HCB 6003 (for HBs 1869, 1871, 1873, 1875)

1	A bill to be entitled
2	An act relating to Medicaid reform; providing a popular
3	name; providing legislative findings and intent; providing
4	waiver authority to the Agency for Health Care
5	Administration; providing for implementation of
6	demonstration projects; providing definitions; identifying
7	categorical groups for eligibility under the waiver;
8	establishing the choice counseling process; providing for
9	disenrollment in a plan during a specified period of time;
10	providing conditions for changes; requiring managed care
11	plans to include mandatory Medicaid services; requiring
12	managed care plans to provide a wellness and disease
13	management program, pharmacy benefits, behavioral health
14	care benefits, and a grievance resolution process;
15	authorizing the agency to establish enhanced benefit
16	coverage and providing procedures therefor; establishing
17	flexible spending accounts; providing for cost sharing by
18	recipients, and requirements; requiring the agency to
19	submit a report to the Legislature relating to enforcement
20	of Medicaid copayment requirements and other measures;
21	providing for the agency to establish a catastrophic
22	coverage fund or purchase stop-loss coverage to cover
23	certain services; requiring a managed care plan to have a
24	certificate of operation from the agency before operating
25	under the waiver; providing certification requirements;
26	providing for reimbursement of provider service networks;
27	providing an exemption from competitive bid requirements
28	for provider service networks under certain circumstances;
29	providing for continuance of contracts previously awarded
30	for a specified period of time; requiring the agency to
31	have accountability and quality assurance standards;
32	requiring the agency to establish a medical care database;
33	providing data collection requirements; requiring certain
34	entities certified to operate a managed care plan to
35	comply with ss. 641.3155 and 641.513, F.S.; providing for
36	the agency to develop a rate setting and risk adjustment
37	system; authorizing the agency to allow recipients to opt
38	out of Medicaid and purchase health care coverage through
39	an employer-sponsored insurer; requiring the agency to
40	apply and enforce certain provisions of law relating to
41	Medicaid fraud and abuse; providing penalties; requiring
42	the agency to develop a reimbursement system for school
43	districts participating in the certified school match
44	program; providing for integrated fixed payment delivery
45	system for Medicaid recipients who are a certain age;
46	authorizing the agency to implement the system in certain
47	counties; providing exceptions; requiring the agency to
48	provide a choice of managed care plans to recipients;
49	providing requirements for managed care plans; requiring
50	the agency to withhold certain funding contingent upon the
51	performance of a plan; requiring the plan to rebate
52	certain profits to the agency; authorizing the agency to
53	limit the number of enrollees in a plan under certain
54	circumstances; providing for eligibility determination and
55	choice counseling for persons who are a certain age;
56	requiring the agency to evaluate the medical loss ratios
57	of certain managed care plans; authorizing the agency to
58	adopt rules for minimum loss ratios; providing for
59	imposition of liquidated damages; authorizing the agency
60	to grant a modification of certificate-of-need conditions
61	to nursing homes under certain circumstances; requiring
62	integration of Medicare and Medicaid services; providing
63	legislative intent; providing for awarding of funds for
64	managed care delivery system development, contingent upon
65	an appropriation; requiring the Office of Program Policy
66	Analysis and Government Accountability conduct a study of
67	the feasibility of establishing a Medicaid buy-in program
68	for certain non-Medicaid eligible persons; requiring the
69	office to submit a report to the Legislature; providing
70	applicability; granting rulemaking authority to the
71	agency; requiring legislative authority to implement the
72	waiver; requiring the Office of Program Policy Analysis
73	and Government Accountability to evaluate the Medicaid
74	reform waiver and issue reports; requiring the agency to
75	submit status reports; requiring the agency to contract
76	for certain evaluation comparisons; providing for future
77	review and repeal of the act; amending s. 409.912, F.S.;
78	requiring the Agency for Health Care Administration to
79	contract with a vendor to monitor and evaluate the
80	clinical practice patterns of providers; authorizing the
81	agency to competitively bid for single-source providers
82	for certain services; authorizing the agency to examine
83	whether purchasing certain durable medical equipment is
84	more cost-effective than long-term rental of such
85	equipment; providing that a contract awarded to a provider
86	service network remains in effect for a certain period;
87	defining a provider service network; providing health care
88	providers with a controlling interest in the governing
89	body of the provider service network organization;
90	requiring that the agency, in partnership with the
91	Department of Elderly Affairs, develop an integrated,
92	fixed-payment delivery system for Medicaid recipients age
93	60 and older; deleting an obsolete provision requiring the
94	agency to develop a plan for implementing emergency and
95	crisis care; requiring the agency to develop a system
96	where health care vendors may provide data demonstrating
97	that higher reimbursement for a good or service will be
98	offset by cost savings in other goods or services;
99	requiring the Comprehensive Assessment and Review for
100	Long-Term Care Services (CARES) teams to consult with any
101	person making a determination that a nursing home resident
102	funded by Medicare is not making progress toward
103	rehabilitation and assist in any appeals of the decision;
104	requiring the agency to contract with an entity to design
105	a clinical-utilization information database or electronic
106	medical record for Medicaid providers; requiring that the
107	agency develop a plan to expand disease-management
108	programs; requiring the agency to coordinate with other
109	entities to create emergency room diversion programs for
110	Medicaid recipients; revising the Medicaid prescription
111	drug spending control program to reduce costs and improve
112	Medicaid recipient safety; requiring that the agency
113	implement a Medicaid prescription drug management system;
114	allowing the agency to require age-related prior
115	authorizations for certain prescription drugs; requiring
116	the agency to determine the extent that prescription drugs
117	are returned and reused in institutional settings and
118	whether this program could be expanded; requiring the
119	agency to develop an in-home, all-inclusive program of
120	services for Medicaid children with life-threatening
121	illnesses; authorizing the agency to pay for emergency
122	mental health services provided through licensed crisis
123	stabilization centers; creating s. 409.91211, F.S.;
124	requiring that the agency develop a pilot program for
125	capitated managed care networks to deliver Medicaid health
126	care services for all eligible Medicaid recipients in
127	Medicaid fee-for-service or the MediPass program;
128	authorizing the agency to include an alternative
129	methodology for making additional Medicaid payments to
130	hospitals; providing legislative intent; providing powers,
131	duties, and responsibilities of the agency under the pilot
132	program; requiring that the agency provide a plan to the
133	Legislature for implementing the pilot program; requiring
134	that the Office of Program Policy Analysis and Government
135	Accountability, in consultation with the Auditor General,
136	evaluate the pilot program and report to the Governor and
137	the Legislature on whether it should be expanded
138	statewide; amending s. 409.9122, F.S.; revising a
139	reference; amending s. 409.913, F.S.; requiring 5 percent
140	of all program integrity audits to be conducted on a
141	random basis; requiring that Medicaid recipients be
142	provided with an explanation of benefits; requiring that
143	the agency report to the Legislature on the legal and
144	administrative barriers to enforcing the copayment
145	requirements of s. 409.9081, F.S.; requiring the agency to
146	recommend ways to ensure that Medicaid is the payer of
147	last resort; requiring the agency to conduct a study of
148	provider pay-for-performance systems; requiring the Office
149	of Program Policy Analysis and Government Accountability
150	to conduct a study of the long-term care diversion
151	programs; requiring the agency to evaluate the cost-saving
152	potential of contracting with a multistate prescription
153	drug purchasing pool; requiring the agency to determine
154	how many individuals in long-term care diversion programs
155	have a patient payment responsibility that is not being
156	collected and to recommend how to collect such payments;
157	requiring the Office of Program Policy Analysis and
158	Government Accountability to conduct a study of Medicaid
159	buy-in programs to determine if these programs can be
160	created in this state without expanding the overall
161	Medicaid program budget or if the Medically Needy program
162	can be changed into a Medicaid buy-in program; providing
163	an appropriation for the purpose of contracting to monitor
164	and evaluate clinical practice patterns; providing an
165	appropriation for the purpose of contracting for the
166	database to review real-time utilization of Medicaid
167	services; providing an appropriation for the purpose of
168	developing infrastructure and administrative resources
169	necessary to implement the pilot project as created in s.
170	409.91211, F.S.; providing an appropriation for developing
171	an encounter data system for Medicaid managed care plans;
172	providing an effective date.
173
174	Be It Enacted by the Legislature of the State of Florida:
175
176	Section 1.  Popular name.--This act shall be known as the
177	"Medicaid Reform Act of 2005."
178	Section 2.  Medicaid reform.--
179	(1)  WAIVER AUTHORITY.-- The Agency for Health Care
180	Administration is authorized to seek experimental, pilot, or
181	demonstration project waivers, pursuant to s. 1115 of the Social
182	Security Act, to reform the Florida Medicaid program pursuant to
183	this section. The initial phase shall be in two geographic
184	areas. One pilot program shall include only Broward County. A
185	second pilot program shall initially include Duval County and
186	shall be expanded to include Baker, Clay, and Nassau Counties
187	within the timeframes approved in the implementation plan. This
188	waiver authority is contingent upon federal approval to preserve
189	the upper-payment-limit funding mechanisms for hospitals and
190	contingent upon protection of the disproportionate share program
191	authorized pursuant to chapter 409, Florida Statutes. The agency
192	is directed to negotiate with the Centers for Medicare and
193	Medicaid Services to include in the approved waiver a
194	methodology whereby savings from the demonstration waiver shall
195	be used to increase total upper-payment-limit and
196	disproportionate share payments. Any increased funds shall be
197	reinvested in programs that provide direct services to uninsured
198	individuals in a cost-effective manner and reduce reliance on
199	hospital emergency care.
200	(3)  IMPLEMENTATION OF DEMONSTRATION PROJECTS.--The agency
201	shall include in the federal waiver request the authority to
202	establish managed care demonstration projects as provided in
203	this section and as approved by the Legislature in the waiver.
204	It is the intent of the Legislature that the agency shall design
205	a demonstration project to initiate a statewide phase-in of
206	reform of the Medicaid program pursuant to this act.
207	Implementation of each phase of reform shall be contingent upon
208	approval of the Legislature or the Legislative Budget Commission
209	if the Legislature is not in session.
210	(4)  DEFINITIONS.--As used in this section, the term:
211	(a)  "Agency" means the Agency for Health Care
212	Administration.
213	(b)  "Enhanced benefit coverage" means additional health
214	care services or alternative health care coverage which can be
215	purchased by qualified recipients.
216	(c)  "Flexible spending account" means an account that
217	encourages consumer ownership and management of resources
218	available for enhanced benefit coverage, wellness activities,
219	preventive services, and other services to improve the health of
220	the recipient.
221	(d)  "Managed care plan" or "plan" means an entity
222	certified by the agency to accept a capitation payment,
223	including, but not limited to, a health maintenance organization
224	authorized under part I of chapter 641, Florida Statutes; an
225	entity under part II or part III of chapter 641, Florida
226	Statutes, or under chapter 627, chapter 636, chapter 391, or s.
227	409.912, Florida Statutes; a licensed mental health provider
228	under chapter 394, Florida Statutes; a licensed substance abuse
229	provider under chapter 397, Florida Statutes; a hospital under
230	chapter 395, Florida Statutes; a provider service network as
231	defined in this section; or a state-certified contractor as
232	defined in this section.
233	(e)  "Medicaid opt-out option" means a program that allows
234	a recipient to purchase health care insurance through an
235	employer-sponsored plan instead of through a Medicaid-certified
236	plan.
237	(f)  "Plan benefits" means the mandatory services specified
238	in s. 409.905, Florida Statutes; behavioral health services
239	specified in s. 409.906(8), Florida Statutes; pharmacy services
240	specified in s. 409.906(20), Florida Statutes; and other
241	services, including, but not limited to, Medicaid optional
242	services specified in s. 409.906, Florida Statutes, for which a
243	plan is receiving a risk adjusted capitation rate. Plans shall
244	provide all mandatory services and may cover optional services
245	to attract recipients and provide needed care. Services to
246	recipients under plan benefits shall include emergency services
247	pursuant to s. 409.9128, Florida Statutes.
248	1.  Mandatory and optional services as delineated in s.
249	409.905, and s. 409.906, Florida Statutes may vary in amount,
250	duration and scope based on actuarial analysis and determination
251	of service utilization among a categorical or predetermined risk
252	group served by the plan.
253	2.  A plan shall provide all mandatory and optional
254	services as delineated in ss. 409.905, and 409.906, Florida
255	Statutes, to a level of amount, duration and scope based on the
256	actuarial analysis and corresponding capitation rate.
257	Contractual stipulations for each risk or categorical group
258	shall not vary among plans.
259	3.  A plan shall be at risk for all services as defined in
260	this section needed by a recipient up to a monetary catastrophic
261	threshold pursuant to this section.
262	4.  Catastrophic coverage pursuant to this section shall
263	not release the plan from continued care management of the
264	recipient and providing other services as stipulated in the
265	contract with the agency.
266	(g)  "Provider service network" means an incorporated
267	network:
268	1.  Established or organized, and operated, by a health
269	care provider or group of affiliated health care providers;
270	2.  That provides a substantial proportion of the health
271	care items and services under a contract directly through the
272	provider or affiliated group;
273	3.  That may make arrangements with physicians, other
274	health care professionals, and health care institutions, to
275	assume all or part of the financial risk on a prospective basis
276	for the provision of basic health services; and
277	4.  Within which health care providers have a controlling
278	interest in the governing body of the provider service network
279	organization, as authorized by s. 409.912, Florida Statutes.
280	(h)  "Shall" means the agency must include the provision of
281	a subsection as delineated in this section in the waiver
282	application and implement the provision to the extent allowed in
283	the demonstration project sites by the Centers for Medicare and
284	Medicaid Services and as approved by the Legislature pursuant to
285	this section.
286	(i)  "State-certified contractor" means an entity not
287	authorized under part I, part II, or part III of chapter 641,
288	Florida Statutes, or under chapter 624, chapter 627, or chapter
289	636, Florida Statutes, qualified by the agency to be certified
290	as a managed care plan. The agency shall develop the standards
291	necessary to authorize an entity to become a state-certified
292	contractor.
293	(5)  ELIGIBILITY.--
294	(a)  The agency shall pursue waivers to reform Medicaid for
295	the following categorical groups:
296	1.  Temporary Assistance for Needy Families, consistent
297	with ss. 402 and 1931 of the Social Security Act and chapter
298	409, chapter 414, or chapter 445, Florida Statutes.
299	2.  Supplemental Security Income recipients as defined in
300	Title XVI of the Social Security Act, except for persons who are
301	dually eligible for Medicaid and Medicare, individuals 60 years
302	of age or older, individuals who have developmental
303	disabilities, and residents of institutions or nursing homes.
304	3.  All children covered pursuant to Title XIX of the
305	Social Security Act.
306	(b)  The agency may pursue any appropriate federal waiver
307	to reform Medicaid for the populations not identified by this
308	subsection, including Title XXI children, if authorized by the
309	Legislature.
310	(6)  CHOICE COUNSELING.--
311	(a)  At the time of eligibility determination, the agency
312	shall provide the recipient with all the Medicaid health care
313	options available in that community to assist the recipient in
314	choosing health care coverage. The recipient shall choose a plan
315	within 30 days after the recipient is eligible unless the
316	recipient loses eligibility. Failure to choose a plan within 30
317	days will result in the recipient being assigned to a managed
318	care plan.
319	(b)  After a recipient has chosen a plan or has been
320	assigned to a plan, the recipient shall have 90 days in which to
321	voluntarily disenroll and select another managed care plan.
322	After 90 days, no further changes may be made except for cause.
323	Cause shall include, but not be limited to, poor quality of
324	care, lack of access to necessary specialty services, an
325	unreasonable delay or denial of service, inordinate or
326	inappropriate changes of primary care providers, service access
327	impairments due to significant changes in the geographic
328	location of services, or fraudulent enrollment. The agency may
329	require a recipient to use the managed care plan's grievance
330	process prior to the agency's determination of cause, except in
331	cases in which immediate risk of permanent damage to the
332	recipient's health is alleged. The grievance process, when used,
333	must be completed in time to permit the recipient to disenroll
334	no later than the first day of the second month after the month
335	the disenrollment request was made. If the capitated managed
336	care network, as a result of the grievance process, approves an
337	enrollee's request to disenroll, the agency is not required to
338	make a determination in the case. The agency must make a
339	determination and take final action on a recipient's request so
340	that disenrollment occurs no later than the first day of the
341	second month after the month the request was made. If the agency
342	fails to act within the specified timeframe, the recipient's
343	request to disenroll is deemed to be approved as of the date
344	agency action was required. Recipients who disagree with the
345	agency's finding that cause does not exist for disenrollment
346	shall be advised of their right to pursue a Medicaid fair
347	hearing to dispute the agency's finding.
348	(c)  In the managed care demonstration projects, the
349	Medicaid recipients who are already enrolled in a managed care
350	plan shall remain with that plan until their next eligibility
351	determination. The agency shall develop a method whereby newly
352	eligible Medicaid recipients, Medicaid recipients with renewed
353	eligibility, and Medipass enrollees shall enroll in managed care
354	plans certified pursuant to this section.
355	(d)  A Medicaid recipient receiving services under this
356	section is eligible for only emergency services until the
357	recipient enrolls in a managed care plan. Emergency services
358	provided under this paragraph shall be reimbursed on a fee-for-
359	service basis.
360	(e)  The agency shall ensure that the recipient is provided
361	with:
362	1.  A list and description of the benefits provided.
363	2.  Information about cost sharing.
364	3.  Plan performance data, if available.
365	4.  An explanation of benefit limitations.
366	5.  Contact information, including identification of
367	providers participating in the network, geographic locations,
368	and transportation limitations.
369	6.  Any other information the agency determines would
370	facilitate a recipient's understanding of the plan or insurance
371	that would best meet his or her needs.
372	(f)  The agency shall ensure that there is a record of
373	recipient acknowledgment that choice counseling has been
374	provided.
375	(g)  To accommodate the needs of recipients, the agency
376	shall ensure that the choice counseling process and related
377	material are designed to provide counseling through face-to-face
378	interaction, by telephone, and in writing and through other
379	forms of relevant media. Materials shall be written at the
380	fourth-grade reading level and available in a language other
381	than English when 5 percent of the county speaks a language
382	other than English. Choice counseling shall also utilize
383	language lines and other services for impaired recipients, such
384	as TTD/TTY.
385	(h)  The agency shall require the entity performing choice
386	counseling to determine if the recipient has made a choice of a
387	plan or has opted out because of duress, threats, payment to the
388	recipient, or incentives promised to the recipient by a third
389	party. If the choice counseling entity determines that the
390	decision to choose a plan was unlawfully influenced or a plan
391	violated any of the provisions of s. 409.912(21), Florida
392	Statutes, the choice counseling entity shall immediately report
393	the violation to the agency's program integrity section for
394	investigation. Verification of choice counseling by the
395	recipient shall include a stipulation that the recipient
396	acknowledges the provisions of this subsection.
397	(i)  It is the intent of the Legislature, within the
398	authority of the waiver and within available resources, that the
399	agency promote health literacy and partner with the Department
400	of Health to provide information aimed to reduce minority health
401	disparities through outreach activities for Medicaid recipients.
402	(j)  The agency is authorized to contract with entities to
403	perform choice counseling and may establish standards and
404	performance contracts, including standards requiring the
405	contractor to hire choice counselors representative of the
406	state's diverse population and to train choice counselors in
407	working with culturally diverse populations.
408	(k)  The agency shall develop processes to ensure that
409	demonstration sites have sufficient levels of enrollment to
410	conduct a valid test of the managed care demonstration project
411	model within a 2-year timeframe.
412	(7)  PLANS.--
413	(a)  Plan benefits.--The agency shall develop a capitated
414	system of care that promotes choice and competition. Plan
415	benefits shall include the mandatory services delineated in
416	federal law and specified in s. 409.905, Florida Statutes;
417	behavioral health services specified in s. 409.906(8), Florida
418	Statutes; pharmacy services specified in s. 409.906(20), Florida
419	Statutes; and other services including, but not limited to,
420	Medicaid optional services specified in s. 409.906, Florida
421	Statutes, for which a plan is receiving a risk-adjusted
422	capitation rate. Plans shall provide all mandatory services and
423	may cover optional services to attract recipients and provide
424	needed care. Mandatory and optional services may vary in amount,
425	duration, and scope of benefits. Services to recipients under
426	plan benefits shall include emergency services pursuant to s.
427	409.9128, Florida Statutes.
428	1.  Mandatory and optional services as delineated in ss.
429	409.905 and 409.906, Florida Statutes, may vary in amount,
430	duration, and scope based on actuarial analysis and
431	determination of service utilization among a categorical or
432	predetermined risk group served by the plan.
433	2.  A plan shall provide all mandatory and optional
434	services as delineated in ss. 409.905 and 409.906, Florida
435	Statutes, to a level of amount, duration, and scope based on the
436	actuarial analysis and corresponding capitation rate.
437	Contractual stipulations for each risk or categorical group
438	shall not vary among plans.
439	3.  A plan shall be at risk for all services as defined in
440	this section needed by a recipient up to a monetary catastrophic
441	threshold pursuant to this section.
442	4.  Catastrophic coverage pursuant to this section shall
443	not release the plan from continued care management of the
444	recipient and providing other services as stipulated in the
445	contract with the agency.
446	(b)  Wellness and disease management.--
447	1.  The agency shall require plans to provide a wellness
448	disease management program for certain Medicaid recipients
449	participating in the waiver. The agency shall require plans to
450	develop disease management programs necessary to meet the needs
451	of the population they serve.
452	2.  The agency shall require a plan to develop appropriate
453	disease management protocols and develop procedures for
454	implementing those protocols, and determine the procedure for
455	providing disease management services to plan enrollees. The
456	agency is authorized to allow a plan to contract separately with
457	another entity for disease management services or provide
458	disease management services directly through the plan.
459	3.  The agency shall provide oversight to ensure that the
460	service network provides the contractually agreed upon level of
461	service.
462	4.  The agency may establish performance contracts that
463	reward a plan when measurable operational targets in both
464	participation and clinical outcomes are reached or exceeded by
465	the plan.
466	5.  The agency may establish performance contracts that
467	penalize a plan when measurable operational targets for both
468	participation and clinical outcomes are not reached by the plan.
469	6.  The agency shall develop oversight requirements and
470	procedures to ensure that plans utilize standardized methods and
471	clinical protocols for determining compliance with a wellness or
472	disease management plan.
473	(c)  Pharmacy benefits.--
474	1.  The agency shall require plans to provide pharmacy
475	benefits and include pharmacy benefits as part of the capitation
476	risk structure to enable a plan to coordinate and fully manage
477	all aspects of patient care as part of the plan or through a
478	pharmacy benefits manager.
479	2.  The agency may set standards for pharmacy benefits for
480	managed care plans and specify the therapeutic classes of
481	pharmacy benefits to enable a plan to coordinate and fully
482	manage all aspects of patient care as part of the plan or
483	through a pharmacy benefits manager.
484	3.  Each plan shall implement a pharmacy fraud, waste, and
485	abuse initiative that may include a surety bond or letter of
486	credit requirement for participating pharmacies, enhanced
487	provider auditing practices, the use of additional fraud and
488	abuse software, recipient management programs for recipients
489	inappropriately using their benefits, and other measures to
490	reduce provider and recipient fraud, waste, and abuse. The
491	initiative shall address enforcement efforts to reduce the
492	number and use of counterfeit prescriptions.
493	4.  The agency shall require plans to report incidences of
494	pharmacy fraud and abuse and establish procedures for receiving
495	and investigating fraud and abuse reports from plans in the
496	demonstration project sites. Plans must report instances of
497	fraud and abuse pursuant to chapter 641, Florida Statutes.
498	5.  The agency may facilitate the establishment of a
499	Florida managed care plan purchasing alliance. The purpose of
500	the alliance is to form agreements among participating plans to
501	purchase pharmaceuticals at a discount, to achieve rebates, or
502	to receive best market price adjustments. Participation in the
503	Florida managed care plan purchasing alliance shall be
504	voluntary.
505	(d)  Behavioral health care benefits.--
506	1.  The agency shall include behavioral health care
507	benefits as part of the capitation structure to enable a plan to
508	coordinate and fully manage all aspects of patient care.
509	2.  Managed care plans shall require their contracted
510	behavioral health providers to have a member's behavioral
511	treatment plan on file in the provider's medical record.
512	3. Managed care plans are encouraged to contract with
513	specialty mental health providers.
514	(e)  Grievance resolution process.--A grievance resolution
515	process shall be established that uses the subscriber assistance
516	panel, as created in s. 408.7056, Florida Statutes, and the
517	Medicaid fair hearing process to address grievances.
518	(8)  ENHANCED BENEFIT COVERAGE.--
519	(a)  The agency may establish enhanced benefit coverage and
520	a methodology to fund the enhanced benefit coverage within funds
521	provided in the General Appropriations Act.
522	(b)  A recipient who complies with the objectives of a
523	wellness or disease management plan, as determined by the
524	agency, shall have access to the enhanced benefit coverage for
525	the purpose of purchasing or securing health-care services or
526	health-care products.
527	(c)  The agency shall establish flexible spending accounts
528	or similar accounts for recipients as approved in the waiver to
529	be administered by the agency or by a managed care plan. The
530	agency shall make deposits to a recipient's flexible spending
531	account contingent upon compliance with a wellness plan or a
532	disease management plan.
533	(d)  It is the intent of the Legislature that enhanced
534	benefits encourage consumer participation in wellness
535	activities, preventive services, and other services to improve
536	the health of the recipient.
537	(e)  The agency shall develop standards and oversight
538	procedures to monitor access to enhanced benefits during the
539	eligibility period and up to 3 years after loss of eligibility
540	as approved by the waiver.
541	(f)  It is the intent of the Legislature that the agency
542	may develop an electronic benefit transfer system for the
543	distribution of enhanced benefit funds earned by the recipient.
544	(9)  COST SHARING; REPORT.--The Agency for Health Care
545	Administration shall submit to the President of the Senate and
546	the Speaker of the House of Representatives by December 15,
547	2005, a report on the legal and administrative barriers to
548	enforcing s. 409.9081, Florida Statutes. The report must
549	describe how many services require copayments, which providers
550	collect copayments, and the total amount of copayments collected
551	from recipients for all services required under s. 409.9081,
552	Florida Statutes, by provider type for the fiscal years 2001-
553	2002 through 2004-2005. The agency shall recommend a mechanism
554	to enforce the requirement for Medicaid recipients to make
555	copayments which does not shift the copayment amount to the
556	provider. The agency shall also identify the federal or state
557	laws or regulations that permit Medicaid recipients to declare
558	impoverishment in order to avoid paying the copayment and extent
559	to which these statements of impoverishment are verified. If
560	claims of impoverishment are not currently verified, the agency
561	shall recommend a system for such verification. The report must
562	also identify any other cost-sharing measures that could be
563	imposed on Medicaid recipients.
564	(10)  CATASTROPHIC COVERAGE.--
565	(a)  To the extent of available appropriations contained in
566	the annual General Appropriations Act for such purposes, all
567	managed care plans shall provide coverage to the extent required
568	by the agency up to a monetary threshold determined by the
569	agency and within the capitation rate set by the agency. This
570	limitation threshold may vary by eligibility group or other
571	appropriate factors, including, but not limited to, recipients
572	with special needs and recipients with certain disease states.
573	(b)  The agency shall establish a fund or purchase stop-
574	loss coverage from a plan under part I of chapter 641, Florida
575	Statutes, or a health insurer authorized under chapter 624,
576	Florida Statutes, for purposes of covering services in excess of
577	those covered by the managed care plan. The catastrophic
578	coverage fund or stop-loss coverage shall provide for payment of
579	medically necessary care for recipients who are enrolled in a
580	plan and whose care has exceeded the predetermined service
581	threshold. The agency may establish an aggregate maximum level
582	of coverage in the catastrophic fund or for the stop-loss
583	coverage.
584	(c)  The agency shall develop policies and procedures to
585	allow all plans to utilize the catastrophic coverage fund or
586	stop-loss coverage for a Medicaid recipient in the plan who has
587	reached the catastrophic coverage threshold.
588	(d)  The agency shall contract for an administrative
589	structure to manage the catastrophic coverage fund.
590	(11)  CERTIFICATION.--Before any entity may operate a
591	managed care plan under the waiver, it shall obtain a
592	certificate of operation from the agency.
593	(a)  Any entity operating under part I, part II, or part
594	III of chapter 641, Florida Statutes, or under chapter 627,
595	chapter 636, chapter 391, or s. 409.912, Florida Statutes; a
596	licensed mental health provider under chapter 394, Florida
597	Statutes; a licensed substance abuse provider under chapter 397,
598	Florida Statutes; a hospital under chapter 395, Florida
599	Statutes; a provider service network as defined in this section;
600	or a state-certified contractor as defined in this section shall
601	be in compliance with the requirements and standards developed
602	by the agency. For purposes of the waiver established under this
603	section, provider service networks shall be exempt from the
604	competitive bid requirements in s. 409.912, Florida Statutes.
605	The agency, in consultation with the Office of Insurance
606	Regulation, shall establish certification requirements. It is
607	the intent of the Legislature that, to the extent possible, any
608	project authorized by the state under this section include any
609	federally qualified health center, federally qualified rural
610	health clinic, county health department, or any other federally,
611	state, or locally funded entity that serves the geographic area
612	within the boundaries of that project. The certification process
613	shall, at a minimum, include all requirements in the current
614	Medicaid prepaid health plan contract and take into account the
615	following requirements:
616	1.  The entity has sufficient financial solvency to be
617	placed at risk for the basic plan benefits under ss. 409.905,
618	409.906(8), and 409.906(20), Florida Statutes, and other covered
619	services.
620	2.  Any plan benefit package shall be actuarially
621	equivalent to the premium calculated by the agency to ensure
622	that competing plan benefits are equivalent in value. In all
623	instances, the benefit package must provide services sufficient
624	to meet the needs of the target population based on historical
625	Medicaid utilization.
626	3.  The entity has sufficient service network capacity to
627	meet the needs of members under ss. 409.905, 409.906(8), and
628	409.906(20), Florida Statutes, and other covered services.
629	4.  The entity's primary care providers are geographically
630	accessible to the recipient.
631	5.  The entity has the capacity to provide a wellness or
632	disease management program.
633	6.  The entity shall provide for ambulance service in
634	accordance with ss. 409.908(13)(d) and 409.9128, Florida
635	Statutes.
636	7.  The entity has the infrastructure to manage financial
637	transactions, recordkeeping, data collection, and other
638	administrative functions.
639	8.  The entity, if not a fully indemnified insurance
640	program under chapter 624, chapter 627, chapter 636, or chapter
641	641, Florida Statutes, must meet the financial solvency
642	requirements under this section.
643	(b)  The agency has the authority to contract with entities
644	not otherwise licensed as an insurer or risk-bearing entity
645	under chapter 627 or chapter 641, Florida Statutes, as long as
646	these entities meet the certification standards of this section
647	and any additional standards as defined by the agency to qualify
648	as managed care plans under this section.
649	(c)  In certifying a risk-bearing entity and determining
650	the financial solvency of such an entity as a provider service
651	network, the following shall apply:
652	1.  The entity shall maintain a minimum surplus in an
653	amount that is the greater of $1 million or 1.5 percent of
654	projected annual premiums.
655	2.  In lieu of the requirements in subparagraph 1., the
656	agency may consider the following:
657	a.  If the organization is a public entity, the agency may
658	take under advisement a statement from the public entity that a
659	county supports the managed care plan with the county's full
660	faith and credit. In order to qualify for the agency's
661	consideration, the county must own, operate, manage, administer,
662	or oversee the managed care plan, either partly or wholly,
663	through a county department or agency;
664	b.  The state guarantees the solvency of the organization;
665	c.  The organization is a federally qualified health center
666	or is controlled by one or more federally qualified health
667	centers and meets the solvency standards established by the
668	state for such organization pursuant to s. 409.912(4)(c),
669	Florida Statute; or
670	d.  The entity meets the solvency requirements for
671	federally approved provider-sponsored organizations as defined
672	in 42 C.F.R. ss. 422.380-422.390. However, if the provider
673	service network does not meet the solvency requirements of
674	either chapter 627 or chapter 641, Florida Statutes, the
675	provider service network is limited to the issuance of Medicaid
676	plans.
677	(d)  Each entity certified by the agency shall submit to
678	the agency any financial, programmatic, or patient-encounter
679	data or other information required by the agency to determine
680	the actual services provided and the cost of administering the
681	plan.
682	(e)  Notwithstanding the provisions of s. 409.912, Florida
683	Statutes, the agency shall extend the existing contract with a
684	hospital-based provider service network for a period not to
685	exceed 3 years.
686	(12)  ACCOUNTABILITY AND QUALITY ASSURANCE.--The agency
687	shall establish standards for plan compliance, including, but
688	not limited to, quality assurance and performance improvement
689	standards, peer or professional review standards, grievance
690	policies, and program integrity policies. The agency shall
691	develop a data reporting system, work with managed care plans to
692	establish reasonable patient-encounter reporting requirements,
693	and ensure that the data reported is accurate and complete.
694	(a)  In performing the duties required under this section,
695	the agency shall work with managed care plans to establish a
696	uniform system to measure, improve, and monitor the clinical and
697	functional outcomes of a recipient of Medicaid services. The
698	system may use financial, clinical, and other criteria based on
699	pharmacy, medical services, and other data related to the
700	provision of Medicaid services, including, but not limited to:
701	1.  Health Plan Employer Data and Information Set.
702	2.  Member satisfaction.
703	3.  Provider satisfaction.
704	4.  Report cards on plan performance and best practices.
705	5.  Quarterly reports on compliance with the prompt payment
706	of claims requirements of ss. 627.613, 641.3155, and 641.513,
707	Florida Statutes.
708	(b)  The agency shall require the managed care plans that
709	have contracted with the agency to establish a quality assurance
710	system that incorporates the provisions of s. 409.912(27),
711	Florida Statutes, and any standards, rules, and guidelines
712	developed by the agency.
713	(c)1.  The agency shall establish a medical care database
714	to compile data on health services rendered by health care
715	practitioners that provide services to patients enrolled in
716	managed care plans in the demonstration sites. The medical care
717	database shall:
718	a.  Collect for each type of patient encounter with a
719	health care practitioner or facility:
720	(I)  The demographic characteristics of the patient.
721	(II)  The principal, secondary, and tertiary diagnosis.
722	(III)  The procedure performed.
723	(IV)  The date and location where the procedure was
724	performed.
725	(V)  The payment for the procedure, if any.
726	(VI)  If applicable, the health care practitioner's
727	universal identification number.
728	(VII)  If the health care practitioner rendering the
729	service is a dependent practitioner, the modifiers appropriate
730	to indicate that the service was delivered by the dependent
731	practitioner.
732	b.  Collect appropriate information relating to
733	prescription drugs for each type of patient encounter.
734	c.  Collect appropriate information related to health care
735	costs, utilization, or resources from managed care plans
736	participating in the demonstration sites.
737	2.  To the extent practicable, when collecting the data
738	required under sub-subparagraph 1.a., the agency shall utilize
739	any standardized claim form or electronic transfer system being
740	used by health care practitioners, facilities, and payers.
741	3.  Health care practitioners and facilities in the
742	demonstration sites shall submit, and managed care plans
743	participating in the demonstration sites shall receive, claims
744	for payment and any other information reasonably related to the
745	medical care database electronically in a standard format as
746	required by the agency.
747	4.  The agency shall establish reasonable deadlines for
748	phasing in of electronic transmittal of claims.
749	5.  The plan shall ensure that the data reported is
750	accurate and complete.
751	(13)  STATUTORY COMPLIANCE.--Any entity certified under
752	this section shall comply with ss. 627.613, 641.3155, and
753	641.513, Florida Statutes as applicable.
754	(14)  RATE SETTING AND RISK ADJUSTMENT.--The agency shall
755	develop an actuarially sound rate setting and risk adjustment
756	system for payment to managed care plans that:
757	(a)  Adjusts payment for differences in risk assumed by
758	managed care plans, based on a widely recognized clinical
759	diagnostic classification system or on categorical groups that
760	are established in consultation with the federal Centers for
761	Medicare and Medicaid Services.
762	(b)  Includes a phase-in of patient-encounter level data
763	reporting.
764	(c)  Includes criteria to adjust risk and validation of the
765	rates and risk adjustments.
766	(d)  Establishes rates in consultation with an actuary and
767	the federal Centers for Medicare and Medicaid Services and
768	supported by actuarial analysis.
769	(e)  Reimburses managed care demonstration projects on a
770	capitated basis, except for the first year of operation of a
771	provider service network. The agency shall develop contractual
772	arrangements with the provider service network for a fee-for-
773	service reimbursement methodology that does not exceed total
774	payments under the risk-adjusted capitation during the first
775	year of operation of a managed care demonstration project.
776	Contracts must, at a minimum, require provider service networks
777	to report patient-encounter data, reconcile costs to established
778	risk-adjusted capitation rates at specified periods, and specify
779	the method and process for settlement of cost differences at the
780	end of the contract period.
781	(f)  Provides actuarial benefit design analyses that
782	indicate the effect on capitation rates and benefits offered in
783	the demonstration program over a prospective 5-year period based
784	on the following assumptions:
785	1.  Growth in capitation rates which is limited to the
786	estimated growth rate in general revenue.
787	2.  Growth in capitation rates which is limited to the
788	average growth rate over the last 3 years in per-recipient
789	Medicaid expenditures.
790	3.  Growth in capitation rates which is limited to the
791	growth rate of aggregate Medicaid expenditures between the 2003-
792	2004 fiscal year and the 2004-2005 fiscal year.
793	(15)  MEDICAID OPT-OUT OPTION.--
794	(a)  The agency shall allow recipients to purchase health
795	care coverage through an employer-sponsored health insurance
796	plan instead of through a Medicaid certified plan.
797	(b)  A recipient who chooses the Medicaid opt-out option
798	shall have an opportunity for a specified period of time, as
799	authorized under a waiver granted by the Centers for Medicare
800	and Medicaid Services, to select and enroll in a Medicaid
801	certified plan. If the recipient remains in the employer-
802	sponsored plan after the specified period, the recipient shall
803	remain in the opt-out program for at least 1 year or until the
804	recipient no longer has access to employer-sponsored coverage,
805	until the employer's open enrollment period for a person who
806	opts out in order to participate in employer-sponsored coverage,
807	or until the person is no longer eligible for Medicaid,
808	whichever time period is shorter.
809	(c)  Notwithstanding any other provision of this section,
810	coverage, cost sharing, and any other component of employer-
811	sponsored health insurance shall be governed by applicable state
812	and federal laws.
813	(16)  FRAUD AND ABUSE.--
814	(a)  To minimize the risk of Medicaid fraud and abuse, the
815	agency shall ensure that applicable provisions of chapters 409,
816	414, 626, 641, and 932, Florida Statutes, relating to Medicaid
817	fraud and abuse, are applied and enforced at the demonstration
818	project sites.
819	(b)  Providers shall have the necessary certification,
820	license and credentials as required by law and waiver
821	requirements.
822	(c)  The agency shall ensure that the plan is in compliance
823	with the provisions of s. 409.912(21) and (22), Florida
824	Statutes.
825	(d)  The agency shall require each plan to establish
826	program integrity functions and activities to reduce the
827	incidence of fraud and abuse. Plans must report instances of
828	fraud and abuse pursuant to chapter 641, Florida Statutes.
829	(e)  The plan shall have written administrative and
830	management arrangements or procedures, including a mandatory
831	compliance plan, that are designed to guard against fraud and
832	abuse. The plan shall designate a compliance officer with
833	sufficient experience in health care.
834	(f)1.  The agency shall require all contractors in the
835	managed care plan to report all instances of suspected fraud and
836	abuse. A failure to report instances of suspected fraud and
837	abuse is a violation of law and subject to the penalties
838	provided by law.
839	2.  An instance of fraud and abuse in the managed care
840	plan, including, but not limited to, defrauding the state health
841	care benefit program by misrepresentation of fact in reports,
842	claims, certifications, enrollment claims, demographic
843	statistics, and patient-encounter data; misrepresentation of the
844	qualifications of persons rendering health care and ancillary
845	services; bribery and false statements relating to the delivery
846	of health care; unfair and deceptive marketing practices; and
847	managed care false claims actions, is a violation of law and
848	subject to the penalties provided by law.
849	3.  The agency shall require that all contractors make all
850	files and relevant billing and claims data accessible to state
851	regulators and investigators and that all such data be linked
852	into a unified system for seamless reviews and investigations.
853	(17)  CERTIFIED SCHOOL MATCH PROGRAM.-The agency shall
854	develop a system whereby school districts participating in the
855	certified school match program pursuant to ss. 409.908(21) and
856	1011.70 shall be reimbursed by Medicaid, subject to the
857	limitations of s. 1011.70(1), for a Medicaid-eligible child
858	participating in the services as authorized in s. 1011.70, as
859	provided for in s. 409.9071, regardless of whether the child is
860	enrolled in a capitated managed care network. Capitated managed
861	care networks must make a good-faith effort to execute
862	agreements with school districts regarding the coordinated
863	provision of services authorized under s. 1011.70. County health
864	departments delivering school-based services pursuant to ss.
865	381.0056 and 381.0057 must be reimbursed by Medicaid for the
866	federal share for a Medicaid-eligible child who receives
867	Medicaid-covered services in a school setting, regardless of
868	whether the child is enrolled in a capitated managed care
869	network. Capitated managed care networks must make a good-faith
870	effort to execute agreements with county health departments
871	regarding the coordinated provision of services to a Medicaid-
872	eligible child. To ensure continuity of care for Medicaid
873	patients, the agency, the Department of Health, and the
874	Department of Education shall develop procedures for ensuring
875	that a student's capitated managed care network provider
876	receives information relating to services provided in accordance
877	with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
878	(18)  INTEGRATED MANAGED LONG-TERM CARE SERVICES.--
879	(a)  By December 1, 2005, the Agency for Health Care
880	Administration may revise or apply for waivers pursuant to s.
881	1915 of the Social Security Act or apply for experimental,
882	pilot, or demonstration project waivers pursuant to s. 1115 of
883	the Social Security Act to create an integrated, fixed-payment
884	delivery system for Medicaid recipients who are 60 years of age
885	or older. The Agency for Health Care Administration shall create
886	the integrated, fixed-payment delivery system in partnership
887	with the Department of Elderly Affairs. Rates shall be developed
888	in accordance with 42 C.F.R. s. 438.60, certified by an actuary,
889	and submitted for approval to the Centers for Medicare and
890	Medicaid Services. Rates must reflect the intent to provide
891	quality care in the least-restrictive setting. The funds to be
892	integrated shall include:
893	1.  All Medicaid home and community-based waiver services
894	funds.
895	2.  All funds for all Medicaid services, including Medicaid
896	nursing home services. Inclusion of funds for nursing home
897	services shall be upon certification by the agency that the
898	integration of nursing home funds will improve coordinated care
899	for these services in a less costly manner.
900	3.  All funds paid for Medicare coinsurance and deductibles
901	for persons dually eligible for Medicaid and Medicare, for which
902	the state is responsible, but not to exceed the federal limits
903	of liability specified in the state plan.
904	(b)  The Agency for Health Care Administration shall
905	implement the integrated system initially on a pilot basis in
906	two areas of the state. In one of the areas enrollment shall be
907	on a voluntary basis. In counties where the integrated system is
908	implemented on a voluntary basis, Medicaid recipients 60 years
909	of age and older shall initially enroll in a managed long-term
910	care delivery system, but may, within 30 days, choose to receive
911	services through the traditional fee-for-service delivery
912	system.
913	(c)  The Agency for Health Care Administration and the
914	Department of Elderly Affairs shall evaluate the feasibility of
915	expanding managed long-term care into additional counties using
916	a combined global budgeting system in which funding for Medicaid
917	services which would be available to provide Medicaid services
918	for an elderly person is combined into a single payment amount
919	that can be used flexibly to provide services required by a
920	participant. Under such a system, a participant is to be
921	assisted in choosing appropriate Medicaid services and providers
922	by means of choice counseling, case management, and other
923	mechanisms designed to assist recipients to choose cost-
924	efficient services in their own homes and communities rather
925	than rely on institutional placement. In evaluating the
926	feasibility of a global budgeting system, the agency and the
927	department shall ensure that such a system is cost-neutral to
928	the state and, to the extent possible, includes services funded
929	by Medicaid, state general revenue programs, and programs funded
930	under the federal Older American's Act.
931	(d)  When the agency integrates the funding for Medicaid
932	services for recipients 60 years of age or older into a managed
933	care delivery system under paragraph (a) in any area of the
934	state, the agency shall provide to recipients a choice of plans
935	which shall include:
936	1.  Entities licensed under chapter 627 or chapter 641,
937	Florida Statutes.
938	2.  Any other entity certified by the agency to accept a
939	capitation payment, including entities eligible to participate
940	in the nursing home diversion program, other qualified providers
941	as defined in s. 430.703(7), Florida Statutes, and community
942	care for the elderly lead agencies. Entities not licensed under
943	chapters 627 or 641 must meet comparable standards as defined by
944	the agency, in consultation with the Department of Elderly
945	Affairs and the Office of Insurance Regulation, to be
946	financially solvent and able to take on financial risk for
947	managed care. Community service networks that are certified
948	pursuant to the comparable standards defined by the agency are
949	not required to be licensed under chapter 641, Florida Statutes.
950	(e)  Individuals who are 60 years of age or older who have
951	developmental disabilities or who are participants in the family
952	and supported-living waiver program, the project AIDS care
953	waiver program, the traumatic brain injury and spinal cord
954	injury waiver program, the consumer-directed care waiver
955	program, or the program of all-inclusive care for the elderly
956	program, and residents of intermediate-care facilities for the
957	developmentally disabled must be excluded from the integrated
958	system.
959	(f)  When the agency implements an integrated system and
960	includes funding for Medicaid nursing home and community-based
961	care services into a managed care delivery system in any area of
962	the state, the agency shall ensure that a plan, in addition to
963	other certification requirements:
964	1.  Allows an enrollee to select any provider with whom the
965	plan has a contract.
966	2.  Makes a good faith effort to develop contracts with
967	qualified providers currently under contract with the Department
968	of Elderly Affairs, area agencies on aging, or community care
969	for the elderly lead agencies.
970	3.  Secures subcontracts with providers of nursing home and
971	community-based long-term care services sufficient to ensure
972	access to and choice of providers.
973	4.  Develops and uses a service provider qualification
974	system that describes the quality-of-care standards that
975	providers of medical, health, and long-term care services must
976	meet in order to obtain a contract from the plan.
977	5.  Makes a good faith effort to develop contracts with all
978	qualified nursing homes located in the area that are served by
979	the plan, including those designated as Gold Seal.
980	6.  Ensures that a Medicaid recipient enrolled in a managed
981	care plan who is a resident of a facility licensed under chapter
982	400, Florida Statutes, and who does not choose to move to
983	another setting is allowed to remain in the facility in which he
984	or she is currently receiving care.
985	7.  Includes persons who are in nursing homes and who
986	convert from non-Medicaid payment sources to Medicaid. Plans
987	shall be at risk for serving persons who convert to Medicaid.
988	The agency shall ensure that persons who choose community
989	alternatives instead of nursing home care and who meet level of
990	care and financial eligibility standards continue to receive
991	Medicaid.
992	8.  Demonstrates a quality assurance system and a
993	performance improvement system that is satisfactory to the
994	agency.
995	9.  Develops a system to identify recipients who have
996	special health care needs such as polypharmacy, mental health
997	and substance abuse problems, falls, chronic pain, nutritional
998	deficits, or cognitive deficits or who are ventilator-dependent
999	in order to respond to and meet these needs.
1000	10.  Ensures a multidisciplinary team approach to recipient
1001	management that facilitates the sharing of information among
1002	providers responsible for delivering care to a recipient.
1003	11.  Ensures medical oversight of care plans and service
1004	delivery, regular medical evaluation of care plans, and the
1005	availability of medical consultation for care managers and
1006	service coordinators.
1007	12.  Develops, monitors, and enforces quality-of-care
1008	requirements using existing Agency for Health Care
1009	Administration survey and certification data, whenever possible,
1010	to avoid duplication of survey or certification activities
1011	between the plans and the agency.
1012	13.  Ensures a system of care coordination that includes
1013	educational and training standards for care managers and service
1014	coordinators.
1015	14.  Develops a business plan that demonstrates the ability
1016	of the plan to organize and operate a risk-bearing entity.
1017	15.  Furnishes evidence of liability insurance coverage or
1018	a self-insurance plan that is determined by the Office of
1019	Insurance Regulation to be adequate to respond to claims for
1020	injuries arising out of the furnishing of health care.
1021	16.  Complies with the prompt payment of claims
1022	requirements of ss. 627.613, 641.3155, and 641.513, Florida
1023	Statutes.
1024	17.  Provides for a periodic review of its facilities, as
1025	required by the agency, which does not duplicate other
1026	requirements of federal or state law. The agency shall provide
1027	provider survey results to the plan.
1028	18.  Provides enrollees the ability, to the extent
1029	possible, to choose care providers, including nursing home,
1030	assisted living, and adult day care service providers affiliated
1031	with a person's religious faith or denomination, nursing home
1032	and assisted living facility providers that are part of a
1033	retirement community in which an enrollee resides, and nursing
1034	homes and assisted living facilities that are geographically
1035	located as close as possible to an enrollee's family, friends,
1036	and social support system.
1037	(g)  In addition to other quality assurance standards
1038	required by law or by rule or in an approved federal waiver, and
1039	in consultation with the Department of Elderly Affairs and area
1040	agencies on aging, the agency shall develop quality assurance
1041	standards that are specific to the care needs of elderly
1042	individuals and that measure enrollee outcomes and satisfaction
1043	with care management and home and community-based services that
1044	are provided to recipients 60 years of age or older by managed
1045	care plans pursuant to this section. The agency in consultation
1046	with the Department of Elderly Affairs shall contract with area
1047	agencies on aging to perform initial and ongoing measurement of
1048	the appropriateness, effectiveness, and quality of care
1049	management and home and community-based services that are
1050	provided to recipients 60 years of age or older by managed care
1051	plans and to collect and report the resolution of enrollee
1052	grievances and complaints. The agency and the department shall
1053	coordinate the quality measurement activities performed by area
1054	agencies on aging with other quality assurance activities
1055	required by this section in a manner that promotes efficiency
1056	and avoids duplication.
1057	(h)  If there is not a contractual relationship between a
1058	nursing home provider and a plan in an area in which the
1059	demonstration project operates, the nursing home shall cooperate
1060	with the efforts of a plan to determine if a recipient would be
1061	more appropriately served in a community setting, and payments
1062	shall be made in accordance with Medicaid nursing home rates as
1063	calculated in the Medicaid state plan.
1064	(i)  The agency may develop innovative risk-sharing
1065	agreements that limit the level of custodial nursing home risk
1066	that the plan assumes, consistent with the intent of the
1067	Legislature to reduce the use and cost of nursing home care.
1068	Under risk-sharing agreements, the agency may reimburse the plan
1069	or a nursing home for the cost of providing nursing home care
1070	for Medicaid-eligible recipients who have been permanently
1071	placed and remain in nursing home care.
1072	(j)  The agency shall withhold a percentage of the
1073	capitation rate that would otherwise have been paid to a plan in
1074	order to create a quality reserve fund, which shall be annually
1075	disbursed to those contracted plans that deliver high-quality
1076	services, have a low rate of enrollee complaints, have
1077	successful enrollee outcomes, are in compliance with quality
1078	improvement standards, and demonstrate other indicators
1079	determined by the agency to be consistent with high-quality
1080	service delivery.
1081	(k)  The agency shall evaluate the medical loss ratios of
1082	managed care plans providing services to individuals 60 years of
1083	age or older in the Medicaid program and shall annually report
1084	such medical loss ratios to the Legislature. Medical loss ratios
1085	are subject to an annual audit. The agency may, by rule, adopt
1086	minimum medical loss ratios for such managed care plans. Failure
1087	to comply with the minimum medical loss ratios shall be grounds
1088	for imposition of fines, reductions in capitated payments in the
1089	current fiscal year, or contract termination.
1090	(l)  The agency may limit the number of persons enrolled in
1091	a plan who are not nursing home facility residents but who would
1092	be Medicaid eligible as defined under s. 409.904(3), Florida
1093	Statutes, if served in an approved home or community-based
1094	waiver program.
1095	(m)  Except as otherwise provided in this section, the
1096	Aging Resource Center, if available, shall be the entry point
1097	for eligibility determination for persons 60 years of age or
1098	older and shall provide choice counseling to assist recipients
1099	in choosing a plan. If an Aging Resource Center is not operating
1100	in an area or if the Aging Resource Center or area agency on
1101	aging has a contractual relationship with or has any ownership
1102	interest in a managed care plan, the agency may, in consultation
1103	with the Department of Elderly Affairs, designate other entities
1104	to perform these functions until an Aging Resource Center is
1105	established and has the capacity to perform these functions.
1106	(n)  In the event that a managed care plan does not meet
1107	its obligations under its contract with the agency or under the
1108	requirements of this section, the agency may impose liquidated
1109	damages. Such liquidated damages shall be calculated by the
1110	agency as reasonable estimates of the agency's financial loss
1111	and are not to be used to penalize the plan. If the agency
1112	imposes liquidated damages, the agency may collect those damages
1113	by reducing the amount of any monthly premium payments otherwise
1114	due to the plan by the amount of the damages. Liquidated damages
1115	are forfeited and will not be subsequently paid to a plan upon
1116	compliance or cure of default unless a determination is made
1117	after appeal that the damages should not have been imposed.
1118	(o)  In any area of the state in which the agency has
1119	implemented a demonstration project pursuant to this section,
1120	the agency may grant a modification of certificate-of-need
1121	conditions related to Medicaid participation to a nursing home
1122	that has experienced decreased Medicaid patient day utilization
1123	due to a transition to a managed care delivery system.
1124	(p)  Notwithstanding any other law to the contrary, the
1125	agency shall ensure that, to the extent possible, Medicare and
1126	Medicaid services are integrated. When possible, persons served
1127	by the managed care delivery system who are eligible for
1128	Medicare may choose to enroll in a Medicare managed health care
1129	plan operated by the same entity that is placed at risk for
1130	Medicaid services.
1131	(q)  It is the intent of the Legislature that the agency
1132	and the Department of Elderly Affairs begin discussions with the
1133	federal Centers for Medicare and Medicaid Services regarding the
1134	inclusion of Medicare in an integrated long-term care system.
1135	(19)  FUNDING DEVELOPMENT COSTS OF ESSENTIAL COMMUNITY
1136	PROVIDERS.--It is the intent of the Legislature to facilitate
1137	the development of managed care delivery systems by networks of
1138	essential community providers comprised of current community
1139	care for the elderly lead agencies. To allow the assumption of
1140	responsibility and financial risk for managing a recipient
1141	through the entire continuum of Medicaid services, the agency
1142	shall, subject to appropriations included in the General
1143	Appropriations Act, award up to $500,000 per applicant for the
1144	purpose of funding managed care delivery system development
1145	costs. The terms of repayment may not extend beyond 6 years
1146	after the date when the funding begins and must include payment
1147	in full with a rate of interest equal to or greater than the
1148	federal funds rate. The agency, in consultation with the
1149	Department of Elderly Affairs shall establish a grant
1150	application process for awards.
1151	(20)  MEDICAID BUY-IN.--The Office of Program Policy
1152	Analysis and Government Accountability shall conduct a study of
1153	state programs that allow non-Medicaid eligible persons under a
1154	certain income level to buy into the Medicaid program as if it
1155	was private insurance. The study shall examine Medicaid buy-in
1156	programs in other states to determine if there are any models
1157	that can be implemented in Florida which would provide access to
1158	uninsured Floridians and what effect this program would have on
1159	Medicaid expenditures based on the experience of similar states.
1160	The study must also examine whether the Medically Needy program
1161	could be redesigned to be a Medicaid buy-in program. The study
1162	must be submitted to the President of the Senate and the Speaker
1163	of the House of representatives by January 1, 2006.
1164	(21)  APPLICABILITY.--
1165	(a)  The provisions of this section apply only to the
1166	demonstration project sites approved by the Legislature.
1167	(b)  The Legislature authorizes the Agency for Health Care
1168	Administration to apply and enforce any provision of law not
1169	referenced in this section to ensure the safety, quality, and
1170	integrity of the waiver.
1171	(22)  RULEMAKING.--The Agency for Health Care
1172	Administration is authorized to adopt rules in consultation with
1173	the appropriate state agencies to implement the provisions of
1174	this section.
1175	(23)  IMPLEMENTATION.--
1176	(a)  This section does not authorize the agency to
1177	implement any provision of s. 1115 of the Social Security Act
1178	experimental, pilot, or demonstration project waiver to reform
1179	the state Medicaid program unless approved by the Legislature.
1180	(b)  The agency shall develop and submit for approval
1181	applications for waivers of applicable federal laws and
1182	regulations as necessary to implement the managed care
1183	demonstration project as defined in this section. The agency
1184	shall post all waiver applications under this section on its
1185	Internet website 30 days before submitting the applications to
1186	the United States Centers for Medicare and Medicaid Services.
1187	All waiver applications shall be provided for review and comment
1188	to the appropriate committees of the Senate and House of
1189	Representatives for at least 10 working days prior to
1190	submission. All waivers submitted to and approved by the United
1191	States Centers for Medicare and Medicaid Services under this
1192	section must be submitted to the appropriate committees of the
1193	Senate and the House of Representatives in order to obtain
1194	authority for implementation as required by s. 409.912(11),
1195	Florida Statutes, before program implementation. The appropriate
1196	committees shall recommend whether to approve the implementation
1197	of the waivers to the Legislature or to the Legislative Budget
1198	Commission if the Legislature is not in session. The agency
1199	shall submit a plan containing a detailed timeline for
1200	implementation and budgetary projections of the effect of the
1201	pilot program on the total Medicaid budget for the 2006-2007
1202	through 2009-2010 fiscal years
1203	(24)  EVALUATION.--
1204	(a)  Two years after the implementation of the waiver and
1205	again 5 years after the implementation of the waiver, the Office
1206	of Program Policy Analysis and Government Accountability, shall
1207	conduct an evaluation study and analyze the impact of the
1208	Medicaid reform waiver pursuant to this section to the extent
1209	allowed in the waiver demonstration sites by the Centers for
1210	Medicare and Medicaid Services and implemented as approved by
1211	the Legislature pursuant to this section. The Office of Program
1212	Policy Analysis and Government Accountability shall consult with
1213	appropriate legislative committees to select provisions of the
1214	waiver to evaluate from among the following:
1215	1.  Demographic characteristics of the recipient of the
1216	waiver.
1217	2.  Plan types and service networks.
1218	3.  Health benefit coverage.
1219	4.  Choice counseling.
1220	5.  Disease management.
1221	6.  Pharmacy benefits.
1222	7.  Behavioral health benefits.
1223	8.  Service utilization.
1224	9.  Catastrophic coverage.
1225	10.  Enhanced benefits.
1226	11.  Medicaid opt-out option.
1227	12.  Quality assurance and accountability.
1228	13.  Fraud and abuse.
1229	14.  Cost and cost benefit of the waiver.
1230	15.  Impact of the waiver on the agency.
1231	16.  Positive impact of plans on health disparities among
1232	minorities.
1233	17.  Administrative or legal barriers to the implementation
1234	and operation of each pilot program.
1235	(b)  The Office of Program Policy Analysis and Government
1236	Accountability shall submit the evaluation study report to the
1237	agency and to the Governor, the President of the Senate, the
1238	Speaker of the House of Representatives, and the appropriate
1239	committees or councils of the Senate and the House of
1240	Representatives.
1241	(c)  One year after implementation of the integrated
1242	managed long-term care plan, the agency shall contract with an
1243	entity experienced in evaluating managed long-term care plans in
1244	another state to evaluate, at a minimum, demonstrated cost
1245	savings realized and expected, consumer satisfaction, the range
1246	of services being provided under the program, and rate-setting
1247	methodology.
1248	(d)  The agency shall submit, every 6 months after the date
1249	of waiver implementation, a status report describing the
1250	progress made on the implementation of the waiver and
1251	identification of any issues or problems to the Governor's
1252	Office of Planning and Budgeting and the appropriate committees
1253	or councils of the Senate and the House of Representatives.
1254	(e)  The agency shall provide to the appropriate committees
1255	or councils of the Senate and House of Representatives copies of
1256	any report or evaluation regarding the waiver that is submitted
1257	to the Center for Medicare and Medicaid Services.
1258	(f)  The agency shall contract for an evaluation comparison
1259	of the waiver demonstration projects with the Medipass fee-for-
1260	service program including, at a minimum:
1261	1.  Administrative or organizational structure of the
1262	service delivery system.
1263	2.  Covered services and service utilization patterns of
1264	mandatory, optional, and other services.
1265	3.  Clinical or health outcomes.
1266	4.  Cost analysis, cost avoidance, and cost benefit.
1267	(25)  REVIEW AND REPEAL.--This section shall stand repealed
1268	on July 1, 2010, unless reviewed and saved from repeal through
1269	reenactment by the Legislature.
1270	Section 3.  Section 409.912, Florida Statutes, is amended
1271	to read:
1272	409.912  Cost-effective purchasing of health care.--The
1273	agency shall purchase goods and services for Medicaid recipients
1274	in the most cost-effective manner consistent with the delivery
1275	of quality medical care. To ensure that medical services are
1276	effectively utilized, the agency may, in any case, require a
1277	confirmation or second physician's opinion of the correct
1278	diagnosis for purposes of authorizing future services under the
1279	Medicaid program. This section does not restrict access to
1280	emergency services or poststabilization care services as defined
1281	in 42 C.F.R. part 438.114. Such confirmation or second opinion
1282	shall be rendered in a manner approved by the agency. The agency
1283	shall maximize the use of prepaid per capita and prepaid
1284	aggregate fixed-sum basis services when appropriate and other
1285	alternative service delivery and reimbursement methodologies,
1286	including competitive bidding pursuant to s. 287.057, designed
1287	to facilitate the cost-effective purchase of a case-managed
1288	continuum of care. The agency shall also require providers to
1289	minimize the exposure of recipients to the need for acute
1290	inpatient, custodial, and other institutional care and the
1291	inappropriate or unnecessary use of high-cost services. The
1292	agency shall contract with a vendor to monitor and evaluate the
1293	clinical practice patterns of providers in order to identify
1294	trends that are outside the normal practice patterns of a
1295	provider's professional peers or the national guidelines of a
1296	provider's professional association. The vendor must be able to
1297	provide information and counseling to a provider whose practice
1298	patterns are outside the norms, in consultation with the agency,
1299	to improve patient care and reduce inappropriate utilization.
1300	The agency may mandate prior authorization, drug therapy
1301	management, or disease management participation for certain
1302	populations of Medicaid beneficiaries, certain drug classes, or
1303	particular drugs to prevent fraud, abuse, overuse, and possible
1304	dangerous drug interactions. The Pharmaceutical and Therapeutics
1305	Committee shall make recommendations to the agency on drugs for
1306	which prior authorization is required. The agency shall inform
1307	the Pharmaceutical and Therapeutics Committee of its decisions
1308	regarding drugs subject to prior authorization. The agency is
1309	authorized to limit the entities it contracts with or enrolls as
1310	Medicaid providers by developing a provider network through
1311	provider credentialing. The agency may competitively bid single-
1312	source-provider contracts if procurement of goods or services
1313	results in demonstrated cost savings to the state without
1314	limiting access to care. The agency may limit its network based
1315	on the assessment of beneficiary access to care, provider
1316	availability, provider quality standards, time and distance
1317	standards for access to care, the cultural competence of the
1318	provider network, demographic characteristics of Medicaid
1319	beneficiaries, practice and provider-to-beneficiary standards,
1320	appointment wait times, beneficiary use of services, provider
1321	turnover, provider profiling, provider licensure history,
1322	previous program integrity investigations and findings, peer
1323	review, provider Medicaid policy and billing compliance records,
1324	clinical and medical record audits, and other factors. Providers
1325	shall not be entitled to enrollment in the Medicaid provider
1326	network. The agency shall determine instances in which allowing
1327	Medicaid beneficiaries to purchase durable medical equipment and
1328	other goods is less expensive to the Medicaid program than long-
1329	term rental of the equipment or goods. The agency may establish
1330	rules to facilitate purchases in lieu of long-term rentals in
1331	order to protect against fraud and abuse in the Medicaid program
1332	as defined in s. 409.913. The agency may is authorized to seek
1333	federal waivers necessary to administer these policies implement
1334	this policy.
1335	(1)  The agency shall work with the Department of Children
1336	and Family Services to ensure access of children and families in
1337	the child protection system to needed and appropriate mental
1338	health and substance abuse services.
1339	(2)  The agency may enter into agreements with appropriate
1340	agents of other state agencies or of any agency of the Federal
1341	Government and accept such duties in respect to social welfare
1342	or public aid as may be necessary to implement the provisions of
1343	Title XIX of the Social Security Act and ss. 409.901-409.920.
1344	(3)  The agency may contract with health maintenance
1345	organizations certified pursuant to part I of chapter 641 for
1346	the provision of services to recipients.
1347	(4)  The agency may contract with:
1348	(a)  An entity that provides no prepaid health care
1349	services other than Medicaid services under contract with the
1350	agency and which is owned and operated by a county, county
1351	health department, or county-owned and operated hospital to
1352	provide health care services on a prepaid or fixed-sum basis to
1353	recipients, which entity may provide such prepaid services
1354	either directly or through arrangements with other providers.
1355	Such prepaid health care services entities must be licensed
1356	under parts I and III by January 1, 1998, and until then are
1357	exempt from the provisions of part I of chapter 641. An entity
1358	recognized under this paragraph which demonstrates to the
1359	satisfaction of the Office of Insurance Regulation of the
1360	Financial Services Commission that it is backed by the full
1361	faith and credit of the county in which it is located may be
1362	exempted from s. 641.225.
1363	(b)  An entity that is providing comprehensive behavioral
1364	health care services to certain Medicaid recipients through a
1365	capitated, prepaid arrangement pursuant to the federal waiver
1366	provided for by s. 409.905(5). Such an entity must be licensed
1367	under chapter 624, chapter 636, or chapter 641 and must possess
1368	the clinical systems and operational competence to manage risk
1369	and provide comprehensive behavioral health care to Medicaid
1370	recipients. As used in this paragraph, the term "comprehensive
1371	behavioral health care services" means covered mental health and
1372	substance abuse treatment services that are available to
1373	Medicaid recipients. The secretary of the Department of Children
1374	and Family Services shall approve provisions of procurements
1375	related to children in the department's care or custody prior to
1376	enrolling such children in a prepaid behavioral health plan. Any
1377	contract awarded under this paragraph must be competitively
1378	procured. In developing the behavioral health care prepaid plan
1379	procurement document, the agency shall ensure that the
1380	procurement document requires the contractor to develop and
1381	implement a plan to ensure compliance with s. 394.4574 related
1382	to services provided to residents of licensed assisted living
1383	facilities that hold a limited mental health license. Except as
1384	provided in subparagraph 8., the agency shall seek federal
1385	approval to contract with a single entity meeting these
1386	requirements to provide comprehensive behavioral health care
1387	services to all Medicaid recipients not enrolled in a managed
1388	care plan in an AHCA area. Each entity must offer sufficient
1389	choice of providers in its network to ensure recipient access to
1390	care and the opportunity to select a provider with whom they are
1391	satisfied. The network shall include all public mental health
1392	hospitals. To ensure unimpaired access to behavioral health care
1393	services by Medicaid recipients, all contracts issued pursuant
1394	to this paragraph shall require 80 percent of the capitation
1395	paid to the managed care plan, including health maintenance
1396	organizations, to be expended for the provision of behavioral
1397	health care services. In the event the managed care plan expends
1398	less than 80 percent of the capitation paid pursuant to this
1399	paragraph for the provision of behavioral health care services,
1400	the difference shall be returned to the agency. The agency shall
1401	provide the managed care plan with a certification letter
1402	indicating the amount of capitation paid during each calendar
1403	year for the provision of behavioral health care services
1404	pursuant to this section. The agency may reimburse for substance
1405	abuse treatment services on a fee-for-service basis until the
1406	agency finds that adequate funds are available for capitated,
1407	prepaid arrangements.
1408	1.  By January 1, 2001, the agency shall modify the
1409	contracts with the entities providing comprehensive inpatient
1410	and outpatient mental health care services to Medicaid
1411	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
1412	Counties, to include substance abuse treatment services.
1413	2.  By July 1, 2003, the agency and the Department of
1414	Children and Family Services shall execute a written agreement
1415	that requires collaboration and joint development of all policy,
1416	budgets, procurement documents, contracts, and monitoring plans
1417	that have an impact on the state and Medicaid community mental
1418	health and targeted case management programs.
1419	3.  Except as provided in subparagraph 8., by July 1, 2006,
1420	the agency and the Department of Children and Family Services
1421	shall contract with managed care entities in each AHCA area
1422	except area 6 or arrange to provide comprehensive inpatient and
1423	outpatient mental health and substance abuse services through
1424	capitated prepaid arrangements to all Medicaid recipients who
1425	are eligible to participate in such plans under federal law and
1426	regulation. In AHCA areas where eligible individuals number less
1427	than 150,000, the agency shall contract with a single managed
1428	care plan to provide comprehensive behavioral health services to
1429	all recipients who are not enrolled in a Medicaid health
1430	maintenance organization. The agency may contract with more than
1431	one comprehensive behavioral health provider to provide care to
1432	recipients who are not enrolled in a Medicaid health maintenance
1433	organization in AHCA areas where the eligible population exceeds
1434	150,000. Contracts for comprehensive behavioral health providers
1435	awarded pursuant to this section shall be competitively
1436	procured. Both for-profit and not-for-profit corporations shall
1437	be eligible to compete. Managed care plans contracting with the
1438	agency under subsection (3) shall provide and receive payment
1439	for the same comprehensive behavioral health benefits as
1440	provided in AHCA rules, including handbooks incorporated by
1441	reference.
1442	4.  By October 1, 2003, the agency and the department shall
1443	submit a plan to the Governor, the President of the Senate, and
1444	the Speaker of the House of Representatives which provides for
1445	the full implementation of capitated prepaid behavioral health
1446	care in all areas of the state.
1447	a.  Implementation shall begin in 2003 in those AHCA areas
1448	of the state where the agency is able to establish sufficient
1449	capitation rates.
1450	b.  If the agency determines that the proposed capitation
1451	rate in any area is insufficient to provide appropriate
1452	services, the agency may adjust the capitation rate to ensure
1453	that care will be available. The agency and the department may
1454	use existing general revenue to address any additional required
1455	match but may not over-obligate existing funds on an annualized
1456	basis.
1457	c.  Subject to any limitations provided for in the General
1458	Appropriations Act, the agency, in compliance with appropriate
1459	federal authorization, shall develop policies and procedures
1460	that allow for certification of local and state funds.
1461	5.  Children residing in a statewide inpatient psychiatric
1462	program, or in a Department of Juvenile Justice or a Department
1463	of Children and Family Services residential program approved as
1464	a Medicaid behavioral health overlay services provider shall not
1465	be included in a behavioral health care prepaid health plan or
1466	any other Medicaid managed care plan pursuant to this paragraph.
1467	6.  In converting to a prepaid system of delivery, the
1468	agency shall in its procurement document require an entity
1469	providing only comprehensive behavioral health care services to
1470	prevent the displacement of indigent care patients by enrollees
1471	in the Medicaid prepaid health plan providing behavioral health
1472	care services from facilities receiving state funding to provide
1473	indigent behavioral health care, to facilities licensed under
1474	chapter 395 which do not receive state funding for indigent
1475	behavioral health care, or reimburse the unsubsidized facility
1476	for the cost of behavioral health care provided to the displaced
1477	indigent care patient.
1478	7.  Traditional community mental health providers under
1479	contract with the Department of Children and Family Services
1480	pursuant to part IV of chapter 394, child welfare providers
1481	under contract with the Department of Children and Family
1482	Services in areas 1 and 6, and inpatient mental health providers
1483	licensed pursuant to chapter 395 must be offered an opportunity
1484	to accept or decline a contract to participate in any provider
1485	network for prepaid behavioral health services.
1486	8.  For fiscal year 2004-2005, all Medicaid eligible
1487	children, except children in areas 1 and 6, whose cases are open
1488	for child welfare services in the HomeSafeNet system, shall be
1489	enrolled in MediPass or in Medicaid fee-for-service and all
1490	their behavioral health care services including inpatient,
1491	outpatient psychiatric, community mental health, and case
1492	management shall be reimbursed on a fee-for-service basis.
1493	Beginning July 1, 2005, such children, who are open for child
1494	welfare services in the HomeSafeNet system, shall receive their
1495	behavioral health care services through a specialty prepaid plan
1496	operated by community-based lead agencies either through a
1497	single agency or formal agreements among several agencies. The
1498	specialty prepaid plan must result in savings to the state
1499	comparable to savings achieved in other Medicaid managed care
1500	and prepaid programs. Such plan must provide mechanisms to
1501	maximize state and local revenues. The specialty prepaid plan
1502	shall be developed by the agency and the Department of Children
1503	and Family Services. The agency is authorized to seek any
1504	federal waivers to implement this initiative.
1505	(c)  A federally qualified health center or an entity owned
1506	by one or more federally qualified health centers or an entity
1507	owned by other migrant and community health centers receiving
1508	non-Medicaid financial support from the Federal Government to
1509	provide health care services on a prepaid or fixed-sum basis to
1510	recipients. Such prepaid health care services entity must be
1511	licensed under parts I and III of chapter 641, but shall be
1512	prohibited from serving Medicaid recipients on a prepaid basis,
1513	until such licensure has been obtained. However, such an entity
1514	is exempt from s. 641.225 if the entity meets the requirements
1515	specified in subsections (16) (17) and (17)(18).
1516	(d)  A provider service network may be reimbursed on a fee-
1517	for-service or prepaid basis. A provider service network which
1518	is reimbursed by the agency on a prepaid basis shall be exempt
1519	from parts I and III of chapter 641, but must meet appropriate
1520	financial reserve, quality assurance, and patient rights
1521	requirements as established by the agency. The agency shall
1522	award contracts on a competitive bid basis and shall select
1523	bidders based upon price and quality of care. Medicaid
1524	recipients assigned to a demonstration project shall be chosen
1525	equally from those who would otherwise have been assigned to
1526	prepaid plans and MediPass. The agency is authorized to seek
1527	federal Medicaid waivers as necessary to implement the
1528	provisions of this section.
1529	(e)  An entity that provides only comprehensive behavioral
1530	health care services to certain Medicaid recipients through an
1531	administrative services organization agreement. Such an entity
1532	must possess the clinical systems and operational competence to
1533	provide comprehensive health care to Medicaid recipients. As
1534	used in this paragraph, the term "comprehensive behavioral
1535	health care services" means covered mental health and substance
1536	abuse treatment services that are available to Medicaid
1537	recipients. Any contract awarded under this paragraph must be
1538	competitively procured. The agency must ensure that Medicaid
1539	recipients have available the choice of at least two managed
1540	care plans for their behavioral health care services.
1541	(f)  An entity that provides in-home physician services to
1542	test the cost-effectiveness of enhanced home-based medical care
1543	to Medicaid recipients with degenerative neurological diseases
1544	and other diseases or disabling conditions associated with high
1545	costs to Medicaid. The program shall be designed to serve very
1546	disabled persons and to reduce Medicaid reimbursed costs for
1547	inpatient, outpatient, and emergency department services. The
1548	agency shall contract with vendors on a risk-sharing basis.
1549	(g)  Children's provider networks that provide care
1550	coordination and care management for Medicaid-eligible pediatric
1551	patients, primary care, authorization of specialty care, and
1552	other urgent and emergency care through organized providers
1553	designed to service Medicaid eligibles under age 18 and
1554	pediatric emergency departments' diversion programs. The
1555	networks shall provide after-hour operations, including evening
1556	and weekend hours, to promote, when appropriate, the use of the
1557	children's networks rather than hospital emergency departments.
1558	(h)  An entity authorized in s. 430.205 to contract with
1559	the agency and the Department of Elderly Affairs to provide
1560	health care and social services on a prepaid or fixed-sum basis
1561	to elderly recipients. Such prepaid health care services
1562	entities are exempt from the provisions of part I of chapter 641
1563	for the first 3 years of operation. An entity recognized under
1564	this paragraph that demonstrates to the satisfaction of the
1565	Office of Insurance Regulation that it is backed by the full
1566	faith and credit of one or more counties in which it operates
1567	may be exempted from s. 641.225.
1568	(i)  A Children's Medical Services Network, as defined in
1569	s. 391.021.
1570	(5)  By October 1, 2003, the agency and the department
1571	shall, to the extent feasible, develop a plan for implementing
1572	new Medicaid procedure codes for emergency and crisis care,
1573	supportive residential services, and other services designed to
1574	maximize the use of Medicaid funds for Medicaid-eligible
1575	recipients. The agency shall include in the agreement developed
1576	pursuant to subsection (4) a provision that ensures that the
1577	match requirements for these new procedure codes are met by
1578	certifying eligible general revenue or local funds that are
1579	currently expended on these services by the department with
1580	contracted alcohol, drug abuse, and mental health providers. The
1581	plan must describe specific procedure codes to be implemented, a
1582	projection of the number of procedures to be delivered during
1583	fiscal year 2003-2004, and a financial analysis that describes
1584	the certified match procedures, and accountability mechanisms,
1585	projects the earnings associated with these procedures, and
1586	describes the sources of state match. This plan may not be
1587	implemented in any part until approved by the Legislative Budget
1588	Commission. If such approval has not occurred by December 31,
1589	2003, the plan shall be submitted for consideration by the 2004
1590	Legislature.
1591	(5)(6)  The agency may contract with any public or private
1592	entity otherwise authorized by this section on a prepaid or
1593	fixed-sum basis for the provision of health care services to
1594	recipients. An entity may provide prepaid services to
1595	recipients, either directly or through arrangements with other
1596	entities, if each entity involved in providing services:
1597	(a)  Is organized primarily for the purpose of providing
1598	health care or other services of the type regularly offered to
1599	Medicaid recipients;
1600	(b)  Ensures that services meet the standards set by the
1601	agency for quality, appropriateness, and timeliness;
1602	(c)  Makes provisions satisfactory to the agency for
1603	insolvency protection and ensures that neither enrolled Medicaid
1604	recipients nor the agency will be liable for the debts of the
1605	entity;
1606	(d)  Submits to the agency, if a private entity, a
1607	financial plan that the agency finds to be fiscally sound and
1608	that provides for working capital in the form of cash or
1609	equivalent liquid assets excluding revenues from Medicaid
1610	premium payments equal to at least the first 3 months of
1611	operating expenses or $200,000, whichever is greater;
1612	(e)  Furnishes evidence satisfactory to the agency of
1613	adequate liability insurance coverage or an adequate plan of
1614	self-insurance to respond to claims for injuries arising out of
1615	the furnishing of health care;
1616	(f)  Provides, through contract or otherwise, for periodic
1617	review of its medical facilities and services, as required by
1618	the agency; and
1619	(g)  Provides organizational, operational, financial, and
1620	other information required by the agency.
1621	(6)(7)  The agency may contract on a prepaid or fixed-sum
1622	basis with any health insurer that:
1623	(a)  Pays for health care services provided to enrolled
1624	Medicaid recipients in exchange for a premium payment paid by
1625	the agency;
1626	(b)  Assumes the underwriting risk; and
1627	(c)  Is organized and licensed under applicable provisions
1628	of the Florida Insurance Code and is currently in good standing
1629	with the Office of Insurance Regulation.
1630	(7)(8)  The agency may contract on a prepaid or fixed-sum
1631	basis with an exclusive provider organization to provide health
1632	care services to Medicaid recipients provided that the exclusive
1633	provider organization meets applicable managed care plan
1634	requirements in this section, ss. 409.9122, 409.9123, 409.9128,
1635	and 627.6472, and other applicable provisions of law.
1636	(8)(9)  The Agency for Health Care Administration may
1637	provide cost-effective purchasing of chiropractic services on a
1638	fee-for-service basis to Medicaid recipients through
1639	arrangements with a statewide chiropractic preferred provider
1640	organization incorporated in this state as a not-for-profit
1641	corporation. The agency shall ensure that the benefit limits and
1642	prior authorization requirements in the current Medicaid program
1643	shall apply to the services provided by the chiropractic
1644	preferred provider organization.
1645	(9)(10)  The agency shall not contract on a prepaid or
1646	fixed-sum basis for Medicaid services with an entity which knows
1647	or reasonably should know that any officer, director, agent,
1648	managing employee, or owner of stock or beneficial interest in
1649	excess of 5 percent common or preferred stock, or the entity
1650	itself, has been found guilty of, regardless of adjudication, or
1651	entered a plea of nolo contendere, or guilty, to:
1652	(a)  Fraud;
1653	(b)  Violation of federal or state antitrust statutes,
1654	including those proscribing price fixing between competitors and
1655	the allocation of customers among competitors;
1656	(c)  Commission of a felony involving embezzlement, theft,
1657	forgery, income tax evasion, bribery, falsification or
1658	destruction of records, making false statements, receiving
1659	stolen property, making false claims, or obstruction of justice;
1660	or
1661	(d)  Any crime in any jurisdiction which directly relates
1662	to the provision of health services on a prepaid or fixed-sum
1663	basis.
1664	(10)(11)  The agency, after notifying the Legislature, may
1665	apply for waivers of applicable federal laws and regulations as
1666	necessary to implement more appropriate systems of health care
1667	for Medicaid recipients and reduce the cost of the Medicaid
1668	program to the state and federal governments and shall implement
1669	such programs, after legislative approval, within a reasonable
1670	period of time after federal approval. These programs must be
1671	designed primarily to reduce the need for inpatient care,
1672	custodial care and other long-term or institutional care, and
1673	other high-cost services.
1674	(a)  Prior to seeking legislative approval of such a waiver
1675	as authorized by this subsection, the agency shall provide
1676	notice and an opportunity for public comment. Notice shall be
1677	provided to all persons who have made requests of the agency for
1678	advance notice and shall be published in the Florida
1679	Administrative Weekly not less than 28 days prior to the
1680	intended action.
1681	(b)  Notwithstanding s. 216.292, funds that are
1682	appropriated to the Department of Elderly Affairs for the
1683	Assisted Living for the Elderly Medicaid waiver and are not
1684	expended shall be transferred to the agency to fund Medicaid-
1685	reimbursed nursing home care.
1686	(11)(12)  The agency shall establish a postpayment
1687	utilization control program designed to identify recipients who
1688	may inappropriately overuse or underuse Medicaid services and
1689	shall provide methods to correct such misuse.
1690	(12)(13)  The agency shall develop and provide coordinated
1691	systems of care for Medicaid recipients and may contract with
1692	public or private entities to develop and administer such
1693	systems of care among public and private health care providers
1694	in a given geographic area.
1695	(13)(14)(a)  The agency shall operate or contract for the
1696	operation of utilization management and incentive systems
1697	designed to encourage cost-effective use services.
1698	(b)  The agency shall develop a procedure for determining
1699	whether health care providers and service vendors can provide
1700	the Medicaid program with a business case that demonstrates
1701	whether a particular good or service can offset the cost of
1702	providing the good or service in an alternative setting or
1703	through other means and therefore should receive a higher
1704	reimbursement.  The business case must include, but need not be
1705	limited to:
1706	1.  A detailed description of the good or service to be
1707	provided, a description and analysis of the agency's current
1708	performance of the service, and a rationale documenting how
1709	providing the service in an alternative setting would be in the
1710	best interest of the state, the agency, and its clients.
1711	2.  A cost-benefit analysis documenting the estimated
1712	specific direct and indirect costs, savings, performance
1713	improvements, risks, and qualitative and quantitative benefits
1714	involved in or resulting from providing the service. The cost-
1715	benefit analysis must include a detailed plan and timeline
1716	identifying all actions that must be implemented to realize
1717	expected benefits.  The Secretary of the Agency for Health Care
1718	Administration shall verify that all costs, savings, and
1719	benefits are valid and achievable.
1720	(14)(15)(a)  The agency shall operate the Comprehensive
1721	Assessment and Review for Long-Term Care Services (CARES)
1722	nursing facility preadmission screening program to ensure that
1723	Medicaid payment for nursing facility care is made only for
1724	individuals whose conditions require such care and to ensure
1725	that long-term care services are provided in the setting most
1726	appropriate to the needs of the person and in the most
1727	economical manner possible. The CARES program shall also ensure
1728	that individuals participating in Medicaid home and community-
1729	based waiver programs meet criteria for those programs,
1730	consistent with approved federal waivers.
1731	(b)  The agency shall operate the CARES program through an
1732	interagency agreement with the Department of Elderly Affairs.
1733	The agency, in consultation with the Department of Elderly
1734	Affairs, may contract for any function or activity of the CARES
1735	program, including any function or activity required by 42
1736	C.F.R. part 483.20, relating to preadmission screening and
1737	resident review.
1738	(c)  Prior to making payment for nursing facility services
1739	for a Medicaid recipient, the agency must verify that the
1740	nursing facility preadmission screening program has determined
1741	that the individual requires nursing facility care and that the
1742	individual cannot be safely served in community-based programs.
1743	The nursing facility preadmission screening program shall refer
1744	a Medicaid recipient to a community-based program if the
1745	individual could be safely served at a lower cost and the
1746	recipient chooses to participate in such program.     (d)  For the
1747	purpose of initiating immediate prescreening and diversion
1748	assistance for individuals residing in nursing homes and in
1749	order to make families aware of alternative long-term care
1750	resources so that they may choose a more cost-effective setting
1751	for long-term placement, CARES staff shall conduct an assessment
1752	and review of a sample of individuals whose nursing home stay is
1753	expected to exceed 20 days, regardless of the initial funding
1754	source for the nursing home placement. CARES staff shall provide
1755	counseling and referral services to these individuals regarding
1756	choosing appropriate long-term care alternatives. This paragraph
1757	does not apply to continuing care facilities licensed under
1758	chapter 651 or to retirement communities that provide a
1759	combination of nursing home, independent living, and other long-
1760	term care services.
1761	(e)  By January 15 of each year, the agency shall submit a
1762	report to the Legislature and the Office of Long-Term-Care
1763	Policy describing the operations of the CARES program. The
1764	report must describe:
1765	1.  Rate of diversion to community alternative programs;
1766	2.  CARES program staffing needs to achieve additional
1767	diversions;
1768	3.  Reasons the program is unable to place individuals in
1769	less restrictive settings when such individuals desired such
1770	services and could have been served in such settings;
1771	4.  Barriers to appropriate placement, including barriers
1772	due to policies or operations of other agencies or state-funded
1773	programs; and
1774	5.  Statutory changes necessary to ensure that individuals
1775	in need of long-term care services receive care in the least
1776	restrictive environment.
1777	(f)  The Department of Elderly Affairs shall track
1778	individuals over time who are assessed under the CARES program
1779	and who are diverted from nursing home placement. By January 15
1780	of each year, the department shall submit to the Legislature and
1781	the Office of Long-Term-Care Policy a longitudinal study of the
1782	individuals who are diverted from nursing home placement. The
1783	study must include:
1784	1.  The demographic characteristics of the individuals
1785	assessed and diverted from nursing home placement, including,
1786	but not limited to, age, race, gender, frailty, caregiver
1787	status, living arrangements, and geographic location;
1788	2.  A summary of community services provided to individuals
1789	for 1 year after assessment and diversion;
1790	3.  A summary of inpatient hospital admissions for
1791	individuals who have been diverted; and
1792	4.  A summary of the length of time between diversion and
1793	subsequent entry into a nursing home or death.
1794	(g)  By July 1, 2005, the department and the Agency for
1795	Health Care Administration shall report to the President of the
1796	Senate and the Speaker of the House of Representatives regarding
1797	the impact to the state of modifying level-of-care criteria to
1798	eliminate the Intermediate II level of care.
1799	(15)(16)(a)  The agency shall identify health care
1800	utilization and price patterns within the Medicaid program which
1801	are not cost-effective or medically appropriate and assess the
1802	effectiveness of new or alternate methods of providing and
1803	monitoring service, and may implement such methods as it
1804	considers appropriate. Such methods may include disease
1805	management initiatives, an integrated and systematic approach
1806	for managing the health care needs of recipients who are at risk
1807	of or diagnosed with a specific disease by using best practices,
1808	prevention strategies, clinical-practice improvement, clinical
1809	interventions and protocols, outcomes research, information
1810	technology, and other tools and resources to reduce overall
1811	costs and improve measurable outcomes.
1812	(b)  The responsibility of the agency under this subsection
1813	shall include the development of capabilities to identify actual
1814	and optimal practice patterns; patient and provider educational
1815	initiatives; methods for determining patient compliance with
1816	prescribed treatments; fraud, waste, and abuse prevention and
1817	detection programs; and beneficiary case management programs.
1818	1.  The practice pattern identification program shall
1819	evaluate practitioner prescribing patterns based on national and
1820	regional practice guidelines, comparing practitioners to their
1821	peer groups. The agency and its Drug Utilization Review Board
1822	shall consult with the Department of Health and a panel of
1823	practicing health care professionals consisting of the
1824	following: the Speaker of the House of Representatives and the
1825	President of the Senate shall each appoint three physicians
1826	licensed under chapter 458 or chapter 459; and the Governor
1827	shall appoint two pharmacists licensed under chapter 465 and one
1828	dentist licensed under chapter 466 who is an oral surgeon. Terms
1829	of the panel members shall expire at the discretion of the
1830	appointing official. The panel shall begin its work by August 1,
1831	1999, regardless of the number of appointments made by that
1832	date. The advisory panel shall be responsible for evaluating
1833	treatment guidelines and recommending ways to incorporate their
1834	use in the practice pattern identification program.
1835	Practitioners who are prescribing inappropriately or
1836	inefficiently, as determined by the agency, may have their
1837	prescribing of certain drugs subject to prior authorization or
1838	may be terminated from all participation in the Medicaid
1839	program.
1840	2.  The agency shall also develop educational interventions
1841	designed to promote the proper use of medications by providers
1842	and beneficiaries.
1843	3.  The agency shall implement a pharmacy fraud, waste, and
1844	abuse initiative that may include a surety bond or letter of
1845	credit requirement for participating pharmacies, enhanced
1846	provider auditing practices, the use of additional fraud and
1847	abuse software, recipient management programs for beneficiaries
1848	inappropriately using their benefits, and other steps that will
1849	eliminate provider and recipient fraud, waste, and abuse. The
1850	initiative shall address enforcement efforts to reduce the
1851	number and use of counterfeit prescriptions.
1852	4.  By September 30, 2002, the agency shall contract with
1853	an entity in the state to implement a wireless handheld clinical
1854	pharmacology drug information database for practitioners. The
1855	initiative shall be designed to enhance the agency's efforts to
1856	reduce fraud, abuse, and errors in the prescription drug benefit
1857	program and to otherwise further the intent of this paragraph.
1858	5.  The agency may apply for any federal waivers needed to
1859	implement this paragraph.
1860	(16)(17)  An entity contracting on a prepaid or fixed-sum
1861	basis shall, in addition to meeting any applicable statutory
1862	surplus requirements, also maintain at all times in the form of
1863	cash, investments that mature in less than 180 days allowable as
1864	admitted assets by the Office of Insurance Regulation, and
1865	restricted funds or deposits controlled by the agency or the
1866	Office of Insurance Regulation, a surplus amount equal to one-
1867	and-one-half times the entity's monthly Medicaid prepaid
1868	revenues. As used in this subsection, the term "surplus" means
1869	the entity's total assets minus total liabilities. If an
1870	entity's surplus falls below an amount equal to one-and-one-half
1871	times the entity's monthly Medicaid prepaid revenues, the agency
1872	shall prohibit the entity from engaging in marketing and
1873	preenrollment activities, shall cease to process new
1874	enrollments, and shall not renew the entity's contract until the
1875	required balance is achieved. The requirements of this
1876	subsection do not apply:
1877	(a)  Where a public entity agrees to fund any deficit
1878	incurred by the contracting entity; or
1879	(b)  Where the entity's performance and obligations are
1880	guaranteed in writing by a guaranteeing organization which:
1881	1.  Has been in operation for at least 5 years and has
1882	assets in excess of $50 million; or
1883	2.  Submits a written guarantee acceptable to the agency
1884	which is irrevocable during the term of the contracting entity's
1885	contract with the agency and, upon termination of the contract,
1886	until the agency receives proof of satisfaction of all
1887	outstanding obligations incurred under the contract.
1888	(17)(18)(a)  The agency may require an entity contracting
1889	on a prepaid or fixed-sum basis to establish a restricted
1890	insolvency protection account with a federally guaranteed
1891	financial institution licensed to do business in this state. The
1892	entity shall deposit into that account 5 percent of the
1893	capitation payments made by the agency each month until a
1894	maximum total of 2 percent of the total current contract amount
1895	is reached. The restricted insolvency protection account may be
1896	drawn upon with the authorized signatures of two persons
1897	designated by the entity and two representatives of the agency.
1898	If the agency finds that the entity is insolvent, the agency may
1899	draw upon the account solely with the two authorized signatures
1900	of representatives of the agency, and the funds may be disbursed
1901	to meet financial obligations incurred by the entity under the
1902	prepaid contract. If the contract is terminated, expired, or not
1903	continued, the account balance must be released by the agency to
1904	the entity upon receipt of proof of satisfaction of all
1905	outstanding obligations incurred under this contract.
1906	(b)  The agency may waive the insolvency protection account
1907	requirement in writing when evidence is on file with the agency
1908	of adequate insolvency insurance and reinsurance that will
1909	protect enrollees if the entity becomes unable to meet its
1910	obligations.
1911	(18)(19)  An entity that contracts with the agency on a
1912	prepaid or fixed-sum basis for the provision of Medicaid
1913	services shall reimburse any hospital or physician that is
1914	outside the entity's authorized geographic service area as
1915	specified in its contract with the agency, and that provides
1916	services authorized by the entity to its members, at a rate
1917	negotiated with the hospital or physician for the provision of
1918	services or according to the lesser of the following:
1919	(a)  The usual and customary charges made to the general
1920	public by the hospital or physician; or
1921	(b)  The Florida Medicaid reimbursement rate established
1922	for the hospital or physician.
1923	(19)(20)  When a merger or acquisition of a Medicaid
1924	prepaid contractor has been approved by the Office of Insurance
1925	Regulation pursuant to s. 628.4615, the agency shall approve the
1926	assignment or transfer of the appropriate Medicaid prepaid
1927	contract upon request of the surviving entity of the merger or
1928	acquisition if the contractor and the other entity have been in
1929	good standing with the agency for the most recent 12-month
1930	period, unless the agency determines that the assignment or
1931	transfer would be detrimental to the Medicaid recipients or the
1932	Medicaid program. To be in good standing, an entity must not
1933	have failed accreditation or committed any material violation of
1934	the requirements of s. 641.52 and must meet the Medicaid
1935	contract requirements. For purposes of this section, a merger or
1936	acquisition means a change in controlling interest of an entity,
1937	including an asset or stock purchase.
1938	(20)(21)  Any entity contracting with the agency pursuant
1939	to this section to provide health care services to Medicaid
1940	recipients is prohibited from engaging in any of the following
1941	practices or activities:
1942	(a)  Practices that are discriminatory, including, but not
1943	limited to, attempts to discourage participation on the basis of
1944	actual or perceived health status.
1945	(b)  Activities that could mislead or confuse recipients,
1946	or misrepresent the organization, its marketing representatives,
1947	or the agency. Violations of this paragraph include, but are not
1948	limited to:
1949	1.  False or misleading claims that marketing
1950	representatives are employees or representatives of the state or
1951	county, or of anyone other than the entity or the organization
1952	by whom they are reimbursed.
1953	2.  False or misleading claims that the entity is
1954	recommended or endorsed by any state or county agency, or by any
1955	other organization which has not certified its endorsement in
1956	writing to the entity.
1957	3.  False or misleading claims that the state or county
1958	recommends that a Medicaid recipient enroll with an entity.
1959	4.  Claims that a Medicaid recipient will lose benefits
1960	under the Medicaid program, or any other health or welfare
1961	benefits to which the recipient is legally entitled, if the
1962	recipient does not enroll with the entity.
1963	(c)  Granting or offering of any monetary or other valuable
1964	consideration for enrollment, except as authorized by subsection
1965	(24).
1966	(d)  Door-to-door solicitation of recipients who have not
1967	contacted the entity or who have not invited the entity to make
1968	a presentation.
1969	(e)  Solicitation of Medicaid recipients by marketing
1970	representatives stationed in state offices unless approved and
1971	supervised by the agency or its agent and approved by the
1972	affected state agency when solicitation occurs in an office of
1973	the state agency. The agency shall ensure that marketing
1974	representatives stationed in state offices shall market their
1975	managed care plans to Medicaid recipients only in designated
1976	areas and in such a way as to not interfere with the recipients'
1977	activities in the state office.
1978	(f)  Enrollment of Medicaid recipients.
1979	(21)(22)  The agency may impose a fine for a violation of
1980	this section or the contract with the agency by a person or
1981	entity that is under contract with the agency. With respect to
1982	any nonwillful violation, such fine shall not exceed $2,500 per
1983	violation. In no event shall such fine exceed an aggregate
1984	amount of $10,000 for all nonwillful violations arising out of
1985	the same action. With respect to any knowing and willful
1986	violation of this section or the contract with the agency, the
1987	agency may impose a fine upon the entity in an amount not to
1988	exceed $20,000 for each such violation. In no event shall such
1989	fine exceed an aggregate amount of $100,000 for all knowing and
1990	willful violations arising out of the same action.
1991	(22)(23)  A health maintenance organization or a person or
1992	entity exempt from chapter 641 that is under contract with the
1993	agency for the provision of health care services to Medicaid
1994	recipients may not use or distribute marketing materials used to
1995	solicit Medicaid recipients, unless such materials have been
1996	approved by the agency. The provisions of this subsection do not
1997	apply to general advertising and marketing materials used by a
1998	health maintenance organization to solicit both non-Medicaid
1999	subscribers and Medicaid recipients.
2000	(23)(24)  Upon approval by the agency, health maintenance
2001	organizations and persons or entities exempt from chapter 641
2002	that are under contract with the agency for the provision of
2003	health care services to Medicaid recipients may be permitted
2004	within the capitation rate to provide additional health benefits
2005	that the agency has found are of high quality, are practicably
2006	available, provide reasonable value to the recipient, and are
2007	provided at no additional cost to the state.
2008	(24)(25)  The agency shall utilize the statewide health
2009	maintenance organization complaint hotline for the purpose of
2010	investigating and resolving Medicaid and prepaid health plan
2011	complaints, maintaining a record of complaints and confirmed
2012	problems, and receiving disenrollment requests made by
2013	recipients.
2014	(25)(26)  The agency shall require the publication of the
2015	health maintenance organization's and the prepaid health plan's
2016	consumer services telephone numbers and the "800" telephone
2017	number of the statewide health maintenance organization
2018	complaint hotline on each Medicaid identification card issued by
2019	a health maintenance organization or prepaid health plan
2020	contracting with the agency to serve Medicaid recipients and on
2021	each subscriber handbook issued to a Medicaid recipient.
2022	(26)(27)  The agency shall establish a health care quality
2023	improvement system for those entities contracting with the
2024	agency pursuant to this section, incorporating all the standards
2025	and guidelines developed by the Medicaid Bureau of the Health
2026	Care Financing Administration as a part of the quality assurance
2027	reform initiative. The system shall include, but need not be
2028	limited to, the following:
2029	(a)  Guidelines for internal quality assurance programs,
2030	including standards for:
2031	1.  Written quality assurance program descriptions.
2032	2.  Responsibilities of the governing body for monitoring,
2033	evaluating, and making improvements to care.
2034	3.  An active quality assurance committee.
2035	4.  Quality assurance program supervision.
2036	5.  Requiring the program to have adequate resources to
2037	effectively carry out its specified activities.
2038	6.  Provider participation in the quality assurance
2039	program.
2040	7.  Delegation of quality assurance program activities.
2041	8.  Credentialing and recredentialing.
2042	9.  Enrollee rights and responsibilities.
2043	10.  Availability and accessibility to services and care.
2044	11.  Ambulatory care facilities.
2045	12.  Accessibility and availability of medical records, as
2046	well as proper recordkeeping and process for record review.
2047	13.  Utilization review.
2048	14.  A continuity of care system.
2049	15.  Quality assurance program documentation.
2050	16.  Coordination of quality assurance activity with other
2051	management activity.
2052	17.  Delivering care to pregnant women and infants; to
2053	elderly and disabled recipients, especially those who are at
2054	risk of institutional placement; to persons with developmental
2055	disabilities; and to adults who have chronic, high-cost medical
2056	conditions.
2057	(b)  Guidelines which require the entities to conduct
2058	quality-of-care studies which:
2059	1.  Target specific conditions and specific health service
2060	delivery issues for focused monitoring and evaluation.
2061	2.  Use clinical care standards or practice guidelines to
2062	objectively evaluate the care the entity delivers or fails to
2063	deliver for the targeted clinical conditions and health services
2064	delivery issues.
2065	3.  Use quality indicators derived from the clinical care
2066	standards or practice guidelines to screen and monitor care and
2067	services delivered.
2068	(c)  Guidelines for external quality review of each
2069	contractor which require: focused studies of patterns of care;
2070	individual care review in specific situations; and followup
2071	activities on previous pattern-of-care study findings and
2072	individual-care-review findings. In designing the external
2073	quality review function and determining how it is to operate as
2074	part of the state's overall quality improvement system, the
2075	agency shall construct its external quality review organization
2076	and entity contracts to address each of the following:
2077	1.  Delineating the role of the external quality review
2078	organization.
2079	2.  Length of the external quality review organization
2080	contract with the state.
2081	3.  Participation of the contracting entities in designing
2082	external quality review organization review activities.
2083	4.  Potential variation in the type of clinical conditions
2084	and health services delivery issues to be studied at each plan.
2085	5.  Determining the number of focused pattern-of-care
2086	studies to be conducted for each plan.
2087	6.  Methods for implementing focused studies.
2088	7.  Individual care review.
2089	8.  Followup activities.
2090	(27)(28)  In order to ensure that children receive health
2091	care services for which an entity has already been compensated,
2092	an entity contracting with the agency pursuant to this section
2093	shall achieve an annual Early and Periodic Screening, Diagnosis,
2094	and Treatment (EPSDT) Service screening rate of at least 60
2095	percent for those recipients continuously enrolled for at least
2096	8 months. The agency shall develop a method by which the EPSDT
2097	screening rate shall be calculated. For any entity which does
2098	not achieve the annual 60 percent rate, the entity must submit a
2099	corrective action plan for the agency's approval. If the entity
2100	does not meet the standard established in the corrective action
2101	plan during the specified timeframe, the agency is authorized to
2102	impose appropriate contract sanctions. At least annually, the
2103	agency shall publicly release the EPSDT Services screening rates
2104	of each entity it has contracted with on a prepaid basis to
2105	serve Medicaid recipients.
2106	(28)(29)  The agency shall perform enrollments and
2107	disenrollments for Medicaid recipients who are eligible for
2108	MediPass or managed care plans. Notwithstanding the prohibition
2109	contained in paragraph (20)(21)(f), managed care plans may
2110	perform preenrollments of Medicaid recipients under the
2111	supervision of the agency or its agents. For the purposes of
2112	this section, "preenrollment" means the provision of marketing
2113	and educational materials to a Medicaid recipient and assistance
2114	in completing the application forms, but shall not include
2115	actual enrollment into a managed care plan. An application for
2116	enrollment shall not be deemed complete until the agency or its
2117	agent verifies that the recipient made an informed, voluntary
2118	choice. The agency, in cooperation with the Department of
2119	Children and Family Services, may test new marketing initiatives
2120	to inform Medicaid recipients about their managed care options
2121	at selected sites. The agency shall report to the Legislature on
2122	the effectiveness of such initiatives. The agency may contract
2123	with a third party to perform managed care plan and MediPass
2124	enrollment and disenrollment services for Medicaid recipients
2125	and is authorized to adopt rules to implement such services. The
2126	agency may adjust the capitation rate only to cover the costs of
2127	a third-party enrollment and disenrollment contract, and for
2128	agency supervision and management of the managed care plan
2129	enrollment and disenrollment contract.
2130	(29)(30)  Any lists of providers made available to Medicaid
2131	recipients, MediPass enrollees, or managed care plan enrollees
2132	shall be arranged alphabetically showing the provider's name and
2133	specialty and, separately, by specialty in alphabetical order.
2134	(30)(31)  The agency shall establish an enhanced managed
2135	care quality assurance oversight function, to include at least
2136	the following components:
2137	(a)  At least quarterly analysis and followup, including
2138	sanctions as appropriate, of managed care participant
2139	utilization of services.
2140	(b)  At least quarterly analysis and followup, including
2141	sanctions as appropriate, of quality findings of the Medicaid
2142	peer review organization and other external quality assurance
2143	programs.
2144	(c)  At least quarterly analysis and followup, including
2145	sanctions as appropriate, of the fiscal viability of managed
2146	care plans.
2147	(d)  At least quarterly analysis and followup, including
2148	sanctions as appropriate, of managed care participant
2149	satisfaction and disenrollment surveys.
2150	(e)  The agency shall conduct regular and ongoing Medicaid
2151	recipient satisfaction surveys.
2152
2153	The analyses and followup activities conducted by the agency
2154	under its enhanced managed care quality assurance oversight
2155	function shall not duplicate the activities of accreditation
2156	reviewers for entities regulated under part III of chapter 641,
2157	but may include a review of the finding of such reviewers.
2158	(31)(32)  Each managed care plan that is under contract
2159	with the agency to provide health care services to Medicaid
2160	recipients shall annually conduct a background check with the
2161	Florida Department of Law Enforcement of all persons with
2162	ownership interest of 5 percent or more or executive management
2163	responsibility for the managed care plan and shall submit to the
2164	agency information concerning any such person who has been found
2165	guilty of, regardless of adjudication, or has entered a plea of
2166	nolo contendere or guilty to, any of the offenses listed in s.
2167	435.03.
2168	(32)(33)  The agency shall, by rule, develop a process
2169	whereby a Medicaid managed care plan enrollee who wishes to
2170	enter hospice care may be disenrolled from the managed care plan
2171	within 24 hours after contacting the agency regarding such
2172	request. The agency rule shall include a methodology for the
2173	agency to recoup managed care plan payments on a pro rata basis
2174	if payment has been made for the enrollment month when
2175	disenrollment occurs.
2176	(33)(34)  The agency and entities that which contract with
2177	the agency to provide health care services to Medicaid
2178	recipients under this section or ss. 409.91211 and s. 409.9122
2179	must comply with the provisions of s. 641.513 in providing
2180	emergency services and care to Medicaid recipients and MediPass
2181	recipients. Where feasible, safe, and cost-effective, the agency
2182	shall encourage hospitals, emergency medical services providers,
2183	and other public and private health care providers to work
2184	together in their local communities to enter into agreements or
2185	arrangements to ensure access to alternatives to emergency
2186	services and care for those Medicaid recipients who need
2187	nonemergent care. The agency shall coordinate with hospitals,
2188	emergency medical services providers, private health plans,
2189	capitated managed care networks as established in s. 409.91211,
2190	and other public and private health care providers to implement
2191	the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
2192	and 641.31097 to develop and implement emergency department
2193	diversion programs for Medicaid recipients.
2194	(38)(39)(a)  The agency shall implement a Medicaid
2195	prescribed-drug spending-control program that includes the
2196	following components:
2197	11.a.  The agency shall implement a Medicaid prescription-
2198	drug-management system. The agency may contract with a vendor
2199	that has experience in operating prescription-drug-management
2200	systems in order to implement this system. Any management system
2201	that is implemented in accordance with this subparagraph must
2202	rely on cooperation between physicians and pharmacists to
2203	determine appropriate practice patterns and clinical guidelines
2204	to improve the prescribing, dispensing, and use of drugs in the
2205	Medicaid program. The agency may seek federal waivers to
2206	implement this program.
2207	b.  The drug-management system must be designed to improve
2208	the quality of care and prescribing practices based on best-
2209	practice guidelines, improve patient adherence to medication
2210	plans, reduce clinical risk, and lower prescribed drug costs and
2211	the rate of inappropriate spending on Medicaid prescription
2212	drugs. The program must:
2213	(I)  Provide for the development and adoption of best-
2214	practice guidelines for the prescribing and use of drugs in the
2215	Medicaid program, including translating best-practice guidelines
2216	into practice; reviewing prescriber patterns and comparing them
2217	to indicators that are based on national standards and practice
2218	patterns of clinical peers in their community, statewide, and
2219	nationally; and determine deviations from best-practice
2220	guidelines.
2221	(II)  Implement processes for providing feedback to and
2222	educating prescribers using best-practice educational materials
2223	and peer-to-peer consultation.
2224	(III)  Assess Medicaid recipients who are outliers in their
2225	use of a single or multiple prescription drugs with regard to
2226	the numbers and types of drugs taken, drug dosages, combination
2227	drug therapies, and other indicators of improper use of
2228	prescription drugs.
2229	(IV)  Alert prescribers to patients who fail to refill
2230	prescriptions in a timely fashion, are prescribed multiple drugs
2231	that may be redundant or contraindicated, or may have other
2232	potential medication problems.
2233	(V)  Track spending trends for prescription drugs and
2234	deviation from best practice guidelines.
2235	(VI)  Use educational and technological approaches to
2236	promote best practices, educate consumers, and train prescribers
2237	in the use of practice guidelines.
2238	(VII)  Disseminate electronic and published materials.
2239	(VIII)  Hold statewide and regional conferences.
2240	(IX)  Implement disease-management programs in cooperation
2241	with physicians and pharmacists, along with a model quality-
2242	based medication component for individuals having chronic
2243	medical conditions.
2244	12.  The agency is authorized to contract for drug rebate
2245	administration, including, but not limited to, calculating
2246	rebate amounts, invoicing manufacturers, negotiating disputes
2247	with manufacturers, and maintaining a database of rebate
2248	collections.
2249	13.  The agency may specify the preferred daily dosing form
2250	or strength for the purpose of promoting best practices with
2251	regard to the prescribing of certain drugs as specified in the
2252	General Appropriations Act and ensuring cost-effective
2253	prescribing practices.
2254	14.  The agency may require prior authorization for the
2255	off-label use of Medicaid-covered prescribed drugs as specified
2256	in the General Appropriations Act. The agency may, but is not
2257	required to, preauthorize the use of a product for an indication
2258	not in the approved labeling. Prior authorization may require
2259	the prescribing professional to provide information about the
2260	rationale and supporting medical evidence for the off-label use
2261	of a drug.
2262	17.15.  The agency shall implement a return and reuse
2263	program for drugs dispensed by pharmacies to institutional
2264	recipients, which includes payment of a $5 restocking fee for
2265	the implementation and operation of the program. The return and
2266	reuse program shall be implemented electronically and in a
2267	manner that promotes efficiency. The program must permit a
2268	pharmacy to exclude drugs from the program if it is not
2269	practical or cost-effective for the drug to be included and must
2270	provide for the return to inventory of drugs that cannot be
2271	credited or returned in a cost-effective manner. The agency
2272	shall determine if the program has reduced the amount of
2273	Medicaid prescription drugs which are destroyed on an annual
2274	basis and if there are additional ways to ensure more
2275	prescription drugs are not destroyed which could safely be
2276	reused. The agency's conclusion and recommendations shall be
2277	reported to the Legislature by December 1, 2005.
2278	(b)  The agency shall implement this subsection to the
2279	extent that funds are appropriated to administer the Medicaid
2280	prescribed-drug spending-control program. The agency may
2281	contract all or any part of this program to private
2282	organizations.
2283	(c)  The agency shall submit quarterly reports to the
2284	Governor, the President of the Senate, and the Speaker of the
2285	House of Representatives which must include, but need not be
2286	limited to, the progress made in implementing this subsection
2287	and its effect on Medicaid prescribed-drug expenditures.
2288	(39)(40)  Notwithstanding the provisions of chapter 287,
2289	the agency may, at its discretion, renew a contract or contracts
2290	for fiscal intermediary services one or more times for such
2291	periods as the agency may decide; however, all such renewals may
2292	not combine to exceed a total period longer than the term of the
2293	original contract.
2294	(40)(41)  The agency shall provide for the development of a
2295	demonstration project by establishment in Miami-Dade County of a
2296	long-term-care facility licensed pursuant to chapter 395 to
2297	improve access to health care for a predominantly minority,
2298	medically underserved, and medically complex population and to
2299	evaluate alternatives to nursing home care and general acute
2300	care for such population. Such project is to be located in a
2301	health care condominium and colocated with licensed facilities
2302	providing a continuum of care. The establishment of this project
2303	is not subject to the provisions of s. 408.036 or s. 408.039.
2304	The agency shall report its findings to the Governor, the
2305	President of the Senate, and the Speaker of the House of
2306	Representatives by January 1, 2003.
2307	(41)(42)  The agency shall develop and implement a
2308	utilization management program for Medicaid-eligible recipients
2309	for the management of occupational, physical, respiratory, and
2310	speech therapies. The agency shall establish a utilization
2311	program that may require prior authorization in order to ensure
2312	medically necessary and cost-effective treatments. The program
2313	shall be operated in accordance with a federally approved waiver
2314	program or state plan amendment. The agency may seek a federal
2315	waiver or state plan amendment to implement this program. The
2316	agency may also competitively procure these services from an
2317	outside vendor on a regional or statewide basis.
2318	(42)(43)  The agency may contract on a prepaid or fixed-sum
2319	basis with appropriately licensed prepaid dental health plans to
2320	provide dental services.
2321	(43)(44)  The Agency for Health Care Administration shall
2322	ensure that any Medicaid managed care plan as defined in s.
2323	409.9122(2)(h), whether paid on a capitated basis or a shared
2324	savings basis, is cost-effective. For purposes of this
2325	subsection, the term "cost-effective" means that a network's
2326	per-member, per-month costs to the state, including, but not
2327	limited to, fee-for-service costs, administrative costs, and
2328	case-management fees, must be no greater than the state's costs
2329	associated with contracts for Medicaid services established
2330	under subsection (3), which shall be actuarially adjusted for
2331	case mix, model, and service area. The agency shall conduct
2332	actuarially sound audits adjusted for case mix and model in
2333	order to ensure such cost-effectiveness and shall publish the
2334	audit results on its Internet website and submit the audit
2335	results annually to the Governor, the President of the Senate,
2336	and the Speaker of the House of Representatives no later than
2337	December 31 of each year. Contracts established pursuant to this
2338	subsection which are not cost-effective may not be renewed.
2339	(44)(45)  Subject to the availability of funds, the agency
2340	shall mandate a recipient's participation in a provider lock-in
2341	program, when appropriate, if a recipient is found by the agency
2342	to have used Medicaid goods or services at a frequency or amount
2343	not medically necessary, limiting the receipt of goods or
2344	services to medically necessary providers after the 21-day
2345	appeal process has ended, for a period of not less than 1 year.
2346	The lock-in programs shall include, but are not limited to,
2347	pharmacies, medical doctors, and infusion clinics. The
2348	limitation does not apply to emergency services and care
2349	provided to the recipient in a hospital emergency department.
2350	The agency shall seek any federal waivers necessary to implement
2351	this subsection. The agency shall adopt any rules necessary to
2352	comply with or administer this subsection.
2353	(45)(46)  The agency shall seek a federal waiver for
2354	permission to terminate the eligibility of a Medicaid recipient
2355	who has been found to have committed fraud, through judicial or
2356	administrative determination, two times in a period of 5 years.
2357	(46)(47)  The agency shall conduct a study of available
2358	electronic systems for the purpose of verifying the identity and
2359	eligibility of a Medicaid recipient. The agency shall recommend
2360	to the Legislature a plan to implement an electronic
2361	verification system for Medicaid recipients by January 31, 2005.
2362	(47)(48)  A provider is not entitled to enrollment in the
2363	Medicaid provider network. The agency may implement a Medicaid
2364	fee-for-service provider network controls, including, but not
2365	limited to, competitive procurement and provider credentialing.
2366	If a credentialing process is used, the agency may limit its
2367	provider network based upon the following considerations:
2368	beneficiary access to care, provider availability, provider
2369	quality standards and quality assurance processes, cultural
2370	competency, demographic characteristics of beneficiaries,
2371	practice standards, service wait times, provider turnover,
2372	provider licensure and accreditation history, program integrity
2373	history, peer review, Medicaid policy and billing compliance
2374	records, clinical and medical record audit findings, and such
2375	other areas that are considered necessary by the agency to
2376	ensure the integrity of the program.
2377	(48)(49)  The agency shall contract with established
2378	minority physician networks that provide services to
2379	historically underserved minority patients. The networks must
2380	provide cost-effective Medicaid services, comply with the
2381	requirements to be a MediPass provider, and provide their
2382	primary care physicians with access to data and other management
2383	tools necessary to assist them in ensuring the appropriate use
2384	of services, including inpatient hospital services and
2385	pharmaceuticals.
2386	(a)  The agency shall provide for the development and
2387	expansion of minority physician networks in each service area to
2388	provide services to Medicaid recipients who are eligible to
2389	participate under federal law and rules.
2390	(b)  The agency shall reimburse each minority physician
2391	network as a fee-for-service provider, including the case
2392	management fee for primary care, or as a capitated rate provider
2393	for Medicaid services. Any savings shall be shared with the
2394	minority physician networks pursuant to the contract.
2395	(c)  For purposes of this subsection, the term "cost-
2396	effective" means that a network's per-member, per-month costs to
2397	the state, including, but not limited to, fee-for-service costs,
2398	administrative costs, and case-management fees, must be no
2399	greater than the state's costs associated with contracts for
2400	Medicaid services established under subsection (3), which shall
2401	be actuarially adjusted for case mix, model, and service area.
2402	The agency shall conduct actuarially sound audits adjusted for
2403	case mix and model in order to ensure such cost-effectiveness
2404	and shall publish the audit results on its Internet website and
2405	submit the audit results annually to the Governor, the President
2406	of the Senate, and the Speaker of the House of Representatives
2407	no later than December 31. Contracts established pursuant to
2408	this subsection which are not cost-effective may not be renewed.
2409	(d)  The agency may apply for any federal waivers needed to
2410	implement this subsection.
2411	(50)  To the extent permitted by federal law and as allowed
2412	under s. 409.906, the agency shall provide reimbursement for
2413	emergency mental health care services for Medicaid recipients in
2414	crisis-stabilization facilities licensed under s. 394.875 as
2415	long as those services are less expensive than the same services
2416	provided in a hospital setting.
2417	Section 4.  Paragraphs (a) and (j) of subsection (2) of
2418	section 409.9122, Florida Statutes, are amended to read:
2419	409.9122  Mandatory Medicaid managed care enrollment;
2420	programs and procedures.--
2421	(2)(a)  The agency shall enroll in a managed care plan or
2422	MediPass all Medicaid recipients, except those Medicaid
2423	recipients who are: in an institution; enrolled in the Medicaid
2424	medically needy program; or eligible for both Medicaid and
2425	Medicare. Upon enrollment, individuals will be able to change
2426	their managed care option during the 90-day opt out period
2427	required by federal Medicaid regulations. The agency is
2428	authorized to seek the necessary Medicaid state plan amendment
2429	to implement this policy. However, to the extent permitted by
2430	federal law, the agency may enroll in a managed care plan or
2431	MediPass a Medicaid recipient who is exempt from mandatory
2432	managed care enrollment, provided that:
2433	1.  The recipient's decision to enroll in a managed care
2434	plan or MediPass is voluntary;
2435	2.  If the recipient chooses to enroll in a managed care
2436	plan, the agency has determined that the managed care plan
2437	provides specific programs and services which address the
2438	special health needs of the recipient; and
2439	3.  The agency receives any necessary waivers from the
2440	federal Centers for Medicare and Medicaid Services Health Care
2441	Financing Administration.
2442
2443	The agency shall develop rules to establish policies by which
2444	exceptions to the mandatory managed care enrollment requirement
2445	may be made on a case-by-case basis. The rules shall include the
2446	specific criteria to be applied when making a determination as
2447	to whether to exempt a recipient from mandatory enrollment in a
2448	managed care plan or MediPass. School districts participating in
2449	the certified school match program pursuant to ss. 409.908(21)
2450	and 1011.70 shall be reimbursed by Medicaid, subject to the
2451	limitations of s. 1011.70(1), for a Medicaid-eligible child
2452	participating in the services as authorized in s. 1011.70, as
2453	provided for in s. 409.9071, regardless of whether the child is
2454	enrolled in MediPass or a managed care plan. Managed care plans
2455	shall make a good faith effort to execute agreements with school
2456	districts regarding the coordinated provision of services
2457	authorized under s. 1011.70. County health departments
2458	delivering school-based services pursuant to ss. 381.0056 and
2459	381.0057 shall be reimbursed by Medicaid for the federal share
2460	for a Medicaid-eligible child who receives Medicaid-covered
2461	services in a school setting, regardless of whether the child is
2462	enrolled in MediPass or a managed care plan. Managed care plans
2463	shall make a good faith effort to execute agreements with county
2464	health departments regarding the coordinated provision of
2465	services to a Medicaid-eligible child. To ensure continuity of
2466	care for Medicaid patients, the agency, the Department of
2467	Health, and the Department of Education shall develop procedures
2468	for ensuring that a student's managed care plan or MediPass
2469	provider receives information relating to services provided in
2470	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2471	(j)  The agency shall apply for a federal waiver from the
2472	Centers for Medicare and Medicaid Services Health Care Financing
2473	Administration to lock eligible Medicaid recipients into a
2474	managed care plan or MediPass for 12 months after an open
2475	enrollment period. After 12 months' enrollment, a recipient may
2476	select another managed care plan or MediPass provider. However,
2477	nothing shall prevent a Medicaid recipient from changing primary
2478	care providers within the managed care plan or MediPass program
2479	during the 12-month period.
2480	Section 5.  Subsection (2) of section 409.913, Florida
2481	Statutes, is amended, and subsection (36) is added to that
2482	section, to read:
2483	409.913  Oversight of the integrity of the Medicaid
2484	program.--The agency shall operate a program to oversee the
2485	activities of Florida Medicaid recipients, and providers and
2486	their representatives, to ensure that fraudulent and abusive
2487	behavior and neglect of recipients occur to the minimum extent
2488	possible, and to recover overpayments and impose sanctions as
2489	appropriate. Beginning January 1, 2003, and each year
2490	thereafter, the agency and the Medicaid Fraud Control Unit of
2491	the Department of Legal Affairs shall submit a joint report to
2492	the Legislature documenting the effectiveness of the state's
2493	efforts to control Medicaid fraud and abuse and to recover
2494	Medicaid overpayments during the previous fiscal year. The
2495	report must describe the number of cases opened and investigated
2496	each year; the sources of the cases opened; the disposition of
2497	the cases closed each year; the amount of overpayments alleged
2498	in preliminary and final audit letters; the number and amount of
2499	fines or penalties imposed; any reductions in overpayment
2500	amounts negotiated in settlement agreements or by other means;
2501	the amount of final agency determinations of overpayments; the
2502	amount deducted from federal claiming as a result of
2503	overpayments; the amount of overpayments recovered each year;
2504	the amount of cost of investigation recovered each year; the
2505	average length of time to collect from the time the case was
2506	opened until the overpayment is paid in full; the amount
2507	determined as uncollectible and the portion of the uncollectible
2508	amount subsequently reclaimed from the Federal Government; the
2509	number of providers, by type, that are terminated from
2510	participation in the Medicaid program as a result of fraud and
2511	abuse; and all costs associated with discovering and prosecuting
2512	cases of Medicaid overpayments and making recoveries in such
2513	cases. The report must also document actions taken to prevent
2514	overpayments and the number of providers prevented from
2515	enrolling in or reenrolling in the Medicaid program as a result
2516	of documented Medicaid fraud and abuse and must recommend
2517	changes necessary to prevent or recover overpayments.
2518	(2)  The agency shall conduct, or cause to be conducted by
2519	contract or otherwise, reviews, investigations, analyses,
2520	audits, or any combination thereof, to determine possible fraud,
2521	abuse, overpayment, or recipient neglect in the Medicaid program
2522	and shall report the findings of any overpayments in audit
2523	reports as appropriate. At least 5 percent of all audits shall
2524	be conducted on a random basis.
2525	(36)  The agency shall provide to each Medicaid recipient
2526	or his or her representative an explanation of benefits in the
2527	form of a letter that is mailed to the most recent address of
2528	the recipient on the record with the Department of Children and
2529	Family Services. The explanation of benefits must include the
2530	patient's name, the name of the health care provider and the
2531	address of the location where the service was provided, a
2532	description of all services billed to Medicaid in terminology
2533	that should be understood by a reasonable person, and
2534	information on how to report inappropriate or incorrect billing
2535	to the agency or other law enforcement entities for review or
2536	investigation.
2537	Section 6.  The Agency for Health Care Administration shall
2538	submit to the Legislature by January 15, 2006, recommendations
2539	to ensure that Medicaid is the payer of last resort as required
2540	by section 409.910, Florida Statutes. The report must identify
2541	the public and private entities that are liable for primary
2542	payment of health care services and recommend methods to improve
2543	enforcement of third-party liability responsibility and
2544	repayment of benefits to the state Medicaid program. The report
2545	must estimate the potential recoveries that may be achieved
2546	through third-party liability efforts if administrative and
2547	legal barriers are removed. The report must recommend whether
2548	modifications to the agency's contingency-fee contract for
2549	third-party liability could enhance third-party liability for
2550	benefits provided to Medicaid recipients.
2551	Section 7.  By January 15, 2006, the Office of Program
2552	Policy Analysis and Government Accountability shall submit to
2553	the Legislature a study of the long-term care community
2554	diversion pilot project authorized under ss. 430.701-430.709.
2555	The study may be conducted by Office of Program Policy Analysis
2556	and Government Accountability staff or by a consultant obtained
2557	through a competitive bid. The study must use a statistically-
2558	valid methodology to assess the percent of persons served in the
2559	project over a 2-year period who would have required Medicaid
2560	nursing home services without the diversion services, which
2561	services are most frequently used, and which services are least
2562	frequently used. The study must determine whether the project is
2563	cost-effective or is an expansion of the Medicaid program
2564	because a preponderance of the project enrollees would not have
2565	required Medicaid nursing home services within a 2-year period
2566	regardless of the availability of the project or that the
2567	enrollees could have been safely served through another Medicaid
2568	program at a lower cost to the state.
2569	Section 8.  The Agency for Health Care Administration shall
2570	identify how many individuals in the long-term care diversion
2571	programs who receive care at home have a patient-responsibility
2572	payment associated with their participation in the diversion
2573	program. If no system is available to assess this information,
2574	the agency shall determine the cost of creating a system to
2575	identify and collect these payments and whether the cost of
2576	developing a system for this purpose is offset by the amount of
2577	patient-responsibility payments which could be collected with
2578	the system. The agency shall report this information to the
2579	Legislature by December 1, 2005.
2580	Section 9.  This act shall take effect July 1, 2005.

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