Amendment
Bill No. 0404
Amendment No. 932633
CHAMBER ACTION
Senate House
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1Representative(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
6400.23, Florida Statutes, is amended to read:
7     400.23  Rules; evaluation and deficiencies; licensure
8status.--
9     (3)(a)  The agency shall adopt rules providing for the
10minimum staffing requirements for nursing homes. These
11requirements shall include, for each nursing home facility, a
12minimum certified nursing assistant staffing of 2.3 hours of
13direct care per resident per day beginning January 1, 2002,
14increasing to 2.6 hours of direct care per resident per day
15beginning January 1, 2003, and increasing to 2.9 hours of direct
16care per resident per day beginning July 1, 2006 2005. Beginning
17January 1, 2002, no facility shall staff below one certified
18nursing assistant per 20 residents, and a minimum licensed
19nursing staffing of 1.0 hour of direct resident care per
20resident per day but never below one licensed nurse per 40
21residents. Nursing assistants employed under s. 400.211(2) may
22be included in computing the staffing ratio for certified
23nursing assistants only if they provide nursing assistance
24services to residents on a full-time basis. Each nursing home
25must document compliance with staffing standards as required
26under this paragraph and post daily the names of staff on duty
27for the benefit of facility residents and the public. The agency
28shall recognize the use of licensed nurses for compliance with
29minimum staffing requirements for certified nursing assistants,
30provided that the facility otherwise meets the minimum staffing
31requirements for licensed nurses and that the licensed nurses so
32recognized are performing the duties of a certified nursing
33assistant. Unless otherwise approved by the agency, licensed
34nurses counted toward the minimum staffing requirements for
35certified nursing assistants must exclusively perform the duties
36of a certified nursing assistant for the entire shift and shall
37not also be counted toward the minimum staffing requirements for
38licensed nurses. If the agency approved a facility's request to
39use a licensed nurse to perform both licensed nursing and
40certified nursing assistant duties, the facility must allocate
41the amount of staff time specifically spent on certified nursing
42assistant duties for the purpose of documenting compliance with
43minimum staffing requirements for certified and licensed nursing
44staff. In no event may the hours of a licensed nurse with dual
45job responsibilities be counted twice.
46     Section 2.  Subsections (2) and (5) of section 409.814,
47Florida Statutes, are amended to read:
48     409.814  Eligibility.--A child who has not reached 19 years
49of age whose family income is equal to or below 200 percent of
50the federal poverty level is eligible for the Florida KidCare
51program as provided in this section. For enrollment in the
52Children's Medical Services Network, a complete application
53includes the medical or behavioral health screening. If,
54subsequently, an individual is determined to be ineligible for
55coverage, he or she must immediately be disenrolled from the
56respective Florida KidCare program component.
57     (2)  A child who is not eligible for Medicaid, but who is
58eligible for the Florida KidCare program, may obtain health
59benefits coverage under any of the other components listed in s.
60409.813 if such coverage is approved and available in the county
61in which the child resides. However, a child who is eligible for
62Medikids, including those eligible under subsection (5), may
63participate in the Florida Healthy Kids program only if the
64child has a sibling participating in the Florida Healthy Kids
65program and the child's county of residence permits such
66enrollment.
67     (5)  A child whose family income is above 200 percent of
68the federal poverty level or a child who is excluded under the
69provisions of subsection (4) may apply for coverage and shall be
70allowed to participate in the Florida KidCare program, excluding
71the Medicaid program, but is subject to the following
72provisions:
73     (a)  The family is not eligible for premium assistance
74payments and must pay the full cost of the premium, including
75any administrative costs.
76     (b)  The agency is authorized to place limits on enrollment
77in Medikids by these children in order to avoid adverse
78selection. The number of children participating in Medikids
79whose family income exceeds 200 percent of the federal poverty
80level must not exceed 10 percent of total enrollees in the
81Medikids program.
82     (c)  The board of directors of the Florida Healthy Kids
83Corporation is authorized to place limits on enrollment of these
84children in order to avoid adverse selection. In addition, the
85board is authorized to offer a reduced benefit package to these
86children in order to limit program costs for such families. The
87number of children participating in the Florida Healthy Kids
88program whose family income exceeds 200 percent of the federal
89poverty level must not exceed 10 percent of total enrollees in
90the Florida Healthy Kids program.
91     (d)  Children described in this subsection are not counted
92in the annual enrollment ceiling for the Florida KidCare
93program.
94     Section 3.  Subsection (5) of section 409.903, Florida
95Statutes, is amended to read:
96     409.903  Mandatory payments for eligible persons.--The
97agency shall make payments for medical assistance and related
98services on behalf of the following persons who the department,
99or the Social Security Administration by contract with the
100Department of Children and Family Services, determines to be
101eligible, subject to the income, assets, and categorical
102eligibility tests set forth in federal and state law. Payment on
103behalf of these Medicaid eligible persons is subject to the
104availability of moneys and any limitations established by the
105General Appropriations Act or chapter 216.
106     (5)  A pregnant woman for the duration of her pregnancy and
107for the postpartum period as defined in federal law and rule, or
108a child under age 1, if either is living in a family that has an
109income which is at or below 150 percent of the most current
110federal poverty level, or, effective January 1, 1992, that has
111an income which is at or below 185 percent of the most current
112federal poverty level. Such a person is not subject to an assets
113test. Further, a pregnant woman who applies for eligibility for
114the Medicaid program through a qualified Medicaid provider must
115be offered the opportunity, subject to federal rules, to be made
116presumptively eligible for the Medicaid program. Effective July
1171, 2005, eligibility for Medicaid services is eliminated for
118women who have incomes above 150 percent of the most current
119federal poverty level.
120     Section 4.  Subsections (1) and (2) of section 409.904,
121Florida Statutes, are amended to read:
122     409.904  Optional payments for eligible persons.--The
123agency may make payments for medical assistance and related
124services on behalf of the following persons who are determined
125to be eligible subject to the income, assets, and categorical
126eligibility tests set forth in federal and state law. Payment on
127behalf of these Medicaid eligible persons is subject to the
128availability of moneys and any limitations established by the
129General Appropriations Act or chapter 216.
130     (1)(a)  From July 1, 2005, through December 31, 2005,
131inclusive, a person who is age 65 or older or is determined to
132be disabled, whose income is at or below 88 percent of federal
133poverty level, and whose assets do not exceed established
134limitations.
135     (b)  Effective January 1, 2006, and subject to federal
136waiver approval, a person who is age 65 or older or is
137determined to be disabled, whose income is at or below 88
138percent of the federal poverty level, whose assets do not exceed
139established limitations, and who is not eligible for Medicare,
140or, if eligible for Medicare, is also eligible for and receiving
141Medicaid-covered institutional care or hospice or home-based and
142community-based services. The agency shall seek federal
143authorization through a waiver to provide this coverage.
144     (2)  A family, a pregnant woman, a child under age 21, a
145person age 65 or over, or a blind or disabled person, who would
146be 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
148exceed established limitations. For a family or person in one of
149these coverage groups, medical expenses are deductible from
150income in accordance with federal requirements in order to make
151a determination of eligibility. A family or person eligible
152under the coverage known as the "medically needy," is eligible
153to receive the same services as other Medicaid recipients, with
154the exception of services in skilled nursing facilities and
155intermediate care facilities for the developmentally disabled.
156Effective July 1, 2005, the medically needy are eligible for
157prescribed drug services only.
158     Section 5.  Paragraph (b) of subsection (1) of section
159409.906, Florida Statutes, is amended to read:
160     409.906  Optional Medicaid services.--Subject to specific
161appropriations, the agency may make payments for services which
162are optional to the state under Title XIX of the Social Security
163Act and are furnished by Medicaid providers to recipients who
164are determined to be eligible on the dates on which the services
165were provided. Any optional service that is provided shall be
166provided only when medically necessary and in accordance with
167state and federal law. Optional services rendered by providers
168in mobile units to Medicaid recipients may be restricted or
169prohibited by the agency. Nothing in this section shall be
170construed to prevent or limit the agency from adjusting fees,
171reimbursement rates, lengths of stay, number of visits, or
172number of services, or making any other adjustments necessary to
173comply with the availability of moneys and any limitations or
174directions provided for in the General Appropriations Act or
175chapter 216. If necessary to safeguard the state's systems of
176providing services to elderly and disabled persons and subject
177to the notice and review provisions of s. 216.177, the Governor
178may direct the Agency for Health Care Administration to amend
179the Medicaid state plan to delete the optional Medicaid service
180known as "Intermediate Care Facilities for the Developmentally
181Disabled." Optional services may include:
182     (1)  ADULT DENTAL SERVICES.--
183     (b)  Beginning January 1, 2005, The agency may pay for
184dentures, the procedures required to seat dentures, and the
185repair and reline of dentures, provided by or under the
186direction of a licensed dentist, for a recipient who is 21 years
187of age or older. This paragraph is repealed effective July 1,
1882005.
189     Section 6.  Effective January 1, 2006, section 409.9065,
190Florida 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
194specific appropriations, the agency shall reimburse Medicaid
195providers, in accordance with state and federal law, according
196to methodologies set forth in the rules of the agency and in
197policy manuals and handbooks incorporated by reference therein.
198These methodologies may include fee schedules, reimbursement
199methods based on cost reporting, negotiated fees, competitive
200bidding pursuant to s. 287.057, and other mechanisms the agency
201considers efficient and effective for purchasing services or
202goods on behalf of recipients. If a provider is reimbursed based
203on cost reporting and submits a cost report late and that cost
204report would have been used to set a lower reimbursement rate
205for a rate semester, then the provider's rate for that semester
206shall be retroactively calculated using the new cost report, and
207full payment at the recalculated rate shall be effected
208retroactively. Medicare-granted extensions for filing cost
209reports, if applicable, shall also apply to Medicaid cost
210reports. Payment for Medicaid compensable services made on
211behalf of Medicaid eligible persons is subject to the
212availability of moneys and any limitations or directions
213provided for in the General Appropriations Act or chapter 216.
214Further, nothing in this section shall be construed to prevent
215or limit the agency from adjusting fees, reimbursement rates,
216lengths of stay, number of visits, or number of services, or
217making any other adjustments necessary to comply with the
218availability of moneys and any limitations or directions
219provided for in the General Appropriations Act, provided the
220adjustment is consistent with legislative intent.
221     (2)
222     (b)  Subject to any limitations or directions provided for
223in the General Appropriations Act, the agency shall establish
224and implement a Florida Title XIX Long-Term Care Reimbursement
225Plan (Medicaid) for nursing home care in order to provide care
226and services in conformance with the applicable state and
227federal laws, rules, regulations, and quality and safety
228standards and to ensure that individuals eligible for medical
229assistance have reasonable geographic access to such care.
230     1.  Changes of ownership or of licensed operator do not
231qualify for increases in reimbursement rates associated with the
232change of ownership or of licensed operator. The agency shall
233amend the Title XIX Long Term Care Reimbursement Plan to provide
234that the initial nursing home reimbursement rates, for the
235operating, patient care, and MAR components, associated with
236related and unrelated party changes of ownership or licensed
237operator filed on or after September 1, 2001, are equivalent to
238the previous owner's reimbursement rate.
239     2.  The agency shall amend the long-term care reimbursement
240plan and cost reporting system to create direct care and
241indirect care subcomponents of the patient care component of the
242per diem rate. These two subcomponents together shall equal the
243patient care component of the per diem rate. Separate cost-based
244ceilings shall be calculated for each patient care subcomponent.
245The direct care and indirect care subcomponents subcomponent of
246the per diem rate shall be limited by the cost-based class
247ceiling, and the indirect care subcomponent shall be limited by
248the lower of a the cost-based class ceiling, a by the target
249rate class ceiling, or an by the individual provider target for
250each subcomponent. The agency shall adjust the patient care
251component effective January 1, 2002. The cost to adjust the
252direct care subcomponent shall be the net of the total funds
253previously allocated for the case mix add-on. The agency shall
254make the required changes to the nursing home cost reporting
255forms to implement this requirement effective January 1, 2002.
256     3.  The direct care subcomponent shall include salaries and
257benefits of direct care staff providing nursing services
258including registered nurses, licensed practical nurses, and
259certified nursing assistants who deliver care directly to
260residents in the nursing home facility. This excludes nursing
261administration, MDS, and care plan coordinators, staff
262development, and staffing coordinator.
263     4.  All other patient care costs shall be included in the
264indirect care cost subcomponent of the patient care per diem
265rate. There shall be no costs directly or indirectly allocated
266to the direct care subcomponent from a home office or management
267company.
268     5.  On July 1 of each year, the agency shall report to the
269Legislature direct and indirect care costs, including average
270direct and indirect care costs per resident per facility and
271direct care and indirect care salaries and benefits per category
272of staff member per facility.
273     6.  In order to offset the cost of general and professional
274liability insurance, the agency shall amend the plan to allow
275for interim rate adjustments to reflect increases in the cost of
276general or professional liability insurance for nursing homes.
277This provision shall be implemented to the extent existing
278appropriations are available.
279
280It is the intent of the Legislature that the reimbursement plan
281achieve the goal of providing access to health care for nursing
282home residents who require large amounts of care while
283encouraging diversion services as an alternative to nursing home
284care for residents who can be served within the community. The
285agency shall base the establishment of any maximum rate of
286payment, whether overall or component, on the available moneys
287as provided for in the General Appropriations Act. The agency
288may base the maximum rate of payment on the results of
289scientifically valid analysis and conclusions derived from
290objective statistical data pertinent to the particular maximum
291rate of payment.
292     (14)  A provider of prescribed drugs shall be reimbursed
293the least of the amount billed by the provider, the provider's
294usual and customary charge, or the Medicaid maximum allowable
295fee established by the agency, plus a dispensing fee.
296     (a)  For pharmacies with less than $75,000 in average
297aggregate monthly payments, the Medicaid maximum allowable fee
298for ingredient cost will be based on the lower of: average
299wholesale price (AWP) minus 15.4 percent, wholesaler acquisition
300cost (WAC) plus 5.75 percent, the federal upper limit (FUL), the
301state 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
304aggregate monthly payments, the Medicaid maximum allowable fee
305for ingredient cost will be based on the lower of: average
306wholesale price (AWP) minus 17 percent, wholesaler acquisition
307cost (WAC) plus 3.75 percent, the federal upper limit (FUL), the
308state 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
311drugs if available at lower cost and the agency has not
312determined that the branded product is more cost-effective,
313unless the prescriber has requested and received approval to
314require the branded product. The agency is directed to implement
315a variable dispensing fee for payments for prescribed medicines
316while ensuring continued access for Medicaid recipients. The
317variable dispensing fee may be based upon, but not limited to,
318either or both the volume of prescriptions dispensed by a
319specific pharmacy provider, the volume of prescriptions
320dispensed to an individual recipient, and dispensing of
321preferred-drug-list products. The agency may increase the
322pharmacy dispensing fee authorized by statute and in the annual
323General Appropriations Act by $0.50 for the dispensing of a
324Medicaid preferred-drug-list product and reduce the pharmacy
325dispensing fee by $0.50 for the dispensing of a Medicaid product
326that is not included on the preferred drug list. The agency may
327establish a supplemental pharmaceutical dispensing fee to be
328paid to providers returning unused unit-dose packaged
329medications to stock and crediting the Medicaid program for the
330ingredient cost of those medications if the ingredient costs to
331be credited exceed the value of the supplemental dispensing fee.
332The agency is authorized to limit reimbursement for prescribed
333medicine in order to comply with any limitations or directions
334provided for in the General Appropriations Act, which may
335include implementing a prospective or concurrent utilization
336review program.
337     Section 8.  Paragraph (a) of subsection (39) of section
338409.912, 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
341agency shall purchase goods and services for Medicaid recipients
342in the most cost-effective manner consistent with the delivery
343of quality medical care. To ensure that medical services are
344effectively utilized, the agency may, in any case, require a
345confirmation or second physician's opinion of the correct
346diagnosis for purposes of authorizing future services under the
347Medicaid program. This section does not restrict access to
348emergency services or poststabilization care services as defined
349in 42 C.F.R. part 438.114. Such confirmation or second opinion
350shall be rendered in a manner approved by the agency. The agency
351shall maximize the use of prepaid per capita and prepaid
352aggregate fixed-sum basis services when appropriate and other
353alternative service delivery and reimbursement methodologies,
354including competitive bidding pursuant to s. 287.057, designed
355to facilitate the cost-effective purchase of a case-managed
356continuum of care. The agency shall also require providers to
357minimize the exposure of recipients to the need for acute
358inpatient, custodial, and other institutional care and the
359inappropriate or unnecessary use of high-cost services. The
360agency may mandate prior authorization, drug therapy management,
361or disease management participation for certain populations of
362Medicaid beneficiaries, certain drug classes, or particular
363drugs to prevent fraud, abuse, overuse, and possible dangerous
364drug interactions. The Pharmaceutical and Therapeutics Committee
365shall make recommendations to the agency on drugs for which
366prior authorization is required. The agency shall inform the
367Pharmaceutical and Therapeutics Committee of its decisions
368regarding drugs subject to prior authorization. The agency is
369authorized to limit the entities it contracts with or enrolls as
370Medicaid providers by developing a provider network through
371provider credentialing. The agency may limit its network based
372on the assessment of beneficiary access to care, provider
373availability, provider quality standards, time and distance
374standards for access to care, the cultural competence of the
375provider network, demographic characteristics of Medicaid
376beneficiaries, practice and provider-to-beneficiary standards,
377appointment wait times, beneficiary use of services, provider
378turnover, provider profiling, provider licensure history,
379previous program integrity investigations and findings, peer
380review, provider Medicaid policy and billing compliance records,
381clinical and medical record audits, and other factors. Providers
382shall not be entitled to enrollment in the Medicaid provider
383network. The agency is authorized to seek federal waivers
384necessary to implement this policy.
385     (39)(a)  The agency shall implement a Medicaid prescribed-
386drug spending-control program that includes the following
387components:
388     1.  Medicaid prescribed-drug coverage for brand-name drugs
389for adult Medicaid recipients is limited to the dispensing of
390three four brand-name drugs and three generic drugs per month
391per recipient. Children are exempt from this restriction.
392Antiretroviral agents are excluded from this limitation. No
393requirements for prior authorization or other restrictions on
394medications used to treat mental illnesses such as
395schizophrenia, severe depression, or bipolar disorder may be
396imposed on Medicaid recipients. Medications that will be
397available without restriction for persons with mental illnesses
398include atypical antipsychotic medications, conventional
399antipsychotic medications, selective serotonin reuptake
400inhibitors, and other medications used for the treatment of
401serious mental illnesses. The agency shall also limit the amount
402of a prescribed drug dispensed to no more than a 34-day supply.
403The agency shall continue to provide unlimited generic drugs,
404contraceptive drugs and items, and diabetic supplies. Although a
405drug may be included on the preferred drug formulary, it would
406not be exempt from the three-brand four-brand limit or the
407generic drug limit. The agency may authorize exceptions to the
408brand-name-drug restriction based upon the treatment needs of
409the patients, only when such exceptions are based on prior
410consultation provided by the agency or an agency contractor, but
411the agency must establish procedures to ensure that:
412     a.  There will be a response to a request for prior
413consultation by telephone or other telecommunication device
414within 24 hours after receipt of a request for prior
415consultation;
416     b.  A 72-hour supply of the drug prescribed will be
417provided in an emergency or when the agency does not provide a
418response within 24 hours as required by sub-subparagraph a.; and
419     c.  Except for the exception for nursing home residents and
420other institutionalized adults and except for drugs on the
421restricted formulary for which prior authorization may be sought
422by an institutional or community pharmacy, prior authorization
423for an exception to the brand-name-drug restriction is sought by
424the prescriber and not by the pharmacy. When prior authorization
425is granted for a patient in an institutional setting beyond the
426brand-name-drug restriction, such approval is authorized for 12
427months and monthly prior authorization is not required for that
428patient.
429     2.  Reimbursement to pharmacies for Medicaid prescribed
430drugs shall be set at the lesser of:
431     a.  The average wholesale price (AWP) minus 15.4 percent,
432the wholesaler acquisition cost (WAC) plus 5.75 percent, the
433federal upper limit (FUL), the state maximum allowable cost
434(SMAC), or the usual and customary (UAC) charge billed by the
435provider for pharmacies with less than $75,000 in average
436aggregate monthly payments.
437     b.  The average wholesale price (AWP) minus 17 percent,
438wholesaler acquisition cost (WAC) plus 3.75 percent, the federal
439upper limit (FUL), the state maximum allowable cost (SMAC), or
440the usual and customary (UAC) charge billed by the provider for
441pharmacies with $75,000 or more in average aggregate monthly
442payments.
443     3.  The agency shall develop and implement a process for
444managing the drug therapies of Medicaid recipients who are using
445significant numbers of prescribed drugs each month. The
446management process may include, but is not limited to,
447comprehensive, physician-directed medical-record reviews, claims
448analyses, and case evaluations to determine the medical
449necessity and appropriateness of a patient's treatment plan and
450drug therapies. The agency may contract with a private
451organization to provide drug-program-management services. The
452Medicaid drug benefit management program shall include
453initiatives to manage drug therapies for HIV/AIDS patients,
454patients using 20 or more unique prescriptions in a 180-day
455period, and the top 1,000 patients in annual spending. The
456agency shall enroll any Medicaid recipient in the drug benefit
457management program if he or she meets the specifications of this
458provision and is not enrolled in a Medicaid health maintenance
459organization.
460     4.  The agency may limit the size of its pharmacy network
461based on need, competitive bidding, price negotiations,
462credentialing, or similar criteria. The agency shall give
463special consideration to rural areas in determining the size and
464location of pharmacies included in the Medicaid pharmacy
465network. A pharmacy credentialing process may include criteria
466such as a pharmacy's full-service status, location, size,
467patient educational programs, patient consultation, disease-
468management services, and other characteristics. The agency may
469impose a moratorium on Medicaid pharmacy enrollment when it is
470determined that it has a sufficient number of Medicaid-
471participating providers.
472     5.  The agency shall develop and implement a program that
473requires Medicaid practitioners who prescribe drugs to use a
474counterfeit-proof prescription pad for Medicaid prescriptions.
475The agency shall require the use of standardized counterfeit-
476proof prescription pads by Medicaid-participating prescribers or
477prescribers who write prescriptions for Medicaid recipients. The
478agency may implement the program in targeted geographic areas or
479statewide.
480     6.  The agency may enter into arrangements that require
481manufacturers of generic drugs prescribed to Medicaid recipients
482to provide rebates of at least 15.1 percent of the average
483manufacturer price for the manufacturer's generic products.
484These arrangements shall require that if a generic-drug
485manufacturer pays federal rebates for Medicaid-reimbursed drugs
486at a level below 15.1 percent, the manufacturer must provide a
487supplemental rebate to the state in an amount necessary to
488achieve a 15.1-percent rebate level.
489     7.  The agency may establish a preferred drug formulary in
490accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
491establishment of such formulary, it is authorized to negotiate
492supplemental rebates from manufacturers that are in addition to
493those required by Title XIX of the Social Security Act and at no
494less than 14 percent of the average manufacturer price as
495defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
496the federal or supplemental rebate, or both, equals or exceeds
49729 percent. There is no upper limit on the supplemental rebates
498the agency may negotiate. The agency may determine that specific
499products, brand-name or generic, are competitive at lower rebate
500percentages. Agreement to pay the minimum supplemental rebate
501percentage will guarantee a manufacturer that the Medicaid
502Pharmaceutical and Therapeutics Committee will consider a
503product for inclusion on the preferred drug formulary. However,
504a pharmaceutical manufacturer is not guaranteed placement on the
505formulary by simply paying the minimum supplemental rebate.
506Agency decisions will be made on the clinical efficacy of a drug
507and recommendations of the Medicaid Pharmaceutical and
508Therapeutics Committee, as well as the price of competing
509products minus federal and state rebates. The agency is
510authorized to contract with an outside agency or contractor to
511conduct negotiations for supplemental rebates. For the purposes
512of this section, the term "supplemental rebates" means cash
513rebates. Effective July 1, 2004, value-added programs as a
514substitution for supplemental rebates are prohibited. The agency
515is authorized to seek any federal waivers to implement this
516initiative.
517     8.  The agency shall establish an advisory committee for
518the purposes of studying the feasibility of using a restricted
519drug formulary for nursing home residents and other
520institutionalized adults. The committee shall be comprised of
521seven members appointed by the Secretary of Health Care
522Administration. The committee members shall include two
523physicians licensed under chapter 458 or chapter 459; three
524pharmacists licensed under chapter 465 and appointed from a list
525of recommendations provided by the Florida Long-Term Care
526Pharmacy Alliance; and two pharmacists licensed under chapter
527465.
528     9.  The Agency for Health Care Administration shall expand
529home delivery of pharmacy products. To assist Medicaid patients
530in securing their prescriptions and reduce program costs, the
531agency shall expand its current mail-order-pharmacy diabetes-
532supply program to include all generic and brand-name drugs used
533by Medicaid patients with diabetes. Medicaid recipients in the
534current program may obtain nondiabetes drugs on a voluntary
535basis. This initiative is limited to the geographic area covered
536by the current contract. The agency may seek and implement any
537federal waivers necessary to implement this subparagraph.
538     10.  The agency shall limit to one dose per month any drug
539prescribed to treat erectile dysfunction.
540     11.a.  The agency shall implement a Medicaid behavioral
541drug management system. The agency may contract with a vendor
542that has experience in operating behavioral drug management
543systems to implement this program. The agency is authorized to
544seek federal waivers to implement this program.
545     b.  The agency, in conjunction with the Department of
546Children and Family Services, may implement the Medicaid
547behavioral drug management system that is designed to improve
548the quality of care and behavioral health prescribing practices
549based on best practice guidelines, improve patient adherence to
550medication plans, reduce clinical risk, and lower prescribed
551drug costs and the rate of inappropriate spending on Medicaid
552behavioral drugs. The program shall include the following
553elements:
554     (I)  Provide for the development and adoption of best
555practice guidelines for behavioral health-related drugs such as
556antipsychotics, antidepressants, and medications for treating
557bipolar disorders and other behavioral conditions; translate
558them into practice; review behavioral health prescribers and
559compare their prescribing patterns to a number of indicators
560that are based on national standards; and determine deviations
561from best practice guidelines.
562     (II)  Implement processes for providing feedback to and
563educating prescribers using best practice educational materials
564and peer-to-peer consultation.
565     (III)  Assess Medicaid beneficiaries who are outliers in
566their use of behavioral health drugs with regard to the numbers
567and types of drugs taken, drug dosages, combination drug
568therapies, and other indicators of improper use of behavioral
569health drugs.
570     (IV)  Alert prescribers to patients who fail to refill
571prescriptions in a timely fashion, are prescribed multiple same-
572class behavioral health drugs, and may have other potential
573medication problems.
574     (V)  Track spending trends for behavioral health drugs and
575deviation from best practice guidelines.
576     (VI)  Use educational and technological approaches to
577promote best practices, educate consumers, and train prescribers
578in 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
582quality-based medication component for severely mentally ill
583individuals and emotionally disturbed children who are high
584users of care.
585     c.  If the agency is unable to negotiate a contract with
586one or more manufacturers to finance and guarantee savings
587associated with a behavioral drug management program by
588September 1, 2004, the four-brand drug limit and preferred drug
589list prior-authorization requirements shall apply to mental
590health-related drugs, notwithstanding any provision in
591subparagraph 1. The agency is authorized to seek federal waivers
592to implement this policy.
593     12.  The agency is authorized to contract for drug rebate
594administration, including, but not limited to, calculating
595rebate amounts, invoicing manufacturers, negotiating disputes
596with manufacturers, and maintaining a database of rebate
597collections.
598     13.  The agency may specify the preferred daily dosing form
599or strength for the purpose of promoting best practices with
600regard to the prescribing of certain drugs as specified in the
601General Appropriations Act and ensuring cost-effective
602prescribing practices.
603     14.  The agency may require prior authorization for the
604off-label use of Medicaid-covered prescribed drugs as specified
605in the General Appropriations Act. The agency may, but is not
606required to, preauthorize the use of a product for an indication
607not in the approved labeling. Prior authorization may require
608the prescribing professional to provide information about the
609rationale and supporting medical evidence for the off-label use
610of a drug.
611     15.  The agency shall implement a return and reuse program
612for drugs dispensed by pharmacies to institutional recipients,
613which includes payment of a $5 restocking fee for the
614implementation and operation of the program. The return and
615reuse program shall be implemented electronically and in a
616manner that promotes efficiency. The program must permit a
617pharmacy to exclude drugs from the program if it is not
618practical or cost-effective for the drug to be included and must
619provide for the return to inventory of drugs that cannot be
620credited or returned in a cost-effective manner.
621     (50)  The agency may implement a program of all-inclusive
622care for children to reduce the need for hospitalization of
623children, as appropriate. The purpose of the program is to
624provide in-home hospice-like support services to children
625diagnosed with a life-threatening illness who are enrolled in
626the Children's Medical Services Network. The agency, in
627consultation with the Department of Health, may implement the
628program of all-inclusive care for children after obtaining
629approval from the Centers for Medicare and Medicaid Services.
630     (51)  By July 1, 2005, the agency shall develop a plan for
631implementing the delivery of comprehensive vision care services
632to Medicaid recipients through a capitated prepaid arrangement.
633The plan shall include contracting with a private entity or
634entities to provide for the comprehensive vision care services
635through a capitated prepaid arrangement. However, the entity
636must:
637     (a)  Be licensed under chapter 627.
638     (b)  Have sufficient financial resources.
639     (c)  Have a contracted provider network that has statewide
640coverage.
641     (d)  Have experience in providing medical and surgical
642vision care services.
643     (e)  Have experience with the implementation of large
644statewide contracts. As used in this section, the term "vision
645care services" means covered vision services, including routine,
646medical, and surgical vision care services that are available to
647Medicaid recipients. If necessary, the agency shall seek federal
648approval to contract with a single entity meeting these
649requirements to provide vision care services to all Medicaid
650recipients. The entity must offer sufficient choice of providers
651within its network to ensure access to care for the recipient
652and the opportunity to select a provider with whom the recipient
653is satisfied.
654     Section 9.  Paragraph (k) of subsection (2) of section
655409.9122, Florida Statutes, is amended to read:
656     409.9122  Mandatory Medicaid managed care enrollment;
657programs and procedures.--
658     (2)
659     (k)  When a Medicaid recipient does not choose a managed
660care plan or MediPass provider, the agency shall assign the
661Medicaid recipient to a managed care plan, except in those
662counties in which there are fewer than two managed care plans
663accepting Medicaid enrollees, in which case assignment shall be
664to a managed care plan or a MediPass provider. Medicaid
665recipients in counties with fewer than two managed care plans
666accepting Medicaid enrollees who are subject to mandatory
667assignment but who fail to make a choice shall be assigned to
668managed care plans until an enrollment of 40 percent in MediPass
669and 60 percent in managed care plans is achieved. Once that
670enrollment is achieved, the assignments shall be divided in
671order to maintain an enrollment in MediPass and managed care
672plans which is in a 40 percent and 60 percent proportion,
673respectively. In geographic areas where the agency is
674contracting for the provision of comprehensive behavioral health
675services through a capitated prepaid arrangement, recipients who
676fail to make a choice shall be assigned equally to MediPass or a
677managed care plan. For purposes of this paragraph, when
678referring to assignment, the term "managed care plans" includes
679exclusive provider organizations, provider service networks,
680Children's Medical Services Network, minority physician
681networks, and pediatric emergency department diversion programs
682authorized by this chapter or the General Appropriations Act.
683When making assignments, the agency shall take into account the
684following criteria:
685     1.  A managed care plan has sufficient network capacity to
686meet the need of members.
687     2.  The managed care plan or MediPass has previously
688enrolled the recipient as a member, or one of the managed care
689plan's primary care providers or MediPass providers has
690previously provided health care to the recipient.
691     3.  The agency has knowledge that the member has previously
692expressed a preference for a particular managed care plan or
693MediPass provider as indicated by Medicaid fee-for-service
694claims data, but has failed to make a choice.
695     4.  The managed care plan's or MediPass primary care
696providers are geographically accessible to the recipient's
697residence.
698     5.  The agency has authority to make mandatory assignments
699based on quality of service and performance of managed care
700plans.
701     Section 10.  Subsections (6) and (7) are added to section
702409.9124, Florida Statutes, to read:
703     409.9124  Managed care reimbursement.--
704     (6)  The agency shall develop rates for children age 0-3
705months and separate rates for children age 4-12 months. The
706agency shall amend the payment methodology for participating
707Medicaid-managed health care plans to comply with this
708subsection.
709     (7)  The agency shall not pay rates at per-member per-month
710averages higher than that allowed for in the General
711Appropriations Act.
712     Section 11.  Except as otherwise provided herein, this act
713shall 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
719An act relating to health care; amending s. 400.23, F.S.;
720delaying a nursing home staffing increase; amending s.
721409.814, F.S.; granting more children access to the
722Florida KidCare program; amending s. 409.903, F.S.;
723deleting a provision eliminating eligibility for Medicaid
724services for certain women; amending s. 409.904, F.S.;
725providing for the Agency for Health Care Administration to
726pay for medical assistance for certain Medicaid-eligible
727persons; deleting a limitation on eligibility for coverage
728under the medically needy program; amending s. 409.906,
729F.S.; deleting a repeal of a provision that provides adult
730denture services; repealing s. 409.9065, F.S., relating to
731pharmaceutical expense assistance; amending s. 409.908,
732F.S.; revising provisions relating to the long-term care
733reimbursement and cost reporting system; revising
734provisions relating to the Medicaid maximum allowable fee
735for certain pharmacies; amending s. 409.912, F.S.;
736revising components of the Medicaid prescribed-drug
737spending-control program; authorizing the agency to
738implement a program of all-inclusive care for certain
739children; authorizing the agency to adopt rules; requiring
740a plan for comprehensive vision care services; amending s.
741409.9122, F.S.; deleting assignment requirement for
742recipients in areas with capitated behavioral health
743services; amending s. 409.9124, F.S.; requiring the agency
744to develop managed care rates for children of specified
745ages and to amend the methodology for reimbursing managed
746care plans to comply therewith; limiting the amount of
747reimbursement; providing effective dates.


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