Senate Bill sb0838c1
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By the Committee on Health Care; and Senator Peaden
587-2018-05
1 A bill to be entitled
2 An act relating to Medicaid; amending s.
3 409.912, F.S.; requiring the Agency for Health
4 Care Administration to contract with a vendor
5 to monitor and evaluate the clinical practice
6 patterns of providers; authorizing the agency
7 to competitively bid for single-source
8 providers for certain services; authorizing the
9 agency to examine whether purchasing certain
10 durable medical equipment is more
11 cost-effective than long-term rental of such
12 equipment; providing that a contract awarded to
13 a provider service network remains in effect
14 for a certain period; defining a provider
15 service network; providing health care
16 providers with a controlling interest in the
17 governing body of the provider service network
18 organization; requiring that the agency, in
19 partnership with the Department of Elderly
20 Affairs, develop an integrated, fixed-payment
21 delivery system for Medicaid recipients age 60
22 and older; deleting an obsolete provision
23 requiring the agency to develop a plan for
24 implementing emergency and crisis care;
25 requiring the agency to develop a system where
26 health care vendors may provide data
27 demonstrating that higher reimbursement for a
28 good or service will be offset by cost savings
29 in other goods or services; requiring the
30 Comprehensive Assessment and Review for
31 Long-Term Care Services (CARES) teams to
1
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1 consult with any person making a determination
2 that a nursing home resident funded by Medicare
3 is not making progress toward rehabilitation
4 and assist in any appeals of the decision;
5 requiring the agency to contract with an entity
6 to design a clinical-utilization information
7 database or electronic medical record for
8 Medicaid providers; requiring that the agency
9 develop a plan to expand disease-management
10 programs; requiring the agency to coordinate
11 with other entities to create emergency room
12 diversion programs for Medicaid recipients;
13 revising the Medicaid prescription drug
14 spending control program to reduce costs and
15 improve Medicaid recipient safety; requiring
16 that the agency implement a Medicaid
17 prescription drug management system; allowing
18 the agency to require age-related prior
19 authorizations for certain prescription drugs;
20 requiring the agency to determine the extent
21 that prescription drugs are returned and reused
22 in institutional settings and whether this
23 program could be expanded; requiring the agency
24 to develop an in-home, all-inclusive program of
25 services for Medicaid children with
26 life-threatening illnesses; authorizing the
27 agency to pay for emergency mental health
28 services provided through licensed crisis
29 stabilization centers; creating s. 409.91211,
30 F.S.; requiring that the agency develop a pilot
31 program for capitated managed care networks to
2
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1 deliver Medicaid health care services for all
2 eligible Medicaid recipients in Medicaid
3 fee-for-service or the MediPass program;
4 authorizing the agency to include an
5 alternative methodology for making additional
6 Medicaid payments to hospitals; providing
7 legislative intent; providing powers, duties,
8 and responsibilities of the agency under the
9 pilot program; requiring that the agency
10 provide a plan to the Legislature for
11 implementing the pilot program; requiring that
12 the Office of Program Policy Analysis and
13 Government Accountability, in consultation with
14 the Auditor General, evaluate the pilot program
15 and report to the Governor and the Legislature
16 on whether it should be expanded statewide;
17 amending s. 409.9122, F.S.; revising a
18 reference; amending s. 409.913, F.S.; requiring
19 5 percent of all program integrity audits to be
20 conducted on a random basis; requiring that
21 Medicaid recipients be provided with an
22 explanation of benefits; requiring that the
23 agency report to the Legislature on the legal
24 and administrative barriers to enforcing the
25 copayment requirements of s. 409.9081, F.S.;
26 requiring the agency to recommend ways to
27 ensure that Medicaid is the payer of last
28 resort; requiring the agency to conduct a study
29 of provider pay-for-performance systems;
30 requiring the Office of Program Policy Analysis
31 and Government Accountability to conduct a
3
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1 study of the long-term care diversion programs;
2 requiring the agency to evaluate the
3 cost-saving potential of contracting with a
4 multistate prescription drug purchasing pool;
5 requiring the agency to determine how many
6 individuals in long-term care diversion
7 programs have a patient payment responsibility
8 that is not being collected and to recommend
9 how to collect such payments; requiring the
10 Office of Program Policy Analysis and
11 Government Accountability to conduct a study of
12 Medicaid buy-in programs to determine if these
13 programs can be created in this state without
14 expanding the overall Medicaid program budget
15 or if the Medically Needy program can be
16 changed into a Medicaid buy-in program;
17 providing an appropriation for the purpose of
18 developing infrastructure and administrative
19 resources necessary to implement the pilot
20 project as created in s. 409.91211, F.S.;
21 providing an appropriation for developing an
22 encounter data system for Medicaid managed care
23 plans; providing an effective date.
24
25 Be It Enacted by the Legislature of the State of Florida:
26
27 Section 1. Section 409.912, Florida Statutes, is
28 amended to read:
29 409.912 Cost-effective purchasing of health care.--The
30 agency shall purchase goods and services for Medicaid
31 recipients in the most cost-effective manner consistent with
4
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1 the delivery of quality medical care. To ensure that medical
2 services are effectively utilized, the agency may, in any
3 case, require a confirmation or second physician's opinion of
4 the correct diagnosis for purposes of authorizing future
5 services under the Medicaid program. This section does not
6 restrict access to emergency services or poststabilization
7 care services as defined in 42 C.F.R. part 438.114. Such
8 confirmation or second opinion shall be rendered in a manner
9 approved by the agency. The agency shall maximize the use of
10 prepaid per capita and prepaid aggregate fixed-sum basis
11 services when appropriate and other alternative service
12 delivery and reimbursement methodologies, including
13 competitive bidding pursuant to s. 287.057, designed to
14 facilitate the cost-effective purchase of a case-managed
15 continuum of care. The agency shall also require providers to
16 minimize the exposure of recipients to the need for acute
17 inpatient, custodial, and other institutional care and the
18 inappropriate or unnecessary use of high-cost services. The
19 agency shall contract with a vendor to monitor and evaluate
20 the clinical practice patterns of providers in order to
21 identify trends that are outside the normal practice patterns
22 of a provider's professional peers or the national guidelines
23 of a provider's professional association. The vendor must be
24 able to provide information and counseling to a provider whose
25 practice patterns are outside the norms, in consultation with
26 the agency, to improve patient care and reduce inappropriate
27 utilization. The agency may mandate prior authorization, drug
28 therapy management, or disease management participation for
29 certain populations of Medicaid beneficiaries, certain drug
30 classes, or particular drugs to prevent fraud, abuse, overuse,
31 and possible dangerous drug interactions. The Pharmaceutical
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1 and Therapeutics Committee shall make recommendations to the
2 agency on drugs for which prior authorization is required. The
3 agency shall inform the Pharmaceutical and Therapeutics
4 Committee of its decisions regarding drugs subject to prior
5 authorization. The agency is authorized to limit the entities
6 it contracts with or enrolls as Medicaid providers by
7 developing a provider network through provider credentialing.
8 The agency may competitively bid single-source-provider
9 contracts if procurement of goods or services results in
10 demonstrated cost savings to the state without limiting access
11 to care. The agency may limit its network based on the
12 assessment of beneficiary access to care, provider
13 availability, provider quality standards, time and distance
14 standards for access to care, the cultural competence of the
15 provider network, demographic characteristics of Medicaid
16 beneficiaries, practice and provider-to-beneficiary standards,
17 appointment wait times, beneficiary use of services, provider
18 turnover, provider profiling, provider licensure history,
19 previous program integrity investigations and findings, peer
20 review, provider Medicaid policy and billing compliance
21 records, clinical and medical record audits, and other
22 factors. Providers shall not be entitled to enrollment in the
23 Medicaid provider network. The agency shall determine
24 instances in which allowing Medicaid beneficiaries to purchase
25 durable medical equipment and other goods is less expensive to
26 the Medicaid program than long-term rental of the equipment or
27 goods. The agency may establish rules to facilitate purchases
28 in lieu of long-term rentals in order to protect against fraud
29 and abuse in the Medicaid program as defined in s. 409.913.
30 The agency may is authorized to seek federal waivers necessary
31 to administer these policies implement this policy.
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1 (1) The agency shall work with the Department of
2 Children and Family Services to ensure access of children and
3 families in the child protection system to needed and
4 appropriate mental health and substance abuse services.
5 (2) The agency may enter into agreements with
6 appropriate agents of other state agencies or of any agency of
7 the Federal Government and accept such duties in respect to
8 social welfare or public aid as may be necessary to implement
9 the provisions of Title XIX of the Social Security Act and ss.
10 409.901-409.920.
11 (3) The agency may contract with health maintenance
12 organizations certified pursuant to part I of chapter 641 for
13 the provision of services to recipients.
14 (4) The agency may contract with:
15 (a) An entity that provides no prepaid health care
16 services other than Medicaid services under contract with the
17 agency and which is owned and operated by a county, county
18 health department, or county-owned and operated hospital to
19 provide health care services on a prepaid or fixed-sum basis
20 to recipients, which entity may provide such prepaid services
21 either directly or through arrangements with other providers.
22 Such prepaid health care services entities must be licensed
23 under parts I and III by January 1, 1998, and until then are
24 exempt from the provisions of part I of chapter 641. An entity
25 recognized under this paragraph which demonstrates to the
26 satisfaction of the Office of Insurance Regulation of the
27 Financial Services Commission that it is backed by the full
28 faith and credit of the county in which it is located may be
29 exempted from s. 641.225.
30 (b) An entity that is providing comprehensive
31 behavioral health care services to certain Medicaid recipients
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1 through a capitated, prepaid arrangement pursuant to the
2 federal waiver provided for by s. 409.905(5). Such an entity
3 must be licensed under chapter 624, chapter 636, or chapter
4 641 and must possess the clinical systems and operational
5 competence to manage risk and provide comprehensive behavioral
6 health care to Medicaid recipients. As used in this paragraph,
7 the term "comprehensive behavioral health care services" means
8 covered mental health and substance abuse treatment services
9 that are available to Medicaid recipients. The secretary of
10 the Department of Children and Family Services shall approve
11 provisions of procurements related to children in the
12 department's care or custody prior to enrolling such children
13 in a prepaid behavioral health plan. Any contract awarded
14 under this paragraph must be competitively procured. In
15 developing the behavioral health care prepaid plan procurement
16 document, the agency shall ensure that the procurement
17 document requires the contractor to develop and implement a
18 plan to ensure compliance with s. 394.4574 related to services
19 provided to residents of licensed assisted living facilities
20 that hold a limited mental health license. Except as provided
21 in subparagraph 8., the agency shall seek federal approval to
22 contract with a single entity meeting these requirements to
23 provide comprehensive behavioral health care services to all
24 Medicaid recipients not enrolled in a managed care plan in an
25 AHCA area. Each entity must offer sufficient choice of
26 providers in its network to ensure recipient access to care
27 and the opportunity to select a provider with whom they are
28 satisfied. The network shall include all public mental health
29 hospitals. To ensure unimpaired access to behavioral health
30 care services by Medicaid recipients, all contracts issued
31 pursuant to this paragraph shall require 80 percent of the
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1 capitation paid to the managed care plan, including health
2 maintenance organizations, to be expended for the provision of
3 behavioral health care services. In the event the managed care
4 plan expends less than 80 percent of the capitation paid
5 pursuant to this paragraph for the provision of behavioral
6 health care services, the difference shall be returned to the
7 agency. The agency shall provide the managed care plan with a
8 certification letter indicating the amount of capitation paid
9 during each calendar year for the provision of behavioral
10 health care services pursuant to this section. The agency may
11 reimburse for substance abuse treatment services on a
12 fee-for-service basis until the agency finds that adequate
13 funds are available for capitated, prepaid arrangements.
14 1. By January 1, 2001, the agency shall modify the
15 contracts with the entities providing comprehensive inpatient
16 and outpatient mental health care services to Medicaid
17 recipients in Hillsborough, Highlands, Hardee, Manatee, and
18 Polk Counties, to include substance abuse treatment services.
19 2. By July 1, 2003, the agency and the Department of
20 Children and Family Services shall execute a written agreement
21 that requires collaboration and joint development of all
22 policy, budgets, procurement documents, contracts, and
23 monitoring plans that have an impact on the state and Medicaid
24 community mental health and targeted case management programs.
25 3. Except as provided in subparagraph 8., by July 1,
26 2006, the agency and the Department of Children and Family
27 Services shall contract with managed care entities in each
28 AHCA area except area 6 or arrange to provide comprehensive
29 inpatient and outpatient mental health and substance abuse
30 services through capitated prepaid arrangements to all
31 Medicaid recipients who are eligible to participate in such
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1 plans under federal law and regulation. In AHCA areas where
2 eligible individuals number less than 150,000, the agency
3 shall contract with a single managed care plan to provide
4 comprehensive behavioral health services to all recipients who
5 are not enrolled in a Medicaid health maintenance
6 organization. The agency may contract with more than one
7 comprehensive behavioral health provider to provide care to
8 recipients who are not enrolled in a Medicaid health
9 maintenance organization in AHCA areas where the eligible
10 population exceeds 150,000. Contracts for comprehensive
11 behavioral health providers awarded pursuant to this section
12 shall be competitively procured. Both for-profit and
13 not-for-profit corporations shall be eligible to compete.
14 Managed care plans contracting with the agency under
15 subsection (3) shall provide and receive payment for the same
16 comprehensive behavioral health benefits as provided in AHCA
17 rules, including handbooks incorporated by reference.
18 4. By October 1, 2003, the agency and the department
19 shall submit a plan to the Governor, the President of the
20 Senate, and the Speaker of the House of Representatives which
21 provides for the full implementation of capitated prepaid
22 behavioral health care in all areas of the state.
23 a. Implementation shall begin in 2003 in those AHCA
24 areas of the state where the agency is able to establish
25 sufficient capitation rates.
26 b. If the agency determines that the proposed
27 capitation rate in any area is insufficient to provide
28 appropriate services, the agency may adjust the capitation
29 rate to ensure that care will be available. The agency and the
30 department may use existing general revenue to address any
31
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1 additional required match but may not over-obligate existing
2 funds on an annualized basis.
3 c. Subject to any limitations provided for in the
4 General Appropriations Act, the agency, in compliance with
5 appropriate federal authorization, shall develop policies and
6 procedures that allow for certification of local and state
7 funds.
8 5. Children residing in a statewide inpatient
9 psychiatric program, or in a Department of Juvenile Justice or
10 a Department of Children and Family Services residential
11 program approved as a Medicaid behavioral health overlay
12 services provider shall not be included in a behavioral health
13 care prepaid health plan or any other Medicaid managed care
14 plan pursuant to this paragraph.
15 6. In converting to a prepaid system of delivery, the
16 agency shall in its procurement document require an entity
17 providing only comprehensive behavioral health care services
18 to prevent the displacement of indigent care patients by
19 enrollees in the Medicaid prepaid health plan providing
20 behavioral health care services from facilities receiving
21 state funding to provide indigent behavioral health care, to
22 facilities licensed under chapter 395 which do not receive
23 state funding for indigent behavioral health care, or
24 reimburse the unsubsidized facility for the cost of behavioral
25 health care provided to the displaced indigent care patient.
26 7. Traditional community mental health providers under
27 contract with the Department of Children and Family Services
28 pursuant to part IV of chapter 394, child welfare providers
29 under contract with the Department of Children and Family
30 Services in areas 1 and 6, and inpatient mental health
31 providers licensed pursuant to chapter 395 must be offered an
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1 opportunity to accept or decline a contract to participate in
2 any provider network for prepaid behavioral health services.
3 8. For fiscal year 2004-2005, all Medicaid eligible
4 children, except children in areas 1 and 6, whose cases are
5 open for child welfare services in the HomeSafeNet system,
6 shall be enrolled in MediPass or in Medicaid fee-for-service
7 and all their behavioral health care services including
8 inpatient, outpatient psychiatric, community mental health,
9 and case management shall be reimbursed on a fee-for-service
10 basis. Beginning July 1, 2005, such children, who are open for
11 child welfare services in the HomeSafeNet system, shall
12 receive their behavioral health care services through a
13 specialty prepaid plan operated by community-based lead
14 agencies either through a single agency or formal agreements
15 among several agencies. The specialty prepaid plan must result
16 in savings to the state comparable to savings achieved in
17 other Medicaid managed care and prepaid programs. Such plan
18 must provide mechanisms to maximize state and local revenues.
19 The specialty prepaid plan shall be developed by the agency
20 and the Department of Children and Family Services. The agency
21 is authorized to seek any federal waivers to implement this
22 initiative.
23 (c) A federally qualified health center or an entity
24 owned by one or more federally qualified health centers or an
25 entity owned by other migrant and community health centers
26 receiving non-Medicaid financial support from the Federal
27 Government to provide health care services on a prepaid or
28 fixed-sum basis to recipients. Such prepaid health care
29 services entity must be licensed under parts I and III of
30 chapter 641, but shall be prohibited from serving Medicaid
31 recipients on a prepaid basis, until such licensure has been
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1 obtained. However, such an entity is exempt from s. 641.225 if
2 the entity meets the requirements specified in subsections
3 (17) and (18).
4 (d) A provider service network may be reimbursed on a
5 fee-for-service or prepaid basis. A provider service network
6 which is reimbursed by the agency on a prepaid basis shall be
7 exempt from parts I and III of chapter 641, but must meet
8 appropriate financial reserve, quality assurance, and patient
9 rights requirements as established by the agency. The agency
10 shall award contracts on a competitive bid basis and shall
11 select bidders based upon price and quality of care. Medicaid
12 recipients assigned to a demonstration project shall be chosen
13 equally from those who would otherwise have been assigned to
14 prepaid plans and MediPass. The agency is authorized to seek
15 federal Medicaid waivers as necessary to implement the
16 provisions of this section. Any contract previously awarded to
17 a provider service network operated by a hospital pursuant to
18 this subsection shall remain in effect for a period of 3 years
19 following the current contract-expiration date, regardless of
20 any contractual provisions to the contrary. A provider service
21 network is a network established or organized and operated by
22 a health care provider, or group of affiliated health care
23 providers, which provides a substantial proportion of the
24 health care items and services under a contract directly
25 through the provider or affiliated group of providers and may
26 make arrangements with physicians or other health care
27 professionals, health care institutions, or any combination of
28 such individuals or institutions to assume all or part of the
29 financial risk on a prospective basis for the provision of
30 basic health services by the physicians, by other health
31 professionals, or through the institutions. The health care
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1 providers must have a controlling interest in the governing
2 body of the provider service network organization.
3 (e) An entity that provides only comprehensive
4 behavioral health care services to certain Medicaid recipients
5 through an administrative services organization agreement.
6 Such an entity must possess the clinical systems and
7 operational competence to provide comprehensive health care to
8 Medicaid recipients. As used in this paragraph, the term
9 "comprehensive behavioral health care services" means covered
10 mental health and substance abuse treatment services that are
11 available to Medicaid recipients. Any contract awarded under
12 this paragraph must be competitively procured. The agency must
13 ensure that Medicaid recipients have available the choice of
14 at least two managed care plans for their behavioral health
15 care services.
16 (f) An entity that provides in-home physician services
17 to test the cost-effectiveness of enhanced home-based medical
18 care to Medicaid recipients with degenerative neurological
19 diseases and other diseases or disabling conditions associated
20 with high costs to Medicaid. The program shall be designed to
21 serve very disabled persons and to reduce Medicaid reimbursed
22 costs for inpatient, outpatient, and emergency department
23 services. The agency shall contract with vendors on a
24 risk-sharing basis.
25 (g) Children's provider networks that provide care
26 coordination and care management for Medicaid-eligible
27 pediatric patients, primary care, authorization of specialty
28 care, and other urgent and emergency care through organized
29 providers designed to service Medicaid eligibles under age 18
30 and pediatric emergency departments' diversion programs. The
31 networks shall provide after-hour operations, including
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1 evening and weekend hours, to promote, when appropriate, the
2 use of the children's networks rather than hospital emergency
3 departments.
4 (h) An entity authorized in s. 430.205 to contract
5 with the agency and the Department of Elderly Affairs to
6 provide health care and social services on a prepaid or
7 fixed-sum basis to elderly recipients. Such prepaid health
8 care services entities are exempt from the provisions of part
9 I of chapter 641 for the first 3 years of operation. An entity
10 recognized under this paragraph that demonstrates to the
11 satisfaction of the Office of Insurance Regulation that it is
12 backed by the full faith and credit of one or more counties in
13 which it operates may be exempted from s. 641.225.
14 (i) A Children's Medical Services Network, as defined
15 in s. 391.021.
16 (5) By December 1, 2005, the Agency for Health Care
17 Administration, in partnership with the Department of Elderly
18 Affairs, shall create an integrated, fixed-payment delivery
19 system for Medicaid recipients who are 60 years of age or
20 older. Eligible Medicaid recipients may participate in the
21 integrated system on a voluntary basis. The program must
22 transfer all Medicaid services for eligible elderly
23 individuals who choose to participate into an integrated-care
24 management model designed to serve Medicaid recipients in the
25 community. The program must combine all funding for Medicaid
26 services provided to individuals 60 years of age or older into
27 the integrated system, including funds for Medicaid home and
28 community-based waiver services; all Medicaid services
29 authorized in ss. 409.905 and 409.906, excluding funds for
30 Medicaid nursing home services unless the agency is able to
31 demonstrate how the integration of the funds will improve
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1 coordinated care for these services in a less costly manner;
2 and Medicare premiums, coinsurance, and deductibles for
3 persons dually eligible for Medicaid and Medicare as
4 prescribed in s. 409.908(13). The agency must begin
5 implementing the integrated system in a pilot area that may
6 only include Orange, Osceola, Lake, and Seminole Counties.
7 (a) Individuals who are 60 years of age or older and
8 enrolled in the the developmental disabilities waiver program,
9 the family and supported-living waiver program, the project
10 AIDS care waiver program, the traumatic brain injury and
11 spinal cord injury waiver program, the consumer-directed care
12 waiver program, and the program of all-inclusive care for the
13 elderly program, and residents of institutional care
14 facilities for the developmentally disabled, must be excluded
15 from the integrated system.
16 (b) The program must use a competitive-procurement
17 process to select entities to operate the integrated system.
18 Entities eligible to submit bids include managed care
19 organizations licensed under chapter 641, including entities
20 eligible to participate in the nursing home diversion program,
21 other qualified providers as defined in s. 430.703(7),
22 community care for the elderly lead agencies, and other
23 state-certified community service networks that meet
24 comparable standards as defined by the agency, in consultation
25 with the Department of Elderly Affairs and the Office of
26 Insurance Regulation, to be financially solvent and able to
27 take on financial risk for managed care. Community service
28 networks that are certified pursuant to the comparable
29 standards defined by the agency are not required to be
30 licensed under chapter 641.
31
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1 (c) The agency must ensure that the
2 capitation-rate-setting methodology for the integrated system
3 is actuarially sound and reflects the intent to provide
4 quality care in the least-restrictive setting. The agency must
5 also require integrated-system providers to develop a
6 credentialing system for service providers and to contract
7 with all Gold Seal nursing homes, where feasible, and exclude,
8 where feasible, chronically poor-performing facilities and
9 providers as defined by the agency. The integrated system must
10 provide that if the recipient resides in a noncontracted
11 residential facility licensed under chapter 400 at the time
12 the integrated system is initiated, the recipient must be
13 permitted to continue to reside in the noncontracted facility
14 as long as the recipient desires. The integrated system must
15 also provide that, in the absence of a contract between the
16 integrated-system provider and the residential facility
17 licensed under chapter 400, current Medicaid rates must
18 prevail. The agency and the Department of Elderly Affairs must
19 jointly develop procedures to manage the services provided
20 through the integrated system in order to ensure quality and
21 recipient choice.
22 (d) The agency may seek federal waivers and adopt
23 rules as necessary to administer the integrated system. By
24 October 1, 2003, the agency and the department shall, to the
25 extent feasible, develop a plan for implementing new Medicaid
26 procedure codes for emergency and crisis care, supportive
27 residential services, and other services designed to maximize
28 the use of Medicaid funds for Medicaid-eligible recipients.
29 The agency shall include in the agreement developed pursuant
30 to subsection (4) a provision that ensures that the match
31 requirements for these new procedure codes are met by
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1 certifying eligible general revenue or local funds that are
2 currently expended on these services by the department with
3 contracted alcohol, drug abuse, and mental health providers.
4 The plan must describe specific procedure codes to be
5 implemented, a projection of the number of procedures to be
6 delivered during fiscal year 2003-2004, and a financial
7 analysis that describes the certified match procedures, and
8 accountability mechanisms, projects the earnings associated
9 with these procedures, and describes the sources of state
10 match. This plan may not be implemented in any part until
11 approved by the Legislative Budget Commission. If such
12 approval has not occurred by December 31, 2003, the plan shall
13 be submitted for consideration by the 2004 Legislature.
14 (6) The agency may contract with any public or private
15 entity otherwise authorized by this section on a prepaid or
16 fixed-sum basis for the provision of health care services to
17 recipients. An entity may provide prepaid services to
18 recipients, either directly or through arrangements with other
19 entities, if each entity involved in providing services:
20 (a) Is organized primarily for the purpose of
21 providing health care or other services of the type regularly
22 offered to Medicaid recipients;
23 (b) Ensures that services meet the standards set by
24 the agency for quality, appropriateness, and timeliness;
25 (c) Makes provisions satisfactory to the agency for
26 insolvency protection and ensures that neither enrolled
27 Medicaid recipients nor the agency will be liable for the
28 debts of the entity;
29 (d) Submits to the agency, if a private entity, a
30 financial plan that the agency finds to be fiscally sound and
31 that provides for working capital in the form of cash or
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1 equivalent liquid assets excluding revenues from Medicaid
2 premium payments equal to at least the first 3 months of
3 operating expenses or $200,000, whichever is greater;
4 (e) Furnishes evidence satisfactory to the agency of
5 adequate liability insurance coverage or an adequate plan of
6 self-insurance to respond to claims for injuries arising out
7 of the furnishing of health care;
8 (f) Provides, through contract or otherwise, for
9 periodic review of its medical facilities and services, as
10 required by the agency; and
11 (g) Provides organizational, operational, financial,
12 and other information required by the agency.
13 (7) The agency may contract on a prepaid or fixed-sum
14 basis with any health insurer that:
15 (a) Pays for health care services provided to enrolled
16 Medicaid recipients in exchange for a premium payment paid by
17 the agency;
18 (b) Assumes the underwriting risk; and
19 (c) Is organized and licensed under applicable
20 provisions of the Florida Insurance Code and is currently in
21 good standing with the Office of Insurance Regulation.
22 (8) The agency may contract on a prepaid or fixed-sum
23 basis with an exclusive provider organization to provide
24 health care services to Medicaid recipients provided that the
25 exclusive provider organization meets applicable managed care
26 plan requirements in this section, ss. 409.9122, 409.9123,
27 409.9128, and 627.6472, and other applicable provisions of
28 law.
29 (9) The Agency for Health Care Administration may
30 provide cost-effective purchasing of chiropractic services on
31 a fee-for-service basis to Medicaid recipients through
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1 arrangements with a statewide chiropractic preferred provider
2 organization incorporated in this state as a not-for-profit
3 corporation. The agency shall ensure that the benefit limits
4 and prior authorization requirements in the current Medicaid
5 program shall apply to the services provided by the
6 chiropractic preferred provider organization.
7 (10) The agency shall not contract on a prepaid or
8 fixed-sum basis for Medicaid services with an entity which
9 knows or reasonably should know that any officer, director,
10 agent, managing employee, or owner of stock or beneficial
11 interest in excess of 5 percent common or preferred stock, or
12 the entity itself, has been found guilty of, regardless of
13 adjudication, or entered a plea of nolo contendere, or guilty,
14 to:
15 (a) Fraud;
16 (b) Violation of federal or state antitrust statutes,
17 including those proscribing price fixing between competitors
18 and the allocation of customers among competitors;
19 (c) Commission of a felony involving embezzlement,
20 theft, forgery, income tax evasion, bribery, falsification or
21 destruction of records, making false statements, receiving
22 stolen property, making false claims, or obstruction of
23 justice; or
24 (d) Any crime in any jurisdiction which directly
25 relates to the provision of health services on a prepaid or
26 fixed-sum basis.
27 (11) The agency, after notifying the Legislature, may
28 apply for waivers of applicable federal laws and regulations
29 as necessary to implement more appropriate systems of health
30 care for Medicaid recipients and reduce the cost of the
31 Medicaid program to the state and federal governments and
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1 shall implement such programs, after legislative approval,
2 within a reasonable period of time after federal approval.
3 These programs must be designed primarily to reduce the need
4 for inpatient care, custodial care and other long-term or
5 institutional care, and other high-cost services.
6 (a) Prior to seeking legislative approval of such a
7 waiver as authorized by this subsection, the agency shall
8 provide notice and an opportunity for public comment. Notice
9 shall be provided to all persons who have made requests of the
10 agency for advance notice and shall be published in the
11 Florida Administrative Weekly not less than 28 days prior to
12 the intended action.
13 (b) Notwithstanding s. 216.292, funds that are
14 appropriated to the Department of Elderly Affairs for the
15 Assisted Living for the Elderly Medicaid waiver and are not
16 expended shall be transferred to the agency to fund
17 Medicaid-reimbursed nursing home care.
18 (12) The agency shall establish a postpayment
19 utilization control program designed to identify recipients
20 who may inappropriately overuse or underuse Medicaid services
21 and shall provide methods to correct such misuse.
22 (13) The agency shall develop and provide coordinated
23 systems of care for Medicaid recipients and may contract with
24 public or private entities to develop and administer such
25 systems of care among public and private health care providers
26 in a given geographic area.
27 (14)(a) The agency shall operate or contract for the
28 operation of utilization management and incentive systems
29 designed to encourage cost-effective use services.
30 (b) The agency shall develop a procedure by which
31 health care providers and service vendors can provide the
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1 Medicaid program with methodologically valid data that
2 demonstrates whether a particular good or service can offset
3 the cost of providing the good or service in an alternative
4 setting or through other means and therefore should receive a
5 higher reimbursement. Any data provided to the agency for such
6 purpose must demonstrate that for every $1 increase in
7 reimbursement rates for the good or service there will be an
8 offset of at least $2 from the decrease in the cost of
9 providing the good or service through the traditional method.
10 The agency shall be the final arbitrator of the cost-benefit
11 analysis and must determine whether the increased
12 reimbursement for a particular good or service offsets the
13 cost of other goods or services in the Medicaid program. If
14 the agency determines that the increased reimbursement is
15 cost-effective, the agency shall recommend a change in the
16 reimbursement schedule for that particular good or service.
17 If, within 12 months after implementing any rate change under
18 this procedure, the agency determines that costs were not
19 offset by the increased reimbursement schedule, the agency may
20 revert to the former reimbursement schedule for the particular
21 good or service.
22 (15)(a) The agency shall operate the Comprehensive
23 Assessment and Review for Long-Term Care Services (CARES)
24 nursing facility preadmission screening program to ensure that
25 Medicaid payment for nursing facility care is made only for
26 individuals whose conditions require such care and to ensure
27 that long-term care services are provided in the setting most
28 appropriate to the needs of the person and in the most
29 economical manner possible. The CARES program shall also
30 ensure that individuals participating in Medicaid home and
31
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1 community-based waiver programs meet criteria for those
2 programs, consistent with approved federal waivers.
3 (b) The agency shall operate the CARES program through
4 an interagency agreement with the Department of Elderly
5 Affairs. The agency, in consultation with the Department of
6 Elderly Affairs, may contract for any function or activity of
7 the CARES program, including any function or activity required
8 by 42 C.F.R. part 483.20, relating to preadmission screening
9 and resident review.
10 (c) Prior to making payment for nursing facility
11 services for a Medicaid recipient, the agency must verify that
12 the nursing facility preadmission screening program has
13 determined that the individual requires nursing facility care
14 and that the individual cannot be safely served in
15 community-based programs. The nursing facility preadmission
16 screening program shall refer a Medicaid recipient to a
17 community-based program if the individual could be safely
18 served at a lower cost and the recipient chooses to
19 participate in such program. For individuals whose nursing
20 home stay is initially funded by Medicare and Medicare
21 coverage is being terminated for lack of progress towards
22 rehabilitation, CARES staff shall consult with the person
23 making the determination of progress toward rehabilitation to
24 ensure that the recipient is not being inappropriately
25 disqualified from Medicare coverage. If, in their professional
26 judgment, CARES staff believes that a Medicare beneficiary is
27 still making progress toward rehabilitation, they may assist
28 the Medicare beneficiary with an appeal of the
29 disqualification from Medicare coverage.
30 (d) For the purpose of initiating immediate
31 prescreening and diversion assistance for individuals residing
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1 in nursing homes and in order to make families aware of
2 alternative long-term care resources so that they may choose a
3 more cost-effective setting for long-term placement, CARES
4 staff shall conduct an assessment and review of a sample of
5 individuals whose nursing home stay is expected to exceed 20
6 days, regardless of the initial funding source for the nursing
7 home placement. CARES staff shall provide counseling and
8 referral services to these individuals regarding choosing
9 appropriate long-term care alternatives. This paragraph does
10 not apply to continuing care facilities licensed under chapter
11 651 or to retirement communities that provide a combination of
12 nursing home, independent living, and other long-term care
13 services.
14 (e) By January 15 of each year, the agency shall
15 submit a report to the Legislature and the Office of
16 Long-Term-Care Policy describing the operations of the CARES
17 program. The report must describe:
18 1. Rate of diversion to community alternative
19 programs;
20 2. CARES program staffing needs to achieve additional
21 diversions;
22 3. Reasons the program is unable to place individuals
23 in less restrictive settings when such individuals desired
24 such services and could have been served in such settings;
25 4. Barriers to appropriate placement, including
26 barriers due to policies or operations of other agencies or
27 state-funded programs; and
28 5. Statutory changes necessary to ensure that
29 individuals in need of long-term care services receive care in
30 the least restrictive environment.
31
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1 (f) The Department of Elderly Affairs shall track
2 individuals over time who are assessed under the CARES program
3 and who are diverted from nursing home placement. By January
4 15 of each year, the department shall submit to the
5 Legislature and the Office of Long-Term-Care Policy a
6 longitudinal study of the individuals who are diverted from
7 nursing home placement. The study must include:
8 1. The demographic characteristics of the individuals
9 assessed and diverted from nursing home placement, including,
10 but not limited to, age, race, gender, frailty, caregiver
11 status, living arrangements, and geographic location;
12 2. A summary of community services provided to
13 individuals for 1 year after assessment and diversion;
14 3. A summary of inpatient hospital admissions for
15 individuals who have been diverted; and
16 4. A summary of the length of time between diversion
17 and subsequent entry into a nursing home or death.
18 (g) By July 1, 2005, the department and the Agency for
19 Health Care Administration shall report to the President of
20 the Senate and the Speaker of the House of Representatives
21 regarding the impact to the state of modifying level-of-care
22 criteria to eliminate the Intermediate II level of care.
23 (16)(a) The agency shall identify health care
24 utilization and price patterns within the Medicaid program
25 which are not cost-effective or medically appropriate and
26 assess the effectiveness of new or alternate methods of
27 providing and monitoring service, and may implement such
28 methods as it considers appropriate. Such methods may include
29 disease management initiatives, an integrated and systematic
30 approach for managing the health care needs of recipients who
31 are at risk of or diagnosed with a specific disease by using
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1 best practices, prevention strategies, clinical-practice
2 improvement, clinical interventions and protocols, outcomes
3 research, information technology, and other tools and
4 resources to reduce overall costs and improve measurable
5 outcomes.
6 (b) The responsibility of the agency under this
7 subsection shall include the development of capabilities to
8 identify actual and optimal practice patterns; patient and
9 provider educational initiatives; methods for determining
10 patient compliance with prescribed treatments; fraud, waste,
11 and abuse prevention and detection programs; and beneficiary
12 case management programs.
13 1. The practice pattern identification program shall
14 evaluate practitioner prescribing patterns based on national
15 and regional practice guidelines, comparing practitioners to
16 their peer groups. The agency and its Drug Utilization Review
17 Board shall consult with the Department of Health and a panel
18 of practicing health care professionals consisting of the
19 following: the Speaker of the House of Representatives and the
20 President of the Senate shall each appoint three physicians
21 licensed under chapter 458 or chapter 459; and the Governor
22 shall appoint two pharmacists licensed under chapter 465 and
23 one dentist licensed under chapter 466 who is an oral surgeon.
24 Terms of the panel members shall expire at the discretion of
25 the appointing official. The panel shall begin its work by
26 August 1, 1999, regardless of the number of appointments made
27 by that date. The advisory panel shall be responsible for
28 evaluating treatment guidelines and recommending ways to
29 incorporate their use in the practice pattern identification
30 program. Practitioners who are prescribing inappropriately or
31 inefficiently, as determined by the agency, may have their
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1 prescribing of certain drugs subject to prior authorization or
2 may be terminated from all participation in the Medicaid
3 program.
4 2. The agency shall also develop educational
5 interventions designed to promote the proper use of
6 medications by providers and beneficiaries.
7 3. The agency shall implement a pharmacy fraud, waste,
8 and abuse initiative that may include a surety bond or letter
9 of credit requirement for participating pharmacies, enhanced
10 provider auditing practices, the use of additional fraud and
11 abuse software, recipient management programs for
12 beneficiaries inappropriately using their benefits, and other
13 steps that will eliminate provider and recipient fraud, waste,
14 and abuse. The initiative shall address enforcement efforts to
15 reduce the number and use of counterfeit prescriptions.
16 4. By September 30, 2002, the agency shall contract
17 with an entity in the state to implement a wireless handheld
18 clinical pharmacology drug information database for
19 practitioners. The initiative shall be designed to enhance the
20 agency's efforts to reduce fraud, abuse, and errors in the
21 prescription drug benefit program and to otherwise further the
22 intent of this paragraph.
23 5. By September 30, 2005, the agency shall contract
24 with an entity to design a database of clinical utilization
25 information or electronic medical records for Medicaid
26 providers. This system must be web-based and allow providers
27 to review on a real-time basis the utilization of Medicaid
28 services, including, but not limited to, physician office
29 visits, inpatient and outpatient hospitalizations, laboratory
30 and pathology services, radiological and other imaging
31 services, dental care, and patterns of dispensing prescription
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1 drugs in order to coordinate care and identify potential fraud
2 and abuse.
3 6. By January 1, 2006, the agency shall provide
4 expanded statewide disease-management programs to provide case
5 management for persons with chronic diseases including
6 diabetes, hypertension, human immunodeficiency virus/acquired
7 immune deficiency syndrome, asthma, congestive heart failure,
8 hemophilia, end-stage renal disease or chronic kidney disease,
9 cancer, sickle cell anemia, chronic fatigue syndrome, and
10 chronic pain. In selecting disease-management vendors,
11 preference must be given to disease-management organizations
12 that are able to provide case management across disease states
13 through coordinated efforts between physicians and
14 pharmacists. The expansion must take two primary forms. The
15 first type of expansion must emphasis changes in clinical
16 practice patterns of physicians and pharmacists in order to
17 meet evidence-based medicine standards and best-practice
18 guidelines for each physician's specialty. The second
19 expansion must emphasize changes in behavior of persons with
20 chronic medical conditions. The expansion must include a
21 randomly assigned, experimental design to evaluate short-term
22 changes in utilization patterns for Medicaid services and
23 clinical outcome measures. The agency shall use an
24 independent, third party to evaluate the expansion of the
25 disease-management program. The agency shall select the
26 geographic areas in which to expand the disease-management
27 program, estimate the costs to implement each expansion, and
28 develop a timeline for statewide implementation. Based on the
29 evaluation of the expansion, the agency may recommend
30 statewide expansion of the disease-management programs having
31 the best fiscal and clinical outcomes.
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1 7.5. The agency may apply for any federal waivers
2 needed to administer implement this paragraph.
3 (17) An entity contracting on a prepaid or fixed-sum
4 basis shall, in addition to meeting any applicable statutory
5 surplus requirements, also maintain at all times in the form
6 of cash, investments that mature in less than 180 days
7 allowable as admitted assets by the Office of Insurance
8 Regulation, and restricted funds or deposits controlled by the
9 agency or the Office of Insurance Regulation, a surplus amount
10 equal to one-and-one-half times the entity's monthly Medicaid
11 prepaid revenues. As used in this subsection, the term
12 "surplus" means the entity's total assets minus total
13 liabilities. If an entity's surplus falls below an amount
14 equal to one-and-one-half times the entity's monthly Medicaid
15 prepaid revenues, the agency shall prohibit the entity from
16 engaging in marketing and preenrollment activities, shall
17 cease to process new enrollments, and shall not renew the
18 entity's contract until the required balance is achieved. The
19 requirements of this subsection do not apply:
20 (a) Where a public entity agrees to fund any deficit
21 incurred by the contracting entity; or
22 (b) Where the entity's performance and obligations are
23 guaranteed in writing by a guaranteeing organization which:
24 1. Has been in operation for at least 5 years and has
25 assets in excess of $50 million; or
26 2. Submits a written guarantee acceptable to the
27 agency which is irrevocable during the term of the contracting
28 entity's contract with the agency and, upon termination of the
29 contract, until the agency receives proof of satisfaction of
30 all outstanding obligations incurred under the contract.
31
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1 (18)(a) The agency may require an entity contracting
2 on a prepaid or fixed-sum basis to establish a restricted
3 insolvency protection account with a federally guaranteed
4 financial institution licensed to do business in this state.
5 The entity shall deposit into that account 5 percent of the
6 capitation payments made by the agency each month until a
7 maximum total of 2 percent of the total current contract
8 amount is reached. The restricted insolvency protection
9 account may be drawn upon with the authorized signatures of
10 two persons designated by the entity and two representatives
11 of the agency. If the agency finds that the entity is
12 insolvent, the agency may draw upon the account solely with
13 the two authorized signatures of representatives of the
14 agency, and the funds may be disbursed to meet financial
15 obligations incurred by the entity under the prepaid contract.
16 If the contract is terminated, expired, or not continued, the
17 account balance must be released by the agency to the entity
18 upon receipt of proof of satisfaction of all outstanding
19 obligations incurred under this contract.
20 (b) The agency may waive the insolvency protection
21 account requirement in writing when evidence is on file with
22 the agency of adequate insolvency insurance and reinsurance
23 that will protect enrollees if the entity becomes unable to
24 meet its obligations.
25 (19) An entity that contracts with the agency on a
26 prepaid or fixed-sum basis for the provision of Medicaid
27 services shall reimburse any hospital or physician that is
28 outside the entity's authorized geographic service area as
29 specified in its contract with the agency, and that provides
30 services authorized by the entity to its members, at a rate
31
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1 negotiated with the hospital or physician for the provision of
2 services or according to the lesser of the following:
3 (a) The usual and customary charges made to the
4 general public by the hospital or physician; or
5 (b) The Florida Medicaid reimbursement rate
6 established for the hospital or physician.
7 (20) When a merger or acquisition of a Medicaid
8 prepaid contractor has been approved by the Office of
9 Insurance Regulation pursuant to s. 628.4615, the agency shall
10 approve the assignment or transfer of the appropriate Medicaid
11 prepaid contract upon request of the surviving entity of the
12 merger or acquisition if the contractor and the other entity
13 have been in good standing with the agency for the most recent
14 12-month period, unless the agency determines that the
15 assignment or transfer would be detrimental to the Medicaid
16 recipients or the Medicaid program. To be in good standing, an
17 entity must not have failed accreditation or committed any
18 material violation of the requirements of s. 641.52 and must
19 meet the Medicaid contract requirements. For purposes of this
20 section, a merger or acquisition means a change in controlling
21 interest of an entity, including an asset or stock purchase.
22 (21) Any entity contracting with the agency pursuant
23 to this section to provide health care services to Medicaid
24 recipients is prohibited from engaging in any of the following
25 practices or activities:
26 (a) Practices that are discriminatory, including, but
27 not limited to, attempts to discourage participation on the
28 basis of actual or perceived health status.
29 (b) Activities that could mislead or confuse
30 recipients, or misrepresent the organization, its marketing
31
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1 representatives, or the agency. Violations of this paragraph
2 include, but are not limited to:
3 1. False or misleading claims that marketing
4 representatives are employees or representatives of the state
5 or county, or of anyone other than the entity or the
6 organization by whom they are reimbursed.
7 2. False or misleading claims that the entity is
8 recommended or endorsed by any state or county agency, or by
9 any other organization which has not certified its endorsement
10 in writing to the entity.
11 3. False or misleading claims that the state or county
12 recommends that a Medicaid recipient enroll with an entity.
13 4. Claims that a Medicaid recipient will lose benefits
14 under the Medicaid program, or any other health or welfare
15 benefits to which the recipient is legally entitled, if the
16 recipient does not enroll with the entity.
17 (c) Granting or offering of any monetary or other
18 valuable consideration for enrollment, except as authorized by
19 subsection (24).
20 (d) Door-to-door solicitation of recipients who have
21 not contacted the entity or who have not invited the entity to
22 make a presentation.
23 (e) Solicitation of Medicaid recipients by marketing
24 representatives stationed in state offices unless approved and
25 supervised by the agency or its agent and approved by the
26 affected state agency when solicitation occurs in an office of
27 the state agency. The agency shall ensure that marketing
28 representatives stationed in state offices shall market their
29 managed care plans to Medicaid recipients only in designated
30 areas and in such a way as to not interfere with the
31 recipients' activities in the state office.
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1 (f) Enrollment of Medicaid recipients.
2 (22) The agency may impose a fine for a violation of
3 this section or the contract with the agency by a person or
4 entity that is under contract with the agency. With respect to
5 any nonwillful violation, such fine shall not exceed $2,500
6 per violation. In no event shall such fine exceed an aggregate
7 amount of $10,000 for all nonwillful violations arising out of
8 the same action. With respect to any knowing and willful
9 violation of this section or the contract with the agency, the
10 agency may impose a fine upon the entity in an amount not to
11 exceed $20,000 for each such violation. In no event shall such
12 fine exceed an aggregate amount of $100,000 for all knowing
13 and willful violations arising out of the same action.
14 (23) A health maintenance organization or a person or
15 entity exempt from chapter 641 that is under contract with the
16 agency for the provision of health care services to Medicaid
17 recipients may not use or distribute marketing materials used
18 to solicit Medicaid recipients, unless such materials have
19 been approved by the agency. The provisions of this subsection
20 do not apply to general advertising and marketing materials
21 used by a health maintenance organization to solicit both
22 non-Medicaid subscribers and Medicaid recipients.
23 (24) Upon approval by the agency, health maintenance
24 organizations and persons or entities exempt from chapter 641
25 that are under contract with the agency for the provision of
26 health care services to Medicaid recipients may be permitted
27 within the capitation rate to provide additional health
28 benefits that the agency has found are of high quality, are
29 practicably available, provide reasonable value to the
30 recipient, and are provided at no additional cost to the
31 state.
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1 (25) The agency shall utilize the statewide health
2 maintenance organization complaint hotline for the purpose of
3 investigating and resolving Medicaid and prepaid health plan
4 complaints, maintaining a record of complaints and confirmed
5 problems, and receiving disenrollment requests made by
6 recipients.
7 (26) The agency shall require the publication of the
8 health maintenance organization's and the prepaid health
9 plan's consumer services telephone numbers and the "800"
10 telephone number of the statewide health maintenance
11 organization complaint hotline on each Medicaid identification
12 card issued by a health maintenance organization or prepaid
13 health plan contracting with the agency to serve Medicaid
14 recipients and on each subscriber handbook issued to a
15 Medicaid recipient.
16 (27) The agency shall establish a health care quality
17 improvement system for those entities contracting with the
18 agency pursuant to this section, incorporating all the
19 standards and guidelines developed by the Medicaid Bureau of
20 the Health Care Financing Administration as a part of the
21 quality assurance reform initiative. The system shall include,
22 but need not be limited to, the following:
23 (a) Guidelines for internal quality assurance
24 programs, including standards for:
25 1. Written quality assurance program descriptions.
26 2. Responsibilities of the governing body for
27 monitoring, evaluating, and making improvements to care.
28 3. An active quality assurance committee.
29 4. Quality assurance program supervision.
30 5. Requiring the program to have adequate resources to
31 effectively carry out its specified activities.
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1 6. Provider participation in the quality assurance
2 program.
3 7. Delegation of quality assurance program activities.
4 8. Credentialing and recredentialing.
5 9. Enrollee rights and responsibilities.
6 10. Availability and accessibility to services and
7 care.
8 11. Ambulatory care facilities.
9 12. Accessibility and availability of medical records,
10 as well as proper recordkeeping and process for record review.
11 13. Utilization review.
12 14. A continuity of care system.
13 15. Quality assurance program documentation.
14 16. Coordination of quality assurance activity with
15 other management activity.
16 17. Delivering care to pregnant women and infants; to
17 elderly and disabled recipients, especially those who are at
18 risk of institutional placement; to persons with developmental
19 disabilities; and to adults who have chronic, high-cost
20 medical conditions.
21 (b) Guidelines which require the entities to conduct
22 quality-of-care studies which:
23 1. Target specific conditions and specific health
24 service delivery issues for focused monitoring and evaluation.
25 2. Use clinical care standards or practice guidelines
26 to objectively evaluate the care the entity delivers or fails
27 to deliver for the targeted clinical conditions and health
28 services delivery issues.
29 3. Use quality indicators derived from the clinical
30 care standards or practice guidelines to screen and monitor
31 care and services delivered.
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1 (c) Guidelines for external quality review of each
2 contractor which require: focused studies of patterns of care;
3 individual care review in specific situations; and followup
4 activities on previous pattern-of-care study findings and
5 individual-care-review findings. In designing the external
6 quality review function and determining how it is to operate
7 as part of the state's overall quality improvement system, the
8 agency shall construct its external quality review
9 organization and entity contracts to address each of the
10 following:
11 1. Delineating the role of the external quality review
12 organization.
13 2. Length of the external quality review organization
14 contract with the state.
15 3. Participation of the contracting entities in
16 designing external quality review organization review
17 activities.
18 4. Potential variation in the type of clinical
19 conditions and health services delivery issues to be studied
20 at each plan.
21 5. Determining the number of focused pattern-of-care
22 studies to be conducted for each plan.
23 6. Methods for implementing focused studies.
24 7. Individual care review.
25 8. Followup activities.
26 (28) In order to ensure that children receive health
27 care services for which an entity has already been
28 compensated, an entity contracting with the agency pursuant to
29 this section shall achieve an annual Early and Periodic
30 Screening, Diagnosis, and Treatment (EPSDT) Service screening
31 rate of at least 60 percent for those recipients continuously
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1 enrolled for at least 8 months. The agency shall develop a
2 method by which the EPSDT screening rate shall be calculated.
3 For any entity which does not achieve the annual 60 percent
4 rate, the entity must submit a corrective action plan for the
5 agency's approval. If the entity does not meet the standard
6 established in the corrective action plan during the specified
7 timeframe, the agency is authorized to impose appropriate
8 contract sanctions. At least annually, the agency shall
9 publicly release the EPSDT Services screening rates of each
10 entity it has contracted with on a prepaid basis to serve
11 Medicaid recipients.
12 (29) The agency shall perform enrollments and
13 disenrollments for Medicaid recipients who are eligible for
14 MediPass or managed care plans. Notwithstanding the
15 prohibition contained in paragraph (21)(f), managed care plans
16 may perform preenrollments of Medicaid recipients under the
17 supervision of the agency or its agents. For the purposes of
18 this section, "preenrollment" means the provision of marketing
19 and educational materials to a Medicaid recipient and
20 assistance in completing the application forms, but shall not
21 include actual enrollment into a managed care plan. An
22 application for enrollment shall not be deemed complete until
23 the agency or its agent verifies that the recipient made an
24 informed, voluntary choice. The agency, in cooperation with
25 the Department of Children and Family Services, may test new
26 marketing initiatives to inform Medicaid recipients about
27 their managed care options at selected sites. The agency shall
28 report to the Legislature on the effectiveness of such
29 initiatives. The agency may contract with a third party to
30 perform managed care plan and MediPass enrollment and
31 disenrollment services for Medicaid recipients and is
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1 authorized to adopt rules to implement such services. The
2 agency may adjust the capitation rate only to cover the costs
3 of a third-party enrollment and disenrollment contract, and
4 for agency supervision and management of the managed care plan
5 enrollment and disenrollment contract.
6 (30) Any lists of providers made available to Medicaid
7 recipients, MediPass enrollees, or managed care plan enrollees
8 shall be arranged alphabetically showing the provider's name
9 and specialty and, separately, by specialty in alphabetical
10 order.
11 (31) The agency shall establish an enhanced managed
12 care quality assurance oversight function, to include at least
13 the following components:
14 (a) At least quarterly analysis and followup,
15 including sanctions as appropriate, of managed care
16 participant utilization of services.
17 (b) At least quarterly analysis and followup,
18 including sanctions as appropriate, of quality findings of the
19 Medicaid peer review organization and other external quality
20 assurance programs.
21 (c) At least quarterly analysis and followup,
22 including sanctions as appropriate, of the fiscal viability of
23 managed care plans.
24 (d) At least quarterly analysis and followup,
25 including sanctions as appropriate, of managed care
26 participant satisfaction and disenrollment surveys.
27 (e) The agency shall conduct regular and ongoing
28 Medicaid recipient satisfaction surveys.
29
30 The analyses and followup activities conducted by the agency
31 under its enhanced managed care quality assurance oversight
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1 function shall not duplicate the activities of accreditation
2 reviewers for entities regulated under part III of chapter
3 641, but may include a review of the finding of such
4 reviewers.
5 (32) Each managed care plan that is under contract
6 with the agency to provide health care services to Medicaid
7 recipients shall annually conduct a background check with the
8 Florida Department of Law Enforcement of all persons with
9 ownership interest of 5 percent or more or executive
10 management responsibility for the managed care plan and shall
11 submit to the agency information concerning any such person
12 who has been found guilty of, regardless of adjudication, or
13 has entered a plea of nolo contendere or guilty to, any of the
14 offenses listed in s. 435.03.
15 (33) The agency shall, by rule, develop a process
16 whereby a Medicaid managed care plan enrollee who wishes to
17 enter hospice care may be disenrolled from the managed care
18 plan within 24 hours after contacting the agency regarding
19 such request. The agency rule shall include a methodology for
20 the agency to recoup managed care plan payments on a pro rata
21 basis if payment has been made for the enrollment month when
22 disenrollment occurs.
23 (34) The agency and entities that which contract with
24 the agency to provide health care services to Medicaid
25 recipients under this section or ss. 409.91211 and s. 409.9122
26 must comply with the provisions of s. 641.513 in providing
27 emergency services and care to Medicaid recipients and
28 MediPass recipients. Where feasible, safe, and cost-effective,
29 the agency shall encourage hospitals, emergency medical
30 services providers, and other public and private health care
31 providers to work together in their local communities to enter
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1 into agreements or arrangements to ensure access to
2 alternatives to emergency services and care for those Medicaid
3 recipients who need nonemergent care. The agency shall
4 coordinate with hospitals, emergency medical services
5 providers, private health plans, capitated managed care
6 networks as established in s. 409.91211, and other public and
7 private health care providers to implement the provisions of
8 ss. 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to
9 develop and implement emergency department diversion programs
10 for Medicaid recipients.
11 (35) All entities providing health care services to
12 Medicaid recipients shall make available, and encourage all
13 pregnant women and mothers with infants to receive, and
14 provide documentation in the medical records to reflect, the
15 following:
16 (a) Healthy Start prenatal or infant screening.
17 (b) Healthy Start care coordination, when screening or
18 other factors indicate need.
19 (c) Healthy Start enhanced services in accordance with
20 the prenatal or infant screening results.
21 (d) Immunizations in accordance with recommendations
22 of the Advisory Committee on Immunization Practices of the
23 United States Public Health Service and the American Academy
24 of Pediatrics, as appropriate.
25 (e) Counseling and services for family planning to all
26 women and their partners.
27 (f) A scheduled postpartum visit for the purpose of
28 voluntary family planning, to include discussion of all
29 methods of contraception, as appropriate.
30 (g) Referral to the Special Supplemental Nutrition
31 Program for Women, Infants, and Children (WIC).
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1 (36) Any entity that provides Medicaid prepaid health
2 plan services shall ensure the appropriate coordination of
3 health care services with an assisted living facility in cases
4 where a Medicaid recipient is both a member of the entity's
5 prepaid health plan and a resident of the assisted living
6 facility. If the entity is at risk for Medicaid targeted case
7 management and behavioral health services, the entity shall
8 inform the assisted living facility of the procedures to
9 follow should an emergent condition arise.
10 (37) The agency may seek and implement federal waivers
11 necessary to provide for cost-effective purchasing of home
12 health services, private duty nursing services,
13 transportation, independent laboratory services, and durable
14 medical equipment and supplies through competitive bidding
15 pursuant to s. 287.057. The agency may request appropriate
16 waivers from the federal Health Care Financing Administration
17 in order to competitively bid such services. The agency may
18 exclude providers not selected through the bidding process
19 from the Medicaid provider network.
20 (38) The agency shall enter into agreements with
21 not-for-profit organizations based in this state for the
22 purpose of providing vision screening.
23 (39)(a) The agency shall implement a Medicaid
24 prescribed-drug spending-control program that includes the
25 following components:
26 1. A Medicaid preferred drug list, which shall be a
27 listing of cost-effective therapeutic options recommended by
28 the Medicaid Pharmacy and Therapeutics Committee established
29 under s. 409.91195 and adopted by the agency for each
30 therapeutic class on the preferred drug list. At the
31 discretion of the committee, and when feasible, the preferred
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1 drug list should include at least two products in a
2 therapeutic class. Medicaid prescribed-drug coverage for
3 brand-name drugs for adult Medicaid recipients is limited to
4 eight the dispensing of four brand-name drugs per month per
5 recipient. Prior authorization is required for all additional
6 prescriptions above the eight-drug limit and must meet the
7 requirements for step therapy and for listing as a preferred
8 drug. Children are exempt from this restriction.
9 Antiretroviral agents are excluded from this limitation. No
10 requirements for prior authorization or other restrictions on
11 medications used to treat mental illnesses such as
12 schizophrenia, severe depression, or bipolar disorder may be
13 imposed on Medicaid recipients. Medications that will be
14 available without restriction for persons with mental
15 illnesses include atypical antipsychotic medications,
16 conventional antipsychotic medications, selective serotonin
17 reuptake inhibitors, and other medications used for the
18 treatment of serious mental illnesses. The agency shall also
19 limit the amount of a prescribed drug dispensed to no more
20 than a 34-day supply unless the drug products' smallest
21 marketed package is greater than a 34-day supply, or the drug
22 is determined by the agency to be a maintenance drug, in which
23 case a 180-day maximum supply may be authorized. The agency
24 may seek any federal waivers necessary to implement these
25 cost-control programs and to continue participation in the
26 federal Medicaid rebate program, or alternatively to negotiate
27 state-only manufacturer rebates. The agency may adopt rules to
28 administer this subparagraph. The agency shall continue to
29 provide unlimited generic drugs, contraceptive drugs and
30 items, and diabetic supplies. Although a drug may be included
31 on the preferred drug formulary, it would not be exempt from
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1 the four-brand limit. The agency may authorize exceptions to
2 the brand-name-drug restriction based upon the treatment needs
3 of the patients, only when such exceptions are based on prior
4 consultation provided by the agency or an agency contractor,
5 but The agency must establish procedures to ensure that:
6 a. There will be a response to a request for prior
7 consultation by telephone or other telecommunication device
8 within 24 hours after receipt of a request for prior
9 consultation; and
10 b. A 72-hour supply of the drug prescribed will be
11 provided in an emergency or when the agency does not provide a
12 response within 24 hours as required by sub-subparagraph a.;
13 and
14 c. Except for the exception for nursing home residents
15 and other institutionalized adults and except for drugs on the
16 restricted formulary for which prior authorization may be
17 sought by an institutional or community pharmacy, prior
18 authorization for an exception to the brand-name-drug
19 restriction is sought by the prescriber and not by the
20 pharmacy. When prior authorization is granted for a patient in
21 an institutional setting beyond the brand-name-drug
22 restriction, such approval is authorized for 12 months and
23 monthly prior authorization is not required for that patient.
24 2. Reimbursement to pharmacies for Medicaid prescribed
25 drugs shall be set at the lesser of: the average wholesale
26 price (AWP) minus 15.4 percent, the wholesaler acquisition
27 cost (WAC) plus 5.75 percent, the federal upper limit (FUL),
28 the state maximum allowable cost (SMAC), or the usual and
29 customary (UAC) charge billed by the provider.
30 3. The agency shall develop and implement a process
31 for managing the drug therapies of Medicaid recipients who are
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1 using significant numbers of prescribed drugs each month. The
2 management process may include, but is not limited to,
3 comprehensive, physician-directed medical-record reviews,
4 claims analyses, and case evaluations to determine the medical
5 necessity and appropriateness of a patient's treatment plan
6 and drug therapies. The agency may contract with a private
7 organization to provide drug-program-management services. The
8 Medicaid drug benefit management program shall include
9 initiatives to manage drug therapies for HIV/AIDS patients,
10 patients using 20 or more unique prescriptions in a 180-day
11 period, and the top 1,000 patients in annual spending. The
12 agency shall enroll any Medicaid recipient in the drug benefit
13 management program if he or she meets the specifications of
14 this provision and is not enrolled in a Medicaid health
15 maintenance organization.
16 4. The agency may limit the size of its pharmacy
17 network based on need, competitive bidding, price
18 negotiations, credentialing, or similar criteria. The agency
19 shall give special consideration to rural areas in determining
20 the size and location of pharmacies included in the Medicaid
21 pharmacy network. A pharmacy credentialing process may include
22 criteria such as a pharmacy's full-service status, location,
23 size, patient educational programs, patient consultation,
24 disease-management services, and other characteristics. The
25 agency may impose a moratorium on Medicaid pharmacy enrollment
26 when it is determined that it has a sufficient number of
27 Medicaid-participating providers. The agency must allow
28 dispensing practitioners to participate as a part of the
29 Medicaid pharmacy network regardless of the practitioner's
30 proximity to any other entity that is dispensing prescription
31 drugs under the Medicaid program. A dispensing practitioner
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1 must meet all credentialing requirements applicable to his or
2 her practice, as determined by the agency.
3 5. The agency shall develop and implement a program
4 that requires Medicaid practitioners who prescribe drugs to
5 use a counterfeit-proof prescription pad for Medicaid
6 prescriptions. The agency shall require the use of
7 standardized counterfeit-proof prescription pads by
8 Medicaid-participating prescribers or prescribers who write
9 prescriptions for Medicaid recipients. The agency may
10 implement the program in targeted geographic areas or
11 statewide.
12 6. The agency may enter into arrangements that require
13 manufacturers of generic drugs prescribed to Medicaid
14 recipients to provide rebates of at least 15.1 percent of the
15 average manufacturer price for the manufacturer's generic
16 products. These arrangements shall require that if a
17 generic-drug manufacturer pays federal rebates for
18 Medicaid-reimbursed drugs at a level below 15.1 percent, the
19 manufacturer must provide a supplemental rebate to the state
20 in an amount necessary to achieve a 15.1-percent rebate level.
21 7. The agency may establish a preferred drug list as
22 described in this subsection formulary in accordance with 42
23 U.S.C. s. 1396r-8, and, pursuant to the establishment of such
24 drug list formulary, it may is authorized to negotiate
25 supplemental rebates from manufacturers which that are in
26 addition to those required by Title XIX of the Social Security
27 Act and at no less than 14 percent of the average manufacturer
28 price as defined in 42 U.S.C. s. 1936 on the last day of a
29 quarter unless the federal or supplemental rebate, or both,
30 equals or exceeds 29 percent. There is no upper limit on the
31 supplemental rebates the agency may negotiate. The agency may
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1 determine that specific products, brand-name or generic, are
2 competitive at lower rebate percentages. Agreement to pay the
3 minimum supplemental rebate percentage will guarantee a
4 manufacturer that the Medicaid Pharmaceutical and Therapeutics
5 Committee will consider a product for inclusion on the
6 preferred drug list formulary. However, a pharmaceutical
7 manufacturer is not guaranteed placement on the preferred drug
8 list formulary by simply paying the minimum supplemental
9 rebate. Agency decisions will be made on the clinical efficacy
10 of a drug and recommendations of the Medicaid Pharmaceutical
11 and Therapeutics Committee, as well as the price of competing
12 products minus federal and state rebates. The agency is
13 authorized to contract with an outside agency or contractor to
14 conduct negotiations for supplemental rebates. For the
15 purposes of this section, the term "supplemental rebates"
16 means cash rebates. Effective July 1, 2004, value-added
17 programs as a substitution for supplemental rebates are
18 prohibited. The agency is authorized to seek any federal
19 waivers to implement this initiative.
20 8. The agency shall establish an advisory committee
21 for the purposes of studying the feasibility of using a
22 restricted drug formulary for nursing home residents and other
23 institutionalized adults. The committee shall be comprised of
24 seven members appointed by the Secretary of Health Care
25 Administration. The committee members shall include two
26 physicians licensed under chapter 458 or chapter 459; three
27 pharmacists licensed under chapter 465 and appointed from a
28 list of recommendations provided by the Florida Long-Term Care
29 Pharmacy Alliance; and two pharmacists licensed under chapter
30 465.
31
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1 8.9. The Agency for Health Care Administration shall
2 expand home delivery of pharmacy products. To assist Medicaid
3 patients in securing their prescriptions and reduce program
4 costs, the agency shall expand its current mail-order-pharmacy
5 diabetes-supply program to include all generic and brand-name
6 drugs used by Medicaid patients with diabetes. Medicaid
7 recipients in the current program may obtain nondiabetes drugs
8 on a voluntary basis. This initiative is limited to the
9 geographic area covered by the current contract. The agency
10 may seek and implement any federal waivers necessary to
11 implement this subparagraph.
12 9.10. The agency shall limit to one dose per month any
13 drug prescribed to treat erectile dysfunction.
14 10.11.a. The agency shall implement a Medicaid
15 behavioral drug management system. The agency may contract
16 with a vendor that has experience in operating behavioral drug
17 management systems to implement this program. The agency is
18 authorized to seek federal waivers to implement this program.
19 b. The agency, in conjunction with the Department of
20 Children and Family Services, may implement the Medicaid
21 behavioral drug management system that is designed to improve
22 the quality of care and behavioral health prescribing
23 practices based on best practice guidelines, improve patient
24 adherence to medication plans, reduce clinical risk, and lower
25 prescribed drug costs and the rate of inappropriate spending
26 on Medicaid behavioral drugs. The program shall include the
27 following elements:
28 (I) Provide for the development and adoption of best
29 practice guidelines for behavioral health-related drugs such
30 as antipsychotics, antidepressants, and medications for
31 treating bipolar disorders and other behavioral conditions;
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1 translate them into practice; review behavioral health
2 prescribers and compare their prescribing patterns to a number
3 of indicators that are based on national standards; and
4 determine deviations from best practice guidelines.
5 (II) Implement processes for providing feedback to and
6 educating prescribers using best practice educational
7 materials and peer-to-peer consultation.
8 (III) Assess Medicaid beneficiaries who are outliers
9 in their use of behavioral health drugs with regard to the
10 numbers and types of drugs taken, drug dosages, combination
11 drug therapies, and other indicators of improper use of
12 behavioral health drugs.
13 (IV) Alert prescribers to patients who fail to refill
14 prescriptions in a timely fashion, are prescribed multiple
15 same-class behavioral health drugs, and may have other
16 potential medication problems.
17 (V) Track spending trends for behavioral health drugs
18 and deviation from best practice guidelines.
19 (VI) Use educational and technological approaches to
20 promote best practices, educate consumers, and train
21 prescribers in the use of practice guidelines.
22 (VII) Disseminate electronic and published materials.
23 (VIII) Hold statewide and regional conferences.
24 (IX) Implement a disease management program with a
25 model quality-based medication component for severely mentally
26 ill individuals and emotionally disturbed children who are
27 high users of care.
28 c. If the agency is unable to negotiate a contract
29 with one or more manufacturers to finance and guarantee
30 savings associated with a behavioral drug management program
31 by September 1, 2004, the four-brand drug limit and preferred
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1 drug list prior-authorization requirements shall apply to
2 mental health-related drugs, notwithstanding any provision in
3 subparagraph 1. The agency is authorized to seek federal
4 waivers to implement this policy.
5 11.a. The agency shall implement a Medicaid
6 prescription-drug-management system. The agency may contract
7 with a vendor that has experience in operating
8 prescription-drug-management systems in order to implement
9 this system. Any management system that is implemented in
10 accordance with this subparagraph must rely on cooperation
11 between physicians and pharmacists to determine appropriate
12 practice patterns and clinical guidelines to improve the
13 prescribing, dispensing, and use of drugs in the Medicaid
14 program. The agency may seek federal waivers to implement this
15 program.
16 b. The drug-management system must be designed to
17 improve the quality of care and prescribing practices based on
18 best-practice guidelines, improve patient adherence to
19 medication plans, reduce clinical risk, and lower prescribed
20 drug costs and the rate of inappropriate spending on Medicaid
21 prescription drugs. The program must:
22 (I) Provide for the development and adoption of
23 best-practice guidelines for the prescribing and use of drugs
24 in the Medicaid program, including translating best-practice
25 guidelines into practice; reviewing prescriber patterns and
26 comparing them to indicators that are based on national
27 standards and practice patterns of clinical peers in their
28 community, statewide, and nationally; and determine deviations
29 from best-practice guidelines.
30
31
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1 (II) Implement processes for providing feedback to and
2 educating prescribers using best-practice educational
3 materials and peer-to-peer consultation.
4 (III) Assess Medicaid recipients who are outliers in
5 their use of a single or multiple prescription drugs with
6 regard to the numbers and types of drugs taken, drug dosages,
7 combination drug therapies, and other indicators of improper
8 use of prescription drugs.
9 (IV) Alert prescribers to patients who fail to refill
10 prescriptions in a timely fashion, are prescribed multiple
11 drugs that may be redundant or contraindicated, or may have
12 other potential medication problems.
13 (V) Track spending trends for prescription drugs and
14 deviation from best practice guidelines.
15 (VI) Use educational and technological approaches to
16 promote best practices, educate consumers, and train
17 prescribers in the use of practice guidelines.
18 (VII) Disseminate electronic and published materials.
19 (VIII) Hold statewide and regional conferences.
20 (IX) Implement disease-management programs in
21 cooperation with physicians and pharmacists, along with a
22 model quality-based medication component for individuals
23 having chronic medical conditions.
24 12. The agency is authorized to contract for drug
25 rebate administration, including, but not limited to,
26 calculating rebate amounts, invoicing manufacturers,
27 negotiating disputes with manufacturers, and maintaining a
28 database of rebate collections.
29 13. The agency may specify the preferred daily dosing
30 form or strength for the purpose of promoting best practices
31 with regard to the prescribing of certain drugs as specified
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1 in the General Appropriations Act and ensuring cost-effective
2 prescribing practices.
3 14. The agency may require prior authorization for the
4 off-label use of Medicaid-covered prescribed drugs as
5 specified in the General Appropriations Act. The agency may,
6 but is not required to, preauthorize the use of a product for
7 an indication not in the approved labeling. Prior
8 authorization may require the prescribing professional to
9 provide information about the rationale and supporting medical
10 evidence for the off-label use of a drug.
11 15. The agency, in conjunction with the Pharmaceutical
12 and Therapeutics Committee, may require age-related prior
13 authorizations for certain prescribed drugs. The agency may
14 preauthorize the use of a drug for a recipient who may not
15 meet the age requirement or may exceed the length of therapy
16 for use of this product as recommended by the manufacturer and
17 approved by the United States Food and Drug Administration.
18 Prior authorization may require the prescribing professional
19 to provide information about the rationale and supporting
20 medical evidence for the use of a drug.
21 16. The agency shall implement a step-therapy
22 prior-authorization-approval process for medications excluded
23 from the preferred drug list. Medications listed on the
24 preferred drug list must be used within the previous 12 months
25 prior to the alternative medications that are not listed. The
26 step-therapy prior authorization may require the prescriber to
27 use the medications of a similar drug class or for a similar
28 medical indication unless contraindicated in the labeling by
29 the Food and Drug Administration. The trial period between the
30 specified steps may vary according to the medical indication.
31 The step-therapy-approval process shall be developed in
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1 accordance with the committee as stated in s. 409.91195(7) and
2 (8).
3 17.15. The agency shall implement a return and reuse
4 program for drugs dispensed by pharmacies to institutional
5 recipients, which includes payment of a $5 restocking fee for
6 the implementation and operation of the program. The return
7 and reuse program shall be implemented electronically and in a
8 manner that promotes efficiency. The program must permit a
9 pharmacy to exclude drugs from the program if it is not
10 practical or cost-effective for the drug to be included and
11 must provide for the return to inventory of drugs that cannot
12 be credited or returned in a cost-effective manner. The agency
13 shall determine if the program has reduced the amount of
14 Medicaid prescription drugs which are destroyed on an annual
15 basis and if there are additional ways to ensure more
16 prescription drugs are not destroyed which could safely be
17 reused. The agency's conclusion and recommendations shall be
18 reported to the Legislature by December 1, 2005.
19 (b) The agency shall implement this subsection to the
20 extent that funds are appropriated to administer the Medicaid
21 prescribed-drug spending-control program. The agency may
22 contract all or any part of this program to private
23 organizations.
24 (c) The agency shall submit quarterly reports to the
25 Governor, the President of the Senate, and the Speaker of the
26 House of Representatives which must include, but need not be
27 limited to, the progress made in implementing this subsection
28 and its effect on Medicaid prescribed-drug expenditures.
29 (40) Notwithstanding the provisions of chapter 287,
30 the agency may, at its discretion, renew a contract or
31 contracts for fiscal intermediary services one or more times
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1 for such periods as the agency may decide; however, all such
2 renewals may not combine to exceed a total period longer than
3 the term of the original contract.
4 (41) The agency shall provide for the development of a
5 demonstration project by establishment in Miami-Dade County of
6 a long-term-care facility licensed pursuant to chapter 395 to
7 improve access to health care for a predominantly minority,
8 medically underserved, and medically complex population and to
9 evaluate alternatives to nursing home care and general acute
10 care for such population. Such project is to be located in a
11 health care condominium and colocated with licensed facilities
12 providing a continuum of care. The establishment of this
13 project is not subject to the provisions of s. 408.036 or s.
14 408.039. The agency shall report its findings to the Governor,
15 the President of the Senate, and the Speaker of the House of
16 Representatives by January 1, 2003.
17 (42) The agency shall develop and implement a
18 utilization management program for Medicaid-eligible
19 recipients for the management of occupational, physical,
20 respiratory, and speech therapies. The agency shall establish
21 a utilization program that may require prior authorization in
22 order to ensure medically necessary and cost-effective
23 treatments. The program shall be operated in accordance with a
24 federally approved waiver program or state plan amendment. The
25 agency may seek a federal waiver or state plan amendment to
26 implement this program. The agency may also competitively
27 procure these services from an outside vendor on a regional or
28 statewide basis.
29 (43) The agency may contract on a prepaid or fixed-sum
30 basis with appropriately licensed prepaid dental health plans
31 to provide dental services.
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1 (44) The Agency for Health Care Administration shall
2 ensure that any Medicaid managed care plan as defined in s.
3 409.9122(2)(h), whether paid on a capitated basis or a shared
4 savings basis, is cost-effective. For purposes of this
5 subsection, the term "cost-effective" means that a network's
6 per-member, per-month costs to the state, including, but not
7 limited to, fee-for-service costs, administrative costs, and
8 case-management fees, must be no greater than the state's
9 costs associated with contracts for Medicaid services
10 established under subsection (3), which shall be actuarially
11 adjusted for case mix, model, and service area. The agency
12 shall conduct actuarially sound audits adjusted for case mix
13 and model in order to ensure such cost-effectiveness and shall
14 publish the audit results on its Internet website and submit
15 the audit results annually to the Governor, the President of
16 the Senate, and the Speaker of the House of Representatives no
17 later than December 31 of each year. Contracts established
18 pursuant to this subsection which are not cost-effective may
19 not be renewed.
20 (45) Subject to the availability of funds, the agency
21 shall mandate a recipient's participation in a provider
22 lock-in program, when appropriate, if a recipient is found by
23 the agency to have used Medicaid goods or services at a
24 frequency or amount not medically necessary, limiting the
25 receipt of goods or services to medically necessary providers
26 after the 21-day appeal process has ended, for a period of not
27 less than 1 year. The lock-in programs shall include, but are
28 not limited to, pharmacies, medical doctors, and infusion
29 clinics. The limitation does not apply to emergency services
30 and care provided to the recipient in a hospital emergency
31 department. The agency shall seek any federal waivers
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1 necessary to implement this subsection. The agency shall adopt
2 any rules necessary to comply with or administer this
3 subsection.
4 (46) The agency shall seek a federal waiver for
5 permission to terminate the eligibility of a Medicaid
6 recipient who has been found to have committed fraud, through
7 judicial or administrative determination, two times in a
8 period of 5 years.
9 (47) The agency shall conduct a study of available
10 electronic systems for the purpose of verifying the identity
11 and eligibility of a Medicaid recipient. The agency shall
12 recommend to the Legislature a plan to implement an electronic
13 verification system for Medicaid recipients by January 31,
14 2005.
15 (48) A provider is not entitled to enrollment in the
16 Medicaid provider network. The agency may implement a Medicaid
17 fee-for-service provider network controls, including, but not
18 limited to, competitive procurement and provider
19 credentialing. If a credentialing process is used, the agency
20 may limit its provider network based upon the following
21 considerations: beneficiary access to care, provider
22 availability, provider quality standards and quality assurance
23 processes, cultural competency, demographic characteristics of
24 beneficiaries, practice standards, service wait times,
25 provider turnover, provider licensure and accreditation
26 history, program integrity history, peer review, Medicaid
27 policy and billing compliance records, clinical and medical
28 record audit findings, and such other areas that are
29 considered necessary by the agency to ensure the integrity of
30 the program.
31
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1 (49) The agency shall contract with established
2 minority physician networks that provide services to
3 historically underserved minority patients. The networks must
4 provide cost-effective Medicaid services, comply with the
5 requirements to be a MediPass provider, and provide their
6 primary care physicians with access to data and other
7 management tools necessary to assist them in ensuring the
8 appropriate use of services, including inpatient hospital
9 services and pharmaceuticals.
10 (a) The agency shall provide for the development and
11 expansion of minority physician networks in each service area
12 to provide services to Medicaid recipients who are eligible to
13 participate under federal law and rules.
14 (b) The agency shall reimburse each minority physician
15 network as a fee-for-service provider, including the case
16 management fee for primary care, or as a capitated rate
17 provider for Medicaid services. Any savings shall be shared
18 with the minority physician networks pursuant to the contract.
19 (c) For purposes of this subsection, the term
20 "cost-effective" means that a network's per-member, per-month
21 costs to the state, including, but not limited to,
22 fee-for-service costs, administrative costs, and
23 case-management fees, must be no greater than the state's
24 costs associated with contracts for Medicaid services
25 established under subsection (3), which shall be actuarially
26 adjusted for case mix, model, and service area. The agency
27 shall conduct actuarially sound audits adjusted for case mix
28 and model in order to ensure such cost-effectiveness and shall
29 publish the audit results on its Internet website and submit
30 the audit results annually to the Governor, the President of
31 the Senate, and the Speaker of the House of Representatives no
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1 later than December 31. Contracts established pursuant to this
2 subsection which are not cost-effective may not be renewed.
3 (d) The agency may apply for any federal waivers
4 needed to implement this subsection.
5 (50) The agency shall implement a program of
6 all-inclusive care for children. The program of all-inclusive
7 care for children shall be established in order to provide
8 in-home, hospice-like support services to children diagnosed
9 as having a life-threatening illness and who are enrolled in
10 the Children's Medical Services network and to reduce
11 hospitalizations as appropriate. The agency, in consultation
12 with the Department of Health, may implement the program of
13 all-inclusive care for children after obtaining approval from
14 the Centers for Medicare and Medicaid Services.
15 (51) To the extent permitted by federal law and as
16 allowed under s. 409.906, the agency shall provide
17 reimbursement for emergency mental health care services for
18 Medicaid recipients in crisis-stabilization facilities
19 licensed under s. 394.875 as long as those services are less
20 expensive than the same services provided in a hospital
21 setting.
22 Section 2. Section 409.91211, Florida Statutes, is
23 created to read:
24 409.91211 Medicaid managed care pilot program.--
25 (1)(a) The agency shall develop a pilot program to
26 deliver health care services specified in ss. 409.905 and
27 409.906 through capitated managed care networks under the
28 Medicaid program to persons in Medicaid fee-for-service or the
29 MediPass program, contingent upon federal approval to preserve
30 the upper-payment-limit funding mechanism for hospitals,
31 including a guarantee of a reasonable growth factor, a
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1 methodology to allow the use of a portion of these funds to
2 serve as risk pool for pilot sites, provisions to preserve the
3 state's ability to use intergovernmental transfers, and
4 provisions to protect the disproportionate share program
5 authorized pursuant to this chapter.
6 (b) The agency may include, as part of the waiver
7 request, an alternative methodology for making additional
8 Medicaid payments to hospitals based on the level of Medicaid
9 or care provided to the uninsured. Any alternative
10 methodology, however, must provide the same level of federal
11 funding as the current upper payment limit and include a
12 reasonable growth factor. Absent federal approval of a
13 reasonable growth factor, the Agency for Health Care
14 Administration shall provide the Legislature, pursuant to the
15 implementation plan provided for in section 3 of this act, the
16 following:
17 1. Based on the historical growth and current federal
18 rules governing the upper-payment-limit funding, an estimate
19 of the projected growth of funding over the next 10 years and
20 an estimate of the loss of federal funding which can be
21 attributed to the implementation of any Medicaid waiver.
22 2. An analysis showing the amount of additional
23 upper-payment-limit-funds that this state would have received
24 if it had been granted the exceptions to the
25 upper-payment-limit cap provided to other states in 42 C.F.R.
26 s. 447.272 from the 2002 through 2009 state fiscal years.
27 3. An analysis with accompanying rationale supporting
28 the implementation of any waiver that would result in
29 hospitals in this state which provide safety net services
30 receiving less federal funds relative to the federal support
31 given to similar hospitals in other states.
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1 (2) The Legislature intends for the capitated managed
2 care pilot program to:
3 (a) Provide recipients in Medicaid fee-for-service or
4 the MediPass program a comprehensive and coordinated capitated
5 managed care system for all health care services specified in
6 ss. 409.905 and 409.906.
7 (b) Stabilize Medicaid expenditures under the pilot
8 program compared to Medicaid expenditures in the pilot area
9 for the 3 years before implementation of the pilot program,
10 while ensuring:
11 1. Consumer education and choice.
12 2. Access to medically necessary services.
13 3. Coordination of preventative, acute, and long-term
14 care.
15 4. Reductions in unnecessary service utilization.
16 (c) Provide an opportunity to evaluate the feasibility
17 of statewide implementation of capitated managed care networks
18 as a replacement for the current Medicaid fee-for-service and
19 MediPass systems.
20 (3) The agency shall have the following powers,
21 duties, and responsibilities with respect to the development
22 of a pilot program to deliver all health care services
23 specified in ss. 409.905 and 409.906 in the form of capitated
24 managed care networks under the Medicaid program to persons in
25 Medicaid fee-for-service or the MediPass program:
26 (a) To define and recommend the medical and financial
27 eligibility standards for capitated managed care networks in
28 the pilot program. This paragraph does not relieve an entity
29 that qualifies as a capitated managed care network under this
30 section from any other licensure or regulatory requirements
31
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1 contained in state or federal law which would otherwise apply
2 to the entity.
3 (b) To include two geographic areas in the pilot
4 program and recommend Medicaid-eligibility categories, from
5 those specified in ss. 409.903 and 409.904, which shall be
6 included in the pilot program. One pilot program must include
7 only Broward County. A second pilot program must initially
8 include Duval County and may be expanded to Baker, Clay, and
9 Nassau Counties after the Duval County program has been
10 operating for at least 1 year. A Medicaid recipient may not be
11 enrolled in or assigned to a capitated managed care plan
12 unless the capitated managed care plan has complied with the
13 standards and credentialing requirements specified in
14 paragraph (e).
15 (c) To determine and recommend how to design the
16 managed care delivery system in order to take maximum
17 advantage of all available state and federal funds, including
18 those obtained through intergovernmental transfers, the
19 upper-payment-level funding systems, and the disproportionate
20 share program.
21 (d) To determine and recommend actuarially sound,
22 risk-adjusted capitation rates for Medicaid recipients in the
23 pilot program which can be separated to cover comprehensive
24 care, enhanced services, and catastrophic care.
25 (e) To determine and recommend policies and guidelines
26 for phasing in financial risk for approved provider service
27 networks over a 3-year period. These shall include an option
28 to pay fee-for-service rates that may include a
29 savings-settlement option for at least 2 years. This model may
30 be converted to a risk adjusted capitated rate in the third
31 year of operation.
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1 (f) To determine and recommend provisions related to
2 stop-loss requirements and the transfer of excess cost to
3 catastrophic coverage that accommodates the risks associated
4 with the development of the pilot projects.
5 (g) To determine and recommend a process to be used by
6 the Social Services Estimating Conference to determine and
7 validate the rate of growth of the per-member costs of
8 providing Medicaid services under the managed care initiative.
9 (h) To determine and recommend descriptions of the
10 eligibility assignment processes that will be used to
11 facilitate client choice while ensuring pilot projects of
12 adequate enrollment levels. These processes shall ensure that
13 pilot sites have sufficient levels of enrollment to conduct a
14 valid test of the managed care pilot project model within a
15 2-year timeframe.
16 (i) To determine and recommend program standards and
17 credentialing requirements for capitated managed care networks
18 to participate in the pilot program, including those related
19 to fiscal solvency, quality of care, and adequacy of access to
20 health care providers. This paragraph does not relieve an
21 entity that qualifies as a capitated managed care network
22 under this section from any other licensure or regulatory
23 requirements contained in state or federal law that would
24 otherwise apply to the entity. These standards must address,
25 but are not limited to:
26 1. Compliance with the accreditation requirements as
27 provided in s. 641.512.
28 2. Compliance with early and periodic screening,
29 diagnosis, and treatment screening requirements under federal
30 law.
31 3. The percentage of voluntary disenrollments.
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1 4. Immunization rates.
2 5. Standards of the National Committee for Quality
3 Assurance and other approved accrediting bodies.
4 6. Recommendations of other authoritative bodies.
5 7. Specific requirements of the Medicaid program, or
6 standards designed to specifically meet the unique needs of
7 Medicaid recipients.
8 8. Compliance with the health quality improvement
9 system as established by the agency, which incorporates
10 standards and guidelines developed by the Centers for Medicare
11 and Medicaid Services as part of the quality assurance reform
12 initiative.
13 (j) To develop and recommend a mechanism for providing
14 information to Medicaid recipients for the purpose of
15 selecting a capitated managed care plan. Examples of such
16 mechanisms may include, but are not limited to, interactive
17 information systems, mailings, mass marketing materials,
18 public information and enrollment fairs, contracted one-on-one
19 counseling services, and peer counseling services.
20 (k) To develop and recommend a system that prohibits
21 capitated managed care plans, their representatives, and
22 providers employed by or contracted with the capitated managed
23 care plans from recruiting persons eligible for or enrolled in
24 Medicaid, from providing inducements to Medicaid recipients to
25 select a particular capitated managed care plan, and from
26 prejudicing Medicaid recipients against other capitated
27 managed care plans.
28 (l) To develop and recommend a system to monitor the
29 provision of health care services in the pilot program,
30 including utilization and quality of health care services for
31 the purpose of ensuring access to medically necessary
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1 services. This system shall include an encounter
2 data-information system that collects and reports utilization
3 information. The system shall include a method for verifying
4 data integrity within the database and within the provider's
5 medical records.
6 (m) To recommend a grievance-resolution process for
7 Medicaid recipients enrolled in a capitated managed care
8 network under the pilot program modeled after the subscriber
9 assistance panel, as created in s. 408.7056. This process
10 shall include a mechanism for an expedited review of no
11 greater than 24 hours after notification of a grievance if the
12 life of a Medicaid recipient is in imminent and emergent
13 jeopardy.
14 (n) To recommend a grievance-resolution process for
15 health care providers employed by or contracted with a
16 capitated managed care network under the pilot program in
17 order to settle disputes among the provider and the managed
18 care network or the provider and the agency.
19 (o) To develop and recommend criteria to designate
20 health care providers as eligible to participate in the pilot
21 program. The agency and capitated managed care networks must
22 follow national guidelines for selecting health care
23 providers, whenever available. These criteria must include at
24 a minimum those criteria specified in s. 409.907.
25 (p) To develop and recommend health care provider
26 agreements for participation in the pilot program.
27 (q) To require that all health care providers under
28 contract with the pilot program be duly licensed in the state,
29 if such licensure is available, and meet other criteria as may
30 be established by the agency. These criteria shall include at
31 a minimum those criteria specified in s. 409.907.
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1 (r) To develop and recommend agreements with other
2 state or local governmental programs or institutions for the
3 coordination of health care to eligible individuals receiving
4 services from such programs or institutions.
5 (s) To develop and recommend a system to oversee the
6 activities of pilot program participants, health care
7 providers, capitated managed care networks, and their
8 representatives in order to prevent fraud or abuse,
9 overutilization or duplicative utilization, underutilization
10 or inappropriate denial of services, and neglect of
11 participants and to recover overpayments as appropriate. For
12 the purposes of this paragraph, the terms "abuse" and "fraud"
13 have the meanings as provided in s. 409.913. The agency must
14 refer incidents of suspected fraud, abuse, overutilization and
15 duplicative utilization, and underutilization or inappropriate
16 denial of services to the appropriate regulatory agency.
17 (t) To develop and provide actuarial and benefit
18 design analyses that indicate the effect on capitation rates
19 and benefits offered in the pilot program over a prospective
20 5-year period based on the following assumptions:
21 1. Growth in capitation rates which is limited to the
22 estimated growth rate in general revenue.
23 2. Growth in capitation rates which is limited to the
24 average growth rate over the last 3 years in per-recipient
25 Medicaid expenditures.
26 3. Growth in capitation rates which is limited to the
27 growth rate of aggregate Medicaid expenditures between the
28 2003-2004 fiscal year and the 2004-2005 fiscal year.
29 (u) To develop a mechanism to require capitated
30 managed care plans to reimburse qualified emergency service
31
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1 providers, including, but not limited to, ambulance services,
2 in accordance with ss. 409.908 and 409.9128.
3 (v) To develop a system whereby school districts
4 participating in the certified school match program pursuant
5 to ss. 409.908(21) and 1011.70 shall be reimbursed by
6 Medicaid, subject to the limitations of s. 1011.70(1), for a
7 Medicaid-eligible child participating in the services as
8 authorized in s. 1011.70, as provided for in s. 409.9071,
9 regardless of whether the child is enrolled in a capitated
10 managed care network. Capitated managed care networks must
11 make a good-faith effort to execute agreements with school
12 districts regarding the coordinated provision of services
13 authorized under s. 1011.70. County health departments
14 delivering school-based services pursuant to ss. 381.0056 and
15 381.0057 must be reimbursed by Medicaid for the federal share
16 for a Medicaid-eligible child who receives Medicaid-covered
17 services in a school setting, regardless of whether the child
18 is enrolled in a capitated managed care network. Capitated
19 managed care networks must make a good-faith effort to execute
20 agreements with county health departments regarding the
21 coordinated provision of services to a Medicaid-eligible
22 child. To ensure continuity of care for Medicaid patients, the
23 agency, the Department of Health, and the Department of
24 Education shall develop procedures for ensuring that a
25 student's capitated managed care network provider receives
26 information relating to services provided in accordance with
27 ss. 381.0056, 381.0057, 409.9071, and 1011.70.
28 (w) To develop and recommend a mechanism whereby
29 Medicaid recipients who are already enrolled in a managed care
30 plan or the MediPass program in the pilot areas shall be
31 offered the opportunity to change to capitated managed care
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1 plans on a staggered basis, as defined by the agency. All
2 Medicaid recipients shall have 30 days in which to make a
3 choice of capitated managed care plans. Those Medicaid
4 recipients who do not make a choice shall be assigned to a
5 capitated managed care plan in accordance with paragraph
6 (4)(a). To facilitate continuity of care for a Medicaid
7 recipient who is also a recipient of Supplemental Security
8 Income (SSI), prior to assigning the SSI recipient to a
9 capitated managed care plan, the agency shall determine
10 whether the SSI recipient has an ongoing relationship with a
11 provider or capitated managed care plan, and if so, the agency
12 shall assign the SSI recipient to that provider or capitated
13 managed care plan where feasible. Those SSI recipients who do
14 not have such a provider relationship shall be assigned to a
15 capitated managed care plan provider in accordance with
16 paragraph (4)(a).
17 (x) To develop and recommend a service delivery
18 alternative for children having chronic medical conditions
19 which establishes a medical home project to provide primary
20 care services to this population. The project shall provide
21 community-based primary care services that are integrated with
22 other subspecialties to meet the medical, developmental, and
23 emotional needs for children and their families. This project
24 shall include an evaluation component to determine impacts on
25 hospitalizations, length of stays, emergency room visits,
26 costs, and access to care, including specialty care and
27 patient, and family satisfaction.
28 (4)(a) A Medicaid recipient in the pilot area who is
29 not currently enrolled in a capitated managed care plan upon
30 implementation is not eligible for services as specified in
31 ss. 409.905 and 409.906, for the amount of time that the
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1 recipient does not enroll in a capitated managed care network.
2 If a Medicaid recipient has not enrolled in a capitated
3 managed care plan within 30 days after eligibility, the agency
4 shall assign the Medicaid recipient to a capitated managed
5 care plan based on the assessed needs of the recipient as
6 determined by the agency. When making assignments, the agency
7 shall take into account the following criteria:
8 1. A capitated managed care network has sufficient
9 network capacity to meet the need of members.
10 2. The capitated managed care network has previously
11 enrolled the recipient as a member, or one of the capitated
12 managed care network's primary care providers has previously
13 provided health care to the recipient.
14 3. The agency has knowledge that the member has
15 previously expressed a preference for a particular capitated
16 managed care network as indicated by Medicaid fee-for-service
17 claims data, but has failed to make a choice.
18 4. The capitated managed care network's primary care
19 providers are geographically accessible to the recipient's
20 residence.
21 (b) When more than one capitated managed care network
22 provider meets the criteria specified in paragraph (3)(j), the
23 agency shall make recipient assignments consecutively by
24 family unit.
25 (c) The agency may not engage in practices that are
26 designed to favor one capitated managed care plan over another
27 or that are designed to influence Medicaid recipients to
28 enroll in a particular capitated managed care network in order
29 to strengthen its particular fiscal viability.
30 (d) After a recipient has made a selection or has been
31 enrolled in a capitated managed care network, the recipient
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1 shall have 90 days in which to voluntarily disenroll and
2 select another capitated managed care network. After 90 days,
3 no further changes may be made except for cause. Cause shall
4 include, but not be limited to, poor quality of care, lack of
5 access to necessary specialty services, an unreasonable delay
6 or denial of service, inordinate or inappropriate changes of
7 primary care providers, service access impairments due to
8 significant changes in the geographic location of services, or
9 fraudulent enrollment. The agency may require a recipient to
10 use the capitated managed care network's grievance process as
11 specified in paragraph (3)(h) prior to the agency's
12 determination of cause, except in cases in which immediate
13 risk of permanent damage to the recipient's health is alleged.
14 The grievance process, when used, must be completed in time to
15 permit the recipient to disenroll no later than the first day
16 of the second month after the month the disenrollment request
17 was made. If the capitated managed care network, as a result
18 of the grievance process, approves an enrollee's request to
19 disenroll, the agency is not required to make a determination
20 in the case. The agency must make a determination and take
21 final action on a recipient's request so that disenrollment
22 occurs no later than the first day of the second month after
23 the month the request was made. If the agency fails to act
24 within the specified timeframe, the recipient's request to
25 disenroll is deemed to be approved as of the date agency
26 action was required. Recipients who disagree with the agency's
27 finding that cause does not exist for disenrollment shall be
28 advised of their right to pursue a Medicaid fair hearing to
29 dispute the agency's finding.
30 (e) The agency shall apply for federal waivers from
31 the Centers for Medicare and Medicaid Services to lock
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1 eligible Medicaid recipients into a capitated managed care
2 network for 12 months after an open enrollment period. After
3 12 months of enrollment, a recipient may select another
4 capitated managed care network. However, nothing shall prevent
5 a Medicaid recipient from changing primary care providers
6 within the capitated managed care network during the 12-month
7 period.
8 (f) The agency shall develop and submit for approval
9 applications for waivers of applicable federal laws and
10 regulations as necessary to implement the capitated managed
11 care pilot program as defined in this section. The agency
12 shall post all waiver applications under this section on its
13 Internet website 30 days before submitting the applications to
14 the United States Centers for Medicare and Medicaid Services.
15 Notwithstanding s. 409.912(11), all waiver applications shall
16 be submitted to the Senate and House of Representatives Select
17 Committees on Medicaid Reform to be approved for submission.
18 All waivers submitted to and approved by the United States
19 Centers for Medicare and Medicaid Services under this section
20 must be submitted to the Senate and House of Representatives
21 Select Committees on Medicaid Reform in order to obtain
22 authority for implementation as required by s. 409.912(11)
23 before program implementation. The Select Committees on
24 Medicaid Reform shall recommend whether to approve the
25 implementation of the waivers to the Legislature or to the
26 Legislative Budget Commission if the Legislature is not in
27 regular or special session.
28 (5) Upon review and approval of the applications for
29 waivers of applicable federal laws and regulations to
30 implement the pilot project by the Legislature, the Agency for
31 Health Care Administration may initiate adoption of rules
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1 pursuant to ss. 120.536(1) and 120.54 to implement and
2 administer the managed care pilot program as provided in this
3 section.
4 Section 3. The Agency for Health Care Administration
5 shall submit an implementation plan for the managed care pilot
6 program created under section 409.91211, Florida Statutes, to
7 the Senate and House of Representatives Select Committees on
8 Medicaid Reform upon approval of all waivers of federal laws
9 and regulations by the United States Centers for Medicare and
10 Medicaid Services which are necessary to implement the managed
11 care pilot program. Based on the review of the implementation
12 plan, the Senate and House Select Committees on Medicaid
13 Reform shall determine whether to recommend implementation of
14 the pilot program for approval by the Legislature or by the
15 Legislative Budget Commission if the Legislature is not in
16 regular or special session. The implementation plan must
17 include all information specified in section 409.91211(3) and
18 (4), Florida Statutes. The plan must contain a detailed
19 timeline for implementation. The plan must contain budgetary
20 projections of the effect of the pilot program on the total
21 Medicaid budget for the 2006-2007 through 2009-2010 fiscal
22 years.
23 Section 4. The Office of Program Policy Analysis and
24 Government Accountability, in consultation with the Auditor
25 General, shall comprehensively evaluate the two managed care
26 pilot programs created under section 409.91211, Florida
27 Statutes. The evaluation shall begin with the implementation
28 of the managed care model in the pilot areas and continue for
29 24 months after the two pilot programs have enrolled Medicaid
30 recipients and started providing health care services. The
31 evaluation must include assessments of cost savings; consumer
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1 education, choice, and access to services; coordination of
2 care; and quality of care by each eligibility category and
3 managed care plan in each pilot site. The evaluation must
4 describe administrative or legal barriers to the
5 implementation and operation of each pilot program and include
6 recommendations regarding statewide expansion of the managed
7 care pilot programs. The office shall submit an evaluation
8 report to the Governor, the President of the Senate, and the
9 Speaker of the House of Representatives no later than June 30,
10 2008. The managed care pilot program may not be expanded to
11 any additional counties that are not identified in this
12 section without the authorization of the Legislature.
13 Section 5. Paragraphs (a) and (j) of subsection (2) of
14 section 409.9122, Florida Statutes, are amended to read:
15 409.9122 Mandatory Medicaid managed care enrollment;
16 programs and procedures.--
17 (2)(a) The agency shall enroll in a managed care plan
18 or MediPass all Medicaid recipients, except those Medicaid
19 recipients who are: in an institution; enrolled in the
20 Medicaid medically needy program; or eligible for both
21 Medicaid and Medicare. Upon enrollment, individuals will be
22 able to change their managed care option during the 90-day opt
23 out period required by federal Medicaid regulations. The
24 agency is authorized to seek the necessary Medicaid state plan
25 amendment to implement this policy. However, to the extent
26 permitted by federal law, the agency may enroll in a managed
27 care plan or MediPass a Medicaid recipient who is exempt from
28 mandatory managed care enrollment, provided that:
29 1. The recipient's decision to enroll in a managed
30 care plan or MediPass is voluntary;
31
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1 2. If the recipient chooses to enroll in a managed
2 care plan, the agency has determined that the managed care
3 plan provides specific programs and services which address the
4 special health needs of the recipient; and
5 3. The agency receives any necessary waivers from the
6 federal Centers for Medicare and Medicaid Services Health Care
7 Financing Administration.
8
9 The agency shall develop rules to establish policies by which
10 exceptions to the mandatory managed care enrollment
11 requirement may be made on a case-by-case basis. The rules
12 shall include the specific criteria to be applied when making
13 a determination as to whether to exempt a recipient from
14 mandatory enrollment in a managed care plan or MediPass.
15 School districts participating in the certified school match
16 program pursuant to ss. 409.908(21) and 1011.70 shall be
17 reimbursed by Medicaid, subject to the limitations of s.
18 1011.70(1), for a Medicaid-eligible child participating in the
19 services as authorized in s. 1011.70, as provided for in s.
20 409.9071, regardless of whether the child is enrolled in
21 MediPass or a managed care plan. Managed care plans shall make
22 a good faith effort to execute agreements with school
23 districts regarding the coordinated provision of services
24 authorized under s. 1011.70. County health departments
25 delivering school-based services pursuant to ss. 381.0056 and
26 381.0057 shall be reimbursed by Medicaid for the federal share
27 for a Medicaid-eligible child who receives Medicaid-covered
28 services in a school setting, regardless of whether the child
29 is enrolled in MediPass or a managed care plan. Managed care
30 plans shall make a good faith effort to execute agreements
31 with county health departments regarding the coordinated
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1 provision of services to a Medicaid-eligible child. To ensure
2 continuity of care for Medicaid patients, the agency, the
3 Department of Health, and the Department of Education shall
4 develop procedures for ensuring that a student's managed care
5 plan or MediPass provider receives information relating to
6 services provided in accordance with ss. 381.0056, 381.0057,
7 409.9071, and 1011.70.
8 (j) The agency shall apply for a federal waiver from
9 the Centers for Medicare and Medicaid Services Health Care
10 Financing Administration to lock eligible Medicaid recipients
11 into a managed care plan or MediPass for 12 months after an
12 open enrollment period. After 12 months' enrollment, a
13 recipient may select another managed care plan or MediPass
14 provider. However, nothing shall prevent a Medicaid recipient
15 from changing primary care providers within the managed care
16 plan or MediPass program during the 12-month period.
17 Section 6. Subsection (2) of section 409.913, Florida
18 Statutes, is amended, and subsection (36) is added to that
19 section, to read:
20 409.913 Oversight of the integrity of the Medicaid
21 program.--The agency shall operate a program to oversee the
22 activities of Florida Medicaid recipients, and providers and
23 their representatives, to ensure that fraudulent and abusive
24 behavior and neglect of recipients occur to the minimum extent
25 possible, and to recover overpayments and impose sanctions as
26 appropriate. Beginning January 1, 2003, and each year
27 thereafter, the agency and the Medicaid Fraud Control Unit of
28 the Department of Legal Affairs shall submit a joint report to
29 the Legislature documenting the effectiveness of the state's
30 efforts to control Medicaid fraud and abuse and to recover
31 Medicaid overpayments during the previous fiscal year. The
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1 report must describe the number of cases opened and
2 investigated each year; the sources of the cases opened; the
3 disposition of the cases closed each year; the amount of
4 overpayments alleged in preliminary and final audit letters;
5 the number and amount of fines or penalties imposed; any
6 reductions in overpayment amounts negotiated in settlement
7 agreements or by other means; the amount of final agency
8 determinations of overpayments; the amount deducted from
9 federal claiming as a result of overpayments; the amount of
10 overpayments recovered each year; the amount of cost of
11 investigation recovered each year; the average length of time
12 to collect from the time the case was opened until the
13 overpayment is paid in full; the amount determined as
14 uncollectible and the portion of the uncollectible amount
15 subsequently reclaimed from the Federal Government; the number
16 of providers, by type, that are terminated from participation
17 in the Medicaid program as a result of fraud and abuse; and
18 all costs associated with discovering and prosecuting cases of
19 Medicaid overpayments and making recoveries in such cases. The
20 report must also document actions taken to prevent
21 overpayments and the number of providers prevented from
22 enrolling in or reenrolling in the Medicaid program as a
23 result of documented Medicaid fraud and abuse and must
24 recommend changes necessary to prevent or recover
25 overpayments.
26 (2) The agency shall conduct, or cause to be conducted
27 by contract or otherwise, reviews, investigations, analyses,
28 audits, or any combination thereof, to determine possible
29 fraud, abuse, overpayment, or recipient neglect in the
30 Medicaid program and shall report the findings of any
31
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1 overpayments in audit reports as appropriate. At least 5
2 percent of all audits shall be conducted on a random basis.
3 (36) The agency shall provide to each Medicaid
4 recipient or his or her representative an explanation of
5 benefits in the form of a letter that is mailed to the most
6 recent address of the recipient on the record with the
7 Department of Children and Family Services. The explanation of
8 benefits must include the patient's name, the name of the
9 health care provider and the address of the location where the
10 service was provided, a description of all services billed to
11 Medicaid in terminology that should be understood by a
12 reasonable person, and information on how to report
13 inappropriate or incorrect billing to the agency or other law
14 enforcement entities for review or investigation.
15 Section 7. The Agency for Health Care Administration
16 shall submit to the Legislature by December 15, 2005, a report
17 on the legal and administrative barriers to enforcing section
18 409.9081, Florida Statutes. The report must describe how many
19 services require copayments, which providers collect
20 copayments, and the total amount of copayments collected from
21 recipients for all services required under section 409.9081,
22 Florida Statutes, by provider type for the 2001-2002 through
23 2004-2005 fiscal years. The agency shall recommend a mechanism
24 to enforce the requirement for Medicaid recipients to make
25 copayments which does not shift the copayment amount to the
26 provider. The agency shall also identify the federal or state
27 laws or regulations that permit Medicaid recipients to declare
28 impoverishment in order to avoid paying the copayment and
29 extent to which these statements of impoverishment are
30 verified. If claims of impoverishment are not currently
31 verified, the agency shall recommend a system for such
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1 verification. The report must also identify any other
2 cost-sharing measures that could be imposed on Medicaid
3 recipients.
4 Section 8. The Agency for Health Care Administration
5 shall submit to the Legislature by January 15, 2006,
6 recommendations to ensure that Medicaid is the payer of last
7 resort as required by section 409.910, Florida Statutes. The
8 report must identify the public and private entities that are
9 liable for primary payment of health care services and
10 recommend methods to improve enforcement of third-party
11 liability responsibility and repayment of benefits to the
12 state Medicaid program. The report must estimate the potential
13 recoveries that may be achieved through third-party liability
14 efforts if administrative and legal barriers are removed. The
15 report must recommend whether modifications to the agency's
16 contingency-fee contract for third-party liability could
17 enhance third-party liability for benefits provided to
18 Medicaid recipients.
19 Section 9. The Agency for Health Care Administration
20 shall study provider pay-for-performance systems developed by
21 the United States Centers for Medicare and Medicaid Services
22 for use in the federal Medicare system and those developed by
23 private health insurance market to determine if these systems
24 can be used in this state's Medicaid program to improve the
25 quality of care while reducing inappropriate utilization. The
26 study must include a cost-benefit analysis to determine the
27 fiscal viability of introducing a pay-for-performance system
28 in this state's Medicaid program. The study must identify any
29 waivers of federal laws or regulations which would be
30 necessary to implement a pay-for-performance system and any
31 changes in provider contracts which are necessary to implement
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1 this type of incentive system. The agency shall submit a
2 report on provider pay-for-performance systems to the
3 Legislature by January 15, 2006.
4 Section 10. By January 15, 2006, the Office of Program
5 Policy Analysis and Government Accountability shall submit to
6 the Legislature a study of the nursing home diversion programs
7 of the Department of Elderly Affairs. The study may be
8 conducted by Office of Program Policy Analysis and Government
9 Accountability staff or by a consultant obtained through a
10 competitive bid. The study must use a statistically-valid
11 methodology to assess the percent of persons over a period of
12 2 years in the diversion program who would have entered a
13 nursing home without the diversion services, which services
14 are most frequently used, and which services are least
15 frequently used in the diversion programs. The study must
16 determine whether the diversion programs are cost-effective or
17 are an expansion of the Medicaid program because persons in
18 the program would not have entered a nursing home within a
19 2-year period regardless of the availability of the diversion
20 programs.
21 Section 11. The Agency for Health Care Administration
22 shall conduct an analysis of potential costs savings achieved
23 through contracting with a multistate purchasing pool approved
24 by the federal Centers for Medicare and Medicaid Services for
25 drug-rebate administration, including, but not limited to,
26 calculating rebate amounts, invoicing manufacturers,
27 negotiating prices with manufacturers, negotiating disputes
28 with manufacturers, and maintaining a database of rebate
29 collections. The agency must submit to the Legislature its
30 analysis of this state's participation in multistate
31 purchasing pools by December 1, 2005.
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1 Section 12. The Agency for Health Care Administration
2 shall identify how many individuals in the long-term care
3 diversion programs who receive care at home have a
4 patient-responsibility payment associated with their
5 participation in the diversion program. If no system is
6 available to assess this information, the agency shall
7 determine the cost of creating a system to identify and
8 collect these payments and whether the cost of developing a
9 system for this purpose is offset by the amount of
10 patient-responsibility payments which could be collected with
11 the system. The agency shall report this information to the
12 Legislature by December 1, 2005.
13 Section 13. The Office of Program Policy Analysis and
14 Government Accountability shall conduct a study of state
15 programs that allow non-Medicaid eligible persons under a
16 certain income level to buy into the Medicaid program as if it
17 was private insurance. The study shall examine Medicaid buy-in
18 programs in other states to determine if there are any models
19 that can be implemented in Florida which would provide access
20 to uninsured Floridians and what effect this program would
21 have on Medicaid expenditures based on the experience of
22 similar states. The study must also examine whether the
23 Medically Needy program could be redesigned to be a Medicaid
24 buy-in program. The study must be submitted to the Legislature
25 by January 1, 2006.
26 Section 14. The sum of $ in nonrecurring
27 funds is appropriated from the General Revenue Fund to the
28 Agency for Health Care Administration for the purpose for
29 developing infrastructure and administrative resources
30 necessary to develop the capitated managed care pilot program
31
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1 established in section 2 of this act during the 2005-2006
2 fiscal year.
3 Section 15. The sum of $ in nonrecurring
4 funds is appropriated from the General Revenue Fund to the
5 Agency for Health Care Administration for the purpose for
6 developing a managed care encounter data information system
7 during the 2005-2006 fiscal year.
8 Section 16. This act shall take effect July 1, 2005.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 838
3
4 The committee substitute for SB 838 contains both short and
long-term Medicaid reform activities, pilot projects, and
5 studies designed to improve efficiency and help achieve
sustainable growth in the Medicaid program.
6
-Requires the Agency for Health Care Administration (AHCA) to
7 contract with a vendor that will identify those providers that
are utilization outliers.
8
-Authorizes AHCA to use more single source contracting to
9 reduce costs.
10 -Requires AHCA to determine if purchasing medical equipment is
less expensive than rental.
11
-Requires any contract previously awarded to a provider
12 service network operated by a hospital to remain in effect for
three years from the current contract expiration date; and
13 provides a definition for a provider service network.
14 -Directs AHCA to redesign and implement the capitated,
integrated long-term care system (Senior Health Choices) in
15 the pilot area of Orange, Osceola, Lake, and Seminole
Counties.
16
-Requires AHCA to consider increasing rates for certain
17 services if it reduces costs in other parts of the Medicaid
program.
18
-Requires the Comprehensive Assessment and Review for
19 Long-term Care Services (CARES) staff to find ways to identify
patients in nursing homes who can continue care under
20 Medicare.
21 -Requires AHCA to contract with an entity to develop a
real-time utilization tracking system or electronic medical
22 record for Medicaid recipients.
23 -Requires the expansion of disease management programs through
pilot projects.
24
-Requires AHCA to provide emergency department diversion
25 programs.
26 -Changes the Medicaid prescription drug cost control program
to reduce costs, waste, and fraud, while improving recipient
27 safety.
28 -Allows mental health crisis care to be provided in a
non-hospital setting if it is less costly.
29
-Authorizes AHCA to continue developing a plan to pilot the
30 Governor's proposed capitated managed care system to replace
the fee-for-service system in Medicaid, contingent upon
31 approval of a waiver that includes a guarantee of a reasonable
growth factor for the upper-payment-level funding mechanism
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1 and other governmental transfers.
2 -Requires AHCA to develop an implementation plan with all
specified elements to be submitted to the Senate and House
3 Select Committees on Medicaid Reform for consideration and
recommendation to the Legislature for implementation approval.
4
-Requires an evaluation of the pilot projects to be conducted
5 by OPPAGA and the Auditor General and a report provided to the
Governor and the Legislature no later than June 30, 2008, to
6 consider statewide expansion.
7 -Requires Medicaid recipients in the MediPass program to have
prior authorization for any non-emergency related service.
8
-Requires that at least 5 percent of Medicaid audits to detect
9 Medicaid funds lost to fraud and abuse be conducted on a
random basis.
10
-Requires that Medicaid recipients be provided explanations of
11 benefits.
12 -Requires AHCA to study the legal and program barriers to
enforcing copayments in the Medicaid program.
13
-Requires AHCA to develop recommendations to improve
14 third-party liability recoveries.
15 -Requires AHCA to study ways to give financial incentives to
physicians and other providers to reduce inappropriate
16 utilization.
17 -Requires OPPAGA to confirm the value of nursing home
diversion programs.
18
-Requires AHCA to conduct an analysis of joining a multi-state
19 drug purchasing pool.
20 -Requires AHCA to explain if there is no mechanism for
collecting the patient responsibility payments of persons in
21 the diversion programs.
22 -Requires OPPAGA to conduct a study of Medicaid buy-in
programs.
23
-Provides an unspecified amount of non-recurring General
24 Revenue funds to AHCA for the purpose of developing the
administrative infrastructure to pilot the managed care pilot
25 project and for the purpose of developing a managed care
encounter data system.
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