Senate Bill sb0404e1
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1 A bill to be entitled
2 An act relating to health care; amending s.
3 393.0661, F.S.; deleting provisions authorizing
4 the Agency for Health Care Administration to
5 adopt emergency rules governing the home and
6 community-based services delivery system;
7 amending s. 400.23, F.S.; delaying provisions
8 requiring a nursing home staffing increase;
9 amending s. 408.034, F.S.; deleting references
10 to the Office of Long-Term Care Policy;
11 requiring the Agency for Health Care
12 Administration to make recommendations to the
13 Legislature relating to the need for nursing
14 facility beds; amending ss. 409.903, 409.904,
15 F.S.; deleting certain limitations on services
16 to the medically needy; amending s. 409.906,
17 F.S., relating to optional Medicaid services;
18 providing for adult denture services; repealing
19 s. 409.9065, F.S., relating to pharmaceutical
20 expense assistance; amending s. 409.907, F.S.,
21 relating to Medicaid provider agreements;
22 prohibiting the incorporation of a fee or rate
23 schedule into a provider agreement; requiring
24 that such agreements be renewed or amended only
25 in writing; amending s. 409.908, F.S.;
26 requiring that the agency reimburse providers
27 according to published methodologies;
28 authorizing adjustments in fees, rates, and
29 other requirements under certain circumstances;
30 removing obsolete provisions; creating s.
31 409.9082, F.S.; providing a Medicaid
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1 rate-setting process; providing that the agency
2 need not comply with ch. 120, F.S., when
3 setting such rates; limiting judicial review of
4 such rates; providing notice requirements or
5 proposed and final rate methodologies; amending
6 ss. 409.911, 409.9112, 409.9113, 409.9117,
7 F.S., relating to the hospital disproportionate
8 share program; revising the method for
9 calculating the disproportionate share payment;
10 deleting obsolete provisions; amending s.
11 409.91195, F.S.; revising provisions relating
12 to the Medicaid Pharmaceutical and Therapeutics
13 Committee and its duties with respect to
14 developing a preferred drug list; amending s.
15 409.912, F.S.; authorizing the agency to
16 contract with comprehensive behavioral health
17 care providers in a specified service area for
18 the purpose of demonstrating the
19 cost-effectiveness of quality mental health
20 services through a public hospital-operated
21 managed care model; providing requirements for
22 the contract; revising the Medicaid prescribed
23 drug spending control program; eliminating case
24 management fees; directing the Agency for
25 Health Care Administration to implement, and
26 authorizing it to seek federal waivers for, the
27 program of all-inclusive care for children;
28 authorizing the agency to adopt rules; amending
29 s. 409.9122, F.S.; revising a provision
30 governing assignment to a managed care option
31 for a Medicaid recipient who does not choose a
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1 plan or provider in certain geographic areas
2 where the Agency for Health Care Administration
3 contracts for comprehensive behavioral health
4 services; amending s. 409.9124, F.S.; requiring
5 the Agency for Health Care Administration to
6 publish managed care reimbursement rates
7 annually; limiting the application of certain
8 rates and rate reductions; providing for rates
9 applicable to children under 1 year of age;
10 repealing s. 430.041, F.S., relating to
11 establishing the Office of Long-Term Care
12 Policy; amending s. 430.502, F.S.; establishing
13 a memory disorder clinic at Florida Atlantic
14 University; amending s. 440.02, F.S.; excluding
15 from the term "employee" as used in ch. 440,
16 F.S., certain Medicaid-enrolled clients served
17 under the Family and Supported Living Medicaid
18 Waiver program; amending s. 21, ch. 2004-270,
19 Laws of Florida; providing criteria for
20 clientele to be served by organizations in Lee
21 County and Martin County under the Program of
22 All-inclusive Care for the Elderly; providing
23 legislative intent with respect to the
24 applicability of provisions of the act
25 governing contracts, fees, rates, and other
26 methods of payment; providing for severability;
27 providing effective dates.
28
29 Be It Enacted by the Legislature of the State of Florida:
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31
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1 Section 1. Section 393.0661, Florida Statutes, is
2 amended to read:
3 393.0661 Home and community-based services delivery
4 system; comprehensive redesign.--The Legislature finds that
5 the home and community-based services delivery system for
6 persons with developmental disabilities and the availability
7 of appropriated funds are two of the critical elements in
8 making services available. Therefore, it is the intent of the
9 Legislature that the Agency for Persons with Disabilities
10 shall develop and implement a comprehensive redesign of the
11 system.
12 (1) The redesign of the home and community-based
13 services system shall include, at a minimum, all actions
14 necessary to achieve an appropriate rate structure, client
15 choice within a specified service package, appropriate
16 assessment strategies, an efficient billing process that
17 contains reconciliation and monitoring components, a redefined
18 role for support coordinators that avoids potential conflicts
19 of interest, and ensures that family/client budgets are linked
20 to levels of need.
21 (a) The agency shall use an assessment instrument that
22 is reliable and valid. The agency may contract with an
23 external vendor or may use support coordinators to complete
24 client assessments if it develops sufficient safeguards and
25 training to ensure ongoing inter-rater reliability.
26 (b) The agency, with the concurrence of the Agency for
27 Health Care Administration, may contract for the determination
28 of medical necessity and establishment of individual budgets.
29 (2) A provider of services rendered to persons with
30 developmental disabilities pursuant to a federally approved
31 waiver shall be reimbursed according to a rate methodology
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1 based upon an analysis of the expenditure history and
2 prospective costs of providers participating in the waiver
3 program, or under any other methodology developed by the
4 Agency for Health Care Administration, in consultation with
5 the Agency for Persons with Disabilities, and approved by the
6 Federal Government in accordance with the waiver.
7 (3) Pending the adoption of rate methodologies
8 pursuant to nonemergency rulemaking under s. 120.54, the
9 Agency for Health Care Administration may, at any time, adopt
10 emergency rules under s. 120.54(4) in order to comply with
11 subsection (4). In adopting such emergency rules, the agency
12 need not make the findings required by s. 120.54(4)(a), and
13 such rules shall be exempt from time limitations provided in
14 s. 120.54(4)(c) and shall remain in effect until replaced by
15 another emergency rule or the nonemergency adoption of the
16 rate methodology.
17 (3)(4) Nothing in this section or in any
18 administrative rule shall be construed to prevent or limit the
19 Agency for Health Care Administration, in consultation with
20 the Agency for Persons with Disabilities, from adjusting fees,
21 reimbursement rates, lengths of stay, number of visits, or
22 number of services, or from limiting enrollment, or making any
23 other adjustment necessary to comply with the availability of
24 moneys and any limitations or directions provided for in the
25 General Appropriations Act. If at any time, based upon an
26 analysis by the Agency for Health Care Administration in
27 consultation with the Agency for Persons with Disabilities,
28 the cost of home and community-based waiver services are
29 expected to exceed the appropriated amount, the Agency for
30 Health Care Administration may implement any adjustment,
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1 including provider rate reductions, within 30 days in order to
2 remain within the appropriation.
3 Section 2. 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
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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 3. Subsection (4) of section 408.034, Florida
15 Statutes, is amended to read:
16 408.034 Duties and responsibilities of agency;
17 rules.--
18 (4) Prior to determining that there is a need for
19 additional community nursing facility beds in any area of the
20 state, the agency shall determine that the need cannot be met
21 through the provision, enhancement, or expansion of home and
22 community-based services. In determining such need, the agency
23 shall examine nursing home placement patterns and demographic
24 patterns of persons entering nursing homes and the
25 availability of and effectiveness of existing home-based and
26 community-based service delivery systems at meeting the
27 long-term care needs of the population. The agency shall
28 recommend to the Legislature Office of Long-Term Care Policy
29 changes that could be made to existing home-based and
30 community-based delivery systems to lessen the need for
31 additional nursing facility beds.
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1 Section 4. Subsection (5) of section 409.903, Florida
2 Statutes, is amended to read:
3 409.903 Mandatory payments for eligible persons.--The
4 agency shall make payments for medical assistance and related
5 services on behalf of the following persons who the
6 department, or the Social Security Administration by contract
7 with the Department of Children and Family Services,
8 determines to be eligible, subject to the income, assets, and
9 categorical eligibility tests set forth in federal and state
10 law. Payment on behalf of these Medicaid eligible persons is
11 subject to the availability of moneys and any limitations
12 established by the General Appropriations Act or chapter 216.
13 (5) A pregnant woman for the duration of her pregnancy
14 and for the postpartum period as defined in federal law and
15 rule, or a child under age 1, if either is living in a family
16 that has an income which is at or below 150 percent of the
17 most current federal poverty level, or, effective January 1,
18 1992, that has an income which is at or below 185 percent of
19 the most current federal poverty level. Such a person is not
20 subject to an assets test. Further, a pregnant woman who
21 applies for eligibility for the Medicaid program through a
22 qualified Medicaid provider must be offered the opportunity,
23 subject to federal rules, to be made presumptively eligible
24 for the Medicaid program. Effective July 1, 2005, eligibility
25 for Medicaid services is eliminated for women who have incomes
26 above 150 percent of the most current federal poverty level.
27 Section 5. Subsections (1) and (2) of section 409.904,
28 Florida Statutes, are amended to read:
29 409.904 Optional payments for eligible persons.--The
30 agency may make payments for medical assistance and related
31 services on behalf of the following persons who are determined
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1 to be eligible subject to the income, assets, and categorical
2 eligibility tests set forth in federal and state law. Payment
3 on behalf of these Medicaid eligible persons is subject to the
4 availability of moneys and any limitations established by the
5 General Appropriations Act or chapter 216.
6 (1)(a) From July 1, 2005, through December 31, 2005, a
7 person who is age 65 or older or is determined to be disabled,
8 whose income is at or below 88 percent of federal poverty
9 level, and whose assets do not exceed established limitations.
10 (b) Effective January 1, 2006, and subject to federal
11 waiver approval, a person who is age 65 or older or is
12 determined to be disabled, whose income is at or below 88
13 percent of the federal poverty level, whose assets do not
14 exceed established limitations, and who is not eligible for
15 Medicare or, if eligible for Medicare, is also eligible for
16 and receiving Medicaid-covered institutional care services,
17 hospice services, or home and community-based services. The
18 agency shall seek federal authorization through a waiver to
19 provide this coverage.
20 (2) A family, a pregnant woman, a child under age 21,
21 a person age 65 or over, or a blind or disabled person, who
22 would be eligible under any group listed in s. 409.903(1),
23 (2), or (3), except that the income or assets of such family
24 or person exceed established limitations. For a family or
25 person in one of these coverage groups, medical expenses are
26 deductible from income in accordance with federal requirements
27 in order to make a determination of eligibility. A family or
28 person eligible under the coverage known as the "medically
29 needy," is eligible to receive the same services as other
30 Medicaid recipients, with the exception of services in skilled
31 nursing facilities and intermediate care facilities for the
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1 developmentally disabled. Effective July 1, 2005, the
2 medically needy are eligible for prescribed drug services
3 only.
4 Section 6. Paragraph (b) of subsection (1) of section
5 409.906, Florida Statutes, is amended to read:
6 409.906 Optional Medicaid services.--Subject to
7 specific appropriations, the agency may make payments for
8 services which are optional to the state under Title XIX of
9 the Social Security Act and are furnished by Medicaid
10 providers to recipients who are determined to be eligible on
11 the dates on which the services were provided. Any optional
12 service that is provided shall be provided only when medically
13 necessary and in accordance with state and federal law.
14 Optional services rendered by providers in mobile units to
15 Medicaid recipients may be restricted or prohibited by the
16 agency. Nothing in this section shall be construed to prevent
17 or limit the agency from adjusting fees, reimbursement rates,
18 lengths of stay, number of visits, or number of services, or
19 making any other adjustments necessary to comply with the
20 availability of moneys and any limitations or directions
21 provided for in the General Appropriations Act or chapter 216.
22 If necessary to safeguard the state's systems of providing
23 services to elderly and disabled persons and subject to the
24 notice and review provisions of s. 216.177, the Governor may
25 direct the Agency for Health Care Administration to amend the
26 Medicaid state plan to delete the optional Medicaid service
27 known as "Intermediate Care Facilities for the Developmentally
28 Disabled." Optional services may include:
29 (1) ADULT DENTAL SERVICES.--
30 (b) Beginning January 1, 2005, the agency may pay for
31 dentures, the procedures required to seat dentures, and the
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1 repair and reline of dentures, provided by or under the
2 direction of a licensed dentist, for a recipient who is 21
3 years of age or older. This paragraph is repealed effective
4 July 1, 2005.
5 Section 7. Effective January 1, 2006, section
6 409.9065, Florida Statutes, is repealed.
7 Section 8. Subsection (2) of section 409.907, Florida
8 Statutes, is amended to read:
9 409.907 Medicaid provider agreements.--The agency may
10 make payments for medical assistance and related services
11 rendered to Medicaid recipients only to an individual or
12 entity who has a provider agreement in effect with the agency,
13 who is performing services or supplying goods in accordance
14 with federal, state, and local law, and who agrees that no
15 person shall, on the grounds of handicap, race, color, or
16 national origin, or for any other reason, be subjected to
17 discrimination under any program or activity for which the
18 provider receives payment from the agency.
19 (2) Each provider agreement shall be a voluntary
20 contract between the agency and the provider, in which the
21 provider agrees to comply with all laws and rules pertaining
22 to the Medicaid program when furnishing a service or goods to
23 a Medicaid recipient and the agency agrees to pay a sum,
24 determined by the agency fee schedule, payment methodology, or
25 other manner, for the service or goods provided to the
26 Medicaid recipient. The agency may require a provider to be
27 subject to a fee or rate schedule or other payment
28 methodology, but a fee or rate schedule or any payment
29 methodology shall not be incorporated into the provider
30 agreement or any other agreement relating to the provision of
31 Medicaid goods or services. The provider agreement and other
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1 agreement shall require that the provider agrees to accept the
2 compensation established from time to time by the agency for
3 Medicaid goods and services. Each provider agreement shall be
4 effective for a stipulated period of time, shall be terminable
5 by either party after reasonable notice, and shall be
6 renewable by mutual agreement. Provider agreements and other
7 agreements relating to the provision of Medicaid goods and
8 services shall be renewed or amended only in writing. Any term
9 of any provider agreement or other Medicaid agreement which is
10 inconsistent with this section shall be amended by operation
11 of law to conform to the requirements set forth in this
12 subsection.
13 Section 9. Section 409.908, Florida Statutes, is
14 amended to read:
15 409.908 Reimbursement of Medicaid providers.--Subject
16 to specific appropriations, the agency shall reimburse
17 Medicaid providers, in accordance with state and federal law,
18 according to published methodologies set forth in the rules of
19 the agency and in policy manuals and handbooks incorporated by
20 reference therein. These methodologies may include fee
21 schedules, reimbursement methods based on cost reporting,
22 negotiated fees, competitive bidding pursuant to s. 287.057,
23 and other mechanisms the agency considers efficient and
24 effective for purchasing services or goods on behalf of
25 recipients. If a provider is reimbursed based on cost
26 reporting and submits a cost report late and that cost report
27 would have been used to set a lower reimbursement rate for a
28 rate semester, then the provider's rate for that semester
29 shall be retroactively calculated using the new cost report,
30 and full payment at the recalculated rate shall be effected
31 retroactively. Medicare-granted extensions for filing cost
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1 reports, if applicable, shall also apply to Medicaid cost
2 reports. Payment for Medicaid compensable services made on
3 behalf of Medicaid eligible persons is subject to the
4 availability of moneys and any limitations or directions
5 provided for in the General Appropriations Act or chapter 216.
6 The agency may adjust Further, nothing in this section shall
7 be construed to prevent or limit the agency from adjusting
8 fees, reimbursement rates, lengths of stay, number of visits,
9 or number of services, or make making any other adjustments
10 necessary to comply with the availability of moneys and any
11 limitations or directions provided for in the General
12 Appropriations Act, provided the adjustment is consistent with
13 legislative intent.
14 (1) Reimbursement to hospitals licensed under part I
15 of chapter 395 must be made prospectively or on the basis of
16 negotiation.
17 (a) Reimbursement for inpatient care is limited as
18 provided for in s. 409.905(5), except for:
19 1. The raising of rate reimbursement caps, excluding
20 rural hospitals.
21 2. Recognition of the costs of graduate medical
22 education.
23 3. Other methodologies recognized in the General
24 Appropriations Act.
25 4. Hospital inpatient rates shall be reduced by 6
26 percent effective July 1, 2001, and restored effective April
27 1, 2002.
28
29 During the years funds are transferred from the Department of
30 Health, any reimbursement supported by such funds shall be
31 subject to certification by the Department of Health that the
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1 hospital has complied with s. 381.0403. The agency is
2 authorized to receive funds from state entities, including,
3 but not limited to, the Department of Health, local
4 governments, and other local political subdivisions, for the
5 purpose of making special exception payments, including
6 federal matching funds, through the Medicaid inpatient
7 reimbursement methodologies. Funds received from state
8 entities or local governments for this purpose shall be
9 separately accounted for and shall not be commingled with
10 other state or local funds in any manner. The agency may
11 certify all local governmental funds used as state match under
12 Title XIX of the Social Security Act, to the extent that the
13 identified local health care provider that is otherwise
14 entitled to and is contracted to receive such local funds is
15 the benefactor under the state's Medicaid program as
16 determined under the General Appropriations Act and pursuant
17 to an agreement between the Agency for Health Care
18 Administration and the local governmental entity. The local
19 governmental entity shall use a certification form prescribed
20 by the agency. At a minimum, the certification form shall
21 identify the amount being certified and describe the
22 relationship between the certifying local governmental entity
23 and the local health care provider. The agency shall prepare
24 an annual statement of impact which documents the specific
25 activities undertaken during the previous fiscal year pursuant
26 to this paragraph, to be submitted to the Legislature no later
27 than January 1, annually.
28 (b) Reimbursement for hospital outpatient care is
29 limited to $1,500 per state fiscal year per recipient, except
30 for:
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1 1. Such care provided to a Medicaid recipient under
2 age 21, in which case the only limitation is medical
3 necessity.
4 2. Renal dialysis services.
5 3. Other exceptions made by the agency.
6
7 The agency is authorized to receive funds from state entities,
8 including, but not limited to, the Department of Health, the
9 Board of Regents, local governments, and other local political
10 subdivisions, for the purpose of making payments, including
11 federal matching funds, through the Medicaid outpatient
12 reimbursement methodologies. Funds received from state
13 entities and local governments for this purpose shall be
14 separately accounted for and shall not be commingled with
15 other state or local funds in any manner.
16 (c) Hospitals that provide services to a
17 disproportionate share of low-income Medicaid recipients, or
18 that participate in the regional perinatal intensive care
19 center program under chapter 383, or that participate in the
20 statutory teaching hospital disproportionate share program may
21 receive additional reimbursement. The total amount of payment
22 for disproportionate share hospitals shall be fixed by the
23 General Appropriations Act. The computation of these payments
24 must be made in compliance with all federal regulations and
25 the methodologies described in ss. 409.911, 409.9112, and
26 409.9113.
27 (d) The agency is authorized to limit inflationary
28 increases for outpatient hospital services as directed by the
29 General Appropriations Act.
30 (2)(a)1. Reimbursement to nursing homes licensed under
31 part II of chapter 400 and state-owned-and-operated
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1 intermediate care facilities for the developmentally disabled
2 licensed under chapter 393 must be made prospectively.
3 2. Unless otherwise limited or directed in the General
4 Appropriations Act, reimbursement to hospitals licensed under
5 part I of chapter 395 for the provision of swing-bed nursing
6 home services must be made on the basis of the average
7 statewide nursing home payment, and reimbursement to a
8 hospital licensed under part I of chapter 395 for the
9 provision of skilled nursing services must be made on the
10 basis of the average nursing home payment for those services
11 in the county in which the hospital is located. When a
12 hospital is located in a county that does not have any
13 community nursing homes, reimbursement must be determined by
14 averaging the nursing home payments, in counties that surround
15 the county in which the hospital is located. Reimbursement to
16 hospitals, including Medicaid payment of Medicare copayments,
17 for skilled nursing services shall be limited to 30 days,
18 unless a prior authorization has been obtained from the
19 agency. Medicaid reimbursement may be extended by the agency
20 beyond 30 days, and approval must be based upon verification
21 by the patient's physician that the patient requires
22 short-term rehabilitative and recuperative services only, in
23 which case an extension of no more than 15 days may be
24 approved. Reimbursement to a hospital licensed under part I of
25 chapter 395 for the temporary provision of skilled nursing
26 services to nursing home residents who have been displaced as
27 the result of a natural disaster or other emergency may not
28 exceed the average county nursing home payment for those
29 services in the county in which the hospital is located and is
30 limited to the period of time which the agency considers
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1 necessary for continued placement of the nursing home
2 residents in the hospital.
3 (b) Subject to any limitations or directions provided
4 for in the General Appropriations Act, the agency shall
5 establish and implement a Florida Title XIX Long-Term Care
6 Reimbursement Plan (Medicaid) for nursing home care in order
7 to provide care and services in conformance with the
8 applicable state and federal laws, rules, regulations, and
9 quality and safety standards and to ensure that individuals
10 eligible for medical assistance have reasonable geographic
11 access to such care.
12 1. Changes of ownership or of licensed operator do not
13 qualify for increases in reimbursement rates associated with
14 the change of ownership or of licensed operator. The agency
15 shall amend the Title XIX Long Term Care Reimbursement Plan to
16 provide that the initial nursing home reimbursement rates, for
17 the operating, patient care, and MAR components, associated
18 with related and unrelated party changes of ownership or
19 licensed operator filed on or after September 1, 2001, are
20 equivalent to the previous owner's reimbursement rate.
21 2. The agency shall amend the long-term care
22 reimbursement plan and cost reporting system to create direct
23 care and indirect care subcomponents of the patient care
24 component of the per diem rate. These two subcomponents
25 together shall equal the patient care component of the per
26 diem rate. Separate cost-based ceilings shall be calculated
27 for each patient care subcomponent. The direct care
28 subcomponent of the per diem rate shall be limited by the
29 cost-based class ceiling, and the indirect care subcomponent
30 shall be limited by the lower of the cost-based class ceiling,
31 by the target rate class ceiling, or by the individual
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1 provider target. The agency shall adjust the patient care
2 component effective January 1, 2002. The cost to adjust the
3 direct care subcomponent shall be net of the total funds
4 previously allocated for the case mix add-on. The agency shall
5 make the required changes to the nursing home cost reporting
6 forms to implement this requirement effective January 1, 2002.
7 3. The direct care subcomponent shall include salaries
8 and benefits of direct care staff providing nursing services
9 including registered nurses, licensed practical nurses, and
10 certified nursing assistants who deliver care directly to
11 residents in the nursing home facility. This excludes nursing
12 administration, minimum data set MDS, and care plan
13 coordinators, staff development, and staffing coordinator.
14 4. All other patient care costs shall be included in
15 the indirect care cost subcomponent of the patient care per
16 diem rate. There shall be no costs directly or indirectly
17 allocated to the direct care subcomponent from a home office
18 or management company.
19 5. On July 1 of each year, the agency shall report to
20 the Legislature direct and indirect care costs, including
21 average direct and indirect care costs per resident per
22 facility and direct care and indirect care salaries and
23 benefits per category of staff member per facility.
24 6. In order to offset the cost of general and
25 professional liability insurance, the agency shall amend the
26 plan to allow for interim rate adjustments to reflect
27 increases in the cost of general or professional liability
28 insurance for nursing homes. This provision shall be
29 implemented to the extent existing appropriations are
30 available.
31
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1 It is the intent of the Legislature that the reimbursement
2 plan achieve the goal of providing access to health care for
3 nursing home residents who require large amounts of care while
4 encouraging diversion services as an alternative to nursing
5 home care for residents who can be served within the
6 community. The agency shall base the establishment of any
7 maximum rate of payment, whether overall or component, on the
8 available moneys as provided for in the General Appropriations
9 Act. The agency may base the maximum rate of payment on the
10 results of scientifically valid analysis and conclusions
11 derived from objective statistical data pertinent to the
12 particular maximum rate of payment.
13 (3) Subject to any limitations or directions provided
14 for in the General Appropriations Act, the following Medicaid
15 services and goods may be reimbursed on a fee-for-service
16 basis. For each allowable service or goods furnished in
17 accordance with Medicaid rules, policy manuals, handbooks, and
18 state and federal law, the payment shall be the amount billed
19 by the provider, the provider's usual and customary charge, or
20 the maximum allowable fee established by the agency, whichever
21 amount is less, with the exception of those services or goods
22 for which the agency makes payment using a methodology based
23 on capitation rates, average costs, or negotiated fees.
24 (a) Advanced registered nurse practitioner services.
25 (b) Birth center services.
26 (c) Chiropractic services.
27 (d) Community mental health services.
28 (e) Dental services, including oral and maxillofacial
29 surgery.
30 (f) Durable medical equipment.
31 (g) Hearing services.
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1 (h) Occupational therapy for Medicaid recipients under
2 age 21.
3 (i) Optometric services.
4 (j) Orthodontic services.
5 (k) Personal care for Medicaid recipients under age
6 21.
7 (l) Physical therapy for Medicaid recipients under age
8 21.
9 (m) Physician assistant services.
10 (n) Podiatric services.
11 (o) Portable X-ray services.
12 (p) Private-duty nursing for Medicaid recipients under
13 age 21.
14 (q) Registered nurse first assistant services.
15 (r) Respiratory therapy for Medicaid recipients under
16 age 21.
17 (s) Speech therapy for Medicaid recipients under age
18 21.
19 (t) Visual services.
20 (4) Subject to any limitations or directions provided
21 for in the General Appropriations Act, alternative health
22 plans, health maintenance organizations, and prepaid health
23 plans shall be reimbursed a fixed, prepaid amount negotiated,
24 or competitively bid pursuant to s. 287.057, by the agency and
25 prospectively paid to the provider monthly for each Medicaid
26 recipient enrolled. The amount may not exceed the average
27 amount the agency determines it would have paid, based on
28 claims experience, for recipients in the same or similar
29 category of eligibility. The agency shall calculate capitation
30 rates on a regional basis and, beginning September 1, 1995,
31 shall include age-band differentials in such calculations.
20
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1 (5) An ambulatory surgical center shall be reimbursed
2 the lesser of the amount billed by the provider or the
3 Medicare-established allowable amount for the facility.
4 (6) A provider of early and periodic screening,
5 diagnosis, and treatment services to Medicaid recipients who
6 are children under age 21 shall be reimbursed using an
7 all-inclusive rate stipulated in a fee schedule established by
8 the agency. A provider of the visual, dental, and hearing
9 components of such services shall be reimbursed the lesser of
10 the amount billed by the provider or the Medicaid maximum
11 allowable fee established by the agency.
12 (7) A provider of family planning services shall be
13 reimbursed the lesser of the amount billed by the provider or
14 an all-inclusive amount per type of visit for physicians and
15 advanced registered nurse practitioners, as established by the
16 agency in a fee schedule.
17 (8) A provider of home-based or community-based
18 services rendered pursuant to a federally approved waiver
19 shall be reimbursed based on an established or negotiated rate
20 for each service. These rates shall be established according
21 to an analysis of the expenditure history and prospective
22 budget developed by each contract provider participating in
23 the waiver program, or under any other methodology adopted by
24 the agency and approved by the Federal Government in
25 accordance with the waiver. Effective July 1, 1996, privately
26 owned and operated community-based residential facilities
27 which meet agency requirements and which formerly received
28 Medicaid reimbursement for the optional intermediate care
29 facility for the mentally retarded service may participate in
30 the developmental services waiver as part of a
31
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1 home-and-community-based continuum of care for Medicaid
2 recipients who receive waiver services.
3 (9) A provider of home health care services or of
4 medical supplies and appliances shall be reimbursed on the
5 basis of competitive bidding or for the lesser of the amount
6 billed by the provider or the agency's established maximum
7 allowable amount, except that, in the case of the rental of
8 durable medical equipment, the total rental payments may not
9 exceed the purchase price of the equipment over its expected
10 useful life or the agency's established maximum allowable
11 amount, whichever amount is less.
12 (10) A hospice shall be reimbursed through a
13 prospective system for each Medicaid hospice patient at
14 Medicaid rates using the methodology established for hospice
15 reimbursement pursuant to Title XVIII of the federal Social
16 Security Act.
17 (11) A provider of independent laboratory services
18 shall be reimbursed on the basis of competitive bidding or for
19 the least of the amount billed by the provider, the provider's
20 usual and customary charge, or the Medicaid maximum allowable
21 fee established by the agency.
22 (12)(a) A physician shall be reimbursed the lesser of
23 the amount billed by the provider or the Medicaid maximum
24 allowable fee established by the agency.
25 (b) The agency shall adopt a fee schedule, subject to
26 any limitations or directions provided for in the General
27 Appropriations Act, based on a resource-based relative value
28 scale for pricing Medicaid physician services. Under this fee
29 schedule, physicians shall be paid a dollar amount for each
30 service based on the average resources required to provide the
31 service, including, but not limited to, estimates of average
22
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1 physician time and effort, practice expense, and the costs of
2 professional liability insurance. The fee schedule shall
3 provide increased reimbursement for preventive and primary
4 care services and lowered reimbursement for specialty services
5 by using at least two conversion factors, one for cognitive
6 services and another for procedural services. The fee
7 schedule shall not increase total Medicaid physician
8 expenditures unless moneys are available, and shall be phased
9 in over a 2-year period beginning on July 1, 1994. The Agency
10 for Health Care Administration shall seek the advice of a
11 16-member advisory panel in formulating and adopting the fee
12 schedule. The panel shall consist of Medicaid physicians
13 licensed under chapters 458 and 459 and shall be composed of
14 50 percent primary care physicians and 50 percent specialty
15 care physicians.
16 (c) Notwithstanding paragraph (b), reimbursement fees
17 to physicians for providing total obstetrical services to
18 Medicaid recipients, which include prenatal, delivery, and
19 postpartum care, shall be at least $1,500 per delivery for a
20 pregnant woman with low medical risk and at least $2,000 per
21 delivery for a pregnant woman with high medical risk. However,
22 reimbursement to physicians working in Regional Perinatal
23 Intensive Care Centers designated pursuant to chapter 383, for
24 services to certain pregnant Medicaid recipients with a high
25 medical risk, may be made according to obstetrical care and
26 neonatal care groupings and rates established by the agency.
27 Nurse midwives licensed under part I of chapter 464 or
28 midwives licensed under chapter 467 shall be reimbursed at no
29 less than 80 percent of the low medical risk fee. The agency
30 shall by rule determine, for the purpose of this paragraph,
31 what constitutes a high or low medical risk pregnant woman and
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1 shall not pay more based solely on the fact that a caesarean
2 section was performed, rather than a vaginal delivery. The
3 agency shall by rule determine a prorated payment for
4 obstetrical services in cases where only part of the total
5 prenatal, delivery, or postpartum care was performed. The
6 Department of Health shall adopt rules for appropriate
7 insurance coverage for midwives licensed under chapter 467.
8 Prior to the issuance and renewal of an active license, or
9 reactivation of an inactive license for midwives licensed
10 under chapter 467, such licensees shall submit proof of
11 coverage with each application.
12 (13) Medicare premiums for persons eligible for both
13 Medicare and Medicaid coverage shall be paid at the rates
14 established by Title XVIII of the Social Security Act. For
15 Medicare services rendered to Medicaid-eligible persons,
16 Medicaid shall pay Medicare deductibles and coinsurance as
17 follows:
18 (a) Medicaid shall make no payment toward deductibles
19 and coinsurance for any service that is not covered by
20 Medicaid.
21 (b) Medicaid's financial obligation for deductibles
22 and coinsurance payments shall be based on Medicare allowable
23 fees, not on a provider's billed charges.
24 (c) Medicaid will pay no portion of Medicare
25 deductibles and coinsurance when payment that Medicare has
26 made for the service equals or exceeds what Medicaid would
27 have paid if it had been the sole payor. The combined payment
28 of Medicare and Medicaid shall not exceed the amount Medicaid
29 would have paid had it been the sole payor. The Legislature
30 finds that there has been confusion regarding the
31 reimbursement for services rendered to dually eligible
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1 Medicare beneficiaries. Accordingly, the Legislature clarifies
2 that it has always been the intent of the Legislature before
3 and after 1991 that, in reimbursing in accordance with fees
4 established by Title XVIII for premiums, deductibles, and
5 coinsurance for Medicare services rendered by physicians to
6 Medicaid eligible persons, physicians be reimbursed at the
7 lesser of the amount billed by the physician or the Medicaid
8 maximum allowable fee established by the Agency for Health
9 Care Administration, as is permitted by federal law. It has
10 never been the intent of the Legislature with regard to such
11 services rendered by physicians that Medicaid be required to
12 provide any payment for deductibles, coinsurance, or
13 copayments for Medicare cost sharing, or any expenses incurred
14 relating thereto, in excess of the payment amount provided for
15 under the State Medicaid plan for such service. This payment
16 methodology is applicable even in those situations in which
17 the payment for Medicare cost sharing for a qualified Medicare
18 beneficiary with respect to an item or service is reduced or
19 eliminated. This expression of the Legislature is in
20 clarification of existing law and shall apply to payment for,
21 and with respect to provider agreements with respect to, items
22 or services furnished on or after the effective date of this
23 act. This paragraph applies to payment by Medicaid for items
24 and services furnished before the effective date of this act
25 if such payment is the subject of a lawsuit that is based on
26 the provisions of this section, and that is pending as of, or
27 is initiated after, the effective date of this act.
28 (d) Notwithstanding paragraphs (a)-(c):
29 1. Medicaid payments for Nursing Home Medicare part A
30 coinsurance shall be the lesser of the Medicare coinsurance
31 amount or the Medicaid nursing home per diem rate.
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1 2. Medicaid shall pay all deductibles and coinsurance
2 for Medicare-eligible recipients receiving freestanding end
3 stage renal dialysis center services.
4 3. Medicaid payments for general hospital inpatient
5 services shall be limited to the Medicare deductible per spell
6 of illness. Medicaid shall make no payment toward coinsurance
7 for Medicare general hospital inpatient services.
8 4. Medicaid shall pay all deductibles and coinsurance
9 for Medicare emergency transportation services provided by
10 ambulances licensed pursuant to chapter 401.
11 (14) A provider of prescribed drugs shall be
12 reimbursed the least of the amount billed by the provider, the
13 provider's usual and customary charge, or the Medicaid maximum
14 allowable fee established by the agency, plus a dispensing
15 fee. The Medicaid maximum allowable fee for ingredient cost
16 will be based on the lower of: average wholesale price (AWP)
17 minus 15.4 percent, wholesaler acquisition cost (WAC) plus
18 5.75 percent, the federal upper limit (FUL), the state maximum
19 allowable cost (SMAC), or the usual and customary (UAC) charge
20 billed by the provider. Medicaid providers are required to
21 dispense generic drugs if available at lower cost and the
22 agency has not determined that the branded product is more
23 cost-effective, unless the prescriber has requested and
24 received approval to require the branded product. The agency
25 is directed to implement a variable dispensing fee for
26 payments for prescribed medicines while ensuring continued
27 access for Medicaid recipients. The variable dispensing fee
28 may be based upon, but not limited to, either or both the
29 volume of prescriptions dispensed by a specific pharmacy
30 provider, the volume of prescriptions dispensed to an
31 individual recipient, and dispensing of preferred-drug-list
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1 products. The agency may increase the pharmacy dispensing fee
2 authorized by statute and in the annual General Appropriations
3 Act by $0.50 for the dispensing of a Medicaid
4 preferred-drug-list product and reduce the pharmacy dispensing
5 fee by $0.50 for the dispensing of a Medicaid product that is
6 not included on the preferred drug list. The agency may
7 establish a supplemental pharmaceutical dispensing fee to be
8 paid to providers returning unused unit-dose packaged
9 medications to stock and crediting the Medicaid program for
10 the ingredient cost of those medications if the ingredient
11 costs to be credited exceed the value of the supplemental
12 dispensing fee. The agency is authorized to limit
13 reimbursement for prescribed medicine in order to comply with
14 any limitations or directions provided for in the General
15 Appropriations Act, which may include implementing a
16 prospective or concurrent utilization review program.
17 (15) A provider of primary care case management
18 services rendered pursuant to a federally approved waiver
19 shall be reimbursed by payment of a fixed, prepaid monthly sum
20 for each Medicaid recipient enrolled with the provider.
21 (16) A provider of rural health clinic services and
22 federally qualified health center services shall be reimbursed
23 a rate per visit based on total reasonable costs of the
24 clinic, as determined by the agency in accordance with federal
25 regulations.
26 (17) A provider of targeted case management services
27 shall be reimbursed pursuant to an established fee, except
28 where the Federal Government requires a public provider be
29 reimbursed on the basis of average actual costs.
30 (18) Unless otherwise provided for in the General
31 Appropriations Act, a provider of transportation services
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1 shall be reimbursed the lesser of the amount billed by the
2 provider or the Medicaid maximum allowable fee established by
3 the agency, except when the agency has entered into a direct
4 contract with the provider, or with a community transportation
5 coordinator, for the provision of an all-inclusive service, or
6 when services are provided pursuant to an agreement negotiated
7 between the agency and the provider. The agency, as provided
8 for in s. 427.0135, shall purchase transportation services
9 through the community coordinated transportation system, if
10 available, unless the agency determines a more cost-effective
11 method for Medicaid clients. Nothing in this subsection shall
12 be construed to limit or preclude the agency from contracting
13 for services using a prepaid capitation rate or from
14 establishing maximum fee schedules, individualized
15 reimbursement policies by provider type, negotiated fees,
16 prior authorization, competitive bidding, increased use of
17 mass transit, or any other mechanism that the agency considers
18 efficient and effective for the purchase of services on behalf
19 of Medicaid clients, including implementing a transportation
20 eligibility process. The agency shall not be required to
21 contract with any community transportation coordinator or
22 transportation operator that has been determined by the
23 agency, the Department of Legal Affairs Medicaid Fraud Control
24 Unit, or any other state or federal agency to have engaged in
25 any abusive or fraudulent billing activities. The agency is
26 authorized to competitively procure transportation services or
27 make other changes necessary to secure approval of federal
28 waivers needed to permit federal financing of Medicaid
29 transportation services at the service matching rate rather
30 than the administrative matching rate.
31
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1 (19) County health department services shall be
2 reimbursed a rate per visit based on total reasonable costs of
3 the clinic, as determined by the agency in accordance with
4 federal regulations under the authority of 42 C.F.R. s.
5 431.615.
6 (20) A renal dialysis facility that provides dialysis
7 services under s. 409.906(9) must be reimbursed the lesser of
8 the amount billed by the provider, the provider's usual and
9 customary charge, or the maximum allowable fee established by
10 the agency, whichever amount is less.
11 (21) The agency shall reimburse school districts which
12 certify the state match pursuant to ss. 409.9071 and 1011.70
13 for the federal portion of the school district's allowable
14 costs to deliver the services, based on the reimbursement
15 schedule. The school district shall determine the costs for
16 delivering services as authorized in ss. 409.9071 and 1011.70
17 for which the state match will be certified. Reimbursement of
18 school-based providers is contingent on such providers being
19 enrolled as Medicaid providers and meeting the qualifications
20 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
21 the federal Health Care Financing Administration. Speech
22 therapy providers who are certified through the Department of
23 Education pursuant to rule 6A-4.0176, Florida Administrative
24 Code, are eligible for reimbursement for services that are
25 provided on school premises. Any employee of the school
26 district who has been fingerprinted and has received a
27 criminal background check in accordance with Department of
28 Education rules and guidelines shall be exempt from any agency
29 requirements relating to criminal background checks.
30 (22) The agency shall request and implement Medicaid
31 waivers from the federal Health Care Financing Administration
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1 to advance and treat a portion of the Medicaid nursing home
2 per diem as capital for creating and operating a
3 risk-retention group for self-insurance purposes, consistent
4 with federal and state laws and rules.
5 Section 10. Section 409.9082, Florida Statutes, is
6 created to read:
7 409.9082 Medicaid rate-setting process.--The agency is
8 authorized to adopt fees, rates, or other methods of payment
9 for Medicaid goods and services which may be amended from time
10 to time consistent with the needs of the state Medicaid
11 program and any limitations or directions provided for in the
12 General Appropriations Act. The agency is not required to
13 comply with chapter 120 when setting rates and methods of
14 payment. The substance of Medicaid rates are not subject to
15 judicial review, except to the extent decisions setting rates
16 or methods of payment violate the State Constitution or
17 federal law.
18 (1) For determining rates of payment for hospital
19 services, nursing facility services, and services for
20 intermediate care facilities for the developmentally disabled:
21 (a) Notice of proposed rate methodologies and
22 justifications for the proposed rate methodologies shall be
23 published in the Florida Administrative Weekly.
24 1. The notice must generally describe the proposed
25 changes in rate methodologies and the justification for change
26 so as to put interested persons on reasonable notice of
27 proposed changes of rates and methodologies and their
28 justification.
29 2. The notice must state how or where proposed rate
30 methodologies and justifications can be obtained.
31
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1 3. The notice must state that comments will be
2 received, the period of time during which they will be
3 received, and the person to whom they should be sent.
4 (b) Providers, beneficiaries and their
5 representatives, and other concerned state residents shall be
6 given a reasonable opportunity to review and comment on the
7 proposed rate methodologies and justifications.
8 (c) Notice of final rate methodologies and
9 justifications for such final rate methodologies shall be
10 published in the Florida Administrative Weekly. The notice
11 must generally describe the final rate methodologies and the
12 justification for change so as to put interested persons on
13 reasonable notice of the substance of final rate methodologies
14 and their justification.
15 (d) The notice must state how or where final rate
16 methodologies and justifications can be obtained.
17 (2) For determining all other rates or methods of
18 payment:
19 (a) Notice shall be published in the Florida
20 Administrative Weekly at least 48 hours before the effective
21 date of the rate.
22 (b) The notice must:
23 1. Generally describe the proposed changes in rates or
24 methodologies and the justification for change so as to put
25 interested persons on reasonable notice of proposed changes of
26 rates and methodologies and their justification;
27 2. Estimate any changes in annual aggregate
28 expenditures caused or anticipated by the change;
29 3. State how or where the proposed changes in rates or
30 methodologies and the justification may be obtained; and
31 4. State where comments may be sent.
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1 Section 11. Paragraphs (a) and (b) of subsection (2)
2 and paragraph (b) of subsection (4) of section 409.911,
3 Florida Statutes, are amended to read:
4 409.911 Disproportionate share program.--Subject to
5 specific allocations established within the General
6 Appropriations Act and any limitations established pursuant to
7 chapter 216, the agency shall distribute, pursuant to this
8 section, moneys to hospitals providing a disproportionate
9 share of Medicaid or charity care services by making quarterly
10 Medicaid payments as required. Notwithstanding the provisions
11 of s. 409.915, counties are exempt from contributing toward
12 the cost of this special reimbursement for hospitals serving a
13 disproportionate share of low-income patients.
14 (2) The Agency for Health Care Administration shall
15 use the following actual audited data to determine the
16 Medicaid days and charity care to be used in calculating the
17 disproportionate share payment:
18 (a) The average of the 1998, 1999, and 2000 audited
19 disproportionate share data to determine each hospital's
20 Medicaid days and charity care for the 2004-2005 state fiscal
21 year and the average of the 1999, 2000, and 2001 audited
22 disproportionate share data to determine the Medicaid days and
23 charity care for the 2005-2006 state fiscal year.
24 (b) If the Agency for Health Care Administration does
25 not have the prescribed 3 years of audited disproportionate
26 share data as noted in paragraph (a) for a hospital, the
27 agency shall use the average of the years of the audited
28 disproportionate share data as noted in paragraph (a) which is
29 available. The average of the audited disproportionate share
30 data for the years available if the Agency for Health Care
31
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1 Administration does not have the prescribed 3 years of audited
2 disproportionate share data for a hospital.
3 (4) The following formulas shall be used to pay
4 disproportionate share dollars to public hospitals:
5 (b) For non-state government owned or operated
6 hospitals with 3,300 or more Medicaid days:
7
8 DSHP = [(.82 x HCCD/TCCD) + (.18 x HMD/TMD)]
9 x TAAPH
10 TAAPH = TAA - TAAMH
11
12 Where:
13 TAA = total available appropriation.
14 TAAPH = total amount available for public hospitals.
15 DSHP = disproportionate share hospital payments.
16 HMD = hospital Medicaid days.
17 TMD = total state Medicaid days for public hospitals.
18 HCCD = hospital charity care dollars.
19 TCCD = total state charity care dollars for public
20 non-state hospitals.
21 1. For the 2005-2006 state fiscal year only, the DSHP
22 for the public nonstate hospitals shall be computed using a
23 weighted average of the disproportionate share payments for
24 the 2004-2005 state fiscal year which uses an average of the
25 1998, 1999, and 2000 audited disproportionate share data and
26 the disproportionate share payments for the 2005-2006 state
27 fiscal year as computed using the formula above and using the
28 average of the 1999, 2000, and 2001 audited disproportionate
29 share data. The final DSHP for the public nonstate hospitals
30 shall be computed as an average using the calculated payments
31 for the 2005-2006 state fiscal year weighted at 65 percent and
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1 the disproportionate share payments for the 2004-2005 state
2 fiscal year weighted at 35 percent.
3 2. The TAAPH shall be reduced by $6,365,257 before
4 computing the DSHP for each public hospital. The $6,365,257
5 shall be distributed equally between the public hospitals that
6 are also designated statutory teaching hospitals.
7 Section 12. Section 409.9112, Florida Statutes, is
8 amended to read:
9 409.9112 Disproportionate share program for regional
10 perinatal intensive care centers.--In addition to the payments
11 made under s. 409.911, the Agency for Health Care
12 Administration shall design and implement a system of making
13 disproportionate share payments to those hospitals that
14 participate in the regional perinatal intensive care center
15 program established pursuant to chapter 383. This system of
16 payments shall conform with federal requirements and shall
17 distribute funds in each fiscal year for which an
18 appropriation is made by making quarterly Medicaid payments.
19 Notwithstanding the provisions of s. 409.915, counties are
20 exempt from contributing toward the cost of this special
21 reimbursement for hospitals serving a disproportionate share
22 of low-income patients. For the state fiscal year 2005-2006
23 2004-2005, the agency shall not distribute moneys under the
24 regional perinatal intensive care centers disproportionate
25 share program, except as noted in subsection (2). In the event
26 the Centers for Medicare and Medicaid Services do not approve
27 Florida's inpatient hospital state plan amendment for the
28 public disproportionate share program by January 1, 2005, the
29 agency may make payments to hospitals under the regional
30 perinatal intensive care centers disproportionate share
31 program.
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1 (1) The following formula shall be used by the agency
2 to calculate the total amount earned for hospitals that
3 participate in the regional perinatal intensive care center
4 program:
5
6 TAE = HDSP/THDSP
7
8 Where:
9 TAE = total amount earned by a regional perinatal
10 intensive care center.
11 HDSP = the prior state fiscal year regional perinatal
12 intensive care center disproportionate share payment to the
13 individual hospital.
14 THDSP = the prior state fiscal year total regional
15 perinatal intensive care center disproportionate share
16 payments to all hospitals.
17
18 (2) The total additional payment for hospitals that
19 participate in the regional perinatal intensive care center
20 program shall be calculated by the agency as follows:
21
22 TAP = TAE x TA
23
24 Where:
25 TAP = total additional payment for a regional perinatal
26 intensive care center.
27 TAE = total amount earned by a regional perinatal
28 intensive care center.
29 TA = total appropriation for the regional perinatal
30 intensive care center disproportionate share program.
31
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1 (3) In order to receive payments under this section, a
2 hospital must be participating in the regional perinatal
3 intensive care center program pursuant to chapter 383 and must
4 meet the following additional requirements:
5 (a) Agree to conform to all departmental and agency
6 requirements to ensure high quality in the provision of
7 services, including criteria adopted by departmental and
8 agency rule concerning staffing ratios, medical records,
9 standards of care, equipment, space, and such other standards
10 and criteria as the department and agency deem appropriate as
11 specified by rule.
12 (b) Agree to provide information to the department and
13 agency, in a form and manner to be prescribed by rule of the
14 department and agency, concerning the care provided to all
15 patients in neonatal intensive care centers and high-risk
16 maternity care.
17 (c) Agree to accept all patients for neonatal
18 intensive care and high-risk maternity care, regardless of
19 ability to pay, on a functional space-available basis.
20 (d) Agree to develop arrangements with other maternity
21 and neonatal care providers in the hospital's region for the
22 appropriate receipt and transfer of patients in need of
23 specialized maternity and neonatal intensive care services.
24 (e) Agree to establish and provide a developmental
25 evaluation and services program for certain high-risk
26 neonates, as prescribed and defined by rule of the department.
27 (f) Agree to sponsor a program of continuing education
28 in perinatal care for health care professionals within the
29 region of the hospital, as specified by rule.
30 (g) Agree to provide backup and referral services to
31 the department's county health departments and other
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1 low-income perinatal providers within the hospital's region,
2 including the development of written agreements between these
3 organizations and the hospital.
4 (h) Agree to arrange for transportation for high-risk
5 obstetrical patients and neonates in need of transfer from the
6 community to the hospital or from the hospital to another more
7 appropriate facility.
8 (4) Hospitals which fail to comply with any of the
9 conditions in subsection (3) or the applicable rules of the
10 department and agency shall not receive any payments under
11 this section until full compliance is achieved. A hospital
12 which is not in compliance in two or more consecutive quarters
13 shall not receive its share of the funds. Any forfeited funds
14 shall be distributed by the remaining participating regional
15 perinatal intensive care center program hospitals.
16 Section 13. Section 409.9113, Florida Statutes, is
17 amended to read:
18 409.9113 Disproportionate share program for teaching
19 hospitals.--In addition to the payments made under ss. 409.911
20 and 409.9112, the Agency for Health Care Administration shall
21 make disproportionate share payments to statutorily defined
22 teaching hospitals for their increased costs associated with
23 medical education programs and for tertiary health care
24 services provided to the indigent. This system of payments
25 shall conform with federal requirements and shall distribute
26 funds in each fiscal year for which an appropriation is made
27 by making quarterly Medicaid payments. Notwithstanding s.
28 409.915, counties are exempt from contributing toward the cost
29 of this special reimbursement for hospitals serving a
30 disproportionate share of low-income patients. For the state
31 fiscal year 2005-2006 2004-2005, the agency shall not
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1 distribute moneys under the teaching hospital disproportionate
2 share program, except as noted in subsection (2). In the event
3 the Centers for Medicare and Medicaid Services do not approve
4 Florida's inpatient hospital state plan amendment for the
5 public disproportionate share program by January 1, 2005, the
6 agency may make payments to hospitals under the teaching
7 hospital disproportionate share program.
8 (1) On or before September 15 of each year, the Agency
9 for Health Care Administration shall calculate an allocation
10 fraction to be used for distributing funds to state statutory
11 teaching hospitals. Subsequent to the end of each quarter of
12 the state fiscal year, the agency shall distribute to each
13 statutory teaching hospital, as defined in s. 408.07, an
14 amount determined by multiplying one-fourth of the funds
15 appropriated for this purpose by the Legislature times such
16 hospital's allocation fraction. The allocation fraction for
17 each such hospital shall be determined by the sum of three
18 primary factors, divided by three. The primary factors are:
19 (a) The number of nationally accredited graduate
20 medical education programs offered by the hospital, including
21 programs accredited by the Accreditation Council for Graduate
22 Medical Education and the combined Internal Medicine and
23 Pediatrics programs acceptable to both the American Board of
24 Internal Medicine and the American Board of Pediatrics at the
25 beginning of the state fiscal year preceding the date on which
26 the allocation fraction is calculated. The numerical value of
27 this factor is the fraction that the hospital represents of
28 the total number of programs, where the total is computed for
29 all state statutory teaching hospitals.
30 (b) The number of full-time equivalent trainees in the
31 hospital, which comprises two components:
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1 1. The number of trainees enrolled in nationally
2 accredited graduate medical education programs, as defined in
3 paragraph (a). Full-time equivalents are computed using the
4 fraction of the year during which each trainee is primarily
5 assigned to the given institution, over the state fiscal year
6 preceding the date on which the allocation fraction is
7 calculated. The numerical value of this factor is the fraction
8 that the hospital represents of the total number of full-time
9 equivalent trainees enrolled in accredited graduate programs,
10 where the total is computed for all state statutory teaching
11 hospitals.
12 2. The number of medical students enrolled in
13 accredited colleges of medicine and engaged in clinical
14 activities, including required clinical clerkships and
15 clinical electives. Full-time equivalents are computed using
16 the fraction of the year during which each trainee is
17 primarily assigned to the given institution, over the course
18 of the state fiscal year preceding the date on which the
19 allocation fraction is calculated. The numerical value of this
20 factor is the fraction that the given hospital represents of
21 the total number of full-time equivalent students enrolled in
22 accredited colleges of medicine, where the total is computed
23 for all state statutory teaching hospitals.
24
25 The primary factor for full-time equivalent trainees is
26 computed as the sum of these two components, divided by two.
27 (c) A service index that comprises three components:
28 1. The Agency for Health Care Administration Service
29 Index, computed by applying the standard Service Inventory
30 Scores established by the Agency for Health Care
31 Administration to services offered by the given hospital, as
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1 reported on Worksheet A-2 for the last fiscal year reported to
2 the agency before the date on which the allocation fraction is
3 calculated. The numerical value of this factor is the
4 fraction that the given hospital represents of the total
5 Agency for Health Care Administration Service Index values,
6 where the total is computed for all state statutory teaching
7 hospitals.
8 2. A volume-weighted service index, computed by
9 applying the standard Service Inventory Scores established by
10 the Agency for Health Care Administration to the volume of
11 each service, expressed in terms of the standard units of
12 measure reported on Worksheet A-2 for the last fiscal year
13 reported to the agency before the date on which the allocation
14 factor is calculated. The numerical value of this factor is
15 the fraction that the given hospital represents of the total
16 volume-weighted service index values, where the total is
17 computed for all state statutory teaching hospitals.
18 3. Total Medicaid payments to each hospital for direct
19 inpatient and outpatient services during the fiscal year
20 preceding the date on which the allocation factor is
21 calculated. This includes payments made to each hospital for
22 such services by Medicaid prepaid health plans, whether the
23 plan was administered by the hospital or not. The numerical
24 value of this factor is the fraction that each hospital
25 represents of the total of such Medicaid payments, where the
26 total is computed for all state statutory teaching hospitals.
27
28 The primary factor for the service index is computed as the
29 sum of these three components, divided by three.
30 (2) By October 1 of each year, the agency shall use
31 the following formula to calculate the maximum additional
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1 disproportionate share payment for statutorily defined
2 teaching hospitals:
3
4 TAP = THAF x A
5
6 Where:
7 TAP = total additional payment.
8 THAF = teaching hospital allocation factor.
9 A = amount appropriated for a teaching hospital
10 disproportionate share program.
11 Section 14. Section 409.9117, Florida Statutes, is
12 amended to read:
13 409.9117 Primary care disproportionate share
14 program.--For the state fiscal year 2005-2006 2004-2005, the
15 agency shall not distribute moneys under the primary care
16 disproportionate share program, except as noted in subsection
17 (2). In the event the Centers for Medicare and Medicaid
18 Services do not approve Florida's inpatient hospital state
19 plan amendment for the public disproportionate share program
20 by January 1, 2005, the agency may make payments to hospitals
21 under the primary care disproportionate share program.
22 (1) If federal funds are available for
23 disproportionate share programs in addition to those otherwise
24 provided by law, there shall be created a primary care
25 disproportionate share program.
26 (2) The following formula shall be used by the agency
27 to calculate the total amount earned for hospitals that
28 participate in the primary care disproportionate share
29 program:
30
31 TAE = HDSP/THDSP
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1
2 Where:
3 TAE = total amount earned by a hospital participating
4 in the primary care disproportionate share program.
5 HDSP = the prior state fiscal year primary care
6 disproportionate share payment to the individual hospital.
7 THDSP = the prior state fiscal year total primary care
8 disproportionate share payments to all hospitals.
9
10 (3) The total additional payment for hospitals that
11 participate in the primary care disproportionate share program
12 shall be calculated by the agency as follows:
13
14 TAP = TAE x TA
15
16 Where:
17 TAP = total additional payment for a primary care
18 hospital.
19 TAE = total amount earned by a primary care hospital.
20 TA = total appropriation for the primary care
21 disproportionate share program.
22
23 (4) In the establishment and funding of this program,
24 the agency shall use the following criteria in addition to
25 those specified in s. 409.911, payments may not be made to a
26 hospital unless the hospital agrees to:
27 (a) Cooperate with a Medicaid prepaid health plan, if
28 one exists in the community.
29 (b) Ensure the availability of primary and specialty
30 care physicians to Medicaid recipients who are not enrolled in
31
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1 a prepaid capitated arrangement and who are in need of access
2 to such physicians.
3 (c) Coordinate and provide primary care services free
4 of charge, except copayments, to all persons with incomes up
5 to 100 percent of the federal poverty level who are not
6 otherwise covered by Medicaid or another program administered
7 by a governmental entity, and to provide such services based
8 on a sliding fee scale to all persons with incomes up to 200
9 percent of the federal poverty level who are not otherwise
10 covered by Medicaid or another program administered by a
11 governmental entity, except that eligibility may be limited to
12 persons who reside within a more limited area, as agreed to by
13 the agency and the hospital.
14 (d) Contract with any federally qualified health
15 center, if one exists within the agreed geopolitical
16 boundaries, concerning the provision of primary care services,
17 in order to guarantee delivery of services in a nonduplicative
18 fashion, and to provide for referral arrangements, privileges,
19 and admissions, as appropriate. The hospital shall agree to
20 provide at an onsite or offsite facility primary care services
21 within 24 hours to which all Medicaid recipients and persons
22 eligible under this paragraph who do not require emergency
23 room services are referred during normal daylight hours.
24 (e) Cooperate with the agency, the county, and other
25 entities to ensure the provision of certain public health
26 services, case management, referral and acceptance of
27 patients, and sharing of epidemiological data, as the agency
28 and the hospital find mutually necessary and desirable to
29 promote and protect the public health within the agreed
30 geopolitical boundaries.
31
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1 (f) In cooperation with the county in which the
2 hospital resides, develop a low-cost, outpatient, prepaid
3 health care program to persons who are not eligible for the
4 Medicaid program, and who reside within the area.
5 (g) Provide inpatient services to residents within the
6 area who are not eligible for Medicaid or Medicare, and who do
7 not have private health insurance, regardless of ability to
8 pay, on the basis of available space, except that nothing
9 shall prevent the hospital from establishing bill collection
10 programs based on ability to pay.
11 (h) Work with the Florida Healthy Kids Corporation,
12 the Florida Health Care Purchasing Cooperative, and business
13 health coalitions, as appropriate, to develop a feasibility
14 study and plan to provide a low-cost comprehensive health
15 insurance plan to persons who reside within the area and who
16 do not have access to such a plan.
17 (i) Work with public health officials and other
18 experts to provide community health education and prevention
19 activities designed to promote healthy lifestyles and
20 appropriate use of health services.
21 (j) Work with the local health council to develop a
22 plan for promoting access to affordable health care services
23 for all persons who reside within the area, including, but not
24 limited to, public health services, primary care services,
25 inpatient services, and affordable health insurance generally.
26
27 Any hospital that fails to comply with any of the provisions
28 of this subsection, or any other contractual condition, may
29 not receive payments under this section until full compliance
30 is achieved.
31
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1 Section 15. Section 409.91195, Florida Statutes, is
2 amended to read:
3 409.91195 Medicaid Pharmaceutical and Therapeutics
4 Committee.--There is created a Medicaid Pharmaceutical and
5 Therapeutics Committee within the agency for Health Care
6 Administration for the purpose of developing a Medicaid
7 preferred drug list formulary pursuant to 42 U.S.C. s.
8 1396r-8.
9 (1) The Medicaid Pharmaceutical and Therapeutics
10 committee shall be composed comprised as specified in 42
11 U.S.C. s. 1396r-8 and consist of 11 members appointed by the
12 Governor. Four members shall be physicians, licensed under
13 chapter 458; one member licensed under chapter 459; five
14 members shall be pharmacists licensed under chapter 465; and
15 one member shall be a consumer representative. The members
16 shall be appointed to serve for terms of 2 years from the date
17 of their appointment. Members may be appointed to more than
18 one term. The agency for Health Care Administration shall
19 serve as staff for the committee and assist them with all
20 ministerial duties. The Governor shall ensure that at least
21 some of the members of the Medicaid Pharmaceutical and
22 Therapeutics committee represent Medicaid participating
23 physicians and pharmacies serving all segments and diversity
24 of the Medicaid population, and have experience in either
25 developing or practicing under a preferred drug list
26 formulary. At least one of the members shall represent the
27 interests of pharmaceutical manufacturers.
28 (2) Committee members shall select a chairperson and a
29 vice chairperson each year from the committee membership.
30 (3) The committee shall meet at least quarterly and
31 may meet at other times at the discretion of the chairperson
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1 and members. The committee shall comply with rules adopted by
2 the agency, including notice of any meeting of the committee
3 pursuant to the requirements of the Administrative Procedure
4 Act.
5 (4) Upon recommendation of the Medicaid Pharmaceutical
6 and Therapeutics committee, the agency shall adopt a preferred
7 drug list as described in s. 409.912(39). To the extent
8 feasible, the committee shall review all drug classes included
9 on in the preferred drug list formulary at least every 12
10 months, and may recommend additions to and deletions from the
11 preferred drug list formulary, such that the preferred drug
12 list formulary provides for medically appropriate drug
13 therapies for Medicaid patients which achieve cost savings
14 contained in the General Appropriations Act.
15 (5) Except for mental health-related drugs,
16 antiretroviral drugs, and drugs for nursing home residents and
17 other institutional residents, reimbursement of drugs not
18 included on the preferred drug list in the formulary is
19 subject to prior authorization.
20 (5)(6) The agency for Health Care Administration shall
21 publish and disseminate the preferred drug list formulary to
22 all Medicaid providers in the state by Internet posting on the
23 agency's website or in other media.
24 (6)(7) The committee shall ensure that interested
25 parties, including pharmaceutical manufacturers agreeing to
26 provide a supplemental rebate as outlined in this chapter,
27 have an opportunity to present public testimony to the
28 committee with information or evidence supporting inclusion of
29 a product on the preferred drug list. Such public testimony
30 shall occur prior to any recommendations made by the committee
31 for inclusion or exclusion from the preferred drug list. Upon
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1 timely notice, the agency shall ensure that any drug that has
2 been approved or had any of its particular uses approved by
3 the United States Food and Drug Administration under a
4 priority review classification will be reviewed by the
5 Medicaid Pharmaceutical and Therapeutics committee at the next
6 regularly scheduled meeting following 3 months of distribution
7 of the drug to the general public. To the extent possible,
8 upon notice by a manufacturer the agency shall also schedule a
9 product review for any new product at the next regularly
10 scheduled Medicaid Pharmaceutical and Therapeutics Committee.
11 (8) Until the Medicaid Pharmaceutical and Therapeutics
12 Committee is appointed and a preferred drug list adopted by
13 the agency, the agency shall use the existing voluntary
14 preferred drug list adopted pursuant to s. 72, chapter
15 2000-367, Laws of Florida. Drugs not listed on the voluntary
16 preferred drug list will require prior authorization by the
17 agency or its contractor.
18 (7)(9) The Medicaid Pharmaceutical and Therapeutics
19 committee shall develop its preferred drug list
20 recommendations by considering the clinical efficacy, safety,
21 and cost-effectiveness of a product. When the preferred drug
22 formulary is adopted by the agency, if a product on the
23 formulary is one of the first four brand-name drugs used by a
24 recipient in a month the drug shall not require prior
25 authorization.
26 (8) Upon timely notice, the agency shall ensure that
27 any therapeutic class of drugs which includes a drug that has
28 been removed from distribution to the public by its
29 manufacturer or the United States Food and Drug Administration
30 or has been required to carry a black box warning label by the
31 United States Food and Drug Administration because of safety
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1 concerns is reviewed by the committee at the next regularly
2 scheduled meeting. After such review, the committee must
3 recommend whether to retain the therapeutic class of drugs or
4 subcategories of drugs within a therapeutic class on the
5 preferred drug list and whether to institute prior
6 authorization requirements necessary to ensure patient safety.
7 (9)(10) The Medicaid Pharmaceutical and Therapeutics
8 Committee may also make recommendations to the agency
9 regarding the prior authorization of any prescribed drug
10 covered by Medicaid.
11 (10)(11) Medicaid recipients may appeal agency
12 preferred drug formulary decisions using the Medicaid fair
13 hearing process administered by the Department of Children and
14 Family Services.
15 Section 16. Paragraph (b) of subsection (4),
16 paragraphs (e) and (f) of subsection (15), paragraph (a) of
17 subsection (39), and subsections (44) and (49) of section
18 409.912, Florida Statutes, are amended, and subsection (50) is
19 added to that section, to read:
20 409.912 Cost-effective purchasing of health care.--The
21 agency shall purchase goods and services for Medicaid
22 recipients in the most cost-effective manner consistent with
23 the delivery of quality medical care. To ensure that medical
24 services are effectively utilized, the agency may, in any
25 case, require a confirmation or second physician's opinion of
26 the correct diagnosis for purposes of authorizing future
27 services under the Medicaid program. This section does not
28 restrict access to emergency services or poststabilization
29 care services as defined in 42 C.F.R. part 438.114. Such
30 confirmation or second opinion shall be rendered in a manner
31 approved by the agency. The agency shall maximize the use of
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1 prepaid per capita and prepaid aggregate fixed-sum basis
2 services when appropriate and other alternative service
3 delivery and reimbursement methodologies, including
4 competitive bidding pursuant to s. 287.057, designed to
5 facilitate the cost-effective purchase of a case-managed
6 continuum of care. The agency shall also require providers to
7 minimize the exposure of recipients to the need for acute
8 inpatient, custodial, and other institutional care and the
9 inappropriate or unnecessary use of high-cost services. The
10 agency may mandate prior authorization, drug therapy
11 management, or disease management participation for certain
12 populations of Medicaid beneficiaries, certain drug classes,
13 or particular drugs to prevent fraud, abuse, overuse, and
14 possible dangerous drug interactions. The Pharmaceutical and
15 Therapeutics Committee shall make recommendations to the
16 agency on drugs for which prior authorization is required. The
17 agency shall inform the Pharmaceutical and Therapeutics
18 Committee of its decisions regarding drugs subject to prior
19 authorization. The agency is authorized to limit the entities
20 it contracts with or enrolls as Medicaid providers by
21 developing a provider network through provider credentialing.
22 The agency may limit its network based on the assessment of
23 beneficiary access to care, provider availability, provider
24 quality standards, time and distance standards for access to
25 care, the cultural competence of the provider network,
26 demographic characteristics of Medicaid beneficiaries,
27 practice and provider-to-beneficiary standards, appointment
28 wait times, beneficiary use of services, provider turnover,
29 provider profiling, provider licensure history, previous
30 program integrity investigations and findings, peer review,
31 provider Medicaid policy and billing compliance records,
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1 clinical and medical record audits, and other factors.
2 Providers shall not be entitled to enrollment in the Medicaid
3 provider network. The agency is authorized to seek federal
4 waivers necessary to implement this policy.
5 (4) The agency may contract with:
6 (b) An entity that is providing comprehensive
7 behavioral health care services to certain Medicaid recipients
8 through a capitated, prepaid arrangement pursuant to the
9 federal waiver provided for by s. 409.905(5). Such an entity
10 must be licensed under chapter 624, chapter 636, or chapter
11 641 and must possess the clinical systems and operational
12 competence to manage risk and provide comprehensive behavioral
13 health care to Medicaid recipients. As used in this paragraph,
14 the term "comprehensive behavioral health care services" means
15 covered mental health and substance abuse treatment services
16 that are available to Medicaid recipients. The secretary of
17 the Department of Children and Family Services shall approve
18 provisions of procurements related to children in the
19 department's care or custody prior to enrolling such children
20 in a prepaid behavioral health plan. Any contract awarded
21 under this paragraph must be competitively procured. In
22 developing the behavioral health care prepaid plan procurement
23 document, the agency shall ensure that the procurement
24 document requires the contractor to develop and implement a
25 plan to ensure compliance with s. 394.4574 related to services
26 provided to residents of licensed assisted living facilities
27 that hold a limited mental health license. Except as provided
28 in subparagraph 8., the agency shall seek federal approval to
29 contract with a single entity meeting these requirements to
30 provide comprehensive behavioral health care services to all
31 Medicaid recipients not enrolled in a managed care plan in an
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1 AHCA area. Each entity must offer sufficient choice of
2 providers in its network to ensure recipient access to care
3 and the opportunity to select a provider with whom they are
4 satisfied. The network shall include all public mental health
5 hospitals. To ensure unimpaired access to behavioral health
6 care services by Medicaid recipients, all contracts issued
7 pursuant to this paragraph shall require 80 percent of the
8 capitation paid to the managed care plan, including health
9 maintenance organizations, to be expended for the provision of
10 behavioral health care services. In the event the managed care
11 plan expends less than 80 percent of the capitation paid
12 pursuant to this paragraph for the provision of behavioral
13 health care services, the difference shall be returned to the
14 agency. The agency shall provide the managed care plan with a
15 certification letter indicating the amount of capitation paid
16 during each calendar year for the provision of behavioral
17 health care services pursuant to this section. The agency may
18 reimburse for substance abuse treatment services on a
19 fee-for-service basis until the agency finds that adequate
20 funds are available for capitated, prepaid arrangements.
21 1. By January 1, 2001, the agency shall modify the
22 contracts with the entities providing comprehensive inpatient
23 and outpatient mental health care services to Medicaid
24 recipients in Hillsborough, Highlands, Hardee, Manatee, and
25 Polk Counties, to include substance abuse treatment services.
26 2. By July 1, 2003, the agency and the Department of
27 Children and Family Services shall execute a written agreement
28 that requires collaboration and joint development of all
29 policy, budgets, procurement documents, contracts, and
30 monitoring plans that have an impact on the state and Medicaid
31 community mental health and targeted case management programs.
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1 3. Except as provided in subparagraph 8., by July 1,
2 2006, the agency and the Department of Children and Family
3 Services shall contract with managed care entities in each
4 AHCA area except area 6 or arrange to provide comprehensive
5 inpatient and outpatient mental health and substance abuse
6 services through capitated prepaid arrangements to all
7 Medicaid recipients who are eligible to participate in such
8 plans under federal law and regulation. In AHCA areas where
9 eligible individuals number less than 150,000, the agency
10 shall contract with a single managed care plan to provide
11 comprehensive behavioral health services to all recipients who
12 are not enrolled in a Medicaid health maintenance
13 organization. The agency may contract with more than one
14 comprehensive behavioral health provider to provide care to
15 recipients who are not enrolled in a Medicaid health
16 maintenance organization in AHCA areas where the eligible
17 population exceeds 150,000. Contracts for comprehensive
18 behavioral health providers awarded pursuant to this section
19 shall be competitively procured. Both for-profit and
20 not-for-profit corporations shall be eligible to compete.
21 Managed care plans contracting with the agency under
22 subsection (3) shall provide and receive payment for the same
23 comprehensive behavioral health benefits as provided in AHCA
24 rules, including handbooks incorporated by reference. In AHCA
25 Area 11, the agency shall contract with at least two
26 comprehensive behavioral health care providers to provide
27 behavioral health care to recipients in that area who are
28 enrolled in, or assigned to, the MediPass program. One of the
29 behavioral health care contracts shall be with the existing
30 provider service network pilot project, as described in
31 paragraph (d), for the purpose of demonstrating the
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1 cost-effectiveness of the provision of quality mental health
2 services through a public hospital-operated managed care
3 model. Payment shall be at an agreed-upon capitated rate to
4 ensure cost savings. Of the recipients in Area 11 who are
5 assigned to MediPass under the provisions of s.
6 409.9122(2)(k), a minimum of 50,000 of those MediPass-enrolled
7 recipients shall be assigned to the existing provider service
8 network in Area 11 for their behavioral care.
9 4. By October 1, 2003, the agency and the department
10 shall submit a plan to the Governor, the President of the
11 Senate, and the Speaker of the House of Representatives which
12 provides for the full implementation of capitated prepaid
13 behavioral health care in all areas of the state.
14 a. Implementation shall begin in 2003 in those AHCA
15 areas of the state where the agency is able to establish
16 sufficient capitation rates.
17 b. If the agency determines that the proposed
18 capitation rate in any area is insufficient to provide
19 appropriate services, the agency may adjust the capitation
20 rate to ensure that care will be available. The agency and the
21 department may use existing general revenue to address any
22 additional required match but may not over-obligate existing
23 funds on an annualized basis.
24 c. Subject to any limitations provided for in the
25 General Appropriations Act, the agency, in compliance with
26 appropriate federal authorization, shall develop policies and
27 procedures that allow for certification of local and state
28 funds.
29 5. Children residing in a statewide inpatient
30 psychiatric program, or in a Department of Juvenile Justice or
31 a Department of Children and Family Services residential
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1 program approved as a Medicaid behavioral health overlay
2 services provider shall not be included in a behavioral health
3 care prepaid health plan or any other Medicaid managed care
4 plan pursuant to this paragraph.
5 6. In converting to a prepaid system of delivery, the
6 agency shall in its procurement document require an entity
7 providing only comprehensive behavioral health care services
8 to prevent the displacement of indigent care patients by
9 enrollees in the Medicaid prepaid health plan providing
10 behavioral health care services from facilities receiving
11 state funding to provide indigent behavioral health care, to
12 facilities licensed under chapter 395 which do not receive
13 state funding for indigent behavioral health care, or
14 reimburse the unsubsidized facility for the cost of behavioral
15 health care provided to the displaced indigent care patient.
16 7. Traditional community mental health providers under
17 contract with the Department of Children and Family Services
18 pursuant to part IV of chapter 394, child welfare providers
19 under contract with the Department of Children and Family
20 Services in areas 1 and 6, and inpatient mental health
21 providers licensed pursuant to chapter 395 must be offered an
22 opportunity to accept or decline a contract to participate in
23 any provider network for prepaid behavioral health services.
24 8. For fiscal year 2004-2005, all Medicaid eligible
25 children, except children in areas 1 and 6, whose cases are
26 open for child welfare services in the HomeSafeNet system,
27 shall be enrolled in MediPass or in Medicaid fee-for-service
28 and all their behavioral health care services including
29 inpatient, outpatient psychiatric, community mental health,
30 and case management shall be reimbursed on a fee-for-service
31 basis. Beginning July 1, 2005, such children, who are open for
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1 child welfare services in the HomeSafeNet system, shall
2 receive their behavioral health care services through a
3 specialty prepaid plan operated by community-based lead
4 agencies either through a single agency or formal agreements
5 among several agencies. The specialty prepaid plan must result
6 in savings to the state comparable to savings achieved in
7 other Medicaid managed care and prepaid programs. Such plan
8 must provide mechanisms to maximize state and local revenues.
9 The specialty prepaid plan shall be developed by the agency
10 and the Department of Children and Family Services. The agency
11 is authorized to seek any federal waivers to implement this
12 initiative.
13 (15)
14 (e) By January 15 of each year, the agency shall
15 submit a report to the Legislature and the Office of
16 Long-Term-Care Policy describing the operations of the CARES
17 program. The report must describe:
18 1. Rate of diversion to community alternative
19 programs;
20 2. CARES program staffing needs to achieve additional
21 diversions;
22 3. Reasons the program is unable to place individuals
23 in less restrictive settings when such individuals desired
24 such services and could have been served in such settings;
25 4. Barriers to appropriate placement, including
26 barriers due to policies or operations of other agencies or
27 state-funded programs; and
28 5. Statutory changes necessary to ensure that
29 individuals in need of long-term care services receive care in
30 the least restrictive environment.
31
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1 (f) The Department of Elderly Affairs shall track
2 individuals over time who are assessed under the CARES program
3 and who are diverted from nursing home placement. By January
4 15 of each year, the department shall submit to the
5 Legislature and the Office of Long-Term-Care Policy a
6 longitudinal study of the individuals who are diverted from
7 nursing home placement. The study must include:
8 1. The demographic characteristics of the individuals
9 assessed and diverted from nursing home placement, including,
10 but not limited to, age, race, gender, frailty, caregiver
11 status, living arrangements, and geographic location;
12 2. A summary of community services provided to
13 individuals for 1 year after assessment and diversion;
14 3. A summary of inpatient hospital admissions for
15 individuals who have been diverted; and
16 4. A summary of the length of time between diversion
17 and subsequent entry into a nursing home or death.
18 (39)(a) The agency shall implement a Medicaid
19 prescribed-drug spending-control program that includes the
20 following components:
21 1. A Medicaid preferred drug list, which shall be a
22 listing of cost-effective therapeutic options recommended by
23 the Medicaid Pharmacy and Therapeutics Committee established
24 pursuant to s. 409.91195 and adopted by the agency for each
25 therapeutic class on the preferred drug list. At the
26 discretion of the committee, and when feasible, the preferred
27 drug list should include at least two products in a
28 therapeutic class. Medicaid prescribed-drug coverage for
29 brand-name drugs for adult Medicaid recipients is limited to
30 the dispensing of four brand-name drugs per month per
31 recipient. Children are exempt from this restriction.
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1 Antiretroviral agents are excluded from the preferred drug
2 list this limitation. No requirements for prior authorization
3 or other restrictions on medications used to treat mental
4 illnesses such as schizophrenia, severe depression, or bipolar
5 disorder may be imposed on Medicaid recipients. Medications
6 that will be available without restriction for persons with
7 mental 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 may 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 may shall include
14 the 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, prior-authorize preauthorize the use
7 of a product:
8 a. For an indication not approved in labeling;
9 b. To comply with certain clinical guidelines; or
10 c. If the product has the potential for overuse,
11 misuse, or abuse for an indication not in the approved
12 labeling.
13
14 The agency Prior authorization may require the prescribing
15 professional to provide information about the rationale and
16 supporting medical evidence for the off-label use of a drug.
17 The agency may post prior-authorization criteria and protocol
18 and updates to the list of drugs that are subject to prior
19 authorization on an Internet website without amending its rule
20 or engaging in additional rulemaking.
21 14. The agency, in conjunction with the Pharmaceutical
22 and Therapeutics Committee, may require age-related prior
23 authorizations for certain prescribed drugs. The agency may
24 preauthorize the use of a drug for a recipient who may not
25 meet the age requirement or may exceed the length of therapy
26 for use of this product as recommended by the manufacturer and
27 approved by the Food and Drug Administration. Prior
28 authorization may require the prescribing professional to
29 provide information about the rationale and supporting medical
30 evidence for the use of a drug.
31
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1 15. The agency shall implement a step-therapy-prior
2 authorization-approval process for medications excluded from
3 the preferred drug list. Medications listed on the preferred
4 drug list must be used within the previous 12 months prior to
5 the alternative medications that are not listed. The
6 step-therapy-prior authorization may require the prescriber to
7 use the medications of a similar drug class or for a similar
8 medical indication unless contraindicated in the Food and Drug
9 Administration labeling. The trial period between the
10 specified steps may vary according to the medical indication.
11 The step-therapy-approval process shall be developed in
12 accordance with the committee as stated in s. 409.91195(7) and
13 (8). A drug product may be approved without meeting the
14 step-therapy-prior-authorization criteria if the prescribing
15 physician provides the agency with additional written medical
16 or clinical documentation that the product is medically
17 necessary because:
18 a. There is not a drug on the preferred drug list to
19 treat the disease or medical condition which is an acceptable
20 clinical alternative;
21 b. The alternatives have been ineffective in the
22 treatment of the beneficiary's disease; or
23 c. Based on historic evidence and known
24 characteristics of the patient and the drug, the drug is
25 likely to be ineffective, or the number of doses have been
26 ineffective.
27
28 The agency shall work with the physician to determine the best
29 alternative for the patient. The agency may adopt rules
30 waiving the requirements for written clinical documentation
31 for specific drugs in limited clinical situations.
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1 16.15. The agency shall implement a return and reuse
2 program for drugs dispensed by pharmacies to institutional
3 recipients, which includes payment of a $5 restocking fee for
4 the implementation and operation of the program. The return
5 and reuse program shall be implemented electronically and in a
6 manner that promotes efficiency. The program must permit a
7 pharmacy to exclude drugs from the program if it is not
8 practical or cost-effective for the drug to be included and
9 must provide for the return to inventory of drugs that cannot
10 be credited or returned in a cost-effective manner.
11 (44) The Agency for Health Care Administration shall
12 ensure that any Medicaid managed care plan as defined in s.
13 409.9122(2)(h), whether paid on a capitated basis or a shared
14 savings basis, is cost-effective. For purposes of this
15 subsection, the term "cost-effective" means that a network's
16 per-member, per-month costs to the state, including, but not
17 limited to, fee-for-service costs, administrative costs, and
18 case-management fees, if any, must be no greater than the
19 state's costs associated with contracts for Medicaid services
20 established under subsection (3), which shall be actuarially
21 adjusted for case mix, model, and service area. The agency
22 shall conduct actuarially sound audits adjusted for case mix
23 and model in order to ensure such cost-effectiveness and shall
24 publish the audit results on its Internet website and submit
25 the audit results annually to the Governor, the President of
26 the Senate, and the Speaker of the House of Representatives no
27 later than December 31 of each year. Contracts established
28 pursuant to this subsection which are not cost-effective may
29 not be renewed.
30 (49) The agency shall contract with established
31 minority physician networks that provide services to
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1 historically underserved minority patients. The networks must
2 provide cost-effective Medicaid services, comply with the
3 requirements to be a MediPass provider, and provide their
4 primary care physicians with access to data and other
5 management tools necessary to assist them in ensuring the
6 appropriate use of services, including inpatient hospital
7 services and pharmaceuticals.
8 (a) The agency shall provide for the development and
9 expansion of minority physician networks in each service area
10 to provide services to Medicaid recipients who are eligible to
11 participate under federal law and rules.
12 (b) The agency shall reimburse each minority physician
13 network as a fee-for-service provider, including the case
14 management fee for primary care, if any, or as a capitated
15 rate provider for Medicaid services. Any savings shall be
16 shared with the minority physician networks pursuant to the
17 contract.
18 (c) For purposes of this subsection, the term
19 "cost-effective" means that a network's per-member, per-month
20 costs to the state, including, but not limited to,
21 fee-for-service costs, administrative costs, and
22 case-management fees, if any, must be no greater than the
23 state's costs associated with contracts for Medicaid services
24 established under subsection (3), which shall be actuarially
25 adjusted for case mix, model, and service area. The agency
26 shall conduct actuarially sound audits adjusted for case mix
27 and model in order to ensure such cost-effectiveness and shall
28 publish the audit results on its Internet website and submit
29 the audit results annually to the Governor, the President of
30 the Senate, and the Speaker of the House of Representatives no
31
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1 later than December 31. Contracts established pursuant to this
2 subsection which are not cost-effective may not be renewed.
3 (d) The agency may apply for any federal waivers
4 needed to implement this subsection.
5 (50) The agency shall implement a program of
6 all-inclusive care for children. The program of all-inclusive
7 care for children shall be established to provide in-home
8 hospice-like support services to children diagnosed with a
9 life-threatening illness and enrolled in the Children's
10 Medical Services network to reduce hospitalizations as
11 appropriate. The agency, in consultation with the Department
12 of Health, may implement the program of all-inclusive care for
13 children after obtaining approval from the Centers for
14 Medicare and Medicaid Services.
15 Section 17. Paragraph (k) of subsection (2) of section
16 409.9122, Florida Statutes, is amended to read:
17 409.9122 Mandatory Medicaid managed care enrollment;
18 programs and procedures.--
19 (2)
20 (k) When a Medicaid recipient does not choose a
21 managed care plan or MediPass provider, the agency shall
22 assign the Medicaid recipient to a managed care plan, except
23 in those counties in which there are fewer than two managed
24 care plans accepting Medicaid enrollees, in which case
25 assignment shall be to a managed care plan or a MediPass
26 provider. Medicaid recipients in counties with fewer than two
27 managed care plans accepting Medicaid enrollees who are
28 subject to mandatory assignment but who fail to make a choice
29 shall be assigned to managed care plans until an enrollment of
30 40 percent in MediPass and 60 percent in managed care plans is
31 achieved. Once that enrollment is achieved, the assignments
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1 shall be divided in order to maintain an enrollment in
2 MediPass and managed care plans which is in a 40 percent and
3 60 percent proportion, respectively. In service areas 1 and 6
4 of the Agency for Health Care Administration geographic areas
5 where the agency is contracting for the provision of
6 comprehensive behavioral health services through a capitated
7 prepaid arrangement, recipients who fail to make a choice
8 shall be assigned equally to MediPass or a managed care plan.
9 For purposes of this paragraph, when referring to assignment,
10 the term "managed care plans" includes exclusive provider
11 organizations, provider service networks, Children's Medical
12 Services Network, minority physician networks, and pediatric
13 emergency department diversion programs authorized by this
14 chapter or the General Appropriations Act. When making
15 assignments, the agency shall take into account the following
16 criteria:
17 1. A managed care plan has sufficient network capacity
18 to meet the need of members.
19 2. The managed care plan or MediPass has previously
20 enrolled the recipient as a member, or one of the managed care
21 plan's primary care providers or MediPass providers has
22 previously provided health care to the recipient.
23 3. The agency has knowledge that the member has
24 previously expressed a preference for a particular managed
25 care plan or MediPass provider as indicated by Medicaid
26 fee-for-service claims data, but has failed to make a choice.
27 4. The managed care plan's or MediPass primary care
28 providers are geographically accessible to the recipient's
29 residence.
30
31
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1 5. The agency has authority to make mandatory
2 assignments based on quality of service and performance of
3 managed care plans.
4 Section 18. Section 409.9124, Florida Statutes, is
5 amended to read:
6 409.9124 Managed care reimbursement.--
7 (1) The agency shall develop and adopt by rule a
8 methodology for reimbursing managed care plans.
9 (1)(2) Final managed care rates shall be published
10 annually prior to September 1 of each year, based on
11 methodology that:
12 (a) Uses Medicaid's fee-for-service expenditures.
13 (b) Is certified as an actuarially sound computation
14 of Medicaid fee-for-service expenditures for comparable groups
15 of Medicaid recipients and includes all fee-for-service
16 expenditures, including those fee-for-service expenditures
17 attributable to recipients who are enrolled for a portion of a
18 year in a managed care plan or waiver program.
19 (c) Is compliant with applicable federal laws and
20 regulations, including, but not limited to, the requirements
21 to include an allowance for administrative expenses and to
22 account for all fee-for-service expenditures, including
23 fee-for-service expenditures for those groups enrolled for
24 part of a year.
25 (2)(3) Each year prior to establishing new managed
26 care rates, the agency shall review all prior year adjustments
27 for changes in trend, and shall reduce or eliminate those
28 adjustments which are not reasonable and which reflect
29 policies or programs which are not in effect. In addition, the
30 agency shall apply only those policy reductions applicable to
31 the fiscal year for which the rates are being set, which can
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1 be accurately estimated and verified by an independent
2 actuary, and which have been implemented prior to or will be
3 implemented during the fiscal year. The agency shall pay rates
4 at per-member, per-month averages that equal, but do not
5 exceed, the amounts allowed for in the General Appropriations
6 Act applicable to the fiscal year for which the rates will be
7 in effect.
8 (3)(4) The agency shall by rule prescribe those items
9 of financial information which each managed care plan shall
10 report to the agency, in the time periods prescribed by rule.
11 In prescribing items for reporting and definitions of terms,
12 the agency shall consult with the Office of Insurance
13 Regulation of the Financial Services Commission wherever
14 possible.
15 (4)(5) The agency shall quarterly examine the
16 financial condition of each managed care plan, and its
17 performance in serving Medicaid patients, and shall utilize
18 examinations performed by the Office of Insurance Regulation
19 wherever possible.
20 (5) The agency shall develop two rates for children
21 under 1 year of age. One set of rates shall cover the month of
22 birth through the second complete month subsequent to the
23 month of birth, and a separate set of rates shall cover the
24 third complete month subsequent to the month of birth through
25 the eleventh complete month subsequent to the month of birth.
26 The agency shall amend the payment methodology for
27 participating Medicaid-managed health care plans to comply
28 with this subsection.
29 Section 19. Section 430.041, Florida Statutes, is
30 repealed.
31
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1 Section 20. Subsection (1) of section 430.502, Florida
2 Statutes, is amended to read:
3 430.502 Alzheimer's disease; memory disorder clinics
4 and day care and respite care programs.--
5 (1) There is established:
6 (a) A memory disorder clinic at each of the three
7 medical schools in this state;
8 (b) A memory disorder clinic at a major private
9 nonprofit research-oriented teaching hospital, and may fund a
10 memory disorder clinic at any of the other affiliated teaching
11 hospitals;
12 (c) A memory disorder clinic at the Mayo Clinic in
13 Jacksonville;
14 (d) A memory disorder clinic at the West Florida
15 Regional Medical Center;
16 (e) The East Central Florida Memory Disorder Clinic at
17 the Joint Center for Advanced Therapeutics and Biomedical
18 Research of the Florida Institute of Technology and Holmes
19 Regional Medical Center, Inc.;
20 (f) A memory disorder clinic at the Orlando Regional
21 Healthcare System, Inc.;
22 (g) A memory disorder center located in a public
23 hospital that is operated by an independent special hospital
24 taxing district that governs multiple hospitals and is located
25 in a county with a population greater than 800,000 persons;
26 (h) A memory disorder clinic at St. Mary's Medical
27 Center in Palm Beach County;
28 (i) A memory disorder clinic at Tallahassee Memorial
29 Healthcare;
30 (j) A memory disorder clinic at Lee Memorial Hospital
31 created by chapter 63-1552, Laws of Florida, as amended;
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1 (k) A memory disorder clinic at Sarasota Memorial
2 Hospital in Sarasota County; and
3 (l) A memory disorder clinic at Morton Plant Hospital,
4 Clearwater, in Pinellas County; and,
5 (m) A memory disorder clinic at Florida Atlantic
6 University, Boca Raton, in Palm Beach County,
7
8 for the purpose of conducting research and training in a
9 diagnostic and therapeutic setting for persons suffering from
10 Alzheimer's disease and related memory disorders. However,
11 memory disorder clinics funded as of June 30, 1995, shall not
12 receive decreased funding due solely to subsequent additions
13 of memory disorder clinics in this subsection.
14 Section 21. Paragraph (d) of subsection (15) of
15 section 440.02, Florida Statutes, is amended to read:
16 440.02 Definitions.--When used in this chapter, unless
17 the context clearly requires otherwise, the following terms
18 shall have the following meanings:
19 (15)
20 (d) "Employee" does not include:
21 1. An independent contractor who is not engaged in the
22 construction industry.
23 a. In order to meet the definition of independent
24 contractor, at least four of the following criteria must be
25 met:
26 (I) The independent contractor maintains a separate
27 business with his or her own work facility, truck, equipment,
28 materials, or similar accommodations;
29 (II) The independent contractor holds or has applied
30 for a federal employer identification number, unless the
31 independent contractor is a sole proprietor who is not
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1 required to obtain a federal employer identification number
2 under state or federal regulations;
3 (III) The independent contractor receives compensation
4 for services rendered or work performed and such compensation
5 is paid to a business rather than to an individual;
6 (IV) The independent contractor holds one or more bank
7 accounts in the name of the business entity for purposes of
8 paying business expenses or other expenses related to services
9 rendered or work performed for compensation;
10 (V) The independent contractor performs work or is
11 able to perform work for any entity in addition to or besides
12 the employer at his or her own election without the necessity
13 of completing an employment application or process; or
14 (VI) The independent contractor receives compensation
15 for work or services rendered on a competitive-bid basis or
16 completion of a task or a set of tasks as defined by a
17 contractual agreement, unless such contractual agreement
18 expressly states that an employment relationship exists.
19 b. If four of the criteria listed in sub-subparagraph
20 a. do not exist, an individual may still be presumed to be an
21 independent contractor and not an employee based on full
22 consideration of the nature of the individual situation with
23 regard to satisfying any of the following conditions:
24 (I) The independent contractor performs or agrees to
25 perform specific services or work for a specific amount of
26 money and controls the means of performing the services or
27 work.
28 (II) The independent contractor incurs the principal
29 expenses related to the service or work that he or she
30 performs or agrees to perform.
31
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1 (III) The independent contractor is responsible for
2 the satisfactory completion of the work or services that he or
3 she performs or agrees to perform.
4 (IV) The independent contractor receives compensation
5 for work or services performed for a commission or on a
6 per-job basis and not on any other basis.
7 (V) The independent contractor may realize a profit or
8 suffer a loss in connection with performing work or services.
9 (VI) The independent contractor has continuing or
10 recurring business liabilities or obligations.
11 (VII) The success or failure of the independent
12 contractor's business depends on the relationship of business
13 receipts to expenditures.
14 c. Notwithstanding anything to the contrary in this
15 subparagraph, an individual claiming to be an independent
16 contractor has the burden of proving that he or she is an
17 independent contractor for purposes of this chapter.
18 2. A real estate licensee, if that person agrees, in
19 writing, to perform for remuneration solely by way of
20 commission.
21 3. Bands, orchestras, and musical and theatrical
22 performers, including disk jockeys, performing in licensed
23 premises as defined in chapter 562, if a written contract
24 evidencing an independent contractor relationship is entered
25 into before the commencement of such entertainment.
26 4. An owner-operator of a motor vehicle who transports
27 property under a written contract with a motor carrier which
28 evidences a relationship by which the owner-operator assumes
29 the responsibility of an employer for the performance of the
30 contract, if the owner-operator is required to furnish the
31 necessary motor vehicle equipment and all costs incidental to
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1 the performance of the contract, including, but not limited
2 to, fuel, taxes, licenses, repairs, and hired help; and the
3 owner-operator is paid a commission for transportation service
4 and is not paid by the hour or on some other time-measured
5 basis.
6 5. A person whose employment is both casual and not in
7 the course of the trade, business, profession, or occupation
8 of the employer.
9 6. A volunteer, except a volunteer worker for the
10 state or a county, municipality, or other governmental entity.
11 A person who does not receive monetary remuneration for
12 services is presumed to be a volunteer unless there is
13 substantial evidence that a valuable consideration was
14 intended by both employer and employee. For purposes of this
15 chapter, the term "volunteer" includes, but is not limited to:
16 a. Persons who serve in private nonprofit agencies and
17 who receive no compensation other than expenses in an amount
18 less than or equivalent to the standard mileage and per diem
19 expenses provided to salaried employees in the same agency or,
20 if such agency does not have salaried employees who receive
21 mileage and per diem, then such volunteers who receive no
22 compensation other than expenses in an amount less than or
23 equivalent to the customary mileage and per diem paid to
24 salaried workers in the community as determined by the
25 department; and
26 b. Volunteers participating in federal programs
27 established under Pub. L. No. 93-113.
28 7. Unless otherwise prohibited by this chapter, any
29 officer of a corporation who elects to be exempt from this
30 chapter. Such officer is not an employee for any reason under
31
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1 this chapter until the notice of revocation of election filed
2 pursuant to s. 440.05 is effective.
3 8. An officer of a corporation that is engaged in the
4 construction industry who elects to be exempt from the
5 provisions of this chapter, as otherwise permitted by this
6 chapter. Such officer is not an employee for any reason until
7 the notice of revocation of election filed pursuant to s.
8 440.05 is effective.
9 9. An exercise rider who does not work for a single
10 horse farm or breeder, and who is compensated for riding on a
11 case-by-case basis, provided a written contract is entered
12 into prior to the commencement of such activity which
13 evidences that an employee/employer relationship does not
14 exist.
15 10. A taxicab, limousine, or other passenger
16 vehicle-for-hire driver who operates said vehicles pursuant to
17 a written agreement with a company which provides any
18 dispatch, marketing, insurance, communications, or other
19 services under which the driver and any fees or charges paid
20 by the driver to the company for such services are not
21 conditioned upon, or expressed as a proportion of, fare
22 revenues.
23 11. A person who performs services as a sports
24 official for an entity sponsoring an interscholastic sports
25 event or for a public entity or private, nonprofit
26 organization that sponsors an amateur sports event. For
27 purposes of this subparagraph, such a person is an independent
28 contractor. For purposes of this subparagraph, the term
29 "sports official" means any person who is a neutral
30 participant in a sports event, including, but not limited to,
31 umpires, referees, judges, linespersons, scorekeepers, or
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1 timekeepers. This subparagraph does not apply to any person
2 employed by a district school board who serves as a sports
3 official as required by the employing school board or who
4 serves as a sports official as part of his or her
5 responsibilities during normal school hours.
6 12. Medicaid-enrolled clients under chapter 393 who
7 are excluded from the definition of employment under s.
8 443.1216(4)(d) and served by Adult Day Training Services under
9 the Home and Community-Based or the Family and Supported
10 Living Medicaid Waiver program in a sheltered workshop setting
11 licensed by the United States Department of Labor for the
12 purpose of training and earning less than the federal hourly
13 minimum wage.
14 Section 22. Section 21 of chapter 2004-270, Laws of
15 Florida, is amended to read:
16 Section 21. Notwithstanding s. 430.707, Florida
17 Statutes, no later than September 1, 2005, or subject to
18 federal approval of the application to be a Program of
19 All-inclusive Care for the Elderly site, the agency shall
20 contract with one private, not-for-profit hospice organization
21 located in Lee County and one such organization in Martin
22 County, such an entity shall be exempt from the requirements
23 of chapter 641 Florida Statutes, each of which provides
24 comprehensive services, including hospice care for frail and
25 elderly persons. The agency shall approve 100 initial
26 enrollees in the Program of All-inclusive Care for the Elderly
27 for the in Lee and Martin programs, subject to an
28 appropriation by the Legislature counties. The organization in
29 Lee County shall serve eligible residents in Lee County and in
30 the counties contiguous to Lee County. The organization in
31 Martin County shall serve eligible residents in Martin County
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1 and in the counties contiguous to Martin County. Each program
2 may continue to enroll eligible residents when the Agency for
3 Health Care Administration determines such residents to be
4 eligible for nursing home confinement. Residents currently
5 designated by the agency as eligible for nursing home
6 confinement are automatically eligible for PACE program
7 enrollment. There shall be 50 initial enrollees in each
8 county.
9 Section 23. Sections 8, 9, and 10 of this act are
10 remedial in nature and it is the intent of the Legislature
11 that the provisions of those sections apply to contracts,
12 fees, rates, and other methods of payment in existence before,
13 on, or after the effective date of this act.
14 Section 24. If any provision of this act or its
15 application to any person or circumstance is held invalid, the
16 invalidity does not affect other provisions or applications of
17 the act which can be given effect without the invalid
18 provision or application, and to this end the provisions of
19 this act are severable.
20 Section 25. Except as otherwise expressly provided in
21 this act, this act shall take effect July 1, 2005.
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