Senate Bill sb0404c1
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Florida Senate - 2005 CS for SB 404
By the Committee on Health and Human Services Appropriations;
and Senator Saunders
603-1731B-05
1 A bill to be entitled
2 An act relating to health care; amending s.
3 400.23, F.S.; delaying provisions requiring a
4 nursing home staffing increase; amending ss.
5 409.903, 409.904, F.S.; deleting certain
6 limitations on services to the medically needy;
7 amending s. 409.906, F.S., relating to optional
8 Medicaid services; providing for adult denture
9 services; repealing s. 409.9065, F.S., relating
10 to pharmaceutical expense assistance; amending
11 s. 409.908, F.S.; revising guidelines relating
12 to reimbursement of Medicaid providers;
13 amending ss. 409.9112, 409.9113, 409.9117,
14 F.S., relating to the hospital disproportionate
15 share program; deleting obsolete provisions;
16 amending s. 409.91195, F.S.; revising
17 provisions relating to the Medicaid
18 Pharmaceutical and Therapeutics Committee and
19 its duties with respect to developing a
20 preferred drug list; amending s. 409.912, F.S.;
21 revising the Medicaid prescribed drug spending
22 control program; eliminating case management
23 fees; directing the Agency for Health Care
24 Administration to implement, and authorizing it
25 to seek federal waivers for, the program of
26 all-inclusive care for children; amending s.
27 409.9124, F.S.; requiring the Agency for Health
28 Care Administration to publish managed care
29 reimbursement rates annually; providing
30 effective dates.
31
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1 Be It Enacted by the Legislature of the State of Florida:
2
3 Section 1. Paragraph (a) of subsection (3) of section
4 400.23, Florida Statutes, is amended to read:
5 400.23 Rules; evaluation and deficiencies; licensure
6 status.--
7 (3)(a) The agency shall adopt rules providing for the
8 minimum staffing requirements for nursing homes. These
9 requirements shall include, for each nursing home facility, a
10 minimum certified nursing assistant staffing of 2.3 hours of
11 direct care per resident per day beginning January 1, 2002,
12 increasing to 2.6 hours of direct care per resident per day
13 beginning January 1, 2003, and increasing to 2.9 hours of
14 direct care per resident per day beginning July 1, 2006 2005.
15 Beginning January 1, 2002, no facility shall staff below one
16 certified nursing assistant per 20 residents, and a minimum
17 licensed nursing staffing of 1.0 hour of direct resident care
18 per resident per day but never below one licensed nurse per 40
19 residents. Nursing assistants employed under s. 400.211(2) may
20 be included in computing the staffing ratio for certified
21 nursing assistants only if they provide nursing assistance
22 services to residents on a full-time basis. Each nursing home
23 must document compliance with staffing standards as required
24 under this paragraph and post daily the names of staff on duty
25 for the benefit of facility residents and the public. The
26 agency shall recognize the use of licensed nurses for
27 compliance with minimum staffing requirements for certified
28 nursing assistants, provided that the facility otherwise meets
29 the minimum staffing requirements for licensed nurses and that
30 the licensed nurses so recognized are performing the duties of
31 a certified nursing assistant. Unless otherwise approved by
2
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1 the agency, licensed nurses counted toward the minimum
2 staffing requirements for certified nursing assistants must
3 exclusively perform the duties of a certified nursing
4 assistant for the entire shift and shall not also be counted
5 toward the minimum staffing requirements for licensed nurses.
6 If the agency approved a facility's request to use a licensed
7 nurse to perform both licensed nursing and certified nursing
8 assistant duties, the facility must allocate the amount of
9 staff time specifically spent on certified nursing assistant
10 duties for the purpose of documenting compliance with minimum
11 staffing requirements for certified and licensed nursing
12 staff. In no event may the hours of a licensed nurse with dual
13 job responsibilities be counted twice.
14 Section 2. Subsection (5) of section 409.903, Florida
15 Statutes, is amended to read:
16 409.903 Mandatory payments for eligible persons.--The
17 agency shall make payments for medical assistance and related
18 services on behalf of the following persons who the
19 department, or the Social Security Administration by contract
20 with the Department of Children and Family Services,
21 determines to be eligible, subject to the income, assets, and
22 categorical eligibility tests set forth in federal and state
23 law. Payment on behalf of these Medicaid eligible persons is
24 subject to the availability of moneys and any limitations
25 established by the General Appropriations Act or chapter 216.
26 (5) A pregnant woman for the duration of her pregnancy
27 and for the postpartum period as defined in federal law and
28 rule, or a child under age 1, if either is living in a family
29 that has an income which is at or below 150 percent of the
30 most current federal poverty level, or, effective January 1,
31 1992, that has an income which is at or below 185 percent of
3
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1 the most current federal poverty level. Such a person is not
2 subject to an assets test. Further, a pregnant woman who
3 applies for eligibility for the Medicaid program through a
4 qualified Medicaid provider must be offered the opportunity,
5 subject to federal rules, to be made presumptively eligible
6 for the Medicaid program. Effective July 1, 2005, eligibility
7 for Medicaid services is eliminated for women who have incomes
8 above 150 percent of the most current federal poverty level.
9 Section 3. Subsections (1) and (2) of section 409.904,
10 Florida Statutes, are amended to read:
11 409.904 Optional payments for eligible persons.--The
12 agency may make payments for medical assistance and related
13 services on behalf of the following persons who are determined
14 to be eligible subject to the income, assets, and categorical
15 eligibility tests set forth in federal and state law. Payment
16 on behalf of these Medicaid eligible persons is subject to the
17 availability of moneys and any limitations established by the
18 General Appropriations Act or chapter 216.
19 (1)(a) From July 1, 2005, through December 31, 2005, a
20 person who is age 65 or older or is determined to be disabled,
21 whose income is at or below 88 percent of federal poverty
22 level, and whose assets do not exceed established limitations.
23 (b) Effective January 1, 2006, and subject to federal
24 waiver approval, a person who is age 65 or older or is
25 determined to be disabled, whose income is at or below 88
26 percent of the federal poverty level, whose assets do not
27 exceed established limitations, and who is not eligible for
28 Medicare or, if eligible for Medicare, is also eligible for
29 and receiving Medicaid-covered institutional care services,
30 hospice services, or home and community-based services. The
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1 agency shall seek federal authorization through a waiver to
2 provide this coverage.
3 (2) A family, a pregnant woman, a child under age 21,
4 a person age 65 or over, or a blind or disabled person, who
5 would be eligible under any group listed in s. 409.903(1),
6 (2), or (3), except that the income or assets of such family
7 or person exceed established limitations. For a family or
8 person in one of these coverage groups, medical expenses are
9 deductible from income in accordance with federal requirements
10 in order to make a determination of eligibility. A family or
11 person eligible under the coverage known as the "medically
12 needy," is eligible to receive the same services as other
13 Medicaid recipients, with the exception of services in skilled
14 nursing facilities and intermediate care facilities for the
15 developmentally disabled. Effective July 1, 2005, the
16 medically needy are eligible for prescribed drug services
17 only.
18 Section 4. Paragraph (b) of subsection (1) of section
19 409.906, Florida Statutes, is amended to read:
20 409.906 Optional Medicaid services.--Subject to
21 specific appropriations, the agency may make payments for
22 services which are optional to the state under Title XIX of
23 the Social Security Act and are furnished by Medicaid
24 providers to recipients who are determined to be eligible on
25 the dates on which the services were provided. Any optional
26 service that is provided shall be provided only when medically
27 necessary and in accordance with state and federal law.
28 Optional services rendered by providers in mobile units to
29 Medicaid recipients may be restricted or prohibited by the
30 agency. Nothing in this section shall be construed to prevent
31 or limit the agency from adjusting fees, reimbursement rates,
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1 lengths of stay, number of visits, or number of services, or
2 making any other adjustments necessary to comply with the
3 availability of moneys and any limitations or directions
4 provided for in the General Appropriations Act or chapter 216.
5 If necessary to safeguard the state's systems of providing
6 services to elderly and disabled persons and subject to the
7 notice and review provisions of s. 216.177, the Governor may
8 direct the Agency for Health Care Administration to amend the
9 Medicaid state plan to delete the optional Medicaid service
10 known as "Intermediate Care Facilities for the Developmentally
11 Disabled." Optional services may include:
12 (1) ADULT DENTAL SERVICES.--
13 (b) Beginning January 1, 2005, the agency may pay for
14 dentures, the procedures required to seat dentures, and the
15 repair and reline of dentures, provided by or under the
16 direction of a licensed dentist, for a recipient who is 21
17 years of age or older. This paragraph is repealed effective
18 July 1, 2005.
19 Section 5. Effective January 1, 2006, section
20 409.9065, Florida Statutes, is repealed.
21 Section 6. Paragraph (a) of subsection (1) and
22 paragraph (b) of subsection (2) of section 409.908, Florida
23 Statutes, are amended to read:
24 409.908 Reimbursement of Medicaid providers.--Subject
25 to specific appropriations, the agency shall reimburse
26 Medicaid providers, in accordance with state and federal law,
27 according to methodologies set forth in the rules of the
28 agency and in policy manuals and handbooks incorporated by
29 reference therein. These methodologies may include fee
30 schedules, reimbursement methods based on cost reporting,
31 negotiated fees, competitive bidding pursuant to s. 287.057,
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1 and other mechanisms the agency considers efficient and
2 effective for purchasing services or goods on behalf of
3 recipients. If a provider is reimbursed based on cost
4 reporting and submits a cost report late and that cost report
5 would have been used to set a lower reimbursement rate for a
6 rate semester, then the provider's rate for that semester
7 shall be retroactively calculated using the new cost report,
8 and full payment at the recalculated rate shall be effected
9 retroactively. Medicare-granted extensions for filing cost
10 reports, if applicable, shall also apply to Medicaid cost
11 reports. Payment for Medicaid compensable services made on
12 behalf of Medicaid eligible persons is subject to the
13 availability of moneys and any limitations or directions
14 provided for in the General Appropriations Act or chapter 216.
15 Further, nothing in this section shall be construed to prevent
16 or limit the agency from adjusting fees, reimbursement rates,
17 lengths of stay, number of visits, or number of services, or
18 making any other adjustments necessary to comply with the
19 availability of moneys and any limitations or directions
20 provided for in the General Appropriations Act, provided the
21 adjustment is consistent with legislative intent.
22 (1) Reimbursement to hospitals licensed under part I
23 of chapter 395 must be made prospectively or on the basis of
24 negotiation.
25 (a) Reimbursement for inpatient care is limited as
26 provided for in s. 409.905(5), except for:
27 1. The raising of rate reimbursement caps, excluding
28 rural hospitals.
29 2. Recognition of the costs of graduate medical
30 education.
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1 3. Other methodologies recognized in the General
2 Appropriations Act.
3 4. Hospital inpatient rates shall be reduced by 6
4 percent effective July 1, 2001, and restored effective April
5 1, 2002.
6
7 During the years funds are transferred from the Department of
8 Health, any reimbursement supported by such funds shall be
9 subject to certification by the Department of Health that the
10 hospital has complied with s. 381.0403. The agency is
11 authorized to receive funds from state entities, including,
12 but not limited to, the Department of Health, local
13 governments, and other local political subdivisions, for the
14 purpose of making special exception payments, including
15 federal matching funds, through the Medicaid inpatient
16 reimbursement methodologies. Funds received from state
17 entities or local governments for this purpose shall be
18 separately accounted for and shall not be commingled with
19 other state or local funds in any manner. The agency may
20 certify all local governmental funds used as state match under
21 Title XIX of the Social Security Act, to the extent that the
22 identified local health care provider that is otherwise
23 entitled to and is contracted to receive such local funds is
24 the benefactor under the state's Medicaid program as
25 determined under the General Appropriations Act and pursuant
26 to an agreement between the Agency for Health Care
27 Administration and the local governmental entity. The local
28 governmental entity shall use a certification form prescribed
29 by the agency. At a minimum, the certification form shall
30 identify the amount being certified and describe the
31 relationship between the certifying local governmental entity
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1 and the local health care provider. The agency shall prepare
2 an annual statement of impact which documents the specific
3 activities undertaken during the previous fiscal year pursuant
4 to this paragraph, to be submitted to the Legislature no later
5 than January 1, annually.
6 (2)
7 (b) Subject to any limitations or directions provided
8 for in the General Appropriations Act, the agency shall
9 establish and implement a Florida Title XIX Long-Term Care
10 Reimbursement Plan (Medicaid) for nursing home care in order
11 to provide care and services in conformance with the
12 applicable state and federal laws, rules, regulations, and
13 quality and safety standards and to ensure that individuals
14 eligible for medical assistance have reasonable geographic
15 access to such care.
16 1. Changes of ownership or of licensed operator do not
17 qualify for increases in reimbursement rates associated with
18 the change of ownership or of licensed operator. The agency
19 shall amend the Title XIX Long Term Care Reimbursement Plan to
20 provide that the initial nursing home reimbursement rates, for
21 the operating, patient care, and MAR components, associated
22 with related and unrelated party changes of ownership or
23 licensed operator filed on or after September 1, 2001, are
24 equivalent to the previous owner's reimbursement rate.
25 2. The agency shall amend the long-term care
26 reimbursement plan and cost reporting system to create direct
27 care and indirect care subcomponents of the patient care
28 component of the per diem rate. These two subcomponents
29 together shall equal the patient care component of the per
30 diem rate. Separate cost-based ceilings shall be calculated
31 for each patient care subcomponent. The direct care and
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1 indirect care subcomponents subcomponent of the per diem rate
2 shall be limited by the cost-based class ceiling, and the
3 indirect care subcomponent shall be limited by the lower of a
4 the cost-based class ceiling, a by the target rate class
5 ceiling, or an by the individual provider target for each
6 subcomponent. The agency shall adjust the patient care
7 component effective January 1, 2002. The cost to adjust the
8 direct care subcomponent shall be net of the total funds
9 previously allocated for the case mix add-on. The agency shall
10 make the required changes to the nursing home cost reporting
11 forms to implement this requirement effective January 1, 2002.
12 3. The direct care subcomponent shall include salaries
13 and benefits of direct care staff providing nursing services
14 including registered nurses, licensed practical nurses, and
15 certified nursing assistants who deliver care directly to
16 residents in the nursing home facility. This excludes nursing
17 administration, minimum data set MDS, and care plan
18 coordinators, staff development, and staffing coordinator.
19 4. All other patient care costs shall be included in
20 the indirect care cost subcomponent of the patient care per
21 diem rate. There shall be no costs directly or indirectly
22 allocated to the direct care subcomponent from a home office
23 or management company.
24 5. On July 1 of each year, the agency shall report to
25 the Legislature direct and indirect care costs, including
26 average direct and indirect care costs per resident per
27 facility and direct care and indirect care salaries and
28 benefits per category of staff member per facility.
29 6. In order to offset the cost of general and
30 professional liability insurance, the agency shall amend the
31 plan to allow for interim rate adjustments to reflect
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1 increases in the cost of general or professional liability
2 insurance for nursing homes. This provision shall be
3 implemented to the extent existing appropriations are
4 available.
5
6 It is the intent of the Legislature that the reimbursement
7 plan achieve the goal of providing access to health care for
8 nursing home residents who require large amounts of care while
9 encouraging diversion services as an alternative to nursing
10 home care for residents who can be served within the
11 community. The agency shall base the establishment of any
12 maximum rate of payment, whether overall or component, on the
13 available moneys as provided for in the General Appropriations
14 Act. The agency may base the maximum rate of payment on the
15 results of scientifically valid analysis and conclusions
16 derived from objective statistical data pertinent to the
17 particular maximum rate of payment.
18 Section 7. Section 409.9112, Florida Statutes, is
19 amended to read:
20 409.9112 Disproportionate share program for regional
21 perinatal intensive care centers.--In addition to the payments
22 made under s. 409.911, the Agency for Health Care
23 Administration shall design and implement a system of making
24 disproportionate share payments to those hospitals that
25 participate in the regional perinatal intensive care center
26 program established pursuant to chapter 383. This system of
27 payments shall conform with federal requirements and shall
28 distribute funds in each fiscal year for which an
29 appropriation is made by making quarterly Medicaid payments.
30 Notwithstanding the provisions of s. 409.915, counties are
31 exempt from contributing toward the cost of this special
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1 reimbursement for hospitals serving a disproportionate share
2 of low-income patients. For the state fiscal year 2005-2006
3 2004-2005, the agency shall not distribute moneys under the
4 regional perinatal intensive care centers disproportionate
5 share program, except as noted in subsection (2). In the event
6 the Centers for Medicare and Medicaid Services do not approve
7 Florida's inpatient hospital state plan amendment for the
8 public disproportionate share program by January 1, 2005, the
9 agency may make payments to hospitals under the regional
10 perinatal intensive care centers disproportionate share
11 program.
12 (1) The following formula shall be used by the agency
13 to calculate the total amount earned for hospitals that
14 participate in the regional perinatal intensive care center
15 program:
16
17 TAE = HDSP/THDSP
18
19 Where:
20 TAE = total amount earned by a regional perinatal
21 intensive care center.
22 HDSP = the prior state fiscal year regional perinatal
23 intensive care center disproportionate share payment to the
24 individual hospital.
25 THDSP = the prior state fiscal year total regional
26 perinatal intensive care center disproportionate share
27 payments to all hospitals.
28
29 (2) The total additional payment for hospitals that
30 participate in the regional perinatal intensive care center
31 program shall be calculated by the agency as follows:
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1
2 TAP = TAE x TA
3
4 Where:
5 TAP = total additional payment for a regional perinatal
6 intensive care center.
7 TAE = total amount earned by a regional perinatal
8 intensive care center.
9 TA = total appropriation for the regional perinatal
10 intensive care center disproportionate share program.
11
12 (3) In order to receive payments under this section, a
13 hospital must be participating in the regional perinatal
14 intensive care center program pursuant to chapter 383 and must
15 meet the following additional requirements:
16 (a) Agree to conform to all departmental and agency
17 requirements to ensure high quality in the provision of
18 services, including criteria adopted by departmental and
19 agency rule concerning staffing ratios, medical records,
20 standards of care, equipment, space, and such other standards
21 and criteria as the department and agency deem appropriate as
22 specified by rule.
23 (b) Agree to provide information to the department and
24 agency, in a form and manner to be prescribed by rule of the
25 department and agency, concerning the care provided to all
26 patients in neonatal intensive care centers and high-risk
27 maternity care.
28 (c) Agree to accept all patients for neonatal
29 intensive care and high-risk maternity care, regardless of
30 ability to pay, on a functional space-available basis.
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1 (d) Agree to develop arrangements with other maternity
2 and neonatal care providers in the hospital's region for the
3 appropriate receipt and transfer of patients in need of
4 specialized maternity and neonatal intensive care services.
5 (e) Agree to establish and provide a developmental
6 evaluation and services program for certain high-risk
7 neonates, as prescribed and defined by rule of the department.
8 (f) Agree to sponsor a program of continuing education
9 in perinatal care for health care professionals within the
10 region of the hospital, as specified by rule.
11 (g) Agree to provide backup and referral services to
12 the department's county health departments and other
13 low-income perinatal providers within the hospital's region,
14 including the development of written agreements between these
15 organizations and the hospital.
16 (h) Agree to arrange for transportation for high-risk
17 obstetrical patients and neonates in need of transfer from the
18 community to the hospital or from the hospital to another more
19 appropriate facility.
20 (4) Hospitals which fail to comply with any of the
21 conditions in subsection (3) or the applicable rules of the
22 department and agency shall not receive any payments under
23 this section until full compliance is achieved. A hospital
24 which is not in compliance in two or more consecutive quarters
25 shall not receive its share of the funds. Any forfeited funds
26 shall be distributed by the remaining participating regional
27 perinatal intensive care center program hospitals.
28 Section 8. Section 409.9113, Florida Statutes, is
29 amended to read:
30 409.9113 Disproportionate share program for teaching
31 hospitals.--In addition to the payments made under ss. 409.911
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1 and 409.9112, the Agency for Health Care Administration shall
2 make disproportionate share payments to statutorily defined
3 teaching hospitals for their increased costs associated with
4 medical education programs and for tertiary health care
5 services provided to the indigent. This system of payments
6 shall conform with federal requirements and shall distribute
7 funds in each fiscal year for which an appropriation is made
8 by making quarterly Medicaid payments. Notwithstanding s.
9 409.915, counties are exempt from contributing toward the cost
10 of this special reimbursement for hospitals serving a
11 disproportionate share of low-income patients. For the state
12 fiscal year 2005-2006 2004-2005, the agency shall not
13 distribute moneys under the teaching hospital disproportionate
14 share program, except as noted in subsection (2). In the event
15 the Centers for Medicare and Medicaid Services do not approve
16 Florida's inpatient hospital state plan amendment for the
17 public disproportionate share program by January 1, 2005, the
18 agency may make payments to hospitals under the teaching
19 hospital disproportionate share program.
20 (1) On or before September 15 of each year, the Agency
21 for Health Care Administration shall calculate an allocation
22 fraction to be used for distributing funds to state statutory
23 teaching hospitals. Subsequent to the end of each quarter of
24 the state fiscal year, the agency shall distribute to each
25 statutory teaching hospital, as defined in s. 408.07, an
26 amount determined by multiplying one-fourth of the funds
27 appropriated for this purpose by the Legislature times such
28 hospital's allocation fraction. The allocation fraction for
29 each such hospital shall be determined by the sum of three
30 primary factors, divided by three. The primary factors are:
31
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1 (a) The number of nationally accredited graduate
2 medical education programs offered by the hospital, including
3 programs accredited by the Accreditation Council for Graduate
4 Medical Education and the combined Internal Medicine and
5 Pediatrics programs acceptable to both the American Board of
6 Internal Medicine and the American Board of Pediatrics at the
7 beginning of the state fiscal year preceding the date on which
8 the allocation fraction is calculated. The numerical value of
9 this factor is the fraction that the hospital represents of
10 the total number of programs, where the total is computed for
11 all state statutory teaching hospitals.
12 (b) The number of full-time equivalent trainees in the
13 hospital, which comprises two components:
14 1. The number of trainees enrolled in nationally
15 accredited graduate medical education programs, as defined in
16 paragraph (a). Full-time equivalents are computed using the
17 fraction of the year during which each trainee is primarily
18 assigned to the given institution, over the state fiscal year
19 preceding the date on which the allocation fraction is
20 calculated. The numerical value of this factor is the fraction
21 that the hospital represents of the total number of full-time
22 equivalent trainees enrolled in accredited graduate programs,
23 where the total is computed for all state statutory teaching
24 hospitals.
25 2. The number of medical students enrolled in
26 accredited colleges of medicine and engaged in clinical
27 activities, including required clinical clerkships and
28 clinical electives. Full-time equivalents are computed using
29 the fraction of the year during which each trainee is
30 primarily assigned to the given institution, over the course
31 of the state fiscal year preceding the date on which the
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1 allocation fraction is calculated. The numerical value of this
2 factor is the fraction that the given hospital represents of
3 the total number of full-time equivalent students enrolled in
4 accredited colleges of medicine, where the total is computed
5 for all state statutory teaching hospitals.
6
7 The primary factor for full-time equivalent trainees is
8 computed as the sum of these two components, divided by two.
9 (c) A service index that comprises three components:
10 1. The Agency for Health Care Administration Service
11 Index, computed by applying the standard Service Inventory
12 Scores established by the Agency for Health Care
13 Administration to services offered by the given hospital, as
14 reported on Worksheet A-2 for the last fiscal year reported to
15 the agency before the date on which the allocation fraction is
16 calculated. The numerical value of this factor is the
17 fraction that the given hospital represents of the total
18 Agency for Health Care Administration Service Index values,
19 where the total is computed for all state statutory teaching
20 hospitals.
21 2. A volume-weighted service index, computed by
22 applying the standard Service Inventory Scores established by
23 the Agency for Health Care Administration to the volume of
24 each service, expressed in terms of the standard units of
25 measure reported on Worksheet A-2 for the last fiscal year
26 reported to the agency before the date on which the allocation
27 factor is calculated. The numerical value of this factor is
28 the fraction that the given hospital represents of the total
29 volume-weighted service index values, where the total is
30 computed for all state statutory teaching hospitals.
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1 3. Total Medicaid payments to each hospital for direct
2 inpatient and outpatient services during the fiscal year
3 preceding the date on which the allocation factor is
4 calculated. This includes payments made to each hospital for
5 such services by Medicaid prepaid health plans, whether the
6 plan was administered by the hospital or not. The numerical
7 value of this factor is the fraction that each hospital
8 represents of the total of such Medicaid payments, where the
9 total is computed for all state statutory teaching hospitals.
10
11 The primary factor for the service index is computed as the
12 sum of these three components, divided by three.
13 (2) By October 1 of each year, the agency shall use
14 the following formula to calculate the maximum additional
15 disproportionate share payment for statutorily defined
16 teaching hospitals:
17
18 TAP = THAF x A
19
20 Where:
21 TAP = total additional payment.
22 THAF = teaching hospital allocation factor.
23 A = amount appropriated for a teaching hospital
24 disproportionate share program.
25 Section 9. Section 409.9117, Florida Statutes, is
26 amended to read:
27 409.9117 Primary care disproportionate share
28 program.--For the state fiscal year 2005-2006 2004-2005, the
29 agency shall not distribute moneys under the primary care
30 disproportionate share program, except as noted in subsection
31 (2). In the event the Centers for Medicare and Medicaid
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1 Services do not approve Florida's inpatient hospital state
2 plan amendment for the public disproportionate share program
3 by January 1, 2005, the agency may make payments to hospitals
4 under the primary care disproportionate share program.
5 (1) If federal funds are available for
6 disproportionate share programs in addition to those otherwise
7 provided by law, there shall be created a primary care
8 disproportionate share program.
9 (2) The following formula shall be used by the agency
10 to calculate the total amount earned for hospitals that
11 participate in the primary care disproportionate share
12 program:
13
14 TAE = HDSP/THDSP
15
16 Where:
17 TAE = total amount earned by a hospital participating
18 in the primary care disproportionate share program.
19 HDSP = the prior state fiscal year primary care
20 disproportionate share payment to the individual hospital.
21 THDSP = the prior state fiscal year total primary care
22 disproportionate share payments to all hospitals.
23
24 (3) The total additional payment for hospitals that
25 participate in the primary care disproportionate share program
26 shall be calculated by the agency as follows:
27
28 TAP = TAE x TA
29
30 Where:
31
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1 TAP = total additional payment for a primary care
2 hospital.
3 TAE = total amount earned by a primary care hospital.
4 TA = total appropriation for the primary care
5 disproportionate share program.
6
7 (4) In the establishment and funding of this program,
8 the agency shall use the following criteria in addition to
9 those specified in s. 409.911, payments may not be made to a
10 hospital unless the hospital agrees to:
11 (a) Cooperate with a Medicaid prepaid health plan, if
12 one exists in the community.
13 (b) Ensure the availability of primary and specialty
14 care physicians to Medicaid recipients who are not enrolled in
15 a prepaid capitated arrangement and who are in need of access
16 to such physicians.
17 (c) Coordinate and provide primary care services free
18 of charge, except copayments, to all persons with incomes up
19 to 100 percent of the federal poverty level who are not
20 otherwise covered by Medicaid or another program administered
21 by a governmental entity, and to provide such services based
22 on a sliding fee scale to all persons with incomes up to 200
23 percent of the federal poverty level who are not otherwise
24 covered by Medicaid or another program administered by a
25 governmental entity, except that eligibility may be limited to
26 persons who reside within a more limited area, as agreed to by
27 the agency and the hospital.
28 (d) Contract with any federally qualified health
29 center, if one exists within the agreed geopolitical
30 boundaries, concerning the provision of primary care services,
31 in order to guarantee delivery of services in a nonduplicative
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1 fashion, and to provide for referral arrangements, privileges,
2 and admissions, as appropriate. The hospital shall agree to
3 provide at an onsite or offsite facility primary care services
4 within 24 hours to which all Medicaid recipients and persons
5 eligible under this paragraph who do not require emergency
6 room services are referred during normal daylight hours.
7 (e) Cooperate with the agency, the county, and other
8 entities to ensure the provision of certain public health
9 services, case management, referral and acceptance of
10 patients, and sharing of epidemiological data, as the agency
11 and the hospital find mutually necessary and desirable to
12 promote and protect the public health within the agreed
13 geopolitical boundaries.
14 (f) In cooperation with the county in which the
15 hospital resides, develop a low-cost, outpatient, prepaid
16 health care program to persons who are not eligible for the
17 Medicaid program, and who reside within the area.
18 (g) Provide inpatient services to residents within the
19 area who are not eligible for Medicaid or Medicare, and who do
20 not have private health insurance, regardless of ability to
21 pay, on the basis of available space, except that nothing
22 shall prevent the hospital from establishing bill collection
23 programs based on ability to pay.
24 (h) Work with the Florida Healthy Kids Corporation,
25 the Florida Health Care Purchasing Cooperative, and business
26 health coalitions, as appropriate, to develop a feasibility
27 study and plan to provide a low-cost comprehensive health
28 insurance plan to persons who reside within the area and who
29 do not have access to such a plan.
30 (i) Work with public health officials and other
31 experts to provide community health education and prevention
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1 activities designed to promote healthy lifestyles and
2 appropriate use of health services.
3 (j) Work with the local health council to develop a
4 plan for promoting access to affordable health care services
5 for all persons who reside within the area, including, but not
6 limited to, public health services, primary care services,
7 inpatient services, and affordable health insurance generally.
8
9 Any hospital that fails to comply with any of the provisions
10 of this subsection, or any other contractual condition, may
11 not receive payments under this section until full compliance
12 is achieved.
13 Section 10. Section 409.91195, Florida Statutes, is
14 amended to read:
15 409.91195 Medicaid Pharmaceutical and Therapeutics
16 Committee.--There is created a Medicaid Pharmaceutical and
17 Therapeutics Committee within the agency for Health Care
18 Administration for the purpose of developing a Medicaid
19 preferred drug list formulary pursuant to 42 U.S.C. s.
20 1396r-8.
21 (1) The Medicaid Pharmaceutical and Therapeutics
22 committee shall be comprised as specified in 42 U.S.C. s.
23 1396r-8 and consist of 11 members appointed by the Governor.
24 Four members shall be physicians, licensed under chapter 458;
25 one member licensed under chapter 459; five members shall be
26 pharmacists licensed under chapter 465; and one member shall
27 be a consumer representative. The members shall be appointed
28 to serve for terms of 2 years from the date of their
29 appointment. Members may be appointed to more than one term.
30 The agency for Health Care Administration shall serve as staff
31 for the committee and assist them with all ministerial duties.
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1 The Governor shall ensure that at least some of the members of
2 the Medicaid Pharmaceutical and Therapeutics committee
3 represent Medicaid participating physicians and pharmacies
4 serving all segments and diversity of the Medicaid population,
5 and have experience in either developing or practicing under a
6 preferred drug list formulary. At least one of the members
7 shall represent the interests of pharmaceutical manufacturers.
8 (2) Committee members shall select a chairperson and a
9 vice chairperson each year from the committee membership.
10 (3) The committee shall meet at least quarterly and
11 may meet at other times at the discretion of the chairperson
12 and members. The committee shall comply with rules adopted by
13 the agency, including notice of any meeting of the committee
14 pursuant to the requirements of the Administrative Procedure
15 Act.
16 (4) Upon recommendation of the Medicaid Pharmaceutical
17 and Therapeutics committee, the agency shall adopt a preferred
18 drug list as described in s. 409.912(39). To the extent
19 feasible, the committee shall review all drug classes included
20 on in the preferred drug list formulary at least every 12
21 months, and may recommend additions to and deletions from the
22 preferred drug list formulary, such that the preferred drug
23 list formulary provides for medically appropriate drug
24 therapies for Medicaid patients which achieve cost savings
25 contained in the General Appropriations Act.
26 (5) Except for mental health-related drugs,
27 antiretroviral drugs, and drugs for nursing home residents and
28 other institutional residents, reimbursement of drugs not
29 included in the formulary is subject to prior authorization.
30 (5)(6) The agency for Health Care Administration shall
31 publish and disseminate the preferred drug list formulary to
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1 all Medicaid providers in the state by Internet posting on the
2 agency's website or in other media.
3 (6)(7) The committee shall ensure that interested
4 parties, including pharmaceutical manufacturers agreeing to
5 provide a supplemental rebate as outlined in this chapter,
6 have an opportunity to present public testimony to the
7 committee with information or evidence supporting inclusion of
8 a product on the preferred drug list. Such public testimony
9 shall occur prior to any recommendations made by the committee
10 for inclusion or exclusion from the preferred drug list. Upon
11 timely notice, the agency shall ensure that any drug that has
12 been approved or had any of its particular uses approved by
13 the United States Food and Drug Administration under a
14 priority review classification will be reviewed by the
15 Medicaid Pharmaceutical and Therapeutics committee at the next
16 regularly scheduled meeting following 12 months of
17 distribution of the drug to the general public. To the extent
18 possible, upon notice by a manufacturer the agency shall also
19 schedule a product review for any new product at the next
20 regularly scheduled Medicaid Pharmaceutical and Therapeutics
21 Committee.
22 (8) Until the Medicaid Pharmaceutical and Therapeutics
23 Committee is appointed and a preferred drug list adopted by
24 the agency, the agency shall use the existing voluntary
25 preferred drug list adopted pursuant to s. 72, chapter
26 2000-367, Laws of Florida. Drugs not listed on the voluntary
27 preferred drug list will require prior authorization by the
28 agency or its contractor.
29 (7)(9) The Medicaid Pharmaceutical and Therapeutics
30 committee shall develop its preferred drug list
31 recommendations by considering the clinical efficacy, safety,
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1 and cost-effectiveness of a product. When the preferred drug
2 formulary is adopted by the agency, if a product on the
3 formulary is one of the first four brand-name drugs used by a
4 recipient in a month the drug shall not require prior
5 authorization.
6 (8) Upon timely notice, the agency shall ensure that
7 any therapeutic class of drugs which includes a drug that has
8 been removed from distribution to the public by its
9 manufacturer or the United States Food and Drug Administration
10 or has been required to carry a black box warning label by the
11 United States Food and Drug Administration because of safety
12 concerns is reviewed by the committee at the next regularly
13 scheduled meeting. After such review, the committee must
14 recommend whether to retain the therapeutic class of drugs or
15 subcategories of drugs within a therapeutic class on the
16 preferred drug list and whether to institute prior
17 authorization requirements necessary to ensure patient safety.
18 (9)(10) The Medicaid Pharmaceutical and Therapeutics
19 Committee may also make recommendations to the agency
20 regarding the prior authorization of any prescribed drug
21 covered by Medicaid.
22 (10)(11) Medicaid recipients may appeal agency
23 preferred drug formulary decisions using the Medicaid fair
24 hearing process administered by the Department of Children and
25 Family Services.
26 Section 11. Paragraph (a) of subsection (39) and
27 subsections (44) and (49) of section 409.912, Florida
28 Statutes, are amended, and subsection (50) is added to that
29 section, to read:
30 409.912 Cost-effective purchasing of health care.--The
31 agency shall purchase goods and services for Medicaid
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1 recipients in the most cost-effective manner consistent with
2 the delivery of quality medical care. To ensure that medical
3 services are effectively utilized, the agency may, in any
4 case, require a confirmation or second physician's opinion of
5 the correct diagnosis for purposes of authorizing future
6 services under the Medicaid program. This section does not
7 restrict access to emergency services or poststabilization
8 care services as defined in 42 C.F.R. part 438.114. Such
9 confirmation or second opinion shall be rendered in a manner
10 approved by the agency. The agency shall maximize the use of
11 prepaid per capita and prepaid aggregate fixed-sum basis
12 services when appropriate and other alternative service
13 delivery and reimbursement methodologies, including
14 competitive bidding pursuant to s. 287.057, designed to
15 facilitate the cost-effective purchase of a case-managed
16 continuum of care. The agency shall also require providers to
17 minimize the exposure of recipients to the need for acute
18 inpatient, custodial, and other institutional care and the
19 inappropriate or unnecessary use of high-cost services. The
20 agency may mandate prior authorization, drug therapy
21 management, or disease management participation for certain
22 populations of Medicaid beneficiaries, certain drug classes,
23 or particular drugs to prevent fraud, abuse, overuse, and
24 possible dangerous drug interactions. The Pharmaceutical and
25 Therapeutics Committee shall make recommendations to the
26 agency on drugs for which prior authorization is required. The
27 agency shall inform the Pharmaceutical and Therapeutics
28 Committee of its decisions regarding drugs subject to prior
29 authorization. The agency is authorized to limit the entities
30 it contracts with or enrolls as Medicaid providers by
31 developing a provider network through provider credentialing.
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1 The agency may limit its network based on the assessment of
2 beneficiary access to care, provider availability, provider
3 quality standards, time and distance standards for access to
4 care, the cultural competence of the provider network,
5 demographic characteristics of Medicaid beneficiaries,
6 practice and provider-to-beneficiary standards, appointment
7 wait times, beneficiary use of services, provider turnover,
8 provider profiling, provider licensure history, previous
9 program integrity investigations and findings, peer review,
10 provider Medicaid policy and billing compliance records,
11 clinical and medical record audits, and other factors.
12 Providers shall not be entitled to enrollment in the Medicaid
13 provider network. The agency is authorized to seek federal
14 waivers necessary to implement this policy.
15 (39)(a) The agency shall implement a Medicaid
16 prescribed-drug spending-control program that includes the
17 following components:
18 1. A Medicaid preferred drug list, which shall be a
19 listing of cost-effective therapeutic options recommended by
20 the Medicaid Pharmacy and Therapeutics Committee established
21 pursuant to s. 409.91195 and adopted by the agency for each
22 therapeutic class on the preferred drug list. At the
23 discretion of the committee, and when feasible, the preferred
24 drug list should include at least two products in a
25 therapeutic class. Medicaid prescribed-drug coverage for
26 brand-name drugs for adult Medicaid recipients is limited to
27 eight drugs per month the dispensing of four brand-name drugs
28 per month per recipient. Prior authorization is required for
29 all additional prescriptions above the eight-drug limit and
30 must meet step therapy and preferred drug list listing
31 requirements. Children are exempt from this restriction.
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1 Antiretroviral agents are excluded from this limitation. No
2 requirements for prior authorization or other restrictions on
3 medications used to treat mental illnesses such as
4 schizophrenia, severe depression, or bipolar disorder may be
5 imposed on Medicaid recipients. Medications that will be
6 available without restriction for persons with mental
7 illnesses include atypical antipsychotic medications,
8 conventional antipsychotic medications, selective serotonin
9 reuptake inhibitors, and other medications used for the
10 treatment of serious mental illnesses. The agency shall also
11 limit the amount of a prescribed drug dispensed to no more
12 than a 34-day supply unless the drug products' smallest
13 marketed package is greater than a 34-day supply, or the drug
14 is determined by the agency to be a maintenance drug in which
15 case a 100-day maximum supply may be authorized. The agency is
16 authorized to seek any federal waivers necessary to implement
17 these cost-control programs and to continue participation in
18 the federal Medicaid rebate program, or alternatively to
19 negotiate state-only manufacturer rebates. The agency may
20 adopt rules to implement this subparagraph. The agency shall
21 continue to provide unlimited generic drugs, contraceptive
22 drugs and items, and diabetic supplies. Although a drug may be
23 included on the preferred drug formulary, it would not be
24 exempt from the four-brand limit. The agency may authorize
25 exceptions to the brand-name-drug restriction based upon the
26 treatment needs of the patients, only when such exceptions are
27 based on prior consultation provided by the agency or an
28 agency contractor, but The agency must establish procedures to
29 ensure that:
30 a. There will be a response to a request for prior
31 consultation by telephone or other telecommunication device
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1 within 24 hours after receipt of a request for prior
2 consultation; and
3 b. A 72-hour supply of the drug prescribed will be
4 provided in an emergency or when the agency does not provide a
5 response within 24 hours as required by sub-subparagraph a.;
6 and
7 c. Except for the exception for nursing home residents
8 and other institutionalized adults and except for drugs on the
9 restricted formulary for which prior authorization may be
10 sought by an institutional or community pharmacy, prior
11 authorization for an exception to the brand-name-drug
12 restriction is sought by the prescriber and not by the
13 pharmacy. When prior authorization is granted for a patient in
14 an institutional setting beyond the brand-name-drug
15 restriction, such approval is authorized for 12 months and
16 monthly prior authorization is not required for that patient.
17 2. Reimbursement to pharmacies for Medicaid prescribed
18 drugs shall be set at the lesser of: the average wholesale
19 price (AWP) minus 15.4 percent, the wholesaler acquisition
20 cost (WAC) plus 5.75 percent, the federal upper limit (FUL),
21 the state maximum allowable cost (SMAC), or the usual and
22 customary (UAC) charge billed by the provider.
23 3. The agency shall develop and implement a process
24 for managing the drug therapies of Medicaid recipients who are
25 using significant numbers of prescribed drugs each month. The
26 management process may include, but is not limited to,
27 comprehensive, physician-directed medical-record reviews,
28 claims analyses, and case evaluations to determine the medical
29 necessity and appropriateness of a patient's treatment plan
30 and drug therapies. The agency may contract with a private
31 organization to provide drug-program-management services. The
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1 Medicaid drug benefit management program shall include
2 initiatives to manage drug therapies for HIV/AIDS patients,
3 patients using 20 or more unique prescriptions in a 180-day
4 period, and the top 1,000 patients in annual spending. The
5 agency shall enroll any Medicaid recipient in the drug benefit
6 management program if he or she meets the specifications of
7 this provision and is not enrolled in a Medicaid health
8 maintenance organization.
9 4. The agency may limit the size of its pharmacy
10 network based on need, competitive bidding, price
11 negotiations, credentialing, or similar criteria. The agency
12 shall give special consideration to rural areas in determining
13 the size and location of pharmacies included in the Medicaid
14 pharmacy network. A pharmacy credentialing process may include
15 criteria such as a pharmacy's full-service status, location,
16 size, patient educational programs, patient consultation,
17 disease-management services, and other characteristics. The
18 agency may impose a moratorium on Medicaid pharmacy enrollment
19 when it is determined that it has a sufficient number of
20 Medicaid-participating providers.
21 5. The agency shall develop and implement a program
22 that requires Medicaid practitioners who prescribe drugs to
23 use a counterfeit-proof prescription pad for Medicaid
24 prescriptions. The agency shall require the use of
25 standardized counterfeit-proof prescription pads by
26 Medicaid-participating prescribers or prescribers who write
27 prescriptions for Medicaid recipients. The agency may
28 implement the program in targeted geographic areas or
29 statewide.
30 6. The agency may enter into arrangements that require
31 manufacturers of generic drugs prescribed to Medicaid
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1 recipients to provide rebates of at least 15.1 percent of the
2 average manufacturer price for the manufacturer's generic
3 products. These arrangements shall require that if a
4 generic-drug manufacturer pays federal rebates for
5 Medicaid-reimbursed drugs at a level below 15.1 percent, the
6 manufacturer must provide a supplemental rebate to the state
7 in an amount necessary to achieve a 15.1-percent rebate level.
8 7. The agency may establish a preferred drug list as
9 described in this subsection formulary in accordance with 42
10 U.S.C. s. 1396r-8, and, pursuant to the establishment of such
11 preferred drug list formulary, it is authorized to negotiate
12 supplemental rebates from manufacturers that are in addition
13 to those required by Title XIX of the Social Security Act and
14 at no less than 14 percent of the average manufacturer price
15 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
16 unless the federal or supplemental rebate, or both, equals or
17 exceeds 29 percent. There is no upper limit on the
18 supplemental rebates the agency may negotiate. The agency may
19 determine that specific products, brand-name or generic, are
20 competitive at lower rebate percentages. Agreement to pay the
21 minimum supplemental rebate percentage will guarantee a
22 manufacturer that the Medicaid Pharmaceutical and Therapeutics
23 Committee will consider a product for inclusion on the
24 preferred drug list formulary. However, a pharmaceutical
25 manufacturer is not guaranteed placement on the preferred drug
26 list formulary by simply paying the minimum supplemental
27 rebate. Agency decisions will be made on the clinical efficacy
28 of a drug and recommendations of the Medicaid Pharmaceutical
29 and Therapeutics Committee, as well as the price of competing
30 products minus federal and state rebates. The agency is
31 authorized to contract with an outside agency or contractor to
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1 conduct negotiations for supplemental rebates. For the
2 purposes of this section, the term "supplemental rebates"
3 means cash rebates. Effective July 1, 2004, value-added
4 programs as a substitution for supplemental rebates are
5 prohibited. The agency is authorized to seek any federal
6 waivers to implement this initiative.
7 8. The agency shall establish an advisory committee
8 for the purposes of studying the feasibility of using a
9 restricted drug formulary for nursing home residents and other
10 institutionalized adults. The committee shall be comprised of
11 seven members appointed by the Secretary of Health Care
12 Administration. The committee members shall include two
13 physicians licensed under chapter 458 or chapter 459; three
14 pharmacists licensed under chapter 465 and appointed from a
15 list of recommendations provided by the Florida Long-Term Care
16 Pharmacy Alliance; and two pharmacists licensed under chapter
17 465.
18 8.9. The Agency for Health Care Administration shall
19 expand home delivery of pharmacy products. To assist Medicaid
20 patients in securing their prescriptions and reduce program
21 costs, the agency shall expand its current mail-order-pharmacy
22 diabetes-supply program to include all generic and brand-name
23 drugs used by Medicaid patients with diabetes. Medicaid
24 recipients in the current program may obtain nondiabetes drugs
25 on a voluntary basis. This initiative is limited to the
26 geographic area covered by the current contract. The agency
27 may seek and implement any federal waivers necessary to
28 implement this subparagraph.
29 9.10. The agency shall limit to one dose per month any
30 drug prescribed to treat erectile dysfunction.
31
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1 10.a.11.a. The agency shall implement a Medicaid
2 behavioral drug management system. The agency may contract
3 with a vendor that has experience in operating behavioral drug
4 management systems to implement this program. The agency is
5 authorized to seek federal waivers to implement this program.
6 b. The agency, in conjunction with the Department of
7 Children and Family Services, may implement the Medicaid
8 behavioral drug management system that is designed to improve
9 the quality of care and behavioral health prescribing
10 practices based on best practice guidelines, improve patient
11 adherence to medication plans, reduce clinical risk, and lower
12 prescribed drug costs and the rate of inappropriate spending
13 on Medicaid behavioral drugs. The program shall include the
14 following elements:
15 (I) Provide for the development and adoption of best
16 practice guidelines for behavioral health-related drugs such
17 as antipsychotics, antidepressants, and medications for
18 treating bipolar disorders and other behavioral conditions;
19 translate them into practice; review behavioral health
20 prescribers and compare their prescribing patterns to a number
21 of indicators that are based on national standards; and
22 determine deviations from best practice guidelines.
23 (II) Implement processes for providing feedback to and
24 educating prescribers using best practice educational
25 materials and peer-to-peer consultation.
26 (III) Assess Medicaid beneficiaries who are outliers
27 in their use of behavioral health drugs with regard to the
28 numbers and types of drugs taken, drug dosages, combination
29 drug therapies, and other indicators of improper use of
30 behavioral health drugs.
31
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1 (IV) Alert prescribers to patients who fail to refill
2 prescriptions in a timely fashion, are prescribed multiple
3 same-class behavioral health drugs, and may have other
4 potential medication problems.
5 (V) Track spending trends for behavioral health drugs
6 and deviation from best practice guidelines.
7 (VI) Use educational and technological approaches to
8 promote best practices, educate consumers, and train
9 prescribers in the use of practice guidelines.
10 (VII) Disseminate electronic and published materials.
11 (VIII) Hold statewide and regional conferences.
12 (IX) Implement a disease management program with a
13 model quality-based medication component for severely mentally
14 ill individuals and emotionally disturbed children who are
15 high users of care.
16 c. If the agency is unable to negotiate a contract
17 with one or more manufacturers to finance and guarantee
18 savings associated with a behavioral drug management program
19 by September 1, 2004, the four-brand drug limit and preferred
20 drug list prior-authorization requirements shall apply to
21 mental health-related drugs, notwithstanding any provision in
22 subparagraph 1. The agency is authorized to seek federal
23 waivers to implement this policy.
24 11.12. The agency is authorized to contract for drug
25 rebate administration, including, but not limited to,
26 calculating rebate amounts, invoicing manufacturers,
27 negotiating disputes with manufacturers, and maintaining a
28 database of rebate collections.
29 12.13. The agency may specify the preferred daily
30 dosing form or strength for the purpose of promoting best
31 practices with regard to the prescribing of certain drugs as
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1 specified in the General Appropriations Act and ensuring
2 cost-effective prescribing practices.
3 13.14. The agency may require prior authorization for
4 the off-label use of Medicaid-covered prescribed drugs as
5 specified in the General Appropriations Act. The agency may,
6 but is not required to, preauthorize the use of a product for
7 an indication not in the approved labeling. Prior
8 authorization may require the prescribing professional to
9 provide information about the rationale and supporting medical
10 evidence for the off-label use of a drug.
11 14. The agency, in conjunction with the Pharmaceutical
12 and Therapeutics Committee, may require age-related prior
13 authorizations for certain prescribed drugs. The agency may
14 preauthorize the use of a drug for a recipient who may not
15 meet the age requirement or may exceed the length of therapy
16 for use of this product as recommended by the manufacturer and
17 approved by the Food and Drug Administration. Prior
18 authorization may require the prescribing professional to
19 provide information about the rationale and supporting medical
20 evidence for the use of a drug.
21 15. The agency shall implement a step-therapy-prior
22 authorization-approval process for medications excluded from
23 the preferred drug list. Medications listed on the preferred
24 drug list must be used within the previous 12 months prior to
25 the alternative medications that are not listed. The
26 step-therapy-prior authorization may require the prescriber to
27 use the medications of a similar drug class or for a similar
28 medical indication unless contraindicated in the Food and Drug
29 Administration labeling. The trial period between the
30 specified steps may vary according to the medical indication.
31 The step-therapy-approval process shall be developed in
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1 accordance with the committee as stated in s. 409.91195(7) and
2 (8).
3 16.15. The agency shall implement a return and reuse
4 program for drugs dispensed by pharmacies to institutional
5 recipients, which includes payment of a $5 restocking fee for
6 the implementation and operation of the program. The return
7 and reuse program shall be implemented electronically and in a
8 manner that promotes efficiency. The program must permit a
9 pharmacy to exclude drugs from the program if it is not
10 practical or cost-effective for the drug to be included and
11 must provide for the return to inventory of drugs that cannot
12 be credited or returned in a cost-effective manner.
13 (44) The Agency for Health Care Administration shall
14 ensure that any Medicaid managed care plan as defined in s.
15 409.9122(2)(h), whether paid on a capitated basis or a shared
16 savings basis, is cost-effective. For purposes of this
17 subsection, the term "cost-effective" means that a network's
18 per-member, per-month costs to the state, including, but not
19 limited to, fee-for-service costs, administrative costs, and
20 case-management fees, if any, must be no greater than the
21 state's costs associated with contracts for Medicaid services
22 established under subsection (3), which shall be actuarially
23 adjusted for case mix, model, and service area. The agency
24 shall conduct actuarially sound audits adjusted for case mix
25 and model in order to ensure such cost-effectiveness and shall
26 publish the audit results on its Internet website and submit
27 the audit results annually to the Governor, the President of
28 the Senate, and the Speaker of the House of Representatives no
29 later than December 31 of each year. Contracts established
30 pursuant to this subsection which are not cost-effective may
31 not be renewed.
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1 (49) The agency shall contract with established
2 minority physician networks that provide services to
3 historically underserved minority patients. The networks must
4 provide cost-effective Medicaid services, comply with the
5 requirements to be a MediPass provider, and provide their
6 primary care physicians with access to data and other
7 management tools necessary to assist them in ensuring the
8 appropriate use of services, including inpatient hospital
9 services and pharmaceuticals.
10 (a) The agency shall provide for the development and
11 expansion of minority physician networks in each service area
12 to provide services to Medicaid recipients who are eligible to
13 participate under federal law and rules.
14 (b) The agency shall reimburse each minority physician
15 network as a fee-for-service provider, including the case
16 management fee for primary care, if any, or as a capitated
17 rate provider for Medicaid services. Any savings shall be
18 shared with the minority physician networks pursuant to the
19 contract.
20 (c) For purposes of this subsection, the term
21 "cost-effective" means that a network's per-member, per-month
22 costs to the state, including, but not limited to,
23 fee-for-service costs, administrative costs, and
24 case-management fees, if any, must be no greater than the
25 state's costs associated with contracts for Medicaid services
26 established under subsection (3), which shall be actuarially
27 adjusted for case mix, model, and service area. The agency
28 shall conduct actuarially sound audits adjusted for case mix
29 and model in order to ensure such cost-effectiveness and shall
30 publish the audit results on its Internet website and submit
31 the audit results annually to the Governor, the President of
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1 the Senate, and the Speaker of the House of Representatives no
2 later than December 31. Contracts established pursuant to this
3 subsection which are not cost-effective may not be renewed.
4 (d) The agency may apply for any federal waivers
5 needed to implement this subsection.
6 (50) The agency shall implement a program of
7 all-inclusive care for children. The program of all-inclusive
8 care for children shall be established to provide in-home
9 hospice-like support services to children diagnosed with a
10 life-threatening illness and enrolled in the Children's
11 Medical Services network to reduce hospitalizations as
12 appropriate. The agency, in consultation with the Department
13 of Health, may implement the program of all-inclusive care for
14 children after obtaining approval from the Centers for
15 Medicare and Medicaid Services.
16 Section 12. Section 409.9124, Florida Statutes, is
17 amended to read:
18 409.9124 Managed care reimbursement.--
19 (1) The agency shall develop and adopt by rule a
20 methodology for reimbursing managed care plans.
21 (1)(2) Final managed care rates shall be published
22 annually prior to September 1 of each year, based on
23 methodology that:
24 (a) Uses Medicaid's fee-for-service expenditures.
25 (b) Is certified as an actuarially sound computation
26 of Medicaid fee-for-service expenditures for comparable groups
27 of Medicaid recipients and includes all fee-for-service
28 expenditures, including those fee-for-service expenditures
29 attributable to recipients who are enrolled for a portion of a
30 year in a managed care plan or waiver program.
31
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1 (c) Is compliant with applicable federal laws and
2 regulations, including, but not limited to, the requirements
3 to include an allowance for administrative expenses and to
4 account for all fee-for-service expenditures, including
5 fee-for-service expenditures for those groups enrolled for
6 part of a year.
7 (2)(3) Each year prior to establishing new managed
8 care rates, the agency shall review all prior year adjustments
9 for changes in trend, and shall reduce or eliminate those
10 adjustments which are not reasonable and which reflect
11 policies or programs which are not in effect.
12 (3)(4) The agency shall by rule prescribe those items
13 of financial information which each managed care plan shall
14 report to the agency, in the time periods prescribed by rule.
15 In prescribing items for reporting and definitions of terms,
16 the agency shall consult with the Office of Insurance
17 Regulation of the Financial Services Commission wherever
18 possible.
19 (4)(5) The agency shall quarterly examine the
20 financial condition of each managed care plan, and its
21 performance in serving Medicaid patients, and shall utilize
22 examinations performed by the Office of Insurance Regulation
23 wherever possible.
24 Section 13. Except as otherwise expressly provided in
25 this act, this act shall take effect July 1, 2005.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 404
3
4
- Delays the scheduled increase in the minimum staffing
5 standards for nursing homes from 2.6 hours to 2.9 hours
of direct care per patient per day until July 1, 2006.
6
- Restores Medicaid eligibility for pregnant women with
7 incomes between 150 to 185 percent of the federal poverty
level, effective July 1,2005.
8
- Limits eligibility standards for the Medicaid Aged and
9 Disabled program(MEDS AD).
10 - Restores coverage for all Medicaid services to Medically
Needy recipients, effective July 1, 2005.
11
- Restores Medicaid coverage for adult denture services,
12 effective July 1, 2005.
13 - Eliminates the Silver Saver prescription drug program,
effective January 1, 2006, as a result of the
14 implementation of Medicare Part D.
15 - Eliminates outdated language that reduced hospital
inpatient rates by 6 percent between July 1, 2001 and
16 April 1, 2002.
17 - Revises guidelines for direct and indirect care
subcomponents for nursing home reimbursement.
18
- Eliminates outdated language relating to the RPICC,
19 teaching and primary care disproportionate share hospital
programs.
20
- Eliminates the exemption of the prior authorization
21 requirements for mental health, antiretroviral drugs, and
drugs for nursing home recipients and other
22 institutionalized individuals.
23 - Requires the agency to publish the preferred drug list on
the Internet.
24
- Extends the requirement for the Pharmaceutical and
25 Therapeutics Committee review of newly approved drugs
from the next scheduled meeting after FDA approval to the
26 next scheduled meeting after the drug has been in
distribution for twelve months.
27
- Removes outdated language allowing the agency to adopt a
28 voluntary preferred drug list.
29 - Implements prescription drug safety requirements.
30 - Establishes a Medicaid preferred drug list that includes
a list of cost effective therapeutic options with at
31 least two products in each therapeutic class.
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1 - Requires prior authorization of all drugs in excess of
eight per recipient per month.
2
- Eliminates the four brand name drug limit and prior
3 authorization requirements.
4 - Eliminates language that exempts children and medications
to treat mental illness from prior authorization
5 requirements.
6 - Authorizes the dispensing of one-hundred day maximum
supplies of maintenance medications.
7
- Eliminates the exception that allows prior authorization
8 requirements from the pharmacy rather than by the
prescribing physician for nursing home residents and
9 other institutionalized adults.
10 - Eliminates language which established an advisory
committee for the purpose of studying the feasibility of
11 using a restricted formulary for nursing home residents.
12 - Eliminates language that required the Agency for Health
Care Administration to negotiate a contract for a
13 behavioral health management program by September 1,
2004.
14
- Authorizes the agency, in conjunction with the
15 Pharmaceutical and Therapeutics Committee, to place
certain age related recipient prior authorization
16 requirements.
17 - Authorizes the agency to implement a step therapy prior
authorization process for prescriptions that are not
18 included on the preferred drug list.
19 - Authorizes the agency to implement the program of
all-inclusive care for children to provide in-home
20 hospice-like support services to children diagnosed with
life-threatening illness and enrolled in the Children's
21 Medical Services network.
22 - Removes language related to administrative expenses and
accounting for all fee-for-service expenditures currently
23 duplicated in HMO capitation rate setting methodology
used by the agency.
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