Amendment
Bill No. 0404

Amendment No. 932633

CHAMBER ACTION
Senate		House
.
.
.

---

---

1	Representative(s) Bean offered the following:
2
3	Amendment (with title amendment)
4	Remove the entire body and insert:
5	Section 1.  Paragraph (a) of subsection (3) of section
6	400.23, Florida Statutes, is amended to read:
7	400.23  Rules; evaluation and deficiencies; licensure
8	status.--
9	(3)(a)  The agency shall adopt rules providing for the
10	minimum staffing requirements for nursing homes. These
11	requirements shall include, for each nursing home facility, a
12	minimum certified nursing assistant staffing of 2.3 hours of
13	direct care per resident per day beginning January 1, 2002,
14	increasing to 2.6 hours of direct care per resident per day
15	beginning January 1, 2003, and increasing to 2.9 hours of direct
16	care per resident per day beginning July 1, 2006 2005. Beginning
17	January 1, 2002, no facility shall staff below one certified
18	nursing assistant per 20 residents, and a minimum licensed
19	nursing staffing of 1.0 hour of direct resident care per
20	resident per day but never below one licensed nurse per 40
21	residents. Nursing assistants employed under s. 400.211(2) may
22	be included in computing the staffing ratio for certified
23	nursing assistants only if they provide nursing assistance
24	services to residents on a full-time basis. Each nursing home
25	must document compliance with staffing standards as required
26	under this paragraph and post daily the names of staff on duty
27	for the benefit of facility residents and the public. The agency
28	shall recognize the use of licensed nurses for compliance with
29	minimum staffing requirements for certified nursing assistants,
30	provided that the facility otherwise meets the minimum staffing
31	requirements for licensed nurses and that the licensed nurses so
32	recognized are performing the duties of a certified nursing
33	assistant. Unless otherwise approved by the agency, licensed
34	nurses counted toward the minimum staffing requirements for
35	certified nursing assistants must exclusively perform the duties
36	of a certified nursing assistant for the entire shift and shall
37	not also be counted toward the minimum staffing requirements for
38	licensed nurses. If the agency approved a facility's request to
39	use a licensed nurse to perform both licensed nursing and
40	certified nursing assistant duties, the facility must allocate
41	the amount of staff time specifically spent on certified nursing
42	assistant duties for the purpose of documenting compliance with
43	minimum staffing requirements for certified and licensed nursing
44	staff. In no event may the hours of a licensed nurse with dual
45	job responsibilities be counted twice.
46	Section 2.  Subsections (2) and (5) of section 409.814,
47	Florida Statutes, are amended to read:
48	409.814  Eligibility.--A child who has not reached 19 years
49	of age whose family income is equal to or below 200 percent of
50	the federal poverty level is eligible for the Florida KidCare
51	program as provided in this section. For enrollment in the
52	Children's Medical Services Network, a complete application
53	includes the medical or behavioral health screening. If,
54	subsequently, an individual is determined to be ineligible for
55	coverage, he or she must immediately be disenrolled from the
56	respective Florida KidCare program component.
57	(2)  A child who is not eligible for Medicaid, but who is
58	eligible for the Florida KidCare program, may obtain health
59	benefits coverage under any of the other components listed in s.
60	409.813 if such coverage is approved and available in the county
61	in which the child resides. However, a child who is eligible for
62	Medikids, including those eligible under subsection (5), may
63	participate in the Florida Healthy Kids program only if the
64	child has a sibling participating in the Florida Healthy Kids
65	program and the child's county of residence permits such
66	enrollment.
67	(5)  A child whose family income is above 200 percent of
68	the federal poverty level or a child who is excluded under the
69	provisions of subsection (4) may apply for coverage and shall be
70	allowed to participate in the Florida KidCare program, excluding
71	the Medicaid program, but is subject to the following
72	provisions:
73	(a)  The family is not eligible for premium assistance
74	payments and must pay the full cost of the premium, including
75	any administrative costs.
76	(b)  The agency is authorized to place limits on enrollment
77	in Medikids by these children in order to avoid adverse
78	selection. The number of children participating in Medikids
79	whose family income exceeds 200 percent of the federal poverty
80	level must not exceed 10 percent of total enrollees in the
81	Medikids program.
82	(c)  The board of directors of the Florida Healthy Kids
83	Corporation is authorized to place limits on enrollment of these
84	children in order to avoid adverse selection. In addition, the
85	board is authorized to offer a reduced benefit package to these
86	children in order to limit program costs for such families. The
87	number of children participating in the Florida Healthy Kids
88	program whose family income exceeds 200 percent of the federal
89	poverty level must not exceed 10 percent of total enrollees in
90	the Florida Healthy Kids program.
91	(d)  Children described in this subsection are not counted
92	in the annual enrollment ceiling for the Florida KidCare
93	program.
94	Section 3.  Subsection (5) of section 409.903, Florida
95	Statutes, is amended to read:
96	409.903  Mandatory payments for eligible persons.--The
97	agency shall make payments for medical assistance and related
98	services on behalf of the following persons who the department,
99	or the Social Security Administration by contract with the
100	Department of Children and Family Services, determines to be
101	eligible, subject to the income, assets, and categorical
102	eligibility tests set forth in federal and state law. Payment on
103	behalf of these Medicaid eligible persons is subject to the
104	availability of moneys and any limitations established by the
105	General Appropriations Act or chapter 216.
106	(5)  A pregnant woman for the duration of her pregnancy and
107	for the postpartum period as defined in federal law and rule, or
108	a child under age 1, if either is living in a family that has an
109	income which is at or below 150 percent of the most current
110	federal poverty level, or, effective January 1, 1992, that has
111	an income which is at or below 185 percent of the most current
112	federal poverty level. Such a person is not subject to an assets
113	test. Further, a pregnant woman who applies for eligibility for
114	the Medicaid program through a qualified Medicaid provider must
115	be offered the opportunity, subject to federal rules, to be made
116	presumptively eligible for the Medicaid program. Effective July
117	1, 2005, eligibility for Medicaid services is eliminated for
118	women who have incomes above 150 percent of the most current
119	federal poverty level.
120	Section 4.  Subsections (1) and (2) of section 409.904,
121	Florida Statutes, are amended to read:
122	409.904  Optional payments for eligible persons.--The
123	agency may make payments for medical assistance and related
124	services on behalf of the following persons who are determined
125	to be eligible subject to the income, assets, and categorical
126	eligibility tests set forth in federal and state law. Payment on
127	behalf of these Medicaid eligible persons is subject to the
128	availability of moneys and any limitations established by the
129	General Appropriations Act or chapter 216.
130	(1)(a)  From July 1, 2005, through December 31, 2005,
131	inclusive, a person who is age 65 or older or is determined to
132	be disabled, whose income is at or below 88 percent of federal
133	poverty level, and whose assets do not exceed established
134	limitations.
135	(b)  Effective January 1, 2006, and subject to federal
136	waiver approval, a person who is age 65 or older or is
137	determined to be disabled, whose income is at or below 88
138	percent of the federal poverty level, whose assets do not exceed
139	established limitations, and who is not eligible for Medicare,
140	or, if eligible for Medicare, is also eligible for and receiving
141	Medicaid-covered institutional care or hospice or home-based and
142	community-based services. The agency shall seek federal
143	authorization through a waiver to provide this coverage.
144	(2)  A family, a pregnant woman, a child under age 21, a
145	person age 65 or over, or a blind or disabled person, who would
146	be eligible under any group listed in s. 409.903(1), (2), or
147	(3), except that the income or assets of such family or person
148	exceed established limitations. For a family or person in one of
149	these coverage groups, medical expenses are deductible from
150	income in accordance with federal requirements in order to make
151	a determination of eligibility. A family or person eligible
152	under the coverage known as the "medically needy," is eligible
153	to receive the same services as other Medicaid recipients, with
154	the exception of services in skilled nursing facilities and
155	intermediate care facilities for the developmentally disabled.
156	Effective July 1, 2005, the medically needy are eligible for
157	prescribed drug services only.
158	Section 5.  Paragraph (b) of subsection (1) of section
159	409.906, Florida Statutes, is amended to read:
160	409.906  Optional Medicaid services.--Subject to specific
161	appropriations, the agency may make payments for services which
162	are optional to the state under Title XIX of the Social Security
163	Act and are furnished by Medicaid providers to recipients who
164	are determined to be eligible on the dates on which the services
165	were provided. Any optional service that is provided shall be
166	provided only when medically necessary and in accordance with
167	state and federal law. Optional services rendered by providers
168	in mobile units to Medicaid recipients may be restricted or
169	prohibited by the agency. Nothing in this section shall be
170	construed to prevent or limit the agency from adjusting fees,
171	reimbursement rates, lengths of stay, number of visits, or
172	number of services, or making any other adjustments necessary to
173	comply with the availability of moneys and any limitations or
174	directions provided for in the General Appropriations Act or
175	chapter 216. If necessary to safeguard the state's systems of
176	providing services to elderly and disabled persons and subject
177	to the notice and review provisions of s. 216.177, the Governor
178	may direct the Agency for Health Care Administration to amend
179	the Medicaid state plan to delete the optional Medicaid service
180	known as "Intermediate Care Facilities for the Developmentally
181	Disabled." Optional services may include:
182	(1)  ADULT DENTAL SERVICES.--
183	(b)  Beginning January 1, 2005, The agency may pay for
184	dentures, the procedures required to seat dentures, and the
185	repair and reline of dentures, provided by or under the
186	direction of a licensed dentist, for a recipient who is 21 years
187	of age or older. This paragraph is repealed effective July 1,
188	2005.
189	Section 6.  Effective January 1, 2006, section 409.9065,
190	Florida Statutes, is repealed.
191	Section 7.  Paragraph (b) of subsection (2) and subsection
192	(14) of section 409.908, Florida Statutes, are amended to read:
193	409.908  Reimbursement of Medicaid providers.--Subject to
194	specific appropriations, the agency shall reimburse Medicaid
195	providers, in accordance with state and federal law, according
196	to methodologies set forth in the rules of the agency and in
197	policy manuals and handbooks incorporated by reference therein.
198	These methodologies may include fee schedules, reimbursement
199	methods based on cost reporting, negotiated fees, competitive
200	bidding pursuant to s. 287.057, and other mechanisms the agency
201	considers efficient and effective for purchasing services or
202	goods on behalf of recipients. If a provider is reimbursed based
203	on cost reporting and submits a cost report late and that cost
204	report would have been used to set a lower reimbursement rate
205	for a rate semester, then the provider's rate for that semester
206	shall be retroactively calculated using the new cost report, and
207	full payment at the recalculated rate shall be effected
208	retroactively. Medicare-granted extensions for filing cost
209	reports, if applicable, shall also apply to Medicaid cost
210	reports. Payment for Medicaid compensable services made on
211	behalf of Medicaid eligible persons is subject to the
212	availability of moneys and any limitations or directions
213	provided for in the General Appropriations Act or chapter 216.
214	Further, nothing in this section shall be construed to prevent
215	or limit the agency from adjusting fees, reimbursement rates,
216	lengths of stay, number of visits, or number of services, or
217	making any other adjustments necessary to comply with the
218	availability of moneys and any limitations or directions
219	provided for in the General Appropriations Act, provided the
220	adjustment is consistent with legislative intent.
221	(2)
222	(b)  Subject to any limitations or directions provided for
223	in the General Appropriations Act, the agency shall establish
224	and implement a Florida Title XIX Long-Term Care Reimbursement
225	Plan (Medicaid) for nursing home care in order to provide care
226	and services in conformance with the applicable state and
227	federal laws, rules, regulations, and quality and safety
228	standards and to ensure that individuals eligible for medical
229	assistance have reasonable geographic access to such care.
230	1.  Changes of ownership or of licensed operator do not
231	qualify for increases in reimbursement rates associated with the
232	change of ownership or of licensed operator. The agency shall
233	amend the Title XIX Long Term Care Reimbursement Plan to provide
234	that the initial nursing home reimbursement rates, for the
235	operating, patient care, and MAR components, associated with
236	related and unrelated party changes of ownership or licensed
237	operator filed on or after September 1, 2001, are equivalent to
238	the previous owner's reimbursement rate.
239	2.  The agency shall amend the long-term care reimbursement
240	plan and cost reporting system to create direct care and
241	indirect care subcomponents of the patient care component of the
242	per diem rate. These two subcomponents together shall equal the
243	patient care component of the per diem rate. Separate cost-based
244	ceilings shall be calculated for each patient care subcomponent.
245	The direct care and indirect care subcomponents subcomponent of
246	the per diem rate shall be limited by the cost-based class
247	ceiling, and the indirect care subcomponent shall be limited by
248	the lower of a the cost-based class ceiling, a by the target
249	rate class ceiling, or an by the individual provider target for
250	each subcomponent. The agency shall adjust the patient care
251	component effective January 1, 2002. The cost to adjust the
252	direct care subcomponent shall be the net of the total funds
253	previously allocated for the case mix add-on. The agency shall
254	make the required changes to the nursing home cost reporting
255	forms to implement this requirement effective January 1, 2002.
256	3.  The direct care subcomponent shall include salaries and
257	benefits of direct care staff providing nursing services
258	including registered nurses, licensed practical nurses, and
259	certified nursing assistants who deliver care directly to
260	residents in the nursing home facility. This excludes nursing
261	administration, MDS, and care plan coordinators, staff
262	development, and staffing coordinator.
263	4.  All other patient care costs shall be included in the
264	indirect care cost subcomponent of the patient care per diem
265	rate. There shall be no costs directly or indirectly allocated
266	to the direct care subcomponent from a home office or management
267	company.
268	5.  On July 1 of each year, the agency shall report to the
269	Legislature direct and indirect care costs, including average
270	direct and indirect care costs per resident per facility and
271	direct care and indirect care salaries and benefits per category
272	of staff member per facility.
273	6.  In order to offset the cost of general and professional
274	liability insurance, the agency shall amend the plan to allow
275	for interim rate adjustments to reflect increases in the cost of
276	general or professional liability insurance for nursing homes.
277	This provision shall be implemented to the extent existing
278	appropriations are available.
279
280	It is the intent of the Legislature that the reimbursement plan
281	achieve the goal of providing access to health care for nursing
282	home residents who require large amounts of care while
283	encouraging diversion services as an alternative to nursing home
284	care for residents who can be served within the community. The
285	agency shall base the establishment of any maximum rate of
286	payment, whether overall or component, on the available moneys
287	as provided for in the General Appropriations Act. The agency
288	may base the maximum rate of payment on the results of
289	scientifically valid analysis and conclusions derived from
290	objective statistical data pertinent to the particular maximum
291	rate of payment.
292	(14)  A provider of prescribed drugs shall be reimbursed
293	the least of the amount billed by the provider, the provider's
294	usual and customary charge, or the Medicaid maximum allowable
295	fee established by the agency, plus a dispensing fee.
296	(a)  For pharmacies with less than $75,000 in average
297	aggregate monthly payments, the Medicaid maximum allowable fee
298	for ingredient cost will be based on the lower of: average
299	wholesale price (AWP) minus 15.4 percent, wholesaler acquisition
300	cost (WAC) plus 5.75 percent, the federal upper limit (FUL), the
301	state maximum allowable cost (SMAC), or the usual and customary
302	(UAC) charge billed by the provider.
303	(b)  For pharmacies with $75,000 or more in average
304	aggregate monthly payments, the Medicaid maximum allowable fee
305	for ingredient cost will be based on the lower of: average
306	wholesale price (AWP) minus 17 percent, wholesaler acquisition
307	cost (WAC) plus 3.75 percent, the federal upper limit (FUL), the
308	state maximum allowable cost (SMAC), or the usual and customary
309	(UAC) charge billed by the provider.
310	(c)  Medicaid providers are required to dispense generic
311	drugs if available at lower cost and the agency has not
312	determined that the branded product is more cost-effective,
313	unless the prescriber has requested and received approval to
314	require the branded product. The agency is directed to implement
315	a variable dispensing fee for payments for prescribed medicines
316	while ensuring continued access for Medicaid recipients. The
317	variable dispensing fee may be based upon, but not limited to,
318	either or both the volume of prescriptions dispensed by a
319	specific pharmacy provider, the volume of prescriptions
320	dispensed to an individual recipient, and dispensing of
321	preferred-drug-list products. The agency may increase the
322	pharmacy dispensing fee authorized by statute and in the annual
323	General Appropriations Act by $0.50 for the dispensing of a
324	Medicaid preferred-drug-list product and reduce the pharmacy
325	dispensing fee by $0.50 for the dispensing of a Medicaid product
326	that is not included on the preferred drug list. The agency may
327	establish a supplemental pharmaceutical dispensing fee to be
328	paid to providers returning unused unit-dose packaged
329	medications to stock and crediting the Medicaid program for the
330	ingredient cost of those medications if the ingredient costs to
331	be credited exceed the value of the supplemental dispensing fee.
332	The agency is authorized to limit reimbursement for prescribed
333	medicine in order to comply with any limitations or directions
334	provided for in the General Appropriations Act, which may
335	include implementing a prospective or concurrent utilization
336	review program.
337	Section 8.  Paragraph (a) of subsection (39) of section
338	409.912, Florida Statutes, is amended, and subsections (50) and
339	(51) are added to said section, to read:
340	409.912  Cost-effective purchasing of health care.--The
341	agency shall purchase goods and services for Medicaid recipients
342	in the most cost-effective manner consistent with the delivery
343	of quality medical care. To ensure that medical services are
344	effectively utilized, the agency may, in any case, require a
345	confirmation or second physician's opinion of the correct
346	diagnosis for purposes of authorizing future services under the
347	Medicaid program. This section does not restrict access to
348	emergency services or poststabilization care services as defined
349	in 42 C.F.R. part 438.114. Such confirmation or second opinion
350	shall be rendered in a manner approved by the agency. The agency
351	shall maximize the use of prepaid per capita and prepaid
352	aggregate fixed-sum basis services when appropriate and other
353	alternative service delivery and reimbursement methodologies,
354	including competitive bidding pursuant to s. 287.057, designed
355	to facilitate the cost-effective purchase of a case-managed
356	continuum of care. The agency shall also require providers to
357	minimize the exposure of recipients to the need for acute
358	inpatient, custodial, and other institutional care and the
359	inappropriate or unnecessary use of high-cost services. The
360	agency may mandate prior authorization, drug therapy management,
361	or disease management participation for certain populations of
362	Medicaid beneficiaries, certain drug classes, or particular
363	drugs to prevent fraud, abuse, overuse, and possible dangerous
364	drug interactions. The Pharmaceutical and Therapeutics Committee
365	shall make recommendations to the agency on drugs for which
366	prior authorization is required. The agency shall inform the
367	Pharmaceutical and Therapeutics Committee of its decisions
368	regarding drugs subject to prior authorization. The agency is
369	authorized to limit the entities it contracts with or enrolls as
370	Medicaid providers by developing a provider network through
371	provider credentialing. The agency may limit its network based
372	on the assessment of beneficiary access to care, provider
373	availability, provider quality standards, time and distance
374	standards for access to care, the cultural competence of the
375	provider network, demographic characteristics of Medicaid
376	beneficiaries, practice and provider-to-beneficiary standards,
377	appointment wait times, beneficiary use of services, provider
378	turnover, provider profiling, provider licensure history,
379	previous program integrity investigations and findings, peer
380	review, provider Medicaid policy and billing compliance records,
381	clinical and medical record audits, and other factors. Providers
382	shall not be entitled to enrollment in the Medicaid provider
383	network. The agency is authorized to seek federal waivers
384	necessary to implement this policy.
385	(39)(a)  The agency shall implement a Medicaid prescribed-
386	drug spending-control program that includes the following
387	components:
388	1.  Medicaid prescribed-drug coverage for brand-name drugs
389	for adult Medicaid recipients is limited to the dispensing of
390	three four brand-name drugs and three generic drugs per month
391	per recipient. Children are exempt from this restriction.
392	Antiretroviral agents are excluded from this limitation. No
393	requirements for prior authorization or other restrictions on
394	medications used to treat mental illnesses such as
395	schizophrenia, severe depression, or bipolar disorder may be
396	imposed on Medicaid recipients. Medications that will be
397	available without restriction for persons with mental illnesses
398	include atypical antipsychotic medications, conventional
399	antipsychotic medications, selective serotonin reuptake
400	inhibitors, and other medications used for the treatment of
401	serious mental illnesses. The agency shall also limit the amount
402	of a prescribed drug dispensed to no more than a 34-day supply.
403	The agency shall continue to provide unlimited generic drugs,
404	contraceptive drugs and items, and diabetic supplies. Although a
405	drug may be included on the preferred drug formulary, it would
406	not be exempt from the three-brand four-brand limit or the
407	generic drug limit. The agency may authorize exceptions to the
408	brand-name-drug restriction based upon the treatment needs of
409	the patients, only when such exceptions are based on prior
410	consultation provided by the agency or an agency contractor, but
411	the agency must establish procedures to ensure that:
412	a.  There will be a response to a request for prior
413	consultation by telephone or other telecommunication device
414	within 24 hours after receipt of a request for prior
415	consultation;
416	b.  A 72-hour supply of the drug prescribed will be
417	provided in an emergency or when the agency does not provide a
418	response within 24 hours as required by sub-subparagraph a.; and
419	c.  Except for the exception for nursing home residents and
420	other institutionalized adults and except for drugs on the
421	restricted formulary for which prior authorization may be sought
422	by an institutional or community pharmacy, prior authorization
423	for an exception to the brand-name-drug restriction is sought by
424	the prescriber and not by the pharmacy. When prior authorization
425	is granted for a patient in an institutional setting beyond the
426	brand-name-drug restriction, such approval is authorized for 12
427	months and monthly prior authorization is not required for that
428	patient.
429	2.  Reimbursement to pharmacies for Medicaid prescribed
430	drugs shall be set at the lesser of:
431	a.  The average wholesale price (AWP) minus 15.4 percent,
432	the wholesaler acquisition cost (WAC) plus 5.75 percent, the
433	federal upper limit (FUL), the state maximum allowable cost
434	(SMAC), or the usual and customary (UAC) charge billed by the
435	provider for pharmacies with less than $75,000 in average
436	aggregate monthly payments.
437	b.  The average wholesale price (AWP) minus 17 percent,
438	wholesaler acquisition cost (WAC) plus 3.75 percent, the federal
439	upper limit (FUL), the state maximum allowable cost (SMAC), or
440	the usual and customary (UAC) charge billed by the provider for
441	pharmacies with $75,000 or more in average aggregate monthly
442	payments.
443	3.  The agency shall develop and implement a process for
444	managing the drug therapies of Medicaid recipients who are using
445	significant numbers of prescribed drugs each month. The
446	management process may include, but is not limited to,
447	comprehensive, physician-directed medical-record reviews, claims
448	analyses, and case evaluations to determine the medical
449	necessity and appropriateness of a patient's treatment plan and
450	drug therapies. The agency may contract with a private
451	organization to provide drug-program-management services. The
452	Medicaid drug benefit management program shall include
453	initiatives to manage drug therapies for HIV/AIDS patients,
454	patients using 20 or more unique prescriptions in a 180-day
455	period, and the top 1,000 patients in annual spending. The
456	agency shall enroll any Medicaid recipient in the drug benefit
457	management program if he or she meets the specifications of this
458	provision and is not enrolled in a Medicaid health maintenance
459	organization.
460	4.  The agency may limit the size of its pharmacy network
461	based on need, competitive bidding, price negotiations,
462	credentialing, or similar criteria. The agency shall give
463	special consideration to rural areas in determining the size and
464	location of pharmacies included in the Medicaid pharmacy
465	network. A pharmacy credentialing process may include criteria
466	such as a pharmacy's full-service status, location, size,
467	patient educational programs, patient consultation, disease-
468	management services, and other characteristics. The agency may
469	impose a moratorium on Medicaid pharmacy enrollment when it is
470	determined that it has a sufficient number of Medicaid-
471	participating providers.
472	5.  The agency shall develop and implement a program that
473	requires Medicaid practitioners who prescribe drugs to use a
474	counterfeit-proof prescription pad for Medicaid prescriptions.
475	The agency shall require the use of standardized counterfeit-
476	proof prescription pads by Medicaid-participating prescribers or
477	prescribers who write prescriptions for Medicaid recipients. The
478	agency may implement the program in targeted geographic areas or
479	statewide.
480	6.  The agency may enter into arrangements that require
481	manufacturers of generic drugs prescribed to Medicaid recipients
482	to provide rebates of at least 15.1 percent of the average
483	manufacturer price for the manufacturer's generic products.
484	These arrangements shall require that if a generic-drug
485	manufacturer pays federal rebates for Medicaid-reimbursed drugs
486	at a level below 15.1 percent, the manufacturer must provide a
487	supplemental rebate to the state in an amount necessary to
488	achieve a 15.1-percent rebate level.
489	7.  The agency may establish a preferred drug formulary in
490	accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
491	establishment of such formulary, it is authorized to negotiate
492	supplemental rebates from manufacturers that are in addition to
493	those required by Title XIX of the Social Security Act and at no
494	less than 14 percent of the average manufacturer price as
495	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
496	the federal or supplemental rebate, or both, equals or exceeds
497	29 percent. There is no upper limit on the supplemental rebates
498	the agency may negotiate. The agency may determine that specific
499	products, brand-name or generic, are competitive at lower rebate
500	percentages. Agreement to pay the minimum supplemental rebate
501	percentage will guarantee a manufacturer that the Medicaid
502	Pharmaceutical and Therapeutics Committee will consider a
503	product for inclusion on the preferred drug formulary. However,
504	a pharmaceutical manufacturer is not guaranteed placement on the
505	formulary by simply paying the minimum supplemental rebate.
506	Agency decisions will be made on the clinical efficacy of a drug
507	and recommendations of the Medicaid Pharmaceutical and
508	Therapeutics Committee, as well as the price of competing
509	products minus federal and state rebates. The agency is
510	authorized to contract with an outside agency or contractor to
511	conduct negotiations for supplemental rebates. For the purposes
512	of this section, the term "supplemental rebates" means cash
513	rebates. Effective July 1, 2004, value-added programs as a
514	substitution for supplemental rebates are prohibited. The agency
515	is authorized to seek any federal waivers to implement this
516	initiative.
517	8.  The agency shall establish an advisory committee for
518	the purposes of studying the feasibility of using a restricted
519	drug formulary for nursing home residents and other
520	institutionalized adults. The committee shall be comprised of
521	seven members appointed by the Secretary of Health Care
522	Administration. The committee members shall include two
523	physicians licensed under chapter 458 or chapter 459; three
524	pharmacists licensed under chapter 465 and appointed from a list
525	of recommendations provided by the Florida Long-Term Care
526	Pharmacy Alliance; and two pharmacists licensed under chapter
527	465.
528	9.  The Agency for Health Care Administration shall expand
529	home delivery of pharmacy products. To assist Medicaid patients
530	in securing their prescriptions and reduce program costs, the
531	agency shall expand its current mail-order-pharmacy diabetes-
532	supply program to include all generic and brand-name drugs used
533	by Medicaid patients with diabetes. Medicaid recipients in the
534	current program may obtain nondiabetes drugs on a voluntary
535	basis. This initiative is limited to the geographic area covered
536	by the current contract. The agency may seek and implement any
537	federal waivers necessary to implement this subparagraph.
538	10.  The agency shall limit to one dose per month any drug
539	prescribed to treat erectile dysfunction.
540	11.a.  The agency shall implement a Medicaid behavioral
541	drug management system. The agency may contract with a vendor
542	that has experience in operating behavioral drug management
543	systems to implement this program. The agency is authorized to
544	seek federal waivers to implement this program.
545	b.  The agency, in conjunction with the Department of
546	Children and Family Services, may implement the Medicaid
547	behavioral drug management system that is designed to improve
548	the quality of care and behavioral health prescribing practices
549	based on best practice guidelines, improve patient adherence to
550	medication plans, reduce clinical risk, and lower prescribed
551	drug costs and the rate of inappropriate spending on Medicaid
552	behavioral drugs. The program shall include the following
553	elements:
554	(I)  Provide for the development and adoption of best
555	practice guidelines for behavioral health-related drugs such as
556	antipsychotics, antidepressants, and medications for treating
557	bipolar disorders and other behavioral conditions; translate
558	them into practice; review behavioral health prescribers and
559	compare their prescribing patterns to a number of indicators
560	that are based on national standards; and determine deviations
561	from best practice guidelines.
562	(II)  Implement processes for providing feedback to and
563	educating prescribers using best practice educational materials
564	and peer-to-peer consultation.
565	(III)  Assess Medicaid beneficiaries who are outliers in
566	their use of behavioral health drugs with regard to the numbers
567	and types of drugs taken, drug dosages, combination drug
568	therapies, and other indicators of improper use of behavioral
569	health drugs.
570	(IV)  Alert prescribers to patients who fail to refill
571	prescriptions in a timely fashion, are prescribed multiple same-
572	class behavioral health drugs, and may have other potential
573	medication problems.
574	(V)  Track spending trends for behavioral health drugs and
575	deviation from best practice guidelines.
576	(VI)  Use educational and technological approaches to
577	promote best practices, educate consumers, and train prescribers
578	in the use of practice guidelines.
579	(VII)  Disseminate electronic and published materials.
580	(VIII)  Hold statewide and regional conferences.
581	(IX)  Implement a disease management program with a model
582	quality-based medication component for severely mentally ill
583	individuals and emotionally disturbed children who are high
584	users of care.
585	c.  If the agency is unable to negotiate a contract with
586	one or more manufacturers to finance and guarantee savings
587	associated with a behavioral drug management program by
588	September 1, 2004, the four-brand drug limit and preferred drug
589	list prior-authorization requirements shall apply to mental
590	health-related drugs, notwithstanding any provision in
591	subparagraph 1. The agency is authorized to seek federal waivers
592	to implement this policy.
593	12.  The agency is authorized to contract for drug rebate
594	administration, including, but not limited to, calculating
595	rebate amounts, invoicing manufacturers, negotiating disputes
596	with manufacturers, and maintaining a database of rebate
597	collections.
598	13.  The agency may specify the preferred daily dosing form
599	or strength for the purpose of promoting best practices with
600	regard to the prescribing of certain drugs as specified in the
601	General Appropriations Act and ensuring cost-effective
602	prescribing practices.
603	14.  The agency may require prior authorization for the
604	off-label use of Medicaid-covered prescribed drugs as specified
605	in the General Appropriations Act. The agency may, but is not
606	required to, preauthorize the use of a product for an indication
607	not in the approved labeling. Prior authorization may require
608	the prescribing professional to provide information about the
609	rationale and supporting medical evidence for the off-label use
610	of a drug.
611	15.  The agency shall implement a return and reuse program
612	for drugs dispensed by pharmacies to institutional recipients,
613	which includes payment of a $5 restocking fee for the
614	implementation and operation of the program. The return and
615	reuse program shall be implemented electronically and in a
616	manner that promotes efficiency. The program must permit a
617	pharmacy to exclude drugs from the program if it is not
618	practical or cost-effective for the drug to be included and must
619	provide for the return to inventory of drugs that cannot be
620	credited or returned in a cost-effective manner.
621	(50)  The agency may implement a program of all-inclusive
622	care for children to reduce the need for hospitalization of
623	children, as appropriate. The purpose of the program is to
624	provide in-home hospice-like support services to children
625	diagnosed with a life-threatening illness who are enrolled in
626	the Children's Medical Services Network. The agency, in
627	consultation with the Department of Health, may implement the
628	program of all-inclusive care for children after obtaining
629	approval from the Centers for Medicare and Medicaid Services.
630	(51)  By July 1, 2005, the agency shall develop a plan for
631	implementing the delivery of comprehensive vision care services
632	to Medicaid recipients through a capitated prepaid arrangement.
633	The plan shall include contracting with a private entity or
634	entities to provide for the comprehensive vision care services
635	through a capitated prepaid arrangement. However, the entity
636	must:
637	(a)  Be licensed under chapter 627.
638	(b)  Have sufficient financial resources.
639	(c)  Have a contracted provider network that has statewide
640	coverage.
641	(d)  Have experience in providing medical and surgical
642	vision care services.
643	(e)  Have experience with the implementation of large
644	statewide contracts. As used in this section, the term "vision
645	care services" means covered vision services, including routine,
646	medical, and surgical vision care services that are available to
647	Medicaid recipients. If necessary, the agency shall seek federal
648	approval to contract with a single entity meeting these
649	requirements to provide vision care services to all Medicaid
650	recipients. The entity must offer sufficient choice of providers
651	within its network to ensure access to care for the recipient
652	and the opportunity to select a provider with whom the recipient
653	is satisfied.
654	Section 9.  Paragraph (k) of subsection (2) of section
655	409.9122, Florida Statutes, is amended to read:
656	409.9122  Mandatory Medicaid managed care enrollment;
657	programs and procedures.--
658	(2)
659	(k)  When a Medicaid recipient does not choose a managed
660	care plan or MediPass provider, the agency shall assign the
661	Medicaid recipient to a managed care plan, except in those
662	counties in which there are fewer than two managed care plans
663	accepting Medicaid enrollees, in which case assignment shall be
664	to a managed care plan or a MediPass provider. Medicaid
665	recipients in counties with fewer than two managed care plans
666	accepting Medicaid enrollees who are subject to mandatory
667	assignment but who fail to make a choice shall be assigned to
668	managed care plans until an enrollment of 40 percent in MediPass
669	and 60 percent in managed care plans is achieved. Once that
670	enrollment is achieved, the assignments shall be divided in
671	order to maintain an enrollment in MediPass and managed care
672	plans which is in a 40 percent and 60 percent proportion,
673	respectively. In geographic areas where the agency is
674	contracting for the provision of comprehensive behavioral health
675	services through a capitated prepaid arrangement, recipients who
676	fail to make a choice shall be assigned equally to MediPass or a
677	managed care plan. For purposes of this paragraph, when
678	referring to assignment, the term "managed care plans" includes
679	exclusive provider organizations, provider service networks,
680	Children's Medical Services Network, minority physician
681	networks, and pediatric emergency department diversion programs
682	authorized by this chapter or the General Appropriations Act.
683	When making assignments, the agency shall take into account the
684	following criteria:
685	1.  A managed care plan has sufficient network capacity to
686	meet the need of members.
687	2.  The managed care plan or MediPass has previously
688	enrolled the recipient as a member, or one of the managed care
689	plan's primary care providers or MediPass providers has
690	previously provided health care to the recipient.
691	3.  The agency has knowledge that the member has previously
692	expressed a preference for a particular managed care plan or
693	MediPass provider as indicated by Medicaid fee-for-service
694	claims data, but has failed to make a choice.
695	4.  The managed care plan's or MediPass primary care
696	providers are geographically accessible to the recipient's
697	residence.
698	5.  The agency has authority to make mandatory assignments
699	based on quality of service and performance of managed care
700	plans.
701	Section 10.  Subsections (6) and (7) are added to section
702	409.9124, Florida Statutes, to read:
703	409.9124  Managed care reimbursement.--
704	(6)  The agency shall develop rates for children age 0-3
705	months and separate rates for children age 4-12 months. The
706	agency shall amend the payment methodology for participating
707	Medicaid-managed health care plans to comply with this
708	subsection.
709	(7)  The agency shall not pay rates at per-member per-month
710	averages higher than that allowed for in the General
711	Appropriations Act.
712	Section 11.  Except as otherwise provided herein, this act
713	shall take effect July 1, 2005.
714
715
716	================= T I T L E  A M E N D M E N T =================
717	Remove the entire title and insert:
718	A bill to be entitled
719	An act relating to health care; amending s. 400.23, F.S.;
720	delaying a nursing home staffing increase; amending s.
721	409.814, F.S.; granting more children access to the
722	Florida KidCare program; amending s. 409.903, F.S.;
723	deleting a provision eliminating eligibility for Medicaid
724	services for certain women; amending s. 409.904, F.S.;
725	providing for the Agency for Health Care Administration to
726	pay for medical assistance for certain Medicaid-eligible
727	persons; deleting a limitation on eligibility for coverage
728	under the medically needy program; amending s. 409.906,
729	F.S.; deleting a repeal of a provision that provides adult
730	denture services; repealing s. 409.9065, F.S., relating to
731	pharmaceutical expense assistance; amending s. 409.908,
732	F.S.; revising provisions relating to the long-term care
733	reimbursement and cost reporting system; revising
734	provisions relating to the Medicaid maximum allowable fee
735	for certain pharmacies; amending s. 409.912, F.S.;
736	revising components of the Medicaid prescribed-drug
737	spending-control program; authorizing the agency to
738	implement a program of all-inclusive care for certain
739	children; authorizing the agency to adopt rules; requiring
740	a plan for comprehensive vision care services; amending s.
741	409.9122, F.S.; deleting assignment requirement for
742	recipients in areas with capitated behavioral health
743	services; amending s. 409.9124, F.S.; requiring the agency
744	to develop managed care rates for children of specified
745	ages and to amend the methodology for reimbursing managed
746	care plans to comply therewith; limiting the amount of
747	reimbursement; providing effective dates.

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