Florida Senate - 2005 CONFERENCE COMMITTEE AMENDMENT
Bill No. CS for CS for SB 404
Barcode 871600
CHAMBER ACTION
Senate House
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11 The Conference Committee on CS for CS for SB 404 recommended
12 the following amendment:
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14 Conference Committee Amendment (with title amendment)
15 Delete everything after the enacting clause
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17 and insert:
18 Section 1. Section 393.0661, Flotutes, is
19 amended to read:
20 393.0661 Home and community-based services delivery
21 system; comprehensive redesign.--The Legislature finds that
22 the home and community-based services delivery system for
23 persons with developmental disabilities and the availability
24 of appropriated funds are two of the critical elements in
25 making services available. Therefore, it is the intent of the
26 Legislature that the Agency for Persons with Disabilities
27 shall develop and implement a comprehensive redesign of the
28 system.
29 (1) The redesign of the home and community-based
30 services system shall include, at a minimum, all actions
31 necessary to achieve an appropriate rate structure, client
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1 choice within a specified service package, appropriate
2 assessment strategies, an efficient billing process that
3 contains reconciliation and monitoring components, a redefined
4 role for support coordinators that avoids potential conflicts
5 of interest, and ensures that family/client budgets are linked
6 to levels of need.
7 (a) The agency shall use an assessment instrument that
8 is reliable and valid. The agency may contract with an
9 external vendor or may use support coordinators to complete
10 client assessments if it develops sufficient safeguards and
11 training to ensure ongoing inter-rater reliability.
12 (b) The agency, with the concurrence of the Agency for
13 Health Care Administration, may contract for the determination
14 of medical necessity and establishment of individual budgets.
15 (2) A provider of services rendered to persons with
16 developmental disabilities pursuant to a federally approved
17 waiver shall be reimbursed according to a rate methodology
18 based upon an analysis of the expenditure history and
19 prospective costs of providers participating in the waiver
20 program, or under any other methodology developed by the
21 Agency for Health Care Administration, in consultation with
22 the Agency for Persons with Disabilities, and approved by the
23 Federal Government in accordance with the waiver.
24 (3) Pending the adoption of rate methodologies
25 pursuant to nonemergency rulemaking under s. 120.54, the
26 Agency for Health Care Administration may, at any time, adopt
27 emergency rules under s. 120.54(4) in order to comply with
28 subsection (4). In adopting such emergency rules, the agency
29 need not make the findings required by s. 120.54(4)(a), and
30 such rules shall be exempt from time limitations provided in
31 s. 120.54(4)(c) and shall remain in effect until replaced by
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1 another emergency rule or the nonemergency adoption of the
2 rate methodology.
3 (3)(4) Nothing in this section or in any
4 administrative rule shall be construed to prevent or limit the
5 Agency for Health Care Administration, in consultation with
6 the Agency for Persons with Disabilities, from adjusting fees,
7 reimbursement rates, lengths of stay, number of visits, or
8 number of services, or from limiting enrollment, or making any
9 other adjustment necessary to comply with the availability of
10 moneys and any limitations or directions provided for in the
11 General Appropriations Act. If at any time, based upon an
12 analysis by the Agency for Health Care Administration in
13 consultation with the Agency for Persons with Disabilities,
14 the cost of home and community-based waiver services are
15 expected to exceed the appropriated amount, the Agency for
16 Health Care Administration may implement any adjustment,
17 including provider rate reductions, within 30 days in order to
18 remain within the appropriation.
19 Section 2. Paragraph (a) of subsection (3) of section
20 400.23, Florida Statutes, is amended to read:
21 400.23 Rules; evaluation and deficiencies; licensure
22 status.--
23 (3)(a) The agency shall adopt rules providing for the
24 minimum staffing requirements for nursing homes. These
25 requirements shall include, for each nursing home facility, a
26 minimum certified nursing assistant staffing of 2.3 hours of
27 direct care per resident per day beginning January 1, 2002,
28 increasing to 2.6 hours of direct care per resident per day
29 beginning January 1, 2003, and increasing to 2.9 hours of
30 direct care per resident per day beginning July 1, 2006 2005.
31 Beginning January 1, 2002, no facility shall staff below one
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1 certified nursing assistant per 20 residents, and a minimum
2 licensed nursing staffing of 1.0 hour of direct resident care
3 per resident per day but never below one licensed nurse per 40
4 residents. Nursing assistants employed under s. 400.211(2) may
5 be included in computing the staffing ratio for certified
6 nursing assistants only if they provide nursing assistance
7 services to residents on a full-time basis. Each nursing home
8 must document compliance with staffing standards as required
9 under this paragraph and post daily the names of staff on duty
10 for the benefit of facility residents and the public. The
11 agency shall recognize the use of licensed nurses for
12 compliance with minimum staffing requirements for certified
13 nursing assistants, provided that the facility otherwise meets
14 the minimum staffing requirements for licensed nurses and that
15 the licensed nurses so recognized are performing the duties of
16 a certified nursing assistant. Unless otherwise approved by
17 the agency, licensed nurses counted toward the minimum
18 staffing requirements for certified nursing assistants must
19 exclusively perform the duties of a certified nursing
20 assistant for the entire shift and shall not also be counted
21 toward the minimum staffing requirements for licensed nurses.
22 If the agency approved a facility's request to use a licensed
23 nurse to perform both licensed nursing and certified nursing
24 assistant duties, the facility must allocate the amount of
25 staff time specifically spent on certified nursing assistant
26 duties for the purpose of documenting compliance with minimum
27 staffing requirements for certified and licensed nursing
28 staff. In no event may the hours of a licensed nurse with dual
29 job responsibilities be counted twice.
30 Section 3. Subsection (4) of section 408.034, Florida
31 Statutes, is amended to read:
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1 408.034 Duties and responsibilities of agency;
2 rules.--
3 (4) Prior to determining that there is a need for
4 additional community nursing facility beds in any area of the
5 state, the agency shall determine that the need cannot be met
6 through the provision, enhancement, or expansion of home and
7 community-based services. In determining such need, the agency
8 shall examine nursing home placement patterns and demographic
9 patterns of persons entering nursing homes and the
10 availability of and effectiveness of existing home-based and
11 community-based service delivery systems at meeting the
12 long-term care needs of the population. The agency shall
13 recommend to the Legislature Office of Long-Term Care Policy
14 changes that could be made to existing home-based and
15 community-based delivery systems to lessen the need for
16 additional nursing facility beds.
17 Section 4. Subsection (5) of section 409.903, Florida
18 Statutes, is amended to read:
19 409.903 Mandatory payments for eligible persons.--The
20 agency shall make payments for medical assistance and related
21 services on behalf of the following persons who the
22 department, or the Social Security Administration by contract
23 with the Department of Children and Family Services,
24 determines to be eligible, subject to the income, assets, and
25 categorical eligibility tests set forth in federal and state
26 law. Payment on behalf of these Medicaid eligible persons is
27 subject to the availability of moneys and any limitations
28 established by the General Appropriations Act or chapter 216.
29 (5) A pregnant woman for the duration of her pregnancy
30 and for the postpartum period as defined in federal law and
31 rule, or a child under age 1, if either is living in a family
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1 that has an income which is at or below 150 percent of the
2 most current federal poverty level, or, effective January 1,
3 1992, that has an income which is at or below 185 percent of
4 the most current federal poverty level. Such a person is not
5 subject to an assets test. Further, a pregnant woman who
6 applies for eligibility for the Medicaid program through a
7 qualified Medicaid provider must be offered the opportunity,
8 subject to federal rules, to be made presumptively eligible
9 for the Medicaid program. Effective July 1, 2005, eligibility
10 for Medicaid services is eliminated for women who have incomes
11 above 150 percent of the most current federal poverty level.
12 Section 5. Subsections (1) and (2) of section 409.904,
13 Florida Statutes, are amended to read:
14 409.904 Optional payments for eligible persons.--The
15 agency may make payments for medical assistance and related
16 services on behalf of the following persons who are determined
17 to be eligible subject to the income, assets, and categorical
18 eligibility tests set forth in federal and state law. Payment
19 on behalf of these Medicaid eligible persons is subject to the
20 availability of moneys and any limitations established by the
21 General Appropriations Act or chapter 216.
22 (1)(a) From July 1, 2005, through December 31, 2005, a
23 person who is age 65 or older or is determined to be disabled,
24 whose income is at or below 88 percent of federal poverty
25 level, and whose assets do not exceed established limitations.
26 (b) Effective January 1, 2006, and subject to federal
27 waiver approval, a person who is age 65 or older or is
28 determined to be disabled, whose income is at or below 88
29 percent of the federal poverty level, whose assets do not
30 exceed established limitations, and who is not eligible for
31 Medicare or, if eligible for Medicare, is also eligible for
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1 and receiving Medicaid-covered institutional care services,
2 hospice services, or home and community-based services. The
3 agency shall seek federal authorization through a waiver to
4 provide this coverage.
5 (2) A family, a pregnant woman, a child under age 21,
6 a person age 65 or over, or a blind or disabled person, who
7 would be eligible under any group listed in s. 409.903(1),
8 (2), or (3), except that the income or assets of such family
9 or person exceed established limitations. For a family or
10 person in one of these coverage groups, medical expenses are
11 deductible from income in accordance with federal requirements
12 in order to make a determination of eligibility. A family or
13 person eligible under the coverage known as the "medically
14 needy," is eligible to receive the same services as other
15 Medicaid recipients, with the exception of services in skilled
16 nursing facilities and intermediate care facilities for the
17 developmentally disabled. Effective July 1, 2005, the
18 medically needy are eligible for prescribed drug services
19 only.
20 Section 6. Paragraph (b) of subsection (1) of section
21 409.906, Florida Statutes, is amended to read:
22 409.906 Optional Medicaid services.--Subject to
23 specific appropriations, the agency may make payments for
24 services which are optional to the state under Title XIX of
25 the Social Security Act and are furnished by Medicaid
26 providers to recipients who are determined to be eligible on
27 the dates on which the services were provided. Any optional
28 service that is provided shall be provided only when medically
29 necessary and in accordance with state and federal law.
30 Optional services rendered by providers in mobile units to
31 Medicaid recipients may be restricted or prohibited by the
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1 agency. Nothing in this section shall be construed to prevent
2 or limit the agency from adjusting fees, reimbursement rates,
3 lengths of stay, number of visits, or number of services, or
4 making any other adjustments necessary to comply with the
5 availability of moneys and any limitations or directions
6 provided for in the General Appropriations Act or chapter 216.
7 If necessary to safeguard the state's systems of providing
8 services to elderly and disabled persons and subject to the
9 notice and review provisions of s. 216.177, the Governor may
10 direct the Agency for Health Care Administration to amend the
11 Medicaid state plan to delete the optional Medicaid service
12 known as "Intermediate Care Facilities for the Developmentally
13 Disabled." Optional services may include:
14 (1) ADULT DENTAL SERVICES.--
15 (b) Beginning January 1, 2005, the agency may pay for
16 dentures, the procedures required to seat dentures, and the
17 repair and reline of dentures, provided by or under the
18 direction of a licensed dentist, for a recipient who is 21
19 years of age or older. This paragraph is repealed effective
20 July 1, 2005.
21 Section 7. Effective January 1, 2006, section
22 409.9065, Florida Statutes, is repealed.
23 Section 8. Subsection (2) of section 409.907, Florida
24 Statutes, is amended to read:
25 409.907 Medicaid provider agreements.--The agency may
26 make payments for medical assistance and related services
27 rendered to Medicaid recipients only to an individual or
28 entity who has a provider agreement in effect with the agency,
29 who is performing services or supplying goods in accordance
30 with federal, state, and local law, and who agrees that no
31 person shall, on the grounds of handicap, race, color, or
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1 national origin, or for any other reason, be subjected to
2 discrimination under any program or activity for which the
3 provider receives payment from the agency.
4 (2) Each provider agreement shall be a voluntary
5 contract between the agency and the provider, in which the
6 provider agrees to comply with all laws and rules pertaining
7 to the Medicaid program when furnishing a service or goods to
8 a Medicaid recipient and the agency agrees to pay a sum,
9 determined by the agency fee schedule, payment methodology, or
10 other manner, for the service or goods provided to the
11 Medicaid recipient. The agency may require a provider to be
12 subject to a fee or rate schedule or other payment
13 methodology, but a fee or rate schedule or any payment
14 methodology shall not be incorporated into the provider
15 agreement or any other agreement relating to the provision of
16 Medicaid goods or services. The provider agreement and other
17 agreement shall require that the provider agrees to accept the
18 compensation established from time to time by the agency for
19 Medicaid goods and services. Each provider agreement shall be
20 effective for a stipulated period of time, shall be terminable
21 by either party after reasonable notice, and shall be
22 renewable by mutual agreement. Provider agreements and other
23 agreements relating to the provision of Medicaid goods and
24 services shall be renewed or amended only in writing. Any term
25 of any provider agreement or other Medicaid agreement which is
26 inconsistent with this section shall be amended by operation
27 of law to conform to the requirements set forth in this
28 subsection.
29 Section 9. Section 409.908, Florida Statutes, is
30 amended to read:
31 409.908 Reimbursement of Medicaid providers.--Subject
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1 to specific appropriations, the agency shall reimburse
2 Medicaid providers, in accordance with state and federal law,
3 according to published methodologies set forth in the rules of
4 the agency and in policy manuals and handbooks incorporated by
5 reference therein. These methodologies may include fee
6 schedules, reimbursement methods based on cost reporting,
7 negotiated fees, competitive bidding pursuant to s. 287.057,
8 and other mechanisms the agency considers efficient and
9 effective for purchasing services or goods on behalf of
10 recipients. If a provider is reimbursed based on cost
11 reporting and submits a cost report late and that cost report
12 would have been used to set a lower reimbursement rate for a
13 rate semester, then the provider's rate for that semester
14 shall be retroactively calculated using the new cost report,
15 and full payment at the recalculated rate shall be effected
16 retroactively. Medicare-granted extensions for filing cost
17 reports, if applicable, shall also apply to Medicaid cost
18 reports. Payment for Medicaid compensable services made on
19 behalf of Medicaid eligible persons is subject to the
20 availability of moneys and any limitations or directions
21 provided for in the General Appropriations Act or chapter 216.
22 The agency may adjust Further, nothing in this section shall
23 be construed to prevent or limit the agency from adjusting
24 fees, reimbursement rates, lengths of stay, number of visits,
25 or number of services, or make making any other adjustments
26 necessary to comply with the availability of moneys and any
27 limitations or directions provided for in the General
28 Appropriations Act, provided the adjustment is consistent with
29 legislative intent.
30 (1) Reimbursement to hospitals licensed under part I
31 of chapter 395 must be made prospectively or on the basis of
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1 negotiation.
2 (a) Reimbursement for inpatient care is limited as
3 provided for in s. 409.905(5), except for:
4 1. The raising of rate reimbursement caps, excluding
5 rural hospitals.
6 2. Recognition of the costs of graduate medical
7 education.
8 3. Other methodologies recognized in the General
9 Appropriations Act.
10 4. Hospital inpatient rates shall be reduced by 6
11 percent effective July 1, 2001, and restored effective April
12 1, 2002.
13
14 During the years funds are transferred from the Department of
15 Health, any reimbursement supported by such funds shall be
16 subject to certification by the Department of Health that the
17 hospital has complied with s. 381.0403. The agency is
18 authorized to receive funds from state entities, including,
19 but not limited to, the Department of Health, local
20 governments, and other local political subdivisions, for the
21 purpose of making special exception payments, including
22 federal matching funds, through the Medicaid inpatient
23 reimbursement methodologies. Funds received from state
24 entities or local governments for this purpose shall be
25 separately accounted for and shall not be commingled with
26 other state or local funds in any manner. The agency may
27 certify all local governmental funds used as state match under
28 Title XIX of the Social Security Act, to the extent that the
29 identified local health care provider that is otherwise
30 entitled to and is contracted to receive such local funds is
31 the benefactor under the state's Medicaid program as
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1 determined under the General Appropriations Act and pursuant
2 to an agreement between the Agency for Health Care
3 Administration and the local governmental entity. The local
4 governmental entity shall use a certification form prescribed
5 by the agency. At a minimum, the certification form shall
6 identify the amount being certified and describe the
7 relationship between the certifying local governmental entity
8 and the local health care provider. The agency shall prepare
9 an annual statement of impact which documents the specific
10 activities undertaken during the previous fiscal year pursuant
11 to this paragraph, to be submitted to the Legislature no later
12 than January 1, annually.
13 (b) Reimbursement for hospital outpatient care is
14 limited to $1,500 per state fiscal year per recipient, except
15 for:
16 1. Such care provided to a Medicaid recipient under
17 age 21, in which case the only limitation is medical
18 necessity.
19 2. Renal dialysis services.
20 3. Other exceptions made by the agency.
21
22 The agency is authorized to receive funds from state entities,
23 including, but not limited to, the Department of Health, the
24 Board of Regents, local governments, and other local political
25 subdivisions, for the purpose of making payments, including
26 federal matching funds, through the Medicaid outpatient
27 reimbursement methodologies. Funds received from state
28 entities and local governments for this purpose shall be
29 separately accounted for and shall not be commingled with
30 other state or local funds in any manner.
31 (c) Hospitals that provide services to a
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1 disproportionate share of low-income Medicaid recipients, or
2 that participate in the regional perinatal intensive care
3 center program under chapter 383, or that participate in the
4 statutory teaching hospital disproportionate share program may
5 receive additional reimbursement. The total amount of payment
6 for disproportionate share hospitals shall be fixed by the
7 General Appropriations Act. The computation of these payments
8 must be made in compliance with all federal regulations and
9 the methodologies described in ss. 409.911, 409.9112, and
10 409.9113.
11 (d) The agency is authorized to limit inflationary
12 increases for outpatient hospital services as directed by the
13 General Appropriations Act.
14 (2)(a)1. Reimbursement to nursing homes licensed under
15 part II of chapter 400 and state-owned-and-operated
16 intermediate care facilities for the developmentally disabled
17 licensed under chapter 393 must be made prospectively.
18 2. Unless otherwise limited or directed in the General
19 Appropriations Act, reimbursement to hospitals licensed under
20 part I of chapter 395 for the provision of swing-bed nursing
21 home services must be made on the basis of the average
22 statewide nursing home payment, and reimbursement to a
23 hospital licensed under part I of chapter 395 for the
24 provision of skilled nursing services must be made on the
25 basis of the average nursing home payment for those services
26 in the county in which the hospital is located. When a
27 hospital is located in a county that does not have any
28 community nursing homes, reimbursement must be determined by
29 averaging the nursing home payments, in counties that surround
30 the county in which the hospital is located. Reimbursement to
31 hospitals, including Medicaid payment of Medicare copayments,
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1 for skilled nursing services shall be limited to 30 days,
2 unless a prior authorization has been obtained from the
3 agency. Medicaid reimbursement may be extended by the agency
4 beyond 30 days, and approval must be based upon verification
5 by the patient's physician that the patient requires
6 short-term rehabilitative and recuperative services only, in
7 which case an extension of no more than 15 days may be
8 approved. Reimbursement to a hospital licensed under part I of
9 chapter 395 for the temporary provision of skilled nursing
10 services to nursing home residents who have been displaced as
11 the result of a natural disaster or other emergency may not
12 exceed the average county nursing home payment for those
13 services in the county in which the hospital is located and is
14 limited to the period of time which the agency considers
15 necessary for continued placement of the nursing home
16 residents in the hospital.
17 (b) Subject to any limitations or directions provided
18 for in the General Appropriations Act, the agency shall
19 establish and implement a Florida Title XIX Long-Term Care
20 Reimbursement Plan (Medicaid) for nursing home care in order
21 to provide care and services in conformance with the
22 applicable state and federal laws, rules, regulations, and
23 quality and safety standards and to ensure that individuals
24 eligible for medical assistance have reasonable geographic
25 access to such care.
26 1. Changes of ownership or of licensed operator do not
27 qualify for increases in reimbursement rates associated with
28 the change of ownership or of licensed operator. The agency
29 shall amend the Title XIX Long Term Care Reimbursement Plan to
30 provide that the initial nursing home reimbursement rates, for
31 the operating, patient care, and MAR components, associated
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1 with related and unrelated party changes of ownership or
2 licensed operator filed on or after September 1, 2001, are
3 equivalent to the previous owner's reimbursement rate.
4 2. The agency shall amend the long-term care
5 reimbursement plan and cost reporting system to create direct
6 care and indirect care subcomponents of the patient care
7 component of the per diem rate. These two subcomponents
8 together shall equal the patient care component of the per
9 diem rate. Separate cost-based ceilings shall be calculated
10 for each patient care subcomponent. The direct care
11 subcomponent of the per diem rate shall be limited by the
12 cost-based class ceiling, and the indirect care subcomponent
13 shall be limited by the lower of the cost-based class ceiling,
14 by the target rate class ceiling, or by the individual
15 provider target. The agency shall adjust the patient care
16 component effective January 1, 2002. The cost to adjust the
17 direct care subcomponent shall be net of the total funds
18 previously allocated for the case mix add-on. The agency shall
19 make the required changes to the nursing home cost reporting
20 forms to implement this requirement effective January 1, 2002.
21 3. The direct care subcomponent shall include salaries
22 and benefits of direct care staff providing nursing services
23 including registered nurses, licensed practical nurses, and
24 certified nursing assistants who deliver care directly to
25 residents in the nursing home facility. This excludes nursing
26 administration, minimum data set MDS, and care plan
27 coordinators, staff development, and staffing coordinator.
28 4. All other patient care costs shall be included in
29 the indirect care cost subcomponent of the patient care per
30 diem rate. There shall be no costs directly or indirectly
31 allocated to the direct care subcomponent from a home office
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1 or management company.
2 5. On July 1 of each year, the agency shall report to
3 the Legislature direct and indirect care costs, including
4 average direct and indirect care costs per resident per
5 facility and direct care and indirect care salaries and
6 benefits per category of staff member per facility.
7 6. In order to offset the cost of general and
8 professional liability insurance, the agency shall amend the
9 plan to allow for interim rate adjustments to reflect
10 increases in the cost of general or professional liability
11 insurance for nursing homes. This provision shall be
12 implemented to the extent existing appropriations are
13 available.
14
15 It is the intent of the Legislature that the reimbursement
16 plan achieve the goal of providing access to health care for
17 nursing home residents who require large amounts of care while
18 encouraging diversion services as an alternative to nursing
19 home care for residents who can be served within the
20 community. The agency shall base the establishment of any
21 maximum rate of payment, whether overall or component, on the
22 available moneys as provided for in the General Appropriations
23 Act. The agency may base the maximum rate of payment on the
24 results of scientifically valid analysis and conclusions
25 derived from objective statistical data pertinent to the
26 particular maximum rate of payment.
27 (3) Subject to any limitations or directions provided
28 for in the General Appropriations Act, the following Medicaid
29 services and goods may be reimbursed on a fee-for-service
30 basis. For each allowable service or goods furnished in
31 accordance with Medicaid rules, policy manuals, handbooks, and
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1 state and federal law, the payment shall be the amount billed
2 by the provider, the provider's usual and customary charge, or
3 the maximum allowable fee established by the agency, whichever
4 amount is less, with the exception of those services or goods
5 for which the agency makes payment using a methodology based
6 on capitation rates, average costs, or negotiated fees.
7 (a) Advanced registered nurse practitioner services.
8 (b) Birth center services.
9 (c) Chiropractic services.
10 (d) Community mental health services.
11 (e) Dental services, including oral and maxillofacial
12 surgery.
13 (f) Durable medical equipment.
14 (g) Hearing services.
15 (h) Occupational therapy for Medicaid recipients under
16 age 21.
17 (i) Optometric services.
18 (j) Orthodontic services.
19 (k) Personal care for Medicaid recipients under age
20 21.
21 (l) Physical therapy for Medicaid recipients under age
22 21.
23 (m) Physician assistant services.
24 (n) Podiatric services.
25 (o) Portable X-ray services.
26 (p) Private-duty nursing for Medicaid recipients under
27 age 21.
28 (q) Registered nurse first assistant services.
29 (r) Respiratory therapy for Medicaid recipients under
30 age 21.
31 (s) Speech therapy for Medicaid recipients under age
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1 21.
2 (t) Visual services.
3 (4) Subject to any limitations or directions provided
4 for in the General Appropriations Act, alternative health
5 plans, health maintenance organizations, and prepaid health
6 plans shall be reimbursed a fixed, prepaid amount negotiated,
7 or competitively bid pursuant to s. 287.057, by the agency and
8 prospectively paid to the provider monthly for each Medicaid
9 recipient enrolled. The amount may not exceed the average
10 amount the agency determines it would have paid, based on
11 claims experience, for recipients in the same or similar
12 category of eligibility. The agency shall calculate capitation
13 rates on a regional basis and, beginning September 1, 1995,
14 shall include age-band differentials in such calculations.
15 (5) An ambulatory surgical center shall be reimbursed
16 the lesser of the amount billed by the provider or the
17 Medicare-established allowable amount for the facility.
18 (6) A provider of early and periodic screening,
19 diagnosis, and treatment services to Medicaid recipients who
20 are children under age 21 shall be reimbursed using an
21 all-inclusive rate stipulated in a fee schedule established by
22 the agency. A provider of the visual, dental, and hearing
23 components of such services shall be reimbursed the lesser of
24 the amount billed by the provider or the Medicaid maximum
25 allowable fee established by the agency.
26 (7) A provider of family planning services shall be
27 reimbursed the lesser of the amount billed by the provider or
28 an all-inclusive amount per type of visit for physicians and
29 advanced registered nurse practitioners, as established by the
30 agency in a fee schedule.
31 (8) A provider of home-based or community-based
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1 services rendered pursuant to a federally approved waiver
2 shall be reimbursed based on an established or negotiated rate
3 for each service. These rates shall be established according
4 to an analysis of the expenditure history and prospective
5 budget developed by each contract provider participating in
6 the waiver program, or under any other methodology adopted by
7 the agency and approved by the Federal Government in
8 accordance with the waiver. Effective July 1, 1996, privately
9 owned and operated community-based residential facilities
10 which meet agency requirements and which formerly received
11 Medicaid reimbursement for the optional intermediate care
12 facility for the mentally retarded service may participate in
13 the developmental services waiver as part of a
14 home-and-community-based continuum of care for Medicaid
15 recipients who receive waiver services.
16 (9) A provider of home health care services or of
17 medical supplies and appliances shall be reimbursed on the
18 basis of competitive bidding or for the lesser of the amount
19 billed by the provider or the agency's established maximum
20 allowable amount, except that, in the case of the rental of
21 durable medical equipment, the total rental payments may not
22 exceed the purchase price of the equipment over its expected
23 useful life or the agency's established maximum allowable
24 amount, whichever amount is less.
25 (10) A hospice shall be reimbursed through a
26 prospective system for each Medicaid hospice patient at
27 Medicaid rates using the methodology established for hospice
28 reimbursement pursuant to Title XVIII of the federal Social
29 Security Act.
30 (11) A provider of independent laboratory services
31 shall be reimbursed on the basis of competitive bidding or for
19
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1 the least of the amount billed by the provider, the provider's
2 usual and customary charge, or the Medicaid maximum allowable
3 fee established by the agency.
4 (12)(a) A physician shall be reimbursed the lesser of
5 the amount billed by the provider or the Medicaid maximum
6 allowable fee established by the agency.
7 (b) The agency shall adopt a fee schedule, subject to
8 any limitations or directions provided for in the General
9 Appropriations Act, based on a resource-based relative value
10 scale for pricing Medicaid physician services. Under this fee
11 schedule, physicians shall be paid a dollar amount for each
12 service based on the average resources required to provide the
13 service, including, but not limited to, estimates of average
14 physician time and effort, practice expense, and the costs of
15 professional liability insurance. The fee schedule shall
16 provide increased reimbursement for preventive and primary
17 care services and lowered reimbursement for specialty services
18 by using at least two conversion factors, one for cognitive
19 services and another for procedural services. The fee
20 schedule shall not increase total Medicaid physician
21 expenditures unless moneys are available, and shall be phased
22 in over a 2-year period beginning on July 1, 1994. The Agency
23 for Health Care Administration shall seek the advice of a
24 16-member advisory panel in formulating and adopting the fee
25 schedule. The panel shall consist of Medicaid physicians
26 licensed under chapters 458 and 459 and shall be composed of
27 50 percent primary care physicians and 50 percent specialty
28 care physicians.
29 (c) Notwithstanding paragraph (b), reimbursement fees
30 to physicians for providing total obstetrical services to
31 Medicaid recipients, which include prenatal, delivery, and
20
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1 postpartum care, shall be at least $1,500 per delivery for a
2 pregnant woman with low medical risk and at least $2,000 per
3 delivery for a pregnant woman with high medical risk. However,
4 reimbursement to physicians working in Regional Perinatal
5 Intensive Care Centers designated pursuant to chapter 383, for
6 services to certain pregnant Medicaid recipients with a high
7 medical risk, may be made according to obstetrical care and
8 neonatal care groupings and rates established by the agency.
9 Nurse midwives licensed under part I of chapter 464 or
10 midwives licensed under chapter 467 shall be reimbursed at no
11 less than 80 percent of the low medical risk fee. The agency
12 shall by rule determine, for the purpose of this paragraph,
13 what constitutes a high or low medical risk pregnant woman and
14 shall not pay more based solely on the fact that a caesarean
15 section was performed, rather than a vaginal delivery. The
16 agency shall by rule determine a prorated payment for
17 obstetrical services in cases where only part of the total
18 prenatal, delivery, or postpartum care was performed. The
19 Department of Health shall adopt rules for appropriate
20 insurance coverage for midwives licensed under chapter 467.
21 Prior to the issuance and renewal of an active license, or
22 reactivation of an inactive license for midwives licensed
23 under chapter 467, such licensees shall submit proof of
24 coverage with each application.
25 (13) Medicare premiums for persons eligible for both
26 Medicare and Medicaid coverage shall be paid at the rates
27 established by Title XVIII of the Social Security Act. For
28 Medicare services rendered to Medicaid-eligible persons,
29 Medicaid shall pay Medicare deductibles and coinsurance as
30 follows:
31 (a) Medicaid shall make no payment toward deductibles
21
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1 and coinsurance for any service that is not covered by
2 Medicaid.
3 (b) Medicaid's financial obligation for deductibles
4 and coinsurance payments shall be based on Medicare allowable
5 fees, not on a provider's billed charges.
6 (c) Medicaid will pay no portion of Medicare
7 deductibles and coinsurance when payment that Medicare has
8 made for the service equals or exceeds what Medicaid would
9 have paid if it had been the sole payor. The combined payment
10 of Medicare and Medicaid shall not exceed the amount Medicaid
11 would have paid had it been the sole payor. The Legislature
12 finds that there has been confusion regarding the
13 reimbursement for services rendered to dually eligible
14 Medicare beneficiaries. Accordingly, the Legislature clarifies
15 that it has always been the intent of the Legislature before
16 and after 1991 that, in reimbursing in accordance with fees
17 established by Title XVIII for premiums, deductibles, and
18 coinsurance for Medicare services rendered by physicians to
19 Medicaid eligible persons, physicians be reimbursed at the
20 lesser of the amount billed by the physician or the Medicaid
21 maximum allowable fee established by the Agency for Health
22 Care Administration, as is permitted by federal law. It has
23 never been the intent of the Legislature with regard to such
24 services rendered by physicians that Medicaid be required to
25 provide any payment for deductibles, coinsurance, or
26 copayments for Medicare cost sharing, or any expenses incurred
27 relating thereto, in excess of the payment amount provided for
28 under the State Medicaid plan for such service. This payment
29 methodology is applicable even in those situations in which
30 the payment for Medicare cost sharing for a qualified Medicare
31 beneficiary with respect to an item or service is reduced or
22
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1 eliminated. This expression of the Legislature is in
2 clarification of existing law and shall apply to payment for,
3 and with respect to provider agreements with respect to, items
4 or services furnished on or after the effective date of this
5 act. This paragraph applies to payment by Medicaid for items
6 and services furnished before the effective date of this act
7 if such payment is the subject of a lawsuit that is based on
8 the provisions of this section, and that is pending as of, or
9 is initiated after, the effective date of this act.
10 (d) Notwithstanding paragraphs (a)-(c):
11 1. Medicaid payments for Nursing Home Medicare part A
12 coinsurance shall be the lesser of the Medicare coinsurance
13 amount or the Medicaid nursing home per diem rate.
14 2. Medicaid shall pay all deductibles and coinsurance
15 for Medicare-eligible recipients receiving freestanding end
16 stage renal dialysis center services.
17 3. Medicaid payments for general hospital inpatient
18 services shall be limited to the Medicare deductible per spell
19 of illness. Medicaid shall make no payment toward coinsurance
20 for Medicare general hospital inpatient services.
21 4. Medicaid shall pay all deductibles and coinsurance
22 for Medicare emergency transportation services provided by
23 ambulances licensed pursuant to chapter 401.
24 (14) A provider of prescribed drugs shall be
25 reimbursed the least of the amount billed by the provider, the
26 provider's usual and customary charge, or the Medicaid maximum
27 allowable fee established by the agency, plus a dispensing
28 fee. The Medicaid maximum allowable fee for ingredient cost
29 will be based on the lower of: average wholesale price (AWP)
30 minus 15.4 percent, wholesaler acquisition cost (WAC) plus
31 5.75 percent, the federal upper limit (FUL), the state maximum
23
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1 allowable cost (SMAC), or the usual and customary (UAC) charge
2 billed by the provider. Medicaid providers are required to
3 dispense generic drugs if available at lower cost and the
4 agency has not determined that the branded product is more
5 cost-effective, unless the prescriber has requested and
6 received approval to require the branded product. The agency
7 is directed to implement a variable dispensing fee for
8 payments for prescribed medicines while ensuring continued
9 access for Medicaid recipients. The variable dispensing fee
10 may be based upon, but not limited to, either or both the
11 volume of prescriptions dispensed by a specific pharmacy
12 provider, the volume of prescriptions dispensed to an
13 individual recipient, and dispensing of preferred-drug-list
14 products. The agency may increase the pharmacy dispensing fee
15 authorized by statute and in the annual General Appropriations
16 Act by $0.50 for the dispensing of a Medicaid
17 preferred-drug-list product and reduce the pharmacy dispensing
18 fee by $0.50 for the dispensing of a Medicaid product that is
19 not included on the preferred drug list. The agency may
20 establish a supplemental pharmaceutical dispensing fee to be
21 paid to providers returning unused unit-dose packaged
22 medications to stock and crediting the Medicaid program for
23 the ingredient cost of those medications if the ingredient
24 costs to be credited exceed the value of the supplemental
25 dispensing fee. The agency is authorized to limit
26 reimbursement for prescribed medicine in order to comply with
27 any limitations or directions provided for in the General
28 Appropriations Act, which may include implementing a
29 prospective or concurrent utilization review program.
30 (15) A provider of primary care case management
31 services rendered pursuant to a federally approved waiver
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1 shall be reimbursed by payment of a fixed, prepaid monthly sum
2 for each Medicaid recipient enrolled with the provider.
3 (16) A provider of rural health clinic services and
4 federally qualified health center services shall be reimbursed
5 a rate per visit based on total reasonable costs of the
6 clinic, as determined by the agency in accordance with federal
7 regulations.
8 (17) A provider of targeted case management services
9 shall be reimbursed pursuant to an established fee, except
10 where the Federal Government requires a public provider be
11 reimbursed on the basis of average actual costs.
12 (18) Unless otherwise provided for in the General
13 Appropriations Act, a provider of transportation services
14 shall be reimbursed the lesser of the amount billed by the
15 provider or the Medicaid maximum allowable fee established by
16 the agency, except when the agency has entered into a direct
17 contract with the provider, or with a community transportation
18 coordinator, for the provision of an all-inclusive service, or
19 when services are provided pursuant to an agreement negotiated
20 between the agency and the provider. The agency, as provided
21 for in s. 427.0135, shall purchase transportation services
22 through the community coordinated transportation system, if
23 available, unless the agency determines a more cost-effective
24 method for Medicaid clients. Nothing in this subsection shall
25 be construed to limit or preclude the agency from contracting
26 for services using a prepaid capitation rate or from
27 establishing maximum fee schedules, individualized
28 reimbursement policies by provider type, negotiated fees,
29 prior authorization, competitive bidding, increased use of
30 mass transit, or any other mechanism that the agency considers
31 efficient and effective for the purchase of services on behalf
25
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1 of Medicaid clients, including implementing a transportation
2 eligibility process. The agency shall not be required to
3 contract with any community transportation coordinator or
4 transportation operator that has been determined by the
5 agency, the Department of Legal Affairs Medicaid Fraud Control
6 Unit, or any other state or federal agency to have engaged in
7 any abusive or fraudulent billing activities. The agency is
8 authorized to competitively procure transportation services or
9 make other changes necessary to secure approval of federal
10 waivers needed to permit federal financing of Medicaid
11 transportation services at the service matching rate rather
12 than the administrative matching rate.
13 (19) County health department services shall be
14 reimbursed a rate per visit based on total reasonable costs of
15 the clinic, as determined by the agency in accordance with
16 federal regulations under the authority of 42 C.F.R. s.
17 431.615.
18 (20) A renal dialysis facility that provides dialysis
19 services under s. 409.906(9) must be reimbursed the lesser of
20 the amount billed by the provider, the provider's usual and
21 customary charge, or the maximum allowable fee established by
22 the agency, whichever amount is less.
23 (21) The agency shall reimburse school districts which
24 certify the state match pursuant to ss. 409.9071 and 1011.70
25 for the federal portion of the school district's allowable
26 costs to deliver the services, based on the reimbursement
27 schedule. The school district shall determine the costs for
28 delivering services as authorized in ss. 409.9071 and 1011.70
29 for which the state match will be certified. Reimbursement of
30 school-based providers is contingent on such providers being
31 enrolled as Medicaid providers and meeting the qualifications
26
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1 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
2 the federal Health Care Financing Administration. Speech
3 therapy providers who are certified through the Department of
4 Education pursuant to rule 6A-4.0176, Florida Administrative
5 Code, are eligible for reimbursement for services that are
6 provided on school premises. Any employee of the school
7 district who has been fingerprinted and has received a
8 criminal background check in accordance with Department of
9 Education rules and guidelines shall be exempt from any agency
10 requirements relating to criminal background checks.
11 (22) The agency shall request and implement Medicaid
12 waivers from the federal Health Care Financing Administration
13 to advance and treat a portion of the Medicaid nursing home
14 per diem as capital for creating and operating a
15 risk-retention group for self-insurance purposes, consistent
16 with federal and state laws and rules.
17 Section 10. Section 409.9082, Florida Statutes, is
18 created to read:
19 409.9082 Medicaid rate-setting process.--The agency is
20 authorized to adopt fees, rates, or other methods of payment
21 for Medicaid goods and services which may be amended from time
22 to time consistent with the needs of the state Medicaid
23 program and any limitations or directions provided for in the
24 General Appropriations Act. The agency is not required to
25 comply with chapter 120 when setting rates and methods of
26 payment. The substance of Medicaid rates are not subject to
27 judicial review, except to the extent decisions setting rates
28 or methods of payment violate the State Constitution or
29 federal law.
30 (1) For determining rates of payment for hospital
31 services, nursing facility services, and services for
27
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1 intermediate care facilities for the developmentally disabled:
2 (a) Notice of proposed rate methodologies and
3 justifications for the proposed rate methodologies shall be
4 published in the Florida Administrative Weekly.
5 1. The notice must generally describe the proposed
6 changes in rate methodologies and the justification for change
7 so as to put interested persons on reasonable notice of
8 proposed changes of rates and methodologies and their
9 justification.
10 2. The notice must state how or where proposed rate
11 methodologies and justifications can be obtained.
12 3. The notice must state that comments will be
13 received, the period of time during which they will be
14 received, and the person to whom they should be sent.
15 (b) Providers, beneficiaries and their
16 representatives, and other concerned state residents shall be
17 given a reasonable opportunity to review and comment on the
18 proposed rate methodologies and justifications.
19 (c) Notice of final rate methodologies and
20 justifications for such final rate methodologies shall be
21 published in the Florida Administrative Weekly. The notice
22 must generally describe the final rate methodologies and the
23 justification for change so as to put interested persons on
24 reasonable notice of the substance of final rate methodologies
25 and their justification.
26 (d) The notice must state how or where final rate
27 methodologies and justifications can be obtained.
28 (2) For determining all other rates or methods of
29 payment:
30 (a) Notice shall be published in the Florida
31 Administrative Weekly at least 48 hours before the effective
28
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1 date of the rate.
2 (b) The notice must:
3 1. Generally describe the proposed changes in rates or
4 methodologies and the justification for change so as to put
5 interested persons on reasonable notice of proposed changes of
6 rates and methodologies and their justification;
7 2. Estimate any changes in annual aggregate
8 expenditures caused or anticipated by the change;
9 3. State how or where the proposed changes in rates or
10 methodologies and the justification may be obtained; and
11 4. State where comments may be sent.
12 Section 11. Paragraphs (a) and (b) of subsection (2)
13 and paragraph (b) of subsection (4) of section 409.911,
14 Florida Statutes, are amended to read:
15 409.911 Disproportionate share program.--Subject to
16 specific allocations established within the General
17 Appropriations Act and any limitations established pursuant to
18 chapter 216, the agency shall distribute, pursuant to this
19 section, moneys to hospitals providing a disproportionate
20 share of Medicaid or charity care services by making quarterly
21 Medicaid payments as required. Notwithstanding the provisions
22 of s. 409.915, counties are exempt from contributing toward
23 the cost of this special reimbursement for hospitals serving a
24 disproportionate share of low-income patients.
25 (2) The Agency for Health Care Administration shall
26 use the following actual audited data to determine the
27 Medicaid days and charity care to be used in calculating the
28 disproportionate share payment:
29 (a) The average of the 1998, 1999, and 2000 audited
30 disproportionate share data to determine each hospital's
31 Medicaid days and charity care for the 2004-2005 state fiscal
29
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1 year and the average of the 1999, 2000, and 2001 audited
2 disproportionate share data to determine the Medicaid days and
3 charity care for the 2005-2006 state fiscal year.
4 (b) If the Agency for Health Care Administration does
5 not have the prescribed 3 years of audited disproportionate
6 share data as noted in paragraph (a) for a hospital, the
7 agency shall use the average of the years of the audited
8 disproportionate share data as noted in paragraph (a) which is
9 available. The average of the audited disproportionate share
10 data for the years available if the Agency for Health Care
11 Administration does not have the prescribed 3 years of audited
12 disproportionate share data for a hospital.
13 (4) The following formulas shall be used to pay
14 disproportionate share dollars to public hospitals:
15 (b) For non-state government owned or operated
16 hospitals with 3,300 or more Medicaid days:
17
18 DSHP = [(.82 x HCCD/TCCD) + (.18 x HMD/TMD)]
19 x TAAPH
20 TAAPH = TAA - TAAMH
21
22 Where:
23 TAA = total available appropriation.
24 TAAPH = total amount available for public hospitals.
25 DSHP = disproportionate share hospital payments.
26 HMD = hospital Medicaid days.
27 TMD = total state Medicaid days for public hospitals.
28 HCCD = hospital charity care dollars.
29 TCCD = total state charity care dollars for public
30 non-state hospitals.
31 1. For the 2005-2006 state fiscal year only, the DSHP
30
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1 for the public nonstate hospitals shall be computed using a
2 weighted average of the disproportionate share payments for
3 the 2004-2005 state fiscal year which uses an average of the
4 1998, 1999, and 2000 audited disproportionate share data and
5 the disproportionate share payments for the 2005-2006 state
6 fiscal year as computed using the formula above and using the
7 average of the 1999, 2000, and 2001 audited disproportionate
8 share data. The final DSHP for the public nonstate hospitals
9 shall be computed as an average using the calculated payments
10 for the 2005-2006 state fiscal year weighted at 65 percent and
11 the disproportionate share payments for the 2004-2005 state
12 fiscal year weighted at 35 percent.
13 2. The TAAPH shall be reduced by $6,365,257 before
14 computing the DSHP for each public hospital. The $6,365,257
15 shall be distributed equally between the public hospitals that
16 are also designated statutory teaching hospitals.
17 Section 12. Section 409.9112, Florida Statutes, is
18 amended to read:
19 409.9112 Disproportionate share program for regional
20 perinatal intensive care centers.--In addition to the payments
21 made under s. 409.911, the Agency for Health Care
22 Administration shall design and implement a system of making
23 disproportionate share payments to those hospitals that
24 participate in the regional perinatal intensive care center
25 program established pursuant to chapter 383. This system of
26 payments shall conform with federal requirements and shall
27 distribute funds in each fiscal year for which an
28 appropriation is made by making quarterly Medicaid payments.
29 Notwithstanding the provisions of s. 409.915, counties are
30 exempt from contributing toward the cost of this special
31 reimbursement for hospitals serving a disproportionate share
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1 of low-income patients. For the state fiscal year 2005-2006
2 2004-2005, the agency shall not distribute moneys under the
3 regional perinatal intensive care centers disproportionate
4 share program, except as noted in subsection (2). In the event
5 the Centers for Medicare and Medicaid Services do not approve
6 Florida's inpatient hospital state plan amendment for the
7 public disproportionate share program by January 1, 2005, the
8 agency may make payments to hospitals under the regional
9 perinatal intensive care centers disproportionate share
10 program.
11 (1) The following formula shall be used by the agency
12 to calculate the total amount earned for hospitals that
13 participate in the regional perinatal intensive care center
14 program:
15
16 TAE = HDSP/THDSP
17
18 Where:
19 TAE = total amount earned by a regional perinatal
20 intensive care center.
21 HDSP = the prior state fiscal year regional perinatal
22 intensive care center disproportionate share payment to the
23 individual hospital.
24 THDSP = the prior state fiscal year total regional
25 perinatal intensive care center disproportionate share
26 payments to all hospitals.
27
28 (2) The total additional payment for hospitals that
29 participate in the regional perinatal intensive care center
30 program shall be calculated by the agency as follows:
31
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1 TAP = TAE x TA
2
3 Where:
4 TAP = total additional payment for a regional perinatal
5 intensive care center.
6 TAE = total amount earned by a regional perinatal
7 intensive care center.
8 TA = total appropriation for the regional perinatal
9 intensive care center disproportionate share program.
10
11 (3) In order to receive payments under this section, a
12 hospital must be participating in the regional perinatal
13 intensive care center program pursuant to chapter 383 and must
14 meet the following additional requirements:
15 (a) Agree to conform to all departmental and agency
16 requirements to ensure high quality in the provision of
17 services, including criteria adopted by departmental and
18 agency rule concerning staffing ratios, medical records,
19 standards of care, equipment, space, and such other standards
20 and criteria as the department and agency deem appropriate as
21 specified by rule.
22 (b) Agree to provide information to the department and
23 agency, in a form and manner to be prescribed by rule of the
24 department and agency, concerning the care provided to all
25 patients in neonatal intensive care centers and high-risk
26 maternity care.
27 (c) Agree to accept all patients for neonatal
28 intensive care and high-risk maternity care, regardless of
29 ability to pay, on a functional space-available basis.
30 (d) Agree to develop arrangements with other maternity
31 and neonatal care providers in the hospital's region for the
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1 appropriate receipt and transfer of patients in need of
2 specialized maternity and neonatal intensive care services.
3 (e) Agree to establish and provide a developmental
4 evaluation and services program for certain high-risk
5 neonates, as prescribed and defined by rule of the department.
6 (f) Agree to sponsor a program of continuing education
7 in perinatal care for health care professionals within the
8 region of the hospital, as specified by rule.
9 (g) Agree to provide backup and referral services to
10 the department's county health departments and other
11 low-income perinatal providers within the hospital's region,
12 including the development of written agreements between these
13 organizations and the hospital.
14 (h) Agree to arrange for transportation for high-risk
15 obstetrical patients and neonates in need of transfer from the
16 community to the hospital or from the hospital to another more
17 appropriate facility.
18 (4) Hospitals which fail to comply with any of the
19 conditions in subsection (3) or the applicable rules of the
20 department and agency shall not receive any payments under
21 this section until full compliance is achieved. A hospital
22 which is not in compliance in two or more consecutive quarters
23 shall not receive its share of the funds. Any forfeited funds
24 shall be distributed by the remaining participating regional
25 perinatal intensive care center program hospitals.
26 Section 13. Section 409.9113, Florida Statutes, is
27 amended to read:
28 409.9113 Disproportionate share program for teaching
29 hospitals.--In addition to the payments made under ss. 409.911
30 and 409.9112, the Agency for Health Care Administration shall
31 make disproportionate share payments to statutorily defined
34
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1 teaching hospitals for their increased costs associated with
2 medical education programs and for tertiary health care
3 services provided to the indigent. This system of payments
4 shall conform with federal requirements and shall distribute
5 funds in each fiscal year for which an appropriation is made
6 by making quarterly Medicaid payments. Notwithstanding s.
7 409.915, counties are exempt from contributing toward the cost
8 of this special reimbursement for hospitals serving a
9 disproportionate share of low-income patients. For the state
10 fiscal year 2005-2006 2004-2005, the agency shall not
11 distribute moneys under the teaching hospital disproportionate
12 share program, except as noted in subsection (2). In the event
13 the Centers for Medicare and Medicaid Services do not approve
14 Florida's inpatient hospital state plan amendment for the
15 public disproportionate share program by January 1, 2005, the
16 agency may make payments to hospitals under the teaching
17 hospital disproportionate share program.
18 (1) On or before September 15 of each year, the Agency
19 for Health Care Administration shall calculate an allocation
20 fraction to be used for distributing funds to state statutory
21 teaching hospitals. Subsequent to the end of each quarter of
22 the state fiscal year, the agency shall distribute to each
23 statutory teaching hospital, as defined in s. 408.07, an
24 amount determined by multiplying one-fourth of the funds
25 appropriated for this purpose by the Legislature times such
26 hospital's allocation fraction. The allocation fraction for
27 each such hospital shall be determined by the sum of three
28 primary factors, divided by three. The primary factors are:
29 (a) The number of nationally accredited graduate
30 medical education programs offered by the hospital, including
31 programs accredited by the Accreditation Council for Graduate
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1 Medical Education and the combined Internal Medicine and
2 Pediatrics programs acceptable to both the American Board of
3 Internal Medicine and the American Board of Pediatrics at the
4 beginning of the state fiscal year preceding the date on which
5 the allocation fraction is calculated. The numerical value of
6 this factor is the fraction that the hospital represents of
7 the total number of programs, where the total is computed for
8 all state statutory teaching hospitals.
9 (b) The number of full-time equivalent trainees in the
10 hospital, which comprises two components:
11 1. The number of trainees enrolled in nationally
12 accredited graduate medical education programs, as defined in
13 paragraph (a). Full-time equivalents are computed using the
14 fraction of the year during which each trainee is primarily
15 assigned to the given institution, over the state fiscal year
16 preceding the date on which the allocation fraction is
17 calculated. The numerical value of this factor is the fraction
18 that the hospital represents of the total number of full-time
19 equivalent trainees enrolled in accredited graduate programs,
20 where the total is computed for all state statutory teaching
21 hospitals.
22 2. The number of medical students enrolled in
23 accredited colleges of medicine and engaged in clinical
24 activities, including required clinical clerkships and
25 clinical electives. Full-time equivalents are computed using
26 the fraction of the year during which each trainee is
27 primarily assigned to the given institution, over the course
28 of the state fiscal year preceding the date on which the
29 allocation fraction is calculated. The numerical value of this
30 factor is the fraction that the given hospital represents of
31 the total number of full-time equivalent students enrolled in
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1 accredited colleges of medicine, where the total is computed
2 for all state statutory teaching hospitals.
3
4 The primary factor for full-time equivalent trainees is
5 computed as the sum of these two components, divided by two.
6 (c) A service index that comprises three components:
7 1. The Agency for Health Care Administration Service
8 Index, computed by applying the standard Service Inventory
9 Scores established by the Agency for Health Care
10 Administration to services offered by the given hospital, as
11 reported on Worksheet A-2 for the last fiscal year reported to
12 the agency before the date on which the allocation fraction is
13 calculated. The numerical value of this factor is the
14 fraction that the given hospital represents of the total
15 Agency for Health Care Administration Service Index values,
16 where the total is computed for all state statutory teaching
17 hospitals.
18 2. A volume-weighted service index, computed by
19 applying the standard Service Inventory Scores established by
20 the Agency for Health Care Administration to the volume of
21 each service, expressed in terms of the standard units of
22 measure reported on Worksheet A-2 for the last fiscal year
23 reported to the agency before the date on which the allocation
24 factor is calculated. The numerical value of this factor is
25 the fraction that the given hospital represents of the total
26 volume-weighted service index values, where the total is
27 computed for all state statutory teaching hospitals.
28 3. Total Medicaid payments to each hospital for direct
29 inpatient and outpatient services during the fiscal year
30 preceding the date on which the allocation factor is
31 calculated. This includes payments made to each hospital for
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1 such services by Medicaid prepaid health plans, whether the
2 plan was administered by the hospital or not. The numerical
3 value of this factor is the fraction that each hospital
4 represents of the total of such Medicaid payments, where the
5 total is computed for all state statutory teaching hospitals.
6
7 The primary factor for the service index is computed as the
8 sum of these three components, divided by three.
9 (2) By October 1 of each year, the agency shall use
10 the following formula to calculate the maximum additional
11 disproportionate share payment for statutorily defined
12 teaching hospitals:
13
14 TAP = THAF x A
15
16 Where:
17 TAP = total additional payment.
18 THAF = teaching hospital allocation factor.
19 A = amount appropriated for a teaching hospital
20 disproportionate share program.
21 Section 14. Section 409.9117, Florida Statutes, is
22 amended to read:
23 409.9117 Primary care disproportionate share
24 program.--For the state fiscal year 2005-2006 2004-2005, the
25 agency shall not distribute moneys under the primary care
26 disproportionate share program, except as noted in subsection
27 (2). In the event the Centers for Medicare and Medicaid
28 Services do not approve Florida's inpatient hospital state
29 plan amendment for the public disproportionate share program
30 by January 1, 2005, the agency may make payments to hospitals
31 under the primary care disproportionate share program.
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1 (1) If federal funds are available for
2 disproportionate share programs in addition to those otherwise
3 provided by law, there shall be created a primary care
4 disproportionate share program.
5 (2) The following formula shall be used by the agency
6 to calculate the total amount earned for hospitals that
7 participate in the primary care disproportionate share
8 program:
9
10 TAE = HDSP/THDSP
11
12 Where:
13 TAE = total amount earned by a hospital participating
14 in the primary care disproportionate share program.
15 HDSP = the prior state fiscal year primary care
16 disproportionate share payment to the individual hospital.
17 THDSP = the prior state fiscal year total primary care
18 disproportionate share payments to all hospitals.
19
20 (3) The total additional payment for hospitals that
21 participate in the primary care disproportionate share program
22 shall be calculated by the agency as follows:
23
24 TAP = TAE x TA
25
26 Where:
27 TAP = total additional payment for a primary care
28 hospital.
29 TAE = total amount earned by a primary care hospital.
30 TA = total appropriation for the primary care
31 disproportionate share program.
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1
2 (4) In the establishment and funding of this program,
3 the agency shall use the following criteria in addition to
4 those specified in s. 409.911, payments may not be made to a
5 hospital unless the hospital agrees to:
6 (a) Cooperate with a Medicaid prepaid health plan, if
7 one exists in the community.
8 (b) Ensure the availability of primary and specialty
9 care physicians to Medicaid recipients who are not enrolled in
10 a prepaid capitated arrangement and who are in need of access
11 to such physicians.
12 (c) Coordinate and provide primary care services free
13 of charge, except copayments, to all persons with incomes up
14 to 100 percent of the federal poverty level who are not
15 otherwise covered by Medicaid or another program administered
16 by a governmental entity, and to provide such services based
17 on a sliding fee scale to all persons with incomes up to 200
18 percent of the federal poverty level who are not otherwise
19 covered by Medicaid or another program administered by a
20 governmental entity, except that eligibility may be limited to
21 persons who reside within a more limited area, as agreed to by
22 the agency and the hospital.
23 (d) Contract with any federally qualified health
24 center, if one exists within the agreed geopolitical
25 boundaries, concerning the provision of primary care services,
26 in order to guarantee delivery of services in a nonduplicative
27 fashion, and to provide for referral arrangements, privileges,
28 and admissions, as appropriate. The hospital shall agree to
29 provide at an onsite or offsite facility primary care services
30 within 24 hours to which all Medicaid recipients and persons
31 eligible under this paragraph who do not require emergency
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1 room services are referred during normal daylight hours.
2 (e) Cooperate with the agency, the county, and other
3 entities to ensure the provision of certain public health
4 services, case management, referral and acceptance of
5 patients, and sharing of epidemiological data, as the agency
6 and the hospital find mutually necessary and desirable to
7 promote and protect the public health within the agreed
8 geopolitical boundaries.
9 (f) In cooperation with the county in which the
10 hospital resides, develop a low-cost, outpatient, prepaid
11 health care program to persons who are not eligible for the
12 Medicaid program, and who reside within the area.
13 (g) Provide inpatient services to residents within the
14 area who are not eligible for Medicaid or Medicare, and who do
15 not have private health insurance, regardless of ability to
16 pay, on the basis of available space, except that nothing
17 shall prevent the hospital from establishing bill collection
18 programs based on ability to pay.
19 (h) Work with the Florida Healthy Kids Corporation,
20 the Florida Health Care Purchasing Cooperative, and business
21 health coalitions, as appropriate, to develop a feasibility
22 study and plan to provide a low-cost comprehensive health
23 insurance plan to persons who reside within the area and who
24 do not have access to such a plan.
25 (i) Work with public health officials and other
26 experts to provide community health education and prevention
27 activities designed to promote healthy lifestyles and
28 appropriate use of health services.
29 (j) Work with the local health council to develop a
30 plan for promoting access to affordable health care services
31 for all persons who reside within the area, including, but not
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1 limited to, public health services, primary care services,
2 inpatient services, and affordable health insurance generally.
3
4 Any hospital that fails to comply with any of the provisions
5 of this subsection, or any other contractual condition, may
6 not receive payments under this section until full compliance
7 is achieved.
8 Section 15. Section 409.91195, Florida Statutes, is
9 amended to read:
10 409.91195 Medicaid Pharmaceutical and Therapeutics
11 Committee.--There is created a Medicaid Pharmaceutical and
12 Therapeutics Committee within the agency for Health Care
13 Administration for the purpose of developing a Medicaid
14 preferred drug list formulary pursuant to 42 U.S.C. s.
15 1396r-8.
16 (1) The Medicaid Pharmaceutical and Therapeutics
17 committee shall be composed comprised as specified in 42
18 U.S.C. s. 1396r-8 and consist of 11 members appointed by the
19 Governor. Four members shall be physicians, licensed under
20 chapter 458; one member licensed under chapter 459; five
21 members shall be pharmacists licensed under chapter 465; and
22 one member shall be a consumer representative. The members
23 shall be appointed to serve for terms of 2 years from the date
24 of their appointment. Members may be appointed to more than
25 one term. The agency for Health Care Administration shall
26 serve as staff for the committee and assist them with all
27 ministerial duties. The Governor shall ensure that at least
28 some of the members of the Medicaid Pharmaceutical and
29 Therapeutics committee represent Medicaid participating
30 physicians and pharmacies serving all segments and diversity
31 of the Medicaid population, and have experience in either
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1 developing or practicing under a preferred drug list
2 formulary. At least one of the members shall represent the
3 interests of pharmaceutical manufacturers.
4 (2) Committee members shall select a chairperson and a
5 vice chairperson each year from the committee membership.
6 (3) The committee shall meet at least quarterly and
7 may meet at other times at the discretion of the chairperson
8 and members. The committee shall comply with rules adopted by
9 the agency, including notice of any meeting of the committee
10 pursuant to the requirements of the Administrative Procedure
11 Act.
12 (4) Upon recommendation of the Medicaid Pharmaceutical
13 and Therapeutics committee, the agency shall adopt a preferred
14 drug list as described in s. 409.912(39). To the extent
15 feasible, the committee shall review all drug classes included
16 on in the preferred drug list formulary at least every 12
17 months, and may recommend additions to and deletions from the
18 preferred drug list formulary, such that the preferred drug
19 list formulary provides for medically appropriate drug
20 therapies for Medicaid patients which achieve cost savings
21 contained in the General Appropriations Act.
22 (5) Except for mental health-related drugs,
23 antiretroviral drugs, and drugs for nursing home residents and
24 other institutional residents, reimbursement of drugs not
25 included on the preferred drug list in the formulary is
26 subject to prior authorization.
27 (5)(6) The agency for Health Care Administration shall
28 publish and disseminate the preferred drug list formulary to
29 all Medicaid providers in the state by Internet posting on the
30 agency's website or in other media.
31 (6)(7) The committee shall ensure that interested
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1 parties, including pharmaceutical manufacturers agreeing to
2 provide a supplemental rebate as outlined in this chapter,
3 have an opportunity to present public testimony to the
4 committee with information or evidence supporting inclusion of
5 a product on the preferred drug list. Such public testimony
6 shall occur prior to any recommendations made by the committee
7 for inclusion or exclusion from the preferred drug list. Upon
8 timely notice, the agency shall ensure that any drug that has
9 been approved or had any of its particular uses approved by
10 the United States Food and Drug Administration under a
11 priority review classification will be reviewed by the
12 Medicaid Pharmaceutical and Therapeutics committee at the next
13 regularly scheduled meeting following 3 months of distribution
14 of the drug to the general public. To the extent possible,
15 upon notice by a manufacturer the agency shall also schedule a
16 product review for any new product at the next regularly
17 scheduled Medicaid Pharmaceutical and Therapeutics Committee.
18 (8) Until the Medicaid Pharmaceutical and Therapeutics
19 Committee is appointed and a preferred drug list adopted by
20 the agency, the agency shall use the existing voluntary
21 preferred drug list adopted pursuant to s. 72, chapter
22 2000-367, Laws of Florida. Drugs not listed on the voluntary
23 preferred drug list will require prior authorization by the
24 agency or its contractor.
25 (7)(9) The Medicaid Pharmaceutical and Therapeutics
26 committee shall develop its preferred drug list
27 recommendations by considering the clinical efficacy, safety,
28 and cost-effectiveness of a product. When the preferred drug
29 formulary is adopted by the agency, if a product on the
30 formulary is one of the first four brand-name drugs used by a
31 recipient in a month the drug shall not require prior
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1 authorization.
2 (8) Upon timely notice, the agency shall ensure that
3 any therapeutic class of drugs which includes a drug that has
4 been removed from distribution to the public by its
5 manufacturer or the United States Food and Drug Administration
6 or has been required to carry a black box warning label by the
7 United States Food and Drug Administration because of safety
8 concerns is reviewed by the committee at the next regularly
9 scheduled meeting. After such review, the committee must
10 recommend whether to retain the therapeutic class of drugs or
11 subcategories of drugs within a therapeutic class on the
12 preferred drug list and whether to institute prior
13 authorization requirements necessary to ensure patient safety.
14 (9)(10) The Medicaid Pharmaceutical and Therapeutics
15 Committee may also make recommendations to the agency
16 regarding the prior authorization of any prescribed drug
17 covered by Medicaid.
18 (10)(11) Medicaid recipients may appeal agency
19 preferred drug formulary decisions using the Medicaid fair
20 hearing process administered by the Department of Children and
21 Family Services.
22 Section 16. Paragraph (b) of subsection (4),
23 paragraphs (e) and (f) of subsection (15), paragraph (a) of
24 subsection (39), and subsections (44) and (49) of section
25 409.912, Florida Statutes, are amended, and subsection (50) is
26 added to that section, to read:
27 409.912 Cost-effective purchasing of health care.--The
28 agency shall purchase goods and services for Medicaid
29 recipients in the most cost-effective manner consistent with
30 the delivery of quality medical care. To ensure that medical
31 services are effectively utilized, the agency may, in any
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1 case, require a confirmation or second physician's opinion of
2 the correct diagnosis for purposes of authorizing future
3 services under the Medicaid program. This section does not
4 restrict access to emergency services or poststabilization
5 care services as defined in 42 C.F.R. part 438.114. Such
6 confirmation or second opinion shall be rendered in a manner
7 approved by the agency. The agency shall maximize the use of
8 prepaid per capita and prepaid aggregate fixed-sum basis
9 services when appropriate and other alternative service
10 delivery and reimbursement methodologies, including
11 competitive bidding pursuant to s. 287.057, designed to
12 facilitate the cost-effective purchase of a case-managed
13 continuum of care. The agency shall also require providers to
14 minimize the exposure of recipients to the need for acute
15 inpatient, custodial, and other institutional care and the
16 inappropriate or unnecessary use of high-cost services. The
17 agency may mandate prior authorization, drug therapy
18 management, or disease management participation for certain
19 populations of Medicaid beneficiaries, certain drug classes,
20 or particular drugs to prevent fraud, abuse, overuse, and
21 possible dangerous drug interactions. The Pharmaceutical and
22 Therapeutics Committee shall make recommendations to the
23 agency on drugs for which prior authorization is required. The
24 agency shall inform the Pharmaceutical and Therapeutics
25 Committee of its decisions regarding drugs subject to prior
26 authorization. The agency is authorized to limit the entities
27 it contracts with or enrolls as Medicaid providers by
28 developing a provider network through provider credentialing.
29 The agency may limit its network based on the assessment of
30 beneficiary access to care, provider availability, provider
31 quality standards, time and distance standards for access to
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1 care, the cultural competence of the provider network,
2 demographic characteristics of Medicaid beneficiaries,
3 practice and provider-to-beneficiary standards, appointment
4 wait times, beneficiary use of services, provider turnover,
5 provider profiling, provider licensure history, previous
6 program integrity investigations and findings, peer review,
7 provider Medicaid policy and billing compliance records,
8 clinical and medical record audits, and other factors.
9 Providers shall not be entitled to enrollment in the Medicaid
10 provider network. The agency is authorized to seek federal
11 waivers necessary to implement this policy.
12 (4) The agency may contract with:
13 (b) An entity that is providing comprehensive
14 behavioral health care services to certain Medicaid recipients
15 through a capitated, prepaid arrangement pursuant to the
16 federal waiver provided for by s. 409.905(5). Such an entity
17 must be licensed under chapter 624, chapter 636, or chapter
18 641 and must possess the clinical systems and operational
19 competence to manage risk and provide comprehensive behavioral
20 health care to Medicaid recipients. As used in this paragraph,
21 the term "comprehensive behavioral health care services" means
22 covered mental health and substance abuse treatment services
23 that are available to Medicaid recipients. The secretary of
24 the Department of Children and Family Services shall approve
25 provisions of procurements related to children in the
26 department's care or custody prior to enrolling such children
27 in a prepaid behavioral health plan. Any contract awarded
28 under this paragraph must be competitively procured. In
29 developing the behavioral health care prepaid plan procurement
30 document, the agency shall ensure that the procurement
31 document requires the contractor to develop and implement a
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1 plan to ensure compliance with s. 394.4574 related to services
2 provided to residents of licensed assisted living facilities
3 that hold a limited mental health license. Except as provided
4 in subparagraph 8., the agency shall seek federal approval to
5 contract with a single entity meeting these requirements to
6 provide comprehensive behavioral health care services to all
7 Medicaid recipients not enrolled in a managed care plan in an
8 AHCA area. Each entity must offer sufficient choice of
9 providers in its network to ensure recipient access to care
10 and the opportunity to select a provider with whom they are
11 satisfied. The network shall include all public mental health
12 hospitals. To ensure unimpaired access to behavioral health
13 care services by Medicaid recipients, all contracts issued
14 pursuant to this paragraph shall require 80 percent of the
15 capitation paid to the managed care plan, including health
16 maintenance organizations, to be expended for the provision of
17 behavioral health care services. In the event the managed care
18 plan expends less than 80 percent of the capitation paid
19 pursuant to this paragraph for the provision of behavioral
20 health care services, the difference shall be returned to the
21 agency. The agency shall provide the managed care plan with a
22 certification letter indicating the amount of capitation paid
23 during each calendar year for the provision of behavioral
24 health care services pursuant to this section. The agency may
25 reimburse for substance abuse treatment services on a
26 fee-for-service basis until the agency finds that adequate
27 funds are available for capitated, prepaid arrangements.
28 1. By January 1, 2001, the agency shall modify the
29 contracts with the entities providing comprehensive inpatient
30 and outpatient mental health care services to Medicaid
31 recipients in Hillsborough, Highlands, Hardee, Manatee, and
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1 Polk Counties, to include substance abuse treatment services.
2 2. By July 1, 2003, the agency and the Department of
3 Children and Family Services shall execute a written agreement
4 that requires collaboration and joint development of all
5 policy, budgets, procurement documents, contracts, and
6 monitoring plans that have an impact on the state and Medicaid
7 community mental health and targeted case management programs.
8 3. Except as provided in subparagraph 8., by July 1,
9 2006, the agency and the Department of Children and Family
10 Services shall contract with managed care entities in each
11 AHCA area except area 6 or arrange to provide comprehensive
12 inpatient and outpatient mental health and substance abuse
13 services through capitated prepaid arrangements to all
14 Medicaid recipients who are eligible to participate in such
15 plans under federal law and regulation. In AHCA areas where
16 eligible individuals number less than 150,000, the agency
17 shall contract with a single managed care plan to provide
18 comprehensive behavioral health services to all recipients who
19 are not enrolled in a Medicaid health maintenance
20 organization. The agency may contract with more than one
21 comprehensive behavioral health provider to provide care to
22 recipients who are not enrolled in a Medicaid health
23 maintenance organization in AHCA areas where the eligible
24 population exceeds 150,000. Contracts for comprehensive
25 behavioral health providers awarded pursuant to this section
26 shall be competitively procured. Both for-profit and
27 not-for-profit corporations shall be eligible to compete.
28 Managed care plans contracting with the agency under
29 subsection (3) shall provide and receive payment for the same
30 comprehensive behavioral health benefits as provided in AHCA
31 rules, including handbooks incorporated by reference. In AHCA
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1 Area 11, the agency shall contract with at least two
2 comprehensive behavioral health care providers to provide
3 behavioral health care to recipients in that area who are
4 enrolled in, or assigned to, the MediPass program. One of the
5 behavioral health care contracts shall be with the existing
6 provider service network pilot project, as described in
7 paragraph (d), for the purpose of demonstrating the
8 cost-effectiveness of the provision of quality mental health
9 services through a public hospital-operated managed care
10 model. Payment shall be at an agreed-upon capitated rate to
11 ensure cost savings. Of the recipients in Area 11 who are
12 assigned to MediPass under the provisions of s.
13 409.9122(2)(k), a minimum of 50,000 of those MediPass-enrolled
14 recipients shall be assigned to the existing provider service
15 network in Area 11 for their behavioral care.
16 4. By October 1, 2003, the agency and the department
17 shall submit a plan to the Governor, the President of the
18 Senate, and the Speaker of the House of Representatives which
19 provides for the full implementation of capitated prepaid
20 behavioral health care in all areas of the state.
21 a. Implementation shall begin in 2003 in those AHCA
22 areas of the state where the agency is able to establish
23 sufficient capitation rates.
24 b. If the agency determines that the proposed
25 capitation rate in any area is insufficient to provide
26 appropriate services, the agency may adjust the capitation
27 rate to ensure that care will be available. The agency and the
28 department may use existing general revenue to address any
29 additional required match but may not over-obligate existing
30 funds on an annualized basis.
31 c. Subject to any limitations provided for in the
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1 General Appropriations Act, the agency, in compliance with
2 appropriate federal authorization, shall develop policies and
3 procedures that allow for certification of local and state
4 funds.
5 5. Children residing in a statewide inpatient
6 psychiatric program, or in a Department of Juvenile Justice or
7 a Department of Children and Family Services residential
8 program approved as a Medicaid behavioral health overlay
9 services provider shall not be included in a behavioral health
10 care prepaid health plan or any other Medicaid managed care
11 plan pursuant to this paragraph.
12 6. In converting to a prepaid system of delivery, the
13 agency shall in its procurement document require an entity
14 providing only comprehensive behavioral health care services
15 to prevent the displacement of indigent care patients by
16 enrollees in the Medicaid prepaid health plan providing
17 behavioral health care services from facilities receiving
18 state funding to provide indigent behavioral health care, to
19 facilities licensed under chapter 395 which do not receive
20 state funding for indigent behavioral health care, or
21 reimburse the unsubsidized facility for the cost of behavioral
22 health care provided to the displaced indigent care patient.
23 7. Traditional community mental health providers under
24 contract with the Department of Children and Family Services
25 pursuant to part IV of chapter 394, child welfare providers
26 under contract with the Department of Children and Family
27 Services in areas 1 and 6, and inpatient mental health
28 providers licensed pursuant to chapter 395 must be offered an
29 opportunity to accept or decline a contract to participate in
30 any provider network for prepaid behavioral health services.
31 8. For fiscal year 2004-2005, all Medicaid eligible
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1 children, except children in areas 1 and 6, whose cases are
2 open for child welfare services in the HomeSafeNet system,
3 shall be enrolled in MediPass or in Medicaid fee-for-service
4 and all their behavioral health care services including
5 inpatient, outpatient psychiatric, community mental health,
6 and case management shall be reimbursed on a fee-for-service
7 basis. Beginning July 1, 2005, such children, who are open for
8 child welfare services in the HomeSafeNet system, shall
9 receive their behavioral health care services through a
10 specialty prepaid plan operated by community-based lead
11 agencies either through a single agency or formal agreements
12 among several agencies. The specialty prepaid plan must result
13 in savings to the state comparable to savings achieved in
14 other Medicaid managed care and prepaid programs. Such plan
15 must provide mechanisms to maximize state and local revenues.
16 The specialty prepaid plan shall be developed by the agency
17 and the Department of Children and Family Services. The agency
18 is authorized to seek any federal waivers to implement this
19 initiative.
20 (15)
21 (e) By January 15 of each year, the agency shall
22 submit a report to the Legislature and the Office of
23 Long-Term-Care Policy describing the operations of the CARES
24 program. The report must describe:
25 1. Rate of diversion to community alternative
26 programs;
27 2. CARES program staffing needs to achieve additional
28 diversions;
29 3. Reasons the program is unable to place individuals
30 in less restrictive settings when such individuals desired
31 such services and could have been served in such settings;
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1 4. Barriers to appropriate placement, including
2 barriers due to policies or operations of other agencies or
3 state-funded programs; and
4 5. Statutory changes necessary to ensure that
5 individuals in need of long-term care services receive care in
6 the least restrictive environment.
7 (f) The Department of Elderly Affairs shall track
8 individuals over time who are assessed under the CARES program
9 and who are diverted from nursing home placement. By January
10 15 of each year, the department shall submit to the
11 Legislature and the Office of Long-Term-Care Policy a
12 longitudinal study of the individuals who are diverted from
13 nursing home placement. The study must include:
14 1. The demographic characteristics of the individuals
15 assessed and diverted from nursing home placement, including,
16 but not limited to, age, race, gender, frailty, caregiver
17 status, living arrangements, and geographic location;
18 2. A summary of community services provided to
19 individuals for 1 year after assessment and diversion;
20 3. A summary of inpatient hospital admissions for
21 individuals who have been diverted; and
22 4. A summary of the length of time between diversion
23 and subsequent entry into a nursing home or death.
24 (39)(a) The agency shall implement a Medicaid
25 prescribed-drug spending-control program that includes the
26 following components:
27 1. A Medicaid preferred drug list, which shall be a
28 listing of cost-effective therapeutic options recommended by
29 the Medicaid Pharmacy and Therapeutics Committee established
30 pursuant to s. 409.91195 and adopted by the agency for each
31 therapeutic class on the preferred drug list. At the
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1 discretion of the committee, and when feasible, the preferred
2 drug list should include at least two products in a
3 therapeutic class. Medicaid prescribed-drug coverage for
4 brand-name drugs for adult Medicaid recipients is limited to
5 the dispensing of four brand-name drugs per month per
6 recipient. Children are exempt from this restriction.
7 Antiretroviral agents are excluded from the preferred drug
8 list this limitation. No requirements for prior authorization
9 or other restrictions on medications used to treat mental
10 illnesses such as schizophrenia, severe depression, or bipolar
11 disorder may be imposed on Medicaid recipients. Medications
12 that will be available without restriction for persons with
13 mental illnesses include atypical antipsychotic medications,
14 conventional antipsychotic medications, selective serotonin
15 reuptake inhibitors, and other medications used for the
16 treatment of serious mental illnesses. The agency shall also
17 limit the amount of a prescribed drug dispensed to no more
18 than a 34-day supply unless the drug products' smallest
19 marketed package is greater than a 34-day supply, or the drug
20 is determined by the agency to be a maintenance drug in which
21 case a 100-day maximum supply may be authorized. The agency is
22 authorized to seek any federal waivers necessary to implement
23 these cost-control programs and to continue participation in
24 the federal Medicaid rebate program, or alternatively to
25 negotiate state-only manufacturer rebates. The agency may
26 adopt rules to implement this subparagraph. The agency shall
27 continue to provide unlimited generic drugs, contraceptive
28 drugs and items, and diabetic supplies. Although a drug may be
29 included on the preferred drug formulary, it would not be
30 exempt from the four-brand limit. The agency may authorize
31 exceptions to the brand-name-drug restriction based upon the
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1 treatment needs of the patients, only when such exceptions are
2 based on prior consultation provided by the agency or an
3 agency contractor, but The agency must establish procedures to
4 ensure that:
5 a. There will be a response to a request for prior
6 consultation by telephone or other telecommunication device
7 within 24 hours after receipt of a request for prior
8 consultation; and
9 b. A 72-hour supply of the drug prescribed will be
10 provided in an emergency or when the agency does not provide a
11 response within 24 hours as required by sub-subparagraph a.;
12 and
13 c. Except for the exception for nursing home residents
14 and other institutionalized adults and except for drugs on the
15 restricted formulary for which prior authorization may be
16 sought by an institutional or community pharmacy, prior
17 authorization for an exception to the brand-name-drug
18 restriction is sought by the prescriber and not by the
19 pharmacy. When prior authorization is granted for a patient in
20 an institutional setting beyond the brand-name-drug
21 restriction, such approval is authorized for 12 months and
22 monthly prior authorization is not required for that patient.
23 2. Reimbursement to pharmacies for Medicaid prescribed
24 drugs shall be set at the lesser of: the average wholesale
25 price (AWP) minus 15.4 percent, the wholesaler acquisition
26 cost (WAC) plus 5.75 percent, the federal upper limit (FUL),
27 the state maximum allowable cost (SMAC), or the usual and
28 customary (UAC) charge billed by the provider.
29 3. The agency shall develop and implement a process
30 for managing the drug therapies of Medicaid recipients who are
31 using significant numbers of prescribed drugs each month. The
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1 management process may include, but is not limited to,
2 comprehensive, physician-directed medical-record reviews,
3 claims analyses, and case evaluations to determine the medical
4 necessity and appropriateness of a patient's treatment plan
5 and drug therapies. The agency may contract with a private
6 organization to provide drug-program-management services. The
7 Medicaid drug benefit management program shall include
8 initiatives to manage drug therapies for HIV/AIDS patients,
9 patients using 20 or more unique prescriptions in a 180-day
10 period, and the top 1,000 patients in annual spending. The
11 agency shall enroll any Medicaid recipient in the drug benefit
12 management program if he or she meets the specifications of
13 this provision and is not enrolled in a Medicaid health
14 maintenance organization.
15 4. The agency may limit the size of its pharmacy
16 network based on need, competitive bidding, price
17 negotiations, credentialing, or similar criteria. The agency
18 shall give special consideration to rural areas in determining
19 the size and location of pharmacies included in the Medicaid
20 pharmacy network. A pharmacy credentialing process may include
21 criteria such as a pharmacy's full-service status, location,
22 size, patient educational programs, patient consultation,
23 disease-management services, and other characteristics. The
24 agency may impose a moratorium on Medicaid pharmacy enrollment
25 when it is determined that it has a sufficient number of
26 Medicaid-participating providers.
27 5. The agency shall develop and implement a program
28 that requires Medicaid practitioners who prescribe drugs to
29 use a counterfeit-proof prescription pad for Medicaid
30 prescriptions. The agency shall require the use of
31 standardized counterfeit-proof prescription pads by
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1 Medicaid-participating prescribers or prescribers who write
2 prescriptions for Medicaid recipients. The agency may
3 implement the program in targeted geographic areas or
4 statewide.
5 6. The agency may enter into arrangements that require
6 manufacturers of generic drugs prescribed to Medicaid
7 recipients to provide rebates of at least 15.1 percent of the
8 average manufacturer price for the manufacturer's generic
9 products. These arrangements shall require that if a
10 generic-drug manufacturer pays federal rebates for
11 Medicaid-reimbursed drugs at a level below 15.1 percent, the
12 manufacturer must provide a supplemental rebate to the state
13 in an amount necessary to achieve a 15.1-percent rebate level.
14 7. The agency may establish a preferred drug list as
15 described in this subsection formulary in accordance with 42
16 U.S.C. s. 1396r-8, and, pursuant to the establishment of such
17 preferred drug list formulary, it is authorized to negotiate
18 supplemental rebates from manufacturers that are in addition
19 to those required by Title XIX of the Social Security Act and
20 at no less than 14 percent of the average manufacturer price
21 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
22 unless the federal or supplemental rebate, or both, equals or
23 exceeds 29 percent. There is no upper limit on the
24 supplemental rebates the agency may negotiate. The agency may
25 determine that specific products, brand-name or generic, are
26 competitive at lower rebate percentages. Agreement to pay the
27 minimum supplemental rebate percentage will guarantee a
28 manufacturer that the Medicaid Pharmaceutical and Therapeutics
29 Committee will consider a product for inclusion on the
30 preferred drug list formulary. However, a pharmaceutical
31 manufacturer is not guaranteed placement on the preferred drug
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1 list formulary by simply paying the minimum supplemental
2 rebate. Agency decisions will be made on the clinical efficacy
3 of a drug and recommendations of the Medicaid Pharmaceutical
4 and Therapeutics Committee, as well as the price of competing
5 products minus federal and state rebates. The agency is
6 authorized to contract with an outside agency or contractor to
7 conduct negotiations for supplemental rebates. For the
8 purposes of this section, the term "supplemental rebates"
9 means cash rebates. Effective July 1, 2004, value-added
10 programs as a substitution for supplemental rebates are
11 prohibited. The agency is authorized to seek any federal
12 waivers to implement this initiative.
13 8. The agency shall establish an advisory committee
14 for the purposes of studying the feasibility of using a
15 restricted drug formulary for nursing home residents and other
16 institutionalized adults. The committee shall be comprised of
17 seven members appointed by the Secretary of Health Care
18 Administration. The committee members shall include two
19 physicians licensed under chapter 458 or chapter 459; three
20 pharmacists licensed under chapter 465 and appointed from a
21 list of recommendations provided by the Florida Long-Term Care
22 Pharmacy Alliance; and two pharmacists licensed under chapter
23 465.
24 8.9. The Agency for Health Care Administration shall
25 expand home delivery of pharmacy products. To assist Medicaid
26 patients in securing their prescriptions and reduce program
27 costs, the agency shall expand its current mail-order-pharmacy
28 diabetes-supply program to include all generic and brand-name
29 drugs used by Medicaid patients with diabetes. Medicaid
30 recipients in the current program may obtain nondiabetes drugs
31 on a voluntary basis. This initiative is limited to the
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1 geographic area covered by the current contract. The agency
2 may seek and implement any federal waivers necessary to
3 implement this subparagraph.
4 9.10. The agency shall limit to one dose per month any
5 drug prescribed to treat erectile dysfunction.
6 10.a.11.a. The agency may shall implement a Medicaid
7 behavioral drug management system. The agency may contract
8 with a vendor that has experience in operating behavioral drug
9 management systems to implement this program. The agency is
10 authorized to seek federal waivers to implement this program.
11 b. The agency, in conjunction with the Department of
12 Children and Family Services, may implement the Medicaid
13 behavioral drug management system that is designed to improve
14 the quality of care and behavioral health prescribing
15 practices based on best practice guidelines, improve patient
16 adherence to medication plans, reduce clinical risk, and lower
17 prescribed drug costs and the rate of inappropriate spending
18 on Medicaid behavioral drugs. The program may shall include
19 the following elements:
20 (I) Provide for the development and adoption of best
21 practice guidelines for behavioral health-related drugs such
22 as antipsychotics, antidepressants, and medications for
23 treating bipolar disorders and other behavioral conditions;
24 translate them into practice; review behavioral health
25 prescribers and compare their prescribing patterns to a number
26 of indicators that are based on national standards; and
27 determine deviations from best practice guidelines.
28 (II) Implement processes for providing feedback to and
29 educating prescribers using best practice educational
30 materials and peer-to-peer consultation.
31 (III) Assess Medicaid beneficiaries who are outliers
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1 in their use of behavioral health drugs with regard to the
2 numbers and types of drugs taken, drug dosages, combination
3 drug therapies, and other indicators of improper use of
4 behavioral health drugs.
5 (IV) Alert prescribers to patients who fail to refill
6 prescriptions in a timely fashion, are prescribed multiple
7 same-class behavioral health drugs, and may have other
8 potential medication problems.
9 (V) Track spending trends for behavioral health drugs
10 and deviation from best practice guidelines.
11 (VI) Use educational and technological approaches to
12 promote best practices, educate consumers, and train
13 prescribers in the use of practice guidelines.
14 (VII) Disseminate electronic and published materials.
15 (VIII) Hold statewide and regional conferences.
16 (IX) Implement a disease management program with a
17 model quality-based medication component for severely mentally
18 ill individuals and emotionally disturbed children who are
19 high users of care.
20 c. If the agency is unable to negotiate a contract
21 with one or more manufacturers to finance and guarantee
22 savings associated with a behavioral drug management program
23 by September 1, 2004, the four-brand drug limit and preferred
24 drug list prior-authorization requirements shall apply to
25 mental health-related drugs, notwithstanding any provision in
26 subparagraph 1. The agency is authorized to seek federal
27 waivers to implement this policy.
28 11.12. The agency is authorized to contract for drug
29 rebate administration, including, but not limited to,
30 calculating rebate amounts, invoicing manufacturers,
31 negotiating disputes with manufacturers, and maintaining a
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1 database of rebate collections.
2 12.13. The agency may specify the preferred daily
3 dosing form or strength for the purpose of promoting best
4 practices with regard to the prescribing of certain drugs as
5 specified in the General Appropriations Act and ensuring
6 cost-effective prescribing practices.
7 13.14. The agency may require prior authorization for
8 the off-label use of Medicaid-covered prescribed drugs as
9 specified in the General Appropriations Act. The agency may,
10 but is not required to, prior-authorize preauthorize the use
11 of a product:
12 a. For an indication not approved in labeling;
13 b. To comply with certain clinical guidelines; or
14 c. If the product has the potential for overuse,
15 misuse, or abuse for an indication not in the approved
16 labeling.
17
18 The agency Prior authorization may require the prescribing
19 professional to provide information about the rationale and
20 supporting medical evidence for the off-label use of a drug.
21 The agency may post prior-authorization criteria and protocol
22 and updates to the list of drugs that are subject to prior
23 authorization on an Internet website without amending its rule
24 or engaging in additional rulemaking.
25 14. The agency, in conjunction with the Pharmaceutical
26 and Therapeutics Committee, may require age-related prior
27 authorizations for certain prescribed drugs. The agency may
28 preauthorize the use of a drug for a recipient who may not
29 meet the age requirement or may exceed the length of therapy
30 for use of this product as recommended by the manufacturer and
31 approved by the Food and Drug Administration. Prior
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1 authorization may require the prescribing professional to
2 provide information about the rationale and supporting medical
3 evidence for the use of a drug.
4 15. The agency shall implement a step-therapy-prior
5 authorization-approval process for medications excluded from
6 the preferred drug list. Medications listed on the preferred
7 drug list must be used within the previous 12 months prior to
8 the alternative medications that are not listed. The
9 step-therapy-prior authorization may require the prescriber to
10 use the medications of a similar drug class or for a similar
11 medical indication unless contraindicated in the Food and Drug
12 Administration labeling. The trial period between the
13 specified steps may vary according to the medical indication.
14 The step-therapy-approval process shall be developed in
15 accordance with the committee as stated in s. 409.91195(7) and
16 (8). A drug product may be approved without meeting the
17 step-therapy-prior-authorization criteria if the prescribing
18 physician provides the agency with additional written medical
19 or clinical documentation that the product is medically
20 necessary because:
21 a. There is not a drug on the preferred drug list to
22 treat the disease or medical condition which is an acceptable
23 clinical alternative;
24 b. The alternatives have been ineffective in the
25 treatment of the beneficiary's disease; or
26 c. Based on historic evidence and known
27 characteristics of the patient and the drug, the drug is
28 likely to be ineffective, or the number of doses have been
29 ineffective.
30
31 The agency shall work with the physician to determine the best
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1 alternative for the patient. The agency may adopt rules
2 waiving the requirements for written clinical documentation
3 for specific drugs in limited clinical situations.
4 16.15. The agency shall implement a return and reuse
5 program for drugs dispensed by pharmacies to institutional
6 recipients, which includes payment of a $5 restocking fee for
7 the implementation and operation of the program. The return
8 and reuse program shall be implemented electronically and in a
9 manner that promotes efficiency. The program must permit a
10 pharmacy to exclude drugs from the program if it is not
11 practical or cost-effective for the drug to be included and
12 must provide for the return to inventory of drugs that cannot
13 be credited or returned in a cost-effective manner.
14 (44) The Agency for Health Care Administration shall
15 ensure that any Medicaid managed care plan as defined in s.
16 409.9122(2)(h), whether paid on a capitated basis or a shared
17 savings basis, is cost-effective. For purposes of this
18 subsection, the term "cost-effective" means that a network's
19 per-member, per-month costs to the state, including, but not
20 limited to, fee-for-service costs, administrative costs, and
21 case-management fees, if any, must be no greater than the
22 state's costs associated with contracts for Medicaid services
23 established under subsection (3), which shall be actuarially
24 adjusted for case mix, model, and service area. The agency
25 shall conduct actuarially sound audits adjusted for case mix
26 and model in order to ensure such cost-effectiveness and shall
27 publish the audit results on its Internet website and submit
28 the audit results annually to the Governor, the President of
29 the Senate, and the Speaker of the House of Representatives no
30 later than December 31 of each year. Contracts established
31 pursuant to this subsection which are not cost-effective may
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1 not be renewed.
2 (49) The agency shall contract with established
3 minority physician networks that provide services to
4 historically underserved minority patients. The networks must
5 provide cost-effective Medicaid services, comply with the
6 requirements to be a MediPass provider, and provide their
7 primary care physicians with access to data and other
8 management tools necessary to assist them in ensuring the
9 appropriate use of services, including inpatient hospital
10 services and pharmaceuticals.
11 (a) The agency shall provide for the development and
12 expansion of minority physician networks in each service area
13 to provide services to Medicaid recipients who are eligible to
14 participate under federal law and rules.
15 (b) The agency shall reimburse each minority physician
16 network as a fee-for-service provider, including the case
17 management fee for primary care, if any, or as a capitated
18 rate provider for Medicaid services. Any savings shall be
19 shared with the minority physician networks pursuant to the
20 contract.
21 (c) For purposes of this subsection, the term
22 "cost-effective" means that a network's per-member, per-month
23 costs to the state, including, but not limited to,
24 fee-for-service costs, administrative costs, and
25 case-management fees, if any, must be no greater than the
26 state's costs associated with contracts for Medicaid services
27 established under subsection (3), which shall be actuarially
28 adjusted for case mix, model, and service area. The agency
29 shall conduct actuarially sound audits adjusted for case mix
30 and model in order to ensure such cost-effectiveness and shall
31 publish the audit results on its Internet website and submit
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1 the audit results annually to the Governor, the President of
2 the Senate, and the Speaker of the House of Representatives no
3 later than December 31. Contracts established pursuant to this
4 subsection which are not cost-effective may not be renewed.
5 (d) The agency may apply for any federal waivers
6 needed to implement this subsection.
7 (50) The agency shall implement a program of
8 all-inclusive care for children. The program of all-inclusive
9 care for children shall be established to provide in-home
10 hospice-like support services to children diagnosed with a
11 life-threatening illness and enrolled in the Children's
12 Medical Services network to reduce hospitalizations as
13 appropriate. The agency, in consultation with the Department
14 of Health, may implement the program of all-inclusive care for
15 children after obtaining approval from the Centers for
16 Medicare and Medicaid Services.
17 Section 17. Paragraph (k) of subsection (2) of section
18 409.9122, Florida Statutes, is amended to read:
19 409.9122 Mandatory Medicaid managed care enrollment;
20 programs and procedures.--
21 (2)
22 (k) When a Medicaid recipient does not choose a
23 managed care plan or MediPass provider, the agency shall
24 assign the Medicaid recipient to a managed care plan, except
25 in those counties in which there are fewer than two managed
26 care plans accepting Medicaid enrollees, in which case
27 assignment shall be to a managed care plan or a MediPass
28 provider. Medicaid recipients in counties with fewer than two
29 managed care plans accepting Medicaid enrollees who are
30 subject to mandatory assignment but who fail to make a choice
31 shall be assigned to managed care plans until an enrollment of
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1 40 percent in MediPass and 60 percent in managed care plans is
2 achieved. Once that enrollment is achieved, the assignments
3 shall be divided in order to maintain an enrollment in
4 MediPass and managed care plans which is in a 40 percent and
5 60 percent proportion, respectively. In service areas 1 and 6
6 of the Agency for Health Care Administration geographic areas
7 where the agency is contracting for the provision of
8 comprehensive behavioral health services through a capitated
9 prepaid arrangement, recipients who fail to make a choice
10 shall be assigned equally to MediPass or a managed care plan.
11 For purposes of this paragraph, when referring to assignment,
12 the term "managed care plans" includes exclusive provider
13 organizations, provider service networks, Children's Medical
14 Services Network, minority physician networks, and pediatric
15 emergency department diversion programs authorized by this
16 chapter or the General Appropriations Act. When making
17 assignments, the agency shall take into account the following
18 criteria:
19 1. A managed care plan has sufficient network capacity
20 to meet the need of members.
21 2. The managed care plan or MediPass has previously
22 enrolled the recipient as a member, or one of the managed care
23 plan's primary care providers or MediPass providers has
24 previously provided health care to the recipient.
25 3. The agency has knowledge that the member has
26 previously expressed a preference for a particular managed
27 care plan or MediPass provider as indicated by Medicaid
28 fee-for-service claims data, but has failed to make a choice.
29 4. The managed care plan's or MediPass primary care
30 providers are geographically accessible to the recipient's
31 residence.
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1 5. The agency has authority to make mandatory
2 assignments based on quality of service and performance of
3 managed care plans.
4 Section 18. Section 409.9124, Florida Statutes, is
5 amended to read:
6 409.9124 Managed care reimbursement.--
7 (1) The agency shall develop and adopt by rule a
8 methodology for reimbursing managed care plans.
9 (1)(2) Final managed care rates shall be published
10 annually prior to September 1 of each year, based on
11 methodology that:
12 (a) Uses Medicaid's fee-for-service expenditures.
13 (b) Is certified as an actuarially sound computation
14 of Medicaid fee-for-service expenditures for comparable groups
15 of Medicaid recipients and includes all fee-for-service
16 expenditures, including those fee-for-service expenditures
17 attributable to recipients who are enrolled for a portion of a
18 year in a managed care plan or waiver program.
19 (c) Is compliant with applicable federal laws and
20 regulations, including, but not limited to, the requirements
21 to include an allowance for administrative expenses and to
22 account for all fee-for-service expenditures, including
23 fee-for-service expenditures for those groups enrolled for
24 part of a year.
25 (2)(3) Each year prior to establishing new managed
26 care rates, the agency shall review all prior year adjustments
27 for changes in trend, and shall reduce or eliminate those
28 adjustments which are not reasonable and which reflect
29 policies or programs which are not in effect. In addition, the
30 agency shall apply only those policy reductions applicable to
31 the fiscal year for which the rates are being set, which can
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1 be accurately estimated and verified by an independent
2 actuary, and which have been implemented prior to or will be
3 implemented during the fiscal year. The agency shall pay rates
4 at per-member, per-month averages that equal, but do not
5 exceed, the amounts allowed for in the General Appropriations
6 Act applicable to the fiscal year for which the rates will be
7 in effect.
8 (3)(4) The agency shall by rule prescribe those items
9 of financial information which each managed care plan shall
10 report to the agency, in the time periods prescribed by rule.
11 In prescribing items for reporting and definitions of terms,
12 the agency shall consult with the Office of Insurance
13 Regulation of the Financial Services Commission wherever
14 possible.
15 (4)(5) The agency shall quarterly examine the
16 financial condition of each managed care plan, and its
17 performance in serving Medicaid patients, and shall utilize
18 examinations performed by the Office of Insurance Regulation
19 wherever possible.
20 (5) The agency shall develop two rates for children
21 under 1 year of age. One set of rates shall cover the month of
22 birth through the second complete month subsequent to the
23 month of birth, and a separate set of rates shall cover the
24 third complete month subsequent to the month of birth through
25 the eleventh complete month subsequent to the month of birth.
26 The agency shall amend the payment methodology for
27 participating Medicaid-managed health care plans to comply
28 with this subsection.
29 Section 19. Section 430.041, Florida Statutes, is
30 repealed.
31 Section 20. Subsection (1) of section 430.502, Florida
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1 Statutes, is amended to read:
2 430.502 Alzheimer's disease; memory disorder clinics
3 and day care and respite care programs.--
4 (1) There is established:
5 (a) A memory disorder clinic at each of the three
6 medical schools in this state;
7 (b) A memory disorder clinic at a major private
8 nonprofit research-oriented teaching hospital, and may fund a
9 memory disorder clinic at any of the other affiliated teaching
10 hospitals;
11 (c) A memory disorder clinic at the Mayo Clinic in
12 Jacksonville;
13 (d) A memory disorder clinic at the West Florida
14 Regional Medical Center;
15 (e) The East Central Florida Memory Disorder Clinic at
16 the Joint Center for Advanced Therapeutics and Biomedical
17 Research of the Florida Institute of Technology and Holmes
18 Regional Medical Center, Inc.;
19 (f) A memory disorder clinic at the Orlando Regional
20 Healthcare System, Inc.;
21 (g) A memory disorder center located in a public
22 hospital that is operated by an independent special hospital
23 taxing district that governs multiple hospitals and is located
24 in a county with a population greater than 800,000 persons;
25 (h) A memory disorder clinic at St. Mary's Medical
26 Center in Palm Beach County;
27 (i) A memory disorder clinic at Tallahassee Memorial
28 Healthcare;
29 (j) A memory disorder clinic at Lee Memorial Hospital
30 created by chapter 63-1552, Laws of Florida, as amended;
31 (k) A memory disorder clinic at Sarasota Memorial
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1 Hospital in Sarasota County; and
2 (l) A memory disorder clinic at Morton Plant Hospital,
3 Clearwater, in Pinellas County; and,
4 (m) A memory disorder clinic at Florida Atlantic
5 University, Boca Raton, in Palm Beach County,
6
7 for the purpose of conducting research and training in a
8 diagnostic and therapeutic setting for persons suffering from
9 Alzheimer's disease and related memory disorders. However,
10 memory disorder clinics funded as of June 30, 1995, shall not
11 receive decreased funding due solely to subsequent additions
12 of memory disorder clinics in this subsection.
13 Section 21. Paragraph (d) of subsection (15) of
14 section 440.02, Florida Statutes, is amended to read:
15 440.02 Definitions.--When used in this chapter, unless
16 the context clearly requires otherwise, the following terms
17 shall have the following meanings:
18 (15)
19 (d) "Employee" does not include:
20 1. An independent contractor who is not engaged in the
21 construction industry.
22 a. In order to meet the definition of independent
23 contractor, at least four of the following criteria must be
24 met:
25 (I) The independent contractor maintains a separate
26 business with his or her own work facility, truck, equipment,
27 materials, or similar accommodations;
28 (II) The independent contractor holds or has applied
29 for a federal employer identification number, unless the
30 independent contractor is a sole proprietor who is not
31 required to obtain a federal employer identification number
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1 under state or federal regulations;
2 (III) The independent contractor receives compensation
3 for services rendered or work performed and such compensation
4 is paid to a business rather than to an individual;
5 (IV) The independent contractor holds one or more bank
6 accounts in the name of the business entity for purposes of
7 paying business expenses or other expenses related to services
8 rendered or work performed for compensation;
9 (V) The independent contractor performs work or is
10 able to perform work for any entity in addition to or besides
11 the employer at his or her own election without the necessity
12 of completing an employment application or process; or
13 (VI) The independent contractor receives compensation
14 for work or services rendered on a competitive-bid basis or
15 completion of a task or a set of tasks as defined by a
16 contractual agreement, unless such contractual agreement
17 expressly states that an employment relationship exists.
18 b. If four of the criteria listed in sub-subparagraph
19 a. do not exist, an individual may still be presumed to be an
20 independent contractor and not an employee based on full
21 consideration of the nature of the individual situation with
22 regard to satisfying any of the following conditions:
23 (I) The independent contractor performs or agrees to
24 perform specific services or work for a specific amount of
25 money and controls the means of performing the services or
26 work.
27 (II) The independent contractor incurs the principal
28 expenses related to the service or work that he or she
29 performs or agrees to perform.
30 (III) The independent contractor is responsible for
31 the satisfactory completion of the work or services that he or
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1 she performs or agrees to perform.
2 (IV) The independent contractor receives compensation
3 for work or services performed for a commission or on a
4 per-job basis and not on any other basis.
5 (V) The independent contractor may realize a profit or
6 suffer a loss in connection with performing work or services.
7 (VI) The independent contractor has continuing or
8 recurring business liabilities or obligations.
9 (VII) The success or failure of the independent
10 contractor's business depends on the relationship of business
11 receipts to expenditures.
12 c. Notwithstanding anything to the contrary in this
13 subparagraph, an individual claiming to be an independent
14 contractor has the burden of proving that he or she is an
15 independent contractor for purposes of this chapter.
16 2. A real estate licensee, if that person agrees, in
17 writing, to perform for remuneration solely by way of
18 commission.
19 3. Bands, orchestras, and musical and theatrical
20 performers, including disk jockeys, performing in licensed
21 premises as defined in chapter 562, if a written contract
22 evidencing an independent contractor relationship is entered
23 into before the commencement of such entertainment.
24 4. An owner-operator of a motor vehicle who transports
25 property under a written contract with a motor carrier which
26 evidences a relationship by which the owner-operator assumes
27 the responsibility of an employer for the performance of the
28 contract, if the owner-operator is required to furnish the
29 necessary motor vehicle equipment and all costs incidental to
30 the performance of the contract, including, but not limited
31 to, fuel, taxes, licenses, repairs, and hired help; and the
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1 owner-operator is paid a commission for transportation service
2 and is not paid by the hour or on some other time-measured
3 basis.
4 5. A person whose employment is both casual and not in
5 the course of the trade, business, profession, or occupation
6 of the employer.
7 6. A volunteer, except a volunteer worker for the
8 state or a county, municipality, or other governmental entity.
9 A person who does not receive monetary remuneration for
10 services is presumed to be a volunteer unless there is
11 substantial evidence that a valuable consideration was
12 intended by both employer and employee. For purposes of this
13 chapter, the term "volunteer" includes, but is not limited to:
14 a. Persons who serve in private nonprofit agencies and
15 who receive no compensation other than expenses in an amount
16 less than or equivalent to the standard mileage and per diem
17 expenses provided to salaried employees in the same agency or,
18 if such agency does not have salaried employees who receive
19 mileage and per diem, then such volunteers who receive no
20 compensation other than expenses in an amount less than or
21 equivalent to the customary mileage and per diem paid to
22 salaried workers in the community as determined by the
23 department; and
24 b. Volunteers participating in federal programs
25 established under Pub. L. No. 93-113.
26 7. Unless otherwise prohibited by this chapter, any
27 officer of a corporation who elects to be exempt from this
28 chapter. Such officer is not an employee for any reason under
29 this chapter until the notice of revocation of election filed
30 pursuant to s. 440.05 is effective.
31 8. An officer of a corporation that is engaged in the
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1 construction industry who elects to be exempt from the
2 provisions of this chapter, as otherwise permitted by this
3 chapter. Such officer is not an employee for any reason until
4 the notice of revocation of election filed pursuant to s.
5 440.05 is effective.
6 9. An exercise rider who does not work for a single
7 horse farm or breeder, and who is compensated for riding on a
8 case-by-case basis, provided a written contract is entered
9 into prior to the commencement of such activity which
10 evidences that an employee/employer relationship does not
11 exist.
12 10. A taxicab, limousine, or other passenger
13 vehicle-for-hire driver who operates said vehicles pursuant to
14 a written agreement with a company which provides any
15 dispatch, marketing, insurance, communications, or other
16 services under which the driver and any fees or charges paid
17 by the driver to the company for such services are not
18 conditioned upon, or expressed as a proportion of, fare
19 revenues.
20 11. A person who performs services as a sports
21 official for an entity sponsoring an interscholastic sports
22 event or for a public entity or private, nonprofit
23 organization that sponsors an amateur sports event. For
24 purposes of this subparagraph, such a person is an independent
25 contractor. For purposes of this subparagraph, the term
26 "sports official" means any person who is a neutral
27 participant in a sports event, including, but not limited to,
28 umpires, referees, judges, linespersons, scorekeepers, or
29 timekeepers. This subparagraph does not apply to any person
30 employed by a district school board who serves as a sports
31 official as required by the employing school board or who
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1 serves as a sports official as part of his or her
2 responsibilities during normal school hours.
3 12. Medicaid-enrolled clients under chapter 393 who
4 are excluded from the definition of employment under s.
5 443.1216(4)(d) and served by Adult Day Training Services under
6 the Home and Community-Based or the Family and Supported
7 Living Medicaid Waiver program in a sheltered workshop setting
8 licensed by the United States Department of Labor for the
9 purpose of training and earning less than the federal hourly
10 minimum wage.
11 Section 22. Section 21 of chapter 2004-270, Laws of
12 Florida, is amended to read:
13 Section 21. Notwithstanding s. 430.707, Florida
14 Statutes, no later than September 1, 2005, or subject to
15 federal approval of the application to be a Program of
16 All-inclusive Care for the Elderly site, the agency shall
17 contract with one private, not-for-profit hospice organization
18 located in Lee County and one such organization in Martin
19 County, such an entity shall be exempt from the requirements
20 of chapter 641 Florida Statutes, each of which provides
21 comprehensive services, including hospice care for frail and
22 elderly persons. The agency shall approve 100 initial
23 enrollees in the Program of All-inclusive Care for the Elderly
24 for the in Lee and Martin programs, subject to an
25 appropriation by the Legislature counties. The organization in
26 Lee County shall serve eligible residents in Lee County and in
27 the counties contiguous to Lee County. The organization in
28 Martin County shall serve eligible residents in Martin County
29 and in the counties contiguous to Martin County. Each program
30 may continue to enroll eligible residents when the Agency for
31 Health Care Administration determines such residents to be
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1 eligible for nursing home confinement. Residents currently
2 designated by the agency as eligible for nursing home
3 confinement are automatically eligible for PACE program
4 enrollment. There shall be 50 initial enrollees in each
5 county.
6 Section 23. Sections 8, 9, and 10 of this act are
7 remedial in nature and it is the intent of the Legislature
8 that the provisions of those sections apply to contracts,
9 fees, rates, and other methods of payment in existence before,
10 on, or after the effective date of this act.
11 Section 24. If any provision of this act or its
12 application to any person or circumstance is held invalid, the
13 invalidity does not affect other provisions or applications of
14 the act which can be given effect without the invalid
15 provision or application, and to this end the provisions of
16 this act are severable.
17 Section 25. Except as otherwise expressly provided in
18 this act, this act shall take effect July 1, 2005.
19
20
21 ================ T I T L E A M E N D M E N T ===============
22 And the title is amended as follows:
23 Delete everything before the enacting clause
24
25 and insert:
26 A bill to be entitled
27 An act relating to health care; amending s.
28 393.0661, F.S.; deleting provisions authorizing
29 the Agency for Health Care Administration to
30 adopt emergency rules governing the home and
31 community-based services delivery system;
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1 amending s. 400.23, F.S.; delaying provisions
2 requiring a nursing home staffing increase;
3 amending s. 408.034, F.S.; deleting references
4 to the Office of Long-Term Care Policy;
5 requiring the Agency for Health Care
6 Administration to make recommendations to the
7 Legislature relating to the need for nursing
8 facility beds; amending ss. 409.903, 409.904,
9 F.S.; deleting certain limitations on services
10 to the medically needy; amending s. 409.906,
11 F.S., relating to optional Medicaid services;
12 providing for adult denture services; repealing
13 s. 409.9065, F.S., relating to pharmaceutical
14 expense assistance; amending s. 409.907, F.S.,
15 relating to Medicaid provider agreements;
16 prohibiting the incorporation of a fee or rate
17 schedule into a provider agreement; requiring
18 that such agreements be renewed or amended only
19 in writing; amending s. 409.908, F.S.;
20 requiring that the agency reimburse providers
21 according to published methodologies;
22 authorizing adjustments in fees, rates, and
23 other requirements under certain circumstances;
24 removing obsolete provisions; creating s.
25 409.9082, F.S.; providing a Medicaid
26 rate-setting process; providing that the agency
27 need not comply with ch. 120, F.S., when
28 setting such rates; limiting judicial review of
29 such rates; providing notice requirements or
30 proposed and final rate methodologies; amending
31 ss. 409.911, 409.9112, 409.9113, 409.9117,
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1 F.S., relating to the hospital disproportionate
2 share program; revising the method for
3 calculating the disproportionate share payment;
4 deleting obsolete provisions; amending s.
5 409.91195, F.S.; revising provisions relating
6 to the Medicaid Pharmaceutical and Therapeutics
7 Committee and its duties with respect to
8 developing a preferred drug list; amending s.
9 409.912, F.S.; authorizing the agency to
10 contract with comprehensive behavioral health
11 care providers in a specified service area for
12 the purpose of demonstrating the
13 cost-effectiveness of quality mental health
14 services through a public hospital-operated
15 managed care model; providing requirements for
16 the contract; revising the Medicaid prescribed
17 drug spending control program; eliminating case
18 management fees; directing the Agency for
19 Health Care Administration to implement, and
20 authorizing it to seek federal waivers for, the
21 program of all-inclusive care for children;
22 authorizing the agency to adopt rules; amending
23 s. 409.9122, F.S.; revising a provision
24 governing assignment to a managed care option
25 for a Medicaid recipient who does not choose a
26 plan or provider in certain geographic areas
27 where the Agency for Health Care Administration
28 contracts for comprehensive behavioral health
29 services; amending s. 409.9124, F.S.; requiring
30 the Agency for Health Care Administration to
31 publish managed care reimbursement rates
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1 annually; limiting the application of certain
2 rates and rate reductions; providing for rates
3 applicable to children under 1 year of age;
4 repealing s. 430.041, F.S., relating to
5 establishing the Office of Long-Term Care
6 Policy; amending s. 430.502, F.S.; establishing
7 a memory disorder clinic at Florida Atlantic
8 University; amending s. 440.02, F.S.; excluding
9 from the term "employee" as used in ch. 440,
10 F.S., certain Medicaid-enrolled clients served
11 under the Family and Supported Living Medicaid
12 Waiver program; amending s. 21, ch. 2004-270,
13 Laws of Florida; providing criteria for
14 clientele to be served by organizations in Lee
15 County and Martin County under the Program of
16 All-inclusive Care for the Elderly; providing
17 legislative intent with respect to the
18 applicability of provisions of the act
19 governing contracts, fees, rates, and other
20 methods of payment; providing for severability;
21 providing effective dates.
22
23
24
25
26
27
28
29
30
31
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