Senate Bill sb0404c2
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Florida Senate - 2005 CS for CS for SB 404
By the Committees on Ways and Means; Health and Human Services
Appropriations; and Senator Saunders
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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.
27 409.9122, F.S.; revising a provision governing
28 assignment to a managed care option for a
29 Medicaid recipient who does not choose a plan
30 or provider in certain geographic areas where
31 the Agency for Health Care Administration
1
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1 contracts for comprehensive behavioral health
2 services; amending s. 409.9124, F.S.; requiring
3 the Agency for Health Care Administration to
4 publish managed care reimbursement rates
5 annually; limiting the application of certain
6 rates and rate reductions; providing effective
7 dates.
8
9 Be It Enacted by the Legislature of the State of Florida:
10
11 Section 1. Paragraph (a) of subsection (3) of section
12 400.23, Florida Statutes, is amended to read:
13 400.23 Rules; evaluation and deficiencies; licensure
14 status.--
15 (3)(a) The agency shall adopt rules providing for the
16 minimum staffing requirements for nursing homes. These
17 requirements shall include, for each nursing home facility, a
18 minimum certified nursing assistant staffing of 2.3 hours of
19 direct care per resident per day beginning January 1, 2002,
20 increasing to 2.6 hours of direct care per resident per day
21 beginning January 1, 2003, and increasing to 2.9 hours of
22 direct care per resident per day beginning July 1, 2006 2005.
23 Beginning January 1, 2002, no facility shall staff below one
24 certified nursing assistant per 20 residents, and a minimum
25 licensed nursing staffing of 1.0 hour of direct resident care
26 per resident per day but never below one licensed nurse per 40
27 residents. Nursing assistants employed under s. 400.211(2) may
28 be included in computing the staffing ratio for certified
29 nursing assistants only if they provide nursing assistance
30 services to residents on a full-time basis. Each nursing home
31 must document compliance with staffing standards as required
2
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1 under this paragraph and post daily the names of staff on duty
2 for the benefit of facility residents and the public. The
3 agency shall recognize the use of licensed nurses for
4 compliance with minimum staffing requirements for certified
5 nursing assistants, provided that the facility otherwise meets
6 the minimum staffing requirements for licensed nurses and that
7 the licensed nurses so recognized are performing the duties of
8 a certified nursing assistant. Unless otherwise approved by
9 the agency, licensed nurses counted toward the minimum
10 staffing requirements for certified nursing assistants must
11 exclusively perform the duties of a certified nursing
12 assistant for the entire shift and shall not also be counted
13 toward the minimum staffing requirements for licensed nurses.
14 If the agency approved a facility's request to use a licensed
15 nurse to perform both licensed nursing and certified nursing
16 assistant duties, the facility must allocate the amount of
17 staff time specifically spent on certified nursing assistant
18 duties for the purpose of documenting compliance with minimum
19 staffing requirements for certified and licensed nursing
20 staff. In no event may the hours of a licensed nurse with dual
21 job responsibilities be counted twice.
22 Section 2. Subsection (5) of section 409.903, Florida
23 Statutes, is amended to read:
24 409.903 Mandatory payments for eligible persons.--The
25 agency shall make payments for medical assistance and related
26 services on behalf of the following persons who the
27 department, or the Social Security Administration by contract
28 with the Department of Children and Family Services,
29 determines to be eligible, subject to the income, assets, and
30 categorical eligibility tests set forth in federal and state
31 law. Payment on behalf of these Medicaid eligible persons is
3
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1 subject to the availability of moneys and any limitations
2 established by the General Appropriations Act or chapter 216.
3 (5) A pregnant woman for the duration of her pregnancy
4 and for the postpartum period as defined in federal law and
5 rule, or a child under age 1, if either is living in a family
6 that has an income which is at or below 150 percent of the
7 most current federal poverty level, or, effective January 1,
8 1992, that has an income which is at or below 185 percent of
9 the most current federal poverty level. Such a person is not
10 subject to an assets test. Further, a pregnant woman who
11 applies for eligibility for the Medicaid program through a
12 qualified Medicaid provider must be offered the opportunity,
13 subject to federal rules, to be made presumptively eligible
14 for the Medicaid program. Effective July 1, 2005, eligibility
15 for Medicaid services is eliminated for women who have incomes
16 above 150 percent of the most current federal poverty level.
17 Section 3. Subsections (1) and (2) of section 409.904,
18 Florida Statutes, are amended to read:
19 409.904 Optional payments for eligible persons.--The
20 agency may make payments for medical assistance and related
21 services on behalf of the following persons who are determined
22 to be eligible subject to the income, assets, and categorical
23 eligibility tests set forth in federal and state law. Payment
24 on behalf of these Medicaid eligible persons is subject to the
25 availability of moneys and any limitations established by the
26 General Appropriations Act or chapter 216.
27 (1)(a) From July 1, 2005, through December 31, 2005, a
28 person who is age 65 or older or is determined to be disabled,
29 whose income is at or below 88 percent of federal poverty
30 level, and whose assets do not exceed established limitations.
31
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1 (b) Effective January 1, 2006, and subject to federal
2 waiver approval, a person who is age 65 or older or is
3 determined to be disabled, whose income is at or below 88
4 percent of the federal poverty level, whose assets do not
5 exceed established limitations, and who is not eligible for
6 Medicare or, if eligible for Medicare, is also eligible for
7 and receiving Medicaid-covered institutional care services,
8 hospice services, or home and community-based services. The
9 agency shall seek federal authorization through a waiver to
10 provide this coverage.
11 (2) A family, a pregnant woman, a child under age 21,
12 a person age 65 or over, or a blind or disabled person, who
13 would be eligible under any group listed in s. 409.903(1),
14 (2), or (3), except that the income or assets of such family
15 or person exceed established limitations. For a family or
16 person in one of these coverage groups, medical expenses are
17 deductible from income in accordance with federal requirements
18 in order to make a determination of eligibility. A family or
19 person eligible under the coverage known as the "medically
20 needy," is eligible to receive the same services as other
21 Medicaid recipients, with the exception of services in skilled
22 nursing facilities and intermediate care facilities for the
23 developmentally disabled. Effective July 1, 2005, the
24 medically needy are eligible for prescribed drug services
25 only.
26 Section 4. Paragraph (b) of subsection (1) of section
27 409.906, Florida Statutes, is amended to read:
28 409.906 Optional Medicaid services.--Subject to
29 specific appropriations, the agency may make payments for
30 services which are optional to the state under Title XIX of
31 the Social Security Act and are furnished by Medicaid
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1 providers to recipients who are determined to be eligible on
2 the dates on which the services were provided. Any optional
3 service that is provided shall be provided only when medically
4 necessary and in accordance with state and federal law.
5 Optional services rendered by providers in mobile units to
6 Medicaid recipients may be restricted or prohibited by the
7 agency. Nothing in this section shall be construed to prevent
8 or limit the agency from adjusting fees, reimbursement rates,
9 lengths of stay, number of visits, or number of services, or
10 making any other adjustments necessary to comply with the
11 availability of moneys and any limitations or directions
12 provided for in the General Appropriations Act or chapter 216.
13 If necessary to safeguard the state's systems of providing
14 services to elderly and disabled persons and subject to the
15 notice and review provisions of s. 216.177, the Governor may
16 direct the Agency for Health Care Administration to amend the
17 Medicaid state plan to delete the optional Medicaid service
18 known as "Intermediate Care Facilities for the Developmentally
19 Disabled." Optional services may include:
20 (1) ADULT DENTAL SERVICES.--
21 (b) Beginning January 1, 2005, the agency may pay for
22 dentures, the procedures required to seat dentures, and the
23 repair and reline of dentures, provided by or under the
24 direction of a licensed dentist, for a recipient who is 21
25 years of age or older. This paragraph is repealed effective
26 July 1, 2005.
27 Section 5. Effective January 1, 2006, section
28 409.9065, Florida Statutes, is repealed.
29 Section 6. Paragraph (a) of subsection (1) and
30 paragraph (b) of subsection (2) of section 409.908, Florida
31 Statutes, are amended to read:
6
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1 409.908 Reimbursement of Medicaid providers.--Subject
2 to specific appropriations, the agency shall reimburse
3 Medicaid providers, in accordance with state and federal law,
4 according to methodologies set forth in the rules of the
5 agency and in policy manuals and handbooks incorporated by
6 reference therein. These methodologies may include fee
7 schedules, reimbursement methods based on cost reporting,
8 negotiated fees, competitive bidding pursuant to s. 287.057,
9 and other mechanisms the agency considers efficient and
10 effective for purchasing services or goods on behalf of
11 recipients. If a provider is reimbursed based on cost
12 reporting and submits a cost report late and that cost report
13 would have been used to set a lower reimbursement rate for a
14 rate semester, then the provider's rate for that semester
15 shall be retroactively calculated using the new cost report,
16 and full payment at the recalculated rate shall be effected
17 retroactively. Medicare-granted extensions for filing cost
18 reports, if applicable, shall also apply to Medicaid cost
19 reports. Payment for Medicaid compensable services made on
20 behalf of Medicaid eligible persons is subject to the
21 availability of moneys and any limitations or directions
22 provided for in the General Appropriations Act or chapter 216.
23 Further, nothing in this section shall be construed to prevent
24 or limit the agency from adjusting fees, reimbursement rates,
25 lengths of stay, number of visits, or number of services, or
26 making any other adjustments necessary to comply with the
27 availability of moneys and any limitations or directions
28 provided for in the General Appropriations Act, provided the
29 adjustment is consistent with legislative intent.
30
31
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1 (1) Reimbursement to hospitals licensed under part I
2 of chapter 395 must be made prospectively or on the basis of
3 negotiation.
4 (a) Reimbursement for inpatient care is limited as
5 provided for in s. 409.905(5), except for:
6 1. The raising of rate reimbursement caps, excluding
7 rural hospitals.
8 2. Recognition of the costs of graduate medical
9 education.
10 3. Other methodologies recognized in the General
11 Appropriations Act.
12 4. Hospital inpatient rates shall be reduced by 6
13 percent effective July 1, 2001, and restored effective April
14 1, 2002.
15
16 During the years funds are transferred from the Department of
17 Health, any reimbursement supported by such funds shall be
18 subject to certification by the Department of Health that the
19 hospital has complied with s. 381.0403. The agency is
20 authorized to receive funds from state entities, including,
21 but not limited to, the Department of Health, local
22 governments, and other local political subdivisions, for the
23 purpose of making special exception payments, including
24 federal matching funds, through the Medicaid inpatient
25 reimbursement methodologies. Funds received from state
26 entities or local governments for this purpose shall be
27 separately accounted for and shall not be commingled with
28 other state or local funds in any manner. The agency may
29 certify all local governmental funds used as state match under
30 Title XIX of the Social Security Act, to the extent that the
31 identified local health care provider that is otherwise
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1 entitled to and is contracted to receive such local funds is
2 the benefactor under the state's Medicaid program as
3 determined under the General Appropriations Act and pursuant
4 to an agreement between the Agency for Health Care
5 Administration and the local governmental entity. The local
6 governmental entity shall use a certification form prescribed
7 by the agency. At a minimum, the certification form shall
8 identify the amount being certified and describe the
9 relationship between the certifying local governmental entity
10 and the local health care provider. The agency shall prepare
11 an annual statement of impact which documents the specific
12 activities undertaken during the previous fiscal year pursuant
13 to this paragraph, to be submitted to the Legislature no later
14 than January 1, annually.
15 (2)
16 (b) Subject to any limitations or directions provided
17 for in the General Appropriations Act, the agency shall
18 establish and implement a Florida Title XIX Long-Term Care
19 Reimbursement Plan (Medicaid) for nursing home care in order
20 to provide care and services in conformance with the
21 applicable state and federal laws, rules, regulations, and
22 quality and safety standards and to ensure that individuals
23 eligible for medical assistance have reasonable geographic
24 access to such care.
25 1. Changes of ownership or of licensed operator do not
26 qualify for increases in reimbursement rates associated with
27 the change of ownership or of licensed operator. The agency
28 shall amend the Title XIX Long Term Care Reimbursement Plan to
29 provide that the initial nursing home reimbursement rates, for
30 the operating, patient care, and MAR components, associated
31 with related and unrelated party changes of ownership or
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1 licensed operator filed on or after September 1, 2001, are
2 equivalent to the previous owner's reimbursement rate.
3 2. The agency shall amend the long-term care
4 reimbursement plan and cost reporting system to create direct
5 care and indirect care subcomponents of the patient care
6 component of the per diem rate. These two subcomponents
7 together shall equal the patient care component of the per
8 diem rate. Separate cost-based ceilings shall be calculated
9 for each patient care subcomponent. The direct care
10 subcomponent of the per diem rate shall be limited by the
11 cost-based class ceiling and may be limited by the target rate
12 class ceiling, and the indirect care subcomponent shall be
13 limited by the lower of the cost-based class ceiling, by the
14 target rate class ceiling, or by the individual provider
15 target. The agency shall adjust the patient care component
16 effective January 1, 2002. The cost to adjust the direct care
17 subcomponent shall be net of the total funds previously
18 allocated for the case mix add-on. The agency shall make the
19 required changes to the nursing home cost reporting forms to
20 implement this requirement effective January 1, 2002.
21 3. The direct care subcomponent shall include salaries
22 and benefits of direct care staff providing nursing services
23 including registered nurses, licensed practical nurses, and
24 certified nursing assistants who deliver care directly to
25 residents in the nursing home facility. This excludes nursing
26 administration, minimum data set MDS, and care plan
27 coordinators, staff development, and staffing coordinator.
28 4. All other patient care costs shall be included in
29 the indirect care cost subcomponent of the patient care per
30 diem rate. There shall be no costs directly or indirectly
31
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1 allocated to the direct care subcomponent from a home office
2 or management company.
3 5. On July 1 of each year, the agency shall report to
4 the Legislature direct and indirect care costs, including
5 average direct and indirect care costs per resident per
6 facility and direct care and indirect care salaries and
7 benefits per category of staff member per facility.
8 6. In order to offset the cost of general and
9 professional liability insurance, the agency shall amend the
10 plan to allow for interim rate adjustments to reflect
11 increases in the cost of general or professional liability
12 insurance for nursing homes. This provision shall be
13 implemented to the extent existing appropriations are
14 available.
15
16 It is the intent of the Legislature that the reimbursement
17 plan achieve the goal of providing access to health care for
18 nursing home residents who require large amounts of care while
19 encouraging diversion services as an alternative to nursing
20 home care for residents who can be served within the
21 community. The agency shall base the establishment of any
22 maximum rate of payment, whether overall or component, on the
23 available moneys as provided for in the General Appropriations
24 Act. The agency may base the maximum rate of payment on the
25 results of scientifically valid analysis and conclusions
26 derived from objective statistical data pertinent to the
27 particular maximum rate of payment.
28 Section 7. Section 409.9112, Florida Statutes, is
29 amended to read:
30 409.9112 Disproportionate share program for regional
31 perinatal intensive care centers.--In addition to the payments
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1 made under s. 409.911, the Agency for Health Care
2 Administration shall design and implement a system of making
3 disproportionate share payments to those hospitals that
4 participate in the regional perinatal intensive care center
5 program established pursuant to chapter 383. This system of
6 payments shall conform with federal requirements and shall
7 distribute funds in each fiscal year for which an
8 appropriation is made by making quarterly Medicaid payments.
9 Notwithstanding the provisions of s. 409.915, counties are
10 exempt from contributing toward the cost of this special
11 reimbursement for hospitals serving a disproportionate share
12 of low-income patients. For the state fiscal year 2005-2006
13 2004-2005, the agency shall not distribute moneys under the
14 regional perinatal intensive care centers disproportionate
15 share program, except as noted in subsection (2). In the event
16 the Centers for Medicare and Medicaid Services do not approve
17 Florida's inpatient hospital state plan amendment for the
18 public disproportionate share program by January 1, 2005, the
19 agency may make payments to hospitals under the regional
20 perinatal intensive care centers disproportionate share
21 program.
22 (1) The following formula shall be used by the agency
23 to calculate the total amount earned for hospitals that
24 participate in the regional perinatal intensive care center
25 program:
26
27 TAE = HDSP/THDSP
28
29 Where:
30 TAE = total amount earned by a regional perinatal
31 intensive care center.
12
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1 HDSP = the prior state fiscal year regional perinatal
2 intensive care center disproportionate share payment to the
3 individual hospital.
4 THDSP = the prior state fiscal year total regional
5 perinatal intensive care center disproportionate share
6 payments to all hospitals.
7
8 (2) The total additional payment for hospitals that
9 participate in the regional perinatal intensive care center
10 program shall be calculated by the agency as follows:
11
12 TAP = TAE x TA
13
14 Where:
15 TAP = total additional payment for a regional perinatal
16 intensive care center.
17 TAE = total amount earned by a regional perinatal
18 intensive care center.
19 TA = total appropriation for the regional perinatal
20 intensive care center disproportionate share program.
21
22 (3) In order to receive payments under this section, a
23 hospital must be participating in the regional perinatal
24 intensive care center program pursuant to chapter 383 and must
25 meet the following additional requirements:
26 (a) Agree to conform to all departmental and agency
27 requirements to ensure high quality in the provision of
28 services, including criteria adopted by departmental and
29 agency rule concerning staffing ratios, medical records,
30 standards of care, equipment, space, and such other standards
31
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1 and criteria as the department and agency deem appropriate as
2 specified by rule.
3 (b) Agree to provide information to the department and
4 agency, in a form and manner to be prescribed by rule of the
5 department and agency, concerning the care provided to all
6 patients in neonatal intensive care centers and high-risk
7 maternity care.
8 (c) Agree to accept all patients for neonatal
9 intensive care and high-risk maternity care, regardless of
10 ability to pay, on a functional space-available basis.
11 (d) Agree to develop arrangements with other maternity
12 and neonatal care providers in the hospital's region for the
13 appropriate receipt and transfer of patients in need of
14 specialized maternity and neonatal intensive care services.
15 (e) Agree to establish and provide a developmental
16 evaluation and services program for certain high-risk
17 neonates, as prescribed and defined by rule of the department.
18 (f) Agree to sponsor a program of continuing education
19 in perinatal care for health care professionals within the
20 region of the hospital, as specified by rule.
21 (g) Agree to provide backup and referral services to
22 the department's county health departments and other
23 low-income perinatal providers within the hospital's region,
24 including the development of written agreements between these
25 organizations and the hospital.
26 (h) Agree to arrange for transportation for high-risk
27 obstetrical patients and neonates in need of transfer from the
28 community to the hospital or from the hospital to another more
29 appropriate facility.
30 (4) Hospitals which fail to comply with any of the
31 conditions in subsection (3) or the applicable rules of the
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1 department and agency shall not receive any payments under
2 this section until full compliance is achieved. A hospital
3 which is not in compliance in two or more consecutive quarters
4 shall not receive its share of the funds. Any forfeited funds
5 shall be distributed by the remaining participating regional
6 perinatal intensive care center program hospitals.
7 Section 8. Section 409.9113, Florida Statutes, is
8 amended to read:
9 409.9113 Disproportionate share program for teaching
10 hospitals.--In addition to the payments made under ss. 409.911
11 and 409.9112, the Agency for Health Care Administration shall
12 make disproportionate share payments to statutorily defined
13 teaching hospitals for their increased costs associated with
14 medical education programs and for tertiary health care
15 services provided to the indigent. This system of payments
16 shall conform with federal requirements and shall distribute
17 funds in each fiscal year for which an appropriation is made
18 by making quarterly Medicaid payments. Notwithstanding s.
19 409.915, counties are exempt from contributing toward the cost
20 of this special reimbursement for hospitals serving a
21 disproportionate share of low-income patients. For the state
22 fiscal year 2005-2006 2004-2005, the agency shall not
23 distribute moneys under the teaching hospital disproportionate
24 share program, except as noted in subsection (2). In the event
25 the Centers for Medicare and Medicaid Services do not approve
26 Florida's inpatient hospital state plan amendment for the
27 public disproportionate share program by January 1, 2005, the
28 agency may make payments to hospitals under the teaching
29 hospital disproportionate share program.
30 (1) On or before September 15 of each year, the Agency
31 for Health Care Administration shall calculate an allocation
15
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1 fraction to be used for distributing funds to state statutory
2 teaching hospitals. Subsequent to the end of each quarter of
3 the state fiscal year, the agency shall distribute to each
4 statutory teaching hospital, as defined in s. 408.07, an
5 amount determined by multiplying one-fourth of the funds
6 appropriated for this purpose by the Legislature times such
7 hospital's allocation fraction. The allocation fraction for
8 each such hospital shall be determined by the sum of three
9 primary factors, divided by three. The primary factors are:
10 (a) The number of nationally accredited graduate
11 medical education programs offered by the hospital, including
12 programs accredited by the Accreditation Council for Graduate
13 Medical Education and the combined Internal Medicine and
14 Pediatrics programs acceptable to both the American Board of
15 Internal Medicine and the American Board of Pediatrics at the
16 beginning of the state fiscal year preceding the date on which
17 the allocation fraction is calculated. The numerical value of
18 this factor is the fraction that the hospital represents of
19 the total number of programs, where the total is computed for
20 all state statutory teaching hospitals.
21 (b) The number of full-time equivalent trainees in the
22 hospital, which comprises two components:
23 1. The number of trainees enrolled in nationally
24 accredited graduate medical education programs, as defined in
25 paragraph (a). Full-time equivalents are computed using the
26 fraction of the year during which each trainee is primarily
27 assigned to the given institution, over the state fiscal year
28 preceding the date on which the allocation fraction is
29 calculated. The numerical value of this factor is the fraction
30 that the hospital represents of the total number of full-time
31 equivalent trainees enrolled in accredited graduate programs,
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1 where the total is computed for all state statutory teaching
2 hospitals.
3 2. The number of medical students enrolled in
4 accredited colleges of medicine and engaged in clinical
5 activities, including required clinical clerkships and
6 clinical electives. Full-time equivalents are computed using
7 the fraction of the year during which each trainee is
8 primarily assigned to the given institution, over the course
9 of the state fiscal year preceding the date on which the
10 allocation fraction is calculated. The numerical value of this
11 factor is the fraction that the given hospital represents of
12 the total number of full-time equivalent students enrolled in
13 accredited colleges of medicine, where the total is computed
14 for all state statutory teaching hospitals.
15
16 The primary factor for full-time equivalent trainees is
17 computed as the sum of these two components, divided by two.
18 (c) A service index that comprises three components:
19 1. The Agency for Health Care Administration Service
20 Index, computed by applying the standard Service Inventory
21 Scores established by the Agency for Health Care
22 Administration to services offered by the given hospital, as
23 reported on Worksheet A-2 for the last fiscal year reported to
24 the agency before the date on which the allocation fraction is
25 calculated. The numerical value of this factor is the
26 fraction that the given hospital represents of the total
27 Agency for Health Care Administration Service Index values,
28 where the total is computed for all state statutory teaching
29 hospitals.
30 2. A volume-weighted service index, computed by
31 applying the standard Service Inventory Scores established by
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1 the Agency for Health Care Administration to the volume of
2 each service, expressed in terms of the standard units of
3 measure reported on Worksheet A-2 for the last fiscal year
4 reported to the agency before the date on which the allocation
5 factor is calculated. The numerical value of this factor is
6 the fraction that the given hospital represents of the total
7 volume-weighted service index values, where the total is
8 computed for all state statutory teaching hospitals.
9 3. Total Medicaid payments to each hospital for direct
10 inpatient and outpatient services during the fiscal year
11 preceding the date on which the allocation factor is
12 calculated. This includes payments made to each hospital for
13 such services by Medicaid prepaid health plans, whether the
14 plan was administered by the hospital or not. The numerical
15 value of this factor is the fraction that each hospital
16 represents of the total of such Medicaid payments, where the
17 total is computed for all state statutory teaching hospitals.
18
19 The primary factor for the service index is computed as the
20 sum of these three components, divided by three.
21 (2) By October 1 of each year, the agency shall use
22 the following formula to calculate the maximum additional
23 disproportionate share payment for statutorily defined
24 teaching hospitals:
25
26 TAP = THAF x A
27
28 Where:
29 TAP = total additional payment.
30 THAF = teaching hospital allocation factor.
31
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1 A = amount appropriated for a teaching hospital
2 disproportionate share program.
3 Section 9. Section 409.9117, Florida Statutes, is
4 amended to read:
5 409.9117 Primary care disproportionate share
6 program.--For the state fiscal year 2005-2006 2004-2005, the
7 agency shall not distribute moneys under the primary care
8 disproportionate share program, except as noted in subsection
9 (2). In the event the Centers for Medicare and Medicaid
10 Services do not approve Florida's inpatient hospital state
11 plan amendment for the public disproportionate share program
12 by January 1, 2005, the agency may make payments to hospitals
13 under the primary care disproportionate share program.
14 (1) If federal funds are available for
15 disproportionate share programs in addition to those otherwise
16 provided by law, there shall be created a primary care
17 disproportionate share program.
18 (2) The following formula shall be used by the agency
19 to calculate the total amount earned for hospitals that
20 participate in the primary care disproportionate share
21 program:
22
23 TAE = HDSP/THDSP
24
25 Where:
26 TAE = total amount earned by a hospital participating
27 in the primary care disproportionate share program.
28 HDSP = the prior state fiscal year primary care
29 disproportionate share payment to the individual hospital.
30 THDSP = the prior state fiscal year total primary care
31 disproportionate share payments to all hospitals.
19
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1
2 (3) The total additional payment for hospitals that
3 participate in the primary care disproportionate share program
4 shall be calculated by the agency as follows:
5
6 TAP = TAE x TA
7
8 Where:
9 TAP = total additional payment for a primary care
10 hospital.
11 TAE = total amount earned by a primary care hospital.
12 TA = total appropriation for the primary care
13 disproportionate share program.
14
15 (4) In the establishment and funding of this program,
16 the agency shall use the following criteria in addition to
17 those specified in s. 409.911, payments may not be made to a
18 hospital unless the hospital agrees to:
19 (a) Cooperate with a Medicaid prepaid health plan, if
20 one exists in the community.
21 (b) Ensure the availability of primary and specialty
22 care physicians to Medicaid recipients who are not enrolled in
23 a prepaid capitated arrangement and who are in need of access
24 to such physicians.
25 (c) Coordinate and provide primary care services free
26 of charge, except copayments, to all persons with incomes up
27 to 100 percent of the federal poverty level who are not
28 otherwise covered by Medicaid or another program administered
29 by a governmental entity, and to provide such services based
30 on a sliding fee scale to all persons with incomes up to 200
31 percent of the federal poverty level who are not otherwise
20
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1 covered by Medicaid or another program administered by a
2 governmental entity, except that eligibility may be limited to
3 persons who reside within a more limited area, as agreed to by
4 the agency and the hospital.
5 (d) Contract with any federally qualified health
6 center, if one exists within the agreed geopolitical
7 boundaries, concerning the provision of primary care services,
8 in order to guarantee delivery of services in a nonduplicative
9 fashion, and to provide for referral arrangements, privileges,
10 and admissions, as appropriate. The hospital shall agree to
11 provide at an onsite or offsite facility primary care services
12 within 24 hours to which all Medicaid recipients and persons
13 eligible under this paragraph who do not require emergency
14 room services are referred during normal daylight hours.
15 (e) Cooperate with the agency, the county, and other
16 entities to ensure the provision of certain public health
17 services, case management, referral and acceptance of
18 patients, and sharing of epidemiological data, as the agency
19 and the hospital find mutually necessary and desirable to
20 promote and protect the public health within the agreed
21 geopolitical boundaries.
22 (f) In cooperation with the county in which the
23 hospital resides, develop a low-cost, outpatient, prepaid
24 health care program to persons who are not eligible for the
25 Medicaid program, and who reside within the area.
26 (g) Provide inpatient services to residents within the
27 area who are not eligible for Medicaid or Medicare, and who do
28 not have private health insurance, regardless of ability to
29 pay, on the basis of available space, except that nothing
30 shall prevent the hospital from establishing bill collection
31 programs based on ability to pay.
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1 (h) Work with the Florida Healthy Kids Corporation,
2 the Florida Health Care Purchasing Cooperative, and business
3 health coalitions, as appropriate, to develop a feasibility
4 study and plan to provide a low-cost comprehensive health
5 insurance plan to persons who reside within the area and who
6 do not have access to such a plan.
7 (i) Work with public health officials and other
8 experts to provide community health education and prevention
9 activities designed to promote healthy lifestyles and
10 appropriate use of health services.
11 (j) Work with the local health council to develop a
12 plan for promoting access to affordable health care services
13 for all persons who reside within the area, including, but not
14 limited to, public health services, primary care services,
15 inpatient services, and affordable health insurance generally.
16
17 Any hospital that fails to comply with any of the provisions
18 of this subsection, or any other contractual condition, may
19 not receive payments under this section until full compliance
20 is achieved.
21 Section 10. Section 409.91195, Florida Statutes, is
22 amended to read:
23 409.91195 Medicaid Pharmaceutical and Therapeutics
24 Committee.--There is created a Medicaid Pharmaceutical and
25 Therapeutics Committee within the agency for Health Care
26 Administration for the purpose of developing a Medicaid
27 preferred drug list formulary pursuant to 42 U.S.C. s.
28 1396r-8.
29 (1) The Medicaid Pharmaceutical and Therapeutics
30 committee shall be comprised as specified in 42 U.S.C. s.
31 1396r-8 and consist of 11 members appointed by the Governor.
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1 Four members shall be physicians, licensed under chapter 458;
2 one member licensed under chapter 459; five members shall be
3 pharmacists licensed under chapter 465; and one member shall
4 be a consumer representative. The members shall be appointed
5 to serve for terms of 2 years from the date of their
6 appointment. Members may be appointed to more than one term.
7 The agency for Health Care Administration shall serve as staff
8 for the committee and assist them with all ministerial duties.
9 The Governor shall ensure that at least some of the members of
10 the Medicaid Pharmaceutical and Therapeutics committee
11 represent Medicaid participating physicians and pharmacies
12 serving all segments and diversity of the Medicaid population,
13 and have experience in either developing or practicing under a
14 preferred drug list formulary. At least one of the members
15 shall represent the interests of pharmaceutical manufacturers.
16 (2) Committee members shall select a chairperson and a
17 vice chairperson each year from the committee membership.
18 (3) The committee shall meet at least quarterly and
19 may meet at other times at the discretion of the chairperson
20 and members. The committee shall comply with rules adopted by
21 the agency, including notice of any meeting of the committee
22 pursuant to the requirements of the Administrative Procedure
23 Act.
24 (4) Upon recommendation of the Medicaid Pharmaceutical
25 and Therapeutics committee, the agency shall adopt a preferred
26 drug list as described in s. 409.912(39). To the extent
27 feasible, the committee shall review all drug classes included
28 on in the preferred drug list formulary at least every 12
29 months, and may recommend additions to and deletions from the
30 preferred drug list formulary, such that the preferred drug
31 list formulary provides for medically appropriate drug
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1 therapies for Medicaid patients which achieve cost savings
2 contained in the General Appropriations Act.
3 (5) Except for mental health-related drugs,
4 antiretroviral drugs, and drugs for nursing home residents and
5 other institutional residents, reimbursement of drugs not
6 included in the formulary is subject to prior authorization.
7 (5)(6) The agency for Health Care Administration shall
8 publish and disseminate the preferred drug list formulary to
9 all Medicaid providers in the state by Internet posting on the
10 agency's website or in other media.
11 (6)(7) The committee shall ensure that interested
12 parties, including pharmaceutical manufacturers agreeing to
13 provide a supplemental rebate as outlined in this chapter,
14 have an opportunity to present public testimony to the
15 committee with information or evidence supporting inclusion of
16 a product on the preferred drug list. Such public testimony
17 shall occur prior to any recommendations made by the committee
18 for inclusion or exclusion from the preferred drug list. Upon
19 timely notice, the agency shall ensure that any drug that has
20 been approved or had any of its particular uses approved by
21 the United States Food and Drug Administration under a
22 priority review classification will be reviewed by the
23 Medicaid Pharmaceutical and Therapeutics committee at the next
24 regularly scheduled meeting following 12 months of
25 distribution of the drug to the general public. To the extent
26 possible, upon notice by a manufacturer the agency shall also
27 schedule a product review for any new product at the next
28 regularly scheduled Medicaid Pharmaceutical and Therapeutics
29 Committee.
30 (8) Until the Medicaid Pharmaceutical and Therapeutics
31 Committee is appointed and a preferred drug list adopted by
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1 the agency, the agency shall use the existing voluntary
2 preferred drug list adopted pursuant to s. 72, chapter
3 2000-367, Laws of Florida. Drugs not listed on the voluntary
4 preferred drug list will require prior authorization by the
5 agency or its contractor.
6 (7)(9) The Medicaid Pharmaceutical and Therapeutics
7 committee shall develop its preferred drug list
8 recommendations by considering the clinical efficacy, safety,
9 and cost-effectiveness of a product. When the preferred drug
10 formulary is adopted by the agency, if a product on the
11 formulary is one of the first four brand-name drugs used by a
12 recipient in a month the drug shall not require prior
13 authorization.
14 (8) Upon timely notice, the agency shall ensure that
15 any therapeutic class of drugs which includes a drug that has
16 been removed from distribution to the public by its
17 manufacturer or the United States Food and Drug Administration
18 or has been required to carry a black box warning label by the
19 United States Food and Drug Administration because of safety
20 concerns is reviewed by the committee at the next regularly
21 scheduled meeting. After such review, the committee must
22 recommend whether to retain the therapeutic class of drugs or
23 subcategories of drugs within a therapeutic class on the
24 preferred drug list and whether to institute prior
25 authorization requirements necessary to ensure patient safety.
26 (9)(10) The Medicaid Pharmaceutical and Therapeutics
27 Committee may also make recommendations to the agency
28 regarding the prior authorization of any prescribed drug
29 covered by Medicaid.
30 (10)(11) Medicaid recipients may appeal agency
31 preferred drug formulary decisions using the Medicaid fair
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1 hearing process administered by the Department of Children and
2 Family Services.
3 Section 11. Paragraph (a) of subsection (39) and
4 subsections (44) and (49) of section 409.912, Florida
5 Statutes, are amended, and subsection (50) is added to that
6 section, to read:
7 409.912 Cost-effective purchasing of health care.--The
8 agency shall purchase goods and services for Medicaid
9 recipients in the most cost-effective manner consistent with
10 the delivery of quality medical care. To ensure that medical
11 services are effectively utilized, the agency may, in any
12 case, require a confirmation or second physician's opinion of
13 the correct diagnosis for purposes of authorizing future
14 services under the Medicaid program. This section does not
15 restrict access to emergency services or poststabilization
16 care services as defined in 42 C.F.R. part 438.114. Such
17 confirmation or second opinion shall be rendered in a manner
18 approved by the agency. The agency shall maximize the use of
19 prepaid per capita and prepaid aggregate fixed-sum basis
20 services when appropriate and other alternative service
21 delivery and reimbursement methodologies, including
22 competitive bidding pursuant to s. 287.057, designed to
23 facilitate the cost-effective purchase of a case-managed
24 continuum of care. The agency shall also require providers to
25 minimize the exposure of recipients to the need for acute
26 inpatient, custodial, and other institutional care and the
27 inappropriate or unnecessary use of high-cost services. The
28 agency may mandate prior authorization, drug therapy
29 management, or disease management participation for certain
30 populations of Medicaid beneficiaries, certain drug classes,
31 or particular drugs to prevent fraud, abuse, overuse, and
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1 possible dangerous drug interactions. The Pharmaceutical and
2 Therapeutics Committee shall make recommendations to the
3 agency on drugs for which prior authorization is required. The
4 agency shall inform the Pharmaceutical and Therapeutics
5 Committee of its decisions regarding drugs subject to prior
6 authorization. The agency is authorized to limit the entities
7 it contracts with or enrolls as Medicaid providers by
8 developing a provider network through provider credentialing.
9 The agency may limit its network based on the assessment of
10 beneficiary access to care, provider availability, provider
11 quality standards, time and distance standards for access to
12 care, the cultural competence of the provider network,
13 demographic characteristics of Medicaid beneficiaries,
14 practice and provider-to-beneficiary standards, appointment
15 wait times, beneficiary use of services, provider turnover,
16 provider profiling, provider licensure history, previous
17 program integrity investigations and findings, peer review,
18 provider Medicaid policy and billing compliance records,
19 clinical and medical record audits, and other factors.
20 Providers shall not be entitled to enrollment in the Medicaid
21 provider network. The agency is authorized to seek federal
22 waivers necessary to implement this policy.
23 (39)(a) The agency shall implement a Medicaid
24 prescribed-drug spending-control program that includes the
25 following components:
26 1. A Medicaid preferred drug list, which shall be a
27 listing of cost-effective therapeutic options recommended by
28 the Medicaid Pharmacy and Therapeutics Committee established
29 pursuant to s. 409.91195 and adopted by the agency for each
30 therapeutic class on the preferred drug list. At the
31 discretion of the committee, and when feasible, the preferred
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1 drug list should include at least two products in a
2 therapeutic class. Medicaid prescribed-drug coverage for
3 brand-name drugs for adult Medicaid recipients is limited to
4 eight drugs per month the dispensing of four brand-name drugs
5 per month per recipient. Prior authorization is required for
6 all additional prescriptions above the eight-drug limit and
7 must meet step therapy and preferred drug list listing
8 requirements. Children are exempt from this restriction.
9 Antiretroviral agents are excluded from this limitation. No
10 requirements for prior authorization or other restrictions on
11 medications used to treat mental illnesses such as
12 schizophrenia, severe depression, or bipolar disorder may be
13 imposed on Medicaid recipients. Medications that will be
14 available without restriction for persons with mental
15 illnesses include atypical antipsychotic medications,
16 conventional antipsychotic medications, selective serotonin
17 reuptake inhibitors, and other medications used for the
18 treatment of serious mental illnesses. The agency shall also
19 limit the amount of a prescribed drug dispensed to no more
20 than a 34-day supply unless the drug products' smallest
21 marketed package is greater than a 34-day supply, or the drug
22 is determined by the agency to be a maintenance drug in which
23 case a 100-day maximum supply may be authorized. The agency is
24 authorized to seek any federal waivers necessary to implement
25 these cost-control programs and to continue participation in
26 the federal Medicaid rebate program, or alternatively to
27 negotiate state-only manufacturer rebates. The agency may
28 adopt rules to implement this subparagraph. The agency shall
29 continue to provide unlimited generic drugs, contraceptive
30 drugs and items, and diabetic supplies. Although a drug may be
31 included on the preferred drug formulary, it would not be
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1 exempt from the four-brand limit. The agency may authorize
2 exceptions to the brand-name-drug restriction based upon the
3 treatment needs of the patients, only when such exceptions are
4 based on prior consultation provided by the agency or an
5 agency contractor, but The agency must establish procedures to
6 ensure that:
7 a. There will be a response to a request for prior
8 consultation by telephone or other telecommunication device
9 within 24 hours after receipt of a request for prior
10 consultation; and
11 b. A 72-hour supply of the drug prescribed will be
12 provided in an emergency or when the agency does not provide a
13 response within 24 hours as required by sub-subparagraph a.;
14 and
15 c. Except for the exception for nursing home residents
16 and other institutionalized adults and except for drugs on the
17 restricted formulary for which prior authorization may be
18 sought by an institutional or community pharmacy, prior
19 authorization for an exception to the brand-name-drug
20 restriction is sought by the prescriber and not by the
21 pharmacy. When prior authorization is granted for a patient in
22 an institutional setting beyond the brand-name-drug
23 restriction, such approval is authorized for 12 months and
24 monthly prior authorization is not required for that patient.
25 2. Reimbursement to pharmacies for Medicaid prescribed
26 drugs shall be set at the lesser of: the average wholesale
27 price (AWP) minus 15.4 percent, the wholesaler acquisition
28 cost (WAC) plus 5.75 percent, the federal upper limit (FUL),
29 the state maximum allowable cost (SMAC), or the usual and
30 customary (UAC) charge billed by the provider.
31
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1 3. The agency shall develop and implement a process
2 for managing the drug therapies of Medicaid recipients who are
3 using significant numbers of prescribed drugs each month. The
4 management process may include, but is not limited to,
5 comprehensive, physician-directed medical-record reviews,
6 claims analyses, and case evaluations to determine the medical
7 necessity and appropriateness of a patient's treatment plan
8 and drug therapies. The agency may contract with a private
9 organization to provide drug-program-management services. The
10 Medicaid drug benefit management program shall include
11 initiatives to manage drug therapies for HIV/AIDS patients,
12 patients using 20 or more unique prescriptions in a 180-day
13 period, and the top 1,000 patients in annual spending. The
14 agency shall enroll any Medicaid recipient in the drug benefit
15 management program if he or she meets the specifications of
16 this provision and is not enrolled in a Medicaid health
17 maintenance organization.
18 4. The agency may limit the size of its pharmacy
19 network based on need, competitive bidding, price
20 negotiations, credentialing, or similar criteria. The agency
21 shall give special consideration to rural areas in determining
22 the size and location of pharmacies included in the Medicaid
23 pharmacy network. A pharmacy credentialing process may include
24 criteria such as a pharmacy's full-service status, location,
25 size, patient educational programs, patient consultation,
26 disease-management services, and other characteristics. The
27 agency may impose a moratorium on Medicaid pharmacy enrollment
28 when it is determined that it has a sufficient number of
29 Medicaid-participating providers.
30 5. The agency shall develop and implement a program
31 that requires Medicaid practitioners who prescribe drugs to
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1 use a counterfeit-proof prescription pad for Medicaid
2 prescriptions. The agency shall require the use of
3 standardized counterfeit-proof prescription pads by
4 Medicaid-participating prescribers or prescribers who write
5 prescriptions for Medicaid recipients. The agency may
6 implement the program in targeted geographic areas or
7 statewide.
8 6. The agency may enter into arrangements that require
9 manufacturers of generic drugs prescribed to Medicaid
10 recipients to provide rebates of at least 15.1 percent of the
11 average manufacturer price for the manufacturer's generic
12 products. These arrangements shall require that if a
13 generic-drug manufacturer pays federal rebates for
14 Medicaid-reimbursed drugs at a level below 15.1 percent, the
15 manufacturer must provide a supplemental rebate to the state
16 in an amount necessary to achieve a 15.1-percent rebate level.
17 7. The agency may establish a preferred drug list as
18 described in this subsection formulary in accordance with 42
19 U.S.C. s. 1396r-8, and, pursuant to the establishment of such
20 preferred drug list formulary, it is authorized to negotiate
21 supplemental rebates from manufacturers that are in addition
22 to those required by Title XIX of the Social Security Act and
23 at no less than 14 percent of the average manufacturer price
24 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
25 unless the federal or supplemental rebate, or both, equals or
26 exceeds 29 percent. There is no upper limit on the
27 supplemental rebates the agency may negotiate. The agency may
28 determine that specific products, brand-name or generic, are
29 competitive at lower rebate percentages. Agreement to pay the
30 minimum supplemental rebate percentage will guarantee a
31 manufacturer that the Medicaid Pharmaceutical and Therapeutics
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1 Committee will consider a product for inclusion on the
2 preferred drug list formulary. However, a pharmaceutical
3 manufacturer is not guaranteed placement on the preferred drug
4 list formulary by simply paying the minimum supplemental
5 rebate. Agency decisions will be made on the clinical efficacy
6 of a drug and recommendations of the Medicaid Pharmaceutical
7 and Therapeutics Committee, as well as the price of competing
8 products minus federal and state rebates. The agency is
9 authorized to contract with an outside agency or contractor to
10 conduct negotiations for supplemental rebates. For the
11 purposes of this section, the term "supplemental rebates"
12 means cash rebates. Effective July 1, 2004, value-added
13 programs as a substitution for supplemental rebates are
14 prohibited. The agency is authorized to seek any federal
15 waivers to implement this initiative.
16 8. The agency shall establish an advisory committee
17 for the purposes of studying the feasibility of using a
18 restricted drug formulary for nursing home residents and other
19 institutionalized adults. The committee shall be comprised of
20 seven members appointed by the Secretary of Health Care
21 Administration. The committee members shall include two
22 physicians licensed under chapter 458 or chapter 459; three
23 pharmacists licensed under chapter 465 and appointed from a
24 list of recommendations provided by the Florida Long-Term Care
25 Pharmacy Alliance; and two pharmacists licensed under chapter
26 465.
27 8.9. The Agency for Health Care Administration shall
28 expand home delivery of pharmacy products. To assist Medicaid
29 patients in securing their prescriptions and reduce program
30 costs, the agency shall expand its current mail-order-pharmacy
31 diabetes-supply program to include all generic and brand-name
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1 drugs used by Medicaid patients with diabetes. Medicaid
2 recipients in the current program may obtain nondiabetes drugs
3 on a voluntary basis. This initiative is limited to the
4 geographic area covered by the current contract. The agency
5 may seek and implement any federal waivers necessary to
6 implement this subparagraph.
7 9.10. The agency shall limit to one dose per month any
8 drug prescribed to treat erectile dysfunction.
9 10.a.11.a. The agency shall implement a Medicaid
10 behavioral drug management system. The agency may contract
11 with a vendor that has experience in operating behavioral drug
12 management systems to implement this program. The agency is
13 authorized to seek federal waivers to implement this program.
14 b. The agency, in conjunction with the Department of
15 Children and Family Services, may implement the Medicaid
16 behavioral drug management system that is designed to improve
17 the quality of care and behavioral health prescribing
18 practices based on best practice guidelines, improve patient
19 adherence to medication plans, reduce clinical risk, and lower
20 prescribed drug costs and the rate of inappropriate spending
21 on Medicaid behavioral drugs. The program shall include the
22 following elements:
23 (I) Provide for the development and adoption of best
24 practice guidelines for behavioral health-related drugs such
25 as antipsychotics, antidepressants, and medications for
26 treating bipolar disorders and other behavioral conditions;
27 translate them into practice; review behavioral health
28 prescribers and compare their prescribing patterns to a number
29 of indicators that are based on national standards; and
30 determine deviations from best practice guidelines.
31
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1 (II) Implement processes for providing feedback to and
2 educating prescribers using best practice educational
3 materials and peer-to-peer consultation.
4 (III) Assess Medicaid beneficiaries who are outliers
5 in their use of behavioral health drugs with regard to the
6 numbers and types of drugs taken, drug dosages, combination
7 drug therapies, and other indicators of improper use of
8 behavioral health drugs.
9 (IV) Alert prescribers to patients who fail to refill
10 prescriptions in a timely fashion, are prescribed multiple
11 same-class behavioral health drugs, and may have other
12 potential medication problems.
13 (V) Track spending trends for behavioral health drugs
14 and deviation from best practice guidelines.
15 (VI) Use educational and technological approaches to
16 promote best practices, educate consumers, and train
17 prescribers in the use of practice guidelines.
18 (VII) Disseminate electronic and published materials.
19 (VIII) Hold statewide and regional conferences.
20 (IX) Implement a disease management program with a
21 model quality-based medication component for severely mentally
22 ill individuals and emotionally disturbed children who are
23 high users of care.
24 c. If the agency is unable to negotiate a contract
25 with one or more manufacturers to finance and guarantee
26 savings associated with a behavioral drug management program
27 by September 1, 2004, the four-brand drug limit and preferred
28 drug list prior-authorization requirements shall apply to
29 mental health-related drugs, notwithstanding any provision in
30 subparagraph 1. The agency is authorized to seek federal
31 waivers to implement this policy.
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1 11.12. The agency is authorized to contract for drug
2 rebate administration, including, but not limited to,
3 calculating rebate amounts, invoicing manufacturers,
4 negotiating disputes with manufacturers, and maintaining a
5 database of rebate collections.
6 12.13. The agency may specify the preferred daily
7 dosing form or strength for the purpose of promoting best
8 practices with regard to the prescribing of certain drugs as
9 specified in the General Appropriations Act and ensuring
10 cost-effective prescribing practices.
11 13.14. The agency may require prior authorization for
12 the off-label use of Medicaid-covered prescribed drugs as
13 specified in the General Appropriations Act. The agency may,
14 but is not required to, preauthorize the use of a product for
15 an indication not in the approved labeling. Prior
16 authorization may require the prescribing professional to
17 provide information about the rationale and supporting medical
18 evidence for the off-label use of a drug.
19 14. The agency, in conjunction with the Pharmaceutical
20 and Therapeutics Committee, may require age-related prior
21 authorizations for certain prescribed drugs. The agency may
22 preauthorize the use of a drug for a recipient who may not
23 meet the age requirement or may exceed the length of therapy
24 for use of this product as recommended by the manufacturer and
25 approved by the Food and Drug Administration. Prior
26 authorization may require the prescribing professional to
27 provide information about the rationale and supporting medical
28 evidence for the use of a drug.
29 15. The agency shall implement a step-therapy-prior
30 authorization-approval process for medications excluded from
31 the preferred drug list. Medications listed on the preferred
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1 drug list must be used within the previous 12 months prior to
2 the alternative medications that are not listed. The
3 step-therapy-prior authorization may require the prescriber to
4 use the medications of a similar drug class or for a similar
5 medical indication unless contraindicated in the Food and Drug
6 Administration labeling. The trial period between the
7 specified steps may vary according to the medical indication.
8 The step-therapy-approval process shall be developed in
9 accordance with the committee as stated in s. 409.91195(7) and
10 (8).
11 16.15. The agency shall implement a return and reuse
12 program for drugs dispensed by pharmacies to institutional
13 recipients, which includes payment of a $5 restocking fee for
14 the implementation and operation of the program. The return
15 and reuse program shall be implemented electronically and in a
16 manner that promotes efficiency. The program must permit a
17 pharmacy to exclude drugs from the program if it is not
18 practical or cost-effective for the drug to be included and
19 must provide for the return to inventory of drugs that cannot
20 be credited or returned in a cost-effective manner.
21 (44) The Agency for Health Care Administration shall
22 ensure that any Medicaid managed care plan as defined in s.
23 409.9122(2)(h), whether paid on a capitated basis or a shared
24 savings basis, is cost-effective. For purposes of this
25 subsection, the term "cost-effective" means that a network's
26 per-member, per-month costs to the state, including, but not
27 limited to, fee-for-service costs, administrative costs, and
28 case-management fees, if any, must be no greater than the
29 state's costs associated with contracts for Medicaid services
30 established under subsection (3), which shall be actuarially
31 adjusted for case mix, model, and service area. The agency
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1 shall conduct actuarially sound audits adjusted for case mix
2 and model in order to ensure such cost-effectiveness and shall
3 publish the audit results on its Internet website and submit
4 the audit results annually to the Governor, the President of
5 the Senate, and the Speaker of the House of Representatives no
6 later than December 31 of each year. Contracts established
7 pursuant to this subsection which are not cost-effective may
8 not be renewed.
9 (49) The agency shall contract with established
10 minority physician networks that provide services to
11 historically underserved minority patients. The networks must
12 provide cost-effective Medicaid services, comply with the
13 requirements to be a MediPass provider, and provide their
14 primary care physicians with access to data and other
15 management tools necessary to assist them in ensuring the
16 appropriate use of services, including inpatient hospital
17 services and pharmaceuticals.
18 (a) The agency shall provide for the development and
19 expansion of minority physician networks in each service area
20 to provide services to Medicaid recipients who are eligible to
21 participate under federal law and rules.
22 (b) The agency shall reimburse each minority physician
23 network as a fee-for-service provider, including the case
24 management fee for primary care, if any, or as a capitated
25 rate provider for Medicaid services. Any savings shall be
26 shared with the minority physician networks pursuant to the
27 contract.
28 (c) For purposes of this subsection, the term
29 "cost-effective" means that a network's per-member, per-month
30 costs to the state, including, but not limited to,
31 fee-for-service costs, administrative costs, and
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1 case-management fees, if any, must be no greater than the
2 state's costs associated with contracts for Medicaid services
3 established under subsection (3), which shall be actuarially
4 adjusted for case mix, model, and service area. The agency
5 shall conduct actuarially sound audits adjusted for case mix
6 and model in order to ensure such cost-effectiveness and shall
7 publish the audit results on its Internet website and submit
8 the audit results annually to the Governor, the President of
9 the Senate, and the Speaker of the House of Representatives no
10 later than December 31. Contracts established pursuant to this
11 subsection which are not cost-effective may not be renewed.
12 (d) The agency may apply for any federal waivers
13 needed to implement this subsection.
14 (50) The agency shall implement a program of
15 all-inclusive care for children. The program of all-inclusive
16 care for children shall be established to provide in-home
17 hospice-like support services to children diagnosed with a
18 life-threatening illness and enrolled in the Children's
19 Medical Services network to reduce hospitalizations as
20 appropriate. The agency, in consultation with the Department
21 of Health, may implement the program of all-inclusive care for
22 children after obtaining approval from the Centers for
23 Medicare and Medicaid Services.
24 Section 12. Paragraph (k) of subsection (2) of section
25 409.9122, Florida Statutes, is amended to read:
26 409.9122 Mandatory Medicaid managed care enrollment;
27 programs and procedures.--
28 (2)
29 (k) When a Medicaid recipient does not choose a
30 managed care plan or MediPass provider, the agency shall
31 assign the Medicaid recipient to a managed care plan, except
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1 in those counties in which there are fewer than two managed
2 care plans accepting Medicaid enrollees, in which case
3 assignment shall be to a managed care plan or a MediPass
4 provider. Medicaid recipients in counties with fewer than two
5 managed care plans accepting Medicaid enrollees who are
6 subject to mandatory assignment but who fail to make a choice
7 shall be assigned to managed care plans until an enrollment of
8 40 percent in MediPass and 60 percent in managed care plans is
9 achieved. Once that enrollment is achieved, the assignments
10 shall be divided in order to maintain an enrollment in
11 MediPass and managed care plans which is in a 40 percent and
12 60 percent proportion, respectively. In service areas 1 and 6
13 of the Agency for Health Care Administration geographic areas
14 where the agency is contracting for the provision of
15 comprehensive behavioral health services through a capitated
16 prepaid arrangement, recipients who fail to make a choice
17 shall be assigned equally to MediPass or a managed care plan.
18 For purposes of this paragraph, when referring to assignment,
19 the term "managed care plans" includes exclusive provider
20 organizations, provider service networks, Children's Medical
21 Services Network, minority physician networks, and pediatric
22 emergency department diversion programs authorized by this
23 chapter or the General Appropriations Act. When making
24 assignments, the agency shall take into account the following
25 criteria:
26 1. A managed care plan has sufficient network capacity
27 to meet the need of members.
28 2. The managed care plan or MediPass has previously
29 enrolled the recipient as a member, or one of the managed care
30 plan's primary care providers or MediPass providers has
31 previously provided health care to the recipient.
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1 3. The agency has knowledge that the member has
2 previously expressed a preference for a particular managed
3 care plan or MediPass provider as indicated by Medicaid
4 fee-for-service claims data, but has failed to make a choice.
5 4. The managed care plan's or MediPass primary care
6 providers are geographically accessible to the recipient's
7 residence.
8 5. The agency has authority to make mandatory
9 assignments based on quality of service and performance of
10 managed care plans.
11 Section 13. Section 409.9124, Florida Statutes, is
12 amended to read:
13 409.9124 Managed care reimbursement.--
14 (1) The agency shall develop and adopt by rule a
15 methodology for reimbursing managed care plans.
16 (1)(2) Final managed care rates shall be published
17 annually prior to September 1 of each year, based on
18 methodology that:
19 (a) Uses Medicaid's fee-for-service expenditures.
20 (b) Is certified as an actuarially sound computation
21 of Medicaid fee-for-service expenditures for comparable groups
22 of Medicaid recipients and includes all fee-for-service
23 expenditures, including those fee-for-service expenditures
24 attributable to recipients who are enrolled for a portion of a
25 year in a managed care plan or waiver program.
26 (c) Is compliant with applicable federal laws and
27 regulations, including, but not limited to, the requirements
28 to include an allowance for administrative expenses and to
29 account for all fee-for-service expenditures, including
30 fee-for-service expenditures for those groups enrolled for
31 part of a year.
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1 (2)(3) Each year prior to establishing new managed
2 care rates, the agency shall review all prior year adjustments
3 for changes in trend, and shall reduce or eliminate those
4 adjustments which are not reasonable and which reflect
5 policies or programs which are not in effect. In addition, the
6 agency shall apply only those policy reductions applicable to
7 the fiscal year for which the rates are being set, which can
8 be accurately estimated and verified by an independent
9 actuary, and which have been implemented prior to or will be
10 implemented during the fiscal year. The agency shall pay rates
11 at per-member, per-month averages that equal, but do not
12 exceed, the amounts allowed for in the General Appropriations
13 Act applicable to the fiscal year for which the rates will be
14 in effect.
15 (3)(4) The agency shall by rule prescribe those items
16 of financial information which each managed care plan shall
17 report to the agency, in the time periods prescribed by rule.
18 In prescribing items for reporting and definitions of terms,
19 the agency shall consult with the Office of Insurance
20 Regulation of the Financial Services Commission wherever
21 possible.
22 (4)(5) The agency shall quarterly examine the
23 financial condition of each managed care plan, and its
24 performance in serving Medicaid patients, and shall utilize
25 examinations performed by the Office of Insurance Regulation
26 wherever possible.
27 Section 14. Except as otherwise expressly provided in
28 this act, this act shall take effect July 1, 2005.
29
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS for SB 404
3
4 - Revises guidelines for the direct care subcomponent for
nursing home reimbursement.
5
- Requires equal assignment of recipients to MediPass or a
6 managed care plan in service areas 1 and 6 where the
agency is contracting for prepaid behavioral health
7 services and requires the assignment of 40 percent
MediPass and 60 percent managed care in all other areas
8 of the state for recipients who fail to choose a plan at
the time of enrollment.
9
- Requires the agency to include policy reductions when
10 establishing managed care rates, and limits payments of
managed care rates to the amounts allowed in the General
11 Appropriations Act.
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