could be safely served at a lower cost and the
1045	recipient chooses to participate in such program.
1046	(d)  By January 1 of each year, the agency shall submit a
1047	report to the Legislature and the Office of Long-Term-Care
1048	Policy describing the operations of the CARES program. The
1049	report must describe:
1050	1.  Rate of diversion to community alternative programs;
1051	2.  CARES program staffing needs to achieve additional
1052	diversions;
1053	3.  Reasons the program is unable to place individuals in
1054	less restrictive settings when such individuals desired such
1055	services and could have been served in such settings;
1056	4.  Barriers to appropriate placement, including barriers
1057	due to policies or operations of other agencies or state-funded
1058	programs; and
1059	5.  Statutory changes necessary to ensure that individuals
1060	in need of long-term care services receive care in the least
1061	restrictive environment.
1062	(16)(a)  The agency shall identify health care utilization
1063	and price patterns within the Medicaid program which are not
1064	cost-effective or medically appropriate and assess the
1065	effectiveness of new or alternate methods of providing and
1066	monitoring service, and may implement such methods as it
1067	considers appropriate. Such methods may include disease
1068	management initiatives, an integrated and systematic approach
1069	for managing the health care needs of recipients who are at risk
1070	of or diagnosed with a specific disease by using best practices,
1071	prevention strategies, clinical-practice improvement, clinical
1072	interventions and protocols, outcomes research, information
1073	technology, and other tools and resources to reduce overall
1074	costs and improve measurable outcomes.
1075	(b)  The responsibility of the agency under this subsection
1076	shall include the development of capabilities to identify actual
1077	and optimal practice patterns; patient and provider educational
1078	initiatives; methods for determining patient compliance with
1079	prescribed treatments; fraud, waste, and abuse prevention and
1080	detection programs; and beneficiary case management programs.
1081	1.  The practice pattern identification program shall
1082	evaluate practitioner prescribing patterns based on national and
1083	regional practice guidelines, comparing practitioners to their
1084	peer groups. The agency and its Drug Utilization Review Board
1085	shall consult with a panel of practicing health care
1086	professionals consisting of the following: the Speaker of the
1087	House of Representatives and the President of the Senate shall
1088	each appoint three physicians licensed under chapter 458 or
1089	chapter 459; and the Governor shall appoint two pharmacists
1090	licensed under chapter 465 and one dentist licensed under
1091	chapter 466 who is an oral surgeon. Terms of the panel members
1092	shall expire at the discretion of the appointing official. The
1093	panel shall begin its work by August 1, 1999, regardless of the
1094	number of appointments made by that date. The advisory panel
1095	shall be responsible for evaluating treatment guidelines and
1096	recommending ways to incorporate their use in the practice
1097	pattern identification program. Practitioners who are
1098	prescribing inappropriately or inefficiently, as determined by
1099	the agency, may have their prescribing of certain drugs subject
1100	to prior authorization.
1101	2.  The agency shall also develop educational interventions
1102	designed to promote the proper use of medications by providers
1103	and beneficiaries.
1104	3.  The agency shall implement a pharmacy fraud, waste, and
1105	abuse initiative that may include a surety bond or letter of
1106	credit requirement for participating pharmacies, enhanced
1107	provider auditing practices, the use of additional fraud and
1108	abuse software, recipient management programs for beneficiaries
1109	inappropriately using their benefits, and other steps that will
1110	eliminate provider and recipient fraud, waste, and abuse. The
1111	initiative shall address enforcement efforts to reduce the
1112	number and use of counterfeit prescriptions.
1113	4.  By September 30, 2002, the agency shall contract with
1114	an entity in the state to implement a wireless handheld clinical
1115	pharmacology drug information database for practitioners. The
1116	initiative shall be designed to enhance the agency's efforts to
1117	reduce fraud, abuse, and errors in the prescription drug benefit
1118	program and to otherwise further the intent of this paragraph.
1119	5.  The agency may apply for any federal waivers needed to
1120	implement this paragraph.
1121	(17)  An entity contracting on a prepaid or fixed-sum basis
1122	shall, in addition to meeting any applicable statutory surplus
1123	requirements, also maintain at all times in the form of cash,
1124	investments that mature in less than 180 days allowable as
1125	admitted assets by the Office of Insurance Regulation, and
1126	restricted funds or deposits controlled by the agency or the
1127	Office of Insurance Regulation, a surplus amount equal to one-
1128	and-one-half times the entity's monthly Medicaid prepaid
1129	revenues. As used in this subsection, the term "surplus" means
1130	the entity's total assets minus total liabilities. If an
1131	entity's surplus falls below an amount equal to one-and-one-half
1132	times the entity's monthly Medicaid prepaid revenues, the agency
1133	shall prohibit the entity from engaging in marketing and
1134	preenrollment activities, shall cease to process new
1135	enrollments, and shall not renew the entity's contract until the
1136	required balance is achieved. The requirements of this
1137	subsection do not apply:
1138	(a)  Where a public entity agrees to fund any deficit
1139	incurred by the contracting entity; or
1140	(b)  Where the entity's performance and obligations are
1141	guaranteed in writing by a guaranteeing organization which:
1142	1.  Has been in operation for at least 5 years and has
1143	assets in excess of $50 million; or
1144	2.  Submits a written guarantee acceptable to the agency
1145	which is irrevocable during the term of the contracting entity's
1146	contract with the agency and, upon termination of the contract,
1147	until the agency receives proof of satisfaction of all
1148	outstanding obligations incurred under the contract.
1149	(18)(a)  The agency may require an entity contracting on a
1150	prepaid or fixed-sum basis to establish a restricted insolvency
1151	protection account with a federally guaranteed financial
1152	institution licensed to do business in this state. The entity
1153	shall deposit into that account 5 percent of the capitation
1154	payments made by the agency each month until a maximum total of
1155	2 percent of the total current contract amount is reached. The
1156	restricted insolvency protection account may be drawn upon with
1157	the authorized signatures of two persons designated by the
1158	entity and two representatives of the agency. If the agency
1159	finds that the entity is insolvent, the agency may draw upon the
1160	account solely with the two authorized signatures of
1161	representatives of the agency, and the funds may be disbursed to
1162	meet financial obligations incurred by the entity under the
1163	prepaid contract. If the contract is terminated, expired, or not
1164	continued, the account balance must be released by the agency to
1165	the entity upon receipt of proof of satisfaction of all
1166	outstanding obligations incurred under this contract.
1167	(b)  The agency may waive the insolvency protection account
1168	requirement in writing when evidence is on file with the agency
1169	of adequate insolvency insurance and reinsurance that will
1170	protect enrollees if the entity becomes unable to meet its
1171	obligations.
1172	(19)  An entity that contracts with the agency on a prepaid
1173	or fixed-sum basis for the provision of Medicaid services shall
1174	reimburse any hospital or physician that is outside the entity's
1175	authorized geographic service area as specified in its contract
1176	with the agency, and that provides services authorized by the
1177	entity to its members, at a rate negotiated with the hospital or
1178	physician for the provision of services or according to the
1179	lesser of the following:
1180	(a)  The usual and customary charges made to the general
1181	public by the hospital or physician; or
1182	(b)  The Florida Medicaid reimbursement rate established
1183	for the hospital or physician.
1184	(20)  When a merger or acquisition of a Medicaid prepaid
1185	contractor has been approved by the Office of Insurance
1186	Regulation pursuant to s. 628.4615, the agency shall approve the
1187	assignment or transfer of the appropriate Medicaid prepaid
1188	contract upon request of the surviving entity of the merger or
1189	acquisition if the contractor and the other entity have been in
1190	good standing with the agency for the most recent 12-month
1191	period, unless the agency determines that the assignment or
1192	transfer would be detrimental to the Medicaid recipients or the
1193	Medicaid program. To be in good standing, an entity must not
1194	have failed accreditation or committed any material violation of
1195	the requirements of s. 641.52 and must meet the Medicaid
1196	contract requirements. For purposes of this section, a merger or
1197	acquisition means a change in controlling interest of an entity,
1198	including an asset or stock purchase.
1199	(21)  Any entity contracting with the agency pursuant to
1200	this section to provide health care services to Medicaid
1201	recipients is prohibited from engaging in any of the following
1202	practices or activities:
1203	(a)  Practices that are discriminatory, including, but not
1204	limited to, attempts to discourage participation on the basis of
1205	actual or perceived health status.
1206	(b)  Activities that could mislead or confuse recipients,
1207	or misrepresent the organization, its marketing representatives,
1208	or the agency. Violations of this paragraph include, but are not
1209	limited to:
1210	1.  False or misleading claims that marketing
1211	representatives are employees or representatives of the state or
1212	county, or of anyone other than the entity or the organization
1213	by whom they are reimbursed.
1214	2.  False or misleading claims that the entity is
1215	recommended or endorsed by any state or county agency, or by any
1216	other organization which has not certified its endorsement in
1217	writing to the entity.
1218	3.  False or misleading claims that the state or county
1219	recommends that a Medicaid recipient enroll with an entity.
1220	4.  Claims that a Medicaid recipient will lose benefits
1221	under the Medicaid program, or any other health or welfare
1222	benefits to which the recipient is legally entitled, if the
1223	recipient does not enroll with the entity.
1224	(c)  Granting or offering of any monetary or other valuable
1225	consideration for enrollment, except as authorized by subsection
1226	(24) (22).
1227	(d)  Door-to-door solicitation of recipients who have not
1228	contacted the entity or who have not invited the entity to make
1229	a presentation.
1230	(e)  Solicitation of Medicaid recipients by marketing
1231	representatives stationed in state offices unless approved and
1232	supervised by the agency or its agent and approved by the
1233	affected state agency when solicitation occurs in an office of
1234	the state agency. The agency shall ensure that marketing
1235	representatives stationed in state offices shall market their
1236	managed care plans to Medicaid recipients only in designated
1237	areas and in such a way as to not interfere with the recipients'
1238	activities in the state office.
1239	(f)  Enrollment of Medicaid recipients.
1240	(22)  The agency may impose a fine for a violation of this
1241	section or the contract with the agency by a person or entity
1242	that is under contract with the agency. With respect to any
1243	nonwillful violation, such fine shall not exceed $2,500 per
1244	violation. In no event shall such fine exceed an aggregate
1245	amount of $10,000 for all nonwillful violations arising out of
1246	the same action. With respect to any knowing and willful
1247	violation of this section or the contract with the agency, the
1248	agency may impose a fine upon the entity in an amount not to
1249	exceed $20,000 for each such violation. In no event shall such
1250	fine exceed an aggregate amount of $100,000 for all knowing and
1251	willful violations arising out of the same action.
1252	(23)  A health maintenance organization or a person or
1253	entity exempt from chapter 641 that is under contract with the
1254	agency for the provision of health care services to Medicaid
1255	recipients may not use or distribute marketing materials used to
1256	solicit Medicaid recipients, unless such materials have been
1257	approved by the agency. The provisions of this subsection do not
1258	apply to general advertising and marketing materials used by a
1259	health maintenance organization to solicit both non-Medicaid
1260	subscribers and Medicaid recipients.
1261	(24)  Upon approval by the agency, health maintenance
1262	organizations and persons or entities exempt from chapter 641
1263	that are under contract with the agency for the provision of
1264	health care services to Medicaid recipients may be permitted
1265	within the capitation rate to provide additional health benefits
1266	that the agency has found are of high quality, are practicably
1267	available, provide reasonable value to the recipient, and are
1268	provided at no additional cost to the state.
1269	(25)  The agency shall utilize the statewide health
1270	maintenance organization complaint hotline for the purpose of
1271	investigating and resolving Medicaid and prepaid health plan
1272	complaints, maintaining a record of complaints and confirmed
1273	problems, and receiving disenrollment requests made by
1274	recipients.
1275	(26)  The agency shall require the publication of the
1276	health maintenance organization's and the prepaid health plan's
1277	consumer services telephone numbers and the "800" telephone
1278	number of the statewide health maintenance organization
1279	complaint hotline on each Medicaid identification card issued by
1280	a health maintenance organization or prepaid health plan
1281	contracting with the agency to serve Medicaid recipients and on
1282	each subscriber handbook issued to a Medicaid recipient.
1283	(27)  The agency shall establish a health care quality
1284	improvement system for those entities contracting with the
1285	agency pursuant to this section, incorporating all the standards
1286	and guidelines developed by the Medicaid Bureau of the Health
1287	Care Financing Administration as a part of the quality assurance
1288	reform initiative. The system shall include, but need not be
1289	limited to, the following:
1290	(a)  Guidelines for internal quality assurance programs,
1291	including standards for:
1292	1.  Written quality assurance program descriptions.
1293	2.  Responsibilities of the governing body for monitoring,
1294	evaluating, and making improvements to care.
1295	3.  An active quality assurance committee.
1296	4.  Quality assurance program supervision.
1297	5.  Requiring the program to have adequate resources to
1298	effectively carry out its specified activities.
1299	6.  Provider participation in the quality assurance
1300	program.
1301	7.  Delegation of quality assurance program activities.
1302	8.  Credentialing and recredentialing.
1303	9.  Enrollee rights and responsibilities.
1304	10.  Availability and accessibility to services and care.
1305	11.  Ambulatory care facilities.
1306	12.  Accessibility and availability of medical records, as
1307	well as proper recordkeeping and process for record review.
1308	13.  Utilization review.
1309	14.  A continuity of care system.
1310	15.  Quality assurance program documentation.
1311	16.  Coordination of quality assurance activity with other
1312	management activity.
1313	17.  Delivering care to pregnant women and infants; to
1314	elderly and disabled recipients, especially those who are at
1315	risk of institutional placement; to persons with developmental
1316	disabilities; and to adults who have chronic, high-cost medical
1317	conditions.
1318	(b)  Guidelines which require the entities to conduct
1319	quality-of-care studies which:
1320	1.  Target specific conditions and specific health service
1321	delivery issues for focused monitoring and evaluation.
1322	2.  Use clinical care standards or practice guidelines to
1323	objectively evaluate the care the entity delivers or fails to
1324	deliver for the targeted clinical conditions and health services
1325	delivery issues.
1326	3.  Use quality indicators derived from the clinical care
1327	standards or practice guidelines to screen and monitor care and
1328	services delivered.
1329	(c)  Guidelines for external quality review of each
1330	contractor which require: focused studies of patterns of care;
1331	individual care review in specific situations; and followup
1332	activities on previous pattern-of-care study findings and
1333	individual-care-review findings. In designing the external
1334	quality review function and determining how it is to operate as
1335	part of the state's overall quality improvement system, the
1336	agency shall construct its external quality review organization
1337	and entity contracts to address each of the following:
1338	1.  Delineating the role of the external quality review
1339	organization.
1340	2.  Length of the external quality review organization
1341	contract with the state.
1342	3.  Participation of the contracting entities in designing
1343	external quality review organization review activities.
1344	4.  Potential variation in the type of clinical conditions
1345	and health services delivery issues to be studied at each plan.
1346	5.  Determining the number of focused pattern-of-care
1347	studies to be conducted for each plan.
1348	6.  Methods for implementing focused studies.
1349	7.  Individual care review.
1350	8.  Followup activities.
1351	(28)  In order to ensure that children receive health care
1352	services for which an entity has already been compensated, an
1353	entity contracting with the agency pursuant to this section
1354	shall achieve an annual Early and Periodic Screening, Diagnosis,
1355	and Treatment (EPSDT) Service screening rate of at least 60
1356	percent for those recipients continuously enrolled for at least
1357	8 months. The agency shall develop a method by which the EPSDT
1358	screening rate shall be calculated. For any entity which does
1359	not achieve the annual 60 percent rate, the entity must submit a
1360	corrective action plan for the agency's approval. If the entity
1361	does not meet the standard established in the corrective action
1362	plan during the specified timeframe, the agency is authorized to
1363	impose appropriate contract sanctions. At least annually, the
1364	agency shall publicly release the EPSDT Services screening rates
1365	of each entity it has contracted with on a prepaid basis to
1366	serve Medicaid recipients.
1367	(29)  The agency shall perform enrollments and
1368	disenrollments for Medicaid recipients who are eligible for
1369	MediPass or managed care plans. Notwithstanding the prohibition
1370	contained in paragraph (21)(19)(f), managed care plans may
1371	perform preenrollments of Medicaid recipients under the
1372	supervision of the agency or its agents. For the purposes of
1373	this section, "preenrollment" means the provision of marketing
1374	and educational materials to a Medicaid recipient and assistance
1375	in completing the application forms, but shall not include
1376	actual enrollment into a managed care plan. An application for
1377	enrollment shall not be deemed complete until the agency or its
1378	agent verifies that the recipient made an informed, voluntary
1379	choice. The agency, in cooperation with the Department of
1380	Children and Family Services, may test new marketing initiatives
1381	to inform Medicaid recipients about their managed care options
1382	at selected sites. The agency shall report to the Legislature on
1383	the effectiveness of such initiatives. The agency may contract
1384	with a third party to perform managed care plan and MediPass
1385	enrollment and disenrollment services for Medicaid recipients
1386	and is authorized to adopt rules to implement such services. The
1387	agency may adjust the capitation rate only to cover the costs of
1388	a third-party enrollment and disenrollment contract, and for
1389	agency supervision and management of the managed care plan
1390	enrollment and disenrollment contract.
1391	(30)  Any lists of providers made available to Medicaid
1392	recipients, MediPass enrollees, or managed care plan enrollees
1393	shall be arranged alphabetically showing the provider's name and
1394	specialty and, separately, by specialty in alphabetical order.
1395	(31)  The agency shall establish an enhanced managed care
1396	quality assurance oversight function, to include at least the
1397	following components:
1398	(a)  At least quarterly analysis and followup, including
1399	sanctions as appropriate, of managed care participant
1400	utilization of services.
1401	(b)  At least quarterly analysis and followup, including
1402	sanctions as appropriate, of quality findings of the Medicaid
1403	peer review organization and other external quality assurance
1404	programs.
1405	(c)  At least quarterly analysis and followup, including
1406	sanctions as appropriate, of the fiscal viability of managed
1407	care plans.
1408	(d)  At least quarterly analysis and followup, including
1409	sanctions as appropriate, of managed care participant
1410	satisfaction and disenrollment surveys.
1411	(e)  The agency shall conduct regular and ongoing Medicaid
1412	recipient satisfaction surveys.
1413
1414	The analyses and followup activities conducted by the agency
1415	under its enhanced managed care quality assurance oversight
1416	function shall not duplicate the activities of accreditation
1417	reviewers for entities regulated under part III of chapter 641,
1418	but may include a review of the finding of such reviewers.
1419	(32)  Each managed care plan that is under contract with
1420	the agency to provide health care services to Medicaid
1421	recipients shall annually conduct a background check with the
1422	Florida Department of Law Enforcement of all persons with
1423	ownership interest of 5 percent or more or executive management
1424	responsibility for the managed care plan and shall submit to the
1425	agency information concerning any such person who has been found
1426	guilty of, regardless of adjudication, or has entered a plea of
1427	nolo contendere or guilty to, any of the offenses listed in s.
1428	435.03.
1429	(33)  The agency shall, by rule, develop a process whereby
1430	a Medicaid managed care plan enrollee who wishes to enter
1431	hospice care may be disenrolled from the managed care plan
1432	within 24 hours after contacting the agency regarding such
1433	request. The agency rule shall include a methodology for the
1434	agency to recoup managed care plan payments on a pro rata basis
1435	if payment has been made for the enrollment month when
1436	disenrollment occurs.
1437	(34)  The agency and entities which contract with the
1438	agency to provide health care services to Medicaid recipients
1439	under this section or s. 409.9122 must comply with the
1440	provisions of s. 641.513 in providing emergency services and
1441	care to Medicaid recipients and MediPass recipients.
1442	(35)  All entities providing health care services to
1443	Medicaid recipients shall make available, and encourage all
1444	pregnant women and mothers with infants to receive, and provide
1445	documentation in the medical records to reflect, the following:
1446	(a)  Healthy Start prenatal or infant screening.
1447	(b)  Healthy Start care coordination, when screening or
1448	other factors indicate need.
1449	(c)  Healthy Start enhanced services in accordance with the
1450	prenatal or infant screening results.
1451	(d)  Immunizations in accordance with recommendations of
1452	the Advisory Committee on Immunization Practices of the United
1453	States Public Health Service and the American Academy of
1454	Pediatrics, as appropriate.
1455	(e)  Counseling and services for family planning to all
1456	women and their partners.
1457	(f)  A scheduled postpartum visit for the purpose of
1458	voluntary family planning, to include discussion of all methods
1459	of contraception, as appropriate.
1460	(g)  Referral to the Special Supplemental Nutrition Program
1461	for Women, Infants, and Children (WIC).
1462	(36)  Any entity that provides Medicaid prepaid health plan
1463	services shall ensure the appropriate coordination of health
1464	care services with an assisted living facility in cases where a
1465	Medicaid recipient is both a member of the entity's prepaid
1466	health plan and a resident of the assisted living facility. If
1467	the entity is at risk for Medicaid targeted case management and
1468	behavioral health services, the entity shall inform the assisted
1469	living facility of the procedures to follow should an emergent
1470	condition arise.
1471	(37)  The agency may seek and implement federal waivers
1472	necessary to provide for cost-effective purchasing of home
1473	health services, private duty nursing services, transportation,
1474	independent laboratory services, and durable medical equipment
1475	and supplies through competitive bidding pursuant to s. 287.057.
1476	The agency may request appropriate waivers from the federal
1477	Health Care Financing Administration in order to competitively
1478	bid such services. The agency may exclude providers not selected
1479	through the bidding process from the Medicaid provider network.
1480	(38)  The Agency for Health Care Administration is directed
1481	to issue a request for proposal or intent to negotiate to
1482	implement on a demonstration basis an outpatient specialty
1483	services pilot project in a rural and urban county in the state.
1484	As used in this subsection, the term "outpatient specialty
1485	services" means clinical laboratory, diagnostic imaging, and
1486	specified home medical services to include durable medical
1487	equipment, prosthetics and orthotics, and infusion therapy.
1488	(a)  The entity that is awarded the contract to provide
1489	Medicaid managed care outpatient specialty services must, at a
1490	minimum, meet the following criteria:
1491	1.  The entity must be licensed by the Office of Insurance
1492	Regulation under part II of chapter 641.
1493	2.  The entity must be experienced in providing outpatient
1494	specialty services.
1495	3.  The entity must demonstrate to the satisfaction of the
1496	agency that it provides high-quality services to its patients.
1497	4.  The entity must demonstrate that it has in place a
1498	complaints and grievance process to assist Medicaid recipients
1499	enrolled in the pilot managed care program to resolve complaints
1500	and grievances.
1501	(b)  The pilot managed care program shall operate for a
1502	period of 3 years. The objective of the pilot program shall be
1503	to determine the cost-effectiveness and effects on utilization,
1504	access, and quality of providing outpatient specialty services
1505	to Medicaid recipients on a prepaid, capitated basis.
1506	(c)  The agency shall conduct a quality assurance review of
1507	the prepaid health clinic each year that the demonstration
1508	program is in effect. The prepaid health clinic is responsible
1509	for all expenses incurred by the agency in conducting a quality
1510	assurance review.
1511	(d)  The entity that is awarded the contract to provide
1512	outpatient specialty services to Medicaid recipients shall
1513	report data required by the agency in a format specified by the
1514	agency, for the purpose of conducting the evaluation required in
1515	paragraph (e).
1516	(e)  The agency shall conduct an evaluation of the pilot
1517	managed care program and report its findings to the Governor and
1518	the Legislature by no later than January 1, 2001.
1519	(39)  The agency shall enter into agreements with not-for-
1520	profit organizations based in this state for the purpose of
1521	providing vision screening.
1522	(40)(a)  The agency shall implement a Medicaid prescribed-
1523	drug spending-control program that includes the following
1524	components:
1525	1.  Medicaid prescribed-drug coverage for brand-name drugs
1526	for adult Medicaid recipients is limited to the dispensing of
1527	four brand-name drugs per month per recipient. Children are
1528	exempt from this restriction. Antiretroviral agents are excluded
1529	from this limitation. No requirements for prior authorization or
1530	other restrictions on medications used to treat mental illnesses
1531	such as schizophrenia, severe depression, or bipolar disorder
1532	may be imposed on Medicaid recipients. Medications that will be
1533	available without restriction for persons with mental illnesses
1534	include atypical antipsychotic medications, conventional
1535	antipsychotic medications, selective serotonin reuptake
1536	inhibitors, and other medications used for the treatment of
1537	serious mental illnesses. The agency shall also limit the amount
1538	of a prescribed drug dispensed to no more than a 34-day supply.
1539	The agency shall continue to provide unlimited generic drugs,
1540	contraceptive drugs and items, and diabetic supplies. Although a
1541	drug may be included on the preferred drug formulary, it would
1542	not be exempt from the four-brand limit. The agency may
1543	authorize exceptions to the brand-name-drug restriction based
1544	upon the treatment needs of the patients, only when such
1545	exceptions are based on prior consultation provided by the
1546	agency or an agency contractor, but the agency must establish
1547	procedures to ensure that:
1548	a.  There will be a response to a request for prior
1549	consultation by telephone or other telecommunication device
1550	within 24 hours after receipt of a request for prior
1551	consultation;
1552	b.  A 72-hour supply of the drug prescribed will be
1553	provided in an emergency or when the agency does not provide a
1554	response within 24 hours as required by sub-subparagraph a.; and
1555	c.  Except for the exception for nursing home residents and
1556	other institutionalized adults and except for drugs on the
1557	restricted formulary for which prior authorization may be sought
1558	by an institutional or community pharmacy, prior authorization
1559	for an exception to the brand-name-drug restriction is sought by
1560	the prescriber and not by the pharmacy. When prior authorization
1561	is granted for a patient in an institutional setting beyond the
1562	brand-name-drug restriction, such approval is authorized for 12
1563	months and monthly prior authorization is not required for that
1564	patient.
1565	2.  Reimbursement to pharmacies for Medicaid prescribed
1566	drugs shall be set at the average wholesale price less 13.45
1567	13.25 percent or wholesale acquisition cost plus 6 percent,
1568	whichever is less.
1569	3.  The agency shall develop and implement a process for
1570	managing the drug therapies of Medicaid recipients who are using
1571	significant numbers of prescribed drugs each month. The
1572	management process may include, but is not limited to,
1573	comprehensive, physician-directed medical-record reviews, claims
1574	analyses, and case evaluations to determine the medical
1575	necessity and appropriateness of a patient's treatment plan and
1576	drug therapies. The agency may contract with a private
1577	organization to provide drug-program-management services. The
1578	Medicaid drug benefit management program shall include
1579	initiatives to manage drug therapies for HIV/AIDS patients,
1580	patients using 20 or more unique prescriptions in a 180-day
1581	period, and the top 1,000 patients in annual spending.
1582	4.  The agency may limit the size of its pharmacy network
1583	based on need, competitive bidding, price negotiations,
1584	credentialing, or similar criteria. The agency shall give
1585	special consideration to rural areas in determining the size and
1586	location of pharmacies included in the Medicaid pharmacy
1587	network. A pharmacy credentialing process may include criteria
1588	such as a pharmacy's full-service status, location, size,
1589	patient educational programs, patient consultation, disease-
1590	management services, and other characteristics. The agency may
1591	impose a moratorium on Medicaid pharmacy enrollment when it is
1592	determined that it has a sufficient number of Medicaid-
1593	participating providers.
1594	5.  The agency shall develop and implement a program that
1595	requires Medicaid practitioners who prescribe drugs to use a
1596	counterfeit-proof prescription pad for Medicaid prescriptions.
1597	The agency shall require the use of standardized counterfeit-
1598	proof prescription pads by Medicaid-participating prescribers or
1599	prescribers who write prescriptions for Medicaid recipients. The
1600	agency may implement the program in targeted geographic areas or
1601	statewide.
1602	6.  The agency may enter into arrangements that require
1603	manufacturers of generic drugs prescribed to Medicaid recipients
1604	to provide rebates of at least 15.1 percent of the average
1605	manufacturer price for the manufacturer's generic products.
1606	These arrangements shall require that if a generic-drug
1607	manufacturer pays federal rebates for Medicaid-reimbursed drugs
1608	at a level below 15.1 percent, the manufacturer must provide a
1609	supplemental rebate to the state in an amount necessary to
1610	achieve a 15.1-percent rebate level.
1611	7.  The agency may establish a preferred drug formulary in
1612	accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
1613	establishment of such formulary, it is authorized to negotiate
1614	supplemental rebates from manufacturers that are in addition to
1615	those required by Title XIX of the Social Security Act and at no
1616	less than 12 10 percent of the average manufacturer price as
1617	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
1618	the federal or supplemental rebate, or both, equals or exceeds
1619	27 25 percent. There is no upper limit on the supplemental
1620	rebates the agency may negotiate. The agency may determine that
1621	specific products, brand-name or generic, are competitive at
1622	lower rebate percentages. Agreement to pay the minimum
1623	supplemental rebate percentage will guarantee a manufacturer
1624	that the Medicaid Pharmaceutical and Therapeutics Committee will
1625	consider a product for inclusion on the preferred drug
1626	formulary. However, a pharmaceutical manufacturer is not
1627	guaranteed placement on the formulary by simply paying the
1628	minimum supplemental rebate. Agency decisions will be made on
1629	the clinical efficacy of a drug and recommendations of the
1630	Medicaid Pharmaceutical and Therapeutics Committee, as well as
1631	the price of competing products minus federal and state rebates.
1632	The agency is authorized to contract with an outside agency or
1633	contractor to conduct negotiations for supplemental rebates. For
1634	the purposes of this section, the term "supplemental rebates"
1635	may include, at the agency's discretion, cash rebates and other
1636	program benefits that offset a Medicaid expenditure. Effective
1637	July 1, 2004, value-added programs as a substitution for
1638	supplemental rebates are prohibited. Such other program benefits
1639	may include, but are not limited to, disease management
1640	programs, drug product donation programs, drug utilization
1641	control programs, prescriber and beneficiary counseling and
1642	education, fraud and abuse initiatives, and other services or
1643	administrative investments with guaranteed savings to the
1644	Medicaid program in the same year the rebate reduction is
1645	included in the General Appropriations Act. The agency is
1646	authorized to seek any federal waivers to implement this
1647	initiative.
1648	8.  The agency shall establish an advisory committee for
1649	the purposes of studying the feasibility of using a restricted
1650	drug formulary for nursing home residents and other
1651	institutionalized adults. The committee shall be comprised of
1652	seven members appointed by the Secretary of Health Care
1653	Administration. The committee members shall include two
1654	physicians licensed under chapter 458 or chapter 459; three
1655	pharmacists licensed under chapter 465 and appointed from a list
1656	of recommendations provided by the Florida Long-Term Care
1657	Pharmacy Alliance; and two pharmacists licensed under chapter
1658	465.
1659	9.  The Agency for Health Care Administration shall expand
1660	home delivery of pharmacy products. To assist Medicaid patients
1661	in securing their prescriptions and reduce program costs, the
1662	agency shall expand its current mail-order-pharmacy diabetes-
1663	supply program to include all generic and brand-name drugs used
1664	by Medicaid patients with diabetes. Medicaid recipients in the
1665	current program may obtain nondiabetes drugs on a voluntary
1666	basis. This initiative is limited to the geographic area covered
1667	by the current contract. The agency may seek and implement any
1668	federal waivers necessary to implement this subparagraph.
1669	10.  The agency shall limit to one dose per month any drug
1670	prescribed to treat erectile dysfunction. The agency is
1671	authorized to seek a Medicaid state plan amendment to implement
1672	this limitation.
1673	11.a.  The agency shall implement a Medicaid behavioral
1674	pharmacy management system. The agency may contract with a
1675	vendor that has experience in operating behavioral pharmacy
1676	management systems to implement this program. The agency is
1677	authorized to seek a Medicaid waiver or state plan amendment to
1678	implement this program.
1679	b.  The agency, in conjunction with the Department of
1680	Children and Family Services, shall implement the Medicaid
1681	behavioral pharmacy management system that is designed to
1682	improve the quality of care and behavioral health prescribing
1683	practices based on best practice guidelines, improve patient
1684	adherence to medication plans, reduce clinical risk, and lower
1685	prescribed drug costs and the rate of inappropriate spending on
1686	Medicaid behavioral drugs. The program shall include the
1687	following elements:
1688	(I)  Provide for the development and adoption of best
1689	practice guidelines for behavioral health-related drugs such as
1690	antipsychotics, antidepressants, and medications for treating
1691	bipolar disorders and other behavioral conditions; translate
1692	them into practice; review behavioral health prescribers and
1693	compare their prescribing patterns to a number of indicators
1694	that are based on national standards; and determine deviations
1695	from best practice guidelines.
1696	(II)  Implement processes for providing feedback to and
1697	educating prescribers using best practice educational materials
1698	and peer-to-peer consultation.
1699	(III)  Assess Medicaid beneficiaries who are outliers in
1700	their use of behavioral health drugs with regard to the numbers
1701	and types of drugs taken, drug dosages, combination drug
1702	therapies, and other indicators of improper use of behavioral
1703	health drugs.
1704	(IV)  Alert prescribers to patients who fail to refill
1705	prescriptions in a timely fashion, are prescribed multiple same-
1706	class behavioral health drugs, and may have other potential
1707	medication problems.
1708	(V)  Track spending trends for behavioral health drugs and
1709	deviation from best practice guidelines.
1710	(VI)  Use educational and technological approaches to
1711	promote best practices, educate consumers, and train prescribers
1712	in the use of practice guidelines.
1713	(VII)  Disseminate electronic and published materials.
1714	(VIII)  Hold statewide and regional conferences.
1715	(IX)  Implement a disease management program with a model
1716	quality-based medication component for severely mentally ill
1717	individuals and emotionally disturbed children who are high
1718	users of care.
1719	12.  The agency is authorized to contract for drug rebate
1720	administration, including, but not limited to, calculating
1721	rebate amounts, invoicing manufacturers, negotiating disputes
1722	with manufacturers, and maintaining a database of rebate
1723	collections.
1724	(b)  The agency shall implement this subsection to the
1725	extent that funds are appropriated to administer the Medicaid
1726	prescribed-drug spending-control program. The agency may
1727	contract all or any part of this program to private
1728	organizations.
1729	(c)  The agency shall submit quarterly reports to the
1730	Governor, the President of the Senate, and the Speaker of the
1731	House of Representatives which must include, but need not be
1732	limited to, the progress made in implementing this subsection
1733	and its effect on Medicaid prescribed-drug expenditures.
1734	(41)  Notwithstanding the provisions of chapter 287, the
1735	agency may, at its discretion, renew a contract or contracts for
1736	fiscal intermediary services one or more times for such periods
1737	as the agency may decide; however, all such renewals may not
1738	combine to exceed a total period longer than the term of the
1739	original contract.
1740	(42)  The agency shall provide for the development of a
1741	demonstration project by establishment in Miami-Dade County of a
1742	long-term-care facility licensed pursuant to chapter 395 to
1743	improve access to health care for a predominantly minority,
1744	medically underserved, and medically complex population and to
1745	evaluate alternatives to nursing home care and general acute
1746	care for such population. Such project is to be located in a
1747	health care condominium and colocated with licensed facilities
1748	providing a continuum of care. The establishment of this project
1749	is not subject to the provisions of s. 408.036 or s. 408.039.
1750	The agency shall report its findings to the Governor, the
1751	President of the Senate, and the Speaker of the House of
1752	Representatives by January 1, 2003.
1753	(43)  The agency shall develop and implement a utilization
1754	management program for Medicaid-eligible recipients for the
1755	management of occupational, physical, respiratory, and speech
1756	therapies. The agency shall establish a utilization program that
1757	may require prior authorization in order to ensure medically
1758	necessary and cost-effective treatments. The program shall be
1759	operated in accordance with a federally approved waiver program
1760	or state plan amendment. The agency may seek a federal waiver or
1761	state plan amendment to implement this program. The agency may
1762	also competitively procure these services from an outside vendor
1763	on a regional or statewide basis.
1764	(44)  The agency may contract on a prepaid or fixed-sum
1765	basis with appropriately licensed prepaid dental health plans to
1766	provide dental services.
1767	Section 10.  Paragraphs (a), (f), and (k) of subsection (2)
1768	of section 409.9122, Florida Statutes, are amended to read:
1769	409.9122  Mandatory Medicaid managed care enrollment;
1770	programs and procedures.--
1771	(2)(a)  The agency shall enroll in a managed care plan or
1772	MediPass all Medicaid recipients on the effective date of their
1773	eligibility, except those Medicaid recipients who are: in an
1774	institution; enrolled in the Medicaid medically needy program;
1775	or eligible for both Medicaid and Medicare. Upon enrollment,
1776	individuals will be able to change their managed care option
1777	during the 90-day opt out period required by federal Medicaid
1778	regulations. The agency is authorized to seek the necessary
1779	Medicaid state plan amendment to implement this policy. However,
1780	to the extent permitted by federal law, the agency may enroll in
1781	a managed care plan or MediPass a Medicaid recipient who is
1782	exempt from mandatory managed care enrollment, provided that:
1783	1.  The recipient's decision to enroll in a managed care
1784	plan or MediPass is voluntary;
1785	2.  If the recipient chooses to enroll in a managed care
1786	plan, the agency has determined that the managed care plan
1787	provides specific programs and services which address the
1788	special health needs of the recipient; and
1789	3.  The agency receives any necessary waivers from the
1790	federal Health Care Financing Administration.
1791
1792	The agency shall develop rules to establish policies by which
1793	exceptions to the mandatory managed care enrollment requirement
1794	may be made on a case-by-case basis. The rules shall include the
1795	specific criteria to be applied when making a determination as
1796	to whether to exempt a recipient from mandatory enrollment in a
1797	managed care plan or MediPass. School districts participating in
1798	the certified school match program pursuant to ss. 409.908(21)
1799	and 1011.70 shall be reimbursed by Medicaid, subject to the
1800	limitations of s. 1011.70(1), for a Medicaid-eligible child
1801	participating in the services as authorized in s. 1011.70, as
1802	provided for in s. 409.9071, regardless of whether the child is
1803	enrolled in MediPass or a managed care plan. Managed care plans
1804	shall make a good faith effort to execute agreements with school
1805	districts regarding the coordinated provision of services
1806	authorized under s. 1011.70. County health departments
1807	delivering school-based services pursuant to ss. 381.0056 and
1808	381.0057 shall be reimbursed by Medicaid for the federal share
1809	for a Medicaid-eligible child who receives Medicaid-covered
1810	services in a school setting, regardless of whether the child is
1811	enrolled in MediPass or a managed care plan. Managed care plans
1812	shall make a good faith effort to execute agreements with county
1813	health departments regarding the coordinated provision of
1814	services to a Medicaid-eligible child. To ensure continuity of
1815	care for Medicaid patients, the agency, the Department of
1816	Health, and the Department of Education shall develop procedures
1817	for ensuring that a student's managed care plan or MediPass
1818	provider receives information relating to services provided in
1819	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
1820	(f)  When a Medicaid recipient does not choose a managed
1821	care plan or MediPass provider, the agency shall assign the
1822	Medicaid recipient to a managed care plan or MediPass provider.
1823	Medicaid recipients who are subject to mandatory assignment but
1824	who fail to make a choice shall be assigned to managed care
1825	plans until an enrollment of 38 40 percent in MediPass and 62 60
1826	percent in managed care plans is achieved. Once this enrollment
1827	is achieved, the assignments shall be divided in order to
1828	maintain an enrollment in MediPass and managed care plans which
1829	is in a 38 40 percent and 62 60 percent proportion,
1830	respectively. Thereafter, assignment of Medicaid recipients who
1831	fail to make a choice shall be based proportionally on the
1832	preferences of recipients who have made a choice in the previous
1833	period. Such proportions shall be revised at least quarterly to
1834	reflect an update of the preferences of Medicaid recipients. The
1835	agency shall disproportionately assign Medicaid-eligible
1836	recipients who are required to but have failed to make a choice
1837	of managed care plan or MediPass, including children, and who
1838	are to be assigned to the MediPass program to children's
1839	networks as described in s. 409.912(3)(g), Children's Medical
1840	Services network as defined in s. 391.021, exclusive provider
1841	organizations, provider service networks, minority physician
1842	networks, and pediatric emergency department diversion programs
1843	authorized by this chapter or the General Appropriations Act, in
1844	such manner as the agency deems appropriate, until the agency
1845	has determined that the networks and programs have sufficient
1846	numbers to be economically operated. For purposes of this
1847	paragraph, when referring to assignment, the term "managed care
1848	plans" includes health maintenance organizations, exclusive
1849	provider organizations, provider service networks, minority
1850	physician networks, Children's Medical Services network, and
1851	pediatric emergency department diversion programs authorized by
1852	this chapter or the General Appropriations Act. When making
1853	assignments, the agency shall take into account the following
1854	criteria:
1855	1.  A managed care plan has sufficient network capacity to
1856	meet the need of members.
1857	2.  The managed care plan or MediPass has previously
1858	enrolled the recipient as a member, or one of the managed care
1859	plan's primary care providers or MediPass providers has
1860	previously provided health care to the recipient.
1861	3.  The agency has knowledge that the member has previously
1862	expressed a preference for a particular managed care plan or
1863	MediPass provider as indicated by Medicaid fee-for-service
1864	claims data, but has failed to make a choice.
1865	4.  The managed care plan's or MediPass primary care
1866	providers are geographically accessible to the recipient's
1867	residence.
1868	(k)  When a Medicaid recipient does not choose a managed
1869	care plan or MediPass provider, the agency shall assign the
1870	Medicaid recipient to a managed care plan, except in those
1871	counties in which there are fewer than two managed care plans
1872	accepting Medicaid enrollees, in which case assignment shall be
1873	to a managed care plan or a MediPass provider. Medicaid
1874	recipients in counties with fewer than two managed care plans
1875	accepting Medicaid enrollees who are subject to mandatory
1876	assignment but who fail to make a choice shall be assigned to
1877	managed care plans until an enrollment of 38 40 percent in
1878	MediPass and 62 60 percent in managed care plans is achieved.
1879	Once that enrollment is achieved, the assignments shall be
1880	divided in order to maintain an enrollment in MediPass and
1881	managed care plans which is in a 38 40 percent and 62 60 percent
1882	proportion, respectively. In geographic areas where the agency
1883	is contracting for the provision of comprehensive behavioral
1884	health services through a capitated prepaid arrangement,
1885	recipients who fail to make a choice shall be assigned equally
1886	to MediPass or a managed care plan. For purposes of this
1887	paragraph, when referring to assignment, the term "managed care
1888	plans" includes exclusive provider organizations, provider
1889	service networks, Children's Medical Services network, minority
1890	physician networks, and pediatric emergency department diversion
1891	programs authorized by this chapter or the General
1892	Appropriations Act. When making assignments, the agency shall
1893	take into account the following criteria:
1894	1.  A managed care plan has sufficient network capacity to
1895	meet the need of members.
1896	2.  The managed care plan or MediPass has previously
1897	enrolled the recipient as a member, or one of the managed care
1898	plan's primary care providers or MediPass providers has
1899	previously provided health care to the recipient.
1900	3.  The agency has knowledge that the member has previously
1901	expressed a preference for a particular managed care plan or
1902	MediPass provider as indicated by Medicaid fee-for-service
1903	claims data, but has failed to make a choice.
1904	4.  The managed care plan's or MediPass primary care
1905	providers are geographically accessible to the recipient's
1906	residence.
1907	5.  The agency has authority to make mandatory assignments
1908	based on quality of service and performance of managed care
1909	plans.
1910	Section 11.  Subsections (1) and (3) of section 409.915,
1911	Florida Statutes, are amended to read:
1912	409.915  County contributions to Medicaid.--Although the
1913	state is responsible for the full portion of the state share of
1914	the matching funds required for the Medicaid program, in order
1915	to acquire a certain portion of these funds, the state shall
1916	charge the counties for certain items of care and service as
1917	provided in this section.
1918	(1)  Each county shall participate in the following items
1919	of care and service:
1920	(a)  For both health maintenance members and fee-for-
1921	service beneficiaries, payments for inpatient hospitalization in
1922	excess of 10 days, but not in excess of 45 days, with the
1923	exception of pregnant women and children whose income is in
1924	excess of the federal poverty level and who do not participate
1925	in the Medicaid medically needy program, and for adult lung
1926	transplant services. Counties shall pay for items of care and
1927	service provided to the county's eligible recipients regardless
1928	of where in the state the care or service is rendered.
1929	(b)  Payments for nursing home or intermediate facilities
1930	care in excess of $170 per month, with the exception of skilled
1931	nursing care for children under age 21. Beginning on July 1,
1932	2004, county contributions shall be based on each county's
1933	percentage of the total county contribution for fiscal year
1934	2003-2004 adjusted for increases in Medicaid financed nursing
1935	facility residents. The Office of Program Policy Analysis and
1936	Government Accountability shall recommend to the Legislature
1937	each county's share of the total cost every 5 years beginning in
1938	February of 2009. The recommendation shall be based on the
1939	projected number of county residents who will use nursing home
1940	services funded by Medicaid for the subsequent 5-year period.
1941	(3)  Each county shall set aside sufficient funds to pay
1942	for its required county contributions items of care and service
1943	provided to the county's eligible recipients for which county
1944	contributions are required, regardless of where in the state the
1945	care or service is rendered.
1946	Section 12.  Notwithstanding s. 409.912(11), Florida
1947	Statutes, the Agency for Health Care Administration is
1948	authorized to seek federal waivers necessary to implement
1949	Medicaid reform.
1950	Section 13.  Except as otherwise provided herein, this act
1951	shall take effect July 1, 2004.

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