Amendment
Bill No. 0404

Amendment No. 708635

CHAMBER ACTION
Senate		House
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1	Representative(s) Sobel, Seiler, Gelber, Vana, and Cusack
2	offered the following:
3
4	Amendment to Senate Amendment (871600) (with directory and
5	title amendments)
6	On page 8, line(s) 23, through page 76, line 10,
7	remove:  all of said lines
8
9	and insert:
10	Section 8.  Paragraphs (a) and (b) of subsection (2) and
11	paragraph (b) of subsection (4) of section 409.911, Florida
12	Statutes, are amended to read:
13	409.911  Disproportionate share program.--Subject to
14	specific allocations established within the General
15	Appropriations Act and any limitations established pursuant to
16	chapter 216, the agency shall distribute, pursuant to this
17	section, moneys to hospitals providing a disproportionate share
18	of Medicaid or charity care services by making quarterly
19	Medicaid payments as required. Notwithstanding the provisions of
20	s. 409.915, counties are exempt from contributing toward the
21	cost of this special reimbursement for hospitals serving a
22	disproportionate share of low-income patients.
23	(2)  The Agency for Health Care Administration shall use
24	the following actual audited data to determine the Medicaid days
25	and charity care to be used in calculating the disproportionate
26	share payment:
27	(a)  The average of the 1998, 1999, and 2000 audited
28	disproportionate share data to determine each hospital's
29	Medicaid days and charity care for the 2004-2005 state fiscal
30	year and the average of the 1999, 2000, and 2001 audited
31	disproportionate share data to determine the Medicaid days and
32	charity care for the 2005-2006 state fiscal year.
33	(b)  If the Agency for Health Care Administration does not
34	have the prescribed 3 years of audited disproportionate share
35	data as noted in paragraph (a) for a hospital, the agency shall
36	use the average of the years of the audited disproportionate
37	share data as noted in paragraph (a) which is available. The
38	average of the audited disproportionate share data for the years
39	available if the Agency for Health Care Administration does not
40	have the prescribed 3 years of audited disproportionate share
41	data for a hospital.
42	(4)  The following formulas shall be used to pay
43	disproportionate share dollars to public hospitals:
44	(b)  For non-state government owned or operated hospitals
45	with 3,300 or more Medicaid days:
46	DSHP = [(.82 x HCCD/TCCD) + (.18 x HMD/TMD)]
47
48	x TAAPH
49	TAAPH = TAA - TAAMH
50	Where:
51	TAA = total available appropriation.
52	TAAPH = total amount available for public hospitals.
53	DSHP = disproportionate share hospital payments.
54	HMD = hospital Medicaid days.
55	TMD = total state Medicaid days for public hospitals.
56	HCCD = hospital charity care dollars.
57	TCCD = total state charity care dollars for public non-
58	state hospitals.
59	1.  For the 2005-2006 state fiscal year only, the DSHP for
60	the public nonstate hospitals shall be computed using a weighted
61	average of the disproportionate share payments for the 2004-2005
62	state fiscal year which uses an average of the 1998, 1999, and
63	2000 audited disproportionate share data and the
64	disproportionate share payments for the 2005-2006 state fiscal
65	year as computed using the formula above and using the average
66	of the 1999, 2000, and 2001 audited disproportionate share data.
67	The final DSHP for the public nonstate hospitals shall be
68	computed as an average using the calculated payments for the
69	2005-2006 state fiscal year weighted at 65 percent and the
70	disproportionate share payments for the 2004-2005 state fiscal
71	year weighted at 35 percent.
72	2.  The TAAPH shall be reduced by $6,365,257 before
73	computing the DSHP for each public hospital. The $6,365,257
74	shall be distributed equally between the public hospitals that
75	are also designated statutory teaching hospitals.
76	Section 9.  Section 409.9112, Florida Statutes, is amended
77	to read:
78	409.9112  Disproportionate share program for regional
79	perinatal intensive care centers.--In addition to the payments
80	made under s. 409.911, the Agency for Health Care Administration
81	shall design and implement a system of making disproportionate
82	share payments to those hospitals that participate in the
83	regional perinatal intensive care center program established
84	pursuant to chapter 383. This system of payments shall conform
85	with federal requirements and shall distribute funds in each
86	fiscal year for which an appropriation is made by making
87	quarterly Medicaid payments. Notwithstanding the provisions of
88	s. 409.915, counties are exempt from contributing toward the
89	cost of this special reimbursement for hospitals serving a
90	disproportionate share of low-income patients. For the state
91	fiscal year 2005-2006 2004-2005, the agency shall not distribute
92	moneys under the regional perinatal intensive care centers
93	disproportionate share program, except as noted in subsection
94	(2). In the event the Centers for Medicare and Medicaid Services
95	do not approve Florida's inpatient hospital state plan amendment
96	for the public disproportionate share program by January 1,
97	2005, the agency may make payments to hospitals under the
98	regional perinatal intensive care centers disproportionate share
99	program.
100	(1)  The following formula shall be used by the agency to
101	calculate the total amount earned for hospitals that participate
102	in the regional perinatal intensive care center program:
103	TAE = HDSP/THDSP
104	Where:
105	TAE = total amount earned by a regional perinatal intensive
106	care center.
107	HDSP = the prior state fiscal year regional perinatal
108	intensive care center disproportionate share payment to the
109	individual hospital.
110	THDSP = the prior state fiscal year total regional
111	perinatal intensive care center disproportionate share payments
112	to all hospitals.
113	(2)  The total additional payment for hospitals that
114	participate in the regional perinatal intensive care center
115	program shall be calculated by the agency as follows:
116	TAP = TAE x TA
117	Where:
118	TAP = total additional payment for a regional perinatal
119	intensive care center.
120	TAE = total amount earned by a regional perinatal intensive
121	care center.
122	TA = total appropriation for the regional perinatal
123	intensive care center disproportionate share program.
124	(3)  In order to receive payments under this section, a
125	hospital must be participating in the regional perinatal
126	intensive care center program pursuant to chapter 383 and must
127	meet the following additional requirements:
128	(a)  Agree to conform to all departmental and agency
129	requirements to ensure high quality in the provision of
130	services, including criteria adopted by departmental and agency
131	rule concerning staffing ratios, medical records, standards of
132	care, equipment, space, and such other standards and criteria as
133	the department and agency deem appropriate as specified by rule.
134	(b)  Agree to provide information to the department and
135	agency, in a form and manner to be prescribed by rule of the
136	department and agency, concerning the care provided to all
137	patients in neonatal intensive care centers and high-risk
138	maternity care.
139	(c)  Agree to accept all patients for neonatal intensive
140	care and high-risk maternity care, regardless of ability to pay,
141	on a functional space-available basis.
142	(d)  Agree to develop arrangements with other maternity and
143	neonatal care providers in the hospital's region for the
144	appropriate receipt and transfer of patients in need of
145	specialized maternity and neonatal intensive care services.
146	(e)  Agree to establish and provide a developmental
147	evaluation and services program for certain high-risk neonates,
148	as prescribed and defined by rule of the department.
149	(f)  Agree to sponsor a program of continuing education in
150	perinatal care for health care professionals within the region
151	of the hospital, as specified by rule.
152	(g)  Agree to provide backup and referral services to the
153	department's county health departments and other low-income
154	perinatal providers within the hospital's region, including the
155	development of written agreements between these organizations
156	and the hospital.
157	(h)  Agree to arrange for transportation for high-risk
158	obstetrical patients and neonates in need of transfer from the
159	community to the hospital or from the hospital to another more
160	appropriate facility.
161	(4)  Hospitals which fail to comply with any of the
162	conditions in subsection (3) or the applicable rules of the
163	department and agency shall not receive any payments under this
164	section until full compliance is achieved.  A hospital which is
165	not in compliance in two or more consecutive quarters shall not
166	receive its share of the funds.  Any forfeited funds shall be
167	distributed by the remaining participating regional perinatal
168	intensive care center program hospitals.
169	Section 10.  Section 409.9113, Florida Statutes, is amended
170	to read:
171	409.9113  Disproportionate share program for teaching
172	hospitals.--In addition to the payments made under ss. 409.911
173	and 409.9112, the Agency for Health Care Administration shall
174	make disproportionate share payments to statutorily defined
175	teaching hospitals for their increased costs associated with
176	medical education programs and for tertiary health care services
177	provided to the indigent. This system of payments shall conform
178	with federal requirements and shall distribute funds in each
179	fiscal year for which an appropriation is made by making
180	quarterly Medicaid payments. Notwithstanding s. 409.915,
181	counties are exempt from contributing toward the cost of this
182	special reimbursement for hospitals serving a disproportionate
183	share of low-income patients. For the state fiscal year 2005-
184	2006 2004-2005, the agency shall not distribute moneys under the
185	teaching hospital disproportionate share program, except as
186	noted in subsection (2). In the event the Centers for Medicare
187	and Medicaid Services do not approve Florida's inpatient
188	hospital state plan amendment for the public disproportionate
189	share program by January 1, 2005, the agency may make payments
190	to hospitals under the teaching hospital disproportionate share
191	program.
192	(1)  On or before September 15 of each year, the Agency for
193	Health Care Administration shall calculate an allocation
194	fraction to be used for distributing funds to state statutory
195	teaching hospitals. Subsequent to the end of each quarter of the
196	state fiscal year, the agency shall distribute to each statutory
197	teaching hospital, as defined in s. 408.07, an amount determined
198	by multiplying one-fourth of the funds appropriated for this
199	purpose by the Legislature times such hospital's allocation
200	fraction.  The allocation fraction for each such hospital shall
201	be determined by the sum of three primary factors, divided by
202	three. The primary factors are:
203	(a)  The number of nationally accredited graduate medical
204	education programs offered by the hospital, including programs
205	accredited by the Accreditation Council for Graduate Medical
206	Education and the combined Internal Medicine and Pediatrics
207	programs acceptable to both the American Board of Internal
208	Medicine and the American Board of Pediatrics at the beginning
209	of the state fiscal year preceding the date on which the
210	allocation fraction is calculated.  The numerical value of this
211	factor is the fraction that the hospital represents of the total
212	number of programs, where the total is computed for all state
213	statutory teaching hospitals.
214	(b)  The number of full-time equivalent trainees in the
215	hospital, which comprises two components:
216	1.  The number of trainees enrolled in nationally
217	accredited graduate medical education programs, as defined in
218	paragraph (a).  Full-time equivalents are computed using the
219	fraction of the year during which each trainee is primarily
220	assigned to the given institution, over the state fiscal year
221	preceding the date on which the allocation fraction is
222	calculated. The numerical value of this factor is the fraction
223	that the hospital represents of the total number of full-time
224	equivalent trainees enrolled in accredited graduate programs,
225	where the total is computed for all state statutory teaching
226	hospitals.
227	2.  The number of medical students enrolled in accredited
228	colleges of medicine and engaged in clinical activities,
229	including required clinical clerkships and clinical electives.
230	Full-time equivalents are computed using the fraction of the
231	year during which each trainee is primarily assigned to the
232	given institution, over the course of the state fiscal year
233	preceding the date on which the allocation fraction is
234	calculated. The numerical value of this factor is the fraction
235	that the given hospital represents of the total number of full-
236	time equivalent students enrolled in accredited colleges of
237	medicine, where the total is computed for all state statutory
238	teaching hospitals.
239
240	The primary factor for full-time equivalent trainees is computed
241	as the sum of these two components, divided by two.
242	(c)  A service index that comprises three components:
243	1.  The Agency for Health Care Administration Service
244	Index, computed by applying the standard Service Inventory
245	Scores established by the Agency for Health Care Administration
246	to services offered by the given hospital, as reported on
247	Worksheet A-2 for the last fiscal year reported to the agency
248	before the date on which the allocation fraction is calculated.
249	The numerical value of this factor is the fraction that the
250	given hospital represents of the total Agency for Health Care
251	Administration Service Index values, where the total is computed
252	for all state statutory teaching hospitals.
253	2.  A volume-weighted service index, computed by applying
254	the standard Service Inventory Scores established by the Agency
255	for Health Care Administration to the volume of each service,
256	expressed in terms of the standard units of measure reported on
257	Worksheet A-2 for the last fiscal year reported to the agency
258	before the date on which the allocation factor is calculated.
259	The numerical value of this factor is the fraction that the
260	given hospital represents of the total volume-weighted service
261	index values, where the total is computed for all state
262	statutory teaching hospitals.
263	3.  Total Medicaid payments to each hospital for direct
264	inpatient and outpatient services during the fiscal year
265	preceding the date on which the allocation factor is calculated.
266	This includes payments made to each hospital for such services
267	by Medicaid prepaid health plans, whether the plan was
268	administered by the hospital or not.  The numerical value of
269	this factor is the fraction that each hospital represents of the
270	total of such Medicaid payments, where the total is computed for
271	all state statutory teaching hospitals.
272
273	The primary factor for the service index is computed as the sum
274	of these three components, divided by three.
275	(2)  By October 1 of each year, the agency shall use the
276	following formula to calculate the maximum additional
277	disproportionate share payment for statutorily defined teaching
278	hospitals:
279	TAP = THAF x A
280	Where:
281	TAP = total additional payment.
282	THAF = teaching hospital allocation factor.
283	A = amount appropriated for a teaching hospital
284	disproportionate share program.
285	Section 11.  Section 409.9117, Florida Statutes, is amended
286	to read:
287	409.9117  Primary care disproportionate share program.--For
288	the state fiscal year 2005-2006 2004-2005, the agency shall not
289	distribute moneys under the primary care disproportionate share
290	program, except as noted in subsection (2). In the event the
291	Centers for Medicare and Medicaid Services do not approve
292	Florida's inpatient hospital state plan amendment for the public
293	disproportionate share program by January 1, 2005, the agency
294	may make payments to hospitals under the primary care
295	disproportionate share program.
296	(1)  If federal funds are available for disproportionate
297	share programs in addition to those otherwise provided by law,
298	there shall be created a primary care disproportionate share
299	program.
300	(2)  The following formula shall be used by the agency to
301	calculate the total amount earned for hospitals that participate
302	in the primary care disproportionate share program:
303	TAE = HDSP/THDSP
304	Where:
305	TAE = total amount earned by a hospital participating in
306	the primary care disproportionate share program.
307	HDSP = the prior state fiscal year primary care
308	disproportionate share payment to the individual hospital.
309	THDSP = the prior state fiscal year total primary care
310	disproportionate share payments to all hospitals.
311	(3)  The total additional payment for hospitals that
312	participate in the primary care disproportionate share program
313	shall be calculated by the agency as follows:
314	TAP = TAE x TA
315	Where:
316	TAP = total additional payment for a primary care hospital.
317	TAE = total amount earned by a primary care hospital.
318	TA = total appropriation for the primary care
319	disproportionate share program.
320	(4)  In the establishment and funding of this program, the
321	agency shall use the following criteria in addition to those
322	specified in s. 409.911, payments may not be made to a hospital
323	unless the hospital agrees to:
324	(a)  Cooperate with a Medicaid prepaid health plan, if one
325	exists in the community.
326	(b)  Ensure the availability of primary and specialty care
327	physicians to Medicaid recipients who are not enrolled in a
328	prepaid capitated arrangement and who are in need of access to
329	such physicians.
330	(c)  Coordinate and provide primary care services free of
331	charge, except copayments, to all persons with incomes up to 100
332	percent of the federal poverty level who are not otherwise
333	covered by Medicaid or another program administered by a
334	governmental entity, and to provide such services based on a
335	sliding fee scale to all persons with incomes up to 200 percent
336	of the federal poverty level who are not otherwise covered by
337	Medicaid or another program administered by a governmental
338	entity, except that eligibility may be limited to persons who
339	reside within a more limited area, as agreed to by the agency
340	and the hospital.
341	(d)  Contract with any federally qualified health center,
342	if one exists within the agreed geopolitical boundaries,
343	concerning the provision of primary care services, in order to
344	guarantee delivery of services in a nonduplicative fashion, and
345	to provide for referral arrangements, privileges, and
346	admissions, as appropriate.  The hospital shall agree to provide
347	at an onsite or offsite facility primary care services within 24
348	hours to which all Medicaid recipients and persons eligible
349	under this paragraph who do not require emergency room services
350	are referred during normal daylight hours.
351	(e)  Cooperate with the agency, the county, and other
352	entities to ensure the provision of certain public health
353	services, case management, referral and acceptance of patients,
354	and sharing of epidemiological data, as the agency and the
355	hospital find mutually necessary and desirable to promote and
356	protect the public health within the agreed geopolitical
357	boundaries.
358	(f)  In cooperation with the county in which the hospital
359	resides, develop a low-cost, outpatient, prepaid health care
360	program to persons who are not eligible for the Medicaid
361	program, and who reside within the area.
362	(g)  Provide inpatient services to residents within the
363	area who are not eligible for Medicaid or Medicare, and who do
364	not have private health insurance, regardless of ability to pay,
365	on the basis of available space, except that nothing shall
366	prevent the hospital from establishing bill collection programs
367	based on ability to pay.
368	(h)  Work with the Florida Healthy Kids Corporation, the
369	Florida Health Care Purchasing Cooperative, and business health
370	coalitions, as appropriate, to develop a feasibility study and
371	plan to provide a low-cost comprehensive health insurance plan
372	to persons who reside within the area and who do not have access
373	to such a plan.
374	(i)  Work with public health officials and other experts to
375	provide community health education and prevention activities
376	designed to promote healthy lifestyles and appropriate use of
377	health services.
378	(j)  Work with the local health council to develop a plan
379	for promoting access to affordable health care services for all
380	persons who reside within the area, including, but not limited
381	to, public health services, primary care services, inpatient
382	services, and affordable health insurance generally.
383
384	Any hospital that fails to comply with any of the provisions of
385	this subsection, or any other contractual condition, may not
386	receive payments under this section until full compliance is
387	achieved.
388	Section 12.  Section 409.91195, Florida Statutes, is
389	amended to read:
390	409.91195  Medicaid Pharmaceutical and Therapeutics
391	Committee.--There is created a Medicaid Pharmaceutical and
392	Therapeutics Committee within the agency for Health Care
393	Administration for the purpose of developing a Medicaid
394	preferred drug list formulary pursuant to 42 U.S.C. s. 1396r-8.
395	(1)  The Medicaid Pharmaceutical and Therapeutics committee
396	shall be composed comprised as specified in 42 U.S.C. s. 1396r-8
397	and consist of 11 members appointed by the Governor. Four
398	members shall be physicians, licensed under chapter 458; one
399	member licensed under chapter 459; five members shall be
400	pharmacists licensed under chapter 465; and one member shall be
401	a consumer representative. The members shall be appointed to
402	serve for terms of 2 years from the date of their appointment.
403	Members may be appointed to more than one term. The agency for
404	Health Care Administration shall serve as staff for the
405	committee and assist them with all ministerial duties. The
406	Governor shall ensure that at least some of the members of the
407	Medicaid Pharmaceutical and Therapeutics committee represent
408	Medicaid participating physicians and pharmacies serving all
409	segments and diversity of the Medicaid population, and have
410	experience in either developing or practicing under a preferred
411	drug list formulary. At least one of the members shall represent
412	the interests of pharmaceutical manufacturers.
413	(2)  Committee members shall select a chairperson and a
414	vice chairperson each year from the committee membership.
415	(3)  The committee shall meet at least quarterly and may
416	meet at other times at the discretion of the chairperson and
417	members. The committee shall comply with rules adopted by the
418	agency, including notice of any meeting of the committee
419	pursuant to the requirements of the Administrative Procedure
420	Act.
421	(4)  Upon recommendation of the Medicaid Pharmaceutical and
422	Therapeutics committee, the agency shall adopt a preferred drug
423	list as described in s. 409.912(39). To the extent feasible, the
424	committee shall review all drug classes included on in the
425	preferred drug list formulary at least every 12 months, and may
426	recommend additions to and deletions from the preferred drug
427	list formulary, such that the preferred drug list formulary
428	provides for medically appropriate drug therapies for Medicaid
429	patients which achieve cost savings contained in the General
430	Appropriations Act.
431	(5)  Except for mental health-related drugs, antiretroviral
432	drugs, and drugs for nursing home residents and other
433	institutional residents, reimbursement of drugs not included on
434	the preferred drug list in the formulary is subject to prior
435	authorization.
436	(5)(6)  The agency for Health Care Administration shall
437	publish and disseminate the preferred drug list formulary to all
438	Medicaid providers in the state by Internet posting on the
439	agency's website or in other media.
440	(6)(7)  The committee shall ensure that interested parties,
441	including pharmaceutical manufacturers agreeing to provide a
442	supplemental rebate as outlined in this chapter, have an
443	opportunity to present public testimony to the committee with
444	information or evidence supporting inclusion of a product on the
445	preferred drug list. Such public testimony shall occur prior to
446	any recommendations made by the committee for inclusion or
447	exclusion from the preferred drug list. Upon timely notice, the
448	agency shall ensure that any drug that has been approved or had
449	any of its particular uses approved by the United States Food
450	and Drug Administration under a priority review classification
451	will be reviewed by the Medicaid Pharmaceutical and Therapeutics
452	committee at the next regularly scheduled meeting following 3
453	months of distribution of the drug to the general public. To the
454	extent possible, upon notice by a manufacturer the agency shall
455	also schedule a product review for any new product at the next
456	regularly scheduled Medicaid Pharmaceutical and Therapeutics
457	Committee.
458	(8)  Until the Medicaid Pharmaceutical and Therapeutics
459	Committee is appointed and a preferred drug list adopted by the
460	agency, the agency shall use the existing voluntary preferred
461	drug list adopted pursuant to s. 72, chapter 2000-367, Laws of
462	Florida. Drugs not listed on the voluntary preferred drug list
463	will require prior authorization by the agency or its
464	contractor.
465	(7)(9)  The Medicaid Pharmaceutical and Therapeutics
466	committee shall develop its preferred drug list recommendations
467	by considering the clinical efficacy, safety, and cost-
468	effectiveness of a product. When the preferred drug formulary is
469	adopted by the agency, if a product on the formulary is one of
470	the first four brand-name drugs used by a recipient in a month
471	the drug shall not require prior authorization.
472	(8)  Upon timely notice, the agency shall ensure that any
473	therapeutic class of drugs which includes a drug that has been
474	removed from distribution to the public by its manufacturer or
475	the United States Food and Drug Administration or has been
476	required to carry a black box warning label by the United States
477	Food and Drug Administration because of safety concerns is
478	reviewed by the committee at the next regularly scheduled
479	meeting. After such review, the committee must recommend whether
480	to retain the therapeutic class of drugs or subcategories of
481	drugs within a therapeutic class on the preferred drug list and
482	whether to institute prior authorization requirements necessary
483	to ensure patient safety.
484	(9)(10)  The Medicaid Pharmaceutical and Therapeutics
485	Committee may also make recommendations to the agency regarding
486	the prior authorization of any prescribed drug covered by
487	Medicaid.
488	(10)(11)  Medicaid recipients may appeal agency preferred
489	drug formulary decisions using the Medicaid fair hearing process
490	administered by the Department of Children and Family Services.
491	Section 13.  Paragraph (b) of subsection (4), paragraphs
492	(e) and (f) of subsection (15), paragraph (a) of subsection
493	(39), and subsections (44) and (49) of section 409.912, Florida
494	Statutes, are amended, and subsection (50) is added to that
495	section, to read:
496	409.912  Cost-effective purchasing of health care.--The
497	agency shall purchase goods and services for Medicaid recipients
498	in the most cost-effective manner consistent with the delivery
499	of quality medical care. To ensure that medical services are
500	effectively utilized, the agency may, in any case, require a
501	confirmation or second physician's opinion of the correct
502	diagnosis for purposes of authorizing future services under the
503	Medicaid program. This section does not restrict access to
504	emergency services or poststabilization care services as defined
505	in 42 C.F.R. part 438.114. Such confirmation or second opinion
506	shall be rendered in a manner approved by the agency. The agency
507	shall maximize the use of prepaid per capita and prepaid
508	aggregate fixed-sum basis services when appropriate and other
509	alternative service delivery and reimbursement methodologies,
510	including competitive bidding pursuant to s. 287.057, designed
511	to facilitate the cost-effective purchase of a case-managed
512	continuum of care. The agency shall also require providers to
513	minimize the exposure of recipients to the need for acute
514	inpatient, custodial, and other institutional care and the
515	inappropriate or unnecessary use of high-cost services. The
516	agency may mandate prior authorization, drug therapy management,
517	or disease management participation for certain populations of
518	Medicaid beneficiaries, certain drug classes, or particular
519	drugs to prevent fraud, abuse, overuse, and possible dangerous
520	drug interactions. The Pharmaceutical and Therapeutics Committee
521	shall make recommendations to the agency on drugs for which
522	prior authorization is required. The agency shall inform the
523	Pharmaceutical and Therapeutics Committee of its decisions
524	regarding drugs subject to prior authorization. The agency is
525	authorized to limit the entities it contracts with or enrolls as
526	Medicaid providers by developing a provider network through
527	provider credentialing. The agency may limit its network based
528	on the assessment of beneficiary access to care, provider
529	availability, provider quality standards, time and distance
530	standards for access to care, the cultural competence of the
531	provider network, demographic characteristics of Medicaid
532	beneficiaries, practice and provider-to-beneficiary standards,
533	appointment wait times, beneficiary use of services, provider
534	turnover, provider profiling, provider licensure history,
535	previous program integrity investigations and findings, peer
536	review, provider Medicaid policy and billing compliance records,
537	clinical and medical record audits, and other factors. Providers
538	shall not be entitled to enrollment in the Medicaid provider
539	network. The agency is authorized to seek federal waivers
540	necessary to implement this policy.
541	(4)  The agency may contract with:
542	(b)  An entity that is providing comprehensive behavioral
543	health care services to certain Medicaid recipients through a
544	capitated, prepaid arrangement pursuant to the federal waiver
545	provided for by s. 409.905(5). Such an entity must be licensed
546	under chapter 624, chapter 636, or chapter 641 and must possess
547	the clinical systems and operational competence to manage risk
548	and provide comprehensive behavioral health care to Medicaid
549	recipients. As used in this paragraph, the term "comprehensive
550	behavioral health care services" means covered mental health and
551	substance abuse treatment services that are available to
552	Medicaid recipients. The secretary of the Department of Children
553	and Family Services shall approve provisions of procurements
554	related to children in the department's care or custody prior to
555	enrolling such children in a prepaid behavioral health plan. Any
556	contract awarded under this paragraph must be competitively
557	procured. In developing the behavioral health care prepaid plan
558	procurement document, the agency shall ensure that the
559	procurement document requires the contractor to develop and
560	implement a plan to ensure compliance with s. 394.4574 related
561	to services provided to residents of licensed assisted living
562	facilities that hold a limited mental health license. Except as
563	provided in subparagraph 8., the agency shall seek federal
564	approval to contract with a single entity meeting these
565	requirements to provide comprehensive behavioral health care
566	services to all Medicaid recipients not enrolled in a managed
567	care plan in an AHCA area. Each entity must offer sufficient
568	choice of providers in its network to ensure recipient access to
569	care and the opportunity to select a provider with whom they are
570	satisfied. The network shall include all public mental health
571	hospitals. To ensure unimpaired access to behavioral health care
572	services by Medicaid recipients, all contracts issued pursuant
573	to this paragraph shall require 80 percent of the capitation
574	paid to the managed care plan, including health maintenance
575	organizations, to be expended for the provision of behavioral
576	health care services. In the event the managed care plan expends
577	less than 80 percent of the capitation paid pursuant to this
578	paragraph for the provision of behavioral health care services,
579	the difference shall be returned to the agency. The agency shall
580	provide the managed care plan with a certification letter
581	indicating the amount of capitation paid during each calendar
582	year for the provision of behavioral health care services
583	pursuant to this section. The agency may reimburse for substance
584	abuse treatment services on a fee-for-service basis until the
585	agency finds that adequate funds are available for capitated,
586	prepaid arrangements.
587	1.  By January 1, 2001, the agency shall modify the
588	contracts with the entities providing comprehensive inpatient
589	and outpatient mental health care services to Medicaid
590	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
591	Counties, to include substance abuse treatment services.
592	2.  By July 1, 2003, the agency and the Department of
593	Children and Family Services shall execute a written agreement
594	that requires collaboration and joint development of all policy,
595	budgets, procurement documents, contracts, and monitoring plans
596	that have an impact on the state and Medicaid community mental
597	health and targeted case management programs.
598	3.  Except as provided in subparagraph 8., by July 1, 2006,
599	the agency and the Department of Children and Family Services
600	shall contract with managed care entities in each AHCA area
601	except area 6 or arrange to provide comprehensive inpatient and
602	outpatient mental health and substance abuse services through
603	capitated prepaid arrangements to all Medicaid recipients who
604	are eligible to participate in such plans under federal law and
605	regulation. In AHCA areas where eligible individuals number less
606	than 150,000, the agency shall contract with a single managed
607	care plan to provide comprehensive behavioral health services to
608	all recipients who are not enrolled in a Medicaid health
609	maintenance organization. The agency may contract with more than
610	one comprehensive behavioral health provider to provide care to
611	recipients who are not enrolled in a Medicaid health maintenance
612	organization in AHCA areas where the eligible population exceeds
613	150,000. Contracts for comprehensive behavioral health providers
614	awarded pursuant to this section shall be competitively
615	procured. Both for-profit and not-for-profit corporations shall
616	be eligible to compete. Managed care plans contracting with the
617	agency under subsection (3) shall provide and receive payment
618	for the same comprehensive behavioral health benefits as
619	provided in AHCA rules, including handbooks incorporated by
620	reference. In AHCA Area 11, the agency shall contract with at
621	least two comprehensive behavioral health care providers to
622	provide behavioral health care to recipients in that area who
623	are enrolled in, or assigned to, the MediPass program. One of
624	the behavioral health care contracts shall be with the existing
625	provider service network pilot project, as described in
626	paragraph (d), for the purpose of demonstrating the cost-
627	effectiveness of the provision of quality mental health services
628	through a public hospital-operated managed care model. Payment
629	shall be at an agreed-upon capitated rate to ensure cost
630	savings. Of the recipients in Area 11 who are assigned to
631	MediPass under the provisions of s. 409.9122(2)(k), a minimum of
632	50,000 of those MediPass-enrolled recipients shall be assigned
633	to the existing provider service network in Area 11 for their
634	behavioral care.
635	4.  By October 1, 2003, the agency and the department shall
636	submit a plan to the Governor, the President of the Senate, and
637	the Speaker of the House of Representatives which provides for
638	the full implementation of capitated prepaid behavioral health
639	care in all areas of the state.
640	a.  Implementation shall begin in 2003 in those AHCA areas
641	of the state where the agency is able to establish sufficient
642	capitation rates.
643	b.  If the agency determines that the proposed capitation
644	rate in any area is insufficient to provide appropriate
645	services, the agency may adjust the capitation rate to ensure
646	that care will be available. The agency and the department may
647	use existing general revenue to address any additional required
648	match but may not over-obligate existing funds on an annualized
649	basis.
650	c.  Subject to any limitations provided for in the General
651	Appropriations Act, the agency, in compliance with appropriate
652	federal authorization, shall develop policies and procedures
653	that allow for certification of local and state funds.
654	5.  Children residing in a statewide inpatient psychiatric
655	program, or in a Department of Juvenile Justice or a Department
656	of Children and Family Services residential program approved as
657	a Medicaid behavioral health overlay services provider shall not
658	be included in a behavioral health care prepaid health plan or
659	any other Medicaid managed care plan pursuant to this paragraph.
660	6.  In converting to a prepaid system of delivery, the
661	agency shall in its procurement document require an entity
662	providing only comprehensive behavioral health care services to
663	prevent the displacement of indigent care patients by enrollees
664	in the Medicaid prepaid health plan providing behavioral health
665	care services from facilities receiving state funding to provide
666	indigent behavioral health care, to facilities licensed under
667	chapter 395 which do not receive state funding for indigent
668	behavioral health care, or reimburse the unsubsidized facility
669	for the cost of behavioral health care provided to the displaced
670	indigent care patient.
671	7.  Traditional community mental health providers under
672	contract with the Department of Children and Family Services
673	pursuant to part IV of chapter 394, child welfare providers
674	under contract with the Department of Children and Family
675	Services in areas 1 and 6, and inpatient mental health providers
676	licensed pursuant to chapter 395 must be offered an opportunity
677	to accept or decline a contract to participate in any provider
678	network for prepaid behavioral health services.
679	8.  For fiscal year 2004-2005, all Medicaid eligible
680	children, except children in areas 1 and 6, whose cases are open
681	for child welfare services in the HomeSafeNet system, shall be
682	enrolled in MediPass or in Medicaid fee-for-service and all
683	their behavioral health care services including inpatient,
684	outpatient psychiatric, community mental health, and case
685	management shall be reimbursed on a fee-for-service basis.
686	Beginning July 1, 2005, such children, who are open for child
687	welfare services in the HomeSafeNet system, shall receive their
688	behavioral health care services through a specialty prepaid plan
689	operated by community-based lead agencies either through a
690	single agency or formal agreements among several agencies. The
691	specialty prepaid plan must result in savings to the state
692	comparable to savings achieved in other Medicaid managed care
693	and prepaid programs. Such plan must provide mechanisms to
694	maximize state and local revenues. The specialty prepaid plan
695	shall be developed by the agency and the Department of Children
696	and Family Services. The agency is authorized to seek any
697	federal waivers to implement this initiative.
698	(15)
699	(e)  By January 15 of each year, the agency shall submit a
700	report to the Legislature and the Office of Long-Term-Care
701	Policy describing the operations of the CARES program. The
702	report must describe:
703	1.  Rate of diversion to community alternative programs;
704	2.  CARES program staffing needs to achieve additional
705	diversions;
706	3.  Reasons the program is unable to place individuals in
707	less restrictive settings when such individuals desired such
708	services and could have been served in such settings;
709	4.  Barriers to appropriate placement, including barriers
710	due to policies or operations of other agencies or state-funded
711	programs; and
712	5.  Statutory changes necessary to ensure that individuals
713	in need of long-term care services receive care in the least
714	restrictive environment.
715	(f)  The Department of Elderly Affairs shall track
716	individuals over time who are assessed under the CARES program
717	and who are diverted from nursing home placement. By January 15
718	of each year, the department shall submit to the Legislature and
719	the Office of Long-Term-Care Policy a longitudinal study of the
720	individuals who are diverted from nursing home placement. The
721	study must include:
722	1.  The demographic characteristics of the individuals
723	assessed and diverted from nursing home placement, including,
724	but not limited to, age, race, gender, frailty, caregiver
725	status, living arrangements, and geographic location;
726	2.  A summary of community services provided to individuals
727	for 1 year after assessment and diversion;
728	3.  A summary of inpatient hospital admissions for
729	individuals who have been diverted; and
730	4.  A summary of the length of time between diversion and
731	subsequent entry into a nursing home or death.
732	(39)(a)  The agency shall implement a Medicaid prescribed-
733	drug spending-control program that includes the following
734	components:
735	1.  A Medicaid preferred drug list, which shall be a
736	listing of cost-effective therapeutic options recommended by the
737	Medicaid Pharmacy and Therapeutics Committee established
738	pursuant to s. 409.91195 and adopted by the agency for each
739	therapeutic class on the preferred drug list. At the discretion
740	of the committee, and when feasible, the preferred drug list
741	should include at least two products in a therapeutic class.
742	Medicaid prescribed-drug coverage for brand-name drugs for adult
743	Medicaid recipients is limited to the dispensing of four brand-
744	name drugs per month per recipient. Children are exempt from
745	this restriction. Antiretroviral agents are excluded from the
746	preferred drug list this limitation. No requirements for prior
747	authorization or other restrictions on medications used to treat
748	mental illnesses such as schizophrenia, severe depression, or
749	bipolar disorder may be imposed on Medicaid recipients.
750	Medications that will be available without restriction for
751	persons with mental illnesses include atypical antipsychotic
752	medications, conventional antipsychotic medications, selective
753	serotonin reuptake inhibitors, and other medications used for
754	the treatment of serious mental illnesses. The agency shall also
755	limit the amount of a prescribed drug dispensed to no more than
756	a 34-day supply unless the drug products' smallest marketed
757	package is greater than a 34-day supply, or the drug is
758	determined by the agency to be a maintenance drug in which case
759	a 100-day maximum supply may be authorized. The agency is
760	authorized to seek any federal waivers necessary to implement
761	these cost-control programs and to continue participation in the
762	federal Medicaid rebate program, or alternatively to negotiate
763	state-only manufacturer rebates. The agency may adopt rules to
764	implement this subparagraph. The agency shall continue to
765	provide unlimited generic drugs, contraceptive drugs and items,
766	and diabetic supplies. Although a drug may be included on the
767	preferred drug formulary, it would not be exempt from the four-
768	brand limit. The agency may authorize exceptions to the brand-
769	name-drug restriction based upon the treatment needs of the
770	patients, only when such exceptions are based on prior
771	consultation provided by the agency or an agency contractor, but
772	The agency must establish procedures to ensure that:
773	a.  There will be a response to a request for prior
774	consultation by telephone or other telecommunication device
775	within 24 hours after receipt of a request for prior
776	consultation; and
777	b.  A 72-hour supply of the drug prescribed will be
778	provided in an emergency or when the agency does not provide a
779	response within 24 hours as required by sub-subparagraph a.; and
780	c.  Except for the exception for nursing home residents and
781	other institutionalized adults and except for drugs on the
782	restricted formulary for which prior authorization may be sought
783	by an institutional or community pharmacy, prior authorization
784	for an exception to the brand-name-drug restriction is sought by
785	the prescriber and not by the pharmacy. When prior authorization
786	is granted for a patient in an institutional setting beyond the
787	brand-name-drug restriction, such approval is authorized for 12
788	months and monthly prior authorization is not required for that
789	patient.
790	2.  Reimbursement to pharmacies for Medicaid prescribed
791	drugs shall be set at the lesser of: the average wholesale price
792	(AWP) minus 15.4 percent, the wholesaler acquisition cost (WAC)
793	plus 5.75 percent, the federal upper limit (FUL), the state
794	maximum allowable cost (SMAC), or the usual and customary (UAC)
795	charge billed by the provider.
796	3.  The agency shall develop and implement a process for
797	managing the drug therapies of Medicaid recipients who are using
798	significant numbers of prescribed drugs each month. The
799	management process may include, but is not limited to,
800	comprehensive, physician-directed medical-record reviews, claims
801	analyses, and case evaluations to determine the medical
802	necessity and appropriateness of a patient's treatment plan and
803	drug therapies. The agency may contract with a private
804	organization to provide drug-program-management services. The
805	Medicaid drug benefit management program shall include
806	initiatives to manage drug therapies for HIV/AIDS patients,
807	patients using 20 or more unique prescriptions in a 180-day
808	period, and the top 1,000 patients in annual spending. The
809	agency shall enroll any Medicaid recipient in the drug benefit
810	management program if he or she meets the specifications of this
811	provision and is not enrolled in a Medicaid health maintenance
812	organization.
813	4.  The agency may limit the size of its pharmacy network
814	based on need, competitive bidding, price negotiations,
815	credentialing, or similar criteria. The agency shall give
816	special consideration to rural areas in determining the size and
817	location of pharmacies included in the Medicaid pharmacy
818	network. A pharmacy credentialing process may include criteria
819	such as a pharmacy's full-service status, location, size,
820	patient educational programs, patient consultation, disease-
821	management services, and other characteristics. The agency may
822	impose a moratorium on Medicaid pharmacy enrollment when it is
823	determined that it has a sufficient number of Medicaid-
824	participating providers.
825	5.  The agency shall develop and implement a program that
826	requires Medicaid practitioners who prescribe drugs to use a
827	counterfeit-proof prescription pad for Medicaid prescriptions.
828	The agency shall require the use of standardized counterfeit-
829	proof prescription pads by Medicaid-participating prescribers or
830	prescribers who write prescriptions for Medicaid recipients. The
831	agency may implement the program in targeted geographic areas or
832	statewide.
833	6.  The agency may enter into arrangements that require
834	manufacturers of generic drugs prescribed to Medicaid recipients
835	to provide rebates of at least 15.1 percent of the average
836	manufacturer price for the manufacturer's generic products.
837	These arrangements shall require that if a generic-drug
838	manufacturer pays federal rebates for Medicaid-reimbursed drugs
839	at a level below 15.1 percent, the manufacturer must provide a
840	supplemental rebate to the state in an amount necessary to
841	achieve a 15.1-percent rebate level.
842	7.  The agency may establish a preferred drug list as
843	described in this subsection formulary in accordance with 42
844	U.S.C. s. 1396r-8, and, pursuant to the establishment of such
845	preferred drug list formulary, it is authorized to negotiate
846	supplemental rebates from manufacturers that are in addition to
847	those required by Title XIX of the Social Security Act and at no
848	less than 14 percent of the average manufacturer price as
849	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
850	the federal or supplemental rebate, or both, equals or exceeds
851	29 percent. There is no upper limit on the supplemental rebates
852	the agency may negotiate. The agency may determine that specific
853	products, brand-name or generic, are competitive at lower rebate
854	percentages. Agreement to pay the minimum supplemental rebate
855	percentage will guarantee a manufacturer that the Medicaid
856	Pharmaceutical and Therapeutics Committee will consider a
857	product for inclusion on the preferred drug list formulary.
858	However, a pharmaceutical manufacturer is not guaranteed
859	placement on the preferred drug list formulary by simply paying
860	the minimum supplemental rebate. Agency decisions will be made
861	on the clinical efficacy of a drug and recommendations of the
862	Medicaid Pharmaceutical and Therapeutics Committee, as well as
863	the price of competing products minus federal and state rebates.
864	The agency is authorized to contract with an outside agency or
865	contractor to conduct negotiations for supplemental rebates. For
866	the purposes of this section, the term "supplemental rebates"
867	means cash rebates. Effective July 1, 2004, value-added programs
868	as a substitution for supplemental rebates are prohibited. The
869	agency is authorized to seek any federal waivers to implement
870	this initiative.
871	8.  The agency shall establish an advisory committee for
872	the purposes of studying the feasibility of using a restricted
873	drug formulary for nursing home residents and other
874	institutionalized adults. The committee shall be comprised of
875	seven members appointed by the Secretary of Health Care
876	Administration. The committee members shall include two
877	physicians licensed under chapter 458 or chapter 459; three
878	pharmacists licensed under chapter 465 and appointed from a list
879	of recommendations provided by the Florida Long-Term Care
880	Pharmacy Alliance; and two pharmacists licensed under chapter
881	465.
882	8.9.  The Agency for Health Care Administration shall
883	expand home delivery of pharmacy products. To assist Medicaid
884	patients in securing their prescriptions and reduce program
885	costs, the agency shall expand its current mail-order-pharmacy
886	diabetes-supply program to include all generic and brand-name
887	drugs used by Medicaid patients with diabetes. Medicaid
888	recipients in the current program may obtain nondiabetes drugs
889	on a voluntary basis. This initiative is limited to the
890	geographic area covered by the current contract. The agency may
891	seek and implement any federal waivers necessary to implement
892	this subparagraph.
893	9.10.  The agency shall limit to one dose per month any
894	drug prescribed to treat erectile dysfunction.
895	10.a.11.a.  The agency may shall implement a Medicaid
896	behavioral drug management system. The agency may contract with
897	a vendor that has experience in operating behavioral drug
898	management systems to implement this program. The agency is
899	authorized to seek federal waivers to implement this program.
900	b.  The agency, in conjunction with the Department of
901	Children and Family Services, may implement the Medicaid
902	behavioral drug management system that is designed to improve
903	the quality of care and behavioral health prescribing practices
904	based on best practice guidelines, improve patient adherence to
905	medication plans, reduce clinical risk, and lower prescribed
906	drug costs and the rate of inappropriate spending on Medicaid
907	behavioral drugs. The program may shall include the following
908	elements:
909	(I)  Provide for the development and adoption of best
910	practice guidelines for behavioral health-related drugs such as
911	antipsychotics, antidepressants, and medications for treating
912	bipolar disorders and other behavioral conditions; translate
913	them into practice; review behavioral health prescribers and
914	compare their prescribing patterns to a number of indicators
915	that are based on national standards; and determine deviations
916	from best practice guidelines.
917	(II)  Implement processes for providing feedback to and
918	educating prescribers using best practice educational materials
919	and peer-to-peer consultation.
920	(III)  Assess Medicaid beneficiaries who are outliers in
921	their use of behavioral health drugs with regard to the numbers
922	and types of drugs taken, drug dosages, combination drug
923	therapies, and other indicators of improper use of behavioral
924	health drugs.
925	(IV)  Alert prescribers to patients who fail to refill
926	prescriptions in a timely fashion, are prescribed multiple same-
927	class behavioral health drugs, and may have other potential
928	medication problems.
929	(V)  Track spending trends for behavioral health drugs and
930	deviation from best practice guidelines.
931	(VI)  Use educational and technological approaches to
932	promote best practices, educate consumers, and train prescribers
933	in the use of practice guidelines.
934	(VII)  Disseminate electronic and published materials.
935	(VIII)  Hold statewide and regional conferences.
936	(IX)  Implement a disease management program with a model
937	quality-based medication component for severely mentally ill
938	individuals and emotionally disturbed children who are high
939	users of care.
940	c.  If the agency is unable to negotiate a contract with
941	one or more manufacturers to finance and guarantee savings
942	associated with a behavioral drug management program by
943	September 1, 2004, the four-brand drug limit and preferred drug
944	list prior-authorization requirements shall apply to mental
945	health-related drugs, notwithstanding any provision in
946	subparagraph 1. The agency is authorized to seek federal waivers
947	to implement this policy.
948	11.12.  The agency is authorized to contract for drug
949	rebate administration, including, but not limited to,
950	calculating rebate amounts, invoicing manufacturers, negotiating
951	disputes with manufacturers, and maintaining a database of
952	rebate collections.
953	12.13.  The agency may specify the preferred daily dosing
954	form or strength for the purpose of promoting best practices
955	with regard to the prescribing of certain drugs as specified in
956	the General Appropriations Act and ensuring cost-effective
957	prescribing practices.
958	13.14.  The agency may require prior authorization for the
959	off-label use of Medicaid-covered prescribed drugs as specified
960	in the General Appropriations Act. The agency may, but is not
961	required to, prior-authorize preauthorize the use of a product:
962	a.  For an indication not approved in labeling;
963	b.  To comply with certain clinical guidelines; or
964	c.  If the product has the potential for overuse, misuse,
965	or abuse for an indication not in the approved labeling.
966
967	The agency Prior authorization may require the prescribing
968	professional to provide information about the rationale and
969	supporting medical evidence for the off-label use of a drug. The
970	agency may post prior-authorization criteria and protocol and
971	updates to the list of drugs that are subject to prior
972	authorization on an Internet website without amending its rule
973	or engaging in additional rulemaking.
974	14.  The agency, in conjunction with the Pharmaceutical and
975	Therapeutics Committee, may require age-related prior
976	authorizations for certain prescribed drugs. The agency may
977	preauthorize the use of a drug for a recipient who may not meet
978	the age requirement or may exceed the length of therapy for use
979	of this product as recommended by the manufacturer and approved
980	by the Food and Drug Administration. Prior authorization may
981	require the prescribing professional to provide information
982	about the rationale and supporting medical evidence for the use
983	of a drug.
984	15.  The agency shall implement a step-therapy-prior
985	authorization-approval process for medications excluded from the
986	preferred drug list. Medications listed on the preferred drug
987	list must be used within the previous 12 months prior to the
988	alternative medications that are not listed. The step-therapy-
989	prior authorization may require the prescriber to use the
990	medications of a similar drug class or for a similar medical
991	indication unless contraindicated in the Food and Drug
992	Administration labeling. The trial period between the specified
993	steps may vary according to the medical indication. The step-
994	therapy-approval process shall be developed in accordance with
995	the committee as stated in s. 409.91195(7) and (8). A drug
996	product may be approved without meeting the step-therapy-prior-
997	authorization criteria if the prescribing physician provides the
998	agency with additional written medical or clinical documentation
999	that the product is medically necessary because:
1000	a.  There is not a drug on the preferred drug list to treat
1001	the disease or medical condition which is an acceptable clinical
1002	alternative;
1003	b.  The alternatives have been ineffective in the treatment
1004	of the beneficiary's disease; or
1005	c.  Based on historic evidence and known characteristics of
1006	the patient and the drug, the drug is likely to be ineffective,
1007	or the number of doses have been ineffective.
1008
1009	The agency shall work with the physician to determine the best
1010	alternative for the patient. The agency may adopt rules waiving
1011	the requirements for written clinical documentation for specific
1012	drugs in limited clinical situations.
1013	16.15.  The agency shall implement a return and reuse
1014	program for drugs dispensed by pharmacies to institutional
1015	recipients, which includes payment of a $5 restocking fee for
1016	the implementation and operation of the program. The return and
1017	reuse program shall be implemented electronically and in a
1018	manner that promotes efficiency. The program must permit a
1019	pharmacy to exclude drugs from the program if it is not
1020	practical or cost-effective for the drug to be included and must
1021	provide for the return to inventory of drugs that cannot be
1022	credited or returned in a cost-effective manner.
1023	(44)  The Agency for Health Care Administration shall
1024	ensure that any Medicaid managed care plan as defined in s.
1025	409.9122(2)(h), whether paid on a capitated basis or a shared
1026	savings basis, is cost-effective. For purposes of this
1027	subsection, the term "cost-effective" means that a network's
1028	per-member, per-month costs to the state, including, but not
1029	limited to, fee-for-service costs, administrative costs, and
1030	case-management fees, if any, must be no greater than the
1031	state's costs associated with contracts for Medicaid services
1032	established under subsection (3), which shall be actuarially
1033	adjusted for case mix, model, and service area. The agency shall
1034	conduct actuarially sound audits adjusted for case mix and model
1035	in order to ensure such cost-effectiveness and shall publish the
1036	audit results on its Internet website and submit the audit
1037	results annually to the Governor, the President of the Senate,
1038	and the Speaker of the House of Representatives no later than
1039	December 31 of each year. Contracts established pursuant to this
1040	subsection which are not cost-effective may not be renewed.
1041	(49)  The agency shall contract with established minority
1042	physician networks that provide services to historically
1043	underserved minority patients. The networks must provide cost-
1044	effective Medicaid services, comply with the requirements to be
1045	a MediPass provider, and provide their primary care physicians
1046	with access to data and other management tools necessary to
1047	assist them in ensuring the appropriate use of services,
1048	including inpatient hospital services and pharmaceuticals.
1049	(a)  The agency shall provide for the development and
1050	expansion of minority physician networks in each service area to
1051	provide services to Medicaid recipients who are eligible to
1052	participate under federal law and rules.
1053	(b)  The agency shall reimburse each minority physician
1054	network as a fee-for-service provider, including the case
1055	management fee for primary care, if any, or as a capitated rate
1056	provider for Medicaid services. Any savings shall be shared with
1057	the minority physician networks pursuant to the contract.
1058	(c)  For purposes of this subsection, the term "cost-
1059	effective" means that a network's per-member, per-month costs to
1060	the state, including, but not limited to, fee-for-service costs,
1061	administrative costs, and case-management fees, if any, must be
1062	no greater than the state's costs associated with contracts for
1063	Medicaid services established under subsection (3), which shall
1064	be actuarially adjusted for case mix, model, and service area.
1065	The agency shall conduct actuarially sound audits adjusted for
1066	case mix and model in order to ensure such cost-effectiveness
1067	and shall publish the audit results on its Internet website and
1068	submit the audit results annually to the Governor, the President
1069	of the Senate, and the Speaker of the House of Representatives
1070	no later than December 31. Contracts established pursuant to
1071	this subsection which are not cost-effective may not be renewed.
1072	(d)  The agency may apply for any federal waivers needed to
1073	implement this subsection.
1074	(50)  The agency shall implement a program of all-inclusive
1075	care for children. The program of all-inclusive care for
1076	children shall be established to provide in-home hospice-like
1077	support services to children diagnosed with a life-threatening
1078	illness and enrolled in the Children's Medical Services network
1079	to reduce hospitalizations as appropriate. The agency, in
1080	consultation with the Department of Health, may implement the
1081	program of all-inclusive care for children after obtaining
1082	approval from the Centers for Medicare and Medicaid Services.
1083	Section 14.  Paragraph (k) of subsection (2) of section
1084	409.9122, Florida Statutes, is amended to read:
1085	409.9122  Mandatory Medicaid managed care enrollment;
1086	programs and procedures.--
1087	(2)
1088	(k)  When a Medicaid recipient does not choose a managed
1089	care plan or MediPass provider, the agency shall assign the
1090	Medicaid recipient to a managed care plan, except in those
1091	counties in which there are fewer than two managed care plans
1092	accepting Medicaid enrollees, in which case assignment shall be
1093	to a managed care plan or a MediPass provider. Medicaid
1094	recipients in counties with fewer than two managed care plans
1095	accepting Medicaid enrollees who are subject to mandatory
1096	assignment but who fail to make a choice shall be assigned to
1097	managed care plans until an enrollment of 40 percent in MediPass
1098	and 60 percent in managed care plans is achieved. Once that
1099	enrollment is achieved, the assignments shall be divided in
1100	order to maintain an enrollment in MediPass and managed care
1101	plans which is in a 40 percent and 60 percent proportion,
1102	respectively. In service areas 1 and 6 of the Agency for Health
1103	Care Administration geographic areas where the agency is
1104	contracting for the provision of comprehensive behavioral health
1105	services through a capitated prepaid arrangement, recipients who
1106	fail to make a choice shall be assigned equally to MediPass or a
1107	managed care plan. For purposes of this paragraph, when
1108	referring to assignment, the term "managed care plans" includes
1109	exclusive provider organizations, provider service networks,
1110	Children's Medical Services Network, minority physician
1111	networks, and pediatric emergency department diversion programs
1112	authorized by this chapter or the General Appropriations Act.
1113	When making assignments, the agency shall take into account the
1114	following criteria:
1115	1.  A managed care plan has sufficient network capacity to
1116	meet the need of members.
1117	2.  The managed care plan or MediPass has previously
1118	enrolled the recipient as a member, or one of the managed care
1119	plan's primary care providers or MediPass providers has
1120	previously provided health care to the recipient.
1121	3.  The agency has knowledge that the member has previously
1122	expressed a preference for a particular managed care plan or
1123	MediPass provider as indicated by Medicaid fee-for-service
1124	claims data, but has failed to make a choice.
1125	4.  The managed care plan's or MediPass primary care
1126	providers are geographically accessible to the recipient's
1127	residence.
1128	5.  The agency has authority to make mandatory assignments
1129	based on quality of service and performance of managed care
1130	plans.
1131	Section 15.  Section 409.9124, Florida Statutes, is amended
1132	to read:
1133	409.9124  Managed care reimbursement.--
1134	(1)  The agency shall develop and adopt by rule a
1135	methodology for reimbursing managed care plans.
1136	(1)(2)  Final managed care rates shall be published
1137	annually prior to September 1 of each year, based on methodology
1138	that:
1139	(a)  Uses Medicaid's fee-for-service expenditures.
1140	(b)  Is certified as an actuarially sound computation of
1141	Medicaid fee-for-service expenditures for comparable groups of
1142	Medicaid recipients and includes all fee-for-service
1143	expenditures, including those fee-for-service expenditures
1144	attributable to recipients who are enrolled for a portion of a
1145	year in a managed care plan or waiver program.
1146	(c)  Is compliant with applicable federal laws and
1147	regulations, including, but not limited to, the requirements to
1148	include an allowance for administrative expenses and to account
1149	for all fee-for-service expenditures, including fee-for-service
1150	expenditures for those groups enrolled for part of a year.
1151	(2)(3)  Each year prior to establishing new managed care
1152	rates, the agency shall review all prior year adjustments for
1153	changes in trend, and shall reduce or eliminate those
1154	adjustments which are not reasonable and which reflect policies
1155	or programs which are not in effect. In addition, the agency
1156	shall apply only those policy reductions applicable to the
1157	fiscal year for which the rates are being set, which can be
1158	accurately estimated and verified by an independent actuary, and
1159	which have been implemented prior to or will be implemented
1160	during the fiscal year. The agency shall pay rates at per-
1161	member, per-month averages that equal, but do not exceed, the
1162	amounts allowed for in the General Appropriations Act applicable
1163	to the fiscal year for which the rates will be in effect.
1164	(3)(4)  The agency shall by rule prescribe those items of
1165	financial information which each managed care plan shall report
1166	to the agency, in the time periods prescribed by rule. In
1167	prescribing items for reporting and definitions of terms, the
1168	agency shall consult with the Office of Insurance Regulation of
1169	the Financial Services Commission wherever possible.
1170	(4)(5)  The agency shall quarterly examine the financial
1171	condition of each managed care plan, and its performance in
1172	serving Medicaid patients, and shall utilize examinations
1173	performed by the Office of Insurance Regulation wherever
1174	possible.
1175	(5)  The agency shall develop two rates for children under
1176	1 year of age. One set of rates shall cover the month of birth
1177	through the second complete month subsequent to the month of
1178	birth, and a separate set of rates shall cover the third
1179	complete month subsequent to the month of birth through the
1180	eleventh complete month subsequent to the month of birth. The
1181	agency shall amend the payment methodology for participating
1182	Medicaid-managed health care plans to comply with this
1183	subsection.
1184	Section 16.  Section 430.041, Florida Statutes, is
1185	repealed.
1186	Section 17.  Subsection (1) of section 430.502, Florida
1187	Statutes, is amended to read:
1188	430.502  Alzheimer's disease; memory disorder clinics and
1189	day care and respite care programs.--
1190	(1)  There is established:
1191	(a)  A memory disorder clinic at each of the three medical
1192	schools in this state;
1193	(b)  A memory disorder clinic at a major private nonprofit
1194	research-oriented teaching hospital, and may fund a memory
1195	disorder clinic at any of the other affiliated teaching
1196	hospitals;
1197	(c)  A memory disorder clinic at the Mayo Clinic in
1198	Jacksonville;
1199	(d)  A memory disorder clinic at the West Florida Regional
1200	Medical Center;
1201	(e)  The East Central Florida Memory Disorder Clinic at the
1202	Joint Center for Advanced Therapeutics and Biomedical Research
1203	of the Florida Institute of Technology and Holmes Regional
1204	Medical Center, Inc.;
1205	(f)  A memory disorder clinic at the Orlando Regional
1206	Healthcare System, Inc.;
1207	(g)  A memory disorder center located in a public hospital
1208	that is operated by an independent special hospital taxing
1209	district that governs multiple hospitals and is located in a
1210	county with a population greater than 800,000 persons;
1211	(h)  A memory disorder clinic at St. Mary's Medical Center
1212	in Palm Beach County;
1213	(i)  A memory disorder clinic at Tallahassee Memorial
1214	Healthcare;
1215	(j)  A memory disorder clinic at Lee Memorial Hospital
1216	created by chapter 63-1552, Laws of Florida, as amended;
1217	(k)  A memory disorder clinic at Sarasota Memorial Hospital
1218	in Sarasota County; and
1219	(l)  A memory disorder clinic at Morton Plant Hospital,
1220	Clearwater, in Pinellas County; and,
1221	(m)  A memory disorder clinic at Florida Atlantic
1222	University, Boca Raton, in Palm Beach County,
1223
1224	for the purpose of conducting research and training in a
1225	diagnostic and therapeutic setting for persons suffering from
1226	Alzheimer's disease and related memory disorders. However,
1227	memory disorder clinics funded as of June 30, 1995, shall not
1228	receive decreased funding due solely to subsequent additions of
1229	memory disorder clinics in this subsection.
1230	Section 18.  Paragraph (d) of subsection (15) of section
1231	440.02, Florida Statutes, is amended to read:
1232	440.02  Definitions.--When used in this chapter, unless the
1233	context clearly requires otherwise, the following terms shall
1234	have the following meanings:
1235	(15)
1236	(d)  "Employee" does not include:
1237	1.  An independent contractor who is not engaged in the
1238	construction industry.
1239	a.  In order to meet the definition of independent
1240	contractor, at least four of the following criteria must be met:
1241	(I)  The independent contractor maintains a separate
1242	business with his or her own work facility, truck, equipment,
1243	materials, or similar accommodations;
1244	(II)  The independent contractor holds or has applied for a
1245	federal employer identification number, unless the independent
1246	contractor is a sole proprietor who is not required to obtain a
1247	federal employer identification number under state or federal
1248	regulations;
1249	(III)  The independent contractor receives compensation for
1250	services rendered or work performed and such compensation is
1251	paid to a business rather than to an individual;
1252	(IV)  The independent contractor holds one or more bank
1253	accounts in the name of the business entity for purposes of
1254	paying business expenses or other expenses related to services
1255	rendered or work performed for compensation;
1256	(V)  The independent contractor performs work or is able to
1257	perform work for any entity in addition to or besides the
1258	employer at his or her own election without the necessity of
1259	completing an employment application or process; or
1260	(VI)  The independent contractor receives compensation for
1261	work or services rendered on a competitive-bid basis or
1262	completion of a task or a set of tasks as defined by a
1263	contractual agreement, unless such contractual agreement
1264	expressly states that an employment relationship exists.
1265	b.  If four of the criteria listed in sub-subparagraph a.
1266	do not exist, an individual may still be presumed to be an
1267	independent contractor and not an employee based on full
1268	consideration of the nature of the individual situation with
1269	regard to satisfying any of the following conditions:
1270	(I)  The independent contractor performs or agrees to
1271	perform specific services or work for a specific amount of money
1272	and controls the means of performing the services or work.
1273	(II)  The independent contractor incurs the principal
1274	expenses related to the service or work that he or she performs
1275	or agrees to perform.
1276	(III)  The independent contractor is responsible for the
1277	satisfactory completion of the work or services that he or she
1278	performs or agrees to perform.
1279	(IV)  The independent contractor receives compensation for
1280	work or services performed for a commission or on a per-job
1281	basis and not on any other basis.
1282	(V)  The independent contractor may realize a profit or
1283	suffer a loss in connection with performing work or services.
1284	(VI)  The independent contractor has continuing or
1285	recurring business liabilities or obligations.
1286	(VII)  The success or failure of the independent
1287	contractor's business depends on the relationship of business
1288	receipts to expenditures.
1289	c.  Notwithstanding anything to the contrary in this
1290	subparagraph, an individual claiming to be an independent
1291	contractor has the burden of proving that he or she is an
1292	independent contractor for purposes of this chapter.
1293	2.  A real estate licensee, if that person agrees, in
1294	writing, to perform for remuneration solely by way of
1295	commission.
1296	3.  Bands, orchestras, and musical and theatrical
1297	performers, including disk jockeys, performing in licensed
1298	premises as defined in chapter 562, if a written contract
1299	evidencing an independent contractor relationship is entered
1300	into before the commencement of such entertainment.
1301	4.  An owner-operator of a motor vehicle who transports
1302	property under a written contract with a motor carrier which
1303	evidences a relationship by which the owner-operator assumes the
1304	responsibility of an employer for the performance of the
1305	contract, if the owner-operator is required to furnish the
1306	necessary motor vehicle equipment and all costs incidental to
1307	the performance of the contract, including, but not limited to,
1308	fuel, taxes, licenses, repairs, and hired help; and the owner-
1309	operator is paid a commission for transportation service and is
1310	not paid by the hour or on some other time-measured basis.
1311	5.  A person whose employment is both casual and not in the
1312	course of the trade, business, profession, or occupation of the
1313	employer.
1314	6.  A volunteer, except a volunteer worker for the state or
1315	a county, municipality, or other governmental entity. A person
1316	who does not receive monetary remuneration for services is
1317	presumed to be a volunteer unless there is substantial evidence
1318	that a valuable consideration was intended by both employer and
1319	employee. For purposes of this chapter, the term "volunteer"
1320	includes, but is not limited to:
1321	a.  Persons who serve in private nonprofit agencies and who
1322	receive no compensation other than expenses in an amount less
1323	than or equivalent to the standard mileage and per diem expenses
1324	provided to salaried employees in the same agency or, if such
1325	agency does not have salaried employees who receive mileage and
1326	per diem, then such volunteers who receive no compensation other
1327	than expenses in an amount less than or equivalent to the
1328	customary mileage and per diem paid to salaried workers in the
1329	community as determined by the department; and
1330	b.  Volunteers participating in federal programs
1331	established under Pub. L. No. 93-113.
1332	7.  Unless otherwise prohibited by this chapter, any
1333	officer of a corporation who elects to be exempt from this
1334	chapter. Such officer is not an employee for any reason under
1335	this chapter until the notice of revocation of election filed
1336	pursuant to s. 440.05 is effective.
1337	8.  An officer of a corporation that is engaged in the
1338	construction industry who elects to be exempt from the
1339	provisions of this chapter, as otherwise permitted by this
1340	chapter. Such officer is not an employee for any reason until
1341	the notice of revocation of election filed pursuant to s. 440.05
1342	is effective.
1343	9.  An exercise rider who does not work for a single horse
1344	farm or breeder, and who is compensated for riding on a case-by-
1345	case basis, provided a written contract is entered into prior to
1346	the commencement of such activity which evidences that an
1347	employee/employer relationship does not exist.
1348	10.  A taxicab, limousine, or other passenger vehicle-for-
1349	hire driver who operates said vehicles pursuant to a written
1350	agreement with a company which provides any dispatch, marketing,
1351	insurance, communications, or other services under which the
1352	driver and any fees or charges paid by the driver to the company
1353	for such services are not conditioned upon, or expressed as a
1354	proportion of, fare revenues.
1355	11.  A person who performs services as a sports official
1356	for an entity sponsoring an interscholastic sports event or for
1357	a public entity or private, nonprofit organization that sponsors
1358	an amateur sports event. For purposes of this subparagraph, such
1359	a person is an independent contractor. For purposes of this
1360	subparagraph, the term "sports official" means any person who is
1361	a neutral participant in a sports event, including, but not
1362	limited to, umpires, referees, judges, linespersons,
1363	scorekeepers, or timekeepers. This subparagraph does not apply
1364	to any person employed by a district school board who serves as
1365	a sports official as required by the employing school board or
1366	who serves as a sports official as part of his or her
1367	responsibilities during normal school hours.
1368	12.  Medicaid-enrolled clients under chapter 393 who are
1369	excluded from the definition of employment under s.
1370	443.1216(4)(d) and served by Adult Day Training Services under
1371	the Home and Community-Based or the Family and Supported Living
1372	Medicaid Waiver program in a sheltered workshop setting licensed
1373	by the United States Department of Labor for the purpose of
1374	training and earning less than the federal hourly minimum wage.
1375	Section 19.  Section 21 of chapter 2004-270, Laws of
1376	Florida, is amended to read:
1377	Section 20.  Notwithstanding s. 430.707, Florida Statutes,
1378	no later than September 1, 2005, or subject to federal approval
1379	of the application to be a Program of All-inclusive Care for the
1380	Elderly site, the agency shall contract with one private, not-
1381	for-profit hospice organization located in Lee County and one
1382	such organization in Martin County, such an entity shall be
1383	exempt from the requirements of chapter 641 Florida Statutes,
1384	each of which provides comprehensive services, including hospice
1385	care for frail and elderly persons. The agency shall approve 100
1386	initial enrollees in the Program of All-inclusive Care for the
1387	Elderly for the in Lee and Martin programs, subject to an
1388	appropriation by the Legislature counties. The organization in
1389	Lee County shall serve eligible residents in Lee County and in
1390	the counties contiguous to Lee County. The organization in
1391	Martin County shall serve eligible residents in Martin County
1392	and in the counties contiguous to Martin County. Each program
1393	may continue to enroll eligible residents when the Agency for
1394	Health Care Administration determines such residents to be
1395	eligible for nursing home confinement. Residents currently
1396	designated by the agency as eligible for nursing home
1397	confinement are automatically eligible for PACE program
1398	enrollment. There shall be 50 initial enrollees in each county.
1399
1400	================= T I T L E  A M E N D M E N T =================
1401	On page 77, line(s) 14, through page 79, line 20
1402	remove:  all of said lines
1403
1404	and insert:
1405	expense assistance; amending ss. 409.911, 409.9112, 409.9113,
1406	409.9117, F.S., relating to the hospital disproportionate share
1407	program; revising the method for calculating the
1408	disproportionate share payment; deleting obsolete provisions;
1409	amending s. 409.91195, F.S.; revising provisions relating to the
1410	Medicaid Pharmaceutical and Therapeutics Committee and its
1411	duties with respect to developing a preferred drug list;
1412	amending s. 409.912, F.S.; authorizing the agency to contract
1413	with comprehensive behavioral health care providers in a
1414	specified service area for the purpose of demonstrating the
1415	cost-effectiveness of quality mental health services through a
1416	public hospital-operated managed care model; providing
1417	requirements for the contract; revising the Medicaid prescribed
1418	drug spending control program; eliminating case management fees;
1419	directing the Agency for Health Care Administration to
1420	implement, and authorizing it to seek federal waivers for, the
1421	program of all-inclusive care for children; authorizing the
1422	agency to adopt rules; amending s. 409.9122, F.S.; revising a
1423	provision governing assignment to a managed care option for a
1424	Medicaid recipient who does not choose a plan or provider in
1425	certain geographic areas where the Agency for Health Care
1426	Administration contracts for comprehensive behavioral health
1427	services; amending s. 409.9124, F.S.; requiring the Agency for
1428	Health Care Administration to publish managed care reimbursement
1429	rates annually; limiting the application of certain rates and
1430	rate reductions; providing for rates applicable to children
1431	under 1 year of age; repealing s. 430.041, F.S., relating to
1432	establishing the Office of Long-Term Care Policy; amending s.
1433	430.502, F.S.; establishing a memory disorder clinic at Florida
1434	Atlantic University; amending s. 440.02, F.S.; excluding from
1435	the term "employee" as used in ch. 440, F.S., certain Medicaid-
1436	enrolled clients served under the Family and Supported Living
1437	Medicaid Waiver program; amending s. 21, ch. 2004-270, Laws of
1438	Florida; providing criteria for clientele to be served by
1439	organizations in Lee County and Martin County under the Program
1440	of All-inclusive Care for the Elderly; providing for
1441	severability;

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