Senate Bill sb0838c2
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Florida Senate - 2005 CS for CS for SB 838
By the Committees on Ways and Means; Health Care; and Senators
Peaden, Atwater, Campbell, Carlton, Rich and Saunders
576-2236-05
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 contracting to monitor and evaluate clinical
19 practice patterns; providing an appropriation
20 for the purpose of contracting for the database
21 to review real-time utilization of Medicaid
22 services; providing an appropriation for the
23 purpose of developing infrastructure and
24 administrative resources necessary to implement
25 the pilot project as created in s. 409.91211,
26 F.S.; providing an appropriation for developing
27 an encounter data system for Medicaid managed
28 care plans; providing an effective date.
29
30 Be It Enacted by the Legislature of the State of Florida:
31
4
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1 Section 1. Section 409.912, Florida Statutes, is
2 amended to read:
3 409.912 Cost-effective purchasing of health care.--The
4 agency shall purchase goods and services for Medicaid
5 recipients in the most cost-effective manner consistent with
6 the delivery of quality medical care. To ensure that medical
7 services are effectively utilized, the agency may, in any
8 case, require a confirmation or second physician's opinion of
9 the correct diagnosis for purposes of authorizing future
10 services under the Medicaid program. This section does not
11 restrict access to emergency services or poststabilization
12 care services as defined in 42 C.F.R. part 438.114. Such
13 confirmation or second opinion shall be rendered in a manner
14 approved by the agency. The agency shall maximize the use of
15 prepaid per capita and prepaid aggregate fixed-sum basis
16 services when appropriate and other alternative service
17 delivery and reimbursement methodologies, including
18 competitive bidding pursuant to s. 287.057, designed to
19 facilitate the cost-effective purchase of a case-managed
20 continuum of care. The agency shall also require providers to
21 minimize the exposure of recipients to the need for acute
22 inpatient, custodial, and other institutional care and the
23 inappropriate or unnecessary use of high-cost services. The
24 agency shall contract with a vendor to monitor and evaluate
25 the clinical practice patterns of providers in order to
26 identify trends that are outside the normal practice patterns
27 of a provider's professional peers or the national guidelines
28 of a provider's professional association. The vendor must be
29 able to provide information and counseling to a provider whose
30 practice patterns are outside the norms, in consultation with
31 the agency, to improve patient care and reduce inappropriate
5
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1 utilization. The agency may mandate prior authorization, drug
2 therapy management, or disease management participation for
3 certain populations of Medicaid beneficiaries, certain drug
4 classes, or particular drugs to prevent fraud, abuse, overuse,
5 and possible dangerous drug interactions. The Pharmaceutical
6 and Therapeutics Committee shall make recommendations to the
7 agency on drugs for which prior authorization is required. The
8 agency shall inform the Pharmaceutical and Therapeutics
9 Committee of its decisions regarding drugs subject to prior
10 authorization. The agency is authorized to limit the entities
11 it contracts with or enrolls as Medicaid providers by
12 developing a provider network through provider credentialing.
13 The agency may competitively bid single-source-provider
14 contracts if procurement of goods or services results in
15 demonstrated cost savings to the state without limiting access
16 to care. The agency may limit its network based on the
17 assessment of beneficiary access to care, provider
18 availability, provider quality standards, time and distance
19 standards for access to care, the cultural competence of the
20 provider network, demographic characteristics of Medicaid
21 beneficiaries, practice and provider-to-beneficiary standards,
22 appointment wait times, beneficiary use of services, provider
23 turnover, provider profiling, provider licensure history,
24 previous program integrity investigations and findings, peer
25 review, provider Medicaid policy and billing compliance
26 records, clinical and medical record audits, and other
27 factors. Providers shall not be entitled to enrollment in the
28 Medicaid provider network. The agency shall determine
29 instances in which allowing Medicaid beneficiaries to purchase
30 durable medical equipment and other goods is less expensive to
31 the Medicaid program than long-term rental of the equipment or
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1 goods. The agency may establish rules to facilitate purchases
2 in lieu of long-term rentals in order to protect against fraud
3 and abuse in the Medicaid program as defined in s. 409.913.
4 The agency may is authorized to seek federal waivers necessary
5 to administer these policies implement this policy.
6 (1) The agency shall work with the Department of
7 Children and Family Services to ensure access of children and
8 families in the child protection system to needed and
9 appropriate mental health and substance abuse services.
10 (2) The agency may enter into agreements with
11 appropriate agents of other state agencies or of any agency of
12 the Federal Government and accept such duties in respect to
13 social welfare or public aid as may be necessary to implement
14 the provisions of Title XIX of the Social Security Act and ss.
15 409.901-409.920.
16 (3) The agency may contract with health maintenance
17 organizations certified pursuant to part I of chapter 641 for
18 the provision of services to recipients.
19 (4) The agency may contract with:
20 (a) An entity that provides no prepaid health care
21 services other than Medicaid services under contract with the
22 agency and which is owned and operated by a county, county
23 health department, or county-owned and operated hospital to
24 provide health care services on a prepaid or fixed-sum basis
25 to recipients, which entity may provide such prepaid services
26 either directly or through arrangements with other providers.
27 Such prepaid health care services entities must be licensed
28 under parts I and III by January 1, 1998, and until then are
29 exempt from the provisions of part I of chapter 641. An entity
30 recognized under this paragraph which demonstrates to the
31 satisfaction of the Office of Insurance Regulation of the
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1 Financial Services Commission that it is backed by the full
2 faith and credit of the county in which it is located may be
3 exempted from s. 641.225.
4 (b) An entity that is providing comprehensive
5 behavioral health care services to certain Medicaid recipients
6 through a capitated, prepaid arrangement pursuant to the
7 federal waiver provided for by s. 409.905(5). Such an entity
8 must be licensed under chapter 624, chapter 636, or chapter
9 641 and must possess the clinical systems and operational
10 competence to manage risk and provide comprehensive behavioral
11 health care to Medicaid recipients. As used in this paragraph,
12 the term "comprehensive behavioral health care services" means
13 covered mental health and substance abuse treatment services
14 that are available to Medicaid recipients. The secretary of
15 the Department of Children and Family Services shall approve
16 provisions of procurements related to children in the
17 department's care or custody prior to enrolling such children
18 in a prepaid behavioral health plan. Any contract awarded
19 under this paragraph must be competitively procured. In
20 developing the behavioral health care prepaid plan procurement
21 document, the agency shall ensure that the procurement
22 document requires the contractor to develop and implement a
23 plan to ensure compliance with s. 394.4574 related to services
24 provided to residents of licensed assisted living facilities
25 that hold a limited mental health license. Except as provided
26 in subparagraph 8., the agency shall seek federal approval to
27 contract with a single entity meeting these requirements to
28 provide comprehensive behavioral health care services to all
29 Medicaid recipients not enrolled in a managed care plan in an
30 AHCA area. Each entity must offer sufficient choice of
31 providers in its network to ensure recipient access to care
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1 and the opportunity to select a provider with whom they are
2 satisfied. The network shall include all public mental health
3 hospitals. To ensure unimpaired access to behavioral health
4 care services by Medicaid recipients, all contracts issued
5 pursuant to this paragraph shall require 80 percent of the
6 capitation paid to the managed care plan, including health
7 maintenance organizations, to be expended for the provision of
8 behavioral health care services. In the event the managed care
9 plan expends less than 80 percent of the capitation paid
10 pursuant to this paragraph for the provision of behavioral
11 health care services, the difference shall be returned to the
12 agency. The agency shall provide the managed care plan with a
13 certification letter indicating the amount of capitation paid
14 during each calendar year for the provision of behavioral
15 health care services pursuant to this section. The agency may
16 reimburse for substance abuse treatment services on a
17 fee-for-service basis until the agency finds that adequate
18 funds are available for capitated, prepaid arrangements.
19 1. By January 1, 2001, the agency shall modify the
20 contracts with the entities providing comprehensive inpatient
21 and outpatient mental health care services to Medicaid
22 recipients in Hillsborough, Highlands, Hardee, Manatee, and
23 Polk Counties, to include substance abuse treatment services.
24 2. By July 1, 2003, the agency and the Department of
25 Children and Family Services shall execute a written agreement
26 that requires collaboration and joint development of all
27 policy, budgets, procurement documents, contracts, and
28 monitoring plans that have an impact on the state and Medicaid
29 community mental health and targeted case management programs.
30 3. Except as provided in subparagraph 8., by July 1,
31 2006, the agency and the Department of Children and Family
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1 Services shall contract with managed care entities in each
2 AHCA area except area 6 or arrange to provide comprehensive
3 inpatient and outpatient mental health and substance abuse
4 services through capitated prepaid arrangements to all
5 Medicaid recipients who are eligible to participate in such
6 plans under federal law and regulation. In AHCA areas where
7 eligible individuals number less than 150,000, the agency
8 shall contract with a single managed care plan to provide
9 comprehensive behavioral health services to all recipients who
10 are not enrolled in a Medicaid health maintenance
11 organization. The agency may contract with more than one
12 comprehensive behavioral health provider to provide care to
13 recipients who are not enrolled in a Medicaid health
14 maintenance organization in AHCA areas where the eligible
15 population exceeds 150,000. Contracts for comprehensive
16 behavioral health providers awarded pursuant to this section
17 shall be competitively procured. Both for-profit and
18 not-for-profit corporations shall be eligible to compete.
19 Managed care plans contracting with the agency under
20 subsection (3) shall provide and receive payment for the same
21 comprehensive behavioral health benefits as provided in AHCA
22 rules, including handbooks incorporated by reference.
23 4. By October 1, 2003, the agency and the department
24 shall submit a plan to the Governor, the President of the
25 Senate, and the Speaker of the House of Representatives which
26 provides for the full implementation of capitated prepaid
27 behavioral health care in all areas of the state.
28 a. Implementation shall begin in 2003 in those AHCA
29 areas of the state where the agency is able to establish
30 sufficient capitation rates.
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1 b. If the agency determines that the proposed
2 capitation rate in any area is insufficient to provide
3 appropriate services, the agency may adjust the capitation
4 rate to ensure that care will be available. The agency and the
5 department may use existing general revenue to address any
6 additional required match but may not over-obligate existing
7 funds on an annualized basis.
8 c. Subject to any limitations provided for in the
9 General Appropriations Act, the agency, in compliance with
10 appropriate federal authorization, shall develop policies and
11 procedures that allow for certification of local and state
12 funds.
13 5. Children residing in a statewide inpatient
14 psychiatric program, or in a Department of Juvenile Justice or
15 a Department of Children and Family Services residential
16 program approved as a Medicaid behavioral health overlay
17 services provider shall not be included in a behavioral health
18 care prepaid health plan or any other Medicaid managed care
19 plan pursuant to this paragraph.
20 6. In converting to a prepaid system of delivery, the
21 agency shall in its procurement document require an entity
22 providing only comprehensive behavioral health care services
23 to prevent the displacement of indigent care patients by
24 enrollees in the Medicaid prepaid health plan providing
25 behavioral health care services from facilities receiving
26 state funding to provide indigent behavioral health care, to
27 facilities licensed under chapter 395 which do not receive
28 state funding for indigent behavioral health care, or
29 reimburse the unsubsidized facility for the cost of behavioral
30 health care provided to the displaced indigent care patient.
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1 7. Traditional community mental health providers under
2 contract with the Department of Children and Family Services
3 pursuant to part IV of chapter 394, child welfare providers
4 under contract with the Department of Children and Family
5 Services in areas 1 and 6, and inpatient mental health
6 providers licensed pursuant to chapter 395 must be offered an
7 opportunity to accept or decline a contract to participate in
8 any provider network for prepaid behavioral health services.
9 8. For fiscal year 2004-2005, all Medicaid eligible
10 children, except children in areas 1 and 6, whose cases are
11 open for child welfare services in the HomeSafeNet system,
12 shall be enrolled in MediPass or in Medicaid fee-for-service
13 and all their behavioral health care services including
14 inpatient, outpatient psychiatric, community mental health,
15 and case management shall be reimbursed on a fee-for-service
16 basis. Beginning July 1, 2005, such children, who are open for
17 child welfare services in the HomeSafeNet system, shall
18 receive their behavioral health care services through a
19 specialty prepaid plan operated by community-based lead
20 agencies either through a single agency or formal agreements
21 among several agencies. The specialty prepaid plan must result
22 in savings to the state comparable to savings achieved in
23 other Medicaid managed care and prepaid programs. Such plan
24 must provide mechanisms to maximize state and local revenues.
25 The specialty prepaid plan shall be developed by the agency
26 and the Department of Children and Family Services. The agency
27 is authorized to seek any federal waivers to implement this
28 initiative.
29 (c) A federally qualified health center or an entity
30 owned by one or more federally qualified health centers or an
31 entity owned by other migrant and community health centers
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1 receiving non-Medicaid financial support from the Federal
2 Government to provide health care services on a prepaid or
3 fixed-sum basis to recipients. Such prepaid health care
4 services entity must be licensed under parts I and III of
5 chapter 641, but shall be prohibited from serving Medicaid
6 recipients on a prepaid basis, until such licensure has been
7 obtained. However, such an entity is exempt from s. 641.225 if
8 the entity meets the requirements specified in subsections
9 (17) and (18).
10 (d) A provider service network may be reimbursed on a
11 fee-for-service or prepaid basis. A provider service network
12 which is reimbursed by the agency on a prepaid basis shall be
13 exempt from parts I and III of chapter 641, but must meet
14 appropriate financial reserve, quality assurance, and patient
15 rights requirements as established by the agency. The agency
16 shall award contracts on a competitive bid basis and shall
17 select bidders based upon price and quality of care. Medicaid
18 recipients assigned to a demonstration project shall be chosen
19 equally from those who would otherwise have been assigned to
20 prepaid plans and MediPass. The agency is authorized to seek
21 federal Medicaid waivers as necessary to implement the
22 provisions of this section. Any contract previously awarded to
23 a provider service network operated by a hospital pursuant to
24 this subsection shall remain in effect for a period of 3 years
25 following the current contract-expiration date, regardless of
26 any contractual provisions to the contrary. A provider service
27 network is a network established or organized and operated by
28 a health care provider, or group of affiliated health care
29 providers, which provides a substantial proportion of the
30 health care items and services under a contract directly
31 through the provider or affiliated group of providers and may
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1 make arrangements with physicians or other health care
2 professionals, health care institutions, or any combination of
3 such individuals or institutions to assume all or part of the
4 financial risk on a prospective basis for the provision of
5 basic health services by the physicians, by other health
6 professionals, or through the institutions. The health care
7 providers must have a controlling interest in the governing
8 body of the provider service network organization.
9 (e) An entity that provides only comprehensive
10 behavioral health care services to certain Medicaid recipients
11 through an administrative services organization agreement.
12 Such an entity must possess the clinical systems and
13 operational competence to provide comprehensive health care to
14 Medicaid recipients. As used in this paragraph, the term
15 "comprehensive behavioral health care services" means covered
16 mental health and substance abuse treatment services that are
17 available to Medicaid recipients. Any contract awarded under
18 this paragraph must be competitively procured. The agency must
19 ensure that Medicaid recipients have available the choice of
20 at least two managed care plans for their behavioral health
21 care services.
22 (f) An entity that provides in-home physician services
23 to test the cost-effectiveness of enhanced home-based medical
24 care to Medicaid recipients with degenerative neurological
25 diseases and other diseases or disabling conditions associated
26 with high costs to Medicaid. The program shall be designed to
27 serve very disabled persons and to reduce Medicaid reimbursed
28 costs for inpatient, outpatient, and emergency department
29 services. The agency shall contract with vendors on a
30 risk-sharing basis.
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1 (g) Children's provider networks that provide care
2 coordination and care management for Medicaid-eligible
3 pediatric patients, primary care, authorization of specialty
4 care, and other urgent and emergency care through organized
5 providers designed to service Medicaid eligibles under age 18
6 and pediatric emergency departments' diversion programs. The
7 networks shall provide after-hour operations, including
8 evening and weekend hours, to promote, when appropriate, the
9 use of the children's networks rather than hospital emergency
10 departments.
11 (h) An entity authorized in s. 430.205 to contract
12 with the agency and the Department of Elderly Affairs to
13 provide health care and social services on a prepaid or
14 fixed-sum basis to elderly recipients. Such prepaid health
15 care services entities are exempt from the provisions of part
16 I of chapter 641 for the first 3 years of operation. An entity
17 recognized under this paragraph that demonstrates to the
18 satisfaction of the Office of Insurance Regulation that it is
19 backed by the full faith and credit of one or more counties in
20 which it operates may be exempted from s. 641.225.
21 (i) A Children's Medical Services Network, as defined
22 in s. 391.021.
23 (5) By December 1, 2005, the Agency for Health Care
24 Administration, in partnership with the Department of Elderly
25 Affairs, shall create an integrated, fixed-payment delivery
26 system for Medicaid recipients who are 60 years of age or
27 older. Eligible Medicaid recipients may participate in the
28 integrated system on a voluntary basis. The program must
29 transfer all Medicaid services for eligible elderly
30 individuals who choose to participate into an integrated-care
31 management model designed to serve Medicaid recipients in the
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1 community. The program must combine all funding for Medicaid
2 services provided to individuals 60 years of age or older into
3 the integrated system, including funds for Medicaid home and
4 community-based waiver services; all Medicaid services
5 authorized in ss. 409.905 and 409.906, excluding funds for
6 Medicaid nursing home services unless the agency is able to
7 demonstrate how the integration of the funds will improve
8 coordinated care for these services in a less costly manner;
9 and Medicare premiums, coinsurance, and deductibles for
10 persons dually eligible for Medicaid and Medicare as
11 prescribed in s. 409.908(13). The agency must begin
12 implementing the integrated system in a pilot area that may
13 only include Orange, Osceola, Lake, and Seminole Counties.
14 (a) Individuals who are 60 years of age or older and
15 enrolled in the the developmental disabilities waiver program,
16 the family and supported-living waiver program, the project
17 AIDS care waiver program, the traumatic brain injury and
18 spinal cord injury waiver program, the consumer-directed care
19 waiver program, and the program of all-inclusive care for the
20 elderly program, and residents of institutional care
21 facilities for the developmentally disabled, must be excluded
22 from the integrated system.
23 (b) The program must use a competitive-procurement
24 process to select entities to operate the integrated system.
25 Entities eligible to submit bids include managed care
26 organizations licensed under chapter 641, including entities
27 eligible to participate in the nursing home diversion program,
28 other qualified providers as defined in s. 430.703(7),
29 community care for the elderly lead agencies, and other
30 state-certified community service networks that meet
31 comparable standards as defined by the agency, in consultation
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1 with the Department of Elderly Affairs and the Office of
2 Insurance Regulation, to be financially solvent and able to
3 take on financial risk for managed care. Community service
4 networks that are certified pursuant to the comparable
5 standards defined by the agency are not required to be
6 licensed under chapter 641.
7 (c) The agency must ensure that the
8 capitation-rate-setting methodology for the integrated system
9 is actuarially sound and reflects the intent to provide
10 quality care in the least-restrictive setting. The agency must
11 also require integrated-system providers to develop a
12 credentialing system for service providers and to contract
13 with all Gold Seal nursing homes, where feasible, and exclude,
14 where feasible, chronically poor-performing facilities and
15 providers as defined by the agency. The integrated system must
16 provide that if the recipient resides in a noncontracted
17 residential facility licensed under chapter 400 at the time
18 the integrated system is initiated, the recipient must be
19 permitted to continue to reside in the noncontracted facility
20 as long as the recipient desires. The integrated system must
21 also provide that, in the absence of a contract between the
22 integrated-system provider and the residential facility
23 licensed under chapter 400, current Medicaid rates must
24 prevail. The agency and the Department of Elderly Affairs must
25 jointly develop procedures to manage the services provided
26 through the integrated system in order to ensure quality and
27 recipient choice.
28 (d) The agency may seek federal waivers and adopt
29 rules as necessary to administer the integrated system. By
30 October 1, 2003, the agency and the department shall, to the
31 extent feasible, develop a plan for implementing new Medicaid
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1 procedure codes for emergency and crisis care, supportive
2 residential services, and other services designed to maximize
3 the use of Medicaid funds for Medicaid-eligible recipients.
4 The agency shall include in the agreement developed pursuant
5 to subsection (4) a provision that ensures that the match
6 requirements for these new procedure codes are met by
7 certifying eligible general revenue or local funds that are
8 currently expended on these services by the department with
9 contracted alcohol, drug abuse, and mental health providers.
10 The plan must describe specific procedure codes to be
11 implemented, a projection of the number of procedures to be
12 delivered during fiscal year 2003-2004, and a financial
13 analysis that describes the certified match procedures, and
14 accountability mechanisms, projects the earnings associated
15 with these procedures, and describes the sources of state
16 match. This plan may not be implemented in any part until
17 approved by the Legislative Budget Commission. If such
18 approval has not occurred by December 31, 2003, the plan shall
19 be submitted for consideration by the 2004 Legislature.
20 (6) The agency may contract with any public or private
21 entity otherwise authorized by this section on a prepaid or
22 fixed-sum basis for the provision of health care services to
23 recipients. An entity may provide prepaid services to
24 recipients, either directly or through arrangements with other
25 entities, if each entity involved in providing services:
26 (a) Is organized primarily for the purpose of
27 providing health care or other services of the type regularly
28 offered to Medicaid recipients;
29 (b) Ensures that services meet the standards set by
30 the agency for quality, appropriateness, and timeliness;
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1 (c) Makes provisions satisfactory to the agency for
2 insolvency protection and ensures that neither enrolled
3 Medicaid recipients nor the agency will be liable for the
4 debts of the entity;
5 (d) Submits to the agency, if a private entity, a
6 financial plan that the agency finds to be fiscally sound and
7 that provides for working capital in the form of cash or
8 equivalent liquid assets excluding revenues from Medicaid
9 premium payments equal to at least the first 3 months of
10 operating expenses or $200,000, whichever is greater;
11 (e) Furnishes evidence satisfactory to the agency of
12 adequate liability insurance coverage or an adequate plan of
13 self-insurance to respond to claims for injuries arising out
14 of the furnishing of health care;
15 (f) Provides, through contract or otherwise, for
16 periodic review of its medical facilities and services, as
17 required by the agency; and
18 (g) Provides organizational, operational, financial,
19 and other information required by the agency.
20 (7) The agency may contract on a prepaid or fixed-sum
21 basis with any health insurer that:
22 (a) Pays for health care services provided to enrolled
23 Medicaid recipients in exchange for a premium payment paid by
24 the agency;
25 (b) Assumes the underwriting risk; and
26 (c) Is organized and licensed under applicable
27 provisions of the Florida Insurance Code and is currently in
28 good standing with the Office of Insurance Regulation.
29 (8) The agency may contract on a prepaid or fixed-sum
30 basis with an exclusive provider organization to provide
31 health care services to Medicaid recipients provided that the
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1 exclusive provider organization meets applicable managed care
2 plan requirements in this section, ss. 409.9122, 409.9123,
3 409.9128, and 627.6472, and other applicable provisions of
4 law.
5 (9) The Agency for Health Care Administration may
6 provide cost-effective purchasing of chiropractic services on
7 a fee-for-service basis to Medicaid recipients through
8 arrangements with a statewide chiropractic preferred provider
9 organization incorporated in this state as a not-for-profit
10 corporation. The agency shall ensure that the benefit limits
11 and prior authorization requirements in the current Medicaid
12 program shall apply to the services provided by the
13 chiropractic preferred provider organization.
14 (10) The agency shall not contract on a prepaid or
15 fixed-sum basis for Medicaid services with an entity which
16 knows or reasonably should know that any officer, director,
17 agent, managing employee, or owner of stock or beneficial
18 interest in excess of 5 percent common or preferred stock, or
19 the entity itself, has been found guilty of, regardless of
20 adjudication, or entered a plea of nolo contendere, or guilty,
21 to:
22 (a) Fraud;
23 (b) Violation of federal or state antitrust statutes,
24 including those proscribing price fixing between competitors
25 and the allocation of customers among competitors;
26 (c) Commission of a felony involving embezzlement,
27 theft, forgery, income tax evasion, bribery, falsification or
28 destruction of records, making false statements, receiving
29 stolen property, making false claims, or obstruction of
30 justice; or
31
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1 (d) Any crime in any jurisdiction which directly
2 relates to the provision of health services on a prepaid or
3 fixed-sum basis.
4 (11) The agency, after notifying the Legislature, may
5 apply for waivers of applicable federal laws and regulations
6 as necessary to implement more appropriate systems of health
7 care for Medicaid recipients and reduce the cost of the
8 Medicaid program to the state and federal governments and
9 shall implement such programs, after legislative approval,
10 within a reasonable period of time after federal approval.
11 These programs must be designed primarily to reduce the need
12 for inpatient care, custodial care and other long-term or
13 institutional care, and other high-cost services.
14 (a) Prior to seeking legislative approval of such a
15 waiver as authorized by this subsection, the agency shall
16 provide notice and an opportunity for public comment. Notice
17 shall be provided to all persons who have made requests of the
18 agency for advance notice and shall be published in the
19 Florida Administrative Weekly not less than 28 days prior to
20 the intended action.
21 (b) Notwithstanding s. 216.292, funds that are
22 appropriated to the Department of Elderly Affairs for the
23 Assisted Living for the Elderly Medicaid waiver and are not
24 expended shall be transferred to the agency to fund
25 Medicaid-reimbursed nursing home care.
26 (12) The agency shall establish a postpayment
27 utilization control program designed to identify recipients
28 who may inappropriately overuse or underuse Medicaid services
29 and shall provide methods to correct such misuse.
30 (13) The agency shall develop and provide coordinated
31 systems of care for Medicaid recipients and may contract with
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1 public or private entities to develop and administer such
2 systems of care among public and private health care providers
3 in a given geographic area.
4 (14)(a) The agency shall operate or contract for the
5 operation of utilization management and incentive systems
6 designed to encourage cost-effective use services.
7 (b) The agency shall develop a procedure by which
8 health care providers and service vendors can provide the
9 Medicaid program with methodologically valid data that
10 demonstrates whether a particular good or service can offset
11 the cost of providing the good or service in an alternative
12 setting or through other means and therefore should receive a
13 higher reimbursement. Any data provided to the agency for such
14 purpose must demonstrate that for every $1 increase in
15 reimbursement rates for the good or service there will be an
16 offset of at least $2 from the decrease in the cost of
17 providing the good or service through the traditional method.
18 The agency shall be the final arbitrator of the cost-benefit
19 analysis and must determine whether the increased
20 reimbursement for a particular good or service offsets the
21 cost of other goods or services in the Medicaid program. If
22 the agency determines that the increased reimbursement is
23 cost-effective, the agency shall recommend a change in the
24 reimbursement schedule for that particular good or service.
25 If, within 12 months after implementing any rate change under
26 this procedure, the agency determines that costs were not
27 offset by the increased reimbursement schedule, the agency may
28 revert to the former reimbursement schedule for the particular
29 good or service.
30 (15)(a) The agency shall operate the Comprehensive
31 Assessment and Review for Long-Term Care Services (CARES)
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1 nursing facility preadmission screening program to ensure that
2 Medicaid payment for nursing facility care is made only for
3 individuals whose conditions require such care and to ensure
4 that long-term care services are provided in the setting most
5 appropriate to the needs of the person and in the most
6 economical manner possible. The CARES program shall also
7 ensure that individuals participating in Medicaid home and
8 community-based waiver programs meet criteria for those
9 programs, consistent with approved federal waivers.
10 (b) The agency shall operate the CARES program through
11 an interagency agreement with the Department of Elderly
12 Affairs. The agency, in consultation with the Department of
13 Elderly Affairs, may contract for any function or activity of
14 the CARES program, including any function or activity required
15 by 42 C.F.R. part 483.20, relating to preadmission screening
16 and resident review.
17 (c) Prior to making payment for nursing facility
18 services for a Medicaid recipient, the agency must verify that
19 the nursing facility preadmission screening program has
20 determined that the individual requires nursing facility care
21 and that the individual cannot be safely served in
22 community-based programs. The nursing facility preadmission
23 screening program shall refer a Medicaid recipient to a
24 community-based program if the individual could be safely
25 served at a lower cost and the recipient chooses to
26 participate in such program. For individuals whose nursing
27 home stay is initially funded by Medicare and Medicare
28 coverage is being terminated for lack of progress towards
29 rehabilitation, CARES staff shall consult with the person
30 making the determination of progress toward rehabilitation to
31 ensure that the recipient is not being inappropriately
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1 disqualified from Medicare coverage. If, in their professional
2 judgment, CARES staff believes that a Medicare beneficiary is
3 still making progress toward rehabilitation, they may assist
4 the Medicare beneficiary with an appeal of the
5 disqualification from Medicare coverage.
6 (d) For the purpose of initiating immediate
7 prescreening and diversion assistance for individuals residing
8 in nursing homes and in order to make families aware of
9 alternative long-term care resources so that they may choose a
10 more cost-effective setting for long-term placement, CARES
11 staff shall conduct an assessment and review of a sample of
12 individuals whose nursing home stay is expected to exceed 20
13 days, regardless of the initial funding source for the nursing
14 home placement. CARES staff shall provide counseling and
15 referral services to these individuals regarding choosing
16 appropriate long-term care alternatives. This paragraph does
17 not apply to continuing care facilities licensed under chapter
18 651 or to retirement communities that provide a combination of
19 nursing home, independent living, and other long-term care
20 services.
21 (e) By January 15 of each year, the agency shall
22 submit a report to the Legislature and the Office of
23 Long-Term-Care Policy describing the operations of the CARES
24 program. The report must describe:
25 1. Rate of diversion to community alternative
26 programs;
27 2. CARES program staffing needs to achieve additional
28 diversions;
29 3. Reasons the program is unable to place individuals
30 in less restrictive settings when such individuals desired
31 such services and could have been served in such settings;
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1 4. Barriers to appropriate placement, including
2 barriers due to policies or operations of other agencies or
3 state-funded programs; and
4 5. Statutory changes necessary to ensure that
5 individuals in need of long-term care services receive care in
6 the least restrictive environment.
7 (f) The Department of Elderly Affairs shall track
8 individuals over time who are assessed under the CARES program
9 and who are diverted from nursing home placement. By January
10 15 of each year, the department shall submit to the
11 Legislature and the Office of Long-Term-Care Policy a
12 longitudinal study of the individuals who are diverted from
13 nursing home placement. The study must include:
14 1. The demographic characteristics of the individuals
15 assessed and diverted from nursing home placement, including,
16 but not limited to, age, race, gender, frailty, caregiver
17 status, living arrangements, and geographic location;
18 2. A summary of community services provided to
19 individuals for 1 year after assessment and diversion;
20 3. A summary of inpatient hospital admissions for
21 individuals who have been diverted; and
22 4. A summary of the length of time between diversion
23 and subsequent entry into a nursing home or death.
24 (g) By July 1, 2005, the department and the Agency for
25 Health Care Administration shall report to the President of
26 the Senate and the Speaker of the House of Representatives
27 regarding the impact to the state of modifying level-of-care
28 criteria to eliminate the Intermediate II level of care.
29 (16)(a) The agency shall identify health care
30 utilization and price patterns within the Medicaid program
31 which are not cost-effective or medically appropriate and
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1 assess the effectiveness of new or alternate methods of
2 providing and monitoring service, and may implement such
3 methods as it considers appropriate. Such methods may include
4 disease management initiatives, an integrated and systematic
5 approach for managing the health care needs of recipients who
6 are at risk of or diagnosed with a specific disease by using
7 best practices, prevention strategies, clinical-practice
8 improvement, clinical interventions and protocols, outcomes
9 research, information technology, and other tools and
10 resources to reduce overall costs and improve measurable
11 outcomes.
12 (b) The responsibility of the agency under this
13 subsection shall include the development of capabilities to
14 identify actual and optimal practice patterns; patient and
15 provider educational initiatives; methods for determining
16 patient compliance with prescribed treatments; fraud, waste,
17 and abuse prevention and detection programs; and beneficiary
18 case management programs.
19 1. The practice pattern identification program shall
20 evaluate practitioner prescribing patterns based on national
21 and regional practice guidelines, comparing practitioners to
22 their peer groups. The agency and its Drug Utilization Review
23 Board shall consult with the Department of Health and a panel
24 of practicing health care professionals consisting of the
25 following: the Speaker of the House of Representatives and the
26 President of the Senate shall each appoint three physicians
27 licensed under chapter 458 or chapter 459; and the Governor
28 shall appoint two pharmacists licensed under chapter 465 and
29 one dentist licensed under chapter 466 who is an oral surgeon.
30 Terms of the panel members shall expire at the discretion of
31 the appointing official. The panel shall begin its work by
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1 August 1, 1999, regardless of the number of appointments made
2 by that date. The advisory panel shall be responsible for
3 evaluating treatment guidelines and recommending ways to
4 incorporate their use in the practice pattern identification
5 program. Practitioners who are prescribing inappropriately or
6 inefficiently, as determined by the agency, may have their
7 prescribing of certain drugs subject to prior authorization or
8 may be terminated from all participation in the Medicaid
9 program.
10 2. The agency shall also develop educational
11 interventions designed to promote the proper use of
12 medications by providers and beneficiaries.
13 3. The agency shall implement a pharmacy fraud, waste,
14 and abuse initiative that may include a surety bond or letter
15 of credit requirement for participating pharmacies, enhanced
16 provider auditing practices, the use of additional fraud and
17 abuse software, recipient management programs for
18 beneficiaries inappropriately using their benefits, and other
19 steps that will eliminate provider and recipient fraud, waste,
20 and abuse. The initiative shall address enforcement efforts to
21 reduce the number and use of counterfeit prescriptions.
22 4. By September 30, 2002, the agency shall contract
23 with an entity in the state to implement a wireless handheld
24 clinical pharmacology drug information database for
25 practitioners. The initiative shall be designed to enhance the
26 agency's efforts to reduce fraud, abuse, and errors in the
27 prescription drug benefit program and to otherwise further the
28 intent of this paragraph.
29 5. By September 30, 2005, the agency shall contract
30 with an entity to design a database of clinical utilization
31 information or electronic medical records for Medicaid
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1 providers. This system must be web-based and allow providers
2 to review on a real-time basis the utilization of Medicaid
3 services, including, but not limited to, physician office
4 visits, inpatient and outpatient hospitalizations, laboratory
5 and pathology services, radiological and other imaging
6 services, dental care, and patterns of dispensing prescription
7 drugs in order to coordinate care and identify potential fraud
8 and abuse.
9 6. By January 1, 2006, the agency shall provide
10 expanded statewide disease-management programs to provide case
11 management for persons with chronic diseases including
12 diabetes, hypertension, human immunodeficiency virus/acquired
13 immune deficiency syndrome, asthma, congestive heart failure,
14 hemophilia, end-stage renal disease or chronic kidney disease,
15 cancer, sickle cell anemia, chronic fatigue syndrome, and
16 chronic pain. In selecting disease-management vendors,
17 preference must be given to disease-management organizations
18 that are able to provide case management across disease states
19 through coordinated efforts between physicians and
20 pharmacists. The expansion must take two primary forms. The
21 first type of expansion must emphasis changes in clinical
22 practice patterns of physicians and pharmacists in order to
23 meet evidence-based medicine standards and best-practice
24 guidelines for each physician's specialty. The second
25 expansion must emphasize changes in behavior of persons with
26 chronic medical conditions. The expansion must include a
27 randomly assigned, experimental design to evaluate short-term
28 changes in utilization patterns for Medicaid services and
29 clinical outcome measures. The agency shall use an
30 independent, third party to evaluate the expansion of the
31 disease-management program. The agency shall select the
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1 geographic areas in which to expand the disease-management
2 program, estimate the costs to implement each expansion, and
3 develop a timeline for statewide implementation. Based on the
4 evaluation of the expansion, the agency may recommend
5 statewide expansion of the disease-management programs having
6 the best fiscal and clinical outcomes.
7 7.5. The agency may apply for any federal waivers
8 needed to administer implement this paragraph.
9 (17) An entity contracting on a prepaid or fixed-sum
10 basis shall, in addition to meeting any applicable statutory
11 surplus requirements, also maintain at all times in the form
12 of cash, investments that mature in less than 180 days
13 allowable as admitted assets by the Office of Insurance
14 Regulation, and restricted funds or deposits controlled by the
15 agency or the Office of Insurance Regulation, a surplus amount
16 equal to one-and-one-half times the entity's monthly Medicaid
17 prepaid revenues. As used in this subsection, the term
18 "surplus" means the entity's total assets minus total
19 liabilities. If an entity's surplus falls below an amount
20 equal to one-and-one-half times the entity's monthly Medicaid
21 prepaid revenues, the agency shall prohibit the entity from
22 engaging in marketing and preenrollment activities, shall
23 cease to process new enrollments, and shall not renew the
24 entity's contract until the required balance is achieved. The
25 requirements of this subsection do not apply:
26 (a) Where a public entity agrees to fund any deficit
27 incurred by the contracting entity; or
28 (b) Where the entity's performance and obligations are
29 guaranteed in writing by a guaranteeing organization which:
30 1. Has been in operation for at least 5 years and has
31 assets in excess of $50 million; or
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1 2. Submits a written guarantee acceptable to the
2 agency which is irrevocable during the term of the contracting
3 entity's contract with the agency and, upon termination of the
4 contract, until the agency receives proof of satisfaction of
5 all outstanding obligations incurred under the contract.
6 (18)(a) The agency may require an entity contracting
7 on a prepaid or fixed-sum basis to establish a restricted
8 insolvency protection account with a federally guaranteed
9 financial institution licensed to do business in this state.
10 The entity shall deposit into that account 5 percent of the
11 capitation payments made by the agency each month until a
12 maximum total of 2 percent of the total current contract
13 amount is reached. The restricted insolvency protection
14 account may be drawn upon with the authorized signatures of
15 two persons designated by the entity and two representatives
16 of the agency. If the agency finds that the entity is
17 insolvent, the agency may draw upon the account solely with
18 the two authorized signatures of representatives of the
19 agency, and the funds may be disbursed to meet financial
20 obligations incurred by the entity under the prepaid contract.
21 If the contract is terminated, expired, or not continued, the
22 account balance must be released by the agency to the entity
23 upon receipt of proof of satisfaction of all outstanding
24 obligations incurred under this contract.
25 (b) The agency may waive the insolvency protection
26 account requirement in writing when evidence is on file with
27 the agency of adequate insolvency insurance and reinsurance
28 that will protect enrollees if the entity becomes unable to
29 meet its obligations.
30 (19) An entity that contracts with the agency on a
31 prepaid or fixed-sum basis for the provision of Medicaid
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1 services shall reimburse any hospital or physician that is
2 outside the entity's authorized geographic service area as
3 specified in its contract with the agency, and that provides
4 services authorized by the entity to its members, at a rate
5 negotiated with the hospital or physician for the provision of
6 services or according to the lesser of the following:
7 (a) The usual and customary charges made to the
8 general public by the hospital or physician; or
9 (b) The Florida Medicaid reimbursement rate
10 established for the hospital or physician.
11 (20) When a merger or acquisition of a Medicaid
12 prepaid contractor has been approved by the Office of
13 Insurance Regulation pursuant to s. 628.4615, the agency shall
14 approve the assignment or transfer of the appropriate Medicaid
15 prepaid contract upon request of the surviving entity of the
16 merger or acquisition if the contractor and the other entity
17 have been in good standing with the agency for the most recent
18 12-month period, unless the agency determines that the
19 assignment or transfer would be detrimental to the Medicaid
20 recipients or the Medicaid program. To be in good standing, an
21 entity must not have failed accreditation or committed any
22 material violation of the requirements of s. 641.52 and must
23 meet the Medicaid contract requirements. For purposes of this
24 section, a merger or acquisition means a change in controlling
25 interest of an entity, including an asset or stock purchase.
26 (21) Any entity contracting with the agency pursuant
27 to this section to provide health care services to Medicaid
28 recipients is prohibited from engaging in any of the following
29 practices or activities:
30
31
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1 (a) Practices that are discriminatory, including, but
2 not limited to, attempts to discourage participation on the
3 basis of actual or perceived health status.
4 (b) Activities that could mislead or confuse
5 recipients, or misrepresent the organization, its marketing
6 representatives, or the agency. Violations of this paragraph
7 include, but are not limited to:
8 1. False or misleading claims that marketing
9 representatives are employees or representatives of the state
10 or county, or of anyone other than the entity or the
11 organization by whom they are reimbursed.
12 2. False or misleading claims that the entity is
13 recommended or endorsed by any state or county agency, or by
14 any other organization which has not certified its endorsement
15 in writing to the entity.
16 3. False or misleading claims that the state or county
17 recommends that a Medicaid recipient enroll with an entity.
18 4. Claims that a Medicaid recipient will lose benefits
19 under the Medicaid program, or any other health or welfare
20 benefits to which the recipient is legally entitled, if the
21 recipient does not enroll with the entity.
22 (c) Granting or offering of any monetary or other
23 valuable consideration for enrollment, except as authorized by
24 subsection (24).
25 (d) Door-to-door solicitation of recipients who have
26 not contacted the entity or who have not invited the entity to
27 make a presentation.
28 (e) Solicitation of Medicaid recipients by marketing
29 representatives stationed in state offices unless approved and
30 supervised by the agency or its agent and approved by the
31 affected state agency when solicitation occurs in an office of
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1 the state agency. The agency shall ensure that marketing
2 representatives stationed in state offices shall market their
3 managed care plans to Medicaid recipients only in designated
4 areas and in such a way as to not interfere with the
5 recipients' activities in the state office.
6 (f) Enrollment of Medicaid recipients.
7 (22) The agency may impose a fine for a violation of
8 this section or the contract with the agency by a person or
9 entity that is under contract with the agency. With respect to
10 any nonwillful violation, such fine shall not exceed $2,500
11 per violation. In no event shall such fine exceed an aggregate
12 amount of $10,000 for all nonwillful violations arising out of
13 the same action. With respect to any knowing and willful
14 violation of this section or the contract with the agency, the
15 agency may impose a fine upon the entity in an amount not to
16 exceed $20,000 for each such violation. In no event shall such
17 fine exceed an aggregate amount of $100,000 for all knowing
18 and willful violations arising out of the same action.
19 (23) A health maintenance organization or a person or
20 entity exempt from chapter 641 that is under contract with the
21 agency for the provision of health care services to Medicaid
22 recipients may not use or distribute marketing materials used
23 to solicit Medicaid recipients, unless such materials have
24 been approved by the agency. The provisions of this subsection
25 do not apply to general advertising and marketing materials
26 used by a health maintenance organization to solicit both
27 non-Medicaid subscribers and Medicaid recipients.
28 (24) Upon approval by the agency, health maintenance
29 organizations and persons or entities exempt from chapter 641
30 that are under contract with the agency for the provision of
31 health care services to Medicaid recipients may be permitted
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1 within the capitation rate to provide additional health
2 benefits that the agency has found are of high quality, are
3 practicably available, provide reasonable value to the
4 recipient, and are provided at no additional cost to the
5 state.
6 (25) The agency shall utilize the statewide health
7 maintenance organization complaint hotline for the purpose of
8 investigating and resolving Medicaid and prepaid health plan
9 complaints, maintaining a record of complaints and confirmed
10 problems, and receiving disenrollment requests made by
11 recipients.
12 (26) The agency shall require the publication of the
13 health maintenance organization's and the prepaid health
14 plan's consumer services telephone numbers and the "800"
15 telephone number of the statewide health maintenance
16 organization complaint hotline on each Medicaid identification
17 card issued by a health maintenance organization or prepaid
18 health plan contracting with the agency to serve Medicaid
19 recipients and on each subscriber handbook issued to a
20 Medicaid recipient.
21 (27) The agency shall establish a health care quality
22 improvement system for those entities contracting with the
23 agency pursuant to this section, incorporating all the
24 standards and guidelines developed by the Medicaid Bureau of
25 the Health Care Financing Administration as a part of the
26 quality assurance reform initiative. The system shall include,
27 but need not be limited to, the following:
28 (a) Guidelines for internal quality assurance
29 programs, including standards for:
30 1. Written quality assurance program descriptions.
31
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1 2. Responsibilities of the governing body for
2 monitoring, evaluating, and making improvements to care.
3 3. An active quality assurance committee.
4 4. Quality assurance program supervision.
5 5. Requiring the program to have adequate resources to
6 effectively carry out its specified activities.
7 6. Provider participation in the quality assurance
8 program.
9 7. Delegation of quality assurance program activities.
10 8. Credentialing and recredentialing.
11 9. Enrollee rights and responsibilities.
12 10. Availability and accessibility to services and
13 care.
14 11. Ambulatory care facilities.
15 12. Accessibility and availability of medical records,
16 as well as proper recordkeeping and process for record review.
17 13. Utilization review.
18 14. A continuity of care system.
19 15. Quality assurance program documentation.
20 16. Coordination of quality assurance activity with
21 other management activity.
22 17. Delivering care to pregnant women and infants; to
23 elderly and disabled recipients, especially those who are at
24 risk of institutional placement; to persons with developmental
25 disabilities; and to adults who have chronic, high-cost
26 medical conditions.
27 (b) Guidelines which require the entities to conduct
28 quality-of-care studies which:
29 1. Target specific conditions and specific health
30 service delivery issues for focused monitoring and evaluation.
31
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1 2. Use clinical care standards or practice guidelines
2 to objectively evaluate the care the entity delivers or fails
3 to deliver for the targeted clinical conditions and health
4 services delivery issues.
5 3. Use quality indicators derived from the clinical
6 care standards or practice guidelines to screen and monitor
7 care and services delivered.
8 (c) Guidelines for external quality review of each
9 contractor which require: focused studies of patterns of care;
10 individual care review in specific situations; and followup
11 activities on previous pattern-of-care study findings and
12 individual-care-review findings. In designing the external
13 quality review function and determining how it is to operate
14 as part of the state's overall quality improvement system, the
15 agency shall construct its external quality review
16 organization and entity contracts to address each of the
17 following:
18 1. Delineating the role of the external quality review
19 organization.
20 2. Length of the external quality review organization
21 contract with the state.
22 3. Participation of the contracting entities in
23 designing external quality review organization review
24 activities.
25 4. Potential variation in the type of clinical
26 conditions and health services delivery issues to be studied
27 at each plan.
28 5. Determining the number of focused pattern-of-care
29 studies to be conducted for each plan.
30 6. Methods for implementing focused studies.
31 7. Individual care review.
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1 8. Followup activities.
2 (28) In order to ensure that children receive health
3 care services for which an entity has already been
4 compensated, an entity contracting with the agency pursuant to
5 this section shall achieve an annual Early and Periodic
6 Screening, Diagnosis, and Treatment (EPSDT) Service screening
7 rate of at least 60 percent for those recipients continuously
8 enrolled for at least 8 months. The agency shall develop a
9 method by which the EPSDT screening rate shall be calculated.
10 For any entity which does not achieve the annual 60 percent
11 rate, the entity must submit a corrective action plan for the
12 agency's approval. If the entity does not meet the standard
13 established in the corrective action plan during the specified
14 timeframe, the agency is authorized to impose appropriate
15 contract sanctions. At least annually, the agency shall
16 publicly release the EPSDT Services screening rates of each
17 entity it has contracted with on a prepaid basis to serve
18 Medicaid recipients.
19 (29) The agency shall perform enrollments and
20 disenrollments for Medicaid recipients who are eligible for
21 MediPass or managed care plans. Notwithstanding the
22 prohibition contained in paragraph (21)(f), managed care plans
23 may perform preenrollments of Medicaid recipients under the
24 supervision of the agency or its agents. For the purposes of
25 this section, "preenrollment" means the provision of marketing
26 and educational materials to a Medicaid recipient and
27 assistance in completing the application forms, but shall not
28 include actual enrollment into a managed care plan. An
29 application for enrollment shall not be deemed complete until
30 the agency or its agent verifies that the recipient made an
31 informed, voluntary choice. The agency, in cooperation with
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1 the Department of Children and Family Services, may test new
2 marketing initiatives to inform Medicaid recipients about
3 their managed care options at selected sites. The agency shall
4 report to the Legislature on the effectiveness of such
5 initiatives. The agency may contract with a third party to
6 perform managed care plan and MediPass enrollment and
7 disenrollment services for Medicaid recipients and is
8 authorized to adopt rules to implement such services. The
9 agency may adjust the capitation rate only to cover the costs
10 of a third-party enrollment and disenrollment contract, and
11 for agency supervision and management of the managed care plan
12 enrollment and disenrollment contract.
13 (30) Any lists of providers made available to Medicaid
14 recipients, MediPass enrollees, or managed care plan enrollees
15 shall be arranged alphabetically showing the provider's name
16 and specialty and, separately, by specialty in alphabetical
17 order.
18 (31) The agency shall establish an enhanced managed
19 care quality assurance oversight function, to include at least
20 the following components:
21 (a) At least quarterly analysis and followup,
22 including sanctions as appropriate, of managed care
23 participant utilization of services.
24 (b) At least quarterly analysis and followup,
25 including sanctions as appropriate, of quality findings of the
26 Medicaid peer review organization and other external quality
27 assurance programs.
28 (c) At least quarterly analysis and followup,
29 including sanctions as appropriate, of the fiscal viability of
30 managed care plans.
31
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1 (d) At least quarterly analysis and followup,
2 including sanctions as appropriate, of managed care
3 participant satisfaction and disenrollment surveys.
4 (e) The agency shall conduct regular and ongoing
5 Medicaid recipient satisfaction surveys.
6
7 The analyses and followup activities conducted by the agency
8 under its enhanced managed care quality assurance oversight
9 function shall not duplicate the activities of accreditation
10 reviewers for entities regulated under part III of chapter
11 641, but may include a review of the finding of such
12 reviewers.
13 (32) Each managed care plan that is under contract
14 with the agency to provide health care services to Medicaid
15 recipients shall annually conduct a background check with the
16 Florida Department of Law Enforcement of all persons with
17 ownership interest of 5 percent or more or executive
18 management responsibility for the managed care plan and shall
19 submit to the agency information concerning any such person
20 who has been found guilty of, regardless of adjudication, or
21 has entered a plea of nolo contendere or guilty to, any of the
22 offenses listed in s. 435.03.
23 (33) The agency shall, by rule, develop a process
24 whereby a Medicaid managed care plan enrollee who wishes to
25 enter hospice care may be disenrolled from the managed care
26 plan within 24 hours after contacting the agency regarding
27 such request. The agency rule shall include a methodology for
28 the agency to recoup managed care plan payments on a pro rata
29 basis if payment has been made for the enrollment month when
30 disenrollment occurs.
31
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1 (34) The agency and entities that which contract with
2 the agency to provide health care services to Medicaid
3 recipients under this section or ss. 409.91211 and s. 409.9122
4 must comply with the provisions of s. 641.513 in providing
5 emergency services and care to Medicaid recipients and
6 MediPass recipients. Where feasible, safe, and cost-effective,
7 the agency shall encourage hospitals, emergency medical
8 services providers, and other public and private health care
9 providers to work together in their local communities to enter
10 into agreements or arrangements to ensure access to
11 alternatives to emergency services and care for those Medicaid
12 recipients who need nonemergent care. The agency shall
13 coordinate with hospitals, emergency medical services
14 providers, private health plans, capitated managed care
15 networks as established in s. 409.91211, and other public and
16 private health care providers to implement the provisions of
17 ss. 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to
18 develop and implement emergency department diversion programs
19 for Medicaid recipients.
20 (35) All entities providing health care services to
21 Medicaid recipients shall make available, and encourage all
22 pregnant women and mothers with infants to receive, and
23 provide documentation in the medical records to reflect, the
24 following:
25 (a) Healthy Start prenatal or infant screening.
26 (b) Healthy Start care coordination, when screening or
27 other factors indicate need.
28 (c) Healthy Start enhanced services in accordance with
29 the prenatal or infant screening results.
30 (d) Immunizations in accordance with recommendations
31 of the Advisory Committee on Immunization Practices of the
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1 United States Public Health Service and the American Academy
2 of Pediatrics, as appropriate.
3 (e) Counseling and services for family planning to all
4 women and their partners.
5 (f) A scheduled postpartum visit for the purpose of
6 voluntary family planning, to include discussion of all
7 methods of contraception, as appropriate.
8 (g) Referral to the Special Supplemental Nutrition
9 Program for Women, Infants, and Children (WIC).
10 (36) Any entity that provides Medicaid prepaid health
11 plan services shall ensure the appropriate coordination of
12 health care services with an assisted living facility in cases
13 where a Medicaid recipient is both a member of the entity's
14 prepaid health plan and a resident of the assisted living
15 facility. If the entity is at risk for Medicaid targeted case
16 management and behavioral health services, the entity shall
17 inform the assisted living facility of the procedures to
18 follow should an emergent condition arise.
19 (37) The agency may seek and implement federal waivers
20 necessary to provide for cost-effective purchasing of home
21 health services, private duty nursing services,
22 transportation, independent laboratory services, and durable
23 medical equipment and supplies through competitive bidding
24 pursuant to s. 287.057. The agency may request appropriate
25 waivers from the federal Health Care Financing Administration
26 in order to competitively bid such services. The agency may
27 exclude providers not selected through the bidding process
28 from the Medicaid provider network.
29 (38) The agency shall enter into agreements with
30 not-for-profit organizations based in this state for the
31 purpose of providing vision screening.
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1 (39)(a) The agency shall implement a Medicaid
2 prescribed-drug spending-control program that includes the
3 following components:
4 1. A Medicaid preferred drug list, which shall be a
5 listing of cost-effective therapeutic options recommended by
6 the Medicaid Pharmacy and Therapeutics Committee established
7 under s. 409.91195 and adopted by the agency for each
8 therapeutic class on the preferred drug list. At the
9 discretion of the committee, and when feasible, the preferred
10 drug list should include at least two products in a
11 therapeutic class. Medicaid prescribed-drug coverage for
12 brand-name drugs for adult Medicaid recipients is limited to
13 eight the dispensing of four brand-name drugs per month per
14 recipient. Prior authorization is required for all additional
15 prescriptions above the eight-drug limit and must meet the
16 requirements for step therapy and for listing as a preferred
17 drug. Children are exempt from this restriction.
18 Antiretroviral agents are excluded from this limitation. No
19 requirements for prior authorization or other restrictions on
20 medications used to treat mental illnesses such as
21 schizophrenia, severe depression, or bipolar disorder may be
22 imposed on Medicaid recipients. Medications that will be
23 available without restriction for persons with mental
24 illnesses include atypical antipsychotic medications,
25 conventional antipsychotic medications, selective serotonin
26 reuptake inhibitors, and other medications used for the
27 treatment of serious mental illnesses. The agency shall also
28 limit the amount of a prescribed drug dispensed to no more
29 than a 34-day supply unless the drug products' smallest
30 marketed package is greater than a 34-day supply, or the drug
31 is determined by the agency to be a maintenance drug, in which
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1 case a 180-day maximum supply may be authorized. The agency
2 may seek any federal waivers necessary to implement these
3 cost-control programs and to continue participation in the
4 federal Medicaid rebate program, or alternatively to negotiate
5 state-only manufacturer rebates. The agency may adopt rules to
6 administer this subparagraph. The agency shall continue to
7 provide unlimited generic drugs, contraceptive drugs and
8 items, and diabetic supplies. Although a drug may be included
9 on the preferred drug formulary, it would not be exempt from
10 the four-brand limit. The agency may authorize exceptions to
11 the brand-name-drug restriction based upon the treatment needs
12 of the patients, only when such exceptions are based on prior
13 consultation provided by the agency or an agency contractor,
14 but The agency must establish procedures to ensure that:
15 a. There will be a response to a request for prior
16 consultation by telephone or other telecommunication device
17 within 24 hours after receipt of a request for prior
18 consultation; and
19 b. A 72-hour supply of the drug prescribed will be
20 provided in an emergency or when the agency does not provide a
21 response within 24 hours as required by sub-subparagraph a.;
22 and
23 c. Except for the exception for nursing home residents
24 and other institutionalized adults and except for drugs on the
25 restricted formulary for which prior authorization may be
26 sought by an institutional or community pharmacy, prior
27 authorization for an exception to the brand-name-drug
28 restriction is sought by the prescriber and not by the
29 pharmacy. When prior authorization is granted for a patient in
30 an institutional setting beyond the brand-name-drug
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1 restriction, such approval is authorized for 12 months and
2 monthly prior authorization is not required for that patient.
3 2. Reimbursement to pharmacies for Medicaid prescribed
4 drugs shall be set at the lesser of: the average wholesale
5 price (AWP) minus 15.4 percent, the wholesaler acquisition
6 cost (WAC) plus 5.75 percent, the federal upper limit (FUL),
7 the state maximum allowable cost (SMAC), or the usual and
8 customary (UAC) charge billed by the provider.
9 3. The agency shall develop and implement a process
10 for managing the drug therapies of Medicaid recipients who are
11 using significant numbers of prescribed drugs each month. The
12 management process may include, but is not limited to,
13 comprehensive, physician-directed medical-record reviews,
14 claims analyses, and case evaluations to determine the medical
15 necessity and appropriateness of a patient's treatment plan
16 and drug therapies. The agency may contract with a private
17 organization to provide drug-program-management services. The
18 Medicaid drug benefit management program shall include
19 initiatives to manage drug therapies for HIV/AIDS patients,
20 patients using 20 or more unique prescriptions in a 180-day
21 period, and the top 1,000 patients in annual spending. The
22 agency shall enroll any Medicaid recipient in the drug benefit
23 management program if he or she meets the specifications of
24 this provision and is not enrolled in a Medicaid health
25 maintenance organization.
26 4. The agency may limit the size of its pharmacy
27 network based on need, competitive bidding, price
28 negotiations, credentialing, or similar criteria. The agency
29 shall give special consideration to rural areas in determining
30 the size and location of pharmacies included in the Medicaid
31 pharmacy network. A pharmacy credentialing process may include
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1 criteria such as a pharmacy's full-service status, location,
2 size, patient educational programs, patient consultation,
3 disease-management services, and other characteristics. The
4 agency may impose a moratorium on Medicaid pharmacy enrollment
5 when it is determined that it has a sufficient number of
6 Medicaid-participating providers. The agency must allow
7 dispensing practitioners to participate as a part of the
8 Medicaid pharmacy network regardless of the practitioner's
9 proximity to any other entity that is dispensing prescription
10 drugs under the Medicaid program. A dispensing practitioner
11 must meet all credentialing requirements applicable to his or
12 her practice, as determined by the agency.
13 5. The agency shall develop and implement a program
14 that requires Medicaid practitioners who prescribe drugs to
15 use a counterfeit-proof prescription pad for Medicaid
16 prescriptions. The agency shall require the use of
17 standardized counterfeit-proof prescription pads by
18 Medicaid-participating prescribers or prescribers who write
19 prescriptions for Medicaid recipients. The agency may
20 implement the program in targeted geographic areas or
21 statewide.
22 6. The agency may enter into arrangements that require
23 manufacturers of generic drugs prescribed to Medicaid
24 recipients to provide rebates of at least 15.1 percent of the
25 average manufacturer price for the manufacturer's generic
26 products. These arrangements shall require that if a
27 generic-drug manufacturer pays federal rebates for
28 Medicaid-reimbursed drugs at a level below 15.1 percent, the
29 manufacturer must provide a supplemental rebate to the state
30 in an amount necessary to achieve a 15.1-percent rebate level.
31
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1 7. The agency may establish a preferred drug list as
2 described in this subsection formulary in accordance with 42
3 U.S.C. s. 1396r-8, and, pursuant to the establishment of such
4 drug list formulary, it may is authorized to negotiate
5 supplemental rebates from manufacturers which that are in
6 addition to those required by Title XIX of the Social Security
7 Act and at no less than 14 percent of the average manufacturer
8 price as defined in 42 U.S.C. s. 1936 on the last day of a
9 quarter unless the federal or supplemental rebate, or both,
10 equals or exceeds 29 percent. There is no upper limit on the
11 supplemental rebates the agency may negotiate. The agency may
12 determine that specific products, brand-name or generic, are
13 competitive at lower rebate percentages. Agreement to pay the
14 minimum supplemental rebate percentage will guarantee a
15 manufacturer that the Medicaid Pharmaceutical and Therapeutics
16 Committee will consider a product for inclusion on the
17 preferred drug list formulary. However, a pharmaceutical
18 manufacturer is not guaranteed placement on the preferred drug
19 list formulary by simply paying the minimum supplemental
20 rebate. Agency decisions will be made on the clinical efficacy
21 of a drug and recommendations of the Medicaid Pharmaceutical
22 and Therapeutics Committee, as well as the price of competing
23 products minus federal and state rebates. The agency is
24 authorized to contract with an outside agency or contractor to
25 conduct negotiations for supplemental rebates. For the
26 purposes of this section, the term "supplemental rebates"
27 means cash rebates. Effective July 1, 2004, value-added
28 programs as a substitution for supplemental rebates are
29 prohibited. The agency is authorized to seek any federal
30 waivers to implement this initiative.
31
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1 8. The agency shall establish an advisory committee
2 for the purposes of studying the feasibility of using a
3 restricted drug formulary for nursing home residents and other
4 institutionalized adults. The committee shall be comprised of
5 seven members appointed by the Secretary of Health Care
6 Administration. The committee members shall include two
7 physicians licensed under chapter 458 or chapter 459; three
8 pharmacists licensed under chapter 465 and appointed from a
9 list of recommendations provided by the Florida Long-Term Care
10 Pharmacy Alliance; and two pharmacists licensed under chapter
11 465.
12 8.9. The Agency for Health Care Administration shall
13 expand home delivery of pharmacy products. To assist Medicaid
14 patients in securing their prescriptions and reduce program
15 costs, the agency shall expand its current mail-order-pharmacy
16 diabetes-supply program to include all generic and brand-name
17 drugs used by Medicaid patients with diabetes. Medicaid
18 recipients in the current program may obtain nondiabetes drugs
19 on a voluntary basis. This initiative is limited to the
20 geographic area covered by the current contract. The agency
21 may seek and implement any federal waivers necessary to
22 implement this subparagraph.
23 9.10. The agency shall limit to one dose per month any
24 drug prescribed to treat erectile dysfunction.
25 10.11.a. The agency shall implement a Medicaid
26 behavioral drug management system. The agency may contract
27 with a vendor that has experience in operating behavioral drug
28 management systems to implement this program. The agency is
29 authorized to seek federal waivers to implement this program.
30 b. The agency, in conjunction with the Department of
31 Children and Family Services, may implement the Medicaid
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1 behavioral drug management system that is designed to improve
2 the quality of care and behavioral health prescribing
3 practices based on best practice guidelines, improve patient
4 adherence to medication plans, reduce clinical risk, and lower
5 prescribed drug costs and the rate of inappropriate spending
6 on Medicaid behavioral drugs. The program shall include the
7 following elements:
8 (I) Provide for the development and adoption of best
9 practice guidelines for behavioral health-related drugs such
10 as antipsychotics, antidepressants, and medications for
11 treating bipolar disorders and other behavioral conditions;
12 translate them into practice; review behavioral health
13 prescribers and compare their prescribing patterns to a number
14 of indicators that are based on national standards; and
15 determine deviations from best practice guidelines.
16 (II) Implement processes for providing feedback to and
17 educating prescribers using best practice educational
18 materials and peer-to-peer consultation.
19 (III) Assess Medicaid beneficiaries who are outliers
20 in their use of behavioral health drugs with regard to the
21 numbers and types of drugs taken, drug dosages, combination
22 drug therapies, and other indicators of improper use of
23 behavioral health drugs.
24 (IV) Alert prescribers to patients who fail to refill
25 prescriptions in a timely fashion, are prescribed multiple
26 same-class behavioral health drugs, and may have other
27 potential medication problems.
28 (V) Track spending trends for behavioral health drugs
29 and deviation from best practice guidelines.
30
31
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1 (VI) Use educational and technological approaches to
2 promote best practices, educate consumers, and train
3 prescribers in the use of practice guidelines.
4 (VII) Disseminate electronic and published materials.
5 (VIII) Hold statewide and regional conferences.
6 (IX) Implement a disease management program with a
7 model quality-based medication component for severely mentally
8 ill individuals and emotionally disturbed children who are
9 high users of care.
10 c. If the agency is unable to negotiate a contract
11 with one or more manufacturers to finance and guarantee
12 savings associated with a behavioral drug management program
13 by September 1, 2004, the four-brand drug limit and preferred
14 drug list prior-authorization requirements shall apply to
15 mental health-related drugs, notwithstanding any provision in
16 subparagraph 1. The agency is authorized to seek federal
17 waivers to implement this policy.
18 11.a. The agency shall implement a Medicaid
19 prescription-drug-management system. The agency may contract
20 with a vendor that has experience in operating
21 prescription-drug-management systems in order to implement
22 this system. Any management system that is implemented in
23 accordance with this subparagraph must rely on cooperation
24 between physicians and pharmacists to determine appropriate
25 practice patterns and clinical guidelines to improve the
26 prescribing, dispensing, and use of drugs in the Medicaid
27 program. The agency may seek federal waivers to implement this
28 program.
29 b. The drug-management system must be designed to
30 improve the quality of care and prescribing practices based on
31 best-practice guidelines, improve patient adherence to
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1 medication plans, reduce clinical risk, and lower prescribed
2 drug costs and the rate of inappropriate spending on Medicaid
3 prescription drugs. The program must:
4 (I) Provide for the development and adoption of
5 best-practice guidelines for the prescribing and use of drugs
6 in the Medicaid program, including translating best-practice
7 guidelines into practice; reviewing prescriber patterns and
8 comparing them to indicators that are based on national
9 standards and practice patterns of clinical peers in their
10 community, statewide, and nationally; and determine deviations
11 from best-practice guidelines.
12 (II) Implement processes for providing feedback to and
13 educating prescribers using best-practice educational
14 materials and peer-to-peer consultation.
15 (III) Assess Medicaid recipients who are outliers in
16 their use of a single or multiple prescription drugs with
17 regard to the numbers and types of drugs taken, drug dosages,
18 combination drug therapies, and other indicators of improper
19 use of prescription drugs.
20 (IV) Alert prescribers to patients who fail to refill
21 prescriptions in a timely fashion, are prescribed multiple
22 drugs that may be redundant or contraindicated, or may have
23 other potential medication problems.
24 (V) Track spending trends for prescription drugs and
25 deviation from best practice guidelines.
26 (VI) Use educational and technological approaches to
27 promote best practices, educate consumers, and train
28 prescribers in the use of practice guidelines.
29 (VII) Disseminate electronic and published materials.
30 (VIII) Hold statewide and regional conferences.
31
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1 (IX) Implement disease-management programs in
2 cooperation with physicians and pharmacists, along with a
3 model quality-based medication component for individuals
4 having chronic medical conditions.
5 12. The agency is authorized to contract for drug
6 rebate administration, including, but not limited to,
7 calculating rebate amounts, invoicing manufacturers,
8 negotiating disputes with manufacturers, and maintaining a
9 database of rebate collections.
10 13. The agency may specify the preferred daily dosing
11 form or strength for the purpose of promoting best practices
12 with regard to the prescribing of certain drugs as specified
13 in the General Appropriations Act and ensuring cost-effective
14 prescribing practices.
15 14. The agency may require prior authorization for the
16 off-label use of Medicaid-covered prescribed drugs as
17 specified in the General Appropriations Act. The agency may,
18 but is not required to, preauthorize the use of a product for
19 an indication not in the approved labeling. Prior
20 authorization may require the prescribing professional to
21 provide information about the rationale and supporting medical
22 evidence for the off-label use of a drug.
23 15. The agency, in conjunction with the Pharmaceutical
24 and Therapeutics Committee, may require age-related prior
25 authorizations for certain prescribed drugs. The agency may
26 preauthorize the use of a drug for a recipient who may not
27 meet the age requirement or may exceed the length of therapy
28 for use of this product as recommended by the manufacturer and
29 approved by the United States Food and Drug Administration.
30 Prior authorization may require the prescribing professional
31
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1 to provide information about the rationale and supporting
2 medical evidence for the use of a drug.
3 16. The agency shall implement a step-therapy
4 prior-authorization-approval process for medications excluded
5 from the preferred drug list. Medications listed on the
6 preferred drug list must be used within the previous 12 months
7 prior to the alternative medications that are not listed. The
8 step-therapy prior authorization may require the prescriber to
9 use the medications of a similar drug class or for a similar
10 medical indication unless contraindicated in the labeling by
11 the Food and Drug Administration. The trial period between the
12 specified steps may vary according to the medical indication.
13 The step-therapy-approval process shall be developed in
14 accordance with the committee as stated in s. 409.91195(7) and
15 (8).
16 17.15. The agency shall implement a return and reuse
17 program for drugs dispensed by pharmacies to institutional
18 recipients, which includes payment of a $5 restocking fee for
19 the implementation and operation of the program. The return
20 and reuse program shall be implemented electronically and in a
21 manner that promotes efficiency. The program must permit a
22 pharmacy to exclude drugs from the program if it is not
23 practical or cost-effective for the drug to be included and
24 must provide for the return to inventory of drugs that cannot
25 be credited or returned in a cost-effective manner. The agency
26 shall determine if the program has reduced the amount of
27 Medicaid prescription drugs which are destroyed on an annual
28 basis and if there are additional ways to ensure more
29 prescription drugs are not destroyed which could safely be
30 reused. The agency's conclusion and recommendations shall be
31 reported to the Legislature by December 1, 2005.
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1 (b) The agency shall implement this subsection to the
2 extent that funds are appropriated to administer the Medicaid
3 prescribed-drug spending-control program. The agency may
4 contract all or any part of this program to private
5 organizations.
6 (c) The agency shall submit quarterly reports to the
7 Governor, the President of the Senate, and the Speaker of the
8 House of Representatives which must include, but need not be
9 limited to, the progress made in implementing this subsection
10 and its effect on Medicaid prescribed-drug expenditures.
11 (40) Notwithstanding the provisions of chapter 287,
12 the agency may, at its discretion, renew a contract or
13 contracts for fiscal intermediary services one or more times
14 for such periods as the agency may decide; however, all such
15 renewals may not combine to exceed a total period longer than
16 the term of the original contract.
17 (41) The agency shall provide for the development of a
18 demonstration project by establishment in Miami-Dade County of
19 a long-term-care facility licensed pursuant to chapter 395 to
20 improve access to health care for a predominantly minority,
21 medically underserved, and medically complex population and to
22 evaluate alternatives to nursing home care and general acute
23 care for such population. Such project is to be located in a
24 health care condominium and colocated with licensed facilities
25 providing a continuum of care. The establishment of this
26 project is not subject to the provisions of s. 408.036 or s.
27 408.039. The agency shall report its findings to the Governor,
28 the President of the Senate, and the Speaker of the House of
29 Representatives by January 1, 2003.
30 (42) The agency shall develop and implement a
31 utilization management program for Medicaid-eligible
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1 recipients for the management of occupational, physical,
2 respiratory, and speech therapies. The agency shall establish
3 a utilization program that may require prior authorization in
4 order to ensure medically necessary and cost-effective
5 treatments. The program shall be operated in accordance with a
6 federally approved waiver program or state plan amendment. The
7 agency may seek a federal waiver or state plan amendment to
8 implement this program. The agency may also competitively
9 procure these services from an outside vendor on a regional or
10 statewide basis.
11 (43) The agency may contract on a prepaid or fixed-sum
12 basis with appropriately licensed prepaid dental health plans
13 to provide dental services.
14 (44) The Agency for Health Care Administration shall
15 ensure that any Medicaid managed care plan as defined in s.
16 409.9122(2)(h), whether paid on a capitated basis or a shared
17 savings basis, is cost-effective. For purposes of this
18 subsection, the term "cost-effective" means that a network's
19 per-member, per-month costs to the state, including, but not
20 limited to, fee-for-service costs, administrative costs, and
21 case-management fees, must be no greater than the state's
22 costs associated with contracts for Medicaid services
23 established under subsection (3), which shall be actuarially
24 adjusted for case mix, model, and service area. The agency
25 shall conduct actuarially sound audits adjusted for case mix
26 and model in order to ensure such cost-effectiveness and shall
27 publish the audit results on its Internet website and submit
28 the audit results annually to the Governor, the President of
29 the Senate, and the Speaker of the House of Representatives no
30 later than December 31 of each year. Contracts established
31
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1 pursuant to this subsection which are not cost-effective may
2 not be renewed.
3 (45) Subject to the availability of funds, the agency
4 shall mandate a recipient's participation in a provider
5 lock-in program, when appropriate, if a recipient is found by
6 the agency to have used Medicaid goods or services at a
7 frequency or amount not medically necessary, limiting the
8 receipt of goods or services to medically necessary providers
9 after the 21-day appeal process has ended, for a period of not
10 less than 1 year. The lock-in programs shall include, but are
11 not limited to, pharmacies, medical doctors, and infusion
12 clinics. The limitation does not apply to emergency services
13 and care provided to the recipient in a hospital emergency
14 department. The agency shall seek any federal waivers
15 necessary to implement this subsection. The agency shall adopt
16 any rules necessary to comply with or administer this
17 subsection.
18 (46) The agency shall seek a federal waiver for
19 permission to terminate the eligibility of a Medicaid
20 recipient who has been found to have committed fraud, through
21 judicial or administrative determination, two times in a
22 period of 5 years.
23 (47) The agency shall conduct a study of available
24 electronic systems for the purpose of verifying the identity
25 and eligibility of a Medicaid recipient. The agency shall
26 recommend to the Legislature a plan to implement an electronic
27 verification system for Medicaid recipients by January 31,
28 2005.
29 (48) A provider is not entitled to enrollment in the
30 Medicaid provider network. The agency may implement a Medicaid
31 fee-for-service provider network controls, including, but not
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1 limited to, competitive procurement and provider
2 credentialing. If a credentialing process is used, the agency
3 may limit its provider network based upon the following
4 considerations: beneficiary access to care, provider
5 availability, provider quality standards and quality assurance
6 processes, cultural competency, demographic characteristics of
7 beneficiaries, practice standards, service wait times,
8 provider turnover, provider licensure and accreditation
9 history, program integrity history, peer review, Medicaid
10 policy and billing compliance records, clinical and medical
11 record audit findings, and such other areas that are
12 considered necessary by the agency to ensure the integrity of
13 the program.
14 (49) The agency shall contract with established
15 minority physician networks that provide services to
16 historically underserved minority patients. The networks must
17 provide cost-effective Medicaid services, comply with the
18 requirements to be a MediPass provider, and provide their
19 primary care physicians with access to data and other
20 management tools necessary to assist them in ensuring the
21 appropriate use of services, including inpatient hospital
22 services and pharmaceuticals.
23 (a) The agency shall provide for the development and
24 expansion of minority physician networks in each service area
25 to provide services to Medicaid recipients who are eligible to
26 participate under federal law and rules.
27 (b) The agency shall reimburse each minority physician
28 network as a fee-for-service provider, including the case
29 management fee for primary care, or as a capitated rate
30 provider for Medicaid services. Any savings shall be shared
31 with the minority physician networks pursuant to the contract.
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1 (c) For purposes of this subsection, the term
2 "cost-effective" means that a network's per-member, per-month
3 costs to the state, including, but not limited to,
4 fee-for-service costs, administrative costs, and
5 case-management fees, must be no greater than the state's
6 costs associated with contracts for Medicaid services
7 established under subsection (3), which shall be actuarially
8 adjusted for case mix, model, and service area. The agency
9 shall conduct actuarially sound audits adjusted for case mix
10 and model in order to ensure such cost-effectiveness and shall
11 publish the audit results on its Internet website and submit
12 the audit results annually to the Governor, the President of
13 the Senate, and the Speaker of the House of Representatives no
14 later than December 31. Contracts established pursuant to this
15 subsection which are not cost-effective may not be renewed.
16 (d) The agency may apply for any federal waivers
17 needed to implement this subsection.
18 (50) The agency shall implement a program of
19 all-inclusive care for children. The program of all-inclusive
20 care for children shall be established in order to provide
21 in-home, hospice-like support services to children diagnosed
22 as having a life-threatening illness and who are enrolled in
23 the Children's Medical Services network and to reduce
24 hospitalizations as appropriate. The agency, in consultation
25 with the Department of Health, may implement the program of
26 all-inclusive care for children after obtaining approval from
27 the Centers for Medicare and Medicaid Services.
28 (51) To the extent permitted by federal law and as
29 allowed under s. 409.906, the agency shall provide
30 reimbursement for emergency mental health care services for
31 Medicaid recipients in crisis-stabilization facilities
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1 licensed under s. 394.875 as long as those services are less
2 expensive than the same services provided in a hospital
3 setting.
4 Section 2. Section 409.91211, Florida Statutes, is
5 created to read:
6 409.91211 Medicaid managed care pilot program.--
7 (1)(a) The agency shall develop a pilot program to
8 deliver health care services specified in ss. 409.905 and
9 409.906 through capitated managed care networks under the
10 Medicaid program to persons in Medicaid fee-for-service or the
11 MediPass program, contingent upon federal approval to preserve
12 the upper-payment-limit funding mechanism for hospitals,
13 including a guarantee of a reasonable growth factor, a
14 methodology to allow the use of a portion of these funds to
15 serve as risk pool for pilot sites, provisions to preserve the
16 state's ability to use intergovernmental transfers, and
17 provisions to protect the disproportionate share program
18 authorized pursuant to this chapter.
19 (b) The agency may include, as part of the waiver
20 request, an alternative methodology for making additional
21 Medicaid payments to hospitals based on the level of Medicaid
22 or care provided to the uninsured. Any alternative
23 methodology, however, must provide the same level of federal
24 funding as the current upper payment limit and include a
25 reasonable growth factor. Absent federal approval of a
26 reasonable growth factor, the Agency for Health Care
27 Administration shall provide the Legislature, pursuant to the
28 implementation plan provided for in section 3 of this act, the
29 following:
30 1. Based on the historical growth and current federal
31 rules governing the upper-payment-limit funding, an estimate
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1 of the projected growth of funding over the next 10 years and
2 an estimate of the loss of federal funding which can be
3 attributed to the implementation of any Medicaid waiver.
4 2. An analysis showing the amount of additional
5 upper-payment-limit-funds that this state would have received
6 if it had been granted the exceptions to the
7 upper-payment-limit cap provided to other states in 42 C.F.R.
8 s. 447.272 from the 2002 through 2009 state fiscal years.
9 3. An analysis with accompanying rationale supporting
10 the implementation of any waiver that would result in
11 hospitals in this state which provide safety net services
12 receiving less federal funds relative to the federal support
13 given to similar hospitals in other states.
14 (2) The Legislature intends for the capitated managed
15 care pilot program to:
16 (a) Provide recipients in Medicaid fee-for-service or
17 the MediPass program a comprehensive and coordinated capitated
18 managed care system for all health care services specified in
19 ss. 409.905 and 409.906.
20 (b) Stabilize Medicaid expenditures under the pilot
21 program compared to Medicaid expenditures in the pilot area
22 for the 3 years before implementation of the pilot program,
23 while ensuring:
24 1. Consumer education and choice.
25 2. Access to medically necessary services.
26 3. Coordination of preventative, acute, and long-term
27 care.
28 4. Reductions in unnecessary service utilization.
29 (c) Provide an opportunity to evaluate the feasibility
30 of statewide implementation of capitated managed care networks
31
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1 as a replacement for the current Medicaid fee-for-service and
2 MediPass systems.
3 (3) The agency shall have the following powers,
4 duties, and responsibilities with respect to the development
5 of a pilot program to deliver all health care services
6 specified in ss. 409.905 and 409.906 in the form of capitated
7 managed care networks under the Medicaid program to persons in
8 Medicaid fee-for-service or the MediPass program:
9 (a) To define and recommend the medical and financial
10 eligibility standards for capitated managed care networks in
11 the pilot program. This paragraph does not relieve an entity
12 that qualifies as a capitated managed care network under this
13 section from any other licensure or regulatory requirements
14 contained in state or federal law which would otherwise apply
15 to the entity.
16 (b) To include two geographic areas in the pilot
17 program and recommend Medicaid-eligibility categories, from
18 those specified in ss. 409.903 and 409.904, which shall be
19 included in the pilot program. One pilot program must include
20 only Broward County. A second pilot program must initially
21 include Duval County and may be expanded to Baker, Clay, and
22 Nassau Counties after the Duval County program has been
23 operating for at least 1 year. A Medicaid recipient may not be
24 enrolled in or assigned to a capitated managed care plan
25 unless the capitated managed care plan has complied with the
26 standards and credentialing requirements specified in
27 paragraph (e).
28 (c) To determine and recommend how to design the
29 managed care delivery system in order to take maximum
30 advantage of all available state and federal funds, including
31 those obtained through intergovernmental transfers, the
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1 upper-payment-level funding systems, and the disproportionate
2 share program.
3 (d) To determine and recommend actuarially sound,
4 risk-adjusted capitation rates for Medicaid recipients in the
5 pilot program which can be separated to cover comprehensive
6 care, enhanced services, and catastrophic care.
7 (e) To determine and recommend policies and guidelines
8 for phasing in financial risk for approved provider service
9 networks over a 3-year period. These shall include an option
10 to pay fee-for-service rates that may include a
11 savings-settlement option for at least 2 years. This model may
12 be converted to a risk adjusted capitated rate in the third
13 year of operation.
14 (f) To determine and recommend provisions related to
15 stop-loss requirements and the transfer of excess cost to
16 catastrophic coverage that accommodates the risks associated
17 with the development of the pilot projects.
18 (g) To determine and recommend a process to be used by
19 the Social Services Estimating Conference to determine and
20 validate the rate of growth of the per-member costs of
21 providing Medicaid services under the managed care initiative.
22 (h) To determine and recommend descriptions of the
23 eligibility assignment processes that will be used to
24 facilitate client choice while ensuring pilot projects of
25 adequate enrollment levels. These processes shall ensure that
26 pilot sites have sufficient levels of enrollment to conduct a
27 valid test of the managed care pilot project model within a
28 2-year timeframe.
29 (i) To determine and recommend program standards and
30 credentialing requirements for capitated managed care networks
31 to participate in the pilot program, including those related
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1 to fiscal solvency, quality of care, and adequacy of access to
2 health care providers. This paragraph does not relieve an
3 entity that qualifies as a capitated managed care network
4 under this section from any other licensure or regulatory
5 requirements contained in state or federal law that would
6 otherwise apply to the entity. These standards must address,
7 but are not limited to:
8 1. Compliance with the accreditation requirements as
9 provided in s. 641.512.
10 2. Compliance with early and periodic screening,
11 diagnosis, and treatment screening requirements under federal
12 law.
13 3. The percentage of voluntary disenrollments.
14 4. Immunization rates.
15 5. Standards of the National Committee for Quality
16 Assurance and other approved accrediting bodies.
17 6. Recommendations of other authoritative bodies.
18 7. Specific requirements of the Medicaid program, or
19 standards designed to specifically meet the unique needs of
20 Medicaid recipients.
21 8. Compliance with the health quality improvement
22 system as established by the agency, which incorporates
23 standards and guidelines developed by the Centers for Medicare
24 and Medicaid Services as part of the quality assurance reform
25 initiative.
26 (j) To develop and recommend a mechanism for providing
27 information to Medicaid recipients for the purpose of
28 selecting a capitated managed care plan. Examples of such
29 mechanisms may include, but are not limited to, interactive
30 information systems, mailings, mass marketing materials,
31
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1 public information and enrollment fairs, contracted one-on-one
2 counseling services, and peer counseling services.
3 (k) To develop and recommend a system that prohibits
4 capitated managed care plans, their representatives, and
5 providers employed by or contracted with the capitated managed
6 care plans from recruiting persons eligible for or enrolled in
7 Medicaid, from providing inducements to Medicaid recipients to
8 select a particular capitated managed care plan, and from
9 prejudicing Medicaid recipients against other capitated
10 managed care plans.
11 (l) To develop and recommend a system to monitor the
12 provision of health care services in the pilot program,
13 including utilization and quality of health care services for
14 the purpose of ensuring access to medically necessary
15 services. This system shall include an encounter
16 data-information system that collects and reports utilization
17 information. The system shall include a method for verifying
18 data integrity within the database and within the provider's
19 medical records.
20 (m) To recommend a grievance-resolution process for
21 Medicaid recipients enrolled in a capitated managed care
22 network under the pilot program modeled after the subscriber
23 assistance panel, as created in s. 408.7056. This process
24 shall include a mechanism for an expedited review of no
25 greater than 24 hours after notification of a grievance if the
26 life of a Medicaid recipient is in imminent and emergent
27 jeopardy.
28 (n) To recommend a grievance-resolution process for
29 health care providers employed by or contracted with a
30 capitated managed care network under the pilot program in
31
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1 order to settle disputes among the provider and the managed
2 care network or the provider and the agency.
3 (o) To develop and recommend criteria to designate
4 health care providers as eligible to participate in the pilot
5 program. The agency and capitated managed care networks must
6 follow national guidelines for selecting health care
7 providers, whenever available. These criteria must include at
8 a minimum those criteria specified in s. 409.907.
9 (p) To develop and recommend health care provider
10 agreements for participation in the pilot program.
11 (q) To require that all health care providers under
12 contract with the pilot program be duly licensed in the state,
13 if such licensure is available, and meet other criteria as may
14 be established by the agency. These criteria shall include at
15 a minimum those criteria specified in s. 409.907.
16 (r) To develop and recommend agreements with other
17 state or local governmental programs or institutions for the
18 coordination of health care to eligible individuals receiving
19 services from such programs or institutions.
20 (s) To develop and recommend a system to oversee the
21 activities of pilot program participants, health care
22 providers, capitated managed care networks, and their
23 representatives in order to prevent fraud or abuse,
24 overutilization or duplicative utilization, underutilization
25 or inappropriate denial of services, and neglect of
26 participants and to recover overpayments as appropriate. For
27 the purposes of this paragraph, the terms "abuse" and "fraud"
28 have the meanings as provided in s. 409.913. The agency must
29 refer incidents of suspected fraud, abuse, overutilization and
30 duplicative utilization, and underutilization or inappropriate
31 denial of services to the appropriate regulatory agency.
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1 (t) To develop and provide actuarial and benefit
2 design analyses that indicate the effect on capitation rates
3 and benefits offered in the pilot program over a prospective
4 5-year period based on the following assumptions:
5 1. Growth in capitation rates which is limited to the
6 estimated growth rate in general revenue.
7 2. Growth in capitation rates which is limited to the
8 average growth rate over the last 3 years in per-recipient
9 Medicaid expenditures.
10 3. Growth in capitation rates which is limited to the
11 growth rate of aggregate Medicaid expenditures between the
12 2003-2004 fiscal year and the 2004-2005 fiscal year.
13 (u) To develop a mechanism to require capitated
14 managed care plans to reimburse qualified emergency service
15 providers, including, but not limited to, ambulance services,
16 in accordance with ss. 409.908 and 409.9128.
17 (v) To develop a system whereby school districts
18 participating in the certified school match program pursuant
19 to ss. 409.908(21) and 1011.70 shall be reimbursed by
20 Medicaid, subject to the limitations of s. 1011.70(1), for a
21 Medicaid-eligible child participating in the services as
22 authorized in s. 1011.70, as provided for in s. 409.9071,
23 regardless of whether the child is enrolled in a capitated
24 managed care network. Capitated managed care networks must
25 make a good-faith effort to execute agreements with school
26 districts regarding the coordinated provision of services
27 authorized under s. 1011.70. County health departments
28 delivering school-based services pursuant to ss. 381.0056 and
29 381.0057 must be reimbursed by Medicaid for the federal share
30 for a Medicaid-eligible child who receives Medicaid-covered
31 services in a school setting, regardless of whether the child
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1 is enrolled in a capitated managed care network. Capitated
2 managed care networks must make a good-faith effort to execute
3 agreements with county health departments regarding the
4 coordinated provision of services to a Medicaid-eligible
5 child. To ensure continuity of care for Medicaid patients, the
6 agency, the Department of Health, and the Department of
7 Education shall develop procedures for ensuring that a
8 student's capitated managed care network provider receives
9 information relating to services provided in accordance with
10 ss. 381.0056, 381.0057, 409.9071, and 1011.70.
11 (w) To develop and recommend a mechanism whereby
12 Medicaid recipients who are already enrolled in a managed care
13 plan or the MediPass program in the pilot areas shall be
14 offered the opportunity to change to capitated managed care
15 plans on a staggered basis, as defined by the agency. All
16 Medicaid recipients shall have 30 days in which to make a
17 choice of capitated managed care plans. Those Medicaid
18 recipients who do not make a choice shall be assigned to a
19 capitated managed care plan in accordance with paragraph
20 (4)(a). To facilitate continuity of care for a Medicaid
21 recipient who is also a recipient of Supplemental Security
22 Income (SSI), prior to assigning the SSI recipient to a
23 capitated managed care plan, the agency shall determine
24 whether the SSI recipient has an ongoing relationship with a
25 provider or capitated managed care plan, and if so, the agency
26 shall assign the SSI recipient to that provider or capitated
27 managed care plan where feasible. Those SSI recipients who do
28 not have such a provider relationship shall be assigned to a
29 capitated managed care plan provider in accordance with
30 paragraph (4)(a).
31
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1 (x) To develop and recommend a service delivery
2 alternative for children having chronic medical conditions
3 which establishes a medical home project to provide primary
4 care services to this population. The project shall provide
5 community-based primary care services that are integrated with
6 other subspecialties to meet the medical, developmental, and
7 emotional needs for children and their families. This project
8 shall include an evaluation component to determine impacts on
9 hospitalizations, length of stays, emergency room visits,
10 costs, and access to care, including specialty care and
11 patient, and family satisfaction.
12 (4)(a) A Medicaid recipient in the pilot area who is
13 not currently enrolled in a capitated managed care plan upon
14 implementation is not eligible for services as specified in
15 ss. 409.905 and 409.906, for the amount of time that the
16 recipient does not enroll in a capitated managed care network.
17 If a Medicaid recipient has not enrolled in a capitated
18 managed care plan within 30 days after eligibility, the agency
19 shall assign the Medicaid recipient to a capitated managed
20 care plan based on the assessed needs of the recipient as
21 determined by the agency. When making assignments, the agency
22 shall take into account the following criteria:
23 1. A capitated managed care network has sufficient
24 network capacity to meet the need of members.
25 2. The capitated managed care network has previously
26 enrolled the recipient as a member, or one of the capitated
27 managed care network's primary care providers has previously
28 provided health care to the recipient.
29 3. The agency has knowledge that the member has
30 previously expressed a preference for a particular capitated
31
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1 managed care network as indicated by Medicaid fee-for-service
2 claims data, but has failed to make a choice.
3 4. The capitated managed care network's primary care
4 providers are geographically accessible to the recipient's
5 residence.
6 (b) When more than one capitated managed care network
7 provider meets the criteria specified in paragraph (3)(j), the
8 agency shall make recipient assignments consecutively by
9 family unit.
10 (c) The agency may not engage in practices that are
11 designed to favor one capitated managed care plan over another
12 or that are designed to influence Medicaid recipients to
13 enroll in a particular capitated managed care network in order
14 to strengthen its particular fiscal viability.
15 (d) After a recipient has made a selection or has been
16 enrolled in a capitated managed care network, the recipient
17 shall have 90 days in which to voluntarily disenroll and
18 select another capitated managed care network. After 90 days,
19 no further changes may be made except for cause. Cause shall
20 include, but not be limited to, poor quality of care, lack of
21 access to necessary specialty services, an unreasonable delay
22 or denial of service, inordinate or inappropriate changes of
23 primary care providers, service access impairments due to
24 significant changes in the geographic location of services, or
25 fraudulent enrollment. The agency may require a recipient to
26 use the capitated managed care network's grievance process as
27 specified in paragraph (3)(h) prior to the agency's
28 determination of cause, except in cases in which immediate
29 risk of permanent damage to the recipient's health is alleged.
30 The grievance process, when used, must be completed in time to
31 permit the recipient to disenroll no later than the first day
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1 of the second month after the month the disenrollment request
2 was made. If the capitated managed care network, as a result
3 of the grievance process, approves an enrollee's request to
4 disenroll, the agency is not required to make a determination
5 in the case. The agency must make a determination and take
6 final action on a recipient's request so that disenrollment
7 occurs no later than the first day of the second month after
8 the month the request was made. If the agency fails to act
9 within the specified timeframe, the recipient's request to
10 disenroll is deemed to be approved as of the date agency
11 action was required. Recipients who disagree with the agency's
12 finding that cause does not exist for disenrollment shall be
13 advised of their right to pursue a Medicaid fair hearing to
14 dispute the agency's finding.
15 (e) The agency shall apply for federal waivers from
16 the Centers for Medicare and Medicaid Services to lock
17 eligible Medicaid recipients into a capitated managed care
18 network for 12 months after an open enrollment period. After
19 12 months of enrollment, a recipient may select another
20 capitated managed care network. However, nothing shall prevent
21 a Medicaid recipient from changing primary care providers
22 within the capitated managed care network during the 12-month
23 period.
24 (f) The agency shall develop and submit for approval
25 applications for waivers of applicable federal laws and
26 regulations as necessary to implement the capitated managed
27 care pilot program as defined in this section. The agency
28 shall post all waiver applications under this section on its
29 Internet website 30 days before submitting the applications to
30 the United States Centers for Medicare and Medicaid Services.
31 Notwithstanding s. 409.912(11), all waiver applications shall
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1 be submitted to the Senate and House of Representatives Select
2 Committees on Medicaid Reform to be approved for submission.
3 All waivers submitted to and approved by the United States
4 Centers for Medicare and Medicaid Services under this section
5 must be submitted to the Senate and House of Representatives
6 Select Committees on Medicaid Reform in order to obtain
7 authority for implementation as required by s. 409.912(11)
8 before program implementation. The Select Committees on
9 Medicaid Reform shall recommend whether to approve the
10 implementation of the waivers to the Legislature or to the
11 Legislative Budget Commission if the Legislature is not in
12 regular or special session.
13 (5) Upon review and approval of the applications for
14 waivers of applicable federal laws and regulations to
15 implement the pilot project by the Legislature, the Agency for
16 Health Care Administration may initiate adoption of rules
17 pursuant to ss. 120.536(1) and 120.54 to implement and
18 administer the managed care pilot program as provided in this
19 section.
20 Section 3. The Agency for Health Care Administration
21 shall submit an implementation plan for the managed care pilot
22 program created under section 409.91211, Florida Statutes, to
23 the Senate and House of Representatives Select Committees on
24 Medicaid Reform upon approval of all waivers of federal laws
25 and regulations by the United States Centers for Medicare and
26 Medicaid Services which are necessary to implement the managed
27 care pilot program. Based on the review of the implementation
28 plan, the Senate and House Select Committees on Medicaid
29 Reform shall determine whether to recommend implementation of
30 the pilot program for approval by the Legislature or by the
31 Legislative Budget Commission if the Legislature is not in
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1 regular or special session. The implementation plan must
2 include all information specified in section 409.91211(3) and
3 (4), Florida Statutes. The plan must contain a detailed
4 timeline for implementation. The plan must contain budgetary
5 projections of the effect of the pilot program on the total
6 Medicaid budget for the 2006-2007 through 2009-2010 fiscal
7 years.
8 Section 4. The Office of Program Policy Analysis and
9 Government Accountability, in consultation with the Auditor
10 General, shall comprehensively evaluate the two managed care
11 pilot programs created under section 409.91211, Florida
12 Statutes. The evaluation shall begin with the implementation
13 of the managed care model in the pilot areas and continue for
14 24 months after the two pilot programs have enrolled Medicaid
15 recipients and started providing health care services. The
16 evaluation must include assessments of cost savings; consumer
17 education, choice, and access to services; coordination of
18 care; and quality of care by each eligibility category and
19 managed care plan in each pilot site. The evaluation must
20 describe administrative or legal barriers to the
21 implementation and operation of each pilot program and include
22 recommendations regarding statewide expansion of the managed
23 care pilot programs. The office shall submit an evaluation
24 report to the Governor, the President of the Senate, and the
25 Speaker of the House of Representatives no later than June 30,
26 2008. The managed care pilot program may not be expanded to
27 any additional counties that are not identified in this
28 section without the authorization of the Legislature.
29 Section 5. Paragraphs (a) and (j) of subsection (2) of
30 section 409.9122, Florida Statutes, are amended to read:
31
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1 409.9122 Mandatory Medicaid managed care enrollment;
2 programs and procedures.--
3 (2)(a) The agency shall enroll in a managed care plan
4 or MediPass all Medicaid recipients, except those Medicaid
5 recipients who are: in an institution; enrolled in the
6 Medicaid medically needy program; or eligible for both
7 Medicaid and Medicare. Upon enrollment, individuals will be
8 able to change their managed care option during the 90-day opt
9 out period required by federal Medicaid regulations. The
10 agency is authorized to seek the necessary Medicaid state plan
11 amendment to implement this policy. However, to the extent
12 permitted by federal law, the agency may enroll in a managed
13 care plan or MediPass a Medicaid recipient who is exempt from
14 mandatory managed care enrollment, provided that:
15 1. The recipient's decision to enroll in a managed
16 care plan or MediPass is voluntary;
17 2. If the recipient chooses to enroll in a managed
18 care plan, the agency has determined that the managed care
19 plan provides specific programs and services which address the
20 special health needs of the recipient; and
21 3. The agency receives any necessary waivers from the
22 federal Centers for Medicare and Medicaid Services Health Care
23 Financing Administration.
24
25 The agency shall develop rules to establish policies by which
26 exceptions to the mandatory managed care enrollment
27 requirement may be made on a case-by-case basis. The rules
28 shall include the specific criteria to be applied when making
29 a determination as to whether to exempt a recipient from
30 mandatory enrollment in a managed care plan or MediPass.
31 School districts participating in the certified school match
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1 program pursuant to ss. 409.908(21) and 1011.70 shall be
2 reimbursed by Medicaid, subject to the limitations of s.
3 1011.70(1), for a Medicaid-eligible child participating in the
4 services as authorized in s. 1011.70, as provided for in s.
5 409.9071, regardless of whether the child is enrolled in
6 MediPass or a managed care plan. Managed care plans shall make
7 a good faith effort to execute agreements with school
8 districts regarding the coordinated provision of services
9 authorized under s. 1011.70. County health departments
10 delivering school-based services pursuant to ss. 381.0056 and
11 381.0057 shall be reimbursed by Medicaid for the federal share
12 for a Medicaid-eligible child who receives Medicaid-covered
13 services in a school setting, regardless of whether the child
14 is enrolled in MediPass or a managed care plan. Managed care
15 plans shall make a good faith effort to execute agreements
16 with county health departments regarding the coordinated
17 provision of services to a Medicaid-eligible child. To ensure
18 continuity of care for Medicaid patients, the agency, the
19 Department of Health, and the Department of Education shall
20 develop procedures for ensuring that a student's managed care
21 plan or MediPass provider receives information relating to
22 services provided in accordance with ss. 381.0056, 381.0057,
23 409.9071, and 1011.70.
24 (j) The agency shall apply for a federal waiver from
25 the Centers for Medicare and Medicaid Services Health Care
26 Financing Administration to lock eligible Medicaid recipients
27 into a managed care plan or MediPass for 12 months after an
28 open enrollment period. After 12 months' enrollment, a
29 recipient may select another managed care plan or MediPass
30 provider. However, nothing shall prevent a Medicaid recipient
31
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1 from changing primary care providers within the managed care
2 plan or MediPass program during the 12-month period.
3 Section 6. Subsection (2) of section 409.913, Florida
4 Statutes, is amended, and subsection (36) is added to that
5 section, to read:
6 409.913 Oversight of the integrity of the Medicaid
7 program.--The agency shall operate a program to oversee the
8 activities of Florida Medicaid recipients, and providers and
9 their representatives, to ensure that fraudulent and abusive
10 behavior and neglect of recipients occur to the minimum extent
11 possible, and to recover overpayments and impose sanctions as
12 appropriate. Beginning January 1, 2003, and each year
13 thereafter, the agency and the Medicaid Fraud Control Unit of
14 the Department of Legal Affairs shall submit a joint report to
15 the Legislature documenting the effectiveness of the state's
16 efforts to control Medicaid fraud and abuse and to recover
17 Medicaid overpayments during the previous fiscal year. The
18 report must describe the number of cases opened and
19 investigated each year; the sources of the cases opened; the
20 disposition of the cases closed each year; the amount of
21 overpayments alleged in preliminary and final audit letters;
22 the number and amount of fines or penalties imposed; any
23 reductions in overpayment amounts negotiated in settlement
24 agreements or by other means; the amount of final agency
25 determinations of overpayments; the amount deducted from
26 federal claiming as a result of overpayments; the amount of
27 overpayments recovered each year; the amount of cost of
28 investigation recovered each year; the average length of time
29 to collect from the time the case was opened until the
30 overpayment is paid in full; the amount determined as
31 uncollectible and the portion of the uncollectible amount
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1 subsequently reclaimed from the Federal Government; the number
2 of providers, by type, that are terminated from participation
3 in the Medicaid program as a result of fraud and abuse; and
4 all costs associated with discovering and prosecuting cases of
5 Medicaid overpayments and making recoveries in such cases. The
6 report must also document actions taken to prevent
7 overpayments and the number of providers prevented from
8 enrolling in or reenrolling in the Medicaid program as a
9 result of documented Medicaid fraud and abuse and must
10 recommend changes necessary to prevent or recover
11 overpayments.
12 (2) The agency shall conduct, or cause to be conducted
13 by contract or otherwise, reviews, investigations, analyses,
14 audits, or any combination thereof, to determine possible
15 fraud, abuse, overpayment, or recipient neglect in the
16 Medicaid program and shall report the findings of any
17 overpayments in audit reports as appropriate. At least 5
18 percent of all audits shall be conducted on a random basis.
19 (36) The agency shall provide to each Medicaid
20 recipient or his or her representative an explanation of
21 benefits in the form of a letter that is mailed to the most
22 recent address of the recipient on the record with the
23 Department of Children and Family Services. The explanation of
24 benefits must include the patient's name, the name of the
25 health care provider and the address of the location where the
26 service was provided, a description of all services billed to
27 Medicaid in terminology that should be understood by a
28 reasonable person, and information on how to report
29 inappropriate or incorrect billing to the agency or other law
30 enforcement entities for review or investigation.
31
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1 Section 7. The Agency for Health Care Administration
2 shall submit to the Legislature by December 15, 2005, a report
3 on the legal and administrative barriers to enforcing section
4 409.9081, Florida Statutes. The report must describe how many
5 services require copayments, which providers collect
6 copayments, and the total amount of copayments collected from
7 recipients for all services required under section 409.9081,
8 Florida Statutes, by provider type for the 2001-2002 through
9 2004-2005 fiscal years. The agency shall recommend a mechanism
10 to enforce the requirement for Medicaid recipients to make
11 copayments which does not shift the copayment amount to the
12 provider. The agency shall also identify the federal or state
13 laws or regulations that permit Medicaid recipients to declare
14 impoverishment in order to avoid paying the copayment and
15 extent to which these statements of impoverishment are
16 verified. If claims of impoverishment are not currently
17 verified, the agency shall recommend a system for such
18 verification. The report must also identify any other
19 cost-sharing measures that could be imposed on Medicaid
20 recipients.
21 Section 8. The Agency for Health Care Administration
22 shall submit to the Legislature by January 15, 2006,
23 recommendations to ensure that Medicaid is the payer of last
24 resort as required by section 409.910, Florida Statutes. The
25 report must identify the public and private entities that are
26 liable for primary payment of health care services and
27 recommend methods to improve enforcement of third-party
28 liability responsibility and repayment of benefits to the
29 state Medicaid program. The report must estimate the potential
30 recoveries that may be achieved through third-party liability
31 efforts if administrative and legal barriers are removed. The
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1 report must recommend whether modifications to the agency's
2 contingency-fee contract for third-party liability could
3 enhance third-party liability for benefits provided to
4 Medicaid recipients.
5 Section 9. The Agency for Health Care Administration
6 shall study provider pay-for-performance systems developed by
7 the United States Centers for Medicare and Medicaid Services
8 for use in the federal Medicare system and those developed by
9 private health insurance market to determine if these systems
10 can be used in this state's Medicaid program to improve the
11 quality of care while reducing inappropriate utilization. The
12 study must include a cost-benefit analysis to determine the
13 fiscal viability of introducing a pay-for-performance system
14 in this state's Medicaid program. The study must identify any
15 waivers of federal laws or regulations which would be
16 necessary to implement a pay-for-performance system and any
17 changes in provider contracts which are necessary to implement
18 this type of incentive system. The agency shall submit a
19 report on provider pay-for-performance systems to the
20 Legislature by January 15, 2006.
21 Section 10. By January 15, 2006, the Office of Program
22 Policy Analysis and Government Accountability shall submit to
23 the Legislature a study of the nursing home diversion programs
24 of the Department of Elderly Affairs. The study may be
25 conducted by Office of Program Policy Analysis and Government
26 Accountability staff or by a consultant obtained through a
27 competitive bid. The study must use a statistically-valid
28 methodology to assess the percent of persons over a period of
29 2 years in the diversion program who would have entered a
30 nursing home without the diversion services, which services
31 are most frequently used, and which services are least
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1 frequently used in the diversion programs. The study must
2 determine whether the diversion programs are cost-effective or
3 are an expansion of the Medicaid program because persons in
4 the program would not have entered a nursing home within a
5 2-year period regardless of the availability of the diversion
6 programs.
7 Section 11. The Agency for Health Care Administration
8 shall conduct an analysis of potential costs savings achieved
9 through contracting with a multistate purchasing pool approved
10 by the federal Centers for Medicare and Medicaid Services for
11 drug-rebate administration, including, but not limited to,
12 calculating rebate amounts, invoicing manufacturers,
13 negotiating prices with manufacturers, negotiating disputes
14 with manufacturers, and maintaining a database of rebate
15 collections. The agency must submit to the Legislature its
16 analysis of this state's participation in multistate
17 purchasing pools by December 1, 2005.
18 Section 12. The Agency for Health Care Administration
19 shall identify how many individuals in the long-term care
20 diversion programs who receive care at home have a
21 patient-responsibility payment associated with their
22 participation in the diversion program. If no system is
23 available to assess this information, the agency shall
24 determine the cost of creating a system to identify and
25 collect these payments and whether the cost of developing a
26 system for this purpose is offset by the amount of
27 patient-responsibility payments which could be collected with
28 the system. The agency shall report this information to the
29 Legislature by December 1, 2005.
30 Section 13. The Office of Program Policy Analysis and
31 Government Accountability shall conduct a study of state
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1 programs that allow non-Medicaid eligible persons under a
2 certain income level to buy into the Medicaid program as if it
3 was private insurance. The study shall examine Medicaid buy-in
4 programs in other states to determine if there are any models
5 that can be implemented in Florida which would provide access
6 to uninsured Floridians and what effect this program would
7 have on Medicaid expenditures based on the experience of
8 similar states. The study must also examine whether the
9 Medically Needy program could be redesigned to be a Medicaid
10 buy-in program. The study must be submitted to the Legislature
11 by January 1, 2006.
12 Section 14. The sums of $850,000 in recurring funds
13 from the General Revenue Fund and $850,000 in recurring funds
14 from the Administrative Trust Fund are appropriated to the
15 Agency for Health Care Administration for the purpose of
16 contracting with a vendor to monitor and evaluate the clinical
17 practice patterns of providers and provide information to
18 improve patient care and reduce utilization as established in
19 section 1 of this act during the 2005-2006 fiscal year.
20 Section 15. The sums of $1,100,000 in recurring funds
21 from the General Revenue Fund and $1,100,000 in recurring
22 funds from the Administrative Trust Fund are appropriated to
23 the Agency for Health Care Administration for the purpose of
24 contracting with a vendor to design a web-based database to
25 allow providers to review real-time utilization of Medicaid
26 services in order to coordinate care and identify potential
27 fraud and abuse as established in section 1 of this act during
28 the 2005-2006 fiscal year.
29 Section 16. The sums of $7,500,000 in nonrecurring
30 funds from the General Revenue Fund and $7,500,000 in
31 nonrecurring funds from the Administrative Trust Fund are
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1 appropriated to the Agency for Health Care Administration for
2 the purpose of developing infrastructure and administrative
3 resources necessary to develop the capitated managed care
4 pilot program established in section 2 of this act during the
5 2005-2006 fiscal year.
6 Section 17. The sums of $845,223 in recurring funds
7 from the General Revenue Fund and $2,324,224 in recurring
8 funds from the Administrative Trust Fund, and the sums of
9 $3,935 in nonrecurring funds from the General Revenue Fund and
10 $3,934 in nonrecurring funds from the Administrative Trust
11 Fund are appropriated to the Agency for Health Care
12 Administration, and three positions are authorized, for the
13 purpose of developing a managed care encounter data
14 information system during the 2005-2006 fiscal year.
15 Section 18. This act shall take effect July 1, 2005.
16
17 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
18 CS Senate Bill 838
19
20 - Appropriates $15,000,000 in non-recurring funds to AHCA
for the ose of developing administrative infrastructure
21 necessary for the managed care pilot project.
22 - Appropriates $1,700,000 in recurring funds to AHCA for
the purpose of contracting with a vendor to monitor and
23 evaluate the clinical practice patterns of providers and
provide information to improve patient care and reduce
24 utilization.
25 - Appropriates $2,200,000 in recurring funds to AHCA for
the purpose of contracting with a vendor to design a
26 web-based database to allow providers to review real-time
utilization in order to coordinate care and identify
27 fraud and abuse.
28 - Appropriates $3,169,447 in recurring funds, $7,869 in
non-recurring funds, and three FTEs to AHCA for the
29 purpose of developing a managed care encounter data
information system.
30
31
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