Senate Bill sb2586
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Florida Senate - 2004 SB 2586
By Senator Diaz de la Portilla
36-1595-04 See HB
1 A bill to be entitled
2 An act relating to Medicaid program
3 administration; amending s. 409.907, F.S.;
4 authorizing the Agency for Health Care
5 Administration to revoke or refuse to renew
6 certain provider agreements; amending s.
7 409.912, F.S.; requiring the agency to restrict
8 costs at a certain level; requiring the agency
9 to maximize the use of risk contracting in
10 providing for health care services; amending s.
11 409.9122, F.S.; eliminating the proportion
12 restrictions to assigning certain recipients to
13 managed care plans; authorizing the agency to
14 outsource certain Medicaid program
15 administrative functions; requiring the agency
16 to contract with an actuarial firm to conduct
17 an evaluation of certain Medicaid reimbursement
18 methodologies; requiring the agency to report
19 such findings to the Legislature; requiring the
20 agency to conduct a study to design and
21 implement a standard for handling Medicaid
22 records electronically; providing an
23 appropriation; providing an effective date.
24
25 Be It Enacted by the Legislature of the State of Florida:
26
27 Section 1. Subsection (12) is added to section
28 409.907, Florida Statutes, to read:
29 409.907 Medicaid provider agreements.--The agency may
30 make payments for medical assistance and related services
31 rendered to Medicaid recipients only to an individual or
1
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Florida Senate - 2004 SB 2586
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1 entity who has a provider agreement in effect with the agency,
2 who is performing services or supplying goods in accordance
3 with federal, state, and local law, and who agrees that no
4 person shall, on the grounds of handicap, race, color, or
5 national origin, or for any other reason, be subjected to
6 discrimination under any program or activity for which the
7 provider receives payment from the agency.
8 (12) To the extent allowed by federal law, the agency
9 may revoke or refuse to renew a provider agreement if a
10 provider fails to continue meeting the criteria provided under
11 paragraph (9)(b) which would otherwise authorize the agency to
12 deny an application to become a provider.
13 Section 2. Section 409.912, Florida Statutes, is
14 amended to read:
15 409.912 Cost-effective purchasing of health care.--The
16 agency shall purchase goods and services for Medicaid
17 recipients in the most cost-effective manner consistent with
18 the delivery of quality medical care, provided such costs do
19 not exceed the industry standards within a recipient's
20 geographic area by more than 10 percent. The agency shall
21 maximize the use of risk contracting in providing for health
22 care services, including prepaid per capita and prepaid
23 aggregate fixed-sum basis services when appropriate and other
24 alternative service delivery and reimbursement methodologies,
25 including competitive bidding pursuant to s. 287.057, designed
26 to facilitate the cost-effective purchase of a case-managed
27 continuum of care. The agency shall also require providers to
28 minimize the exposure of recipients to the need for acute
29 inpatient, custodial, and other institutional care and the
30 inappropriate or unnecessary use of high-cost services. The
31 agency may establish prior authorization requirements for
2
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Florida Senate - 2004 SB 2586
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1 certain populations of Medicaid beneficiaries, certain drug
2 classes, or particular drugs to prevent fraud, abuse, overuse,
3 and possible dangerous drug interactions. The Pharmaceutical
4 and Therapeutics Committee shall make recommendations to the
5 agency on drugs for which prior authorization is required. The
6 agency shall inform the Pharmaceutical and Therapeutics
7 Committee of its decisions regarding drugs subject to prior
8 authorization.
9 (1) The agency shall work with the Department of
10 Children and Family Services to ensure access of children and
11 families in the child protection system to needed and
12 appropriate mental health and substance abuse services.
13 (2) The agency may enter into agreements with
14 appropriate agents of other state agencies or of any agency of
15 the Federal Government and accept such duties in respect to
16 social welfare or public aid as may be necessary to implement
17 the provisions of Title XIX of the Social Security Act and ss.
18 409.901-409.920.
19 (3) The agency may contract with health maintenance
20 organizations certified pursuant to part I of chapter 641 for
21 the provision of services to recipients.
22 (4) The agency may contract with:
23 (a) An entity that provides no prepaid health care
24 services other than Medicaid services under contract with the
25 agency and which is owned and operated by a county, county
26 health department, or county-owned and operated hospital to
27 provide health care services on a prepaid or fixed-sum basis
28 to recipients, which entity may provide such prepaid services
29 either directly or through arrangements with other providers.
30 Such prepaid health care services entities must be licensed
31 under parts I and III by January 1, 1998, and until then are
3
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Florida Senate - 2004 SB 2586
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1 exempt from the provisions of part I of chapter 641. An entity
2 recognized under this paragraph which demonstrates to the
3 satisfaction of the Office of Insurance Regulation of the
4 Financial Services Commission that it is backed by the full
5 faith and credit of the county in which it is located may be
6 exempted from s. 641.225.
7 (b) An entity that is providing comprehensive
8 behavioral health care services to certain Medicaid recipients
9 through a capitated, prepaid arrangement pursuant to the
10 federal waiver provided for by s. 409.905(5). Such an entity
11 must be licensed under chapter 624, chapter 636, or chapter
12 641 and must possess the clinical systems and operational
13 competence to manage risk and provide comprehensive behavioral
14 health care to Medicaid recipients. As used in this paragraph,
15 the term "comprehensive behavioral health care services" means
16 covered mental health and substance abuse treatment services
17 that are available to Medicaid recipients. The secretary of
18 the Department of Children and Family Services shall approve
19 provisions of procurements related to children in the
20 department's care or custody prior to enrolling such children
21 in a prepaid behavioral health plan. Any contract awarded
22 under this paragraph must be competitively procured. In
23 developing the behavioral health care prepaid plan procurement
24 document, the agency shall ensure that the procurement
25 document requires the contractor to develop and implement a
26 plan to ensure compliance with s. 394.4574 related to services
27 provided to residents of licensed assisted living facilities
28 that hold a limited mental health license. The agency shall
29 seek federal approval to contract with a single entity meeting
30 these requirements to provide comprehensive behavioral health
31 care services to all Medicaid recipients in an AHCA area. Each
4
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Florida Senate - 2004 SB 2586
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1 entity must offer sufficient choice of providers in its
2 network to ensure recipient access to care and the opportunity
3 to select a provider with whom they are satisfied. The network
4 shall include all public mental health hospitals. To ensure
5 unimpaired access to behavioral health care services by
6 Medicaid recipients, all contracts issued pursuant to this
7 paragraph shall require 80 percent of the capitation paid to
8 the managed care plan, including health maintenance
9 organizations, to be expended for the provision of behavioral
10 health care services. In the event the managed care plan
11 expends less than 80 percent of the capitation paid pursuant
12 to this paragraph for the provision of behavioral health care
13 services, the difference shall be returned to the agency. The
14 agency shall provide the managed care plan with a
15 certification letter indicating the amount of capitation paid
16 during each calendar year for the provision of behavioral
17 health care services pursuant to this section. The agency may
18 reimburse for substance abuse treatment services on a
19 fee-for-service basis until the agency finds that adequate
20 funds are available for capitated, prepaid arrangements.
21 1. By January 1, 2001, the agency shall modify the
22 contracts with the entities providing comprehensive inpatient
23 and outpatient mental health care services to Medicaid
24 recipients in Hillsborough, Highlands, Hardee, Manatee, and
25 Polk Counties, to include substance abuse treatment services.
26 2. By July 1, 2003, the agency and the Department of
27 Children and Family Services shall execute a written agreement
28 that requires collaboration and joint development of all
29 policy, budgets, procurement documents, contracts, and
30 monitoring plans that have an impact on the state and Medicaid
31 community mental health and targeted case management programs.
5
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Florida Senate - 2004 SB 2586
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1 3. By July 1, 2006, the agency and the Department of
2 Children and Family Services shall contract with managed care
3 entities in each AHCA area except area 6 or arrange to provide
4 comprehensive inpatient and outpatient mental health and
5 substance abuse services through capitated prepaid
6 arrangements to all Medicaid recipients who are eligible to
7 participate in such plans under federal law and regulation. In
8 AHCA areas where eligible individuals number less than
9 150,000, the agency shall contract with a single managed care
10 plan. The agency may contract with more than one plan in AHCA
11 areas where the eligible population exceeds 150,000. Contracts
12 awarded pursuant to this section shall be competitively
13 procured. Both for-profit and not-for-profit corporations
14 shall be eligible to compete.
15 4. By October 1, 2003, the agency and the department
16 shall submit a plan to the Governor, the President of the
17 Senate, and the Speaker of the House of Representatives which
18 provides for the full implementation of capitated prepaid
19 behavioral health care in all areas of the state. The plan
20 shall include provisions which ensure that children and
21 families receiving foster care and other related services are
22 appropriately served and that these services assist the
23 community-based care lead agencies in meeting the goals and
24 outcomes of the child welfare system. The plan will be
25 developed with the participation of community-based lead
26 agencies, community alliances, sheriffs, and community
27 providers serving dependent children.
28 a. Implementation shall begin in 2003 in those AHCA
29 areas of the state where the agency is able to establish
30 sufficient capitation rates.
31
6
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Florida Senate - 2004 SB 2586
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1 b. If the agency determines that the proposed
2 capitation rate in any area is insufficient to provide
3 appropriate services, the agency may adjust the capitation
4 rate to ensure that care will be available. The agency and the
5 department may use existing general revenue to address any
6 additional required match but may not over-obligate existing
7 funds on an annualized basis.
8 c. Subject to any limitations provided for in the
9 General Appropriations Act, the agency, in compliance with
10 appropriate federal authorization, shall develop policies and
11 procedures that allow for certification of local and state
12 funds.
13 5. Children residing in a statewide inpatient
14 psychiatric program, or in a Department of Juvenile Justice or
15 a Department of Children and Family Services residential
16 program approved as a Medicaid behavioral health overlay
17 services provider shall not be included in a behavioral health
18 care prepaid health plan pursuant to this paragraph.
19 6. In converting to a prepaid system of delivery, the
20 agency shall in its procurement document require an entity
21 providing comprehensive behavioral health care services to
22 prevent the displacement of indigent care patients by
23 enrollees in the Medicaid prepaid health plan providing
24 behavioral health care services from facilities receiving
25 state funding to provide indigent behavioral health care, to
26 facilities licensed under chapter 395 which do not receive
27 state funding for indigent behavioral health care, or
28 reimburse the unsubsidized facility for the cost of behavioral
29 health care provided to the displaced indigent care patient.
30 7. Traditional community mental health providers under
31 contract with the Department of Children and Family Services
7
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Florida Senate - 2004 SB 2586
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1 pursuant to part IV of chapter 394, child welfare providers
2 under contract with the Department of Children and Family
3 Services, and inpatient mental health providers licensed
4 pursuant to chapter 395 must be offered an opportunity to
5 accept or decline a contract to participate in any provider
6 network for prepaid behavioral health services.
7 (c) A federally qualified health center or an entity
8 owned by one or more federally qualified health centers or an
9 entity owned by other migrant and community health centers
10 receiving non-Medicaid financial support from the Federal
11 Government to provide health care services on a prepaid or
12 fixed-sum basis to recipients. Such prepaid health care
13 services entity must be licensed under parts I and III of
14 chapter 641, but shall be prohibited from serving Medicaid
15 recipients on a prepaid basis, until such licensure has been
16 obtained. However, such an entity is exempt from s. 641.225 if
17 the entity meets the requirements specified in subsections
18 (15) and (16).
19 (d) A provider service network may be reimbursed on a
20 fee-for-service or prepaid basis. A provider service network
21 which is reimbursed by the agency on a prepaid basis shall be
22 exempt from parts I and III of chapter 641, but must meet
23 appropriate financial reserve, quality assurance, and patient
24 rights requirements as established by the agency. The agency
25 shall award contracts on a competitive bid basis and shall
26 select bidders based upon price and quality of care. Medicaid
27 recipients assigned to a demonstration project shall be chosen
28 equally from those who would otherwise have been assigned to
29 prepaid plans and MediPass. The agency is authorized to seek
30 federal Medicaid waivers as necessary to implement the
31 provisions of this section.
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Florida Senate - 2004 SB 2586
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1 (e) An entity that provides comprehensive behavioral
2 health care services to certain Medicaid recipients through an
3 administrative services organization agreement. Such an entity
4 must possess the clinical systems and operational competence
5 to provide comprehensive health care to Medicaid recipients.
6 As used in this paragraph, the term "comprehensive behavioral
7 health care services" means covered mental health and
8 substance abuse treatment services that are available to
9 Medicaid recipients. Any contract awarded under this paragraph
10 must be competitively procured. The agency must ensure that
11 Medicaid recipients have available the choice of at least two
12 managed care plans for their behavioral health care services.
13 (f) An entity that provides in-home physician services
14 to test the cost-effectiveness of enhanced home-based medical
15 care to Medicaid recipients with degenerative neurological
16 diseases and other diseases or disabling conditions associated
17 with high costs to Medicaid. The program shall be designed to
18 serve very disabled persons and to reduce Medicaid reimbursed
19 costs for inpatient, outpatient, and emergency department
20 services. The agency shall contract with vendors on a
21 risk-sharing basis.
22 (g) Children's provider networks that provide care
23 coordination and care management for Medicaid-eligible
24 pediatric patients, primary care, authorization of specialty
25 care, and other urgent and emergency care through organized
26 providers designed to service Medicaid eligibles under age 18
27 and pediatric emergency departments' diversion programs. The
28 networks shall provide after-hour operations, including
29 evening and weekend hours, to promote, when appropriate, the
30 use of the children's networks rather than hospital emergency
31 departments.
9
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Florida Senate - 2004 SB 2586
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1 (h) An entity authorized in s. 430.205 to contract
2 with the agency and the Department of Elderly Affairs to
3 provide health care and social services on a prepaid or
4 fixed-sum basis to elderly recipients. Such prepaid health
5 care services entities are exempt from the provisions of part
6 I of chapter 641 for the first 3 years of operation. An entity
7 recognized under this paragraph that demonstrates to the
8 satisfaction of the Office of Insurance Regulation that it is
9 backed by the full faith and credit of one or more counties in
10 which it operates may be exempted from s. 641.225.
11 (i) A Children's Medical Services network, as defined
12 in s. 391.021.
13 (5) By October 1, 2003, the agency and the department
14 shall, to the extent feasible, develop a plan for implementing
15 new Medicaid procedure codes for emergency and crisis care,
16 supportive residential services, and other services designed
17 to maximize the use of Medicaid funds for Medicaid-eligible
18 recipients. The agency shall include in the agreement
19 developed pursuant to subsection (4) a provision that ensures
20 that the match requirements for these new procedure codes are
21 met by certifying eligible general revenue or local funds that
22 are currently expended on these services by the department
23 with contracted alcohol, drug abuse, and mental health
24 providers. The plan must describe specific procedure codes to
25 be implemented, a projection of the number of procedures to be
26 delivered during fiscal year 2003-2004, and a financial
27 analysis that describes the certified match procedures, and
28 accountability mechanisms, projects the earnings associated
29 with these procedures, and describes the sources of state
30 match. This plan may not be implemented in any part until
31 approved by the Legislative Budget Commission. If such
10
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Florida Senate - 2004 SB 2586
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1 approval has not occurred by December 31, 2003, the plan shall
2 be submitted for consideration by the 2004 Legislature.
3 (6) The agency may contract with any public or private
4 entity otherwise authorized by this section on a prepaid or
5 fixed-sum basis for the provision of health care services to
6 recipients. An entity may provide prepaid services to
7 recipients, either directly or through arrangements with other
8 entities, if each entity involved in providing services:
9 (a) Is organized primarily for the purpose of
10 providing health care or other services of the type regularly
11 offered to Medicaid recipients;
12 (b) Ensures that services meet the standards set by
13 the agency for quality, appropriateness, and timeliness;
14 (c) Makes provisions satisfactory to the agency for
15 insolvency protection and ensures that neither enrolled
16 Medicaid recipients nor the agency will be liable for the
17 debts of the entity;
18 (d) Submits to the agency, if a private entity, a
19 financial plan that the agency finds to be fiscally sound and
20 that provides for working capital in the form of cash or
21 equivalent liquid assets excluding revenues from Medicaid
22 premium payments equal to at least the first 3 months of
23 operating expenses or $200,000, whichever is greater;
24 (e) Furnishes evidence satisfactory to the agency of
25 adequate liability insurance coverage or an adequate plan of
26 self-insurance to respond to claims for injuries arising out
27 of the furnishing of health care;
28 (f) Provides, through contract or otherwise, for
29 periodic review of its medical facilities and services, as
30 required by the agency; and
31
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1 (g) Provides organizational, operational, financial,
2 and other information required by the agency.
3 (7) The agency may contract on a prepaid or fixed-sum
4 basis with any health insurer that:
5 (a) Pays for health care services provided to enrolled
6 Medicaid recipients in exchange for a premium payment paid by
7 the agency;
8 (b) Assumes the underwriting risk; and
9 (c) Is organized and licensed under applicable
10 provisions of the Florida Insurance Code and is currently in
11 good standing with the Office of Insurance Regulation.
12 (8) The agency may contract on a prepaid or fixed-sum
13 basis with an exclusive provider organization to provide
14 health care services to Medicaid recipients provided that the
15 exclusive provider organization meets applicable managed care
16 plan requirements in this section, ss. 409.9122, 409.9123,
17 409.9128, and 627.6472, and other applicable provisions of
18 law.
19 (9) The Agency for Health Care Administration may
20 provide cost-effective purchasing of chiropractic services on
21 a fee-for-service basis to Medicaid recipients through
22 arrangements with a statewide chiropractic preferred provider
23 organization incorporated in this state as a not-for-profit
24 corporation. The agency shall ensure that the benefit limits
25 and prior authorization requirements in the current Medicaid
26 program shall apply to the services provided by the
27 chiropractic preferred provider organization.
28 (10) The agency shall not contract on a prepaid or
29 fixed-sum basis for Medicaid services with an entity which
30 knows or reasonably should know that any officer, director,
31 agent, managing employee, or owner of stock or beneficial
12
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Florida Senate - 2004 SB 2586
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1 interest in excess of 5 percent common or preferred stock, or
2 the entity itself, has been found guilty of, regardless of
3 adjudication, or entered a plea of nolo contendere, or guilty,
4 to:
5 (a) Fraud;
6 (b) Violation of federal or state antitrust statutes,
7 including those proscribing price fixing between competitors
8 and the allocation of customers among competitors;
9 (c) Commission of a felony involving embezzlement,
10 theft, forgery, income tax evasion, bribery, falsification or
11 destruction of records, making false statements, receiving
12 stolen property, making false claims, or obstruction of
13 justice; or
14 (d) Any crime in any jurisdiction which directly
15 relates to the provision of health services on a prepaid or
16 fixed-sum basis.
17 (11) The agency, after notifying the Legislature, may
18 apply for waivers of applicable federal laws and regulations
19 as necessary to implement more appropriate systems of health
20 care for Medicaid recipients and reduce the cost of the
21 Medicaid program to the state and federal governments and
22 shall implement such programs, after legislative approval,
23 within a reasonable period of time after federal approval.
24 These programs must be designed primarily to reduce the need
25 for inpatient care, custodial care and other long-term or
26 institutional care, and other high-cost services.
27 (a) Prior to seeking legislative approval of such a
28 waiver as authorized by this subsection, the agency shall
29 provide notice and an opportunity for public comment. Notice
30 shall be provided to all persons who have made requests of the
31 agency for advance notice and shall be published in the
13
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Florida Senate - 2004 SB 2586
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1 Florida Administrative Weekly not less than 28 days prior to
2 the intended action.
3 (b) Notwithstanding s. 216.292, funds that are
4 appropriated to the Department of Elderly Affairs for the
5 Assisted Living for the Elderly Medicaid waiver and are not
6 expended shall be transferred to the agency to fund
7 Medicaid-reimbursed nursing home care.
8 (12) The agency shall establish a postpayment
9 utilization control program designed to identify recipients
10 who may inappropriately overuse or underuse Medicaid services
11 and shall provide methods to correct such misuse.
12 (13) The agency shall develop and provide coordinated
13 systems of care for Medicaid recipients and may contract with
14 public or private entities to develop and administer such
15 systems of care among public and private health care providers
16 in a given geographic area.
17 (14) The agency shall operate or contract for the
18 operation of utilization management and incentive systems
19 designed to encourage cost-effective use services.
20 (15)(a) The agency shall operate the Comprehensive
21 Assessment and Review (CARES) nursing facility preadmission
22 screening program to ensure that Medicaid payment for nursing
23 facility care is made only for individuals whose conditions
24 require such care and to ensure that long-term care services
25 are provided in the setting most appropriate to the needs of
26 the person and in the most economical manner possible. The
27 CARES program shall also ensure that individuals participating
28 in Medicaid home and community-based waiver programs meet
29 criteria for those programs, consistent with approved federal
30 waivers.
31
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1 (b) The agency shall operate the CARES program through
2 an interagency agreement with the Department of Elderly
3 Affairs.
4 (c) Prior to making payment for nursing facility
5 services for a Medicaid recipient, the agency must verify that
6 the nursing facility preadmission screening program has
7 determined that the individual requires nursing facility care
8 and that the individual cannot be safely served in
9 community-based programs. The nursing facility preadmission
10 screening program shall refer a Medicaid recipient to a
11 community-based program if the individual could be safely
12 served at a lower cost and the recipient chooses to
13 participate in such program.
14 (d) By January 1 of each year, the agency shall submit
15 a report to the Legislature and the Office of Long-Term-Care
16 Policy describing the operations of the CARES program. The
17 report must describe:
18 1. Rate of diversion to community alternative
19 programs;
20 2. CARES program staffing needs to achieve additional
21 diversions;
22 3. Reasons the program is unable to place individuals
23 in less restrictive settings when such individuals desired
24 such services and could have been served in such settings;
25 4. Barriers to appropriate placement, including
26 barriers due to policies or operations of other agencies or
27 state-funded programs; and
28 5. Statutory changes necessary to ensure that
29 individuals in need of long-term care services receive care in
30 the least restrictive environment.
31
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1 (16)(a) The agency shall identify health care
2 utilization and price patterns within the Medicaid program
3 which are not cost-effective or medically appropriate and
4 assess the effectiveness of new or alternate methods of
5 providing and monitoring service, and may implement such
6 methods as it considers appropriate. Such methods may include
7 disease management initiatives, an integrated and systematic
8 approach for managing the health care needs of recipients who
9 are at risk of or diagnosed with a specific disease by using
10 best practices, prevention strategies, clinical-practice
11 improvement, clinical interventions and protocols, outcomes
12 research, information technology, and other tools and
13 resources to reduce overall costs and improve measurable
14 outcomes.
15 (b) The responsibility of the agency under this
16 subsection shall include the development of capabilities to
17 identify actual and optimal practice patterns; patient and
18 provider educational initiatives; methods for determining
19 patient compliance with prescribed treatments; fraud, waste,
20 and abuse prevention and detection programs; and beneficiary
21 case management programs.
22 1. The practice pattern identification program shall
23 evaluate practitioner prescribing patterns based on national
24 and regional practice guidelines, comparing practitioners to
25 their peer groups. The agency and its Drug Utilization Review
26 Board shall consult with a panel of practicing health care
27 professionals consisting of the following: the Speaker of the
28 House of Representatives and the President of the Senate shall
29 each appoint three physicians licensed under chapter 458 or
30 chapter 459; and the Governor shall appoint two pharmacists
31 licensed under chapter 465 and one dentist licensed under
16
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1 chapter 466 who is an oral surgeon. Terms of the panel members
2 shall expire at the discretion of the appointing official. The
3 panel shall begin its work by August 1, 1999, regardless of
4 the number of appointments made by that date. The advisory
5 panel shall be responsible for evaluating treatment guidelines
6 and recommending ways to incorporate their use in the practice
7 pattern identification program. Practitioners who are
8 prescribing inappropriately or inefficiently, as determined by
9 the agency, may have their prescribing of certain drugs
10 subject to prior authorization.
11 2. The agency shall also develop educational
12 interventions designed to promote the proper use of
13 medications by providers and beneficiaries.
14 3. The agency shall implement a pharmacy fraud, waste,
15 and abuse initiative that may include a surety bond or letter
16 of credit requirement for participating pharmacies, enhanced
17 provider auditing practices, the use of additional fraud and
18 abuse software, recipient management programs for
19 beneficiaries inappropriately using their benefits, and other
20 steps that will eliminate provider and recipient fraud, waste,
21 and abuse. The initiative shall address enforcement efforts to
22 reduce the number and use of counterfeit prescriptions.
23 4. By September 30, 2002, the agency shall contract
24 with an entity in the state to implement a wireless handheld
25 clinical pharmacology drug information database for
26 practitioners. The initiative shall be designed to enhance the
27 agency's efforts to reduce fraud, abuse, and errors in the
28 prescription drug benefit program and to otherwise further the
29 intent of this paragraph.
30 5. The agency may apply for any federal waivers needed
31 to implement this paragraph.
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1 (17) An entity contracting on a prepaid or fixed-sum
2 basis shall, in addition to meeting any applicable statutory
3 surplus requirements, also maintain at all times in the form
4 of cash, investments that mature in less than 180 days
5 allowable as admitted assets by the Office of Insurance
6 Regulation, and restricted funds or deposits controlled by the
7 agency or the Office of Insurance Regulation, a surplus amount
8 equal to one-and-one-half times the entity's monthly Medicaid
9 prepaid revenues. As used in this subsection, the term
10 "surplus" means the entity's total assets minus total
11 liabilities. If an entity's surplus falls below an amount
12 equal to one-and-one-half times the entity's monthly Medicaid
13 prepaid revenues, the agency shall prohibit the entity from
14 engaging in marketing and preenrollment activities, shall
15 cease to process new enrollments, and shall not renew the
16 entity's contract until the required balance is achieved. The
17 requirements of this subsection do not apply:
18 (a) Where a public entity agrees to fund any deficit
19 incurred by the contracting entity; or
20 (b) Where the entity's performance and obligations are
21 guaranteed in writing by a guaranteeing organization which:
22 1. Has been in operation for at least 5 years and has
23 assets in excess of $50 million; or
24 2. Submits a written guarantee acceptable to the
25 agency which is irrevocable during the term of the contracting
26 entity's contract with the agency and, upon termination of the
27 contract, until the agency receives proof of satisfaction of
28 all outstanding obligations incurred under the contract.
29 (18)(a) The agency may require an entity contracting
30 on a prepaid or fixed-sum basis to establish a restricted
31 insolvency protection account with a federally guaranteed
18
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1 financial institution licensed to do business in this state.
2 The entity shall deposit into that account 5 percent of the
3 capitation payments made by the agency each month until a
4 maximum total of 2 percent of the total current contract
5 amount is reached. The restricted insolvency protection
6 account may be drawn upon with the authorized signatures of
7 two persons designated by the entity and two representatives
8 of the agency. If the agency finds that the entity is
9 insolvent, the agency may draw upon the account solely with
10 the two authorized signatures of representatives of the
11 agency, and the funds may be disbursed to meet financial
12 obligations incurred by the entity under the prepaid contract.
13 If the contract is terminated, expired, or not continued, the
14 account balance must be released by the agency to the entity
15 upon receipt of proof of satisfaction of all outstanding
16 obligations incurred under this contract.
17 (b) The agency may waive the insolvency protection
18 account requirement in writing when evidence is on file with
19 the agency of adequate insolvency insurance and reinsurance
20 that will protect enrollees if the entity becomes unable to
21 meet its obligations.
22 (19) An entity that contracts with the agency on a
23 prepaid or fixed-sum basis for the provision of Medicaid
24 services shall reimburse any hospital or physician that is
25 outside the entity's authorized geographic service area as
26 specified in its contract with the agency, and that provides
27 services authorized by the entity to its members, at a rate
28 negotiated with the hospital or physician for the provision of
29 services or according to the lesser of the following:
30 (a) The usual and customary charges made to the
31 general public by the hospital or physician; or
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1 (b) The Florida Medicaid reimbursement rate
2 established for the hospital or physician.
3 (20) When a merger or acquisition of a Medicaid
4 prepaid contractor has been approved by the Office of
5 Insurance Regulation pursuant to s. 628.4615, the agency shall
6 approve the assignment or transfer of the appropriate Medicaid
7 prepaid contract upon request of the surviving entity of the
8 merger or acquisition if the contractor and the other entity
9 have been in good standing with the agency for the most recent
10 12-month period, unless the agency determines that the
11 assignment or transfer would be detrimental to the Medicaid
12 recipients or the Medicaid program. To be in good standing, an
13 entity must not have failed accreditation or committed any
14 material violation of the requirements of s. 641.52 and must
15 meet the Medicaid contract requirements. For purposes of this
16 section, a merger or acquisition means a change in controlling
17 interest of an entity, including an asset or stock purchase.
18 (21) Any entity contracting with the agency pursuant
19 to this section to provide health care services to Medicaid
20 recipients is prohibited from engaging in any of the following
21 practices or activities:
22 (a) Practices that are discriminatory, including, but
23 not limited to, attempts to discourage participation on the
24 basis of actual or perceived health status.
25 (b) Activities that could mislead or confuse
26 recipients, or misrepresent the organization, its marketing
27 representatives, or the agency. Violations of this paragraph
28 include, but are not limited to:
29 1. False or misleading claims that marketing
30 representatives are employees or representatives of the state
31
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1 or county, or of anyone other than the entity or the
2 organization by whom they are reimbursed.
3 2. False or misleading claims that the entity is
4 recommended or endorsed by any state or county agency, or by
5 any other organization which has not certified its endorsement
6 in writing to the entity.
7 3. False or misleading claims that the state or county
8 recommends that a Medicaid recipient enroll with an entity.
9 4. Claims that a Medicaid recipient will lose benefits
10 under the Medicaid program, or any other health or welfare
11 benefits to which the recipient is legally entitled, if the
12 recipient does not enroll with the entity.
13 (c) Granting or offering of any monetary or other
14 valuable consideration for enrollment, except as authorized by
15 subsection (22).
16 (d) Door-to-door solicitation of recipients who have
17 not contacted the entity or who have not invited the entity to
18 make a presentation.
19 (e) Solicitation of Medicaid recipients by marketing
20 representatives stationed in state offices unless approved and
21 supervised by the agency or its agent and approved by the
22 affected state agency when solicitation occurs in an office of
23 the state agency. The agency shall ensure that marketing
24 representatives stationed in state offices shall market their
25 managed care plans to Medicaid recipients only in designated
26 areas and in such a way as to not interfere with the
27 recipients' activities in the state office.
28 (f) Enrollment of Medicaid recipients.
29 (22) The agency may impose a fine for a violation of
30 this section or the contract with the agency by a person or
31 entity that is under contract with the agency. With respect to
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1 any nonwillful violation, such fine shall not exceed $2,500
2 per violation. In no event shall such fine exceed an aggregate
3 amount of $10,000 for all nonwillful violations arising out of
4 the same action. With respect to any knowing and willful
5 violation of this section or the contract with the agency, the
6 agency may impose a fine upon the entity in an amount not to
7 exceed $20,000 for each such violation. In no event shall such
8 fine exceed an aggregate amount of $100,000 for all knowing
9 and willful violations arising out of the same action.
10 (23) A health maintenance organization or a person or
11 entity exempt from chapter 641 that is under contract with the
12 agency for the provision of health care services to Medicaid
13 recipients may not use or distribute marketing materials used
14 to solicit Medicaid recipients, unless such materials have
15 been approved by the agency. The provisions of this subsection
16 do not apply to general advertising and marketing materials
17 used by a health maintenance organization to solicit both
18 non-Medicaid subscribers and Medicaid recipients.
19 (24) Upon approval by the agency, health maintenance
20 organizations and persons or entities exempt from chapter 641
21 that are under contract with the agency for the provision of
22 health care services to Medicaid recipients may be permitted
23 within the capitation rate to provide additional health
24 benefits that the agency has found are of high quality, are
25 practicably available, provide reasonable value to the
26 recipient, and are provided at no additional cost to the
27 state.
28 (25) The agency shall utilize the statewide health
29 maintenance organization complaint hotline for the purpose of
30 investigating and resolving Medicaid and prepaid health plan
31 complaints, maintaining a record of complaints and confirmed
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1 problems, and receiving disenrollment requests made by
2 recipients.
3 (26) The agency shall require the publication of the
4 health maintenance organization's and the prepaid health
5 plan's consumer services telephone numbers and the "800"
6 telephone number of the statewide health maintenance
7 organization complaint hotline on each Medicaid identification
8 card issued by a health maintenance organization or prepaid
9 health plan contracting with the agency to serve Medicaid
10 recipients and on each subscriber handbook issued to a
11 Medicaid recipient.
12 (27) The agency shall establish a health care quality
13 improvement system for those entities contracting with the
14 agency pursuant to this section, incorporating all the
15 standards and guidelines developed by the Medicaid Bureau of
16 the Health Care Financing Administration as a part of the
17 quality assurance reform initiative. The system shall include,
18 but need not be limited to, the following:
19 (a) Guidelines for internal quality assurance
20 programs, including standards for:
21 1. Written quality assurance program descriptions.
22 2. Responsibilities of the governing body for
23 monitoring, evaluating, and making improvements to care.
24 3. An active quality assurance committee.
25 4. Quality assurance program supervision.
26 5. Requiring the program to have adequate resources to
27 effectively carry out its specified activities.
28 6. Provider participation in the quality assurance
29 program.
30 7. Delegation of quality assurance program activities.
31 8. Credentialing and recredentialing.
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1 9. Enrollee rights and responsibilities.
2 10. Availability and accessibility to services and
3 care.
4 11. Ambulatory care facilities.
5 12. Accessibility and availability of medical records,
6 as well as proper recordkeeping and process for record review.
7 13. Utilization review.
8 14. A continuity of care system.
9 15. Quality assurance program documentation.
10 16. Coordination of quality assurance activity with
11 other management activity.
12 17. Delivering care to pregnant women and infants; to
13 elderly and disabled recipients, especially those who are at
14 risk of institutional placement; to persons with developmental
15 disabilities; and to adults who have chronic, high-cost
16 medical conditions.
17 (b) Guidelines which require the entities to conduct
18 quality-of-care studies which:
19 1. Target specific conditions and specific health
20 service delivery issues for focused monitoring and evaluation.
21 2. Use clinical care standards or practice guidelines
22 to objectively evaluate the care the entity delivers or fails
23 to deliver for the targeted clinical conditions and health
24 services delivery issues.
25 3. Use quality indicators derived from the clinical
26 care standards or practice guidelines to screen and monitor
27 care and services delivered.
28 (c) Guidelines for external quality review of each
29 contractor which require: focused studies of patterns of care;
30 individual care review in specific situations; and followup
31 activities on previous pattern-of-care study findings and
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1 individual-care-review findings. In designing the external
2 quality review function and determining how it is to operate
3 as part of the state's overall quality improvement system, the
4 agency shall construct its external quality review
5 organization and entity contracts to address each of the
6 following:
7 1. Delineating the role of the external quality review
8 organization.
9 2. Length of the external quality review organization
10 contract with the state.
11 3. Participation of the contracting entities in
12 designing external quality review organization review
13 activities.
14 4. Potential variation in the type of clinical
15 conditions and health services delivery issues to be studied
16 at each plan.
17 5. Determining the number of focused pattern-of-care
18 studies to be conducted for each plan.
19 6. Methods for implementing focused studies.
20 7. Individual care review.
21 8. Followup activities.
22 (28) In order to ensure that children receive health
23 care services for which an entity has already been
24 compensated, an entity contracting with the agency pursuant to
25 this section shall achieve an annual Early and Periodic
26 Screening, Diagnosis, and Treatment (EPSDT) Service screening
27 rate of at least 60 percent for those recipients continuously
28 enrolled for at least 8 months. The agency shall develop a
29 method by which the EPSDT screening rate shall be calculated.
30 For any entity which does not achieve the annual 60 percent
31 rate, the entity must submit a corrective action plan for the
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1 agency's approval. If the entity does not meet the standard
2 established in the corrective action plan during the specified
3 timeframe, the agency is authorized to impose appropriate
4 contract sanctions. At least annually, the agency shall
5 publicly release the EPSDT Services screening rates of each
6 entity it has contracted with on a prepaid basis to serve
7 Medicaid recipients.
8 (29) The agency shall perform enrollments and
9 disenrollments for Medicaid recipients who are eligible for
10 MediPass or managed care plans. Notwithstanding the
11 prohibition contained in paragraph (19)(f), managed care plans
12 may perform preenrollments of Medicaid recipients under the
13 supervision of the agency or its agents. For the purposes of
14 this section, "preenrollment" means the provision of marketing
15 and educational materials to a Medicaid recipient and
16 assistance in completing the application forms, but shall not
17 include actual enrollment into a managed care plan. An
18 application for enrollment shall not be deemed complete until
19 the agency or its agent verifies that the recipient made an
20 informed, voluntary choice. The agency, in cooperation with
21 the Department of Children and Family Services, may test new
22 marketing initiatives to inform Medicaid recipients about
23 their managed care options at selected sites. The agency shall
24 report to the Legislature on the effectiveness of such
25 initiatives. The agency may contract with a third party to
26 perform managed care plan and MediPass enrollment and
27 disenrollment services for Medicaid recipients and is
28 authorized to adopt rules to implement such services. The
29 agency may adjust the capitation rate only to cover the costs
30 of a third-party enrollment and disenrollment contract, and
31
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1 for agency supervision and management of the managed care plan
2 enrollment and disenrollment contract.
3 (30) Any lists of providers made available to Medicaid
4 recipients, MediPass enrollees, or managed care plan enrollees
5 shall be arranged alphabetically showing the provider's name
6 and specialty and, separately, by specialty in alphabetical
7 order.
8 (31) The agency shall establish an enhanced managed
9 care quality assurance oversight function, to include at least
10 the following components:
11 (a) At least quarterly analysis and followup,
12 including sanctions as appropriate, of managed care
13 participant utilization of services.
14 (b) At least quarterly analysis and followup,
15 including sanctions as appropriate, of quality findings of the
16 Medicaid peer review organization and other external quality
17 assurance programs.
18 (c) At least quarterly analysis and followup,
19 including sanctions as appropriate, of the fiscal viability of
20 managed care plans.
21 (d) At least quarterly analysis and followup,
22 including sanctions as appropriate, of managed care
23 participant satisfaction and disenrollment surveys.
24 (e) The agency shall conduct regular and ongoing
25 Medicaid recipient satisfaction surveys.
26
27 The analyses and followup activities conducted by the agency
28 under its enhanced managed care quality assurance oversight
29 function shall not duplicate the activities of accreditation
30 reviewers for entities regulated under part III of chapter
31
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1 641, but may include a review of the finding of such
2 reviewers.
3 (32) Each managed care plan that is under contract
4 with the agency to provide health care services to Medicaid
5 recipients shall annually conduct a background check with the
6 Florida Department of Law Enforcement of all persons with
7 ownership interest of 5 percent or more or executive
8 management responsibility for the managed care plan and shall
9 submit to the agency information concerning any such person
10 who has been found guilty of, regardless of adjudication, or
11 has entered a plea of nolo contendere or guilty to, any of the
12 offenses listed in s. 435.03.
13 (33) The agency shall, by rule, develop a process
14 whereby a Medicaid managed care plan enrollee who wishes to
15 enter hospice care may be disenrolled from the managed care
16 plan within 24 hours after contacting the agency regarding
17 such request. The agency rule shall include a methodology for
18 the agency to recoup managed care plan payments on a pro rata
19 basis if payment has been made for the enrollment month when
20 disenrollment occurs.
21 (34) The agency and entities which contract with the
22 agency to provide health care services to Medicaid recipients
23 under this section or s. 409.9122 must comply with the
24 provisions of s. 641.513 in providing emergency services and
25 care to Medicaid recipients and MediPass recipients.
26 (35) All entities providing health care services to
27 Medicaid recipients shall make available, and encourage all
28 pregnant women and mothers with infants to receive, and
29 provide documentation in the medical records to reflect, the
30 following:
31 (a) Healthy Start prenatal or infant screening.
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1 (b) Healthy Start care coordination, when screening or
2 other factors indicate need.
3 (c) Healthy Start enhanced services in accordance with
4 the prenatal or infant screening results.
5 (d) Immunizations in accordance with recommendations
6 of the Advisory Committee on Immunization Practices of the
7 United States Public Health Service and the American Academy
8 of Pediatrics, as appropriate.
9 (e) Counseling and services for family planning to all
10 women and their partners.
11 (f) A scheduled postpartum visit for the purpose of
12 voluntary family planning, to include discussion of all
13 methods of contraception, as appropriate.
14 (g) Referral to the Special Supplemental Nutrition
15 Program for Women, Infants, and Children (WIC).
16 (36) Any entity that provides Medicaid prepaid health
17 plan services shall ensure the appropriate coordination of
18 health care services with an assisted living facility in cases
19 where a Medicaid recipient is both a member of the entity's
20 prepaid health plan and a resident of the assisted living
21 facility. If the entity is at risk for Medicaid targeted case
22 management and behavioral health services, the entity shall
23 inform the assisted living facility of the procedures to
24 follow should an emergent condition arise.
25 (37) The agency may seek and implement federal waivers
26 necessary to provide for cost-effective purchasing of home
27 health services, private duty nursing services,
28 transportation, independent laboratory services, and durable
29 medical equipment and supplies through competitive bidding
30 pursuant to s. 287.057. The agency may request appropriate
31 waivers from the federal Health Care Financing Administration
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1 in order to competitively bid such services. The agency may
2 exclude providers not selected through the bidding process
3 from the Medicaid provider network.
4 (38) The Agency for Health Care Administration is
5 directed to issue a request for proposal or intent to
6 negotiate to implement on a demonstration basis an outpatient
7 specialty services pilot project in a rural and urban county
8 in the state. As used in this subsection, the term "outpatient
9 specialty services" means clinical laboratory, diagnostic
10 imaging, and specified home medical services to include
11 durable medical equipment, prosthetics and orthotics, and
12 infusion therapy.
13 (a) The entity that is awarded the contract to provide
14 Medicaid managed care outpatient specialty services must, at a
15 minimum, meet the following criteria:
16 1. The entity must be licensed by the Office of
17 Insurance Regulation under part II of chapter 641.
18 2. The entity must be experienced in providing
19 outpatient specialty services.
20 3. The entity must demonstrate to the satisfaction of
21 the agency that it provides high-quality services to its
22 patients.
23 4. The entity must demonstrate that it has in place a
24 complaints and grievance process to assist Medicaid recipients
25 enrolled in the pilot managed care program to resolve
26 complaints and grievances.
27 (b) The pilot managed care program shall operate for a
28 period of 3 years. The objective of the pilot program shall be
29 to determine the cost-effectiveness and effects on
30 utilization, access, and quality of providing outpatient
31
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1 specialty services to Medicaid recipients on a prepaid,
2 capitated basis.
3 (c) The agency shall conduct a quality assurance
4 review of the prepaid health clinic each year that the
5 demonstration program is in effect. The prepaid health clinic
6 is responsible for all expenses incurred by the agency in
7 conducting a quality assurance review.
8 (d) The entity that is awarded the contract to provide
9 outpatient specialty services to Medicaid recipients shall
10 report data required by the agency in a format specified by
11 the agency, for the purpose of conducting the evaluation
12 required in paragraph (e).
13 (e) The agency shall conduct an evaluation of the
14 pilot managed care program and report its findings to the
15 Governor and the Legislature by no later than January 1, 2001.
16 (39) The agency shall enter into agreements with
17 not-for-profit organizations based in this state for the
18 purpose of providing vision screening.
19 (40)(a) The agency shall implement a Medicaid
20 prescribed-drug spending-control program that includes the
21 following components:
22 1. Medicaid prescribed-drug coverage for brand-name
23 drugs for adult Medicaid recipients is limited to the
24 dispensing of four brand-name drugs per month per recipient.
25 Children are exempt from this restriction. Antiretroviral
26 agents are excluded from this limitation. No requirements for
27 prior authorization or other restrictions on medications used
28 to treat mental illnesses such as schizophrenia, severe
29 depression, or bipolar disorder may be imposed on Medicaid
30 recipients. Medications that will be available without
31 restriction for persons with mental illnesses include atypical
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1 antipsychotic medications, conventional antipsychotic
2 medications, selective serotonin reuptake inhibitors, and
3 other medications used for the treatment of serious mental
4 illnesses. The agency shall also limit the amount of a
5 prescribed drug dispensed to no more than a 34-day supply. The
6 agency shall continue to provide unlimited generic drugs,
7 contraceptive drugs and items, and diabetic supplies. Although
8 a drug may be included on the preferred drug formulary, it
9 would not be exempt from the four-brand limit. The agency may
10 authorize exceptions to the brand-name-drug restriction based
11 upon the treatment needs of the patients, only when such
12 exceptions are based on prior consultation provided by the
13 agency or an agency contractor, but the agency must establish
14 procedures to ensure that:
15 a. There will be a response to a request for prior
16 consultation by telephone or other telecommunication device
17 within 24 hours after receipt of a request for prior
18 consultation;
19 b. A 72-hour supply of the drug prescribed will be
20 provided in an emergency or when the agency does not provide a
21 response within 24 hours as required by sub-subparagraph a.;
22 and
23 c. Except for the exception for nursing home residents
24 and other institutionalized adults and except for drugs on the
25 restricted formulary for which prior authorization may be
26 sought by an institutional or community pharmacy, prior
27 authorization for an exception to the brand-name-drug
28 restriction is sought by the prescriber and not by the
29 pharmacy. When prior authorization is granted for a patient in
30 an institutional setting beyond the brand-name-drug
31
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1 restriction, such approval is authorized for 12 months and
2 monthly prior authorization is not required for that patient.
3 2. Reimbursement to pharmacies for Medicaid prescribed
4 drugs shall be set at the average wholesale price less 13.25
5 percent.
6 3. The agency shall develop and implement a process
7 for managing the drug therapies of Medicaid recipients who are
8 using significant numbers of prescribed drugs each month. The
9 management process may include, but is not limited to,
10 comprehensive, physician-directed medical-record reviews,
11 claims analyses, and case evaluations to determine the medical
12 necessity and appropriateness of a patient's treatment plan
13 and drug therapies. The agency may contract with a private
14 organization to provide drug-program-management services. The
15 Medicaid drug benefit management program shall include
16 initiatives to manage drug therapies for HIV/AIDS patients,
17 patients using 20 or more unique prescriptions in a 180-day
18 period, and the top 1,000 patients in annual spending.
19 4. The agency may limit the size of its pharmacy
20 network based on need, competitive bidding, price
21 negotiations, credentialing, or similar criteria. The agency
22 shall give special consideration to rural areas in determining
23 the size and location of pharmacies included in the Medicaid
24 pharmacy network. A pharmacy credentialing process may include
25 criteria such as a pharmacy's full-service status, location,
26 size, patient educational programs, patient consultation,
27 disease-management services, and other characteristics. The
28 agency may impose a moratorium on Medicaid pharmacy enrollment
29 when it is determined that it has a sufficient number of
30 Medicaid-participating providers.
31
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1 5. The agency shall develop and implement a program
2 that requires Medicaid practitioners who prescribe drugs to
3 use a counterfeit-proof prescription pad for Medicaid
4 prescriptions. The agency shall require the use of
5 standardized counterfeit-proof prescription pads by
6 Medicaid-participating prescribers or prescribers who write
7 prescriptions for Medicaid recipients. The agency may
8 implement the program in targeted geographic areas or
9 statewide.
10 6. The agency may enter into arrangements that require
11 manufacturers of generic drugs prescribed to Medicaid
12 recipients to provide rebates of at least 15.1 percent of the
13 average manufacturer price for the manufacturer's generic
14 products. These arrangements shall require that if a
15 generic-drug manufacturer pays federal rebates for
16 Medicaid-reimbursed drugs at a level below 15.1 percent, the
17 manufacturer must provide a supplemental rebate to the state
18 in an amount necessary to achieve a 15.1-percent rebate level.
19 7. The agency may establish a preferred drug formulary
20 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
21 establishment of such formulary, it is authorized to negotiate
22 supplemental rebates from manufacturers that are in addition
23 to those required by Title XIX of the Social Security Act and
24 at no less than 10 percent of the average manufacturer price
25 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
26 unless the federal or supplemental rebate, or both, equals or
27 exceeds 25 percent. There is no upper limit on the
28 supplemental rebates the agency may negotiate. The agency may
29 determine that specific products, brand-name or generic, are
30 competitive at lower rebate percentages. Agreement to pay the
31 minimum supplemental rebate percentage will guarantee a
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1 manufacturer that the Medicaid Pharmaceutical and Therapeutics
2 Committee will consider a product for inclusion on the
3 preferred drug formulary. However, a pharmaceutical
4 manufacturer is not guaranteed placement on the formulary by
5 simply paying the minimum supplemental rebate. Agency
6 decisions will be made on the clinical efficacy of a drug and
7 recommendations of the Medicaid Pharmaceutical and
8 Therapeutics Committee, as well as the price of competing
9 products minus federal and state rebates. The agency is
10 authorized to contract with an outside agency or contractor to
11 conduct negotiations for supplemental rebates. For the
12 purposes of this section, the term "supplemental rebates" may
13 include, at the agency's discretion, cash rebates and other
14 program benefits that offset a Medicaid expenditure. Such
15 other program benefits may include, but are not limited to,
16 disease management programs, drug product donation programs,
17 drug utilization control programs, prescriber and beneficiary
18 counseling and education, fraud and abuse initiatives, and
19 other services or administrative investments with guaranteed
20 savings to the Medicaid program in the same year the rebate
21 reduction is included in the General Appropriations Act. The
22 agency is authorized to seek any federal waivers to implement
23 this initiative.
24 8. The agency shall establish an advisory committee
25 for the purposes of studying the feasibility of using a
26 restricted drug formulary for nursing home residents and other
27 institutionalized adults. The committee shall be comprised of
28 seven members appointed by the Secretary of Health Care
29 Administration. The committee members shall include two
30 physicians licensed under chapter 458 or chapter 459; three
31 pharmacists licensed under chapter 465 and appointed from a
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1 list of recommendations provided by the Florida Long-Term Care
2 Pharmacy Alliance; and two pharmacists licensed under chapter
3 465.
4 9. The Agency for Health Care Administration shall
5 expand home delivery of pharmacy products. To assist Medicaid
6 patients in securing their prescriptions and reduce program
7 costs, the agency shall expand its current mail-order-pharmacy
8 diabetes-supply program to include all generic and brand-name
9 drugs used by Medicaid patients with diabetes. Medicaid
10 recipients in the current program may obtain nondiabetes drugs
11 on a voluntary basis. This initiative is limited to the
12 geographic area covered by the current contract. The agency
13 may seek and implement any federal waivers necessary to
14 implement this subparagraph.
15 (b) The agency shall implement this subsection to the
16 extent that funds are appropriated to administer the Medicaid
17 prescribed-drug spending-control program. The agency may
18 contract all or any part of this program to private
19 organizations.
20 (c) The agency shall submit quarterly reports to the
21 Governor, the President of the Senate, and the Speaker of the
22 House of Representatives which must include, but need not be
23 limited to, the progress made in implementing this subsection
24 and its effect on Medicaid prescribed-drug expenditures.
25 (41) Notwithstanding the provisions of chapter 287,
26 the agency may, at its discretion, renew a contract or
27 contracts for fiscal intermediary services one or more times
28 for such periods as the agency may decide; however, all such
29 renewals may not combine to exceed a total period longer than
30 the term of the original contract.
31
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1 (42) The agency shall provide for the development of a
2 demonstration project by establishment in Miami-Dade County of
3 a long-term-care facility licensed pursuant to chapter 395 to
4 improve access to health care for a predominantly minority,
5 medically underserved, and medically complex population and to
6 evaluate alternatives to nursing home care and general acute
7 care for such population. Such project is to be located in a
8 health care condominium and colocated with licensed facilities
9 providing a continuum of care. The establishment of this
10 project is not subject to the provisions of s. 408.036 or s.
11 408.039. The agency shall report its findings to the Governor,
12 the President of the Senate, and the Speaker of the House of
13 Representatives by January 1, 2003.
14 (43) The agency shall develop and implement a
15 utilization management program for Medicaid-eligible
16 recipients for the management of occupational, physical,
17 respiratory, and speech therapies. The agency shall establish
18 a utilization program that may require prior authorization in
19 order to ensure medically necessary and cost-effective
20 treatments. The program shall be operated in accordance with a
21 federally approved waiver program or state plan amendment. The
22 agency may seek a federal waiver or state plan amendment to
23 implement this program. The agency may also competitively
24 procure these services from an outside vendor on a regional or
25 statewide basis.
26 (44) The agency may contract on a prepaid or fixed-sum
27 basis with appropriately licensed prepaid dental health plans
28 to provide dental services.
29 Section 3. Paragraphs (f) and (k) of subsection (2) of
30 section 409.9122, Florida Statutes, are amended to read:
31
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1 409.9122 Mandatory Medicaid managed care enrollment;
2 programs and procedures.--
3 (2)
4 (f) When a Medicaid recipient does not choose a
5 managed care plan or MediPass provider, the agency shall
6 assign the Medicaid recipient to a managed care plan to the
7 extent capacity in such plan allows or to a MediPass provider
8 if all managed care plans have reached capacity. Medicaid
9 recipients who are subject to mandatory assignment but who
10 fail to make a choice shall be assigned to managed care plans
11 until an enrollment of 40 percent in MediPass and 60 percent
12 in managed care plans is achieved. Once this enrollment is
13 achieved, the assignments shall be divided in order to
14 maintain an enrollment in MediPass and managed care plans
15 which is in a 40 percent and 60 percent proportion,
16 respectively. Thereafter, assignment of Medicaid recipients
17 who fail to make a choice shall be based proportionally on the
18 preferences of recipients who have made a choice in the
19 previous period. Such proportions shall be revised at least
20 quarterly to reflect an update of the preferences of Medicaid
21 recipients. The agency shall disproportionately assign
22 Medicaid-eligible recipients who are required to but have
23 failed to make a choice of managed care plan or MediPass,
24 including children, and who are to be assigned to the MediPass
25 program to children's networks as described in s.
26 409.912(3)(g), Children's Medical Services network as defined
27 in s. 391.021, exclusive provider organizations, provider
28 service networks, minority physician networks, and pediatric
29 emergency department diversion programs authorized by this
30 chapter or the General Appropriations Act, in such manner as
31 the agency deems appropriate, until the agency has determined
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1 that the networks and programs have sufficient numbers to be
2 economically operated. For purposes of this paragraph, when
3 referring to assignment, the term "managed care plans"
4 includes health maintenance organizations, exclusive provider
5 organizations, provider service networks, minority physician
6 networks, Children's Medical Services network, and pediatric
7 emergency department diversion programs authorized by this
8 chapter or the General Appropriations Act. When making
9 assignments, the agency shall take into account the following
10 criteria:
11 1. A managed care plan has sufficient network capacity
12 to meet the need of members.
13 2. The managed care plan or MediPass has previously
14 enrolled the recipient as a member, or one of the managed care
15 plan's primary care providers or MediPass providers has
16 previously provided health care to the recipient.
17 3. The agency has knowledge that the member has
18 previously expressed a preference for a particular managed
19 care plan or MediPass provider as indicated by Medicaid
20 fee-for-service claims data, but has failed to make a choice.
21 4. The managed care plan's or MediPass primary care
22 providers are geographically accessible to the recipient's
23 residence.
24 (k) When a Medicaid recipient does not choose a
25 managed care plan or MediPass provider, the agency shall
26 assign the Medicaid recipient to a managed care plan, except
27 in those counties in which there are fewer than two managed
28 care plans accepting Medicaid enrollees, in which case
29 assignment shall be to a managed care plan or a MediPass
30 provider. Medicaid recipients in counties with fewer than two
31 managed care plans accepting Medicaid enrollees who are
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1 subject to mandatory assignment but who fail to make a choice
2 shall be assigned to managed care plans until an enrollment of
3 40 percent in MediPass and 60 percent in managed care plans is
4 achieved. Once that enrollment is achieved, the assignments
5 shall be divided in order to maintain an enrollment in
6 MediPass and managed care plans which is in a 40 percent and
7 60 percent proportion, respectively. In geographic areas where
8 the agency is contracting for the provision of comprehensive
9 behavioral health services through a capitated prepaid
10 arrangement, recipients who fail to make a choice shall be
11 assigned equally to MediPass or a managed care plan. For
12 purposes of this paragraph, when referring to assignment, the
13 term "managed care plans" includes exclusive provider
14 organizations, provider service networks, Children's Medical
15 Services network, minority physician networks, and pediatric
16 emergency department diversion programs authorized by this
17 chapter or the General Appropriations Act. When making
18 assignments, the agency shall take into account the following
19 criteria:
20 1. A managed care plan has sufficient network capacity
21 to meet the need of members.
22 2. The managed care plan or MediPass has previously
23 enrolled the recipient as a member, or one of the managed care
24 plan's primary care providers or MediPass providers has
25 previously provided health care to the recipient.
26 3. The agency has knowledge that the member has
27 previously expressed a preference for a particular managed
28 care plan or MediPass provider as indicated by Medicaid
29 fee-for-service claims data, but has failed to make a choice.
30
31
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1 4. The managed care plan's or MediPass primary care
2 providers are geographically accessible to the recipient's
3 residence.
4 5. The agency has authority to make mandatory
5 assignments based on quality of service and performance of
6 managed care plans.
7 Section 4. Whenever possible and allowable under
8 federal law, and by contract pursuant to s. 287.057, Florida
9 Statutes, the Agency for Health Care Administration shall
10 outsource routine functions that pertain to the administration
11 of the Medicaid program.
12 Section 5. (1) By October 1, 2004, the Agency for
13 Health Care Administration shall contract with an actuarial
14 firm to evaluate the agency's current Medicaid reimbursement
15 methodologies and provide recommendations on the most
16 efficient reimbursement methodologies available to the agency.
17 The agency shall report to the President of the Senate and the
18 Speaker of the House of Representatives no later than October
19 1, 2005, on the results of the evaluation, including such
20 recommendations, and shall provide the agency's recommendation
21 of the most efficient reimbursement methodology for the agency
22 to use.
23 (2) The agency shall conduct a study to design and
24 implement a standard for handling Medicaid records
25 electronically. In conducting the study, the agency may work
26 with the United States Department of Health and Human Services
27 and other states' departments responsible for administering
28 the Medicaid program.
29 Section 6. There is hereby appropriated from the
30 General Revenue Fund to the Agency for Health Care
31
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1 Administration an amount sufficient to carry out the
2 provisions of this act.
3 Section 7. This act shall take effect July 1, 2004.
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