HB 1893

1	A bill to be entitled
2	An act relating to health care; amending s. 400.23, F.S.;
3	delaying a nursing home staffing increase; amending s.
4	409.903, F.S.; deleting a provision eliminating
5	eligibility for Medicaid services for certain women;
6	amending s. 409.904, F.S.; providing for the Agency for
7	Health Care Administration to pay for medical assistance
8	for certain Medicaid-eligible persons; deleting a
9	limitation on eligibility for coverage under the medically
10	needy program; amending s. 409.906, F.S.; deleting a
11	repeal of a provision that provides adult denture
12	services; repealing s. 409.9065, F.S., relating to
13	pharmaceutical expense assistance; amending s. 409.908,
14	F.S.; providing for reimbursement of Medicaid providers
15	pursuant to published methodologies; revising provisions
16	relating to the long-term care reimbursement and cost
17	reporting system; revising provisions relating to the
18	Medicaid maximum allowable fee for certain pharmacies;
19	amending s. 409.912, F.S.; revising components of the
20	Medicaid prescribed-drug spending-control program;
21	authorizing the agency to implement a program of all-
22	inclusive care for certain children; amending s. 409.9122,
23	F.S.; deleting assignment requirement for recipients in
24	areas with capitated behavioral health services; amending
25	s. 409.9124, F.S.; requiring the agency to develop managed
26	care rates for children of specified ages and to amend the
27	methodology for reimbursing managed care plans to comply
28	therewith; limiting the amount of reimbursement; providing
29	effective dates.
30
31	Be It Enacted by the Legislature of the State of Florida:
32
33	Section 1.  Paragraph (a) of subsection (3) of section
34	400.23, Florida Statutes, is amended to read:
35	400.23  Rules; evaluation and deficiencies; licensure
36	status.--
37	(3)(a)  The agency shall adopt rules providing for the
38	minimum staffing requirements for nursing homes. These
39	requirements shall include, for each nursing home facility, a
40	minimum certified nursing assistant staffing of 2.3 hours of
41	direct care per resident per day beginning January 1, 2002,
42	increasing to 2.6 hours of direct care per resident per day
43	beginning January 1, 2003, and increasing to 2.9 hours of direct
44	care per resident per day beginning July 1, 2006 2005. Beginning
45	January 1, 2002, no facility shall staff below one certified
46	nursing assistant per 20 residents, and a minimum licensed
47	nursing staffing of 1.0 hour of direct resident care per
48	resident per day but never below one licensed nurse per 40
49	residents. Nursing assistants employed under s. 400.211(2) may
50	be included in computing the staffing ratio for certified
51	nursing assistants only if they provide nursing assistance
52	services to residents on a full-time basis. Each nursing home
53	must document compliance with staffing standards as required
54	under this paragraph and post daily the names of staff on duty
55	for the benefit of facility residents and the public. The agency
56	shall recognize the use of licensed nurses for compliance with
57	minimum staffing requirements for certified nursing assistants,
58	provided that the facility otherwise meets the minimum staffing
59	requirements for licensed nurses and that the licensed nurses so
60	recognized are performing the duties of a certified nursing
61	assistant. Unless otherwise approved by the agency, licensed
62	nurses counted toward the minimum staffing requirements for
63	certified nursing assistants must exclusively perform the duties
64	of a certified nursing assistant for the entire shift and shall
65	not also be counted toward the minimum staffing requirements for
66	licensed nurses. If the agency approved a facility's request to
67	use a licensed nurse to perform both licensed nursing and
68	certified nursing assistant duties, the facility must allocate
69	the amount of staff time specifically spent on certified nursing
70	assistant duties for the purpose of documenting compliance with
71	minimum staffing requirements for certified and licensed nursing
72	staff. In no event may the hours of a licensed nurse with dual
73	job responsibilities be counted twice.
74	Section 2.  Subsection (5) of section 409.903, Florida
75	Statutes, is amended to read:
76	409.903  Mandatory payments for eligible persons.--The
77	agency shall make payments for medical assistance and related
78	services on behalf of the following persons who the department,
79	or the Social Security Administration by contract with the
80	Department of Children and Family Services, determines to be
81	eligible, subject to the income, assets, and categorical
82	eligibility tests set forth in federal and state law. Payment on
83	behalf of these Medicaid eligible persons is subject to the
84	availability of moneys and any limitations established by the
85	General Appropriations Act or chapter 216.
86	(5)  A pregnant woman for the duration of her pregnancy and
87	for the postpartum period as defined in federal law and rule, or
88	a child under age 1, if either is living in a family that has an
89	income which is at or below 150 percent of the most current
90	federal poverty level, or, effective January 1, 1992, that has
91	an income which is at or below 185 percent of the most current
92	federal poverty level. Such a person is not subject to an assets
93	test. Further, a pregnant woman who applies for eligibility for
94	the Medicaid program through a qualified Medicaid provider must
95	be offered the opportunity, subject to federal rules, to be made
96	presumptively eligible for the Medicaid program. Effective July
97	1, 2005, eligibility for Medicaid services is eliminated for
98	women who have incomes above 150 percent of the most current
99	federal poverty level.
100	Section 3.  Subsections (1) and (2) of section 409.904,
101	Florida Statutes, are amended to read:
102	409.904  Optional payments for eligible persons.--The
103	agency may make payments for medical assistance and related
104	services on behalf of the following persons who are determined
105	to be eligible subject to the income, assets, and categorical
106	eligibility tests set forth in federal and state law. Payment on
107	behalf of these Medicaid eligible persons is subject to the
108	availability of moneys and any limitations established by the
109	General Appropriations Act or chapter 216.
110	(1)(a)  From July 1, 2005, through December 31, 2005,
111	inclusive, a person who is age 65 or older or is determined to
112	be disabled, whose income is at or below 88 percent of federal
113	poverty level, and whose assets do not exceed established
114	limitations.
115	(b)  Effective January 1, 2006, and subject to federal
116	waiver approval, a person who is age 65 or older or is
117	determined to be disabled, whose income is at or below 88
118	percent of the federal poverty level, whose assets do not exceed
119	established limitations, and who is not eligible for Medicare,
120	or, if eligible for Medicare, is also eligible for and receiving
121	Medicaid-covered institutional care or hospice or home-based and
122	community-based services. The agency shall seek federal
123	authorization through a waiver to provide this coverage.
124	(2)  A family, a pregnant woman, a child under age 21, a
125	person age 65 or over, or a blind or disabled person, who would
126	be eligible under any group listed in s. 409.903(1), (2), or
127	(3), except that the income or assets of such family or person
128	exceed established limitations. For a family or person in one of
129	these coverage groups, medical expenses are deductible from
130	income in accordance with federal requirements in order to make
131	a determination of eligibility. A family or person eligible
132	under the coverage known as the "medically needy," is eligible
133	to receive the same services as other Medicaid recipients, with
134	the exception of services in skilled nursing facilities and
135	intermediate care facilities for the developmentally disabled.
136	Effective July 1, 2005, the medically needy are eligible for
137	prescribed drug services only.
138	Section 4.  Paragraph (b) of subsection (1) of section
139	409.906, Florida Statutes, is amended to read:
140	409.906  Optional Medicaid services.--Subject to specific
141	appropriations, the agency may make payments for services which
142	are optional to the state under Title XIX of the Social Security
143	Act and are furnished by Medicaid providers to recipients who
144	are determined to be eligible on the dates on which the services
145	were provided. Any optional service that is provided shall be
146	provided only when medically necessary and in accordance with
147	state and federal law. Optional services rendered by providers
148	in mobile units to Medicaid recipients may be restricted or
149	prohibited by the agency. Nothing in this section shall be
150	construed to prevent or limit the agency from adjusting fees,
151	reimbursement rates, lengths of stay, number of visits, or
152	number of services, or making any other adjustments necessary to
153	comply with the availability of moneys and any limitations or
154	directions provided for in the General Appropriations Act or
155	chapter 216. If necessary to safeguard the state's systems of
156	providing services to elderly and disabled persons and subject
157	to the notice and review provisions of s. 216.177, the Governor
158	may direct the Agency for Health Care Administration to amend
159	the Medicaid state plan to delete the optional Medicaid service
160	known as "Intermediate Care Facilities for the Developmentally
161	Disabled." Optional services may include:
162	(1)  ADULT DENTAL SERVICES.--
163	(b)  Beginning January 1, 2005, The agency may pay for
164	dentures, the procedures required to seat dentures, and the
165	repair and reline of dentures, provided by or under the
166	direction of a licensed dentist, for a recipient who is 21 years
167	of age or older. This paragraph is repealed effective July 1,
168	2005.
169	Section 5.  Effective January 1, 2006, section 409.9065,
170	Florida Statutes, is repealed.
171	Section 6.  Section 409.908, Florida Statutes, is amended
172	to read:
173	409.908  Reimbursement of Medicaid providers.--Subject to
174	specific appropriations, the agency shall reimburse Medicaid
175	providers, in accordance with state and federal law, according
176	to published methodologies set forth in the rules of the agency
177	and in policy manuals and handbooks incorporated by reference
178	therein. These methodologies may include fee schedules,
179	reimbursement methods based on cost reporting, negotiated fees,
180	competitive bidding pursuant to s. 287.057, and other mechanisms
181	the agency considers efficient and effective for purchasing
182	services or goods on behalf of recipients. If a provider is
183	reimbursed based on cost reporting and submits a cost report
184	late and that cost report would have been used to set a lower
185	reimbursement rate for a rate semester, then the provider's rate
186	for that semester shall be retroactively calculated using the
187	new cost report, and full payment at the recalculated rate shall
188	be effected retroactively. Medicare-granted extensions for
189	filing cost reports, if applicable, shall also apply to Medicaid
190	cost reports. Payment for Medicaid compensable services made on
191	behalf of Medicaid eligible persons is subject to the
192	availability of moneys and any limitations or directions
193	provided for in the General Appropriations Act or chapter 216.
194	The agency is authorized to adjust Further, nothing in this
195	section shall be construed to prevent or limit the agency from
196	adjusting fees, reimbursement rates, lengths of stay, number of
197	visits, or number of services, or make making any other
198	adjustments necessary to comply with the availability of moneys
199	and any limitations or directions provided for in the General
200	Appropriations Act, provided the adjustment is consistent with
201	legislative intent.
202	(1)  Reimbursement to hospitals licensed under part I of
203	chapter 395 must be made prospectively or on the basis of
204	negotiation.
205	(a)  Reimbursement for inpatient care is limited as
206	provided for in s. 409.905(5), except for:
207	1.  The raising of rate reimbursement caps, excluding rural
208	hospitals.
209	2.  Recognition of the costs of graduate medical education.
210	3.  Other methodologies recognized in the General
211	Appropriations Act.
212	4.  Hospital inpatient rates shall be reduced by 6 percent
213	effective July 1, 2001, and restored effective April 1, 2002.
214
215	During the years funds are transferred from the Department of
216	Health, any reimbursement supported by such funds shall be
217	subject to certification by the Department of Health that the
218	hospital has complied with s. 381.0403. The agency is authorized
219	to receive funds from state entities, including, but not limited
220	to, the Department of Health, local governments, and other local
221	political subdivisions, for the purpose of making special
222	exception payments, including federal matching funds, through
223	the Medicaid inpatient reimbursement methodologies. Funds
224	received from state entities or local governments for this
225	purpose shall be separately accounted for and shall not be
226	commingled with other state or local funds in any manner. The
227	agency may certify all local governmental funds used as state
228	match under Title XIX of the Social Security Act, to the extent
229	that the identified local health care provider that is otherwise
230	entitled to and is contracted to receive such local funds is the
231	benefactor under the state's Medicaid program as determined
232	under the General Appropriations Act and pursuant to an
233	agreement between the Agency for Health Care Administration and
234	the local governmental entity. The local governmental entity
235	shall use a certification form prescribed by the agency. At a
236	minimum, the certification form shall identify the amount being
237	certified and describe the relationship between the certifying
238	local governmental entity and the local health care provider.
239	The agency shall prepare an annual statement of impact which
240	documents the specific activities undertaken during the previous
241	fiscal year pursuant to this paragraph, to be submitted to the
242	Legislature no later than January 1, annually.
243	(b)  Reimbursement for hospital outpatient care is limited
244	to $1,500 per state fiscal year per recipient, except for:
245	1.  Such care provided to a Medicaid recipient under age
246	21, in which case the only limitation is medical necessity.
247	2.  Renal dialysis services.
248	3.  Other exceptions made by the agency.
249
250	The agency is authorized to receive funds from state entities,
251	including, but not limited to, the Department of Health, the
252	Board of Regents, local governments, and other local political
253	subdivisions, for the purpose of making payments, including
254	federal matching funds, through the Medicaid outpatient
255	reimbursement methodologies. Funds received from state entities
256	and local governments for this purpose shall be separately
257	accounted for and shall not be commingled with other state or
258	local funds in any manner.
259	(c)  Hospitals that provide services to a disproportionate
260	share of low-income Medicaid recipients, or that participate in
261	the regional perinatal intensive care center program under
262	chapter 383, or that participate in the statutory teaching
263	hospital disproportionate share program may receive additional
264	reimbursement. The total amount of payment for disproportionate
265	share hospitals shall be fixed by the General Appropriations
266	Act. The computation of these payments must be made in
267	compliance with all federal regulations and the methodologies
268	described in ss. 409.911, 409.9112, and 409.9113.
269	(d)  The agency is authorized to limit inflationary
270	increases for outpatient hospital services as directed by the
271	General Appropriations Act.
272	(2)(a)1.  Reimbursement to nursing homes licensed under
273	part II of chapter 400 and state-owned-and-operated intermediate
274	care facilities for the developmentally disabled licensed under
275	chapter 393 must be made prospectively.
276	2.  Unless otherwise limited or directed in the General
277	Appropriations Act, reimbursement to hospitals licensed under
278	part I of chapter 395 for the provision of swing-bed nursing
279	home services must be made on the basis of the average statewide
280	nursing home payment, and reimbursement to a hospital licensed
281	under part I of chapter 395 for the provision of skilled nursing
282	services must be made on the basis of the average nursing home
283	payment for those services in the county in which the hospital
284	is located. When a hospital is located in a county that does not
285	have any community nursing homes, reimbursement must be
286	determined by averaging the nursing home payments, in counties
287	that surround the county in which the hospital is located.
288	Reimbursement to hospitals, including Medicaid payment of
289	Medicare copayments, for skilled nursing services shall be
290	limited to 30 days, unless a prior authorization has been
291	obtained from the agency. Medicaid reimbursement may be extended
292	by the agency beyond 30 days, and approval must be based upon
293	verification by the patient's physician that the patient
294	requires short-term rehabilitative and recuperative services
295	only, in which case an extension of no more than 15 days may be
296	approved. Reimbursement to a hospital licensed under part I of
297	chapter 395 for the temporary provision of skilled nursing
298	services to nursing home residents who have been displaced as
299	the result of a natural disaster or other emergency may not
300	exceed the average county nursing home payment for those
301	services in the county in which the hospital is located and is
302	limited to the period of time which the agency considers
303	necessary for continued placement of the nursing home residents
304	in the hospital.
305	(b)  Subject to any limitations or directions provided for
306	in the General Appropriations Act, the agency shall establish
307	and implement a Florida Title XIX Long-Term Care Reimbursement
308	Plan (Medicaid) for nursing home care in order to provide care
309	and services in conformance with the applicable state and
310	federal laws, rules, regulations, and quality and safety
311	standards and to ensure that individuals eligible for medical
312	assistance have reasonable geographic access to such care.
313	1.  Changes of ownership or of licensed operator do not
314	qualify for increases in reimbursement rates associated with the
315	change of ownership or of licensed operator. The agency shall
316	amend the Title XIX Long Term Care Reimbursement Plan to provide
317	that the initial nursing home reimbursement rates, for the
318	operating, patient care, and MAR components, associated with
319	related and unrelated party changes of ownership or licensed
320	operator filed on or after September 1, 2001, are equivalent to
321	the previous owner's reimbursement rate.
322	2.  The agency shall amend the long-term care reimbursement
323	plan and cost reporting system to create direct care and
324	indirect care subcomponents of the patient care component of the
325	per diem rate. These two subcomponents together shall equal the
326	patient care component of the per diem rate. Separate cost-based
327	ceilings shall be calculated for each patient care subcomponent.
328	The direct care and indirect care subcomponents subcomponent of
329	the per diem rate shall be limited by the cost-based class
330	ceiling, and the indirect care subcomponent shall be limited by
331	the lower of a the cost-based class ceiling, a by the target
332	rate class ceiling, or an by the individual provider target for
333	each subcomponent. The agency shall adjust the patient care
334	component effective January 1, 2002. The cost to adjust the
335	direct care subcomponent shall be the net of the total funds
336	previously allocated for the case mix add-on. The agency shall
337	make the required changes to the nursing home cost reporting
338	forms to implement this requirement effective January 1, 2002.
339	3.  The direct care subcomponent shall include salaries and
340	benefits of direct care staff providing nursing services
341	including registered nurses, licensed practical nurses, and
342	certified nursing assistants who deliver care directly to
343	residents in the nursing home facility. This excludes nursing
344	administration, MDS, and care plan coordinators, staff
345	development, and staffing coordinator.
346	4.  All other patient care costs shall be included in the
347	indirect care cost subcomponent of the patient care per diem
348	rate. There shall be no costs directly or indirectly allocated
349	to the direct care subcomponent from a home office or management
350	company.
351	5.  On July 1 of each year, the agency shall report to the
352	Legislature direct and indirect care costs, including average
353	direct and indirect care costs per resident per facility and
354	direct care and indirect care salaries and benefits per category
355	of staff member per facility.
356	6.  In order to offset the cost of general and professional
357	liability insurance, the agency shall amend the plan to allow
358	for interim rate adjustments to reflect increases in the cost of
359	general or professional liability insurance for nursing homes.
360	This provision shall be implemented to the extent existing
361	appropriations are available.
362
363	It is the intent of the Legislature that the reimbursement plan
364	achieve the goal of providing access to health care for nursing
365	home residents who require large amounts of care while
366	encouraging diversion services as an alternative to nursing home
367	care for residents who can be served within the community. The
368	agency shall base the establishment of any maximum rate of
369	payment, whether overall or component, on the available moneys
370	as provided for in the General Appropriations Act. The agency
371	may base the maximum rate of payment on the results of
372	scientifically valid analysis and conclusions derived from
373	objective statistical data pertinent to the particular maximum
374	rate of payment.
375	(3)  Subject to any limitations or directions provided for
376	in the General Appropriations Act, the following Medicaid
377	services and goods may be reimbursed on a fee-for-service basis.
378	For each allowable service or goods furnished in accordance with
379	Medicaid rules, policy manuals, handbooks, and state and federal
380	law, the payment shall be the amount billed by the provider, the
381	provider's usual and customary charge, or the maximum allowable
382	fee established by the agency, whichever amount is less, with
383	the exception of those services or goods for which the agency
384	makes payment using a methodology based on capitation rates,
385	average costs, or negotiated fees.
386	(a)  Advanced registered nurse practitioner services.
387	(b)  Birth center services.
388	(c)  Chiropractic services.
389	(d)  Community mental health services.
390	(e)  Dental services, including oral and maxillofacial
391	surgery.
392	(f)  Durable medical equipment.
393	(g)  Hearing services.
394	(h)  Occupational therapy for Medicaid recipients under age
395	21.
396	(i)  Optometric services.
397	(j)  Orthodontic services.
398	(k)  Personal care for Medicaid recipients under age 21.
399	(l)  Physical therapy for Medicaid recipients under age 21.
400	(m)  Physician assistant services.
401	(n)  Podiatric services.
402	(o)  Portable X-ray services.
403	(p)  Private-duty nursing for Medicaid recipients under age
404	21.
405	(q)  Registered nurse first assistant services.
406	(r)  Respiratory therapy for Medicaid recipients under age
407	21.
408	(s)  Speech therapy for Medicaid recipients under age 21.
409	(t)  Visual services.
410	(4)  Subject to any limitations or directions provided for
411	in the General Appropriations Act, alternative health plans,
412	health maintenance organizations, and prepaid health plans shall
413	be reimbursed a fixed, prepaid amount negotiated, or
414	competitively bid pursuant to s. 287.057, by the agency and
415	prospectively paid to the provider monthly for each Medicaid
416	recipient enrolled. The amount may not exceed the average amount
417	the agency determines it would have paid, based on claims
418	experience, for recipients in the same or similar category of
419	eligibility. The agency shall calculate capitation rates on a
420	regional basis and, beginning September 1, 1995, shall include
421	age-band differentials in such calculations.
422	(5)  An ambulatory surgical center shall be reimbursed the
423	lesser of the amount billed by the provider or the Medicare-
424	established allowable amount for the facility.
425	(6)  A provider of early and periodic screening, diagnosis,
426	and treatment services to Medicaid recipients who are children
427	under age 21 shall be reimbursed using an all-inclusive rate
428	stipulated in a fee schedule established by the agency. A
429	provider of the visual, dental, and hearing components of such
430	services shall be reimbursed the lesser of the amount billed by
431	the provider or the Medicaid maximum allowable fee established
432	by the agency.
433	(7)  A provider of family planning services shall be
434	reimbursed the lesser of the amount billed by the provider or an
435	all-inclusive amount per type of visit for physicians and
436	advanced registered nurse practitioners, as established by the
437	agency in a fee schedule.
438	(8)  A provider of home-based or community-based services
439	rendered pursuant to a federally approved waiver shall be
440	reimbursed based on an established or negotiated rate for each
441	service. These rates shall be established according to an
442	analysis of the expenditure history and prospective budget
443	developed by each contract provider participating in the waiver
444	program, or under any other methodology adopted by the agency
445	and approved by the Federal Government in accordance with the
446	waiver. Effective July 1, 1996, privately owned and operated
447	community-based residential facilities which meet agency
448	requirements and which formerly received Medicaid reimbursement
449	for the optional intermediate care facility for the mentally
450	retarded service may participate in the developmental services
451	waiver as part of a home-and-community-based continuum of care
452	for Medicaid recipients who receive waiver services.
453	(9)  A provider of home health care services or of medical
454	supplies and appliances shall be reimbursed on the basis of
455	competitive bidding or for the lesser of the amount billed by
456	the provider or the agency's established maximum allowable
457	amount, except that, in the case of the rental of durable
458	medical equipment, the total rental payments may not exceed the
459	purchase price of the equipment over its expected useful life or
460	the agency's established maximum allowable amount, whichever
461	amount is less.
462	(10)  A hospice shall be reimbursed through a prospective
463	system for each Medicaid hospice patient at Medicaid rates using
464	the methodology established for hospice reimbursement pursuant
465	to Title XVIII of the federal Social Security Act.
466	(11)  A provider of independent laboratory services shall
467	be reimbursed on the basis of competitive bidding or for the
468	least of the amount billed by the provider, the provider's usual
469	and customary charge, or the Medicaid maximum allowable fee
470	established by the agency.
471	(12)(a)  A physician shall be reimbursed the lesser of the
472	amount billed by the provider or the Medicaid maximum allowable
473	fee established by the agency.
474	(b)  The agency shall adopt a fee schedule, subject to any
475	limitations or directions provided for in the General
476	Appropriations Act, based on a resource-based relative value
477	scale for pricing Medicaid physician services. Under this fee
478	schedule, physicians shall be paid a dollar amount for each
479	service based on the average resources required to provide the
480	service, including, but not limited to, estimates of average
481	physician time and effort, practice expense, and the costs of
482	professional liability insurance. The fee schedule shall provide
483	increased reimbursement for preventive and primary care services
484	and lowered reimbursement for specialty services by using at
485	least two conversion factors, one for cognitive services and
486	another for procedural services. The fee schedule shall not
487	increase total Medicaid physician expenditures unless moneys are
488	available, and shall be phased in over a 2-year period beginning
489	on July 1, 1994. The Agency for Health Care Administration shall
490	seek the advice of a 16-member advisory panel in formulating and
491	adopting the fee schedule. The panel shall consist of Medicaid
492	physicians licensed under chapters 458 and 459 and shall be
493	composed of 50 percent primary care physicians and 50 percent
494	specialty care physicians.
495	(c)  Notwithstanding paragraph (b), reimbursement fees to
496	physicians for providing total obstetrical services to Medicaid
497	recipients, which include prenatal, delivery, and postpartum
498	care, shall be at least $1,500 per delivery for a pregnant woman
499	with low medical risk and at least $2,000 per delivery for a
500	pregnant woman with high medical risk. However, reimbursement to
501	physicians working in Regional Perinatal Intensive Care Centers
502	designated pursuant to chapter 383, for services to certain
503	pregnant Medicaid recipients with a high medical risk, may be
504	made according to obstetrical care and neonatal care groupings
505	and rates established by the agency. Nurse midwives licensed
506	under part I of chapter 464 or midwives licensed under chapter
507	467 shall be reimbursed at no less than 80 percent of the low
508	medical risk fee. The agency shall by rule determine, for the
509	purpose of this paragraph, what constitutes a high or low
510	medical risk pregnant woman and shall not pay more based solely
511	on the fact that a caesarean section was performed, rather than
512	a vaginal delivery. The agency shall by rule determine a
513	prorated payment for obstetrical services in cases where only
514	part of the total prenatal, delivery, or postpartum care was
515	performed. The Department of Health shall adopt rules for
516	appropriate insurance coverage for midwives licensed under
517	chapter 467. Prior to the issuance and renewal of an active
518	license, or reactivation of an inactive license for midwives
519	licensed under chapter 467, such licensees shall submit proof of
520	coverage with each application.
521	(13)  Medicare premiums for persons eligible for both
522	Medicare and Medicaid coverage shall be paid at the rates
523	established by Title XVIII of the Social Security Act. For
524	Medicare services rendered to Medicaid-eligible persons,
525	Medicaid shall pay Medicare deductibles and coinsurance as
526	follows:
527	(a)  Medicaid shall make no payment toward deductibles and
528	coinsurance for any service that is not covered by Medicaid.
529	(b)  Medicaid's financial obligation for deductibles and
530	coinsurance payments shall be based on Medicare allowable fees,
531	not on a provider's billed charges.
532	(c)  Medicaid will pay no portion of Medicare deductibles
533	and coinsurance when payment that Medicare has made for the
534	service equals or exceeds what Medicaid would have paid if it
535	had been the sole payor. The combined payment of Medicare and
536	Medicaid shall not exceed the amount Medicaid would have paid
537	had it been the sole payor. The Legislature finds that there has
538	been confusion regarding the reimbursement for services rendered
539	to dually eligible Medicare beneficiaries. Accordingly, the
540	Legislature clarifies that it has always been the intent of the
541	Legislature before and after 1991 that, in reimbursing in
542	accordance with fees established by Title XVIII for premiums,
543	deductibles, and coinsurance for Medicare services rendered by
544	physicians to Medicaid eligible persons, physicians be
545	reimbursed at the lesser of the amount billed by the physician
546	or the Medicaid maximum allowable fee established by the Agency
547	for Health Care Administration, as is permitted by federal law.
548	It has never been the intent of the Legislature with regard to
549	such services rendered by physicians that Medicaid be required
550	to provide any payment for deductibles, coinsurance, or
551	copayments for Medicare cost sharing, or any expenses incurred
552	relating thereto, in excess of the payment amount provided for
553	under the State Medicaid plan for such service. This payment
554	methodology is applicable even in those situations in which the
555	payment for Medicare cost sharing for a qualified Medicare
556	beneficiary with respect to an item or service is reduced or
557	eliminated. This expression of the Legislature is in
558	clarification of existing law and shall apply to payment for,
559	and with respect to provider agreements with respect to, items
560	or services furnished on or after the effective date of this
561	act. This paragraph applies to payment by Medicaid for items and
562	services furnished before the effective date of this act if such
563	payment is the subject of a lawsuit that is based on the
564	provisions of this section, and that is pending as of, or is
565	initiated after, the effective date of this act.
566	(d)  Notwithstanding paragraphs (a)-(c):
567	1.  Medicaid payments for Nursing Home Medicare part A
568	coinsurance shall be the lesser of the Medicare coinsurance
569	amount or the Medicaid nursing home per diem rate.
570	2.  Medicaid shall pay all deductibles and coinsurance for
571	Medicare-eligible recipients receiving freestanding end stage
572	renal dialysis center services.
573	3.  Medicaid payments for general hospital inpatient
574	services shall be limited to the Medicare deductible per spell
575	of illness. Medicaid shall make no payment toward coinsurance
576	for Medicare general hospital inpatient services.
577	4.  Medicaid shall pay all deductibles and coinsurance for
578	Medicare emergency transportation services provided by
579	ambulances licensed pursuant to chapter 401.
580	(14)  A provider of prescribed drugs shall be reimbursed
581	the least of the amount billed by the provider, the provider's
582	usual and customary charge, or the Medicaid maximum allowable
583	fee established by the agency, plus a dispensing fee.
584	(a)  For pharmacies with less than $75,000 in average
585	aggregate monthly payments, the Medicaid maximum allowable fee
586	for ingredient cost will be based on the lower of: average
587	wholesale price (AWP) minus 15.4 percent, wholesaler acquisition
588	cost (WAC) plus 5.75 percent, the federal upper limit (FUL), the
589	state maximum allowable cost (SMAC), or the usual and customary
590	(UAC) charge billed by the provider.
591	(b)  For pharmacies with $75,000 or more in average
592	aggregate monthly payments, the Medicaid maximum allowable fee
593	for ingredient cost will be based on the lower of: average
594	wholesale price (AWP) minus 17 percent, wholesaler acquisition
595	cost (WAC) plus 3.5 percent, the federal upper limit (FUL), the
596	state maximum allowable cost (SMAC), or the usual and customary
597	(UAC) charge billed by the provider.
598	(c)  Medicaid providers are required to dispense generic
599	drugs if available at lower cost and the agency has not
600	determined that the branded product is more cost-effective,
601	unless the prescriber has requested and received approval to
602	require the branded product. The agency is directed to implement
603	a variable dispensing fee for payments for prescribed medicines
604	while ensuring continued access for Medicaid recipients. The
605	variable dispensing fee may be based upon, but not limited to,
606	either or both the volume of prescriptions dispensed by a
607	specific pharmacy provider, the volume of prescriptions
608	dispensed to an individual recipient, and dispensing of
609	preferred-drug-list products. The agency may increase the
610	pharmacy dispensing fee authorized by statute and in the annual
611	General Appropriations Act by $0.50 for the dispensing of a
612	Medicaid preferred-drug-list product and reduce the pharmacy
613	dispensing fee by $0.50 for the dispensing of a Medicaid product
614	that is not included on the preferred drug list. The agency may
615	establish a supplemental pharmaceutical dispensing fee to be
616	paid to providers returning unused unit-dose packaged
617	medications to stock and crediting the Medicaid program for the
618	ingredient cost of those medications if the ingredient costs to
619	be credited exceed the value of the supplemental dispensing fee.
620	The agency is authorized to limit reimbursement for prescribed
621	medicine in order to comply with any limitations or directions
622	provided for in the General Appropriations Act, which may
623	include implementing a prospective or concurrent utilization
624	review program.
625	(15)  A provider of primary care case management services
626	rendered pursuant to a federally approved waiver shall be
627	reimbursed by payment of a fixed, prepaid monthly sum for each
628	Medicaid recipient enrolled with the provider.
629	(16)  A provider of rural health clinic services and
630	federally qualified health center services shall be reimbursed a
631	rate per visit based on total reasonable costs of the clinic, as
632	determined by the agency in accordance with federal regulations.
633	(17)  A provider of targeted case management services shall
634	be reimbursed pursuant to an established fee, except where the
635	Federal Government requires a public provider be reimbursed on
636	the basis of average actual costs.
637	(18)  Unless otherwise provided for in the General
638	Appropriations Act, a provider of transportation services shall
639	be reimbursed the lesser of the amount billed by the provider or
640	the Medicaid maximum allowable fee established by the agency,
641	except when the agency has entered into a direct contract with
642	the provider, or with a community transportation coordinator,
643	for the provision of an all-inclusive service, or when services
644	are provided pursuant to an agreement negotiated between the
645	agency and the provider. The agency, as provided for in s.
646	427.0135, shall purchase transportation services through the
647	community coordinated transportation system, if available,
648	unless the agency determines a more cost-effective method for
649	Medicaid clients. Nothing in this subsection shall be construed
650	to limit or preclude the agency from contracting for services
651	using a prepaid capitation rate or from establishing maximum fee
652	schedules, individualized reimbursement policies by provider
653	type, negotiated fees, prior authorization, competitive bidding,
654	increased use of mass transit, or any other mechanism that the
655	agency considers efficient and effective for the purchase of
656	services on behalf of Medicaid clients, including implementing a
657	transportation eligibility process. The agency shall not be
658	required to contract with any community transportation
659	coordinator or transportation operator that has been determined
660	by the agency, the Department of Legal Affairs Medicaid Fraud
661	Control Unit, or any other state or federal agency to have
662	engaged in any abusive or fraudulent billing activities. The
663	agency is authorized to competitively procure transportation
664	services or make other changes necessary to secure approval of
665	federal waivers needed to permit federal financing of Medicaid
666	transportation services at the service matching rate rather than
667	the administrative matching rate.
668	(19)  County health department services shall be reimbursed
669	a rate per visit based on total reasonable costs of the clinic,
670	as determined by the agency in accordance with federal
671	regulations under the authority of 42 C.F.R. s. 431.615.
672	(20)  A renal dialysis facility that provides dialysis
673	services under s. 409.906(9) must be reimbursed the lesser of
674	the amount billed by the provider, the provider's usual and
675	customary charge, or the maximum allowable fee established by
676	the agency, whichever amount is less.
677	(21)  The agency shall reimburse school districts which
678	certify the state match pursuant to ss. 409.9071 and 1011.70 for
679	the federal portion of the school district's allowable costs to
680	deliver the services, based on the reimbursement schedule. The
681	school district shall determine the costs for delivering
682	services as authorized in ss. 409.9071 and 1011.70 for which the
683	state match will be certified. Reimbursement of school-based
684	providers is contingent on such providers being enrolled as
685	Medicaid providers and meeting the qualifications contained in
686	42 C.F.R. s. 440.110, unless otherwise waived by the federal
687	Health Care Financing Administration. Speech therapy providers
688	who are certified through the Department of Education pursuant
689	to rule 6A-4.0176, Florida Administrative Code, are eligible for
690	reimbursement for services that are provided on school premises.
691	Any employee of the school district who has been fingerprinted
692	and has received a criminal background check in accordance with
693	Department of Education rules and guidelines shall be exempt
694	from any agency requirements relating to criminal background
695	checks.
696	(22)  The agency shall request and implement Medicaid
697	waivers from the federal Health Care Financing Administration to
698	advance and treat a portion of the Medicaid nursing home per
699	diem as capital for creating and operating a risk-retention
700	group for self-insurance purposes, consistent with federal and
701	state laws and rules.
702	Section 7.  Paragraph (a) of subsection (39) of section
703	409.912, Florida Statutes, is amended, and subsection (50) is
704	added to said section, to read:
705	409.912  Cost-effective purchasing of health care.--The
706	agency shall purchase goods and services for Medicaid recipients
707	in the most cost-effective manner consistent with the delivery
708	of quality medical care. To ensure that medical services are
709	effectively utilized, the agency may, in any case, require a
710	confirmation or second physician's opinion of the correct
711	diagnosis for purposes of authorizing future services under the
712	Medicaid program. This section does not restrict access to
713	emergency services or poststabilization care services as defined
714	in 42 C.F.R. part 438.114. Such confirmation or second opinion
715	shall be rendered in a manner approved by the agency. The agency
716	shall maximize the use of prepaid per capita and prepaid
717	aggregate fixed-sum basis services when appropriate and other
718	alternative service delivery and reimbursement methodologies,
719	including competitive bidding pursuant to s. 287.057, designed
720	to facilitate the cost-effective purchase of a case-managed
721	continuum of care. The agency shall also require providers to
722	minimize the exposure of recipients to the need for acute
723	inpatient, custodial, and other institutional care and the
724	inappropriate or unnecessary use of high-cost services. The
725	agency may mandate prior authorization, drug therapy management,
726	or disease management participation for certain populations of
727	Medicaid beneficiaries, certain drug classes, or particular
728	drugs to prevent fraud, abuse, overuse, and possible dangerous
729	drug interactions. The Pharmaceutical and Therapeutics Committee
730	shall make recommendations to the agency on drugs for which
731	prior authorization is required. The agency shall inform the
732	Pharmaceutical and Therapeutics Committee of its decisions
733	regarding drugs subject to prior authorization. The agency is
734	authorized to limit the entities it contracts with or enrolls as
735	Medicaid providers by developing a provider network through
736	provider credentialing. The agency may limit its network based
737	on the assessment of beneficiary access to care, provider
738	availability, provider quality standards, time and distance
739	standards for access to care, the cultural competence of the
740	provider network, demographic characteristics of Medicaid
741	beneficiaries, practice and provider-to-beneficiary standards,
742	appointment wait times, beneficiary use of services, provider
743	turnover, provider profiling, provider licensure history,
744	previous program integrity investigations and findings, peer
745	review, provider Medicaid policy and billing compliance records,
746	clinical and medical record audits, and other factors. Providers
747	shall not be entitled to enrollment in the Medicaid provider
748	network. The agency is authorized to seek federal waivers
749	necessary to implement this policy.
750	(39)(a)  The agency shall implement a Medicaid prescribed-
751	drug spending-control program that includes the following
752	components:
753	1.  Medicaid prescribed-drug coverage for brand-name drugs
754	for adult Medicaid recipients is limited to the dispensing of
755	three four brand-name drugs and three generic drugs per month
756	per recipient. Children are exempt from this restriction.
757	Antiretroviral agents are excluded from this limitation. No
758	requirements for prior authorization or other restrictions on
759	medications used to treat mental illnesses such as
760	schizophrenia, severe depression, or bipolar disorder may be
761	imposed on Medicaid recipients. Medications that will be
762	available without restriction for persons with mental illnesses
763	include atypical antipsychotic medications, conventional
764	antipsychotic medications, selective serotonin reuptake
765	inhibitors, and other medications used for the treatment of
766	serious mental illnesses. The agency shall also limit the amount
767	of a prescribed drug dispensed to no more than a 34-day supply.
768	The agency shall continue to provide unlimited generic drugs,
769	contraceptive drugs and items, and diabetic supplies. Although a
770	drug may be included on the preferred drug formulary, it would
771	not be exempt from the three-brand four-brand limit or the
772	generic drug limit. The agency may authorize exceptions to the
773	brand-name-drug restriction based upon the treatment needs of
774	the patients, only when such exceptions are based on prior
775	consultation provided by the agency or an agency contractor, but
776	the agency must establish procedures to ensure that:
777	a.  There will be a response to a request for prior
778	consultation by telephone or other telecommunication device
779	within 24 hours after receipt of a request for prior
780	consultation;
781	b.  A 72-hour supply of the drug prescribed will be
782	provided in an emergency or when the agency does not provide a
783	response within 24 hours as required by sub-subparagraph a.; and
784	c.  Except for the exception for nursing home residents and
785	other institutionalized adults and except for drugs on the
786	restricted formulary for which prior authorization may be sought
787	by an institutional or community pharmacy, prior authorization
788	for an exception to the brand-name-drug restriction is sought by
789	the prescriber and not by the pharmacy. When prior authorization
790	is granted for a patient in an institutional setting beyond the
791	brand-name-drug restriction, such approval is authorized for 12
792	months and monthly prior authorization is not required for that
793	patient.
794	2.  Reimbursement to pharmacies for Medicaid prescribed
795	drugs shall be set at the lesser of:
796	a.  The average wholesale price (AWP) minus 15.4 percent,
797	the wholesaler acquisition cost (WAC) plus 5.75 percent, the
798	federal upper limit (FUL), the state maximum allowable cost
799	(SMAC), or the usual and customary (UAC) charge billed by the
800	provider for pharmacies with less than $75,000 in average
801	aggregate monthly payments.
802	b.  The average wholesale price (AWP) minus 17 percent,
803	wholesaler acquisition cost (WAC) plus 3.5 percent, the federal
804	upper limit (FUL), the state maximum allowable cost (SMAC), or
805	the usual and customary (UAC) charge billed by the provider for
806	pharmacies with $75,000 or more in average aggregate monthly
807	payments.
808	3.  The agency shall develop and implement a process for
809	managing the drug therapies of Medicaid recipients who are using
810	significant numbers of prescribed drugs each month. The
811	management process may include, but is not limited to,
812	comprehensive, physician-directed medical-record reviews, claims
813	analyses, and case evaluations to determine the medical
814	necessity and appropriateness of a patient's treatment plan and
815	drug therapies. The agency may contract with a private
816	organization to provide drug-program-management services. The
817	Medicaid drug benefit management program shall include
818	initiatives to manage drug therapies for HIV/AIDS patients,
819	patients using 20 or more unique prescriptions in a 180-day
820	period, and the top 1,000 patients in annual spending. The
821	agency shall enroll any Medicaid recipient in the drug benefit
822	management program if he or she meets the specifications of this
823	provision and is not enrolled in a Medicaid health maintenance
824	organization.
825	4.  The agency may limit the size of its pharmacy network
826	based on need, competitive bidding, price negotiations,
827	credentialing, or similar criteria. The agency shall give
828	special consideration to rural areas in determining the size and
829	location of pharmacies included in the Medicaid pharmacy
830	network. A pharmacy credentialing process may include criteria
831	such as a pharmacy's full-service status, location, size,
832	patient educational programs, patient consultation, disease-
833	management services, and other characteristics. The agency may
834	impose a moratorium on Medicaid pharmacy enrollment when it is
835	determined that it has a sufficient number of Medicaid-
836	participating providers.
837	5.  The agency shall develop and implement a program that
838	requires Medicaid practitioners who prescribe drugs to use a
839	counterfeit-proof prescription pad for Medicaid prescriptions.
840	The agency shall require the use of standardized counterfeit-
841	proof prescription pads by Medicaid-participating prescribers or
842	prescribers who write prescriptions for Medicaid recipients. The
843	agency may implement the program in targeted geographic areas or
844	statewide.
845	6.  The agency may enter into arrangements that require
846	manufacturers of generic drugs prescribed to Medicaid recipients
847	to provide rebates of at least 15.1 percent of the average
848	manufacturer price for the manufacturer's generic products.
849	These arrangements shall require that if a generic-drug
850	manufacturer pays federal rebates for Medicaid-reimbursed drugs
851	at a level below 15.1 percent, the manufacturer must provide a
852	supplemental rebate to the state in an amount necessary to
853	achieve a 15.1-percent rebate level.
854	7.  The agency may establish a preferred drug formulary in
855	accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
856	establishment of such formulary, it is authorized to negotiate
857	supplemental rebates from manufacturers that are in addition to
858	those required by Title XIX of the Social Security Act and at no
859	less than 14 percent of the average manufacturer price as
860	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
861	the federal or supplemental rebate, or both, equals or exceeds
862	29 percent. There is no upper limit on the supplemental rebates
863	the agency may negotiate. The agency may determine that specific
864	products, brand-name or generic, are competitive at lower rebate
865	percentages. Agreement to pay the minimum supplemental rebate
866	percentage will guarantee a manufacturer that the Medicaid
867	Pharmaceutical and Therapeutics Committee will consider a
868	product for inclusion on the preferred drug formulary. However,
869	a pharmaceutical manufacturer is not guaranteed placement on the
870	formulary by simply paying the minimum supplemental rebate.
871	Agency decisions will be made on the clinical efficacy of a drug
872	and recommendations of the Medicaid Pharmaceutical and
873	Therapeutics Committee, as well as the price of competing
874	products minus federal and state rebates. The agency is
875	authorized to contract with an outside agency or contractor to
876	conduct negotiations for supplemental rebates. For the purposes
877	of this section, the term "supplemental rebates" means cash
878	rebates. Effective July 1, 2004, value-added programs as a
879	substitution for supplemental rebates are prohibited. The agency
880	is authorized to seek any federal waivers to implement this
881	initiative.
882	8.  The agency shall establish an advisory committee for
883	the purposes of studying the feasibility of using a restricted
884	drug formulary for nursing home residents and other
885	institutionalized adults. The committee shall be comprised of
886	seven members appointed by the Secretary of Health Care
887	Administration. The committee members shall include two
888	physicians licensed under chapter 458 or chapter 459; three
889	pharmacists licensed under chapter 465 and appointed from a list
890	of recommendations provided by the Florida Long-Term Care
891	Pharmacy Alliance; and two pharmacists licensed under chapter
892	465.
893	9.  The Agency for Health Care Administration shall expand
894	home delivery of pharmacy products. To assist Medicaid patients
895	in securing their prescriptions and reduce program costs, the
896	agency shall expand its current mail-order-pharmacy diabetes-
897	supply program to include all generic and brand-name drugs used
898	by Medicaid patients with diabetes. Medicaid recipients in the
899	current program may obtain nondiabetes drugs on a voluntary
900	basis. This initiative is limited to the geographic area covered
901	by the current contract. The agency may seek and implement any
902	federal waivers necessary to implement this subparagraph.
903	10.  The agency shall limit to one dose per month any drug
904	prescribed to treat erectile dysfunction.
905	11.a.  The agency shall implement a Medicaid behavioral
906	drug management system. The agency may contract with a vendor
907	that has experience in operating behavioral drug management
908	systems to implement this program. The agency is authorized to
909	seek federal waivers to implement this program.
910	b.  The agency, in conjunction with the Department of
911	Children and Family Services, may implement the Medicaid
912	behavioral drug management system that is designed to improve
913	the quality of care and behavioral health prescribing practices
914	based on best practice guidelines, improve patient adherence to
915	medication plans, reduce clinical risk, and lower prescribed
916	drug costs and the rate of inappropriate spending on Medicaid
917	behavioral drugs. The program shall include the following
918	elements:
919	(I)  Provide for the development and adoption of best
920	practice guidelines for behavioral health-related drugs such as
921	antipsychotics, antidepressants, and medications for treating
922	bipolar disorders and other behavioral conditions; translate
923	them into practice; review behavioral health prescribers and
924	compare their prescribing patterns to a number of indicators
925	that are based on national standards; and determine deviations
926	from best practice guidelines.
927	(II)  Implement processes for providing feedback to and
928	educating prescribers using best practice educational materials
929	and peer-to-peer consultation.
930	(III)  Assess Medicaid beneficiaries who are outliers in
931	their use of behavioral health drugs with regard to the numbers
932	and types of drugs taken, drug dosages, combination drug
933	therapies, and other indicators of improper use of behavioral
934	health drugs.
935	(IV)  Alert prescribers to patients who fail to refill
936	prescriptions in a timely fashion, are prescribed multiple same-
937	class behavioral health drugs, and may have other potential
938	medication problems.
939	(V)  Track spending trends for behavioral health drugs and
940	deviation from best practice guidelines.
941	(VI)  Use educational and technological approaches to
942	promote best practices, educate consumers, and train prescribers
943	in the use of practice guidelines.
944	(VII)  Disseminate electronic and published materials.
945	(VIII)  Hold statewide and regional conferences.
946	(IX)  Implement a disease management program with a model
947	quality-based medication component for severely mentally ill
948	individuals and emotionally disturbed children who are high
949	users of care.
950	c.  If the agency is unable to negotiate a contract with
951	one or more manufacturers to finance and guarantee savings
952	associated with a behavioral drug management program by
953	September 1, 2004, the four-brand drug limit and preferred drug
954	list prior-authorization requirements shall apply to mental
955	health-related drugs, notwithstanding any provision in
956	subparagraph 1. The agency is authorized to seek federal waivers
957	to implement this policy.
958	12.  The agency is authorized to contract for drug rebate
959	administration, including, but not limited to, calculating
960	rebate amounts, invoicing manufacturers, negotiating disputes
961	with manufacturers, and maintaining a database of rebate
962	collections.
963	13.  The agency may specify the preferred daily dosing form
964	or strength for the purpose of promoting best practices with
965	regard to the prescribing of certain drugs as specified in the
966	General Appropriations Act and ensuring cost-effective
967	prescribing practices.
968	14.  The agency may require prior authorization for the
969	off-label use of Medicaid-covered prescribed drugs as specified
970	in the General Appropriations Act. The agency may, but is not
971	required to, preauthorize the use of a product for an indication
972	not in the approved labeling. Prior authorization may require
973	the prescribing professional to provide information about the
974	rationale and supporting medical evidence for the off-label use
975	of a drug.
976	15.  The agency shall implement a return and reuse program
977	for drugs dispensed by pharmacies to institutional recipients,
978	which includes payment of a $5 restocking fee for the
979	implementation and operation of the program. The return and
980	reuse program shall be implemented electronically and in a
981	manner that promotes efficiency. The program must permit a
982	pharmacy to exclude drugs from the program if it is not
983	practical or cost-effective for the drug to be included and must
984	provide for the return to inventory of drugs that cannot be
985	credited or returned in a cost-effective manner.
986	(50)  The agency may implement a program of all-inclusive
987	care for children to reduce the need for hospitalization of
988	children, as appropriate. The purpose of the program is to
989	provide in-home hospice-like support services to children
990	diagnosed with a life-threatening illness who are enrolled in
991	the Children's Medical Services Network. The agency, in
992	consultation with the Department of Health, may implement the
993	program of all-inclusive care for children after obtaining
994	approval from the Centers for Medicare and Medicaid Services.
995	Section 8.  Paragraph (k) of subsection (2) of section
996	409.9122, Florida Statutes, is amended to read:
997	409.9122  Mandatory Medicaid managed care enrollment;
998	programs and procedures.--
999	(2)
1000	(k)  When a Medicaid recipient does not choose a managed
1001	care plan or MediPass provider, the agency shall assign the
1002	Medicaid recipient to a managed care plan, except in those
1003	counties in which there are fewer than two managed care plans
1004	accepting Medicaid enrollees, in which case assignment shall be
1005	to a managed care plan or a MediPass provider. Medicaid
1006	recipients in counties with fewer than two managed care plans
1007	accepting Medicaid enrollees who are subject to mandatory
1008	assignment but who fail to make a choice shall be assigned to
1009	managed care plans until an enrollment of 40 percent in MediPass
1010	and 60 percent in managed care plans is achieved. Once that
1011	enrollment is achieved, the assignments shall be divided in
1012	order to maintain an enrollment in MediPass and managed care
1013	plans which is in a 40 percent and 60 percent proportion,
1014	respectively. In geographic areas where the agency is
1015	contracting for the provision of comprehensive behavioral health
1016	services through a capitated prepaid arrangement, recipients who
1017	fail to make a choice shall be assigned equally to MediPass or a
1018	managed care plan. For purposes of this paragraph, when
1019	referring to assignment, the term "managed care plans" includes
1020	exclusive provider organizations, provider service networks,
1021	Children's Medical Services Network, minority physician
1022	networks, and pediatric emergency department diversion programs
1023	authorized by this chapter or the General Appropriations Act.
1024	When making assignments, the agency shall take into account the
1025	following criteria:
1026	1.  A managed care plan has sufficient network capacity to
1027	meet the need of members.
1028	2.  The managed care plan or MediPass has previously
1029	enrolled the recipient as a member, or one of the managed care
1030	plan's primary care providers or MediPass providers has
1031	previously provided health care to the recipient.
1032	3.  The agency has knowledge that the member has previously
1033	expressed a preference for a particular managed care plan or
1034	MediPass provider as indicated by Medicaid fee-for-service
1035	claims data, but has failed to make a choice.
1036	4.  The managed care plan's or MediPass primary care
1037	providers are geographically accessible to the recipient's
1038	residence.
1039	5.  The agency has authority to make mandatory assignments
1040	based on quality of service and performance of managed care
1041	plans.
1042	Section 9.  Subsections (6) and (7) are added to section
1043	409.9124, Florida Statutes, to read:
1044	409.9124  Managed care reimbursement.--
1045	(6)  The agency shall develop rates for children age 0-3
1046	months and separate rates for children age 4-12 months. The
1047	agency shall amend the payment methodology for participating
1048	Medicaid-managed health care plans to comply with this
1049	subsection.
1050	(7)  The agency shall not pay rates at per-member per-month
1051	averages higher than that allowed for in the General
1052	Appropriations Act.
1053	Section 10.  Except as otherwise provided herein, this act
1054	shall take effect July 1, 2005.

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