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	409.814, F.S.; granting more children access to the
5	Florida KidCare program; amending s. 409.903, F.S.;
6	deleting a provision eliminating eligibility for Medicaid
7	services for certain women; amending s. 409.904, F.S.;
8	providing for the Agency for Health Care Administration to
9	pay for medical assistance for certain Medicaid-eligible
10	persons; deleting a limitation on eligibility for coverage
11	under the medically needy program; amending s. 409.906,
12	F.S.; deleting a repeal of a provision that provides adult
13	denture services; repealing s. 409.9065, F.S., relating to
14	pharmaceutical expense assistance; amending s. 409.908,
15	F.S.; revising provisions relating to the long-term care
16	reimbursement and cost reporting system; revising
17	provisions relating to the Medicaid maximum allowable fee
18	for certain pharmacies; amending s. 409.912, F.S.;
19	revising components of the Medicaid prescribed-drug
20	spending-control program; authorizing the agency to
21	implement a program of all-inclusive care for certain
22	children; requiring a plan for comprehensive vision care
23	services; amending s. 409.9122, F.S.; deleting assignment
24	requirement for recipients in areas with capitated
25	behavioral health services; amending s. 409.9124, F.S.;
26	requiring the agency to develop managed care rates for
27	children of specified ages and to amend the methodology
28	for reimbursing managed care plans to comply therewith;
29	limiting the amount of reimbursement; providing effective
30	dates.
31
32	Be It Enacted by the Legislature of the State of Florida:
33
34	Section 1.  Paragraph (a) of subsection (3) of section
35	400.23, Florida Statutes, is amended to read:
36	400.23  Rules; evaluation and deficiencies; licensure
37	status.--
38	(3)(a)  The agency shall adopt rules providing for the
39	minimum staffing requirements for nursing homes. These
40	requirements shall include, for each nursing home facility, a
41	minimum certified nursing assistant staffing of 2.3 hours of
42	direct care per resident per day beginning January 1, 2002,
43	increasing to 2.6 hours of direct care per resident per day
44	beginning January 1, 2003, and increasing to 2.9 hours of direct
45	care per resident per day beginning July 1, 2006 2005. Beginning
46	January 1, 2002, no facility shall staff below one certified
47	nursing assistant per 20 residents, and a minimum licensed
48	nursing staffing of 1.0 hour of direct resident care per
49	resident per day but never below one licensed nurse per 40
50	residents. Nursing assistants employed under s. 400.211(2) may
51	be included in computing the staffing ratio for certified
52	nursing assistants only if they provide nursing assistance
53	services to residents on a full-time basis. Each nursing home
54	must document compliance with staffing standards as required
55	under this paragraph and post daily the names of staff on duty
56	for the benefit of facility residents and the public. The agency
57	shall recognize the use of licensed nurses for compliance with
58	minimum staffing requirements for certified nursing assistants,
59	provided that the facility otherwise meets the minimum staffing
60	requirements for licensed nurses and that the licensed nurses so
61	recognized are performing the duties of a certified nursing
62	assistant. Unless otherwise approved by the agency, licensed
63	nurses counted toward the minimum staffing requirements for
64	certified nursing assistants must exclusively perform the duties
65	of a certified nursing assistant for the entire shift and shall
66	not also be counted toward the minimum staffing requirements for
67	licensed nurses. If the agency approved a facility's request to
68	use a licensed nurse to perform both licensed nursing and
69	certified nursing assistant duties, the facility must allocate
70	the amount of staff time specifically spent on certified nursing
71	assistant duties for the purpose of documenting compliance with
72	minimum staffing requirements for certified and licensed nursing
73	staff. In no event may the hours of a licensed nurse with dual
74	job responsibilities be counted twice.
75	Section 2.  Subsections (2) and (5) of section 409.814,
76	Florida Statutes, are amended to read:
77	409.814  Eligibility.--A child who has not reached 19 years
78	of age whose family income is equal to or below 200 percent of
79	the federal poverty level is eligible for the Florida KidCare
80	program as provided in this section. For enrollment in the
81	Children's Medical Services Network, a complete application
82	includes the medical or behavioral health screening. If,
83	subsequently, an individual is determined to be ineligible for
84	coverage, he or she must immediately be disenrolled from the
85	respective Florida KidCare program component.
86	(2)  A child who is not eligible for Medicaid, but who is
87	eligible for the Florida KidCare program, may obtain health
88	benefits coverage under any of the other components listed in s.
89	409.813 if such coverage is approved and available in the county
90	in which the child resides. However, a child who is eligible for
91	Medikids, including those eligible under subsection (5), may
92	participate in the Florida Healthy Kids program only if the
93	child has a sibling participating in the Florida Healthy Kids
94	program and the child's county of residence permits such
95	enrollment.
96	(5)  A child whose family income is above 200 percent of
97	the federal poverty level or a child who is excluded under the
98	provisions of subsection (4) may apply for coverage and shall be
99	allowed to participate in the Florida KidCare program, excluding
100	the Medicaid program, but is subject to the following
101	provisions:
102	(a)  The family is not eligible for premium assistance
103	payments and must pay the full cost of the premium, including
104	any administrative costs.
105	(b)  The agency is authorized to place limits on enrollment
106	in Medikids by these children in order to avoid adverse
107	selection. The number of children participating in Medikids
108	whose family income exceeds 200 percent of the federal poverty
109	level must not exceed 10 percent of total enrollees in the
110	Medikids program.
111	(c)  The board of directors of the Florida Healthy Kids
112	Corporation is authorized to place limits on enrollment of these
113	children in order to avoid adverse selection. In addition, the
114	board is authorized to offer a reduced benefit package to these
115	children in order to limit program costs for such families. The
116	number of children participating in the Florida Healthy Kids
117	program whose family income exceeds 200 percent of the federal
118	poverty level must not exceed 10 percent of total enrollees in
119	the Florida Healthy Kids program.
120	(d)  Children described in this subsection are not counted
121	in the annual enrollment ceiling for the Florida KidCare
122	program.
123	Section 3.  Subsection (5) of section 409.903, Florida
124	Statutes, is amended to read:
125	409.903  Mandatory payments for eligible persons.--The
126	agency shall make payments for medical assistance and related
127	services on behalf of the following persons who the department,
128	or the Social Security Administration by contract with the
129	Department of Children and Family Services, determines to be
130	eligible, subject to the income, assets, and categorical
131	eligibility tests set forth in federal and state law. Payment on
132	behalf of these Medicaid eligible persons is subject to the
133	availability of moneys and any limitations established by the
134	General Appropriations Act or chapter 216.
135	(5)  A pregnant woman for the duration of her pregnancy and
136	for the postpartum period as defined in federal law and rule, or
137	a child under age 1, if either is living in a family that has an
138	income which is at or below 150 percent of the most current
139	federal poverty level, or, effective January 1, 1992, that has
140	an income which is at or below 185 percent of the most current
141	federal poverty level. Such a person is not subject to an assets
142	test. Further, a pregnant woman who applies for eligibility for
143	the Medicaid program through a qualified Medicaid provider must
144	be offered the opportunity, subject to federal rules, to be made
145	presumptively eligible for the Medicaid program. Effective July
146	1, 2005, eligibility for Medicaid services is eliminated for
147	women who have incomes above 150 percent of the most current
148	federal poverty level.
149	Section 4.  Subsections (1) and (2) of section 409.904,
150	Florida Statutes, are amended to read:
151	409.904  Optional payments for eligible persons.--The
152	agency may make payments for medical assistance and related
153	services on behalf of the following persons who are determined
154	to be eligible subject to the income, assets, and categorical
155	eligibility tests set forth in federal and state law. Payment on
156	behalf of these Medicaid eligible persons is subject to the
157	availability of moneys and any limitations established by the
158	General Appropriations Act or chapter 216.
159	(1)(a)  From July 1, 2005, through December 31, 2005,
160	inclusive, a person who is age 65 or older or is determined to
161	be disabled, whose income is at or below 88 percent of federal
162	poverty level, and whose assets do not exceed established
163	limitations.
164	(b)  Effective January 1, 2006, and subject to federal
165	waiver approval, a person who is age 65 or older or is
166	determined to be disabled, whose income is at or below 88
167	percent of the federal poverty level, whose assets do not exceed
168	established limitations, and who is not eligible for Medicare,
169	or, if eligible for Medicare, is also eligible for and receiving
170	Medicaid-covered institutional care or hospice or home-based and
171	community-based services. The agency shall seek federal
172	authorization through a waiver to provide this coverage.
173	(2)  A family, a pregnant woman, a child under age 21, a
174	person age 65 or over, or a blind or disabled person, who would
175	be eligible under any group listed in s. 409.903(1), (2), or
176	(3), except that the income or assets of such family or person
177	exceed established limitations. For a family or person in one of
178	these coverage groups, medical expenses are deductible from
179	income in accordance with federal requirements in order to make
180	a determination of eligibility. A family or person eligible
181	under the coverage known as the "medically needy," is eligible
182	to receive the same services as other Medicaid recipients, with
183	the exception of services in skilled nursing facilities and
184	intermediate care facilities for the developmentally disabled.
185	Effective July 1, 2005, the medically needy are eligible for
186	prescribed drug services only.
187	Section 5.  Paragraph (b) of subsection (1) of section
188	409.906, Florida Statutes, is amended to read:
189	409.906  Optional Medicaid services.--Subject to specific
190	appropriations, the agency may make payments for services which
191	are optional to the state under Title XIX of the Social Security
192	Act and are furnished by Medicaid providers to recipients who
193	are determined to be eligible on the dates on which the services
194	were provided. Any optional service that is provided shall be
195	provided only when medically necessary and in accordance with
196	state and federal law. Optional services rendered by providers
197	in mobile units to Medicaid recipients may be restricted or
198	prohibited by the agency. Nothing in this section shall be
199	construed to prevent or limit the agency from adjusting fees,
200	reimbursement rates, lengths of stay, number of visits, or
201	number of services, or making any other adjustments necessary to
202	comply with the availability of moneys and any limitations or
203	directions provided for in the General Appropriations Act or
204	chapter 216. If necessary to safeguard the state's systems of
205	providing services to elderly and disabled persons and subject
206	to the notice and review provisions of s. 216.177, the Governor
207	may direct the Agency for Health Care Administration to amend
208	the Medicaid state plan to delete the optional Medicaid service
209	known as "Intermediate Care Facilities for the Developmentally
210	Disabled." Optional services may include:
211	(1)  ADULT DENTAL SERVICES.--
212	(b)  Beginning January 1, 2005, The agency may pay for
213	dentures, the procedures required to seat dentures, and the
214	repair and reline of dentures, provided by or under the
215	direction of a licensed dentist, for a recipient who is 21 years
216	of age or older. This paragraph is repealed effective July 1,
217	2005.
218	Section 6.  Effective January 1, 2006, section 409.9065,
219	Florida Statutes, is repealed.
220	Section 7.  Paragraph (b) of subsection (2) and subsection
221	(14) of section 409.908, Florida Statutes, are amended to read:
222	409.908  Reimbursement of Medicaid providers.--Subject to
223	specific appropriations, the agency shall reimburse Medicaid
224	providers, in accordance with state and federal law, according
225	to methodologies set forth in the rules of the agency and in
226	policy manuals and handbooks incorporated by reference therein.
227	These methodologies may include fee schedules, reimbursement
228	methods based on cost reporting, negotiated fees, competitive
229	bidding pursuant to s. 287.057, and other mechanisms the agency
230	considers efficient and effective for purchasing services or
231	goods on behalf of recipients. If a provider is reimbursed based
232	on cost reporting and submits a cost report late and that cost
233	report would have been used to set a lower reimbursement rate
234	for a rate semester, then the provider's rate for that semester
235	shall be retroactively calculated using the new cost report, and
236	full payment at the recalculated rate shall be effected
237	retroactively. Medicare-granted extensions for filing cost
238	reports, if applicable, shall also apply to Medicaid cost
239	reports. Payment for Medicaid compensable services made on
240	behalf of Medicaid eligible persons is subject to the
241	availability of moneys and any limitations or directions
242	provided for in the General Appropriations Act or chapter 216.
243	Further, nothing in this section shall be construed to prevent
244	or limit the agency from adjusting fees, reimbursement rates,
245	lengths of stay, number of visits, or number of services, or
246	making any other adjustments necessary to comply with the
247	availability of moneys and any limitations or directions
248	provided for in the General Appropriations Act, provided the
249	adjustment is consistent with legislative intent.
250	(2)
251	(b)  Subject to any limitations or directions provided for
252	in the General Appropriations Act, the agency shall establish
253	and implement a Florida Title XIX Long-Term Care Reimbursement
254	Plan (Medicaid) for nursing home care in order to provide care
255	and services in conformance with the applicable state and
256	federal laws, rules, regulations, and quality and safety
257	standards and to ensure that individuals eligible for medical
258	assistance have reasonable geographic access to such care.
259	1.  Changes of ownership or of licensed operator do not
260	qualify for increases in reimbursement rates associated with the
261	change of ownership or of licensed operator. The agency shall
262	amend the Title XIX Long Term Care Reimbursement Plan to provide
263	that the initial nursing home reimbursement rates, for the
264	operating, patient care, and MAR components, associated with
265	related and unrelated party changes of ownership or licensed
266	operator filed on or after September 1, 2001, are equivalent to
267	the previous owner's reimbursement rate.
268	2.  The agency shall amend the long-term care reimbursement
269	plan and cost reporting system to create direct care and
270	indirect care subcomponents of the patient care component of the
271	per diem rate. These two subcomponents together shall equal the
272	patient care component of the per diem rate. Separate cost-based
273	ceilings shall be calculated for each patient care subcomponent.
274	The direct care and indirect care subcomponents subcomponent of
275	the per diem rate shall be limited by the cost-based class
276	ceiling, and the indirect care subcomponent shall be limited by
277	the lower of a the cost-based class ceiling, a by the target
278	rate class ceiling, or an by the individual provider target for
279	each subcomponent. The agency shall adjust the patient care
280	component effective January 1, 2002. The cost to adjust the
281	direct care subcomponent shall be the net of the total funds
282	previously allocated for the case mix add-on. The agency shall
283	make the required changes to the nursing home cost reporting
284	forms to implement this requirement effective January 1, 2002.
285	3.  The direct care subcomponent shall include salaries and
286	benefits of direct care staff providing nursing services
287	including registered nurses, licensed practical nurses, and
288	certified nursing assistants who deliver care directly to
289	residents in the nursing home facility. This excludes nursing
290	administration, MDS, and care plan coordinators, staff
291	development, and staffing coordinator.
292	4.  All other patient care costs shall be included in the
293	indirect care cost subcomponent of the patient care per diem
294	rate. There shall be no costs directly or indirectly allocated
295	to the direct care subcomponent from a home office or management
296	company.
297	5.  On July 1 of each year, the agency shall report to the
298	Legislature direct and indirect care costs, including average
299	direct and indirect care costs per resident per facility and
300	direct care and indirect care salaries and benefits per category
301	of staff member per facility.
302	6.  In order to offset the cost of general and professional
303	liability insurance, the agency shall amend the plan to allow
304	for interim rate adjustments to reflect increases in the cost of
305	general or professional liability insurance for nursing homes.
306	This provision shall be implemented to the extent existing
307	appropriations are available.
308
309	It is the intent of the Legislature that the reimbursement plan
310	achieve the goal of providing access to health care for nursing
311	home residents who require large amounts of care while
312	encouraging diversion services as an alternative to nursing home
313	care for residents who can be served within the community. The
314	agency shall base the establishment of any maximum rate of
315	payment, whether overall or component, on the available moneys
316	as provided for in the General Appropriations Act. The agency
317	may base the maximum rate of payment on the results of
318	scientifically valid analysis and conclusions derived from
319	objective statistical data pertinent to the particular maximum
320	rate of payment.
321	(14)  A provider of prescribed drugs shall be reimbursed
322	the least of the amount billed by the provider, the provider's
323	usual and customary charge, or the Medicaid maximum allowable
324	fee established by the agency, plus a dispensing fee.
325	(a)  For pharmacies with less than $75,000 in average
326	aggregate monthly payments, the Medicaid maximum allowable fee
327	for ingredient cost will be based on the lower of: average
328	wholesale price (AWP) minus 15.4 percent, wholesaler acquisition
329	cost (WAC) plus 5.75 percent, the federal upper limit (FUL), the
330	state maximum allowable cost (SMAC), or the usual and customary
331	(UAC) charge billed by the provider.
332	(b)  For pharmacies with $75,000 or more in average
333	aggregate monthly payments, the Medicaid maximum allowable fee
334	for ingredient cost will be based on the lower of: average
335	wholesale price (AWP) minus 17 percent, wholesaler acquisition
336	cost (WAC) plus 3.5 percent, the federal upper limit (FUL), the
337	state maximum allowable cost (SMAC), or the usual and customary
338	(UAC) charge billed by the provider.
339	(c)  Medicaid providers are required to dispense generic
340	drugs if available at lower cost and the agency has not
341	determined that the branded product is more cost-effective,
342	unless the prescriber has requested and received approval to
343	require the branded product. The agency is directed to implement
344	a variable dispensing fee for payments for prescribed medicines
345	while ensuring continued access for Medicaid recipients. The
346	variable dispensing fee may be based upon, but not limited to,
347	either or both the volume of prescriptions dispensed by a
348	specific pharmacy provider, the volume of prescriptions
349	dispensed to an individual recipient, and dispensing of
350	preferred-drug-list products. The agency may increase the
351	pharmacy dispensing fee authorized by statute and in the annual
352	General Appropriations Act by $0.50 for the dispensing of a
353	Medicaid preferred-drug-list product and reduce the pharmacy
354	dispensing fee by $0.50 for the dispensing of a Medicaid product
355	that is not included on the preferred drug list. The agency may
356	establish a supplemental pharmaceutical dispensing fee to be
357	paid to providers returning unused unit-dose packaged
358	medications to stock and crediting the Medicaid program for the
359	ingredient cost of those medications if the ingredient costs to
360	be credited exceed the value of the supplemental dispensing fee.
361	The agency is authorized to limit reimbursement for prescribed
362	medicine in order to comply with any limitations or directions
363	provided for in the General Appropriations Act, which may
364	include implementing a prospective or concurrent utilization
365	review program.
366	Section 8.  Paragraph (a) of subsection (39) of section
367	409.912, Florida Statutes, is amended, and subsections (50) and
368	(51) are added to said section, to read:
369	409.912  Cost-effective purchasing of health care.--The
370	agency shall purchase goods and services for Medicaid recipients
371	in the most cost-effective manner consistent with the delivery
372	of quality medical care. To ensure that medical services are
373	effectively utilized, the agency may, in any case, require a
374	confirmation or second physician's opinion of the correct
375	diagnosis for purposes of authorizing future services under the
376	Medicaid program. This section does not restrict access to
377	emergency services or poststabilization care services as defined
378	in 42 C.F.R. part 438.114. Such confirmation or second opinion
379	shall be rendered in a manner approved by the agency. The agency
380	shall maximize the use of prepaid per capita and prepaid
381	aggregate fixed-sum basis services when appropriate and other
382	alternative service delivery and reimbursement methodologies,
383	including competitive bidding pursuant to s. 287.057, designed
384	to facilitate the cost-effective purchase of a case-managed
385	continuum of care. The agency shall also require providers to
386	minimize the exposure of recipients to the need for acute
387	inpatient, custodial, and other institutional care and the
388	inappropriate or unnecessary use of high-cost services. The
389	agency may mandate prior authorization, drug therapy management,
390	or disease management participation for certain populations of
391	Medicaid beneficiaries, certain drug classes, or particular
392	drugs to prevent fraud, abuse, overuse, and possible dangerous
393	drug interactions. The Pharmaceutical and Therapeutics Committee
394	shall make recommendations to the agency on drugs for which
395	prior authorization is required. The agency shall inform the
396	Pharmaceutical and Therapeutics Committee of its decisions
397	regarding drugs subject to prior authorization. The agency is
398	authorized to limit the entities it contracts with or enrolls as
399	Medicaid providers by developing a provider network through
400	provider credentialing. The agency may limit its network based
401	on the assessment of beneficiary access to care, provider
402	availability, provider quality standards, time and distance
403	standards for access to care, the cultural competence of the
404	provider network, demographic characteristics of Medicaid
405	beneficiaries, practice and provider-to-beneficiary standards,
406	appointment wait times, beneficiary use of services, provider
407	turnover, provider profiling, provider licensure history,
408	previous program integrity investigations and findings, peer
409	review, provider Medicaid policy and billing compliance records,
410	clinical and medical record audits, and other factors. Providers
411	shall not be entitled to enrollment in the Medicaid provider
412	network. The agency is authorized to seek federal waivers
413	necessary to implement this policy.
414	(39)(a)  The agency shall implement a Medicaid prescribed-
415	drug spending-control program that includes the following
416	components:
417	1.  Medicaid prescribed-drug coverage for brand-name drugs
418	for adult Medicaid recipients is limited to the dispensing of
419	three four brand-name drugs and three generic drugs per month
420	per recipient. Children are exempt from this restriction.
421	Antiretroviral agents are excluded from this limitation. No
422	requirements for prior authorization or other restrictions on
423	medications used to treat mental illnesses such as
424	schizophrenia, severe depression, or bipolar disorder may be
425	imposed on Medicaid recipients. Medications that will be
426	available without restriction for persons with mental illnesses
427	include atypical antipsychotic medications, conventional
428	antipsychotic medications, selective serotonin reuptake
429	inhibitors, and other medications used for the treatment of
430	serious mental illnesses. The agency shall also limit the amount
431	of a prescribed drug dispensed to no more than a 34-day supply.
432	The agency shall continue to provide unlimited generic drugs,
433	contraceptive drugs and items, and diabetic supplies. Although a
434	drug may be included on the preferred drug formulary, it would
435	not be exempt from the three-brand four-brand limit or the
436	generic drug limit. The agency may authorize exceptions to the
437	brand-name-drug restriction based upon the treatment needs of
438	the patients, only when such exceptions are based on prior
439	consultation provided by the agency or an agency contractor, but
440	the agency must establish procedures to ensure that:
441	a.  There will be a response to a request for prior
442	consultation by telephone or other telecommunication device
443	within 24 hours after receipt of a request for prior
444	consultation;
445	b.  A 72-hour supply of the drug prescribed will be
446	provided in an emergency or when the agency does not provide a
447	response within 24 hours as required by sub-subparagraph a.; and
448	c.  Except for the exception for nursing home residents and
449	other institutionalized adults and except for drugs on the
450	restricted formulary for which prior authorization may be sought
451	by an institutional or community pharmacy, prior authorization
452	for an exception to the brand-name-drug restriction is sought by
453	the prescriber and not by the pharmacy. When prior authorization
454	is granted for a patient in an institutional setting beyond the
455	brand-name-drug restriction, such approval is authorized for 12
456	months and monthly prior authorization is not required for that
457	patient.
458	2.  Reimbursement to pharmacies for Medicaid prescribed
459	drugs shall be set at the lesser of:
460	a.  The average wholesale price (AWP) minus 15.4 percent,
461	the wholesaler acquisition cost (WAC) plus 5.75 percent, the
462	federal upper limit (FUL), the state maximum allowable cost
463	(SMAC), or the usual and customary (UAC) charge billed by the
464	provider for pharmacies with less than $75,000 in average
465	aggregate monthly payments.
466	b.  The average wholesale price (AWP) minus 17 percent,
467	wholesaler acquisition cost (WAC) plus 3.5 percent, the federal
468	upper limit (FUL), the state maximum allowable cost (SMAC), or
469	the usual and customary (UAC) charge billed by the provider for
470	pharmacies with $75,000 or more in average aggregate monthly
471	payments.
472	3.  The agency shall develop and implement a process for
473	managing the drug therapies of Medicaid recipients who are using
474	significant numbers of prescribed drugs each month. The
475	management process may include, but is not limited to,
476	comprehensive, physician-directed medical-record reviews, claims
477	analyses, and case evaluations to determine the medical
478	necessity and appropriateness of a patient's treatment plan and
479	drug therapies. The agency may contract with a private
480	organization to provide drug-program-management services. The
481	Medicaid drug benefit management program shall include
482	initiatives to manage drug therapies for HIV/AIDS patients,
483	patients using 20 or more unique prescriptions in a 180-day
484	period, and the top 1,000 patients in annual spending. The
485	agency shall enroll any Medicaid recipient in the drug benefit
486	management program if he or she meets the specifications of this
487	provision and is not enrolled in a Medicaid health maintenance
488	organization.
489	4.  The agency may limit the size of its pharmacy network
490	based on need, competitive bidding, price negotiations,
491	credentialing, or similar criteria. The agency shall give
492	special consideration to rural areas in determining the size and
493	location of pharmacies included in the Medicaid pharmacy
494	network. A pharmacy credentialing process may include criteria
495	such as a pharmacy's full-service status, location, size,
496	patient educational programs, patient consultation, disease-
497	management services, and other characteristics. The agency may
498	impose a moratorium on Medicaid pharmacy enrollment when it is
499	determined that it has a sufficient number of Medicaid-
500	participating providers.
501	5.  The agency shall develop and implement a program that
502	requires Medicaid practitioners who prescribe drugs to use a
503	counterfeit-proof prescription pad for Medicaid prescriptions.
504	The agency shall require the use of standardized counterfeit-
505	proof prescription pads by Medicaid-participating prescribers or
506	prescribers who write prescriptions for Medicaid recipients. The
507	agency may implement the program in targeted geographic areas or
508	statewide.
509	6.  The agency may enter into arrangements that require
510	manufacturers of generic drugs prescribed to Medicaid recipients
511	to provide rebates of at least 15.1 percent of the average
512	manufacturer price for the manufacturer's generic products.
513	These arrangements shall require that if a generic-drug
514	manufacturer pays federal rebates for Medicaid-reimbursed drugs
515	at a level below 15.1 percent, the manufacturer must provide a
516	supplemental rebate to the state in an amount necessary to
517	achieve a 15.1-percent rebate level.
518	7.  The agency may establish a preferred drug formulary in
519	accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
520	establishment of such formulary, it is authorized to negotiate
521	supplemental rebates from manufacturers that are in addition to
522	those required by Title XIX of the Social Security Act and at no
523	less than 14 percent of the average manufacturer price as
524	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
525	the federal or supplemental rebate, or both, equals or exceeds
526	29 percent. There is no upper limit on the supplemental rebates
527	the agency may negotiate. The agency may determine that specific
528	products, brand-name or generic, are competitive at lower rebate
529	percentages. Agreement to pay the minimum supplemental rebate
530	percentage will guarantee a manufacturer that the Medicaid
531	Pharmaceutical and Therapeutics Committee will consider a
532	product for inclusion on the preferred drug formulary. However,
533	a pharmaceutical manufacturer is not guaranteed placement on the
534	formulary by simply paying the minimum supplemental rebate.
535	Agency decisions will be made on the clinical efficacy of a drug
536	and recommendations of the Medicaid Pharmaceutical and
537	Therapeutics Committee, as well as the price of competing
538	products minus federal and state rebates. The agency is
539	authorized to contract with an outside agency or contractor to
540	conduct negotiations for supplemental rebates. For the purposes
541	of this section, the term "supplemental rebates" means cash
542	rebates. Effective July 1, 2004, value-added programs as a
543	substitution for supplemental rebates are prohibited. The agency
544	is authorized to seek any federal waivers to implement this
545	initiative.
546	8.  The agency shall establish an advisory committee for
547	the purposes of studying the feasibility of using a restricted
548	drug formulary for nursing home residents and other
549	institutionalized adults. The committee shall be comprised of
550	seven members appointed by the Secretary of Health Care
551	Administration. The committee members shall include two
552	physicians licensed under chapter 458 or chapter 459; three
553	pharmacists licensed under chapter 465 and appointed from a list
554	of recommendations provided by the Florida Long-Term Care
555	Pharmacy Alliance; and two pharmacists licensed under chapter
556	465.
557	9.  The Agency for Health Care Administration shall expand
558	home delivery of pharmacy products. To assist Medicaid patients
559	in securing their prescriptions and reduce program costs, the
560	agency shall expand its current mail-order-pharmacy diabetes-
561	supply program to include all generic and brand-name drugs used
562	by Medicaid patients with diabetes. Medicaid recipients in the
563	current program may obtain nondiabetes drugs on a voluntary
564	basis. This initiative is limited to the geographic area covered
565	by the current contract. The agency may seek and implement any
566	federal waivers necessary to implement this subparagraph.
567	10.  The agency shall limit to one dose per month any drug
568	prescribed to treat erectile dysfunction.
569	11.a.  The agency shall implement a Medicaid behavioral
570	drug management system. The agency may contract with a vendor
571	that has experience in operating behavioral drug management
572	systems to implement this program. The agency is authorized to
573	seek federal waivers to implement this program.
574	b.  The agency, in conjunction with the Department of
575	Children and Family Services, may implement the Medicaid
576	behavioral drug management system that is designed to improve
577	the quality of care and behavioral health prescribing practices
578	based on best practice guidelines, improve patient adherence to
579	medication plans, reduce clinical risk, and lower prescribed
580	drug costs and the rate of inappropriate spending on Medicaid
581	behavioral drugs. The program shall include the following
582	elements:
583	(I)  Provide for the development and adoption of best
584	practice guidelines for behavioral health-related drugs such as
585	antipsychotics, antidepressants, and medications for treating
586	bipolar disorders and other behavioral conditions; translate
587	them into practice; review behavioral health prescribers and
588	compare their prescribing patterns to a number of indicators
589	that are based on national standards; and determine deviations
590	from best practice guidelines.
591	(II)  Implement processes for providing feedback to and
592	educating prescribers using best practice educational materials
593	and peer-to-peer consultation.
594	(III)  Assess Medicaid beneficiaries who are outliers in
595	their use of behavioral health drugs with regard to the numbers
596	and types of drugs taken, drug dosages, combination drug
597	therapies, and other indicators of improper use of behavioral
598	health drugs.
599	(IV)  Alert prescribers to patients who fail to refill
600	prescriptions in a timely fashion, are prescribed multiple same-
601	class behavioral health drugs, and may have other potential
602	medication problems.
603	(V)  Track spending trends for behavioral health drugs and
604	deviation from best practice guidelines.
605	(VI)  Use educational and technological approaches to
606	promote best practices, educate consumers, and train prescribers
607	in the use of practice guidelines.
608	(VII)  Disseminate electronic and published materials.
609	(VIII)  Hold statewide and regional conferences.
610	(IX)  Implement a disease management program with a model
611	quality-based medication component for severely mentally ill
612	individuals and emotionally disturbed children who are high
613	users of care.
614	c.  If the agency is unable to negotiate a contract with
615	one or more manufacturers to finance and guarantee savings
616	associated with a behavioral drug management program by
617	September 1, 2004, the four-brand drug limit and preferred drug
618	list prior-authorization requirements shall apply to mental
619	health-related drugs, notwithstanding any provision in
620	subparagraph 1. The agency is authorized to seek federal waivers
621	to implement this policy.
622	12.  The agency is authorized to contract for drug rebate
623	administration, including, but not limited to, calculating
624	rebate amounts, invoicing manufacturers, negotiating disputes
625	with manufacturers, and maintaining a database of rebate
626	collections.
627	13.  The agency may specify the preferred daily dosing form
628	or strength for the purpose of promoting best practices with
629	regard to the prescribing of certain drugs as specified in the
630	General Appropriations Act and ensuring cost-effective
631	prescribing practices.
632	14.  The agency may require prior authorization for the
633	off-label use of Medicaid-covered prescribed drugs as specified
634	in the General Appropriations Act. The agency may, but is not
635	required to, preauthorize the use of a product for an indication
636	not in the approved labeling. Prior authorization may require
637	the prescribing professional to provide information about the
638	rationale and supporting medical evidence for the off-label use
639	of a drug.
640	15.  The agency shall implement a return and reuse program
641	for drugs dispensed by pharmacies to institutional recipients,
642	which includes payment of a $5 restocking fee for the
643	implementation and operation of the program. The return and
644	reuse program shall be implemented electronically and in a
645	manner that promotes efficiency. The program must permit a
646	pharmacy to exclude drugs from the program if it is not
647	practical or cost-effective for the drug to be included and must
648	provide for the return to inventory of drugs that cannot be
649	credited or returned in a cost-effective manner.
650	(50)  The agency may implement a program of all-inclusive
651	care for children to reduce the need for hospitalization of
652	children, as appropriate. The purpose of the program is to
653	provide in-home hospice-like support services to children
654	diagnosed with a life-threatening illness who are enrolled in
655	the Children's Medical Services Network. The agency, in
656	consultation with the Department of Health, may implement the
657	program of all-inclusive care for children after obtaining
658	approval from the Centers for Medicare and Medicaid Services.
659	(51)  By July 1, 2005, the agency shall develop a plan for
660	implementing the delivery of comprehensive vision care services
661	to Medicaid recipients through a capitated prepaid arrangement.
662	The plan shall include contracting with a private entity or
663	entities to provide for the comprehensive vision care services
664	through a capitated prepaid arrangement. However, the entity
665	must:
666	(a)  Be licensed under chapter 627.
667	(b)  Have sufficient financial resources.
668	(c)  Have a contracted provider network that has statewide
669	coverage.
670	(d)  Have experience in providing medical and surgical
671	vision care services.
672	(e)  Have experience with the implementation of large
673	statewide contracts. As used in this section, the term "vision
674	care services" means covered vision services, including routine,
675	medical, and surgical vision care services that are available to
676	Medicaid recipients. If necessary, the agency shall seek federal
677	approval to contract with a single entity meeting these
678	requirements to provide vision care services to all Medicaid
679	recipients. The entity must offer sufficient choice of providers
680	within its network to ensure access to care for the recipient
681	and the opportunity to select a provider with whom the recipient
682	is satisfied.
683	Section 9.  Paragraph (k) of subsection (2) of section
684	409.9122, Florida Statutes, is amended to read:
685	409.9122  Mandatory Medicaid managed care enrollment;
686	programs and procedures.--
687	(2)
688	(k)  When a Medicaid recipient does not choose a managed
689	care plan or MediPass provider, the agency shall assign the
690	Medicaid recipient to a managed care plan, except in those
691	counties in which there are fewer than two managed care plans
692	accepting Medicaid enrollees, in which case assignment shall be
693	to a managed care plan or a MediPass provider. Medicaid
694	recipients in counties with fewer than two managed care plans
695	accepting Medicaid enrollees who are subject to mandatory
696	assignment but who fail to make a choice shall be assigned to
697	managed care plans until an enrollment of 40 percent in MediPass
698	and 60 percent in managed care plans is achieved. Once that
699	enrollment is achieved, the assignments shall be divided in
700	order to maintain an enrollment in MediPass and managed care
701	plans which is in a 40 percent and 60 percent proportion,
702	respectively. In geographic areas where the agency is
703	contracting for the provision of comprehensive behavioral health
704	services through a capitated prepaid arrangement, recipients who
705	fail to make a choice shall be assigned equally to MediPass or a
706	managed care plan. For purposes of this paragraph, when
707	referring to assignment, the term "managed care plans" includes
708	exclusive provider organizations, provider service networks,
709	Children's Medical Services Network, minority physician
710	networks, and pediatric emergency department diversion programs
711	authorized by this chapter or the General Appropriations Act.
712	When making assignments, the agency shall take into account the
713	following criteria:
714	1.  A managed care plan has sufficient network capacity to
715	meet the need of members.
716	2.  The managed care plan or MediPass has previously
717	enrolled the recipient as a member, or one of the managed care
718	plan's primary care providers or MediPass providers has
719	previously provided health care to the recipient.
720	3.  The agency has knowledge that the member has previously
721	expressed a preference for a particular managed care plan or
722	MediPass provider as indicated by Medicaid fee-for-service
723	claims data, but has failed to make a choice.
724	4.  The managed care plan's or MediPass primary care
725	providers are geographically accessible to the recipient's
726	residence.
727	5.  The agency has authority to make mandatory assignments
728	based on quality of service and performance of managed care
729	plans.
730	Section 10.  Subsections (6) and (7) are added to section
731	409.9124, Florida Statutes, to read:
732	409.9124  Managed care reimbursement.--
733	(6)  The agency shall develop rates for children age 0-3
734	months and separate rates for children age 4-12 months. The
735	agency shall amend the payment methodology for participating
736	Medicaid-managed health care plans to comply with this
737	subsection.
738	(7)  The agency shall not pay rates at per-member per-month
739	averages higher than that allowed for in the General
740	Appropriations Act.
741	Section 11.  Except as otherwise provided herein, this act
742	shall take effect July 1, 2005.

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