Amendment
Bill No. 6003

Amendment No. 317791

CHAMBER ACTION
Senate		House
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1	Representative(s) Benson offered the following:
2
3	Amendment (with title amendment)
4	Remove everything after the enacting clause and insert:
5	Section 1.  Popular name.--This act shall be known as the
6	"Medicaid Reform Act of 2005."
7	Section 2.  Medicaid reform.--
8	(1)  WAIVER AUTHORITY.-- The Agency for Health Care
9	Administration is authorized to seek experimental, pilot, or
10	demonstration project waivers, pursuant to s. 1115 of the Social
11	Security Act, to reform the Florida Medicaid program pursuant to
12	this section in two geographic areas. One pilot program shall
13	include only Broward County. A second pilot program shall
14	initially include Duval County and shall be expanded to include
15	Baker, Clay, and Nassau Counties within the timeframes approved
16	in the implementation plan. This waiver authority is contingent
17	upon federal approval to preserve the upper-payment-limit
18	funding mechanisms for hospitals and contingent upon protection
19	of the disproportionate share program authorized pursuant to
20	chapter 409, Florida Statutes. The agency is directed to
21	negotiate with the Centers for Medicare and Medicaid Services to
22	include in the approved waiver a methodology whereby savings
23	from the demonstration waiver may be used to increase total
24	upper-payment-limit and disproportionate share payments. Any
25	increased funds shall be reinvested in programs that provide
26	direct services to uninsured individuals in a cost-effective
27	manner and reduce reliance on hospital emergency care.
28	(3)  IMPLEMENTATION OF DEMONSTRATION PROJECTS.--The agency
29	shall include in the federal waiver request the authority to
30	establish managed care demonstration projects as provided in
31	this section and as approved by the Legislature in the waiver.
32	(4)  DEFINITIONS.--As used in this section, the term:
33	(a)  "Agency" means the Agency for Health Care
34	Administration.
35	(b)  "Enhanced benefit coverage" means additional health
36	care services or alternative health care coverage which can be
37	purchased by qualified recipients.
38	(c)  "Flexible spending account" means an account that
39	encourages consumer ownership and management of resources
40	available for enhanced benefit coverage, wellness activities,
41	preventive services, and other services to improve the health of
42	the recipient.
43	(d)  "Managed care plan" or "plan" means an entity
44	certified by the agency to accept a capitation payment,
45	including, but not limited to, a health maintenance organization
46	authorized under part I of chapter 641, Florida Statutes; an
47	entity under part II or part III of chapter 641, Florida
48	Statutes, or under chapter 627, chapter 636, chapter 391, or s.
49	409.912, Florida Statutes; a licensed mental health provider
50	under chapter 394, Florida Statutes; a licensed substance abuse
51	provider under chapter 397, Florida Statutes; a hospital under
52	chapter 395, Florida Statutes; a provider service network as
53	defined in this section; or a state-certified contractor as
54	defined in this section.
55	(f)  "Medicaid opt-out option" means a program that allows
56	a recipient to purchase health care insurance through an
57	employer-sponsored plan instead of through a Medicaid-certified
58	plan.
59	(g)  "Plan benefits" means the mandatory services specified
60	in s. 409.905, Florida Statutes; behavioral health services
61	specified in s. 409.906(8), Florida Statutes; pharmacy services
62	specified in s. 409.906(20), Florida Statutes; and other
63	services, including, but not limited to, Medicaid optional
64	services specified in s. 409.906, Florida Statutes, for which a
65	plan is receiving a risk adjusted capitation rate. Plans shall
66	provide all mandatory services and may cover optional services
67	to attract recipients and provide needed care. Services to
68	recipients under plan benefits shall include emergency services
69	pursuant to s. 409.9128, Florida Statutes.
70	1.  Mandatory and optional services as delineated in s.
71	409.905, and s. 409.906, Florida Statutes may vary in amount,
72	duration and scope based on actuarial analysis and determination
73	of service utilization among a categorical or predetermined risk
74	group served by the plan.
75	2.  A plan shall provide all mandatory and optional
76	services as delineated in ss. 409.905, and 409.906, Florida
77	Statutes, to a level of amount, duration and scope based on the
78	actuarial analysis and corresponding capitation rate.
79	Contractual stipulations for each risk or categorical group
80	shall not vary among plans.
81	3.  A plan shall be at risk for all services as defined in
82	this section needed by a recipient up to a monetary catastrophic
83	threshold pursuant to this section.
84	4.  Catastrophic coverage pursuant to this section shall
85	not release the plan from continued care management of the
86	recipient and providing other services as stipulated in the
87	contract with the agency.
88	(h)  "Provider service network" means an incorporated
89	network:
90	1.  Established or organized, and operated, by a health
91	care provider or group of affiliated health care providers;
92	2.  That provides a substantial proportion of the health
93	care items and services under a contract directly through the
94	provider or affiliated group;
95	3.  That may make arrangements with physicians, other
96	health care professionals, and health care institutions, to
97	assume all or part of the financial risk on a prospective basis
98	for the provision of basic health services; and
99	4.  Within which health care providers have a controlling
100	interest in the governing body of the provider service network
101	organization, as authorized by s. 409.912, Florida Statutes.
102	(i)  "Shall" means the agency must include the provision of
103	a subsection as delineated in this section in the waiver
104	application and implement the provision to the extent allowed in
105	the demonstration project sites by the Centers for Medicare and
106	Medicaid Services and as approved by the Legislature pursuant to
107	this section.
108	(j)  "State-certified contractor" means an entity not
109	authorized under part I, part II, or part III of chapter 641,
110	Florida Statutes, or under chapter 624, chapter 627, or chapter
111	636, Florida Statutes, qualified by the agency to be certified
112	as a managed care plan. The agency shall develop the standards
113	necessary to authorize an entity to become a state-certified
114	contractor.
115	(5)  ELIGIBILITY.--
116	(a)  The agency shall pursue waivers to reform Medicaid for
117	the following categorical groups:
118	1.  Temporary Assistance for Needy Families, consistent
119	with ss. 402 and 1931 of the Social Security Act and chapter
120	409, chapter 414, or chapter 445, Florida Statutes.
121	2.  Supplemental Security Income recipients as defined in
122	Title XVI of the Social Security Act, except for persons who are
123	dually eligible for Medicaid and Medicare, individuals 60 years
124	of age or older, individuals who have developmental
125	disabilities, and residents of institutions or nursing homes.
126	3.  All children covered pursuant to Title XIX of the
127	Social Security Act.
128	(b)  The agency may pursue any appropriate federal waiver
129	to reform Medicaid for the populations not identified by this
130	subsection, including Title XXI children, if authorized by the
131	Legislature.
132	(6)  CHOICE COUNSELING.--
133	(a)  At the time of eligibility determination, the agency
134	shall provide the recipient with all the Medicaid health care
135	options available in that community to assist the recipient in
136	choosing health care coverage. The recipient shall choose a plan
137	within 30 days after the recipient is eligible unless the
138	recipient loses eligibility. Failure to choose a plan within 30
139	days will result in the recipient being assigned to a managed
140	care plan.
141	(b)  After a recipient has chosen a plan or has been
142	assigned to a plan, the recipient shall have 90 days in which to
143	voluntarily disenroll and select another managed care plan.
144	After 90 days, no further changes may be made except for cause.
145	Cause shall include, but not be limited to, poor quality of
146	care, lack of access to necessary specialty services, an
147	unreasonable delay or denial of service, inordinate or
148	inappropriate changes of primary care providers, service access
149	impairments due to significant changes in the geographic
150	location of services, or fraudulent enrollment. The agency may
151	require a recipient to use the managed care plan's grievance
152	process prior to the agency's determination of cause, except in
153	cases in which immediate risk of permanent damage to the
154	recipient's health is alleged. The grievance process, when used,
155	must be completed in time to permit the recipient to disenroll
156	no later than the first day of the second month after the month
157	the disenrollment request was made. If the capitated managed
158	care network, as a result of the grievance process, approves an
159	enrollee's request to disenroll, the agency is not required to
160	make a determination in the case. The agency must make a
161	determination and take final action on a recipient's request so
162	that disenrollment occurs no later than the first day of the
163	second month after the month the request was made. If the agency
164	fails to act within the specified timeframe, the recipient's
165	request to disenroll is deemed to be approved as of the date
166	agency action was required. Recipients who disagree with the
167	agency's finding that cause does not exist for disenrollment
168	shall be advised of their right to pursue a Medicaid fair
169	hearing to dispute the agency's finding.
170	(c)  In the managed care demonstration projects, the
171	Medicaid recipients who are already enrolled in a managed care
172	plan shall remain with that plan until their next eligibility
173	determination. The agency shall develop a method whereby newly
174	eligible Medicaid recipients, Medicaid recipients with renewed
175	eligibility, and Medipass enrollees shall enroll in managed care
176	plans certified pursuant to this section.
177	(d)  A Medicaid recipient receiving services under this
178	section is eligible for only emergency services until the
179	recipient enrolls in a managed care plan.
180	(e)  The agency shall ensure that the recipient is provided
181	with:
182	1.  A list and description of the benefits provided.
183	2.  Information about cost sharing.
184	3.  Plan performance data, if available.
185	4.  An explanation of benefit limitations.
186	5.  Contact information, including identification of
187	providers participating in the network, geographic locations,
188	and transportation limitations.
189	6.  Any other information the agency determines would
190	facilitate a recipient's understanding of the plan or insurance
191	that would best meet his or her needs.
192	(f)  The agency shall ensure that there is a record of
193	recipient acknowledgment that choice counseling has been
194	provided.
195	(g)  To accommodate the needs of recipients, the agency
196	shall ensure that the choice counseling process and related
197	material are designed to provide counseling through face-to-face
198	interaction, by telephone, and in writing and through other
199	forms of relevant media. Materials shall be written at the
200	fourth-grade reading level and available in a language other
201	than English when 5 percent of the county speaks a language
202	other than English. Choice counseling shall also utilize
203	language lines and other services for impaired recipients, such
204	as TTD/TTY.
205	(h)  The agency shall require the entity performing choice
206	counseling to determine if the recipient has made a choice of a
207	plan or has opted out because of duress, threats, payment to the
208	recipient, or incentives promised to the recipient by a third
209	party. If the choice counseling entity determines that the
210	decision to choose a plan was unlawfully influenced or a plan
211	violated any of the provisions of s. 409.912(21), Florida
212	Statutes, the choice counseling entity shall immediately report
213	the violation to the agency's program integrity section for
214	investigation. Verification of choice counseling by the
215	recipient shall include a stipulation that the recipient
216	acknowledges the provisions of this subsection.
217	(i)  It is the intent of the Legislature, within the
218	authority of the waiver and within available resources, that the
219	agency promote health literacy and partner with the Department
220	of Health to provide information aimed to reduce minority health
221	disparities through outreach activities for Medicaid recipients.
222	(j)  The agency is authorized to contract with entities to
223	perform choice counseling and may establish standards and
224	performance contracts, including standards requiring the
225	contractor to hire choice counselors representative of the
226	state's diverse population and to train choice counselors in
227	working with culturally diverse populations.
228	(k)  The agency shall develop processes to ensure that
229	demonstration sites have sufficient levels of enrollment to
230	conduct a valid test of the managed care demonstration project
231	model within a 2-year timeframe.
232	(7)  PLANS.--
233	(a)  Plan benefits.--The agency shall develop a capitated
234	system of care that promotes choice and competition. Plan
235	benefits shall include the mandatory services delineated in
236	federal law and specified in s. 409.905, Florida Statutes;
237	behavioral health services specified in s. 409.906(8), Florida
238	Statutes; pharmacy services specified in s. 409.906(20), Florida
239	Statutes; and other services including, but not limited to,
240	Medicaid optional services specified in s. 409.906, Florida
241	Statutes, for which a plan is receiving a risk-adjusted
242	capitation rate. Plans shall provide all mandatory services and
243	may cover optional services to attract recipients and provide
244	needed care. Mandatory and optional services may vary in amount,
245	duration, and scope of benefits. Services to recipients under
246	plan benefits shall include emergency services pursuant to s.
247	409.9128, Florida Statutes.
248	(b)  Wellness and disease management.--
249	1.  The agency shall require plans to provide a wellness
250	disease management program for certain Medicaid recipients
251	participating in the waiver. The agency shall require plans to
252	develop disease management programs necessary to meet the needs
253	of the population they serve.
254	2.  The agency shall require a plan to develop appropriate
255	disease management protocols and develop procedures for
256	implementing those protocols, and determine the procedure for
257	providing disease management services to plan enrollees. The
258	agency is authorized to allow a plan to contract separately with
259	another entity for disease management services or provide
260	disease management services directly through the plan.
261	3.  The agency shall provide oversight to ensure that the
262	service network provides the contractually agreed upon level of
263	service.
264	4.  The agency may establish performance contracts that
265	reward a plan when measurable operational targets in both
266	participation and clinical outcomes are reached or exceeded by
267	the plan.
268	5.  The agency may establish performance contracts that
269	penalize a plan when measurable operational targets for both
270	participation and clinical outcomes are not reached by the plan.
271	6.  The agency shall develop oversight requirements and
272	procedures to ensure that plans utilize standardized methods and
273	clinical protocols for determining compliance with a wellness or
274	disease management plan.
275	(c)  Pharmacy benefits.--
276	1.  The agency shall require plans to provide pharmacy
277	benefits and include pharmacy benefits as part of the capitation
278	risk structure to enable a plan to coordinate and fully manage
279	all aspects of patient care as part of the plan or through a
280	pharmacy benefits manager.
281	2.  The agency may set standards for pharmacy benefits for
282	managed care plans and specify the therapeutic classes of
283	pharmacy benefits to enable a plan to coordinate and fully
284	manage all aspects of patient care as part of the plan or
285	through a pharmacy benefits manager.
286	3.  Each plan shall implement a pharmacy fraud, waste, and
287	abuse initiative that may include a surety bond or letter of
288	credit requirement for participating pharmacies, enhanced
289	provider auditing practices, the use of additional fraud and
290	abuse software, recipient management programs for recipients
291	inappropriately using their benefits, and other measures to
292	reduce provider and recipient fraud, waste, and abuse. The
293	initiative shall address enforcement efforts to reduce the
294	number and use of counterfeit prescriptions.
295	4.  The agency shall require plans to report incidences of
296	pharmacy fraud and abuse and establish procedures for receiving
297	and investigating fraud and abuse reports from plans in the
298	demonstration project sites. Plans must report instances of
299	fraud and abuse pursuant to chapter 641, Florida Statutes.
300	5.  The agency may facilitate the establishment of a
301	Florida managed care plan purchasing alliance. The purpose of
302	the alliance is to form agreements among participating plans to
303	purchase pharmaceuticals at a discount, to achieve rebates, or
304	to receive best market price adjustments. Participation in the
305	Florida managed care plan purchasing alliance shall be
306	voluntary.
307	(d)  Behavioral health care benefits.--
308	1.  The agency shall include behavioral health care
309	benefits as part of the capitation structure to enable a plan to
310	coordinate and fully manage all aspects of patient care.
311	2.  Managed care plans shall require their contracted
312	behavioral health providers to have a member's behavioral
313	treatment plan on file in the provider's medical record.
314	(e)  Grievance resolution process.--A grievance resolution
315	process shall be established that uses the subscriber assistance
316	panel, as created in s. 408.7056, Florida Statutes, and the
317	Medcaid fair hearing process to address grievances.
318	(8)  ENHANCED BENEFIT COVERAGE.--
319	(a)  The agency may establish enhanced benefit coverage and
320	a methodology to fund the enhanced benefit coverage within funds
321	provided in the General Appropriations Act.
322	(b)  A recipient who complies with the objectives of a
323	wellness or disease management plan, as determined by the
324	agency, shall have access to the enhanced benefit coverage for
325	the purpose of purchasing or securing health-care services or
326	health-care products.
327	(c)  The agency shall establish flexible spending accounts
328	or similar accounts for recipients as approved in the waiver to
329	be administered by the agency or by a managed care plan. The
330	agency shall make deposits to a recipient's flexible spending
331	account contingent upon compliance with a wellness plan or a
332	disease management plan.
333	(d)  It is the intent of the Legislature that enhanced
334	benefits encourage consumer participation in wellness
335	activities, preventive services, and other services to improve
336	the health of the recipient.
337	(e)  The agency shall develop standards and oversight
338	procedures to monitor access to enhanced benefits during the
339	eligibility period and up to 3 years after loss of eligibility
340	as approved by the waiver.
341	(f)  It is the intent of the Legislature that the agency
342	may develop an electronic benefit transfer system for the
343	distribution of enhanced benefit funds earned by the recipient.
344	(9)  COST SHARING; REPORT.--The Agency for Health Care
345	Administration shall submit to the President of the Senate and
346	the Speaker of the House of Representatives by December 15,
347	2005, a report on the legal and administrative barriers to
348	enforcing s. 409.9081, Florida Statutes. The report must
349	describe how many services require copayments, which providers
350	collect copayments, and the total amount of copayments collected
351	from recipients for all services required under s. 409.9081,
352	Florida Statutes, by provider type for the fiscal years 2001-
353	2002 through 2004-2005. The agency shall recommend a mechanism
354	to enforce the requirement for Medicaid recipients to make
355	copayments which does not shift the copayment amount to the
356	provider. The agency shall also identify the federal or state
357	laws or regulations that permit Medicaid recipients to declare
358	impoverishment in order to avoid paying the copayment and extent
359	to which these statements of impoverishment are verified. If
360	claims of impoverishment are not currently verified, the agency
361	shall recommend a system for such verification. The report must
362	also identify any other cost-sharing measures that could be
363	imposed on Medicaid recipients.
364	(10)  CATASTROPHIC COVERAGE.--
365	(a)  To the extent of available appropriations contained in
366	the annual General Appropriations Act for such purposes, all
367	managed care plans shall provide coverage to the extent required
368	by the agency up to a per-recipient service limitation threshold
369	determined by the agency and within the capitation rate set by
370	the agency. This limitation threshold may vary by eligibility
371	group or other appropriate factors, including, but not limited
372	to, recipients with special needs and recipients with certain
373	disease states.
374	(b)  The agency shall establish a fund or purchase stop-
375	loss coverage from a plan under part I of chapter 641, Florida
376	Statutes, or a health insurer authorized under chapter 624,
377	Florida Statutes, for purposes of covering services in excess of
378	those covered by the managed care plan. The catastrophic
379	coverage fund or stop-loss coverage shall provide for payment of
380	medically necessary care for recipients who are enrolled in a
381	plan and whose care has exceeded the predetermined service
382	threshold. The agency may establish an aggregate maximum level
383	of coverage in the catastrophic fund or for the stop-loss
384	coverage.
385	(c)  The agency shall develop policies and procedures to
386	allow all plans to utilize the catastrophic coverage fund or
387	stop-loss coverage for a Medicaid recipient in the plan who has
388	reached the catastrophic coverage threshold.
389	(d)  The agency shall contract for an administrative
390	structure to manage the catastrophic coverage fund.
391	(11)  CERTIFICATION.--Before any entity may operate a
392	managed care plan under the waiver, it shall obtain a
393	certificate of operation from the agency.
394	(a)  Any entity operating under part I, part II, or part
395	III of chapter 641, Florida Statutes, or under chapter 627,
396	chapter 636, chapter 391, or s. 409.912, Florida Statutes; a
397	licensed mental health provider under chapter 394, Florida
398	Statutes; a licensed substance abuse provider under chapter 397,
399	Florida Statutes; a hospital under chapter 395, Florida
400	Statutes; a provider service network as defined in this section;
401	or a state-certified contractor as defined in this section shall
402	be in compliance with the requirements and standards developed
403	by the agency. For purposes of the waiver established under this
404	section, provider service networks shall be exempt from the
405	competitive bid requirements in s. 409.912, Florida Statutes.
406	The agency, in consultation with the Office of Insurance
407	Regulation, shall establish certification requirements. It is
408	the intent of the Legislature that, to the extent possible, any
409	project authorized by the state under this section include any
410	federally qualified health center, federally qualified rural
411	health clinic, county health department, or any other federally,
412	state, or locally funded entity that serves the geographic area
413	within the boundaries of that project. The certification process
414	shall, at a minimum, include all requirements in the current
415	Medicaid prepaid health plan contract and take into account the
416	following requirements:
417	1.  The entity has sufficient financial solvency to be
418	placed at risk for the basic plan benefits under ss. 409.905,
419	409.906(8), and 409.906(20), Florida Statutes, and other covered
420	services.
421	2.  Any plan benefit package shall be actuarially
422	equivalent to the premium calculated by the agency to ensure
423	that competing plan benefits are equivalent in value. In all
424	instances, the benefit package must provide services sufficient
425	to meet the needs of the target population based on historical
426	Medicaid utilization.
427	3.  The entity has sufficient service network capacity to
428	meet the needs of members under ss. 409.905, 409.906(8), and
429	409.906(20), Florida Statutes, and other covered services.
430	4.  The entity's primary care providers are geographically
431	accessible to the recipient.
432	5.  The entity has the capacity to provide a wellness or
433	disease management program.
434	6.  The entity shall provide for ambulance service in
435	accordance with ss. 409.908(13)(d) and 409.9128, Florida
436	Statutes.
437	7.  The entity has the infrastructure to manage financial
438	transactions, recordkeeping, data collection, and other
439	administrative functions.
440	8.  The entity, if not a fully indemnified insurance
441	program under chapter 624, chapter 627, chapter 636, or chapter
442	641, Florida Statutes, must meet the financial solvency
443	requirements under this section.
444	(b)  The agency has the authority to contract with entities
445	not otherwise licensed as an insurer or risk-bearing entity
446	under chapter 627 or chapter 641, Florida Statutes, as long as
447	these entities meet the certification standards of this section
448	and any additional standards as defined by the agency to qualify
449	as managed care plans under this section.
450	(c)  In certifying a risk-bearing entity and determining
451	the financial solvency of such an entity as a provider service
452	network, the following shall apply:
453	1.  The entity shall maintain a minimum surplus in an
454	amount that is the greater of $1 million or 1.5 percent of
455	projected annual premiums.
456	2.  In lieu of the requirements in subparagraph 1., the
457	agency may consider the following:
458	a.  If the organization is a public entity, the agency may
459	take under advisement a statement from the public entity that a
460	county supports the managed care plan with the county's full
461	faith and credit. In order to qualify for the agency's
462	consideration, the county must own, operate, manage, administer,
463	or oversee the managed care plan, either partly or wholly,
464	through a county department or agency;
465	b.  The state guarantees the solvency of the organization;
466	c.  The organization is a federally qualified health center
467	or is controlled by one or more federally qualified health
468	centers and meets the solvency standards established by the
469	state for such organization pursuant to s. 409.912(4)(c),
470	Florida Statute; or
471	d.  The entity meets the solvency requirements for
472	federally approved provider-sponsored organizations as defined
473	in 42 C.F.R. ss. 422.380-422.390. However, if the provider
474	service network does not meet the solvency requirements of
475	either chapter 627 or chapter 641, Florida Statutes, the
476	provider service network is limited to the issuance of Medicaid
477	plans.
478	(d)  Each entity certified by the agency shall submit to
479	the agency any financial, programmatic, or patient-encounter
480	data or other information required by the agency to determine
481	the actual services provided and the cost of administering the
482	plan.
483	(e)  Notwithstanding the provisions of s. 409.912, Florida
484	Statutes, the agency shall extend the existing contract with a
485	hospital-based provider service network for a period not to
486	exceed 3 years.
487	(12)  ACCOUNTABILITY AND QUALITY ASSURANCE.--The agency
488	shall establish standards for plan compliance, including, but
489	not limited to, quality assurance and performance improvement
490	standards, peer or professional review standards, grievance
491	policies, and program integrity policies. The agency shall
492	develop a data reporting system, work with managed care plans to
493	establish reasonable patient-encounter reporting requirements,
494	and ensure that the data reported is accurate and complete.
495	(a)  In performing the duties required under this section,
496	the agency shall work with managed care plans to establish a
497	uniform system to measure, improve, and monitor the clinical and
498	functional outcomes of a recipient of Medicaid services. The
499	system may use financial, clinical, and other criteria based on
500	pharmacy, medical services, and other data related to the
501	provision of Medicaid services, including, but not limited to:
502	1.  Health Plan Employer Data and Information Set.
503	2.  Member satisfaction.
504	3.  Provider satisfaction.
505	4.  Report cards on plan performance and best practices.
506	5.  Quarterly reports on compliance with the prompt payment
507	of claims requirements of ss. 627.613, 641.3155, and 641.513,
508	Florida Statutes.
509	(b)  The agency shall require the managed care plans that
510	have contracted with the agency to establish a quality assurance
511	system that incorporates the provisions of s. 409.912(27),
512	Florida Statutes, and any standards, rules, and guidelines
513	developed by the agency.
514	(c)1.  The agency shall establish a medical care database
515	to compile data on health services rendered by health care
516	practitioners that provide services to patients enrolled in
517	managed care plans in the demonstration sites. The medical care
518	database shall:
519	a.  Collect for each type of patient encounter with a
520	health care practitioner or facility:
521	(I)  The demographic characteristics of the patient.
522	(II)  The principal, secondary, and tertiary diagnosis.
523	(III)  The procedure performed.
524	(IV)  The date and location where the procedure was
525	performed.
526	(V)  The payment for the procedure, if any.
527	(VI)  If applicable, the health care practitioner's
528	universal identification number.
529	(VII)  If the health care practitioner rendering the
530	service is a dependent practitioner, the modifiers appropriate
531	to indicate that the service was delivered by the dependent
532	practitioner.
533	b.  Collect appropriate information relating to
534	prescription drugs for each type of patient encounter.
535	c.  Collect appropriate information related to health care
536	costs, utilization, or resources from managed care plans
537	participating in the demonstration sites.
538	2.  To the extent practicable, when collecting the data
539	required under sub-subparagraph 1.a., the agency shall utilize
540	any standardized claim form or electronic transfer system being
541	used by health care practitioners, facilities, and payers.
542	3.  Health care practitioners and facilities in the
543	demonstration sites shall submit, and managed care plans
544	participating in the demonstration sites shall receive, claims
545	for payment and any other information reasonably related to the
546	medical care database electronically in a standard format as
547	required by the agency.
548	4.  The agency shall establish reasonable deadlines for
549	phasing in of electronic transmittal of claims.
550	5.  The plan shall ensure that the data reported is
551	accurate and complete.
552	(13)  STATUTORY COMPLIANCE.--Any entity certified under
553	this section shall comply with ss. 627.613, 641.3155, and
554	641.513, Florida Statutes as applicable.
555	(14)  RATE SETTING AND RISK ADJUSTMENT.--The agency shall
556	develop an actuarially sound rate setting and risk adjustment
557	system for payment to managed care plans that:
558	(a)  Adjusts payment for differences in risk assumed by
559	managed care plans, based on a widely recognized clinical
560	diagnostic classification system or on categorical groups that
561	are established in consultation with the federal Centers for
562	Medicare and Medicaid Services.
563	(b)  Includes a phase-in of patient-encounter level data
564	reporting.
565	(c)  Includes criteria to adjust risk and validation of the
566	rates and risk adjustments.
567	(d)  Establishes rates in consultation with an actuary and
568	the federal Centers for Medicare and Medicaid Services and
569	supported by actuarial analysis.
570	(e)  Reimburses managed care demonstration projects on a
571	capitated basis, except for the first year of operation of a
572	provider service network. The agency shall develop contractual
573	arrangements with the provider service network for a fee-for-
574	service reimbursement methodology that does not exceed total
575	payments under the risk-adjusted capitation during the first
576	year of operation of a managed care demonstration project.
577	Contracts must, at a minimum, require provider service networks
578	to report patient-encounter data, reconcile costs to established
579	risk-adjusted capitation rates at specified periods, and specify
580	the method and process for settlement of cost differences at the
581	end of the contract period.
582	(f)  Provides actuarial benefit design analyses that
583	indicate the effect on capitation rates and benefits offered in
584	the demonstration program over a prospective 5-year period based
585	on the following assumptions:
586	1.  Growth in capitation rates which is limited to the
587	estimated growth rate in general revenue.
588	2.  Growth in capitation rates which is limited to the
589	average growth rate over the last 3 years in per-recipient
590	Medicaid expenditures.
591	3.  Growth in capitation rates which is limited to the
592	growth rate of aggregate Medicaid expenditures between the 2003-
593	2004 fiscal year and the 2004-2005 fiscal year.
594	(15)  MEDICAID OPT-OUT OPTION.--
595	(a)  The agency shall allow recipients to purchase health
596	care coverage through an employer-sponsored health insurance
597	plan instead of through a Medicaid certified plan.
598	(b)  A recipient who chooses the Medicaid opt-out option
599	shall have an opportunity for a specified period of time, as
600	authorized under a waiver granted by the Centers for Medicare
601	and Medicaid Services, to select and enroll in a Medicaid
602	certified plan. If the recipient remains in the employer-
603	sponsored plan after the specified period, the recipient shall
604	remain in the opt-out program for at least 1 year or until the
605	recipient no longer has access to employer-sponsored coverage,
606	until the employer's open enrollment period for a person who
607	opts out in order to participate in employer-sponsored coverage,
608	or until the person is no longer eligible for Medicaid,
609	whichever time period is shorter.
610	(c)  Notwithstanding any other provision of this section,
611	coverage, cost sharing, and any other component of employer-
612	sponsored health insurance shall be governed by applicable state
613	and federal laws.
614	(16)  FRAUD AND ABUSE.--
615	(a)  To minimize the risk of Medicaid fraud and abuse, the
616	agency shall ensure that applicable provisions of chapters 409,
617	414, 626, 641, and 932, Florida Statutes, relating to Medicaid
618	fraud and abuse, are applied and enforced at the demonstration
619	project sites.
620	(b)  Providers shall have the necessary certification,
621	license and credentials as required by law and waiver
622	requirements.
623	(c)  The agency shall ensure that the plan is in compliance
624	with the provisions of s. 409.912(21) and (22), Florida
625	Statutes.
626	(d)  The agency shall require each plan to establish
627	program integrity functions and activities to reduce the
628	incidence of fraud and abuse. Plans must report instances of
629	fraud and abuse pursuant to chapter 641, Florida Statutes.
630	(e)  The plan shall have written administrative and
631	management arrangements or procedures, including a mandatory
632	compliance plan, that are designed to guard against fraud and
633	abuse. The plan shall designate a compliance officer with
634	sufficient experience in health care.
635	(f)1.  The agency shall require all contractors in the
636	managed care plan to report all instances of suspected fraud and
637	abuse. A failure to report instances of suspected fraud and
638	abuse is a violation of law and subject to the penalties
639	provided by law.
640	2.  An instance of fraud and abuse in the managed care
641	plan, including, but not limited to, defrauding the state health
642	care benefit program by misrepresentation of fact in reports,
643	claims, certifications, enrollment claims, demographic
644	statistics, and patient-encounter data; misrepresentation of the
645	qualifications of persons rendering health care and ancillary
646	services; bribery and false statements relating to the delivery
647	of health care; unfair and deceptive marketing practices; and
648	managed care false claims actions, is a violation of law and
649	subject to the penalties provided by law.
650	3.  The agency shall require that all contractors make all
651	files and relevant billing and claims data accessible to state
652	regulators and investigators and that all such data be linked
653	into a unified system for seamless reviews and investigations.
654	(17)  CERTIFIED SCHOOL MATCH PROGRAM.-The agency shall
655	develop a system whereby school districts participating in the
656	certified school match program pursuant to ss. 409.908(21) and
657	1011.70 shall be reimbursed by Medicaid, subject to the
658	limitations of s. 1011.70(1), for a Medicaid-eligible child
659	participating in the services as authorized in s. 1011.70, as
660	provided for in s. 409.9071, regardless of whether the child is
661	enrolled in a capitated managed care network. Capitated managed
662	care networks must make a good-faith effort to execute
663	agreements with school districts regarding the coordinated
664	provision of services authorized under s. 1011.70. County health
665	departments delivering school-based services pursuant to ss.
666	381.0056 and 381.0057 must be reimbursed by Medicaid for the
667	federal share for a Medicaid-eligible child who receives
668	Medicaid-covered services in a school setting, regardless of
669	whether the child is enrolled in a capitated managed care
670	network. Capitated managed care networks must make a good-faith
671	effort to execute agreements with county health departments
672	regarding the coordinated provision of services to a Medicaid-
673	eligible child. To ensure continuity of care for Medicaid
674	patients, the agency, the Department of Health, and the
675	Department of Education shall develop procedures for ensuring
676	that a student's capitated managed care network provider
677	receives information relating to services provided in accordance
678	with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
679	(18)  INTEGRATED MANAGED LONG-TERM CARE SERVICES.--
680	(a)  By December 1, 2005, and contingent upon federal
681	approval, the Agency for Health Care Administration may revise
682	or apply for waivers pursuant to s. 1915 of the Social Security
683	Act or apply for experimental, pilot, or demonstration project
684	waivers pursuant to s. 1115 of the Social Security Act to create
685	an integrated, fixed-payment delivery system for Medicaid
686	recipients who are 60 years of age or older. The Agency for
687	Health Care Administration shall create the integrated, fixed-
688	payment delivery system in partnership with the Department of
689	Elderly Affairs. Rates shall be developed in accordance with 42
690	C.F.R. s. 438.60, certified by an actuary, and submitted for
691	approval to the Centers for Medicare and Medicaid Services.
692	Rates must reflect the intent to provide quality care in the
693	least-restrictive setting. The funds to be integrated shall
694	include:
695	1.  All Medicaid home and community-based waiver services
696	funds.
697	2.  All funds for all Medicaid services, including Medicaid
698	nursing home services. Inclusion of funds for nursing home
699	services shall be upon certification by the agency that the
700	integration of nursing home funds will improve coordinated care
701	for these services in a less costly manner.
702	3.  All funds paid for Medicare coinsurance and deductibles
703	for persons dually eligible for Medicaid and Medicare, for which
704	the state is responsible, but not to exceed the federal limits
705	of liability specified in the state plan.
706	(b)  The Agency for Health Care Administration shall
707	implement the integrated system initially on a pilot basis in
708	Orange, Osceola, and Seminole counties. The agency shall
709	implement the integrated system on a voluntary enrollment basis
710	in Duval, Baker, Clay and Nassau counties.
711	(c)  The Agency for Health Care Administration and the
712	Department of Elderly Affairs shall evaluate the feasibility of
713	expanding managed long-term care into additional counties using
714	a combined global budgeting system in which funding for Medicaid
715	services which would be available to provide Medicaid services
716	for an elderly person is combined into a single payment amount
717	that can be used flexibly to provide services required by a
718	participant. Under such a system, a participant is to be
719	assisted in choosing appropriate Medicaid services and providers
720	by means of choice counseling, case management, and other
721	mechanisms designed to assist recipients to choose cost-
722	efficient services in their own homes and communities rather
723	than rely on institutional placement. In evaluating the
724	feasibility of a global budgeting system, the agency and the
725	department shall ensure that such a system is cost-neutral to
726	the state and, to the extent possible, includes services funded
727	by Medicaid, state general revenue programs, and programs funded
728	under the federal Older American's Act.
729	(d)  When the agency integrates the funding for Medicaid
730	services for recipients 60 years of age or older into a managed
731	care delivery system under paragraph (a) in any area of the
732	state, the agency shall provide to recipients a choice of plans
733	which shall include:
734	1.  Entities licensed under chapter 627 or chapter 641,
735	Florida Statutes.
736	2.  Any other entity certified by the agency to accept a
737	capitation payment, including entities eligible to participate
738	in the nursing home diversion program, other qualified providers
739	as defined in s. 430.703(7), Florida Statutes, and community
740	care for the elderly lead agencies. Entities not licensed under
741	chapters 627 or 641 must meet comparable standards as defined by
742	the agency, in consultation with the Department of Elderly
743	Affairs and the Office of Insurance Regulation, to be
744	financially solvent and able to take on financial risk for
745	managed care. Community service networks that are certified
746	pursuant to the comparable standards defined by the agency are
747	not required to be licensed under chapter 641, Florida Statutes.
748	(e)  Individuals who are 60 years of age or older who have
749	developmental disabilities or who are participants in the family
750	and supported-living waiver program, the project AIDS care
751	waiver program, the traumatic brain injury and spinal cord
752	injury waiver program, the consumer-directed care waiver
753	program, or the program of all-inclusive care for the elderly
754	program, and residents of intermediate-care facilities for the
755	developmentally disabled must be excluded from the integrated
756	system.
757	(f)  When the agency implements an integrated system and
758	includes funding for Medicaid nursing home and community-based
759	care services into a managed care delivery system in any area of
760	the state, the agency shall ensure that a plan, in addition to
761	other certification requirements:
762	1.  Allows an enrollee to select any provider with whom the
763	plan has a contract.
764	2.  Makes a good faith effort to develop contracts with
765	qualified providers currently under contract with the Department
766	of Elderly Affairs, area agencies on aging, or community care
767	for the elderly lead agencies.
768	3.  Secures subcontracts with providers of nursing home and
769	community-based long-term care services sufficient to ensure
770	access to and choice of providers.
771	4.  Develops and uses a service provider qualification
772	system that describes the quality-of-care standards that
773	providers of medical, health, and long-term care services must
774	meet in order to obtain a contract from the plan.
775	5.  Makes a good faith effort to develop contracts with all
776	qualified nursing homes located in the area that are served by
777	the plan, including those designated as Gold Seal.
778	6.  Ensures that a Medicaid recipient enrolled in a managed
779	care plan who is a resident of a facility licensed under chapter
780	400, Florida Statutes, and who does not choose to move to
781	another setting is allowed to remain in the facility in which he
782	or she is currently receiving care.
783	7.  Includes persons who are in nursing homes and who
784	convert from non-Medicaid payment sources to Medicaid. Plans
785	shall be at risk for serving persons who convert to Medicaid.
786	The agency shall ensure that persons who choose community
787	alternatives instead of nursing home care and who meet level of
788	care and financial eligibility standards continue to receive
789	Medicaid.
790	8.  Demonstrates a quality assurance system and a
791	performance improvement system that is satisfactory to the
792	agency.
793	9.  Develops a system to identify recipients who have
794	special health care needs such as polypharmacy, mental health
795	and substance abuse problems, falls, chronic pain, nutritional
796	deficits, or cognitive deficits or who are ventilator-dependent
797	in order to respond to and meet these needs.
798	10.  Ensures a multidisciplinary team approach to recipient
799	management that facilitates the sharing of information among
800	providers responsible for delivering care to a recipient.
801	11.  Ensures medical oversight of care plans and service
802	delivery, regular medical evaluation of care plans, and the
803	availability of medical consultation for care managers and
804	service coordinators.
805	12.  Develops, monitors, and enforces quality-of-care
806	requirements using existing Agency for Health Care
807	Administration survey and certification data, whenever possible,
808	to avoid duplication of survey or certification activities
809	between the plans and the agency.
810	13.  Ensures a system of care coordination that includes
811	educational and training standards for care managers and service
812	coordinators.
813	14.  Develops a business plan that demonstrates the ability
814	of the plan to organize and operate a risk-bearing entity.
815	15.  Furnishes evidence of liability insurance coverage or
816	a self-insurance plan that is determined by the Office of
817	Insurance Regulation to be adequate to respond to claims for
818	injuries arising out of the furnishing of health care.
819	16.  Complies with the prompt payment of claims
820	requirements of ss. 627.613, 641.3155, and 641.513, Florida
821	Statutes.
822	17.  Provides for a periodic review of its facilities, as
823	required by the agency, which does not duplicate other
824	requirements of federal or state law. The agency shall provide
825	provider survey results to the plan.
826	18.  Provides enrollees the ability, to the extent
827	possible, to choose care providers, including nursing home,
828	assisted living, and adult day care service providers affiliated
829	with a person's religious faith or denomination, nursing home
830	and assisted living facility providers that are part of a
831	retirement community in which an enrollee resides, and nursing
832	homes and assisted living facilities that are geographically
833	located as close as possible to an enrollee's family, friends,
834	and social support system.
835	(g)  In addition to other quality assurance standards
836	required by law or by rule or in an approved federal waiver, and
837	in consultation with the Department of Elderly Affairs and area
838	agencies on aging, the agency shall develop quality assurance
839	standards that are specific to the care needs of elderly
840	individuals and that measure enrollee outcomes and satisfaction
841	with care management and home and community-based services that
842	are provided to recipients 60 years of age or older by managed
843	care plans pursuant to this section. The agency in consultation
844	with the Department of Elderly Affairs shall contract with area
845	agencies on aging to perform initial and ongoing measurement of
846	the appropriateness, effectiveness, and quality of care
847	management and home and community-based services that are
848	provided to recipients 60 years of age or older by managed care
849	plans and to collect and report the resolution of enrollee
850	grievances and complaints. The agency and the department shall
851	coordinate the quality measurement activities performed by area
852	agencies on aging with other quality assurance activities
853	required by this section in a manner that promotes efficiency
854	and avoids duplication.
855	(h)  If there is not a contractual relationship between a
856	nursing home provider and a plan in an area in which the
857	demonstration project operates, the nursing home shall cooperate
858	with the efforts of a plan to determine if a recipient would be
859	more appropriately served in a community setting, and payments
860	shall be made in accordance with Medicaid nursing home rates as
861	calculated in the Medicaid state plan.
862	(i)  The agency may develop innovative risk-sharing
863	agreements that limit the level of custodial nursing home risk
864	that the plan assumes, consistent with the intent of the
865	Legislature to reduce the use and cost of nursing home care.
866	Under risk-sharing agreements, the agency may reimburse the plan
867	or a nursing home for the cost of providing nursing home care
868	for Medicaid-eligible recipients who have been permanently
869	placed and remain in nursing home care.
870	(j)  The agency shall withhold a percentage of the
871	capitation rate that would otherwise have been paid to a plan in
872	order to create a quality reserve fund, which shall be annually
873	disbursed to those contracted plans that deliver high-quality
874	services, have a low rate of enrollee complaints, have
875	successful enrollee outcomes, are in compliance with quality
876	improvement standards, and demonstrate other indicators
877	determined by the agency to be consistent with high-quality
878	service delivery.
879	(k)  The agency shall evaluate the medical loss ratios of
880	managed care plans providing services to individuals 60 years of
881	age or older in the Medicaid program and shall annually report
882	such medical loss ratios to the Legislature. Medical loss ratios
883	are subject to an annual audit. The agency may, by rule, adopt
884	minimum medical loss ratios for such managed care plans. Failure
885	to comply with the minimum medical loss ratios shall be grounds
886	for imposition of fines, reductions in capitated payments in the
887	current fiscal year, or contract termination.
888	(l)  The agency may limit the number of persons enrolled in
889	a plan who are not nursing home facility residents but who would
890	be Medicaid eligible as defined under s. 409.904(3), Florida
891	Statutes, if served in an approved home or community-based
892	waiver program.
893	(m)  Except as otherwise provided in this section, the
894	Aging Resource Center, if available, shall be the entry point
895	for eligibility determination for persons 60 years of age or
896	older and shall provide choice counseling to assist recipients
897	in choosing a plan. If an Aging Resource Center is not operating
898	in an area or if the Aging Resource Center or area agency on
899	aging has a contractual relationship with or has any ownership
900	interest in a managed care plan, the agency may, in consultation
901	with the Department of Elderly Affairs, designate other entities
902	to perform these functions until an Aging Resource Center is
903	established and has the capacity to perform these functions.
904	(n)  In the event that a managed care plan does not meet
905	its obligations under its contract with the agency or under the
906	requirements of this section, the agency may impose liquidated
907	damages. Such liquidated damages shall be calculated by the
908	agency as reasonable estimates of the agency's financial loss
909	and are not to be used to penalize the plan. If the agency
910	imposes liquidated damages, the agency may collect those damages
911	by reducing the amount of any monthly premium payments otherwise
912	due to the plan by the amount of the damages. Liquidated damages
913	are forfeited and will not be subsequently paid to a plan upon
914	compliance or cure of default unless a determination is made
915	after appeal that the damages should not have been imposed.
916	(o)  In any area of the state in which the agency has
917	implemented a demonstration project pursuant to this section,
918	the agency may grant a modification of certificate-of-need
919	conditions related to Medicaid participation to a nursing home
920	that has experienced decreased Medicaid patient day utilization
921	due to a transition to a managed care delivery system.
922	(p)  Notwithstanding any other law to the contrary, the
923	agency shall ensure that, to the extent possible, Medicare and
924	Medicaid services are integrated. When possible, persons served
925	by the managed care delivery system who are eligible for
926	Medicare may choose to enroll in a Medicare managed health care
927	plan operated by the same entity that is placed at risk for
928	Medicaid services.
929	(q)  It is the intent of the Legislature that the agency
930	and the Department of Elderly Affairs begin discussions with the
931	federal Centers for Medicare and Medicaid Services regarding the
932	inclusion of Medicare in an integrated long-term care system.
933	(19)  FUNDING DEVELOPMENT COSTS OF ESSENTIAL COMMUNITY
934	PROVIDERS.--It is the intent of the Legislature to facilitate
935	the development of managed care delivery systems by networks of
936	essential community providers comprised of current community
937	care for the elderly lead agencies. To allow the assumption of
938	responsibility and financial risk for managing a recipient
939	through the entire continuum of Medicaid services, the agency
940	shall, subject to appropriations included in the General
941	Appropriations Act, award up to $500,000 per applicant for the
942	purpose of funding managed care delivery system development
943	costs. The terms of repayment may not extend beyond 6 years
944	after the date when the funding begins and must include payment
945	in full with a rate of interest equal to or greater than the
946	federal funds rate. The agency, in consultation with the
947	Department of Elderly Affairs shall establish a grant
948	application process for awards.
949	(20)  MEDICAID BUY-IN.--The Office of Program Policy
950	Analysis and Government Accountability shall conduct a study of
951	state programs that allow non-Medicaid eligible persons under a
952	certain income level to buy into the Medicaid program as if it
953	was private insurance. The study shall examine Medicaid buy-in
954	programs in other states to determine if there are any models
955	that can be implemented in Florida which would provide access to
956	uninsured Floridians and what effect this program would have on
957	Medicaid expenditures based on the experience of similar states.
958	The study must also examine whether the Medically Needy program
959	could be redesigned to be a Medicaid buy-in program. The study
960	must be submitted to the President of the Senate and the Speaker
961	of the House of representatives by January 1, 2006.
962	(21)  Applicability.--
963	(a)  The provisions of this section apply only to the
964	demonstration project sites approved by the Legislature.
965	(b)  The Legislature authorizes the Agency for Health Care
966	Administration to apply and enforce any provision of law not
967	referenced in this section to ensure the safety, quality, and
968	integrity of the waiver.
969	(22)  RULEMAKING.--The Agency for Health Care
970	Administration is authorized to adopt rules in consultation with
971	the appropriate state agencies to implement the provisions of
972	this section.
973	(23)  Implementation.--
974	(a)  This section does not authorize the agency to
975	implement any provision of s. 1115 of the Social Security Act
976	experimental, pilot, or demonstration project waiver to reform
977	the state Medicaid program unless approved by the Legislature.
978	(b)  The agency shall develop and submit for approval
979	applications for waivers of applicable federal laws and
980	regulations as necessary to implement the managed care
981	demonstration project as defined in this section. The agency
982	shall post all waiver applications under this section on its
983	Internet website 30 days before submitting the applications to
984	the United States Centers for Medicare and Medicaid Services.
985	All waiver applications shall be provided for review and comment
986	to the appropriate committees of the Senate and House of
987	Representatives for at least 10 working days prior to
988	submission. All waivers submitted to and approved by the United
989	States Centers for Medicare and Medicaid Services under this
990	section must be submitted to the appropriate committees of the
991	Senate and the House of Representatives in order to obtain
992	authority for implementation as required by s. 409.912(11),
993	Florida Statutes, before program implementation. The appropriate
994	committees shall recommend whether to approve the implementation
995	of the waivers to the Legislature or to the Legislative Budget
996	Commission if the Legislature is not in session. The agency
997	shall submit a plan containing a detailed timeline for
998	implementation and budgetary projections of the effect of the
999	pilot program on the total Medicaid budget for the 2006-2007
1000	through 2009-2010 fiscal years. Integration of Medicaid services
1001	to the elderly may be implemented pursuant to subsection (17).
1002	(24)  EVALUATION.--
1003	(a)  Two years after the implementation of the waiver and
1004	again 5 years after the implementation of the waiver, the Office
1005	of Program Policy Analysis and Government Accountability, shall
1006	conduct an evaluation study and analyze the impact of the
1007	Medicaid reform waiver pursuant to this section to the extent
1008	allowed in the waiver demonstration sites by the Centers for
1009	Medicare and Medicaid Services and implemented as approved by
1010	the Legislature pursuant to this section. The Office of Program
1011	Policy Analysis and Government Accountability shall consult with
1012	appropriate legislative committees to select provisions of the
1013	waiver to evaluate from among the following:
1014	1.  Demographic characteristics of the recipient of the
1015	waiver.
1016	2.  Plan types and service networks.
1017	3.  Health benefit coverage.
1018	4.  Choice counseling.
1019	5.  Disease management.
1020	6.  Pharmacy benefits.
1021	7.  Behavioral health benefits.
1022	8.  Service utilization.
1023	9.  Catastrophic coverage.
1024	10.  Enhanced benefits.
1025	11.  Medicaid opt-out option.
1026	12.  Quality assurance and accountability.
1027	13.  Fraud and abuse.
1028	14.  Cost and cost benefit of the waiver.
1029	15.  Impact of the waiver on the agency.
1030	16.  Positive impact of plans on health disparities among
1031	minorities.
1032	17.  Administrative or legal barriers to the implementation
1033	and operation of each pilot program.
1034	(b)  The Office of Program Policy Analysis and Government
1035	Accountability shall submit the evaluation study report to the
1036	agency and to the Governor, the President of the Senate, the
1037	Speaker of the House of Representatives, and the appropriate
1038	committees or councils of the Senate and the House of
1039	Representatives.
1040	(c)  One year after implementation of the integrated
1041	managed long-term care plan, the agency shall contract with an
1042	entity experienced in evaluating managed long-term care plans in
1043	another state to evaluate, at a minimum, demonstrated cost
1044	savings realized and expected, consumer satisfaction, the range
1045	of services being provided under the program, and rate-setting
1046	methodology.
1047	(d)  The agency shall submit, every 6 months after the date
1048	of waiver implementation, a status report describing the
1049	progress made on the implementation of the waiver and
1050	identification of any issues or problems to the Governor's
1051	Office of Planning and Budgeting and the appropriate committees
1052	or councils of the Senate and the House of Representatives.
1053	(e)  The agency shall provide to the appropriate committees
1054	or councils of the Senate and House of Representatives copies of
1055	any report or evaluation regarding the waiver that is submitted
1056	to the Center for Medicare and Medicaid Services.
1057	(f)  The agency shall contract for an evaluation comparison
1058	of the waiver demonstration projects with the Medipass fee-for-
1059	service program including, at a minimum:
1060	1.  Administrative or organizational structure of the
1061	service delivery system.
1062	2.  Covered services and service utilization patterns of
1063	mandatory, optional, and other services.
1064	3.  Clinical or health outcomes.
1065	4.  Cost analysis, cost avoidance, and cost benefit.
1066	(25)  REVIEW AND REPEAL.--This section shall stand repealed
1067	on July 1, 2010, unless reviewed and saved from repeal through
1068	reenactment by the Legislature.
1069	Section 3.  Section 409.912, Florida Statutes, is amended
1070	to read:
1071	409.912  Cost-effective purchasing of health care.--The
1072	agency shall purchase goods and services for Medicaid recipients
1073	in the most cost-effective manner consistent with the delivery
1074	of quality medical care. To ensure that medical services are
1075	effectively utilized, the agency may, in any case, require a
1076	confirmation or second physician's opinion of the correct
1077	diagnosis for purposes of authorizing future services under the
1078	Medicaid program. This section does not restrict access to
1079	emergency services or poststabilization care services as defined
1080	in 42 C.F.R. part 438.114. Such confirmation or second opinion
1081	shall be rendered in a manner approved by the agency. The agency
1082	shall maximize the use of prepaid per capita and prepaid
1083	aggregate fixed-sum basis services when appropriate and other
1084	alternative service delivery and reimbursement methodologies,
1085	including competitive bidding pursuant to s. 287.057, designed
1086	to facilitate the cost-effective purchase of a case-managed
1087	continuum of care. The agency shall also require providers to
1088	minimize the exposure of recipients to the need for acute
1089	inpatient, custodial, and other institutional care and the
1090	inappropriate or unnecessary use of high-cost services. The
1091	agency shall contract with a vendor to monitor and evaluate the
1092	clinical practice patterns of providers in order to identify
1093	trends that are outside the normal practice patterns of a
1094	provider's professional peers or the national guidelines of a
1095	provider's professional association. The vendor must be able to
1096	provide information and counseling to a provider whose practice
1097	patterns are outside the norms, in consultation with the agency,
1098	to improve patient care and reduce inappropriate utilization.
1099	The agency may mandate prior authorization, drug therapy
1100	management, or disease management participation for certain
1101	populations of Medicaid beneficiaries, certain drug classes, or
1102	particular drugs to prevent fraud, abuse, overuse, and possible
1103	dangerous drug interactions. The Pharmaceutical and Therapeutics
1104	Committee shall make recommendations to the agency on drugs for
1105	which prior authorization is required. The agency shall inform
1106	the Pharmaceutical and Therapeutics Committee of its decisions
1107	regarding drugs subject to prior authorization. The agency is
1108	authorized to limit the entities it contracts with or enrolls as
1109	Medicaid providers by developing a provider network through
1110	provider credentialing. The agency may competitively bid single-
1111	source-provider contracts if procurement of goods or services
1112	results in demonstrated cost savings to the state without
1113	limiting access to care. The agency may limit its network based
1114	on the assessment of beneficiary access to care, provider
1115	availability, provider quality standards, time and distance
1116	standards for access to care, the cultural competence of the
1117	provider network, demographic characteristics of Medicaid
1118	beneficiaries, practice and provider-to-beneficiary standards,
1119	appointment wait times, beneficiary use of services, provider
1120	turnover, provider profiling, provider licensure history,
1121	previous program integrity investigations and findings, peer
1122	review, provider Medicaid policy and billing compliance records,
1123	clinical and medical record audits, and other factors. Providers
1124	shall not be entitled to enrollment in the Medicaid provider
1125	network. The agency shall determine instances in which allowing
1126	Medicaid beneficiaries to purchase durable medical equipment and
1127	other goods is less expensive to the Medicaid program than long-
1128	term rental of the equipment or goods. The agency may establish
1129	rules to facilitate purchases in lieu of long-term rentals in
1130	order to protect against fraud and abuse in the Medicaid program
1131	as defined in s. 409.913. The agency may is authorized to seek
1132	federal waivers necessary to administer these policies implement
1133	this policy.
1134	(1)  The agency shall work with the Department of Children
1135	and Family Services to ensure access of children and families in
1136	the child protection system to needed and appropriate mental
1137	health and substance abuse services.
1138	(2)  The agency may enter into agreements with appropriate
1139	agents of other state agencies or of any agency of the Federal
1140	Government and accept such duties in respect to social welfare
1141	or public aid as may be necessary to implement the provisions of
1142	Title XIX of the Social Security Act and ss. 409.901-409.920.
1143	(3)  The agency may contract with health maintenance
1144	organizations certified pursuant to part I of chapter 641 for
1145	the provision of services to recipients.
1146	(4)  The agency may contract with:
1147	(a)  An entity that provides no prepaid health care
1148	services other than Medicaid services under contract with the
1149	agency and which is owned and operated by a county, county
1150	health department, or county-owned and operated hospital to
1151	provide health care services on a prepaid or fixed-sum basis to
1152	recipients, which entity may provide such prepaid services
1153	either directly or through arrangements with other providers.
1154	Such prepaid health care services entities must be licensed
1155	under parts I and III by January 1, 1998, and until then are
1156	exempt from the provisions of part I of chapter 641. An entity
1157	recognized under this paragraph which demonstrates to the
1158	satisfaction of the Office of Insurance Regulation of the
1159	Financial Services Commission that it is backed by the full
1160	faith and credit of the county in which it is located may be
1161	exempted from s. 641.225.
1162	(b)  An entity that is providing comprehensive behavioral
1163	health care services to certain Medicaid recipients through a
1164	capitated, prepaid arrangement pursuant to the federal waiver
1165	provided for by s. 409.905(5). Such an entity must be licensed
1166	under chapter 624, chapter 636, or chapter 641 and must possess
1167	the clinical systems and operational competence to manage risk
1168	and provide comprehensive behavioral health care to Medicaid
1169	recipients. As used in this paragraph, the term "comprehensive
1170	behavioral health care services" means covered mental health and
1171	substance abuse treatment services that are available to
1172	Medicaid recipients. The secretary of the Department of Children
1173	and Family Services shall approve provisions of procurements
1174	related to children in the department's care or custody prior to
1175	enrolling such children in a prepaid behavioral health plan. Any
1176	contract awarded under this paragraph must be competitively
1177	procured. In developing the behavioral health care prepaid plan
1178	procurement document, the agency shall ensure that the
1179	procurement document requires the contractor to develop and
1180	implement a plan to ensure compliance with s. 394.4574 related
1181	to services provided to residents of licensed assisted living
1182	facilities that hold a limited mental health license. Except as
1183	provided in subparagraph 8., the agency shall seek federal
1184	approval to contract with a single entity meeting these
1185	requirements to provide comprehensive behavioral health care
1186	services to all Medicaid recipients not enrolled in a managed
1187	care plan in an AHCA area. Each entity must offer sufficient
1188	choice of providers in its network to ensure recipient access to
1189	care and the opportunity to select a provider with whom they are
1190	satisfied. The network shall include all public mental health
1191	hospitals. To ensure unimpaired access to behavioral health care
1192	services by Medicaid recipients, all contracts issued pursuant
1193	to this paragraph shall require 80 percent of the capitation
1194	paid to the managed care plan, including health maintenance
1195	organizations, to be expended for the provision of behavioral
1196	health care services. In the event the managed care plan expends
1197	less than 80 percent of the capitation paid pursuant to this
1198	paragraph for the provision of behavioral health care services,
1199	the difference shall be returned to the agency. The agency shall
1200	provide the managed care plan with a certification letter
1201	indicating the amount of capitation paid during each calendar
1202	year for the provision of behavioral health care services
1203	pursuant to this section. The agency may reimburse for substance
1204	abuse treatment services on a fee-for-service basis until the
1205	agency finds that adequate funds are available for capitated,
1206	prepaid arrangements.
1207	1.  By January 1, 2001, the agency shall modify the
1208	contracts with the entities providing comprehensive inpatient
1209	and outpatient mental health care services to Medicaid
1210	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
1211	Counties, to include substance abuse treatment services.
1212	2.  By July 1, 2003, the agency and the Department of
1213	Children and Family Services shall execute a written agreement
1214	that requires collaboration and joint development of all policy,
1215	budgets, procurement documents, contracts, and monitoring plans
1216	that have an impact on the state and Medicaid community mental
1217	health and targeted case management programs.
1218	3.  Except as provided in subparagraph 8., by July 1, 2006,
1219	the agency and the Department of Children and Family Services
1220	shall contract with managed care entities in each AHCA area
1221	except area 6 or arrange to provide comprehensive inpatient and
1222	outpatient mental health and substance abuse services through
1223	capitated prepaid arrangements to all Medicaid recipients who
1224	are eligible to participate in such plans under federal law and
1225	regulation. In AHCA areas where eligible individuals number less
1226	than 150,000, the agency shall contract with a single managed
1227	care plan to provide comprehensive behavioral health services to
1228	all recipients who are not enrolled in a Medicaid health
1229	maintenance organization. The agency may contract with more than
1230	one comprehensive behavioral health provider to provide care to
1231	recipients who are not enrolled in a Medicaid health maintenance
1232	organization in AHCA areas where the eligible population exceeds
1233	150,000. Contracts for comprehensive behavioral health providers
1234	awarded pursuant to this section shall be competitively
1235	procured. Both for-profit and not-for-profit corporations shall
1236	be eligible to compete. Managed care plans contracting with the
1237	agency under subsection (3) shall provide and receive payment
1238	for the same comprehensive behavioral health benefits as
1239	provided in AHCA rules, including handbooks incorporated by
1240	reference.
1241	4.  By October 1, 2003, the agency and the department shall
1242	submit a plan to the Governor, the President of the Senate, and
1243	the Speaker of the House of Representatives which provides for
1244	the full implementation of capitated prepaid behavioral health
1245	care in all areas of the state.
1246	a.  Implementation shall begin in 2003 in those AHCA areas
1247	of the state where the agency is able to establish sufficient
1248	capitation rates.
1249	b.  If the agency determines that the proposed capitation
1250	rate in any area is insufficient to provide appropriate
1251	services, the agency may adjust the capitation rate to ensure
1252	that care will be available. The agency and the department may
1253	use existing general revenue to address any additional required
1254	match but may not over-obligate existing funds on an annualized
1255	basis.
1256	c.  Subject to any limitations provided for in the General
1257	Appropriations Act, the agency, in compliance with appropriate
1258	federal authorization, shall develop policies and procedures
1259	that allow for certification of local and state funds.
1260	5.  Children residing in a statewide inpatient psychiatric
1261	program, or in a Department of Juvenile Justice or a Department
1262	of Children and Family Services residential program approved as
1263	a Medicaid behavioral health overlay services provider shall not
1264	be included in a behavioral health care prepaid health plan or
1265	any other Medicaid managed care plan pursuant to this paragraph.
1266	6.  In converting to a prepaid system of delivery, the
1267	agency shall in its procurement document require an entity
1268	providing only comprehensive behavioral health care services to
1269	prevent the displacement of indigent care patients by enrollees
1270	in the Medicaid prepaid health plan providing behavioral health
1271	care services from facilities receiving state funding to provide
1272	indigent behavioral health care, to facilities licensed under
1273	chapter 395 which do not receive state funding for indigent
1274	behavioral health care, or reimburse the unsubsidized facility
1275	for the cost of behavioral health care provided to the displaced
1276	indigent care patient.
1277	7.  Traditional community mental health providers under
1278	contract with the Department of Children and Family Services
1279	pursuant to part IV of chapter 394, child welfare providers
1280	under contract with the Department of Children and Family
1281	Services in areas 1 and 6, and inpatient mental health providers
1282	licensed pursuant to chapter 395 must be offered an opportunity
1283	to accept or decline a contract to participate in any provider
1284	network for prepaid behavioral health services.
1285	8.  For fiscal year 2004-2005, all Medicaid eligible
1286	children, except children in areas 1 and 6, whose cases are open
1287	for child welfare services in the HomeSafeNet system, shall be
1288	enrolled in MediPass or in Medicaid fee-for-service and all
1289	their behavioral health care services including inpatient,
1290	outpatient psychiatric, community mental health, and case
1291	management shall be reimbursed on a fee-for-service basis.
1292	Beginning July 1, 2005, such children, who are open for child
1293	welfare services in the HomeSafeNet system, shall receive their
1294	behavioral health care services through a specialty prepaid plan
1295	operated by community-based lead agencies either through a
1296	single agency or formal agreements among several agencies. The
1297	specialty prepaid plan must result in savings to the state
1298	comparable to savings achieved in other Medicaid managed care
1299	and prepaid programs. Such plan must provide mechanisms to
1300	maximize state and local revenues. The specialty prepaid plan
1301	shall be developed by the agency and the Department of Children
1302	and Family Services. The agency is authorized to seek any
1303	federal waivers to implement this initiative.
1304	(c)  A federally qualified health center or an entity owned
1305	by one or more federally qualified health centers or an entity
1306	owned by other migrant and community health centers receiving
1307	non-Medicaid financial support from the Federal Government to
1308	provide health care services on a prepaid or fixed-sum basis to
1309	recipients. Such prepaid health care services entity must be
1310	licensed under parts I and III of chapter 641, but shall be
1311	prohibited from serving Medicaid recipients on a prepaid basis,
1312	until such licensure has been obtained. However, such an entity
1313	is exempt from s. 641.225 if the entity meets the requirements
1314	specified in subsections (16) (17) and (17)(18).
1315	(d)  A provider service network may be reimbursed on a fee-
1316	for-service or prepaid basis. A provider service network which
1317	is reimbursed by the agency on a prepaid basis shall be exempt
1318	from parts I and III of chapter 641, but must meet appropriate
1319	financial reserve, quality assurance, and patient rights
1320	requirements as established by the agency. The agency shall
1321	award contracts on a competitive bid basis and shall select
1322	bidders based upon price and quality of care. Medicaid
1323	recipients assigned to a demonstration project shall be chosen
1324	equally from those who would otherwise have been assigned to
1325	prepaid plans and MediPass. The agency is authorized to seek
1326	federal Medicaid waivers as necessary to implement the
1327	provisions of this section.
1328	(e)  An entity that provides only comprehensive behavioral
1329	health care services to certain Medicaid recipients through an
1330	administrative services organization agreement. Such an entity
1331	must possess the clinical systems and operational competence to
1332	provide comprehensive health care to Medicaid recipients. As
1333	used in this paragraph, the term "comprehensive behavioral
1334	health care services" means covered mental health and substance
1335	abuse treatment services that are available to Medicaid
1336	recipients. Any contract awarded under this paragraph must be
1337	competitively procured. The agency must ensure that Medicaid
1338	recipients have available the choice of at least two managed
1339	care plans for their behavioral health care services.
1340	(f)  An entity that provides in-home physician services to
1341	test the cost-effectiveness of enhanced home-based medical care
1342	to Medicaid recipients with degenerative neurological diseases
1343	and other diseases or disabling conditions associated with high
1344	costs to Medicaid. The program shall be designed to serve very
1345	disabled persons and to reduce Medicaid reimbursed costs for
1346	inpatient, outpatient, and emergency department services. The
1347	agency shall contract with vendors on a risk-sharing basis.
1348	(g)  Children's provider networks that provide care
1349	coordination and care management for Medicaid-eligible pediatric
1350	patients, primary care, authorization of specialty care, and
1351	other urgent and emergency care through organized providers
1352	designed to service Medicaid eligibles under age 18 and
1353	pediatric emergency departments' diversion programs. The
1354	networks shall provide after-hour operations, including evening
1355	and weekend hours, to promote, when appropriate, the use of the
1356	children's networks rather than hospital emergency departments.
1357	(h)  An entity authorized in s. 430.205 to contract with
1358	the agency and the Department of Elderly Affairs to provide
1359	health care and social services on a prepaid or fixed-sum basis
1360	to elderly recipients. Such prepaid health care services
1361	entities are exempt from the provisions of part I of chapter 641
1362	for the first 3 years of operation. An entity recognized under
1363	this paragraph that demonstrates to the satisfaction of the
1364	Office of Insurance Regulation that it is backed by the full
1365	faith and credit of one or more counties in which it operates
1366	may be exempted from s. 641.225.
1367	(i)  A Children's Medical Services Network, as defined in
1368	s. 391.021.
1369	(5)  By October 1, 2003, the agency and the department
1370	shall, to the extent feasible, develop a plan for implementing
1371	new Medicaid procedure codes for emergency and crisis care,
1372	supportive residential services, and other services designed to
1373	maximize the use of Medicaid funds for Medicaid-eligible
1374	recipients. The agency shall include in the agreement developed
1375	pursuant to subsection (4) a provision that ensures that the
1376	match requirements for these new procedure codes are met by
1377	certifying eligible general revenue or local funds that are
1378	currently expended on these services by the department with
1379	contracted alcohol, drug abuse, and mental health providers. The
1380	plan must describe specific procedure codes to be implemented, a
1381	projection of the number of procedures to be delivered during
1382	fiscal year 2003-2004, and a financial analysis that describes
1383	the certified match procedures, and accountability mechanisms,
1384	projects the earnings associated with these procedures, and
1385	describes the sources of state match. This plan may not be
1386	implemented in any part until approved by the Legislative Budget
1387	Commission. If such approval has not occurred by December 31,
1388	2003, the plan shall be submitted for consideration by the 2004
1389	Legislature.
1390	(5)(6)  The agency may contract with any public or private
1391	entity otherwise authorized by this section on a prepaid or
1392	fixed-sum basis for the provision of health care services to
1393	recipients. An entity may provide prepaid services to
1394	recipients, either directly or through arrangements with other
1395	entities, if each entity involved in providing services:
1396	(a)  Is organized primarily for the purpose of providing
1397	health care or other services of the type regularly offered to
1398	Medicaid recipients;
1399	(b)  Ensures that services meet the standards set by the
1400	agency for quality, appropriateness, and timeliness;
1401	(c)  Makes provisions satisfactory to the agency for
1402	insolvency protection and ensures that neither enrolled Medicaid
1403	recipients nor the agency will be liable for the debts of the
1404	entity;
1405	(d)  Submits to the agency, if a private entity, a
1406	financial plan that the agency finds to be fiscally sound and
1407	that provides for working capital in the form of cash or
1408	equivalent liquid assets excluding revenues from Medicaid
1409	premium payments equal to at least the first 3 months of
1410	operating expenses or $200,000, whichever is greater;
1411	(e)  Furnishes evidence satisfactory to the agency of
1412	adequate liability insurance coverage or an adequate plan of
1413	self-insurance to respond to claims for injuries arising out of
1414	the furnishing of health care;
1415	(f)  Provides, through contract or otherwise, for periodic
1416	review of its medical facilities and services, as required by
1417	the agency; and
1418	(g)  Provides organizational, operational, financial, and
1419	other information required by the agency.
1420	(6)(7)  The agency may contract on a prepaid or fixed-sum
1421	basis with any health insurer that:
1422	(a)  Pays for health care services provided to enrolled
1423	Medicaid recipients in exchange for a premium payment paid by
1424	the agency;
1425	(b)  Assumes the underwriting risk; and
1426	(c)  Is organized and licensed under applicable provisions
1427	of the Florida Insurance Code and is currently in good standing
1428	with the Office of Insurance Regulation.
1429	(7)(8)  The agency may contract on a prepaid or fixed-sum
1430	basis with an exclusive provider organization to provide health
1431	care services to Medicaid recipients provided that the exclusive
1432	provider organization meets applicable managed care plan
1433	requirements in this section, ss. 409.9122, 409.9123, 409.9128,
1434	and 627.6472, and other applicable provisions of law.
1435	(8)(9)  The Agency for Health Care Administration may
1436	provide cost-effective purchasing of chiropractic services on a
1437	fee-for-service basis to Medicaid recipients through
1438	arrangements with a statewide chiropractic preferred provider
1439	organization incorporated in this state as a not-for-profit
1440	corporation. The agency shall ensure that the benefit limits and
1441	prior authorization requirements in the current Medicaid program
1442	shall apply to the services provided by the chiropractic
1443	preferred provider organization.
1444	(9)(10)  The agency shall not contract on a prepaid or
1445	fixed-sum basis for Medicaid services with an entity which knows
1446	or reasonably should know that any officer, director, agent,
1447	managing employee, or owner of stock or beneficial interest in
1448	excess of 5 percent common or preferred stock, or the entity
1449	itself, has been found guilty of, regardless of adjudication, or
1450	entered a plea of nolo contendere, or guilty, to:
1451	(a)  Fraud;
1452	(b)  Violation of federal or state antitrust statutes,
1453	including those proscribing price fixing between competitors and
1454	the allocation of customers among competitors;
1455	(c)  Commission of a felony involving embezzlement, theft,
1456	forgery, income tax evasion, bribery, falsification or
1457	destruction of records, making false statements, receiving
1458	stolen property, making false claims, or obstruction of justice;
1459	or
1460	(d)  Any crime in any jurisdiction which directly relates
1461	to the provision of health services on a prepaid or fixed-sum
1462	basis.
1463	(10)(11)  The agency, after notifying the Legislature, may
1464	apply for waivers of applicable federal laws and regulations as
1465	necessary to implement more appropriate systems of health care
1466	for Medicaid recipients and reduce the cost of the Medicaid
1467	program to the state and federal governments and shall implement
1468	such programs, after legislative approval, within a reasonable
1469	period of time after federal approval. These programs must be
1470	designed primarily to reduce the need for inpatient care,
1471	custodial care and other long-term or institutional care, and
1472	other high-cost services.
1473	(a)  Prior to seeking legislative approval of such a waiver
1474	as authorized by this subsection, the agency shall provide
1475	notice and an opportunity for public comment. Notice shall be
1476	provided to all persons who have made requests of the agency for
1477	advance notice and shall be published in the Florida
1478	Administrative Weekly not less than 28 days prior to the
1479	intended action.
1480	(b)  Notwithstanding s. 216.292, funds that are
1481	appropriated to the Department of Elderly Affairs for the
1482	Assisted Living for the Elderly Medicaid waiver and are not
1483	expended shall be transferred to the agency to fund Medicaid-
1484	reimbursed nursing home care.
1485	(11)(12)  The agency shall establish a postpayment
1486	utilization control program designed to identify recipients who
1487	may inappropriately overuse or underuse Medicaid services and
1488	shall provide methods to correct such misuse.
1489	(12)(13)  The agency shall develop and provide coordinated
1490	systems of care for Medicaid recipients and may contract with
1491	public or private entities to develop and administer such
1492	systems of care among public and private health care providers
1493	in a given geographic area.
1494	(13)(14)(a)  The agency shall operate or contract for the
1495	operation of utilization management and incentive systems
1496	designed to encourage cost-effective use services.
1497	(b)  The agency shall develop a procedure for determining
1498	whether health care providers and service vendors can provide
1499	the Medicaid program with a business case that demonstrates
1500	whether a particular good or service can offset the cost of
1501	providing the good or service in an alternative setting or
1502	through other means and therefore should receive a higher
1503	reimbursement.  The business case must include, but need not be
1504	limited to:
1505	1.  A detailed description of the good or service to be
1506	provided, a description and analysis of the agency's current
1507	performance of the service, and a rationale documenting how
1508	providing the service in an alternative setting would be in the
1509	best interest of the state, the agency, and its clients.
1510	2.  A cost-benefit analysis documenting the estimated
1511	specific direct and indirect costs, savings, performance
1512	improvements, risks, and qualitative and quantitative benefits
1513	involved in or resulting from providing the service. The cost-
1514	benefit analysis must include a detailed plan and timeline
1515	identifying all actions that must be implemented to realize
1516	expected benefits.  The Secretary of the Agency for Health Care
1517	Administration shall verify that all costs, savings, and
1518	benefits are valid and achievable.
1519	(14)(15)(a)  The agency shall operate the Comprehensive
1520	Assessment and Review for Long-Term Care Services (CARES)
1521	nursing facility preadmission screening program to ensure that
1522	Medicaid payment for nursing facility care is made only for
1523	individuals whose conditions require such care and to ensure
1524	that long-term care services are provided in the setting most
1525	appropriate to the needs of the person and in the most
1526	economical manner possible. The CARES program shall also ensure
1527	that individuals participating in Medicaid home and community-
1528	based waiver programs meet criteria for those programs,
1529	consistent with approved federal waivers.
1530	(b)  The agency shall operate the CARES program through an
1531	interagency agreement with the Department of Elderly Affairs.
1532	The agency, in consultation with the Department of Elderly
1533	Affairs, may contract for any function or activity of the CARES
1534	program, including any function or activity required by 42
1535	C.F.R. part 483.20, relating to preadmission screening and
1536	resident review.
1537	(c)  Prior to making payment for nursing facility services
1538	for a Medicaid recipient, the agency must verify that the
1539	nursing facility preadmission screening program has determined
1540	that the individual requires nursing facility care and that the
1541	individual cannot be safely served in community-based programs.
1542	The nursing facility preadmission screening program shall refer
1543	a Medicaid recipient to a community-based program if the
1544	individual could be safely served at a lower cost and the
1545	recipient chooses to participate in such program.     (d)  For the
1546	purpose of initiating immediate prescreening and diversion
1547	assistance for individuals residing in nursing homes and in
1548	order to make families aware of alternative long-term care
1549	resources so that they may choose a more cost-effective setting
1550	for long-term placement, CARES staff shall conduct an assessment
1551	and review of a sample of individuals whose nursing home stay is
1552	expected to exceed 20 days, regardless of the initial funding
1553	source for the nursing home placement. CARES staff shall provide
1554	counseling and referral services to these individuals regarding
1555	choosing appropriate long-term care alternatives. This paragraph
1556	does not apply to continuing care facilities licensed under
1557	chapter 651 or to retirement communities that provide a
1558	combination of nursing home, independent living, and other long-
1559	term care services.
1560	(e)  By January 15 of each year, the agency shall submit a
1561	report to the Legislature and the Office of Long-Term-Care
1562	Policy describing the operations of the CARES program. The
1563	report must describe:
1564	1.  Rate of diversion to community alternative programs;
1565	2.  CARES program staffing needs to achieve additional
1566	diversions;
1567	3.  Reasons the program is unable to place individuals in
1568	less restrictive settings when such individuals desired such
1569	services and could have been served in such settings;
1570	4.  Barriers to appropriate placement, including barriers
1571	due to policies or operations of other agencies or state-funded
1572	programs; and
1573	5.  Statutory changes necessary to ensure that individuals
1574	in need of long-term care services receive care in the least
1575	restrictive environment.
1576	(f)  The Department of Elderly Affairs shall track
1577	individuals over time who are assessed under the CARES program
1578	and who are diverted from nursing home placement. By January 15
1579	of each year, the department shall submit to the Legislature and
1580	the Office of Long-Term-Care Policy a longitudinal study of the
1581	individuals who are diverted from nursing home placement. The
1582	study must include:
1583	1.  The demographic characteristics of the individuals
1584	assessed and diverted from nursing home placement, including,
1585	but not limited to, age, race, gender, frailty, caregiver
1586	status, living arrangements, and geographic location;
1587	2.  A summary of community services provided to individuals
1588	for 1 year after assessment and diversion;
1589	3.  A summary of inpatient hospital admissions for
1590	individuals who have been diverted; and
1591	4.  A summary of the length of time between diversion and
1592	subsequent entry into a nursing home or death.
1593	(g)  By July 1, 2005, the department and the Agency for
1594	Health Care Administration shall report to the President of the
1595	Senate and the Speaker of the House of Representatives regarding
1596	the impact to the state of modifying level-of-care criteria to
1597	eliminate the Intermediate II level of care.
1598	(15)(16)(a)  The agency shall identify health care
1599	utilization and price patterns within the Medicaid program which
1600	are not cost-effective or medically appropriate and assess the
1601	effectiveness of new or alternate methods of providing and
1602	monitoring service, and may implement such methods as it
1603	considers appropriate. Such methods may include disease
1604	management initiatives, an integrated and systematic approach
1605	for managing the health care needs of recipients who are at risk
1606	of or diagnosed with a specific disease by using best practices,
1607	prevention strategies, clinical-practice improvement, clinical
1608	interventions and protocols, outcomes research, information
1609	technology, and other tools and resources to reduce overall
1610	costs and improve measurable outcomes.
1611	(b)  The responsibility of the agency under this subsection
1612	shall include the development of capabilities to identify actual
1613	and optimal practice patterns; patient and provider educational
1614	initiatives; methods for determining patient compliance with
1615	prescribed treatments; fraud, waste, and abuse prevention and
1616	detection programs; and beneficiary case management programs.
1617	1.  The practice pattern identification program shall
1618	evaluate practitioner prescribing patterns based on national and
1619	regional practice guidelines, comparing practitioners to their
1620	peer groups. The agency and its Drug Utilization Review Board
1621	shall consult with the Department of Health and a panel of
1622	practicing health care professionals consisting of the
1623	following: the Speaker of the House of Representatives and the
1624	President of the Senate shall each appoint three physicians
1625	licensed under chapter 458 or chapter 459; and the Governor
1626	shall appoint two pharmacists licensed under chapter 465 and one
1627	dentist licensed under chapter 466 who is an oral surgeon. Terms
1628	of the panel members shall expire at the discretion of the
1629	appointing official. The panel shall begin its work by August 1,
1630	1999, regardless of the number of appointments made by that
1631	date. The advisory panel shall be responsible for evaluating
1632	treatment guidelines and recommending ways to incorporate their
1633	use in the practice pattern identification program.
1634	Practitioners who are prescribing inappropriately or
1635	inefficiently, as determined by the agency, may have their
1636	prescribing of certain drugs subject to prior authorization or
1637	may be terminated from all participation in the Medicaid
1638	program.
1639	2.  The agency shall also develop educational interventions
1640	designed to promote the proper use of medications by providers
1641	and beneficiaries.
1642	3.  The agency shall implement a pharmacy fraud, waste, and
1643	abuse initiative that may include a surety bond or letter of
1644	credit requirement for participating pharmacies, enhanced
1645	provider auditing practices, the use of additional fraud and
1646	abuse software, recipient management programs for beneficiaries
1647	inappropriately using their benefits, and other steps that will
1648	eliminate provider and recipient fraud, waste, and abuse. The
1649	initiative shall address enforcement efforts to reduce the
1650	number and use of counterfeit prescriptions.
1651	4.  By September 30, 2002, the agency shall contract with
1652	an entity in the state to implement a wireless handheld clinical
1653	pharmacology drug information database for practitioners. The
1654	initiative shall be designed to enhance the agency's efforts to
1655	reduce fraud, abuse, and errors in the prescription drug benefit
1656	program and to otherwise further the intent of this paragraph.
1657	5.  The agency may apply for any federal waivers needed to
1658	administer implement this paragraph.
1659	(16)(17)  An entity contracting on a prepaid or fixed-sum
1660	basis shall, in addition to meeting any applicable statutory
1661	surplus requirements, also maintain at all times in the form of
1662	cash, investments that mature in less than 180 days allowable as
1663	admitted assets by the Office of Insurance Regulation, and
1664	restricted funds or deposits controlled by the agency or the
1665	Office of Insurance Regulation, a surplus amount equal to one-
1666	and-one-half times the entity's monthly Medicaid prepaid
1667	revenues. As used in this subsection, the term "surplus" means
1668	the entity's total assets minus total liabilities. If an
1669	entity's surplus falls below an amount equal to one-and-one-half
1670	times the entity's monthly Medicaid prepaid revenues, the agency
1671	shall prohibit the entity from engaging in marketing and
1672	preenrollment activities, shall cease to process new
1673	enrollments, and shall not renew the entity's contract until the
1674	required balance is achieved. The requirements of this
1675	subsection do not apply:
1676	(a)  Where a public entity agrees to fund any deficit
1677	incurred by the contracting entity; or
1678	(b)  Where the entity's performance and obligations are
1679	guaranteed in writing by a guaranteeing organization which:
1680	1.  Has been in operation for at least 5 years and has
1681	assets in excess of $50 million; or
1682	2.  Submits a written guarantee acceptable to the agency
1683	which is irrevocable during the term of the contracting entity's
1684	contract with the agency and, upon termination of the contract,
1685	until the agency receives proof of satisfaction of all
1686	outstanding obligations incurred under the contract.
1687	(17)(18)(a)  The agency may require an entity contracting
1688	on a prepaid or fixed-sum basis to establish a restricted
1689	insolvency protection account with a federally guaranteed
1690	financial institution licensed to do business in this state. The
1691	entity shall deposit into that account 5 percent of the
1692	capitation payments made by the agency each month until a
1693	maximum total of 2 percent of the total current contract amount
1694	is reached. The restricted insolvency protection account may be
1695	drawn upon with the authorized signatures of two persons
1696	designated by the entity and two representatives of the agency.
1697	If the agency finds that the entity is insolvent, the agency may
1698	draw upon the account solely with the two authorized signatures
1699	of representatives of the agency, and the funds may be disbursed
1700	to meet financial obligations incurred by the entity under the
1701	prepaid contract. If the contract is terminated, expired, or not
1702	continued, the account balance must be released by the agency to
1703	the entity upon receipt of proof of satisfaction of all
1704	outstanding obligations incurred under this contract.
1705	(b)  The agency may waive the insolvency protection account
1706	requirement in writing when evidence is on file with the agency
1707	of adequate insolvency insurance and reinsurance that will
1708	protect enrollees if the entity becomes unable to meet its
1709	obligations.
1710	(18)(19)  An entity that contracts with the agency on a
1711	prepaid or fixed-sum basis for the provision of Medicaid
1712	services shall reimburse any hospital or physician that is
1713	outside the entity's authorized geographic service area as
1714	specified in its contract with the agency, and that provides
1715	services authorized by the entity to its members, at a rate
1716	negotiated with the hospital or physician for the provision of
1717	services or according to the lesser of the following:
1718	(a)  The usual and customary charges made to the general
1719	public by the hospital or physician; or
1720	(b)  The Florida Medicaid reimbursement rate established
1721	for the hospital or physician.
1722	(19)(20)  When a merger or acquisition of a Medicaid
1723	prepaid contractor has been approved by the Office of Insurance
1724	Regulation pursuant to s. 628.4615, the agency shall approve the
1725	assignment or transfer of the appropriate Medicaid prepaid
1726	contract upon request of the surviving entity of the merger or
1727	acquisition if the contractor and the other entity have been in
1728	good standing with the agency for the most recent 12-month
1729	period, unless the agency determines that the assignment or
1730	transfer would be detrimental to the Medicaid recipients or the
1731	Medicaid program. To be in good standing, an entity must not
1732	have failed accreditation or committed any material violation of
1733	the requirements of s. 641.52 and must meet the Medicaid
1734	contract requirements. For purposes of this section, a merger or
1735	acquisition means a change in controlling interest of an entity,
1736	including an asset or stock purchase.
1737	(20)(21)  Any entity contracting with the agency pursuant
1738	to this section to provide health care services to Medicaid
1739	recipients is prohibited from engaging in any of the following
1740	practices or activities:
1741	(a)  Practices that are discriminatory, including, but not
1742	limited to, attempts to discourage participation on the basis of
1743	actual or perceived health status.
1744	(b)  Activities that could mislead or confuse recipients,
1745	or misrepresent the organization, its marketing representatives,
1746	or the agency. Violations of this paragraph include, but are not
1747	limited to:
1748	1.  False or misleading claims that marketing
1749	representatives are employees or representatives of the state or
1750	county, or of anyone other than the entity or the organization
1751	by whom they are reimbursed.
1752	2.  False or misleading claims that the entity is
1753	recommended or endorsed by any state or county agency, or by any
1754	other organization which has not certified its endorsement in
1755	writing to the entity.
1756	3.  False or misleading claims that the state or county
1757	recommends that a Medicaid recipient enroll with an entity.
1758	4.  Claims that a Medicaid recipient will lose benefits
1759	under the Medicaid program, or any other health or welfare
1760	benefits to which the recipient is legally entitled, if the
1761	recipient does not enroll with the entity.
1762	(c)  Granting or offering of any monetary or other valuable
1763	consideration for enrollment, except as authorized by subsection
1764	(24).
1765	(d)  Door-to-door solicitation of recipients who have not
1766	contacted the entity or who have not invited the entity to make
1767	a presentation.
1768	(e)  Solicitation of Medicaid recipients by marketing
1769	representatives stationed in state offices unless approved and
1770	supervised by the agency or its agent and approved by the
1771	affected state agency when solicitation occurs in an office of
1772	the state agency. The agency shall ensure that marketing
1773	representatives stationed in state offices shall market their
1774	managed care plans to Medicaid recipients only in designated
1775	areas and in such a way as to not interfere with the recipients'
1776	activities in the state office.
1777	(f)  Enrollment of Medicaid recipients.
1778	(21)(22)  The agency may impose a fine for a violation of
1779	this section or the contract with the agency by a person or
1780	entity that is under contract with the agency. With respect to
1781	any nonwillful violation, such fine shall not exceed $2,500 per
1782	violation. In no event shall such fine exceed an aggregate
1783	amount of $10,000 for all nonwillful violations arising out of
1784	the same action. With respect to any knowing and willful
1785	violation of this section or the contract with the agency, the
1786	agency may impose a fine upon the entity in an amount not to
1787	exceed $20,000 for each such violation. In no event shall such
1788	fine exceed an aggregate amount of $100,000 for all knowing and
1789	willful violations arising out of the same action.
1790	(22)(23)  A health maintenance organization or a person or
1791	entity exempt from chapter 641 that is under contract with the
1792	agency for the provision of health care services to Medicaid
1793	recipients may not use or distribute marketing materials used to
1794	solicit Medicaid recipients, unless such materials have been
1795	approved by the agency. The provisions of this subsection do not
1796	apply to general advertising and marketing materials used by a
1797	health maintenance organization to solicit both non-Medicaid
1798	subscribers and Medicaid recipients.
1799	(23)(24)  Upon approval by the agency, health maintenance
1800	organizations and persons or entities exempt from chapter 641
1801	that are under contract with the agency for the provision of
1802	health care services to Medicaid recipients may be permitted
1803	within the capitation rate to provide additional health benefits
1804	that the agency has found are of high quality, are practicably
1805	available, provide reasonable value to the recipient, and are
1806	provided at no additional cost to the state.
1807	(24)(25)  The agency shall utilize the statewide health
1808	maintenance organization complaint hotline for the purpose of
1809	investigating and resolving Medicaid and prepaid health plan
1810	complaints, maintaining a record of complaints and confirmed
1811	problems, and receiving disenrollment requests made by
1812	recipients.
1813	(25)(26)  The agency shall require the publication of the
1814	health maintenance organization's and the prepaid health plan's
1815	consumer services telephone numbers and the "800" telephone
1816	number of the statewide health maintenance organization
1817	complaint hotline on each Medicaid identification card issued by
1818	a health maintenance organization or prepaid health plan
1819	contracting with the agency to serve Medicaid recipients and on
1820	each subscriber handbook issued to a Medicaid recipient.
1821	(26)(27)  The agency shall establish a health care quality
1822	improvement system for those entities contracting with the
1823	agency pursuant to this section, incorporating all the standards
1824	and guidelines developed by the Medicaid Bureau of the Health
1825	Care Financing Administration as a part of the quality assurance
1826	reform initiative. The system shall include, but need not be
1827	limited to, the following:
1828	(a)  Guidelines for internal quality assurance programs,
1829	including standards for:
1830	1.  Written quality assurance program descriptions.
1831	2.  Responsibilities of the governing body for monitoring,
1832	evaluating, and making improvements to care.
1833	3.  An active quality assurance committee.
1834	4.  Quality assurance program supervision.
1835	5.  Requiring the program to have adequate resources to
1836	effectively carry out its specified activities.
1837	6.  Provider participation in the quality assurance
1838	program.
1839	7.  Delegation of quality assurance program activities.
1840	8.  Credentialing and recredentialing.
1841	9.  Enrollee rights and responsibilities.
1842	10.  Availability and accessibility to services and care.
1843	11.  Ambulatory care facilities.
1844	12.  Accessibility and availability of medical records, as
1845	well as proper recordkeeping and process for record review.
1846	13.  Utilization review.
1847	14.  A continuity of care system.
1848	15.  Quality assurance program documentation.
1849	16.  Coordination of quality assurance activity with other
1850	management activity.
1851	17.  Delivering care to pregnant women and infants; to
1852	elderly and disabled recipients, especially those who are at
1853	risk of institutional placement; to persons with developmental
1854	disabilities; and to adults who have chronic, high-cost medical
1855	conditions.
1856	(b)  Guidelines which require the entities to conduct
1857	quality-of-care studies which:
1858	1.  Target specific conditions and specific health service
1859	delivery issues for focused monitoring and evaluation.
1860	2.  Use clinical care standards or practice guidelines to
1861	objectively evaluate the care the entity delivers or fails to
1862	deliver for the targeted clinical conditions and health services
1863	delivery issues.
1864	3.  Use quality indicators derived from the clinical care
1865	standards or practice guidelines to screen and monitor care and
1866	services delivered.
1867	(c)  Guidelines for external quality review of each
1868	contractor which require: focused studies of patterns of care;
1869	individual care review in specific situations; and followup
1870	activities on previous pattern-of-care study findings and
1871	individual-care-review findings. In designing the external
1872	quality review function and determining how it is to operate as
1873	part of the state's overall quality improvement system, the
1874	agency shall construct its external quality review organization
1875	and entity contracts to address each of the following:
1876	1.  Delineating the role of the external quality review
1877	organization.
1878	2.  Length of the external quality review organization
1879	contract with the state.
1880	3.  Participation of the contracting entities in designing
1881	external quality review organization review activities.
1882	4.  Potential variation in the type of clinical conditions
1883	and health services delivery issues to be studied at each plan.
1884	5.  Determining the number of focused pattern-of-care
1885	studies to be conducted for each plan.
1886	6.  Methods for implementing focused studies.
1887	7.  Individual care review.
1888	8.  Followup activities.
1889	(27)(28)  In order to ensure that children receive health
1890	care services for which an entity has already been compensated,
1891	an entity contracting with the agency pursuant to this section
1892	shall achieve an annual Early and Periodic Screening, Diagnosis,
1893	and Treatment (EPSDT) Service screening rate of at least 60
1894	percent for those recipients continuously enrolled for at least
1895	8 months. The agency shall develop a method by which the EPSDT
1896	screening rate shall be calculated. For any entity which does
1897	not achieve the annual 60 percent rate, the entity must submit a
1898	corrective action plan for the agency's approval. If the entity
1899	does not meet the standard established in the corrective action
1900	plan during the specified timeframe, the agency is authorized to
1901	impose appropriate contract sanctions. At least annually, the
1902	agency shall publicly release the EPSDT Services screening rates
1903	of each entity it has contracted with on a prepaid basis to
1904	serve Medicaid recipients.
1905	(28)(29)  The agency shall perform enrollments and
1906	disenrollments for Medicaid recipients who are eligible for
1907	MediPass or managed care plans. Notwithstanding the prohibition
1908	contained in paragraph (20)(21)(f), managed care plans may
1909	perform preenrollments of Medicaid recipients under the
1910	supervision of the agency or its agents. For the purposes of
1911	this section, "preenrollment" means the provision of marketing
1912	and educational materials to a Medicaid recipient and assistance
1913	in completing the application forms, but shall not include
1914	actual enrollment into a managed care plan. An application for
1915	enrollment shall not be deemed complete until the agency or its
1916	agent verifies that the recipient made an informed, voluntary
1917	choice. The agency, in cooperation with the Department of
1918	Children and Family Services, may test new marketing initiatives
1919	to inform Medicaid recipients about their managed care options
1920	at selected sites. The agency shall report to the Legislature on
1921	the effectiveness of such initiatives. The agency may contract
1922	with a third party to perform managed care plan and MediPass
1923	enrollment and disenrollment services for Medicaid recipients
1924	and is authorized to adopt rules to implement such services. The
1925	agency may adjust the capitation rate only to cover the costs of
1926	a third-party enrollment and disenrollment contract, and for
1927	agency supervision and management of the managed care plan
1928	enrollment and disenrollment contract.
1929	(29)(30)  Any lists of providers made available to Medicaid
1930	recipients, MediPass enrollees, or managed care plan enrollees
1931	shall be arranged alphabetically showing the provider's name and
1932	specialty and, separately, by specialty in alphabetical order.
1933	(30)(31)  The agency shall establish an enhanced managed
1934	care quality assurance oversight function, to include at least
1935	the following components:
1936	(a)  At least quarterly analysis and followup, including
1937	sanctions as appropriate, of managed care participant
1938	utilization of services.
1939	(b)  At least quarterly analysis and followup, including
1940	sanctions as appropriate, of quality findings of the Medicaid
1941	peer review organization and other external quality assurance
1942	programs.
1943	(c)  At least quarterly analysis and followup, including
1944	sanctions as appropriate, of the fiscal viability of managed
1945	care plans.
1946	(d)  At least quarterly analysis and followup, including
1947	sanctions as appropriate, of managed care participant
1948	satisfaction and disenrollment surveys.
1949	(e)  The agency shall conduct regular and ongoing Medicaid
1950	recipient satisfaction surveys.
1951
1952	The analyses and followup activities conducted by the agency
1953	under its enhanced managed care quality assurance oversight
1954	function shall not duplicate the activities of accreditation
1955	reviewers for entities regulated under part III of chapter 641,
1956	but may include a review of the finding of such reviewers.
1957	(31)(32)  Each managed care plan that is under contract
1958	with the agency to provide health care services to Medicaid
1959	recipients shall annually conduct a background check with the
1960	Florida Department of Law Enforcement of all persons with
1961	ownership interest of 5 percent or more or executive management
1962	responsibility for the managed care plan and shall submit to the
1963	agency information concerning any such person who has been found
1964	guilty of, regardless of adjudication, or has entered a plea of
1965	nolo contendere or guilty to, any of the offenses listed in s.
1966	435.03.
1967	(34)(33)  The agency shall, by rule, develop a process
1968	whereby a Medicaid managed care plan enrollee who wishes to
1969	enter hospice care may be disenrolled from the managed care plan
1970	within 24 hours after contacting the agency regarding such
1971	request. The agency rule shall include a methodology for the
1972	agency to recoup managed care plan payments on a pro rata basis
1973	if payment has been made for the enrollment month when
1974	disenrollment occurs.
1975	(33)(34)  The agency and entities that which contract with
1976	the agency to provide health care services to Medicaid
1977	recipients under this section or ss. 409.91211 and s. 409.9122
1978	must comply with the provisions of s. 641.513 in providing
1979	emergency services and care to Medicaid recipients and MediPass
1980	recipients. Where feasible, safe, and cost-effective, the agency
1981	shall encourage hospitals, emergency medical services providers,
1982	and other public and private health care providers to work
1983	together in their local communities to enter into agreements or
1984	arrangements to ensure access to alternatives to emergency
1985	services and care for those Medicaid recipients who need
1986	nonemergent care. The agency shall coordinate with hospitals,
1987	emergency medical services providers, private health plans,
1988	capitated managed care networks as established in s. 409.91211,
1989	and other public and private health care providers to implement
1990	the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1991	and 641.31097 to develop and implement emergency department
1992	diversion programs for Medicaid recipients.
1993	(38)(39)(a)  The agency shall implement a Medicaid
1994	prescribed-drug spending-control program that includes the
1995	following components:
1996	11.a.  The agency shall implement a Medicaid prescription-
1997	drug-management system. The agency may contract with a vendor
1998	that has experience in operating prescription-drug-management
1999	systems in order to implement this system. Any management system
2000	that is implemented in accordance with this subparagraph must
2001	rely on cooperation between physicians and pharmacists to
2002	determine appropriate practice patterns and clinical guidelines
2003	to improve the prescribing, dispensing, and use of drugs in the
2004	Medicaid program. The agency may seek federal waivers to
2005	implement this program.
2006	b.  The drug-management system must be designed to improve
2007	the quality of care and prescribing practices based on best-
2008	practice guidelines, improve patient adherence to medication
2009	plans, reduce clinical risk, and lower prescribed drug costs and
2010	the rate of inappropriate spending on Medicaid prescription
2011	drugs. The program must:
2012	(I)  Provide for the development and adoption of best-
2013	practice guidelines for the prescribing and use of drugs in the
2014	Medicaid program, including translating best-practice guidelines
2015	into practice; reviewing prescriber patterns and comparing them
2016	to indicators that are based on national standards and practice
2017	patterns of clinical peers in their community, statewide, and
2018	nationally; and determine deviations from best-practice
2019	guidelines.
2020	(II)  Implement processes for providing feedback to and
2021	educating prescribers using best-practice educational materials
2022	and peer-to-peer consultation.
2023	(III)  Assess Medicaid recipients who are outliers in their
2024	use of a single or multiple prescription drugs with regard to
2025	the numbers and types of drugs taken, drug dosages, combination
2026	drug therapies, and other indicators of improper use of
2027	prescription drugs.
2028	(IV)  Alert prescribers to patients who fail to refill
2029	prescriptions in a timely fashion, are prescribed multiple drugs
2030	that may be redundant or contraindicated, or may have other
2031	potential medication problems.
2032	(V)  Track spending trends for prescription drugs and
2033	deviation from best practice guidelines.
2034	(VI)  Use educational and technological approaches to
2035	promote best practices, educate consumers, and train prescribers
2036	in the use of practice guidelines.
2037	(VII)  Disseminate electronic and published materials.
2038	(VIII)  Hold statewide and regional conferences.
2039	(IX)  Implement disease-management programs in cooperation
2040	with physicians and pharmacists, along with a model quality-
2041	based medication component for individuals having chronic
2042	medical conditions.
2043	12.  The agency is authorized to contract for drug rebate
2044	administration, including, but not limited to, calculating
2045	rebate amounts, invoicing manufacturers, negotiating disputes
2046	with manufacturers, and maintaining a database of rebate
2047	collections.
2048	13.  The agency may specify the preferred daily dosing form
2049	or strength for the purpose of promoting best practices with
2050	regard to the prescribing of certain drugs as specified in the
2051	General Appropriations Act and ensuring cost-effective
2052	prescribing practices.
2053	14.  The agency may require prior authorization for the
2054	off-label use of Medicaid-covered prescribed drugs as specified
2055	in the General Appropriations Act. The agency may, but is not
2056	required to, preauthorize the use of a product for an indication
2057	not in the approved labeling. Prior authorization may require
2058	the prescribing professional to provide information about the
2059	rationale and supporting medical evidence for the off-label use
2060	of a drug.
2061	17.15.  The agency shall implement a return and reuse
2062	program for drugs dispensed by pharmacies to institutional
2063	recipients, which includes payment of a $5 restocking fee for
2064	the implementation and operation of the program. The return and
2065	reuse program shall be implemented electronically and in a
2066	manner that promotes efficiency. The program must permit a
2067	pharmacy to exclude drugs from the program if it is not
2068	practical or cost-effective for the drug to be included and must
2069	provide for the return to inventory of drugs that cannot be
2070	credited or returned in a cost-effective manner. The agency
2071	shall determine if the program has reduced the amount of
2072	Medicaid prescription drugs which are destroyed on an annual
2073	basis and if there are additional ways to ensure more
2074	prescription drugs are not destroyed which could safely be
2075	reused. The agency's conclusion and recommendations shall be
2076	reported to the Legislature by December 1, 2005.
2077	(b)  The agency shall implement this subsection to the
2078	extent that funds are appropriated to administer the Medicaid
2079	prescribed-drug spending-control program. The agency may
2080	contract all or any part of this program to private
2081	organizations.
2082	(c)  The agency shall submit quarterly reports to the
2083	Governor, the President of the Senate, and the Speaker of the
2084	House of Representatives which must include, but need not be
2085	limited to, the progress made in implementing this subsection
2086	and its effect on Medicaid prescribed-drug expenditures.
2087	39(40)  Notwithstanding the provisions of chapter 287, the
2088	agency may, at its discretion, renew a contract or contracts for
2089	fiscal intermediary services one or more times for such periods
2090	as the agency may decide; however, all such renewals may not
2091	combine to exceed a total period longer than the term of the
2092	original contract.
2093	(40)(41)  The agency shall provide for the development of a
2094	demonstration project by establishment in Miami-Dade County of a
2095	long-term-care facility licensed pursuant to chapter 395 to
2096	improve access to health care for a predominantly minority,
2097	medically underserved, and medically complex population and to
2098	evaluate alternatives to nursing home care and general acute
2099	care for such population. Such project is to be located in a
2100	health care condominium and colocated with licensed facilities
2101	providing a continuum of care. The establishment of this project
2102	is not subject to the provisions of s. 408.036 or s. 408.039.
2103	The agency shall report its findings to the Governor, the
2104	President of the Senate, and the Speaker of the House of
2105	Representatives by January 1, 2003.
2106	(41)(42)  The agency shall develop and implement a
2107	utilization management program for Medicaid-eligible recipients
2108	for the management of occupational, physical, respiratory, and
2109	speech therapies. The agency shall establish a utilization
2110	program that may require prior authorization in order to ensure
2111	medically necessary and cost-effective treatments. The program
2112	shall be operated in accordance with a federally approved waiver
2113	program or state plan amendment. The agency may seek a federal
2114	waiver or state plan amendment to implement this program. The
2115	agency may also competitively procure these services from an
2116	outside vendor on a regional or statewide basis.
2117	(42)(43)  The agency may contract on a prepaid or fixed-sum
2118	basis with appropriately licensed prepaid dental health plans to
2119	provide dental services.
2120	(43)(44)  The Agency for Health Care Administration shall
2121	ensure that any Medicaid managed care plan as defined in s.
2122	409.9122(2)(h), whether paid on a capitated basis or a shared
2123	savings basis, is cost-effective. For purposes of this
2124	subsection, the term "cost-effective" means that a network's
2125	per-member, per-month costs to the state, including, but not
2126	limited to, fee-for-service costs, administrative costs, and
2127	case-management fees, must be no greater than the state's costs
2128	associated with contracts for Medicaid services established
2129	under subsection (3), which shall be actuarially adjusted for
2130	case mix, model, and service area. The agency shall conduct
2131	actuarially sound audits adjusted for case mix and model in
2132	order to ensure such cost-effectiveness and shall publish the
2133	audit results on its Internet website and submit the audit
2134	results annually to the Governor, the President of the Senate,
2135	and the Speaker of the House of Representatives no later than
2136	December 31 of each year. Contracts established pursuant to this
2137	subsection which are not cost-effective may not be renewed.
2138	(44)(45)  Subject to the availability of funds, the agency
2139	shall mandate a recipient's participation in a provider lock-in
2140	program, when appropriate, if a recipient is found by the agency
2141	to have used Medicaid goods or services at a frequency or amount
2142	not medically necessary, limiting the receipt of goods or
2143	services to medically necessary providers after the 21-day
2144	appeal process has ended, for a period of not less than 1 year.
2145	The lock-in programs shall include, but are not limited to,
2146	pharmacies, medical doctors, and infusion clinics. The
2147	limitation does not apply to emergency services and care
2148	provided to the recipient in a hospital emergency department.
2149	The agency shall seek any federal waivers necessary to implement
2150	this subsection. The agency shall adopt any rules necessary to
2151	comply with or administer this subsection.
2152	(45)(46)  The agency shall seek a federal waiver for
2153	permission to terminate the eligibility of a Medicaid recipient
2154	who has been found to have committed fraud, through judicial or
2155	administrative determination, two times in a period of 5 years.
2156	(46)(47)  The agency shall conduct a study of available
2157	electronic systems for the purpose of verifying the identity and
2158	eligibility of a Medicaid recipient. The agency shall recommend
2159	to the Legislature a plan to implement an electronic
2160	verification system for Medicaid recipients by January 31, 2005.
2161	(47)(48)  A provider is not entitled to enrollment in the
2162	Medicaid provider network. The agency may implement a Medicaid
2163	fee-for-service provider network controls, including, but not
2164	limited to, competitive procurement and provider credentialing.
2165	If a credentialing process is used, the agency may limit its
2166	provider network based upon the following considerations:
2167	beneficiary access to care, provider availability, provider
2168	quality standards and quality assurance processes, cultural
2169	competency, demographic characteristics of beneficiaries,
2170	practice standards, service wait times, provider turnover,
2171	provider licensure and accreditation history, program integrity
2172	history, peer review, Medicaid policy and billing compliance
2173	records, clinical and medical record audit findings, and such
2174	other areas that are considered necessary by the agency to
2175	ensure the integrity of the program.
2176	(48)(49)  The agency shall contract with established
2177	minority physician networks that provide services to
2178	historically underserved minority patients. The networks must
2179	provide cost-effective Medicaid services, comply with the
2180	requirements to be a MediPass provider, and provide their
2181	primary care physicians with access to data and other management
2182	tools necessary to assist them in ensuring the appropriate use
2183	of services, including inpatient hospital services and
2184	pharmaceuticals.
2185	(a)  The agency shall provide for the development and
2186	expansion of minority physician networks in each service area to
2187	provide services to Medicaid recipients who are eligible to
2188	participate under federal law and rules.
2189	(b)  The agency shall reimburse each minority physician
2190	network as a fee-for-service provider, including the case
2191	management fee for primary care, or as a capitated rate provider
2192	for Medicaid services. Any savings shall be shared with the
2193	minority physician networks pursuant to the contract.
2194	(c)  For purposes of this subsection, the term "cost-
2195	effective" means that a network's per-member, per-month costs to
2196	the state, including, but not limited to, fee-for-service costs,
2197	administrative costs, and case-management fees, must be no
2198	greater than the state's costs associated with contracts for
2199	Medicaid services established under subsection (3), which shall
2200	be actuarially adjusted for case mix, model, and service area.
2201	The agency shall conduct actuarially sound audits adjusted for
2202	case mix and model in order to ensure such cost-effectiveness
2203	and shall publish the audit results on its Internet website and
2204	submit the audit results annually to the Governor, the President
2205	of the Senate, and the Speaker of the House of Representatives
2206	no later than December 31. Contracts established pursuant to
2207	this subsection which are not cost-effective may not be renewed.
2208	(d)  The agency may apply for any federal waivers needed to
2209	implement this subsection.
2210	(50)  To the extent permitted by federal law and as allowed
2211	under s. 409.906, the agency shall provide reimbursement for
2212	emergency mental health care services for Medicaid recipients in
2213	crisis-stabilization facilities licensed under s. 394.875 as
2214	long as those services are less expensive than the same services
2215	provided in a hospital setting.
2216	Section 4.  Paragraphs (a) and (j) of subsection (2) of
2217	section 409.9122, Florida Statutes, are amended to read:
2218	409.9122  Mandatory Medicaid managed care enrollment;
2219	programs and procedures.--
2220	(2)(a)  The agency shall enroll in a managed care plan or
2221	MediPass all Medicaid recipients, except those Medicaid
2222	recipients who are: in an institution; enrolled in the Medicaid
2223	medically needy program; or eligible for both Medicaid and
2224	Medicare. Upon enrollment, individuals will be able to change
2225	their managed care option during the 90-day opt out period
2226	required by federal Medicaid regulations. The agency is
2227	authorized to seek the necessary Medicaid state plan amendment
2228	to implement this policy. However, to the extent permitted by
2229	federal law, the agency may enroll in a managed care plan or
2230	MediPass a Medicaid recipient who is exempt from mandatory
2231	managed care enrollment, provided that:
2232	1.  The recipient's decision to enroll in a managed care
2233	plan or MediPass is voluntary;
2234	2.  If the recipient chooses to enroll in a managed care
2235	plan, the agency has determined that the managed care plan
2236	provides specific programs and services which address the
2237	special health needs of the recipient; and
2238	3.  The agency receives any necessary waivers from the
2239	federal Centers for Medicare and Medicaid Services Health Care
2240	Financing Administration.
2241
2242	The agency shall develop rules to establish policies by which
2243	exceptions to the mandatory managed care enrollment requirement
2244	may be made on a case-by-case basis. The rules shall include the
2245	specific criteria to be applied when making a determination as
2246	to whether to exempt a recipient from mandatory enrollment in a
2247	managed care plan or MediPass. School districts participating in
2248	the certified school match program pursuant to ss. 409.908(21)
2249	and 1011.70 shall be reimbursed by Medicaid, subject to the
2250	limitations of s. 1011.70(1), for a Medicaid-eligible child
2251	participating in the services as authorized in s. 1011.70, as
2252	provided for in s. 409.9071, regardless of whether the child is
2253	enrolled in MediPass or a managed care plan. Managed care plans
2254	shall make a good faith effort to execute agreements with school
2255	districts regarding the coordinated provision of services
2256	authorized under s. 1011.70. County health departments
2257	delivering school-based services pursuant to ss. 381.0056 and
2258	381.0057 shall be reimbursed by Medicaid for the federal share
2259	for a Medicaid-eligible child who receives Medicaid-covered
2260	services in a school setting, regardless of whether the child is
2261	enrolled in MediPass or a managed care plan. Managed care plans
2262	shall make a good faith effort to execute agreements with county
2263	health departments regarding the coordinated provision of
2264	services to a Medicaid-eligible child. To ensure continuity of
2265	care for Medicaid patients, the agency, the Department of
2266	Health, and the Department of Education shall develop procedures
2267	for ensuring that a student's managed care plan or MediPass
2268	provider receives information relating to services provided in
2269	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2270	(j)  The agency shall apply for a federal waiver from the
2271	Centers for Medicare and Medicaid Services Health Care Financing
2272	Administration to lock eligible Medicaid recipients into a
2273	managed care plan or MediPass for 12 months after an open
2274	enrollment period. After 12 months' enrollment, a recipient may
2275	select another managed care plan or MediPass provider. However,
2276	nothing shall prevent a Medicaid recipient from changing primary
2277	care providers within the managed care plan or MediPass program
2278	during the 12-month period.
2279	Section 5.  Subsection (2) of section 409.913, Florida
2280	Statutes, is amended, and subsection (36) is added to that
2281	section, to read:
2282	409.913  Oversight of the integrity of the Medicaid
2283	program.--The agency shall operate a program to oversee the
2284	activities of Florida Medicaid recipients, and providers and
2285	their representatives, to ensure that fraudulent and abusive
2286	behavior and neglect of recipients occur to the minimum extent
2287	possible, and to recover overpayments and impose sanctions as
2288	appropriate. Beginning January 1, 2003, and each year
2289	thereafter, the agency and the Medicaid Fraud Control Unit of
2290	the Department of Legal Affairs shall submit a joint report to
2291	the Legislature documenting the effectiveness of the state's
2292	efforts to control Medicaid fraud and abuse and to recover
2293	Medicaid overpayments during the previous fiscal year. The
2294	report must describe the number of cases opened and investigated
2295	each year; the sources of the cases opened; the disposition of
2296	the cases closed each year; the amount of overpayments alleged
2297	in preliminary and final audit letters; the number and amount of
2298	fines or penalties imposed; any reductions in overpayment
2299	amounts negotiated in settlement agreements or by other means;
2300	the amount of final agency determinations of overpayments; the
2301	amount deducted from federal claiming as a result of
2302	overpayments; the amount of overpayments recovered each year;
2303	the amount of cost of investigation recovered each year; the
2304	average length of time to collect from the time the case was
2305	opened until the overpayment is paid in full; the amount
2306	determined as uncollectible and the portion of the uncollectible
2307	amount subsequently reclaimed from the Federal Government; the
2308	number of providers, by type, that are terminated from
2309	participation in the Medicaid program as a result of fraud and
2310	abuse; and all costs associated with discovering and prosecuting
2311	cases of Medicaid overpayments and making recoveries in such
2312	cases. The report must also document actions taken to prevent
2313	overpayments and the number of providers prevented from
2314	enrolling in or reenrolling in the Medicaid program as a result
2315	of documented Medicaid fraud and abuse and must recommend
2316	changes necessary to prevent or recover overpayments.
2317	(2)  The agency shall conduct, or cause to be conducted by
2318	contract or otherwise, reviews, investigations, analyses,
2319	audits, or any combination thereof, to determine possible fraud,
2320	abuse, overpayment, or recipient neglect in the Medicaid program
2321	and shall report the findings of any overpayments in audit
2322	reports as appropriate. At least 5 percent of all audits shall
2323	be conducted on a random basis.
2324	(36)  The agency shall provide to each Medicaid recipient
2325	or his or her representative an explanation of benefits in the
2326	form of a letter that is mailed to the most recent address of
2327	the recipient on the record with the Department of Children and
2328	Family Services. The explanation of benefits must include the
2329	patient's name, the name of the health care provider and the
2330	address of the location where the service was provided, a
2331	description of all services billed to Medicaid in terminology
2332	that should be understood by a reasonable person, and
2333	information on how to report inappropriate or incorrect billing
2334	to the agency or other law enforcement entities for review or
2335	investigation.
2336	Section 6.  The Agency for Health Care Administration shall
2337	submit to the Legislature by January 15, 2006, recommendations
2338	to ensure that Medicaid is the payer of last resort as required
2339	by section 409.910, Florida Statutes. The report must identify
2340	the public and private entities that are liable for primary
2341	payment of health care services and recommend methods to improve
2342	enforcement of third-party liability responsibility and
2343	repayment of benefits to the state Medicaid program. The report
2344	must estimate the potential recoveries that may be achieved
2345	through third-party liability efforts if administrative and
2346	legal barriers are removed. The report must recommend whether
2347	modifications to the agency's contingency-fee contract for
2348	third-party liability could enhance third-party liability for
2349	benefits provided to Medicaid recipients.
2350	Section 7.  By January 15, 2006, the Office of Program
2351	Policy Analysis and Government Accountability shall submit to
2352	the Legislature a study of the long-term care community
2353	diversion pilot project authorized under ss. 430.701-430.709.
2354	The study may be conducted by Office of Program Policy Analysis
2355	and Government Accountability staff or by a consultant obtained
2356	through a competitive bid. The study must use a statistically-
2357	valid methodology to assess the percent of persons served in the
2358	project over a 2-year period who would have required Medicaid
2359	nursing home services without the diversion services, which
2360	services are most frequently used, and which services are least
2361	frequently used. The study must determine whether the project is
2362	cost-effective or is an expansion of the Medicaid program
2363	because a preponderance of the project enrollees would not have
2364	required Medicaid nursing home services within a 2-year period
2365	regardless of the availability of the project or that the
2366	enrollees could have been safely served through another Medicaid
2367	program at a lower cost to the state.
2368	Section 8.  The Agency for Health Care Administration shall
2369	identify how many individuals in the long-term care diversion
2370	programs who receive care at home have a patient-responsibility
2371	payment associated with their participation in the diversion
2372	program. If no system is available to assess this information,
2373	the agency shall determine the cost of creating a system to
2374	identify and collect these payments and whether the cost of
2375	developing a system for this purpose is offset by the amount of
2376	patient-responsibility payments which could be collected with
2377	the system. The agency shall report this information to the
2378	Legislature by December 1, 2005.
2379	Section 9.  This act shall take effect July 1, 2005.
2380
2381	================= T I T L E  A M E N D M E N T =================
2382	================= T I T L E  A M E N D M E N T =================
2383	Remove the entire title and insert:
2384	A bill to be entitled
2385	An act relating to Medicaid reform; providing a popular
2386	name; providing legislative findings and intent; providing
2387	waiver authority to the Agency for Health Care
2388	Administration; providing for implementation of
2389	demonstration projects; providing definitions; identifying
2390	categorical groups for eligibility under the waiver;
2391	establishing the choice counseling process; providing for
2392	disenrollment in a plan during a specified period of time;
2393	providing conditions for changes; requiring managed care
2394	plans to include mandatory Medicaid services; requiring
2395	managed care plans to provide a wellness and disease
2396	management program, pharmacy benefits, behavioral health
2397	care benefits, and a grievance resolution process;
2398	authorizing the agency to establish enhanced benefit
2399	coverage and providing procedures therefor; establishing
2400	flexible spending accounts; providing for cost sharing by
2401	recipients, and requirements; requiring the agency to
2402	submit a report to the Legislature relating to enforcement
2403	of Medicaid copayment requirements and other measures;
2404	providing for the agency to establish a catastrophic
2405	coverage fund or purchase stop-loss coverage to cover
2406	certain services; requiring a managed care plan to have a
2407	certificate of operation from the agency before operating
2408	under the waiver; providing certification requirements;
2409	providing for reimbursement of provider service networks;
2410	providing an exemption from competitive bid requirements
2411	for provider service networks under certain circumstances;
2412	providing for continuance of contracts previously awarded
2413	for a specified period of time; requiring the agency to
2414	have accountability and quality assurance standards;
2415	requiring the agency to establish a medical care database;
2416	providing data collection requirements; requiring certain
2417	entities certified to operate a managed care plan to
2418	comply with ss. 641.3155 and 641.513, F.S.; providing for
2419	the agency to develop a rate setting and risk adjustment
2420	system; authorizing the agency to allow recipients to opt
2421	out of Medicaid and purchase health care coverage through
2422	an employer-sponsored insurer; requiring the agency to
2423	apply and enforce certain provisions of law relating to
2424	Medicaid fraud and abuse; providing penalties; requiring
2425	the agency to develop a reimbursement system for school
2426	districts participating in the certified school match
2427	program; providing for integrated fixed payment delivery
2428	system for Medicaid recipients who are a certain age;
2429	authorizing the agency to implement the system in certain
2430	counties; providing exceptions; requiring the agency to
2431	provide a choice of managed care plans to recipients;
2432	providing requirements for managed care plans; requiring
2433	the agency to withhold certain funding contingent upon the
2434	performance of a plan; requiring the plan to rebate
2435	certain profits to the agency; authorizing the agency to
2436	limit the number of enrollees in a plan under certain
2437	circumstances; providing for eligibility determination and
2438	choice counseling for persons who are a certain age;
2439	requiring the agency to evaluate the medical loss ratios
2440	of certain managed care plans; authorizing the agency to
2441	adopt rules for minimum loss ratios; providing for
2442	imposition of liquidated damages; authorizing the agency
2443	to grant a modification of certificate-of-need conditions
2444	to nursing homes under certain circumstances; requiring
2445	integration of Medicare and Medicaid services; providing
2446	legislative intent; providing for awarding of funds for
2447	managed care delivery system development, contingent upon
2448	an appropriation; requiring the Office of Program Policy
2449	Analysis and Government Accountability conduct a study of
2450	the feasibility of establishing a Medicaid buy-in program
2451	for certain non-Medicaid eligible persons; requiring the
2452	office to submit a report to the Legislature; providing
2453	applicability; granting rulemaking authority to the
2454	agency; requiring legislative authority to implement the
2455	waiver; requiring the Office of Program Policy Analysis
2456	and Government Accountability to evaluate the Medicaid
2457	reform waiver and issue reports; requiring the agency to
2458	submit status reports; requiring the agency to contract
2459	for certain evaluation comparisons; providing for future
2460	review and repeal of the act; amending s. 409.912, F.S.;
2461	requiring the Agency for Health Care Administration to
2462	contract with a vendor to monitor and evaluate the
2463	clinical practice patterns of providers; authorizing the
2464	agency to competitively bid for single-source providers
2465	for certain services; authorizing the agency to examine
2466	whether purchasing certain durable medical equipment is
2467	more cost-effective than long-term rental of such
2468	equipment; providing that a contract awarded to a provider
2469	service network remains in effect for a certain period;
2470	defining a provider service network; providing health care
2471	providers with a controlling interest in the governing
2472	body of the provider service network organization;
2473	requiring that the agency, in partnership with the
2474	Department of Elderly Affairs, develop an integrated,
2475	fixed-payment delivery system for Medicaid recipients age
2476	60 and older; deleting an obsolete provision requiring the
2477	agency to develop a plan for implementing emergency and
2478	crisis care; requiring the agency to develop a system
2479	where health care vendors may provide data demonstrating
2480	that higher reimbursement for a good or service will be
2481	offset by cost savings in other goods or services;
2482	requiring the Comprehensive Assessment and Review for
2483	Long-Term Care Services (CARES) teams to consult with any
2484	person making a determination that a nursing home resident
2485	funded by Medicare is not making progress toward
2486	rehabilitation and assist in any appeals of the decision;
2487	requiring the agency to contract with an entity to design
2488	a clinical-utilization information database or electronic
2489	medical record for Medicaid providers; requiring that the
2490	agency develop a plan to expand disease-management
2491	programs; requiring the agency to coordinate with other
2492	entities to create emergency room diversion programs for
2493	Medicaid recipients; revising the Medicaid prescription
2494	drug spending control program to reduce costs and improve
2495	Medicaid recipient safety; requiring that the agency
2496	implement a Medicaid prescription drug management system;
2497	allowing the agency to require age-related prior
2498	authorizations for certain prescription drugs; requiring
2499	the agency to determine the extent that prescription drugs
2500	are returned and reused in institutional settings and
2501	whether this program could be expanded; requiring the
2502	agency to develop an in-home, all-inclusive program of
2503	services for Medicaid children with life-threatening
2504	illnesses; authorizing the agency to pay for emergency
2505	mental health services provided through licensed crisis
2506	stabilization centers; creating s. 409.91211, F.S.;
2507	requiring that the agency develop a pilot program for
2508	capitated managed care networks to deliver Medicaid health
2509	care services for all eligible Medicaid recipients in
2510	Medicaid fee-for-service or the MediPass program;
2511	authorizing the agency to include an alternative
2512	methodology for making additional Medicaid payments to
2513	hospitals; providing legislative intent; providing powers,
2514	duties, and responsibilities of the agency under the pilot
2515	program; requiring that the agency provide a plan to the
2516	Legislature for implementing the pilot program; requiring
2517	that the Office of Program Policy Analysis and Government
2518	Accountability, in consultation with the Auditor General,
2519	evaluate the pilot program and report to the Governor and
2520	the Legislature on whether it should be expanded
2521	statewide; amending s. 409.9122, F.S.; revising a
2522	reference; amending s. 409.913, F.S.; requiring 5 percent
2523	of all program integrity audits to be conducted on a
2524	random basis; requiring that Medicaid recipients be
2525	provided with an explanation of benefits; requiring that
2526	the agency report to the Legislature on the legal and
2527	administrative barriers to enforcing the copayment
2528	requirements of s. 409.9081, F.S.; requiring the agency to
2529	recommend ways to ensure that Medicaid is the payer of
2530	last resort; requiring the agency to conduct a study of
2531	provider pay-for-performance systems; requiring the Office
2532	of Program Policy Analysis and Government Accountability
2533	to conduct a study of the long-term care diversion
2534	programs; requiring the agency to evaluate the cost-saving
2535	potential of contracting with a multistate prescription
2536	drug purchasing pool; requiring the agency to determine
2537	how many individuals in long-term care diversion programs
2538	have a patient payment responsibility that is not being
2539	collected and to recommend how to collect such payments;
2540	requiring the Office of Program Policy Analysis and
2541	Government Accountability to conduct a study of Medicaid
2542	buy-in programs to determine if these programs can be
2543	created in this state without expanding the overall
2544	Medicaid program budget or if the Medically Needy program
2545	can be changed into a Medicaid buy-in program; providing
2546	an appropriation for the purpose of contracting to monitor
2547	and evaluate clinical practice patterns; providing an
2548	appropriation for the purpose of contracting for the
2549	database to review real-time utilization of Medicaid
2550	services; providing an appropriation for the purpose of
2551	developing infrastructure and administrative resources
2552	necessary to implement the pilot project as created in s.
2553	409.91211, F.S.; providing an appropriation for developing
2554	an encounter data system for Medicaid managed care plans;
2555	providing an effective date.

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