Senate Bill sb0838e1
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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; requiring the Office of Program
23 Policy Analysis and Government Accountability
24 to conduct an evaluation; deleting an obsolete
25 provision requiring the agency to develop a
26 plan for implementing emergency and crisis
27 care; requiring the agency to develop a system
28 where health care vendors may provide a
29 business case demonstrating that higher
30 reimbursement for a good or service will be
31 offset by cost savings in other goods or
1
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1 services; requiring the Comprehensive
2 Assessment and Review for Long-Term Care
3 Services (CARES) teams to consult with any
4 person making a determination that a nursing
5 home resident funded by Medicare is not making
6 progress toward rehabilitation and assist in
7 any appeals of the decision; requiring the
8 agency to contract with an entity to design a
9 clinical-utilization information database or
10 electronic medical record for Medicaid
11 providers; requiring the agency to coordinate
12 with other entities to create emergency room
13 diversion programs for Medicaid recipients;
14 allowing dispensing practitioners to
15 participate in Medicaid; requiring that the
16 agency implement a Medicaid
17 prescription-drug-management system; requiring
18 the agency to determine the extent that
19 prescription drugs are returned and reused in
20 institutional settings and whether this program
21 could be expanded; authorizing the agency to
22 pay for emergency mental health services
23 provided through licensed crisis-stabilization
24 facilities; creating s. 409.91211, F.S.;
25 specifying waiver authority for the Agency for
26 Health Care Administration to establish a
27 Medicaid reform program contingent on federal
28 approval to preserve the upper-payment-limit
29 finding mechanism for hospitals and contingent
30 on protection of the disproportionate share
31 program authorized pursuant to ch. 409, F.S.;
2
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1 providing legislative intent; providing powers,
2 duties, and responsibilities of the agency
3 under the pilot program; requiring that the
4 agency submit any waivers to the Legislature
5 for approval before implementation; allowing
6 the agency to develop rules; requiring that the
7 Office of Program Policy Analysis and
8 Government Accountability, in consultation with
9 the Auditor General, evaluate the pilot program
10 and report to the Governor and the Legislature
11 on whether it should be expanded statewide;
12 amending s. 409.9122, F.S.; revising a
13 reference; amending s. 409.913, F.S.; requiring
14 5 percent of all program integrity audits to be
15 conducted on a random basis; requiring that
16 Medicaid recipients be provided with an
17 explanation of benefits; requiring that the
18 agency report to the Legislature on the legal
19 and administrative barriers to enforcing the
20 copayment requirements of s. 409.9081, F.S.;
21 requiring the agency to recommend ways to
22 ensure that Medicaid is the payer of last
23 resort; requiring the Office of Program Policy
24 Analysis and Government Accountability to
25 conduct a study of the long-term care diversion
26 programs; requiring the agency to determine how
27 many individuals in long-term care diversion
28 programs have a patient payment responsibility
29 that is not being collected and to recommend
30 how to collect such payments; requiring the
31 Office of Program Policy Analysis and
3
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1 Government Accountability to conduct a study of
2 Medicaid buy-in programs to determine if these
3 programs can be created in this state without
4 expanding the overall Medicaid program budget
5 or if the Medically Needy program can be
6 changed into a Medicaid buy-in program;
7 providing an appropriation and authorizing
8 positions to implement this act; requiring the
9 Office of Program Policy Analysis and
10 Government Accountability, in consultation with
11 the Office of Attorney General and the Auditor
12 General, to conduct a study to examine whether
13 state and federal dollars are lost due to fraud
14 and abuse in the Medicaid prescription drug
15 program; providing duties; requiring that a
16 report with findings and recommendations be
17 submitted to the Governor and the Legislature
18 by a specified date; providing an effective
19 date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Section 409.912, Florida Statutes, is
24 amended to read:
25 409.912 Cost-effective purchasing of health care.--The
26 agency shall purchase goods and services for Medicaid
27 recipients in the most cost-effective manner consistent with
28 the delivery of quality medical care. To ensure that medical
29 services are effectively utilized, the agency may, in any
30 case, require a confirmation or second physician's opinion of
31 the correct diagnosis for purposes of authorizing future
4
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1 services under the Medicaid program. This section does not
2 restrict access to emergency services or poststabilization
3 care services as defined in 42 C.F.R. part 438.114. Such
4 confirmation or second opinion shall be rendered in a manner
5 approved by the agency. The agency shall maximize the use of
6 prepaid per capita and prepaid aggregate fixed-sum basis
7 services when appropriate and other alternative service
8 delivery and reimbursement methodologies, including
9 competitive bidding pursuant to s. 287.057, designed to
10 facilitate the cost-effective purchase of a case-managed
11 continuum of care. The agency shall also require providers to
12 minimize the exposure of recipients to the need for acute
13 inpatient, custodial, and other institutional care and the
14 inappropriate or unnecessary use of high-cost services. The
15 agency shall contract with a vendor to monitor and evaluate
16 the clinical practice patterns of providers in order to
17 identify trends that are outside the normal practice patterns
18 of a provider's professional peers or the national guidelines
19 of a provider's professional association. The vendor must be
20 able to provide information and counseling to a provider whose
21 practice patterns are outside the norms, in consultation with
22 the agency, to improve patient care and reduce inappropriate
23 utilization. The agency may mandate prior authorization, drug
24 therapy management, or disease management participation for
25 certain populations of Medicaid beneficiaries, certain drug
26 classes, or particular drugs to prevent fraud, abuse, overuse,
27 and possible dangerous drug interactions. The Pharmaceutical
28 and Therapeutics Committee shall make recommendations to the
29 agency on drugs for which prior authorization is required. The
30 agency shall inform the Pharmaceutical and Therapeutics
31 Committee of its decisions regarding drugs subject to prior
5
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1 authorization. The agency is authorized to limit the entities
2 it contracts with or enrolls as Medicaid providers by
3 developing a provider network through provider credentialing.
4 The agency may competitively bid single-source-provider
5 contracts if procurement of goods or services results in
6 demonstrated cost savings to the state without limiting access
7 to care. The agency may limit its network based on the
8 assessment of beneficiary access to care, provider
9 availability, provider quality standards, time and distance
10 standards for access to care, the cultural competence of the
11 provider network, demographic characteristics of Medicaid
12 beneficiaries, practice and provider-to-beneficiary standards,
13 appointment wait times, beneficiary use of services, provider
14 turnover, provider profiling, provider licensure history,
15 previous program integrity investigations and findings, peer
16 review, provider Medicaid policy and billing compliance
17 records, clinical and medical record audits, and other
18 factors. Providers shall not be entitled to enrollment in the
19 Medicaid provider network. The agency shall determine
20 instances in which allowing Medicaid beneficiaries to purchase
21 durable medical equipment and other goods is less expensive to
22 the Medicaid program than long-term rental of the equipment or
23 goods. The agency may establish rules to facilitate purchases
24 in lieu of long-term rentals in order to protect against fraud
25 and abuse in the Medicaid program as defined in s. 409.913.
26 The agency may is authorized to seek federal waivers necessary
27 to administer these policies implement this policy.
28 (1) The agency shall work with the Department of
29 Children and Family Services to ensure access of children and
30 families in the child protection system to needed and
31 appropriate mental health and substance abuse services.
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1 (2) The agency may enter into agreements with
2 appropriate agents of other state agencies or of any agency of
3 the Federal Government and accept such duties in respect to
4 social welfare or public aid as may be necessary to implement
5 the provisions of Title XIX of the Social Security Act and ss.
6 409.901-409.920.
7 (3) The agency may contract with health maintenance
8 organizations certified pursuant to part I of chapter 641 for
9 the provision of services to recipients.
10 (4) The agency may contract with:
11 (a) An entity that provides no prepaid health care
12 services other than Medicaid services under contract with the
13 agency and which is owned and operated by a county, county
14 health department, or county-owned and operated hospital to
15 provide health care services on a prepaid or fixed-sum basis
16 to recipients, which entity may provide such prepaid services
17 either directly or through arrangements with other providers.
18 Such prepaid health care services entities must be licensed
19 under parts I and III by January 1, 1998, and until then are
20 exempt from the provisions of part I of chapter 641. An entity
21 recognized under this paragraph which demonstrates to the
22 satisfaction of the Office of Insurance Regulation of the
23 Financial Services Commission that it is backed by the full
24 faith and credit of the county in which it is located may be
25 exempted from s. 641.225.
26 (b) An entity that is providing comprehensive
27 behavioral health care services to certain Medicaid recipients
28 through a capitated, prepaid arrangement pursuant to the
29 federal waiver provided for by s. 409.905(5). Such an entity
30 must be licensed under chapter 624, chapter 636, or chapter
31 641 and must possess the clinical systems and operational
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1 competence to manage risk and provide comprehensive behavioral
2 health care to Medicaid recipients. As used in this paragraph,
3 the term "comprehensive behavioral health care services" means
4 covered mental health and substance abuse treatment services
5 that are available to Medicaid recipients. The secretary of
6 the Department of Children and Family Services shall approve
7 provisions of procurements related to children in the
8 department's care or custody prior to enrolling such children
9 in a prepaid behavioral health plan. Any contract awarded
10 under this paragraph must be competitively procured. In
11 developing the behavioral health care prepaid plan procurement
12 document, the agency shall ensure that the procurement
13 document requires the contractor to develop and implement a
14 plan to ensure compliance with s. 394.4574 related to services
15 provided to residents of licensed assisted living facilities
16 that hold a limited mental health license. Except as provided
17 in subparagraph 8., the agency shall seek federal approval to
18 contract with a single entity meeting these requirements to
19 provide comprehensive behavioral health care services to all
20 Medicaid recipients not enrolled in a managed care plan in an
21 AHCA area. Each entity must offer sufficient choice of
22 providers in its network to ensure recipient access to care
23 and the opportunity to select a provider with whom they are
24 satisfied. The network shall include all public mental health
25 hospitals. To ensure unimpaired access to behavioral health
26 care services by Medicaid recipients, all contracts issued
27 pursuant to this paragraph shall require 80 percent of the
28 capitation paid to the managed care plan, including health
29 maintenance organizations, to be expended for the provision of
30 behavioral health care services. In the event the managed care
31 plan expends less than 80 percent of the capitation paid
8
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1 pursuant to this paragraph for the provision of behavioral
2 health care services, the difference shall be returned to the
3 agency. The agency shall provide the managed care plan with a
4 certification letter indicating the amount of capitation paid
5 during each calendar year for the provision of behavioral
6 health care services pursuant to this section. The agency may
7 reimburse for substance abuse treatment services on a
8 fee-for-service basis until the agency finds that adequate
9 funds are available for capitated, prepaid arrangements.
10 1. By January 1, 2001, the agency shall modify the
11 contracts with the entities providing comprehensive inpatient
12 and outpatient mental health care services to Medicaid
13 recipients in Hillsborough, Highlands, Hardee, Manatee, and
14 Polk Counties, to include substance abuse treatment services.
15 2. By July 1, 2003, the agency and the Department of
16 Children and Family Services shall execute a written agreement
17 that requires collaboration and joint development of all
18 policy, budgets, procurement documents, contracts, and
19 monitoring plans that have an impact on the state and Medicaid
20 community mental health and targeted case management programs.
21 3. Except as provided in subparagraph 8., by July 1,
22 2006, the agency and the Department of Children and Family
23 Services shall contract with managed care entities in each
24 AHCA area except area 6 or arrange to provide comprehensive
25 inpatient and outpatient mental health and substance abuse
26 services through capitated prepaid arrangements to all
27 Medicaid recipients who are eligible to participate in such
28 plans under federal law and regulation. In AHCA areas where
29 eligible individuals number less than 150,000, the agency
30 shall contract with a single managed care plan to provide
31 comprehensive behavioral health services to all recipients who
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1 are not enrolled in a Medicaid health maintenance
2 organization. The agency may contract with more than one
3 comprehensive behavioral health provider to provide care to
4 recipients who are not enrolled in a Medicaid health
5 maintenance organization in AHCA areas where the eligible
6 population exceeds 150,000. Contracts for comprehensive
7 behavioral health providers awarded pursuant to this section
8 shall be competitively procured. Both for-profit and
9 not-for-profit corporations shall be eligible to compete.
10 Managed care plans contracting with the agency under
11 subsection (3) shall provide and receive payment for the same
12 comprehensive behavioral health benefits as provided in AHCA
13 rules, including handbooks incorporated by reference.
14 4. By October 1, 2003, the agency and the department
15 shall submit a plan to the Governor, the President of the
16 Senate, and the Speaker of the House of Representatives which
17 provides for the full implementation of capitated prepaid
18 behavioral health care in all areas of the state.
19 a. Implementation shall begin in 2003 in those AHCA
20 areas of the state where the agency is able to establish
21 sufficient capitation rates.
22 b. If the agency determines that the proposed
23 capitation rate in any area is insufficient to provide
24 appropriate services, the agency may adjust the capitation
25 rate to ensure that care will be available. The agency and the
26 department may use existing general revenue to address any
27 additional required match but may not over-obligate existing
28 funds on an annualized basis.
29 c. Subject to any limitations provided for in the
30 General Appropriations Act, the agency, in compliance with
31 appropriate federal authorization, shall develop policies and
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1 procedures that allow for certification of local and state
2 funds.
3 5. Children residing in a statewide inpatient
4 psychiatric program, or in a Department of Juvenile Justice or
5 a Department of Children and Family Services residential
6 program approved as a Medicaid behavioral health overlay
7 services provider shall not be included in a behavioral health
8 care prepaid health plan or any other Medicaid managed care
9 plan pursuant to this paragraph.
10 6. In converting to a prepaid system of delivery, the
11 agency shall in its procurement document require an entity
12 providing only comprehensive behavioral health care services
13 to prevent the displacement of indigent care patients by
14 enrollees in the Medicaid prepaid health plan providing
15 behavioral health care services from facilities receiving
16 state funding to provide indigent behavioral health care, to
17 facilities licensed under chapter 395 which do not receive
18 state funding for indigent behavioral health care, or
19 reimburse the unsubsidized facility for the cost of behavioral
20 health care provided to the displaced indigent care patient.
21 7. Traditional community mental health providers under
22 contract with the Department of Children and Family Services
23 pursuant to part IV of chapter 394, child welfare providers
24 under contract with the Department of Children and Family
25 Services in areas 1 and 6, and inpatient mental health
26 providers licensed pursuant to chapter 395 must be offered an
27 opportunity to accept or decline a contract to participate in
28 any provider network for prepaid behavioral health services.
29 8. For fiscal year 2004-2005, all Medicaid eligible
30 children, except children in areas 1 and 6, whose cases are
31 open for child welfare services in the HomeSafeNet system,
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1 shall be enrolled in MediPass or in Medicaid fee-for-service
2 and all their behavioral health care services including
3 inpatient, outpatient psychiatric, community mental health,
4 and case management shall be reimbursed on a fee-for-service
5 basis. Beginning July 1, 2005, such children, who are open for
6 child welfare services in the HomeSafeNet system, shall
7 receive their behavioral health care services through a
8 specialty prepaid plan operated by community-based lead
9 agencies either through a single agency or formal agreements
10 among several agencies. The specialty prepaid plan must result
11 in savings to the state comparable to savings achieved in
12 other Medicaid managed care and prepaid programs. Such plan
13 must provide mechanisms to maximize state and local revenues.
14 The specialty prepaid plan shall be developed by the agency
15 and the Department of Children and Family Services. The agency
16 is authorized to seek any federal waivers to implement this
17 initiative.
18 (c) A federally qualified health center or an entity
19 owned by one or more federally qualified health centers or an
20 entity owned by other migrant and community health centers
21 receiving non-Medicaid financial support from the Federal
22 Government to provide health care services on a prepaid or
23 fixed-sum basis to recipients. Such prepaid health care
24 services entity must be licensed under parts I and III of
25 chapter 641, but shall be prohibited from serving Medicaid
26 recipients on a prepaid basis, until such licensure has been
27 obtained. However, such an entity is exempt from s. 641.225 if
28 the entity meets the requirements specified in subsections
29 (17) and (18).
30 (d) A provider service network may be reimbursed on a
31 fee-for-service or prepaid basis. A provider service network
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1 which is reimbursed by the agency on a prepaid basis shall be
2 exempt from parts I and III of chapter 641, but must meet
3 appropriate financial reserve, quality assurance, and patient
4 rights requirements as established by the agency. The agency
5 shall award contracts on a competitive bid basis and shall
6 select bidders based upon price and quality of care. Medicaid
7 recipients assigned to a demonstration project shall be chosen
8 equally from those who would otherwise have been assigned to
9 prepaid plans and MediPass. The agency is authorized to seek
10 federal Medicaid waivers as necessary to implement the
11 provisions of this section. Any contract previously awarded to
12 a provider service network operated by a hospital pursuant to
13 this subsection shall remain in effect for a period of 3 years
14 following the current contract-expiration date, regardless of
15 any contractual provisions to the contrary. A provider service
16 network is a network established or organized and operated by
17 a health care provider, or group of affiliated health care
18 providers, which provides a substantial proportion of the
19 health care items and services under a contract directly
20 through the provider or affiliated group of providers and may
21 make arrangements with physicians or other health care
22 professionals, health care institutions, or any combination of
23 such individuals or institutions to assume all or part of the
24 financial risk on a prospective basis for the provision of
25 basic health services by the physicians, by other health
26 professionals, or through the institutions. The health care
27 providers must have a controlling interest in the governing
28 body of the provider service network organization.
29 (e) An entity that provides only comprehensive
30 behavioral health care services to certain Medicaid recipients
31 through an administrative services organization agreement.
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1 Such an entity must possess the clinical systems and
2 operational competence to provide comprehensive health care to
3 Medicaid recipients. As used in this paragraph, the term
4 "comprehensive behavioral health care services" means covered
5 mental health and substance abuse treatment services that are
6 available to Medicaid recipients. Any contract awarded under
7 this paragraph must be competitively procured. The agency must
8 ensure that Medicaid recipients have available the choice of
9 at least two managed care plans for their behavioral health
10 care services.
11 (f) An entity that provides in-home physician services
12 to test the cost-effectiveness of enhanced home-based medical
13 care to Medicaid recipients with degenerative neurological
14 diseases and other diseases or disabling conditions associated
15 with high costs to Medicaid. The program shall be designed to
16 serve very disabled persons and to reduce Medicaid reimbursed
17 costs for inpatient, outpatient, and emergency department
18 services. The agency shall contract with vendors on a
19 risk-sharing basis.
20 (g) Children's provider networks that provide care
21 coordination and care management for Medicaid-eligible
22 pediatric patients, primary care, authorization of specialty
23 care, and other urgent and emergency care through organized
24 providers designed to service Medicaid eligibles under age 18
25 and pediatric emergency departments' diversion programs. The
26 networks shall provide after-hour operations, including
27 evening and weekend hours, to promote, when appropriate, the
28 use of the children's networks rather than hospital emergency
29 departments.
30 (h) An entity authorized in s. 430.205 to contract
31 with the agency and the Department of Elderly Affairs to
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1 provide health care and social services on a prepaid or
2 fixed-sum basis to elderly recipients. Such prepaid health
3 care services entities are exempt from the provisions of part
4 I of chapter 641 for the first 3 years of operation. An entity
5 recognized under this paragraph that demonstrates to the
6 satisfaction of the Office of Insurance Regulation that it is
7 backed by the full faith and credit of one or more counties in
8 which it operates may be exempted from s. 641.225.
9 (i) A Children's Medical Services Network, as defined
10 in s. 391.021.
11 (5) By December 1, 2005, the Agency for Health Care
12 Administration, in partnership with the Department of Elderly
13 Affairs, shall create an integrated, fixed-payment delivery
14 system for Medicaid recipients who are 60 years of age or
15 older. Eligible Medicaid recipients may participate in the
16 integrated system on a voluntary basis. The program must
17 transfer all Medicaid services for eligible elderly
18 individuals who choose to participate into an integrated-care
19 management model designed to serve Medicaid recipients in the
20 community. The program must combine all funding for Medicaid
21 services provided to individuals 60 years of age or older into
22 the integrated system, including funds for Medicaid home and
23 community-based waiver services; all Medicaid services
24 authorized in ss. 409.905 and 409.906, excluding funds for
25 Medicaid nursing home services unless the agency is able to
26 demonstrate how the integration of the funds will improve
27 coordinated care for these services in a less costly manner;
28 and Medicare premiums, coinsurance, and deductibles for
29 persons dually eligible for Medicaid and Medicare as
30 prescribed in s. 409.908(13). The agency must begin
31
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1 implementing the integrated system in a pilot area that may
2 only include Orange, Osceola, Lake, and Seminole Counties.
3 (a) Individuals who are 60 years of age or older and
4 enrolled in the the developmental disabilities waiver program,
5 the family and supported-living waiver program, the project
6 AIDS care waiver program, the traumatic brain injury and
7 spinal cord injury waiver program, the consumer-directed care
8 waiver program, and the program of all-inclusive care for the
9 elderly program, and residents of institutional care
10 facilities for the developmentally disabled, must be excluded
11 from the integrated system.
12 (b) The program must use a competitive-procurement
13 process to select entities to operate the integrated system.
14 Entities eligible to submit bids include managed care
15 organizations licensed under chapter 641, including entities
16 eligible to participate in the nursing home diversion program,
17 other qualified providers as defined in s. 430.703(7),
18 community care for the elderly lead agencies, and other
19 state-certified community service networks that meet
20 comparable standards as defined by the agency, in consultation
21 with the Department of Elderly Affairs and the Office of
22 Insurance Regulation, to be financially solvent and able to
23 take on financial risk for managed care. Community service
24 networks that are certified pursuant to the comparable
25 standards defined by the agency are not required to be
26 licensed under chapter 641.
27 (c) The agency must ensure that the
28 capitation-rate-setting methodology for the integrated system
29 is actuarially sound and reflects the intent to provide
30 quality care in the least-restrictive setting. The agency must
31 also require integrated-system providers to develop a
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1 credentialing system for service providers and to contract
2 with all Gold Seal nursing homes, where feasible, and exclude,
3 where feasible, chronically poor-performing facilities and
4 providers as defined by the agency. The integrated system must
5 provide that if the recipient resides in a noncontracted
6 residential facility licensed under chapter 400 at the time
7 the integrated system is initiated, the recipient must be
8 permitted to continue to reside in the noncontracted facility
9 as long as the recipient desires. The integrated system must
10 also provide that, in the absence of a contract between the
11 integrated-system provider and the residential facility
12 licensed under chapter 400, current Medicaid rates must
13 prevail. The agency and the Department of Elderly Affairs must
14 jointly develop procedures to manage the services provided
15 through the integrated system in order to ensure quality and
16 recipient choice.
17 (d) Within 24 months after implementation, the Office
18 of Program Policy Analysis and Government Accountability, in
19 consultation with the Auditor General, shall comprehensively
20 evaluate the pilot project for the integrated, fixed-payment
21 delivery system for Medicaid recipients who are 60 years of
22 age or older. The evaluation must include assessments of cost
23 savings; consumer education, choice, and access to services;
24 coordination of care; and quality of care. The evaluation must
25 describe administrative or legal barriers to the
26 implementation and operation of the pilot program and include
27 recommendations regarding statewide expansion of the pilot
28 program. The office shall submit an evaluation report to the
29 Governor, the President of the Senate, and the Speaker of the
30 House of Representatives no later than June 30, 2008.
31
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1 (e) The agency may seek federal waivers and adopt
2 rules as necessary to administer the integrated system. By
3 October 1, 2003, the agency and the department shall, to the
4 extent feasible, develop a plan for implementing new Medicaid
5 procedure codes for emergency and crisis care, supportive
6 residential services, and other services designed to maximize
7 the use of Medicaid funds for Medicaid-eligible recipients.
8 The agency shall include in the agreement developed pursuant
9 to subsection (4) a provision that ensures that the match
10 requirements for these new procedure codes are met by
11 certifying eligible general revenue or local funds that are
12 currently expended on these services by the department with
13 contracted alcohol, drug abuse, and mental health providers.
14 The plan must describe specific procedure codes to be
15 implemented, a projection of the number of procedures to be
16 delivered during fiscal year 2003-2004, and a financial
17 analysis that describes the certified match procedures, and
18 accountability mechanisms, projects the earnings associated
19 with these procedures, and describes the sources of state
20 match. This plan may not be implemented in any part until
21 approved by the Legislative Budget Commission. If such
22 approval has not occurred by December 31, 2003, the plan shall
23 be submitted for consideration by the 2004 Legislature.
24 (6) The agency may contract with any public or private
25 entity otherwise authorized by this section on a prepaid or
26 fixed-sum basis for the provision of health care services to
27 recipients. An entity may provide prepaid services to
28 recipients, either directly or through arrangements with other
29 entities, if each entity involved in providing services:
30
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1 (a) Is organized primarily for the purpose of
2 providing health care or other services of the type regularly
3 offered to Medicaid recipients;
4 (b) Ensures that services meet the standards set by
5 the agency for quality, appropriateness, and timeliness;
6 (c) Makes provisions satisfactory to the agency for
7 insolvency protection and ensures that neither enrolled
8 Medicaid recipients nor the agency will be liable for the
9 debts of the entity;
10 (d) Submits to the agency, if a private entity, a
11 financial plan that the agency finds to be fiscally sound and
12 that provides for working capital in the form of cash or
13 equivalent liquid assets excluding revenues from Medicaid
14 premium payments equal to at least the first 3 months of
15 operating expenses or $200,000, whichever is greater;
16 (e) Furnishes evidence satisfactory to the agency of
17 adequate liability insurance coverage or an adequate plan of
18 self-insurance to respond to claims for injuries arising out
19 of the furnishing of health care;
20 (f) Provides, through contract or otherwise, for
21 periodic review of its medical facilities and services, as
22 required by the agency; and
23 (g) Provides organizational, operational, financial,
24 and other information required by the agency.
25 (7) The agency may contract on a prepaid or fixed-sum
26 basis with any health insurer that:
27 (a) Pays for health care services provided to enrolled
28 Medicaid recipients in exchange for a premium payment paid by
29 the agency;
30 (b) Assumes the underwriting risk; and
31
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1 (c) Is organized and licensed under applicable
2 provisions of the Florida Insurance Code and is currently in
3 good standing with the Office of Insurance Regulation.
4 (8) The agency may contract on a prepaid or fixed-sum
5 basis with an exclusive provider organization to provide
6 health care services to Medicaid recipients provided that the
7 exclusive provider organization meets applicable managed care
8 plan requirements in this section, ss. 409.9122, 409.9123,
9 409.9128, and 627.6472, and other applicable provisions of
10 law.
11 (9) The Agency for Health Care Administration may
12 provide cost-effective purchasing of chiropractic services on
13 a fee-for-service basis to Medicaid recipients through
14 arrangements with a statewide chiropractic preferred provider
15 organization incorporated in this state as a not-for-profit
16 corporation. The agency shall ensure that the benefit limits
17 and prior authorization requirements in the current Medicaid
18 program shall apply to the services provided by the
19 chiropractic preferred provider organization.
20 (10) The agency shall not contract on a prepaid or
21 fixed-sum basis for Medicaid services with an entity which
22 knows or reasonably should know that any officer, director,
23 agent, managing employee, or owner of stock or beneficial
24 interest in excess of 5 percent common or preferred stock, or
25 the entity itself, has been found guilty of, regardless of
26 adjudication, or entered a plea of nolo contendere, or guilty,
27 to:
28 (a) Fraud;
29 (b) Violation of federal or state antitrust statutes,
30 including those proscribing price fixing between competitors
31 and the allocation of customers among competitors;
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1 (c) Commission of a felony involving embezzlement,
2 theft, forgery, income tax evasion, bribery, falsification or
3 destruction of records, making false statements, receiving
4 stolen property, making false claims, or obstruction of
5 justice; or
6 (d) Any crime in any jurisdiction which directly
7 relates to the provision of health services on a prepaid or
8 fixed-sum basis.
9 (11) The agency, after notifying the Legislature, may
10 apply for waivers of applicable federal laws and regulations
11 as necessary to implement more appropriate systems of health
12 care for Medicaid recipients and reduce the cost of the
13 Medicaid program to the state and federal governments and
14 shall implement such programs, after legislative approval,
15 within a reasonable period of time after federal approval.
16 These programs must be designed primarily to reduce the need
17 for inpatient care, custodial care and other long-term or
18 institutional care, and other high-cost services.
19 (a) Prior to seeking legislative approval of such a
20 waiver as authorized by this subsection, the agency shall
21 provide notice and an opportunity for public comment. Notice
22 shall be provided to all persons who have made requests of the
23 agency for advance notice and shall be published in the
24 Florida Administrative Weekly not less than 28 days prior to
25 the intended action.
26 (b) Notwithstanding s. 216.292, funds that are
27 appropriated to the Department of Elderly Affairs for the
28 Assisted Living for the Elderly Medicaid waiver and are not
29 expended shall be transferred to the agency to fund
30 Medicaid-reimbursed nursing home care.
31
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1 (12) The agency shall establish a postpayment
2 utilization control program designed to identify recipients
3 who may inappropriately overuse or underuse Medicaid services
4 and shall provide methods to correct such misuse.
5 (13) The agency shall develop and provide coordinated
6 systems of care for Medicaid recipients and may contract with
7 public or private entities to develop and administer such
8 systems of care among public and private health care providers
9 in a given geographic area.
10 (14)(a) The agency shall operate or contract for the
11 operation of utilization management and incentive systems
12 designed to encourage cost-effective use services.
13 (b) The agency shall develop a procedure for
14 determining whether health care providers and service vendors
15 can provide the Medicaid program using a business case that
16 demonstrates whether a particular good or service can offset
17 the cost of providing the good or service in an alternative
18 setting or through other means and therefore should receive a
19 higher reimbursement. The business case must include, but need
20 not be limited to:
21 1. A detailed description of the good or service to be
22 provided, a description and analysis of the agency's current
23 performance of the service, and a rationale documenting how
24 providing the service in an alternative setting would be in
25 the best interest of the state, the agency, and its clients.
26 2. A cost-benefit analysis documenting the estimated
27 specific direct and indirect costs, savings, performance
28 improvements, risks, and qualitative and quantitative benefits
29 involved in or resulting from providing the service. The
30 cost-benefit analysis must include a detailed plan and
31 timeline identifying all actions that must be implemented to
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1 realize expected benefits. The Secretary of Health Care
2 Administration shall verify that all costs, savings, and
3 benefits are valid and achievable.
4 (c) If the agency determines that the increased
5 reimbursement is cost-effective, the agency shall recommend a
6 change in the reimbursement schedule for that particular good
7 or service. If, within 12 months after implementing any rate
8 change under this procedure, the agency determines that costs
9 were not offset by the increased reimbursement schedule, the
10 agency may revert to the former reimbursement schedule for the
11 particular good or service.
12 (15)(a) The agency shall operate the Comprehensive
13 Assessment and Review for Long-Term Care Services (CARES)
14 nursing facility preadmission screening program to ensure that
15 Medicaid payment for nursing facility care is made only for
16 individuals whose conditions require such care and to ensure
17 that long-term care services are provided in the setting most
18 appropriate to the needs of the person and in the most
19 economical manner possible. The CARES program shall also
20 ensure that individuals participating in Medicaid home and
21 community-based waiver programs meet criteria for those
22 programs, consistent with approved federal waivers.
23 (b) The agency shall operate the CARES program through
24 an interagency agreement with the Department of Elderly
25 Affairs. The agency, in consultation with the Department of
26 Elderly Affairs, may contract for any function or activity of
27 the CARES program, including any function or activity required
28 by 42 C.F.R. part 483.20, relating to preadmission screening
29 and resident review.
30 (c) Prior to making payment for nursing facility
31 services for a Medicaid recipient, the agency must verify that
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1 the nursing facility preadmission screening program has
2 determined that the individual requires nursing facility care
3 and that the individual cannot be safely served in
4 community-based programs. The nursing facility preadmission
5 screening program shall refer a Medicaid recipient to a
6 community-based program if the individual could be safely
7 served at a lower cost and the recipient chooses to
8 participate in such program. For individuals whose nursing
9 home stay is initially funded by Medicare and Medicare
10 coverage is being terminated for lack of progress towards
11 rehabilitation, CARES staff shall consult with the person
12 making the determination of progress toward rehabilitation to
13 ensure that the recipient is not being inappropriately
14 disqualified from Medicare coverage. If, in their professional
15 judgment, CARES staff believes that a Medicare beneficiary is
16 still making progress toward rehabilitation, they may assist
17 the Medicare beneficiary with an appeal of the
18 disqualification from Medicare coverage. The use of CARES
19 teams to review Medicare denials for coverage under this
20 section is authorized only if it is determined that such
21 reviews qualify for federal matching funds through Medicaid.
22 The agency shall seek or amend federal waivers as necessary to
23 implement this section.
24 (d) For the purpose of initiating immediate
25 prescreening and diversion assistance for individuals residing
26 in nursing homes and in order to make families aware of
27 alternative long-term care resources so that they may choose a
28 more cost-effective setting for long-term placement, CARES
29 staff shall conduct an assessment and review of a sample of
30 individuals whose nursing home stay is expected to exceed 20
31 days, regardless of the initial funding source for the nursing
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1 home placement. CARES staff shall provide counseling and
2 referral services to these individuals regarding choosing
3 appropriate long-term care alternatives. This paragraph does
4 not apply to continuing care facilities licensed under chapter
5 651 or to retirement communities that provide a combination of
6 nursing home, independent living, and other long-term care
7 services.
8 (e) By January 15 of each year, the agency shall
9 submit a report to the Legislature and the Office of
10 Long-Term-Care Policy describing the operations of the CARES
11 program. The report must describe:
12 1. Rate of diversion to community alternative
13 programs;
14 2. CARES program staffing needs to achieve additional
15 diversions;
16 3. Reasons the program is unable to place individuals
17 in less restrictive settings when such individuals desired
18 such services and could have been served in such settings;
19 4. Barriers to appropriate placement, including
20 barriers due to policies or operations of other agencies or
21 state-funded programs; and
22 5. Statutory changes necessary to ensure that
23 individuals in need of long-term care services receive care in
24 the least restrictive environment.
25 (f) The Department of Elderly Affairs shall track
26 individuals over time who are assessed under the CARES program
27 and who are diverted from nursing home placement. By January
28 15 of each year, the department shall submit to the
29 Legislature and the Office of Long-Term-Care Policy a
30 longitudinal study of the individuals who are diverted from
31 nursing home placement. The study must include:
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1 1. The demographic characteristics of the individuals
2 assessed and diverted from nursing home placement, including,
3 but not limited to, age, race, gender, frailty, caregiver
4 status, living arrangements, and geographic location;
5 2. A summary of community services provided to
6 individuals for 1 year after assessment and diversion;
7 3. A summary of inpatient hospital admissions for
8 individuals who have been diverted; and
9 4. A summary of the length of time between diversion
10 and subsequent entry into a nursing home or death.
11 (g) By July 1, 2005, the department and the Agency for
12 Health Care Administration shall report to the President of
13 the Senate and the Speaker of the House of Representatives
14 regarding the impact to the state of modifying level-of-care
15 criteria to eliminate the Intermediate II level of care.
16 (16)(a) The agency shall identify health care
17 utilization and price patterns within the Medicaid program
18 which are not cost-effective or medically appropriate and
19 assess the effectiveness of new or alternate methods of
20 providing and monitoring service, and may implement such
21 methods as it considers appropriate. Such methods may include
22 disease management initiatives, an integrated and systematic
23 approach for managing the health care needs of recipients who
24 are at risk of or diagnosed with a specific disease by using
25 best practices, prevention strategies, clinical-practice
26 improvement, clinical interventions and protocols, outcomes
27 research, information technology, and other tools and
28 resources to reduce overall costs and improve measurable
29 outcomes.
30 (b) The responsibility of the agency under this
31 subsection shall include the development of capabilities to
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1 identify actual and optimal practice patterns; patient and
2 provider educational initiatives; methods for determining
3 patient compliance with prescribed treatments; fraud, waste,
4 and abuse prevention and detection programs; and beneficiary
5 case management programs.
6 1. The practice pattern identification program shall
7 evaluate practitioner prescribing patterns based on national
8 and regional practice guidelines, comparing practitioners to
9 their peer groups. The agency and its Drug Utilization Review
10 Board shall consult with the Department of Health and a panel
11 of practicing health care professionals consisting of the
12 following: the Speaker of the House of Representatives and the
13 President of the Senate shall each appoint three physicians
14 licensed under chapter 458 or chapter 459; and the Governor
15 shall appoint two pharmacists licensed under chapter 465 and
16 one dentist licensed under chapter 466 who is an oral surgeon.
17 Terms of the panel members shall expire at the discretion of
18 the appointing official. The panel shall begin its work by
19 August 1, 1999, regardless of the number of appointments made
20 by that date. The advisory panel shall be responsible for
21 evaluating treatment guidelines and recommending ways to
22 incorporate their use in the practice pattern identification
23 program. Practitioners who are prescribing inappropriately or
24 inefficiently, as determined by the agency, may have their
25 prescribing of certain drugs subject to prior authorization or
26 may be terminated from all participation in the Medicaid
27 program.
28 2. The agency shall also develop educational
29 interventions designed to promote the proper use of
30 medications by providers and beneficiaries.
31
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1 3. The agency shall implement a pharmacy fraud, waste,
2 and abuse initiative that may include a surety bond or letter
3 of credit requirement for participating pharmacies, enhanced
4 provider auditing practices, the use of additional fraud and
5 abuse software, recipient management programs for
6 beneficiaries inappropriately using their benefits, and other
7 steps that will eliminate provider and recipient fraud, waste,
8 and abuse. The initiative shall address enforcement efforts to
9 reduce the number and use of counterfeit prescriptions.
10 4. By September 30, 2002, the agency shall contract
11 with an entity in the state to implement a wireless handheld
12 clinical pharmacology drug information database for
13 practitioners. The initiative shall be designed to enhance the
14 agency's efforts to reduce fraud, abuse, and errors in the
15 prescription drug benefit program and to otherwise further the
16 intent of this paragraph.
17 5. By April 1, 2006, the agency shall contract with an
18 entity to design a database of clinical utilization
19 information or electronic medical records for Medicaid
20 providers. This system must be web-based and allow providers
21 to review on a real-time basis the utilization of Medicaid
22 services, including, but not limited to, physician office
23 visits, inpatient and outpatient hospitalizations, laboratory
24 and pathology services, radiological and other imaging
25 services, dental care, and patterns of dispensing prescription
26 drugs in order to coordinate care and identify potential fraud
27 and abuse.
28 6.5. The agency may apply for any federal waivers
29 needed to administer implement this paragraph.
30 (17) An entity contracting on a prepaid or fixed-sum
31 basis shall, in addition to meeting any applicable statutory
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1 surplus requirements, also maintain at all times in the form
2 of cash, investments that mature in less than 180 days
3 allowable as admitted assets by the Office of Insurance
4 Regulation, and restricted funds or deposits controlled by the
5 agency or the Office of Insurance Regulation, a surplus amount
6 equal to one-and-one-half times the entity's monthly Medicaid
7 prepaid revenues. As used in this subsection, the term
8 "surplus" means the entity's total assets minus total
9 liabilities. If an entity's surplus falls below an amount
10 equal to one-and-one-half times the entity's monthly Medicaid
11 prepaid revenues, the agency shall prohibit the entity from
12 engaging in marketing and preenrollment activities, shall
13 cease to process new enrollments, and shall not renew the
14 entity's contract until the required balance is achieved. The
15 requirements of this subsection do not apply:
16 (a) Where a public entity agrees to fund any deficit
17 incurred by the contracting entity; or
18 (b) Where the entity's performance and obligations are
19 guaranteed in writing by a guaranteeing organization which:
20 1. Has been in operation for at least 5 years and has
21 assets in excess of $50 million; or
22 2. Submits a written guarantee acceptable to the
23 agency which is irrevocable during the term of the contracting
24 entity's contract with the agency and, upon termination of the
25 contract, until the agency receives proof of satisfaction of
26 all outstanding obligations incurred under the contract.
27 (18)(a) The agency may require an entity contracting
28 on a prepaid or fixed-sum basis to establish a restricted
29 insolvency protection account with a federally guaranteed
30 financial institution licensed to do business in this state.
31 The entity shall deposit into that account 5 percent of the
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1 capitation payments made by the agency each month until a
2 maximum total of 2 percent of the total current contract
3 amount is reached. The restricted insolvency protection
4 account may be drawn upon with the authorized signatures of
5 two persons designated by the entity and two representatives
6 of the agency. If the agency finds that the entity is
7 insolvent, the agency may draw upon the account solely with
8 the two authorized signatures of representatives of the
9 agency, and the funds may be disbursed to meet financial
10 obligations incurred by the entity under the prepaid contract.
11 If the contract is terminated, expired, or not continued, the
12 account balance must be released by the agency to the entity
13 upon receipt of proof of satisfaction of all outstanding
14 obligations incurred under this contract.
15 (b) The agency may waive the insolvency protection
16 account requirement in writing when evidence is on file with
17 the agency of adequate insolvency insurance and reinsurance
18 that will protect enrollees if the entity becomes unable to
19 meet its obligations.
20 (19) An entity that contracts with the agency on a
21 prepaid or fixed-sum basis for the provision of Medicaid
22 services shall reimburse any hospital or physician that is
23 outside the entity's authorized geographic service area as
24 specified in its contract with the agency, and that provides
25 services authorized by the entity to its members, at a rate
26 negotiated with the hospital or physician for the provision of
27 services or according to the lesser of the following:
28 (a) The usual and customary charges made to the
29 general public by the hospital or physician; or
30 (b) The Florida Medicaid reimbursement rate
31 established for the hospital or physician.
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1 (20) When a merger or acquisition of a Medicaid
2 prepaid contractor has been approved by the Office of
3 Insurance Regulation pursuant to s. 628.4615, the agency shall
4 approve the assignment or transfer of the appropriate Medicaid
5 prepaid contract upon request of the surviving entity of the
6 merger or acquisition if the contractor and the other entity
7 have been in good standing with the agency for the most recent
8 12-month period, unless the agency determines that the
9 assignment or transfer would be detrimental to the Medicaid
10 recipients or the Medicaid program. To be in good standing, an
11 entity must not have failed accreditation or committed any
12 material violation of the requirements of s. 641.52 and must
13 meet the Medicaid contract requirements. For purposes of this
14 section, a merger or acquisition means a change in controlling
15 interest of an entity, including an asset or stock purchase.
16 (21) Any entity contracting with the agency pursuant
17 to this section to provide health care services to Medicaid
18 recipients is prohibited from engaging in any of the following
19 practices or activities:
20 (a) Practices that are discriminatory, including, but
21 not limited to, attempts to discourage participation on the
22 basis of actual or perceived health status.
23 (b) Activities that could mislead or confuse
24 recipients, or misrepresent the organization, its marketing
25 representatives, or the agency. Violations of this paragraph
26 include, but are not limited to:
27 1. False or misleading claims that marketing
28 representatives are employees or representatives of the state
29 or county, or of anyone other than the entity or the
30 organization by whom they are reimbursed.
31
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1 2. False or misleading claims that the entity is
2 recommended or endorsed by any state or county agency, or by
3 any other organization which has not certified its endorsement
4 in writing to the entity.
5 3. False or misleading claims that the state or county
6 recommends that a Medicaid recipient enroll with an entity.
7 4. Claims that a Medicaid recipient will lose benefits
8 under the Medicaid program, or any other health or welfare
9 benefits to which the recipient is legally entitled, if the
10 recipient does not enroll with the entity.
11 (c) Granting or offering of any monetary or other
12 valuable consideration for enrollment, except as authorized by
13 subsection (24).
14 (d) Door-to-door solicitation of recipients who have
15 not contacted the entity or who have not invited the entity to
16 make a presentation.
17 (e) Solicitation of Medicaid recipients by marketing
18 representatives stationed in state offices unless approved and
19 supervised by the agency or its agent and approved by the
20 affected state agency when solicitation occurs in an office of
21 the state agency. The agency shall ensure that marketing
22 representatives stationed in state offices shall market their
23 managed care plans to Medicaid recipients only in designated
24 areas and in such a way as to not interfere with the
25 recipients' activities in the state office.
26 (f) Enrollment of Medicaid recipients.
27 (22) The agency may impose a fine for a violation of
28 this section or the contract with the agency by a person or
29 entity that is under contract with the agency. With respect to
30 any nonwillful violation, such fine shall not exceed $2,500
31 per violation. In no event shall such fine exceed an aggregate
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1 amount of $10,000 for all nonwillful violations arising out of
2 the same action. With respect to any knowing and willful
3 violation of this section or the contract with the agency, the
4 agency may impose a fine upon the entity in an amount not to
5 exceed $20,000 for each such violation. In no event shall such
6 fine exceed an aggregate amount of $100,000 for all knowing
7 and willful violations arising out of the same action.
8 (23) A health maintenance organization or a person or
9 entity exempt from chapter 641 that is under contract with the
10 agency for the provision of health care services to Medicaid
11 recipients may not use or distribute marketing materials used
12 to solicit Medicaid recipients, unless such materials have
13 been approved by the agency. The provisions of this subsection
14 do not apply to general advertising and marketing materials
15 used by a health maintenance organization to solicit both
16 non-Medicaid subscribers and Medicaid recipients.
17 (24) Upon approval by the agency, health maintenance
18 organizations and persons or entities exempt from chapter 641
19 that are under contract with the agency for the provision of
20 health care services to Medicaid recipients may be permitted
21 within the capitation rate to provide additional health
22 benefits that the agency has found are of high quality, are
23 practicably available, provide reasonable value to the
24 recipient, and are provided at no additional cost to the
25 state.
26 (25) The agency shall utilize the statewide health
27 maintenance organization complaint hotline for the purpose of
28 investigating and resolving Medicaid and prepaid health plan
29 complaints, maintaining a record of complaints and confirmed
30 problems, and receiving disenrollment requests made by
31 recipients.
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1 (26) The agency shall require the publication of the
2 health maintenance organization's and the prepaid health
3 plan's consumer services telephone numbers and the "800"
4 telephone number of the statewide health maintenance
5 organization complaint hotline on each Medicaid identification
6 card issued by a health maintenance organization or prepaid
7 health plan contracting with the agency to serve Medicaid
8 recipients and on each subscriber handbook issued to a
9 Medicaid recipient.
10 (27) The agency shall establish a health care quality
11 improvement system for those entities contracting with the
12 agency pursuant to this section, incorporating all the
13 standards and guidelines developed by the Medicaid Bureau of
14 the Health Care Financing Administration as a part of the
15 quality assurance reform initiative. The system shall include,
16 but need not be limited to, the following:
17 (a) Guidelines for internal quality assurance
18 programs, including standards for:
19 1. Written quality assurance program descriptions.
20 2. Responsibilities of the governing body for
21 monitoring, evaluating, and making improvements to care.
22 3. An active quality assurance committee.
23 4. Quality assurance program supervision.
24 5. Requiring the program to have adequate resources to
25 effectively carry out its specified activities.
26 6. Provider participation in the quality assurance
27 program.
28 7. Delegation of quality assurance program activities.
29 8. Credentialing and recredentialing.
30 9. Enrollee rights and responsibilities.
31
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1 10. Availability and accessibility to services and
2 care.
3 11. Ambulatory care facilities.
4 12. Accessibility and availability of medical records,
5 as well as proper recordkeeping and process for record review.
6 13. Utilization review.
7 14. A continuity of care system.
8 15. Quality assurance program documentation.
9 16. Coordination of quality assurance activity with
10 other management activity.
11 17. Delivering care to pregnant women and infants; to
12 elderly and disabled recipients, especially those who are at
13 risk of institutional placement; to persons with developmental
14 disabilities; and to adults who have chronic, high-cost
15 medical conditions.
16 (b) Guidelines which require the entities to conduct
17 quality-of-care studies which:
18 1. Target specific conditions and specific health
19 service delivery issues for focused monitoring and evaluation.
20 2. Use clinical care standards or practice guidelines
21 to objectively evaluate the care the entity delivers or fails
22 to deliver for the targeted clinical conditions and health
23 services delivery issues.
24 3. Use quality indicators derived from the clinical
25 care standards or practice guidelines to screen and monitor
26 care and services delivered.
27 (c) Guidelines for external quality review of each
28 contractor which require: focused studies of patterns of care;
29 individual care review in specific situations; and followup
30 activities on previous pattern-of-care study findings and
31 individual-care-review findings. In designing the external
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1 quality review function and determining how it is to operate
2 as part of the state's overall quality improvement system, the
3 agency shall construct its external quality review
4 organization and entity contracts to address each of the
5 following:
6 1. Delineating the role of the external quality review
7 organization.
8 2. Length of the external quality review organization
9 contract with the state.
10 3. Participation of the contracting entities in
11 designing external quality review organization review
12 activities.
13 4. Potential variation in the type of clinical
14 conditions and health services delivery issues to be studied
15 at each plan.
16 5. Determining the number of focused pattern-of-care
17 studies to be conducted for each plan.
18 6. Methods for implementing focused studies.
19 7. Individual care review.
20 8. Followup activities.
21 (28) In order to ensure that children receive health
22 care services for which an entity has already been
23 compensated, an entity contracting with the agency pursuant to
24 this section shall achieve an annual Early and Periodic
25 Screening, Diagnosis, and Treatment (EPSDT) Service screening
26 rate of at least 60 percent for those recipients continuously
27 enrolled for at least 8 months. The agency shall develop a
28 method by which the EPSDT screening rate shall be calculated.
29 For any entity which does not achieve the annual 60 percent
30 rate, the entity must submit a corrective action plan for the
31 agency's approval. If the entity does not meet the standard
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1 established in the corrective action plan during the specified
2 timeframe, the agency is authorized to impose appropriate
3 contract sanctions. At least annually, the agency shall
4 publicly release the EPSDT Services screening rates of each
5 entity it has contracted with on a prepaid basis to serve
6 Medicaid recipients.
7 (29) The agency shall perform enrollments and
8 disenrollments for Medicaid recipients who are eligible for
9 MediPass or managed care plans. Notwithstanding the
10 prohibition contained in paragraph (21)(f), managed care plans
11 may perform preenrollments of Medicaid recipients under the
12 supervision of the agency or its agents. For the purposes of
13 this section, "preenrollment" means the provision of marketing
14 and educational materials to a Medicaid recipient and
15 assistance in completing the application forms, but shall not
16 include actual enrollment into a managed care plan. An
17 application for enrollment shall not be deemed complete until
18 the agency or its agent verifies that the recipient made an
19 informed, voluntary choice. The agency, in cooperation with
20 the Department of Children and Family Services, may test new
21 marketing initiatives to inform Medicaid recipients about
22 their managed care options at selected sites. The agency shall
23 report to the Legislature on the effectiveness of such
24 initiatives. The agency may contract with a third party to
25 perform managed care plan and MediPass enrollment and
26 disenrollment services for Medicaid recipients and is
27 authorized to adopt rules to implement such services. The
28 agency may adjust the capitation rate only to cover the costs
29 of a third-party enrollment and disenrollment contract, and
30 for agency supervision and management of the managed care plan
31 enrollment and disenrollment contract.
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1 (30) Any lists of providers made available to Medicaid
2 recipients, MediPass enrollees, or managed care plan enrollees
3 shall be arranged alphabetically showing the provider's name
4 and specialty and, separately, by specialty in alphabetical
5 order.
6 (31) The agency shall establish an enhanced managed
7 care quality assurance oversight function, to include at least
8 the following components:
9 (a) At least quarterly analysis and followup,
10 including sanctions as appropriate, of managed care
11 participant utilization of services.
12 (b) At least quarterly analysis and followup,
13 including sanctions as appropriate, of quality findings of the
14 Medicaid peer review organization and other external quality
15 assurance programs.
16 (c) At least quarterly analysis and followup,
17 including sanctions as appropriate, of the fiscal viability of
18 managed care plans.
19 (d) At least quarterly analysis and followup,
20 including sanctions as appropriate, of managed care
21 participant satisfaction and disenrollment surveys.
22 (e) The agency shall conduct regular and ongoing
23 Medicaid recipient satisfaction surveys.
24
25 The analyses and followup activities conducted by the agency
26 under its enhanced managed care quality assurance oversight
27 function shall not duplicate the activities of accreditation
28 reviewers for entities regulated under part III of chapter
29 641, but may include a review of the finding of such
30 reviewers.
31
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1 (32) Each managed care plan that is under contract
2 with the agency to provide health care services to Medicaid
3 recipients shall annually conduct a background check with the
4 Florida Department of Law Enforcement of all persons with
5 ownership interest of 5 percent or more or executive
6 management responsibility for the managed care plan and shall
7 submit to the agency information concerning any such person
8 who has been found guilty of, regardless of adjudication, or
9 has entered a plea of nolo contendere or guilty to, any of the
10 offenses listed in s. 435.03.
11 (33) The agency shall, by rule, develop a process
12 whereby a Medicaid managed care plan enrollee who wishes to
13 enter hospice care may be disenrolled from the managed care
14 plan within 24 hours after contacting the agency regarding
15 such request. The agency rule shall include a methodology for
16 the agency to recoup managed care plan payments on a pro rata
17 basis if payment has been made for the enrollment month when
18 disenrollment occurs.
19 (34) The agency and entities that which contract with
20 the agency to provide health care services to Medicaid
21 recipients under this section or ss. 409.91211 and s. 409.9122
22 must comply with the provisions of s. 641.513 in providing
23 emergency services and care to Medicaid recipients and
24 MediPass recipients. Where feasible, safe, and cost-effective,
25 the agency shall encourage hospitals, emergency medical
26 services providers, and other public and private health care
27 providers to work together in their local communities to enter
28 into agreements or arrangements to ensure access to
29 alternatives to emergency services and care for those Medicaid
30 recipients who need nonemergent care. The agency shall
31 coordinate with hospitals, emergency medical services
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1 providers, private health plans, capitated managed care
2 networks as established in s. 409.91211, and other public and
3 private health care providers to implement the provisions of
4 ss. 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to
5 develop and implement emergency department diversion programs
6 for Medicaid recipients.
7 (35) All entities providing health care services to
8 Medicaid recipients shall make available, and encourage all
9 pregnant women and mothers with infants to receive, and
10 provide documentation in the medical records to reflect, the
11 following:
12 (a) Healthy Start prenatal or infant screening.
13 (b) Healthy Start care coordination, when screening or
14 other factors indicate need.
15 (c) Healthy Start enhanced services in accordance with
16 the prenatal or infant screening results.
17 (d) Immunizations in accordance with recommendations
18 of the Advisory Committee on Immunization Practices of the
19 United States Public Health Service and the American Academy
20 of Pediatrics, as appropriate.
21 (e) Counseling and services for family planning to all
22 women and their partners.
23 (f) A scheduled postpartum visit for the purpose of
24 voluntary family planning, to include discussion of all
25 methods of contraception, as appropriate.
26 (g) Referral to the Special Supplemental Nutrition
27 Program for Women, Infants, and Children (WIC).
28 (36) Any entity that provides Medicaid prepaid health
29 plan services shall ensure the appropriate coordination of
30 health care services with an assisted living facility in cases
31 where a Medicaid recipient is both a member of the entity's
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1 prepaid health plan and a resident of the assisted living
2 facility. If the entity is at risk for Medicaid targeted case
3 management and behavioral health services, the entity shall
4 inform the assisted living facility of the procedures to
5 follow should an emergent condition arise.
6 (37) The agency may seek and implement federal waivers
7 necessary to provide for cost-effective purchasing of home
8 health services, private duty nursing services,
9 transportation, independent laboratory services, and durable
10 medical equipment and supplies through competitive bidding
11 pursuant to s. 287.057. The agency may request appropriate
12 waivers from the federal Health Care Financing Administration
13 in order to competitively bid such services. The agency may
14 exclude providers not selected through the bidding process
15 from the Medicaid provider network.
16 (38) The agency shall enter into agreements with
17 not-for-profit organizations based in this state for the
18 purpose of providing vision screening.
19 (39)(a) The agency shall implement a Medicaid
20 prescribed-drug spending-control program that includes the
21 following components:
22 1. Medicaid prescribed-drug coverage for brand-name
23 drugs for adult Medicaid recipients is limited to the
24 dispensing of four brand-name drugs per month per recipient.
25 Children are exempt from this restriction. Antiretroviral
26 agents are excluded from this limitation. No requirements for
27 prior authorization or other restrictions on medications used
28 to treat mental illnesses such as schizophrenia, severe
29 depression, or bipolar disorder may be imposed on Medicaid
30 recipients. Medications that will be available without
31 restriction for persons with mental illnesses include atypical
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1 antipsychotic medications, conventional antipsychotic
2 medications, selective serotonin reuptake inhibitors, and
3 other medications used for the treatment of serious mental
4 illnesses. The agency shall also limit the amount of a
5 prescribed drug dispensed to no more than a 34-day supply. The
6 agency shall continue to provide unlimited generic drugs,
7 contraceptive drugs and items, and diabetic supplies. Although
8 a drug may be included on the preferred drug formulary, it
9 would not be exempt from the four-brand limit. The agency may
10 authorize exceptions to the brand-name-drug restriction based
11 upon the treatment needs of the patients, only when such
12 exceptions are based on prior consultation provided by the
13 agency or an agency contractor, but the agency must establish
14 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;
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
31
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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 formulary
2 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
3 establishment of such formulary, it is authorized to negotiate
4 supplemental rebates from manufacturers that are in addition
5 to those required by Title XIX of the Social Security Act and
6 at no less than 14 percent of the average manufacturer price
7 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
8 unless the federal or supplemental rebate, or both, equals or
9 exceeds 29 percent. There is no upper limit on the
10 supplemental rebates the agency may negotiate. The agency may
11 determine that specific products, brand-name or generic, are
12 competitive at lower rebate percentages. Agreement to pay the
13 minimum supplemental rebate percentage will guarantee a
14 manufacturer that the Medicaid Pharmaceutical and Therapeutics
15 Committee will consider a product for inclusion on the
16 preferred drug formulary. However, a pharmaceutical
17 manufacturer is not guaranteed placement on the formulary by
18 simply paying the minimum supplemental rebate. Agency
19 decisions will be made on the clinical efficacy of a drug and
20 recommendations of the Medicaid Pharmaceutical and
21 Therapeutics Committee, as well as the price of competing
22 products minus federal and state rebates. The agency is
23 authorized to contract with an outside agency or contractor to
24 conduct negotiations for supplemental rebates. For the
25 purposes of this section, the term "supplemental rebates"
26 means cash rebates. Effective July 1, 2004, value-added
27 programs as a substitution for supplemental rebates are
28 prohibited. The agency is authorized to seek any federal
29 waivers to implement this initiative.
30 8. The agency shall establish an advisory committee
31 for the purposes of studying the feasibility of using a
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1 restricted drug formulary for nursing home residents and other
2 institutionalized adults. The committee shall be comprised of
3 seven members appointed by the Secretary of Health Care
4 Administration. The committee members shall include two
5 physicians licensed under chapter 458 or chapter 459; three
6 pharmacists licensed under chapter 465 and appointed from a
7 list of recommendations provided by the Florida Long-Term Care
8 Pharmacy Alliance; and two pharmacists licensed under chapter
9 465.
10 9. The Agency for Health Care Administration shall
11 expand home delivery of pharmacy products. To assist Medicaid
12 patients in securing their prescriptions and reduce program
13 costs, the agency shall expand its current mail-order-pharmacy
14 diabetes-supply program to include all generic and brand-name
15 drugs used by Medicaid patients with diabetes. Medicaid
16 recipients in the current program may obtain nondiabetes drugs
17 on a voluntary basis. This initiative is limited to the
18 geographic area covered by the current contract. The agency
19 may seek and implement any federal waivers necessary to
20 implement this subparagraph.
21 10. The agency shall limit to one dose per month any
22 drug prescribed to treat erectile dysfunction.
23 11.a. The agency shall implement a Medicaid behavioral
24 drug management system. The agency may contract with a vendor
25 that has experience in operating behavioral drug management
26 systems to implement this program. The agency is authorized to
27 seek federal waivers to implement this program.
28 b. The agency, in conjunction with the Department of
29 Children and Family Services, may implement the Medicaid
30 behavioral drug management system that is designed to improve
31 the quality of care and behavioral health prescribing
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1 practices based on best practice guidelines, improve patient
2 adherence to medication plans, reduce clinical risk, and lower
3 prescribed drug costs and the rate of inappropriate spending
4 on Medicaid behavioral drugs. The program shall include the
5 following elements:
6 (I) Provide for the development and adoption of best
7 practice guidelines for behavioral health-related drugs such
8 as antipsychotics, antidepressants, and medications for
9 treating bipolar disorders and other behavioral conditions;
10 translate them into practice; review behavioral health
11 prescribers and compare their prescribing patterns to a number
12 of indicators that are based on national standards; and
13 determine deviations from best practice guidelines.
14 (II) Implement processes for providing feedback to and
15 educating prescribers using best practice educational
16 materials and peer-to-peer consultation.
17 (III) Assess Medicaid beneficiaries who are outliers
18 in their use of behavioral health drugs with regard to the
19 numbers and types of drugs taken, drug dosages, combination
20 drug therapies, and other indicators of improper use of
21 behavioral health drugs.
22 (IV) Alert prescribers to patients who fail to refill
23 prescriptions in a timely fashion, are prescribed multiple
24 same-class behavioral health drugs, and may have other
25 potential medication problems.
26 (V) Track spending trends for behavioral health drugs
27 and deviation from best practice guidelines.
28 (VI) Use educational and technological approaches to
29 promote best practices, educate consumers, and train
30 prescribers in the use of practice guidelines.
31 (VII) Disseminate electronic and published materials.
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1 (VIII) Hold statewide and regional conferences.
2 (IX) Implement a disease management program with a
3 model quality-based medication component for severely mentally
4 ill individuals and emotionally disturbed children who are
5 high users of care.
6 c. If the agency is unable to negotiate a contract
7 with one or more manufacturers to finance and guarantee
8 savings associated with a behavioral drug management program
9 by September 1, 2004, the four-brand drug limit and preferred
10 drug list prior-authorization requirements shall apply to
11 mental health-related drugs, notwithstanding any provision in
12 subparagraph 1. The agency is authorized to seek federal
13 waivers to implement this policy.
14 12.a. The agency shall implement a Medicaid
15 prescription-drug-management system. The agency may contract
16 with a vendor that has experience in operating
17 prescription-drug-management systems in order to implement
18 this system. Any management system that is implemented in
19 accordance with this subparagraph must rely on cooperation
20 between physicians and pharmacists to determine appropriate
21 practice patterns and clinical guidelines to improve the
22 prescribing, dispensing, and use of drugs in the Medicaid
23 program. The agency may seek federal waivers to implement this
24 program.
25 b. The drug-management system must be designed to
26 improve the quality of care and prescribing practices based on
27 best-practice guidelines, improve patient adherence to
28 medication plans, reduce clinical risk, and lower prescribed
29 drug costs and the rate of inappropriate spending on Medicaid
30 prescription drugs. The program must:
31
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1 (I) Provide for the development and adoption of
2 best-practice guidelines for the prescribing and use of drugs
3 in the Medicaid program, including translating best-practice
4 guidelines into practice; reviewing prescriber patterns and
5 comparing them to indicators that are based on national
6 standards and practice patterns of clinical peers in their
7 community, statewide, and nationally; and determine deviations
8 from best-practice guidelines.
9 (II) Implement processes for providing feedback to and
10 educating prescribers using best-practice educational
11 materials and peer-to-peer consultation.
12 (III) Assess Medicaid recipients who are outliers in
13 their use of a single or multiple prescription drugs with
14 regard to the numbers and types of drugs taken, drug dosages,
15 combination drug therapies, and other indicators of improper
16 use of prescription drugs.
17 (IV) Alert prescribers to patients who fail to refill
18 prescriptions in a timely fashion, are prescribed multiple
19 drugs that may be redundant or contraindicated, or may have
20 other potential medication problems.
21 (V) Track spending trends for prescription drugs and
22 deviation from best-practice guidelines.
23 (VI) Use educational and technological approaches to
24 promote best practices, educate consumers, and train
25 prescribers in the use of practice guidelines.
26 (VII) Disseminate electronic and published materials.
27 (VIII) Hold statewide and regional conferences.
28 (IX) Implement disease-management programs in
29 cooperation with physicians and pharmacists, along with a
30 model quality-based medication component for individuals
31 having chronic medical conditions.
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1 13.12. The agency is authorized to contract for drug
2 rebate administration, including, but not limited to,
3 calculating rebate amounts, invoicing manufacturers,
4 negotiating disputes with manufacturers, and maintaining a
5 database of rebate collections.
6 14.13. The agency may specify the preferred daily
7 dosing form or strength for the purpose of promoting best
8 practices with regard to the prescribing of certain drugs as
9 specified in the General Appropriations Act and ensuring
10 cost-effective prescribing practices.
11 15.14. The agency may require prior authorization for
12 the off-label use of Medicaid-covered prescribed drugs as
13 specified in the General Appropriations Act. The agency may,
14 but is not required to, preauthorize the use of a product for
15 an indication not in the approved labeling. Prior
16 authorization may require the prescribing professional to
17 provide information about the rationale and supporting medical
18 evidence for the off-label use of a drug.
19 16.15. The agency shall implement a return and reuse
20 program for drugs dispensed by pharmacies to institutional
21 recipients, which includes payment of a $5 restocking fee for
22 the implementation and operation of the program. The return
23 and reuse program shall be implemented electronically and in a
24 manner that promotes efficiency. The program must permit a
25 pharmacy to exclude drugs from the program if it is not
26 practical or cost-effective for the drug to be included and
27 must provide for the return to inventory of drugs that cannot
28 be credited or returned in a cost-effective manner. The agency
29 shall determine if the program has reduced the amount of
30 Medicaid prescription drugs which are destroyed on an annual
31 basis and if there are additional ways to ensure more
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1 prescription drugs are not destroyed which could safely be
2 reused. The agency's conclusion and recommendations shall be
3 reported to the Legislature by December 1, 2005.
4 (b) The agency shall implement this subsection to the
5 extent that funds are appropriated to administer the Medicaid
6 prescribed-drug spending-control program. The agency may
7 contract all or any part of this program to private
8 organizations.
9 (c) The agency shall submit quarterly reports to the
10 Governor, the President of the Senate, and the Speaker of the
11 House of Representatives which must include, but need not be
12 limited to, the progress made in implementing this subsection
13 and its effect on Medicaid prescribed-drug expenditures.
14 (40) Notwithstanding the provisions of chapter 287,
15 the agency may, at its discretion, renew a contract or
16 contracts for fiscal intermediary services one or more times
17 for such periods as the agency may decide; however, all such
18 renewals may not combine to exceed a total period longer than
19 the term of the original contract.
20 (41) The agency shall provide for the development of a
21 demonstration project by establishment in Miami-Dade County of
22 a long-term-care facility licensed pursuant to chapter 395 to
23 improve access to health care for a predominantly minority,
24 medically underserved, and medically complex population and to
25 evaluate alternatives to nursing home care and general acute
26 care for such population. Such project is to be located in a
27 health care condominium and colocated with licensed facilities
28 providing a continuum of care. The establishment of this
29 project is not subject to the provisions of s. 408.036 or s.
30 408.039. The agency shall report its findings to the Governor,
31
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1 the President of the Senate, and the Speaker of the House of
2 Representatives by January 1, 2003.
3 (42) The agency shall develop and implement a
4 utilization management program for Medicaid-eligible
5 recipients for the management of occupational, physical,
6 respiratory, and speech therapies. The agency shall establish
7 a utilization program that may require prior authorization in
8 order to ensure medically necessary and cost-effective
9 treatments. The program shall be operated in accordance with a
10 federally approved waiver program or state plan amendment. The
11 agency may seek a federal waiver or state plan amendment to
12 implement this program. The agency may also competitively
13 procure these services from an outside vendor on a regional or
14 statewide basis.
15 (43) The agency may contract on a prepaid or fixed-sum
16 basis with appropriately licensed prepaid dental health plans
17 to provide dental services.
18 (44) The Agency for Health Care Administration shall
19 ensure that any Medicaid managed care plan as defined in s.
20 409.9122(2)(h), whether paid on a capitated basis or a shared
21 savings basis, is cost-effective. For purposes of this
22 subsection, the term "cost-effective" means that a network's
23 per-member, per-month costs to the state, including, but not
24 limited to, fee-for-service costs, administrative costs, and
25 case-management fees, must be no greater than the state's
26 costs associated with contracts for Medicaid services
27 established under subsection (3), which shall be actuarially
28 adjusted for case mix, model, and service area. The agency
29 shall conduct actuarially sound audits adjusted for case mix
30 and model in order to ensure such cost-effectiveness and shall
31 publish the audit results on its Internet website and submit
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1 the audit results annually to the Governor, the President of
2 the Senate, and the Speaker of the House of Representatives no
3 later than December 31 of each year. Contracts established
4 pursuant to this subsection which are not cost-effective may
5 not be renewed.
6 (45) Subject to the availability of funds, the agency
7 shall mandate a recipient's participation in a provider
8 lock-in program, when appropriate, if a recipient is found by
9 the agency to have used Medicaid goods or services at a
10 frequency or amount not medically necessary, limiting the
11 receipt of goods or services to medically necessary providers
12 after the 21-day appeal process has ended, for a period of not
13 less than 1 year. The lock-in programs shall include, but are
14 not limited to, pharmacies, medical doctors, and infusion
15 clinics. The limitation does not apply to emergency services
16 and care provided to the recipient in a hospital emergency
17 department. The agency shall seek any federal waivers
18 necessary to implement this subsection. The agency shall adopt
19 any rules necessary to comply with or administer this
20 subsection.
21 (46) The agency shall seek a federal waiver for
22 permission to terminate the eligibility of a Medicaid
23 recipient who has been found to have committed fraud, through
24 judicial or administrative determination, two times in a
25 period of 5 years.
26 (47) The agency shall conduct a study of available
27 electronic systems for the purpose of verifying the identity
28 and eligibility of a Medicaid recipient. The agency shall
29 recommend to the Legislature a plan to implement an electronic
30 verification system for Medicaid recipients by January 31,
31 2005.
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1 (48) A provider is not entitled to enrollment in the
2 Medicaid provider network. The agency may implement a Medicaid
3 fee-for-service provider network controls, including, but not
4 limited to, competitive procurement and provider
5 credentialing. If a credentialing process is used, the agency
6 may limit its provider network based upon the following
7 considerations: beneficiary access to care, provider
8 availability, provider quality standards and quality assurance
9 processes, cultural competency, demographic characteristics of
10 beneficiaries, practice standards, service wait times,
11 provider turnover, provider licensure and accreditation
12 history, program integrity history, peer review, Medicaid
13 policy and billing compliance records, clinical and medical
14 record audit findings, and such other areas that are
15 considered necessary by the agency to ensure the integrity of
16 the program.
17 (49) The agency shall contract with established
18 minority physician networks that provide services to
19 historically underserved minority patients. The networks must
20 provide cost-effective Medicaid services, comply with the
21 requirements to be a MediPass provider, and provide their
22 primary care physicians with access to data and other
23 management tools necessary to assist them in ensuring the
24 appropriate use of services, including inpatient hospital
25 services and pharmaceuticals.
26 (a) The agency shall provide for the development and
27 expansion of minority physician networks in each service area
28 to provide services to Medicaid recipients who are eligible to
29 participate under federal law and rules.
30 (b) The agency shall reimburse each minority physician
31 network as a fee-for-service provider, including the case
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1 management fee for primary care, or as a capitated rate
2 provider for Medicaid services. Any savings shall be shared
3 with the minority physician networks pursuant to the contract.
4 (c) For purposes of this subsection, the term
5 "cost-effective" means that a network's per-member, per-month
6 costs to the state, including, but not limited to,
7 fee-for-service costs, administrative costs, and
8 case-management fees, must be no greater than the state's
9 costs associated with contracts for Medicaid services
10 established under subsection (3), which shall be actuarially
11 adjusted for case mix, model, and service area. The agency
12 shall conduct actuarially sound audits adjusted for case mix
13 and model in order to ensure such cost-effectiveness and shall
14 publish the audit results on its Internet website and submit
15 the audit results annually to the Governor, the President of
16 the Senate, and the Speaker of the House of Representatives no
17 later than December 31. Contracts established pursuant to this
18 subsection which are not cost-effective may not be renewed.
19 (d) The agency may apply for any federal waivers
20 needed to implement this subsection.
21 (50) The agency may contract with established
22 federally qualified health centers that provide services to
23 historically underserved and uninsured patients. The networks
24 must provide cost-effective Medicaid services, comply with the
25 requirements of a MediPass provider, and provide their primary
26 care physicians with access to data and other management tools
27 necessary to assist them in ensuring the appropriate use of
28 services, including inpatient hospital services and
29 pharmaceuticals.
30 (a) The agency may provide for the development and
31 expansion of federally qualified health center based provider
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1 service networks in each service area to provide services to
2 Medicaid recipients who are eligible to participate under
3 federal law and rules.
4 (b) The agency may reimburse each federally qualified
5 health center based network as a fee-for-service provider,
6 including the case management fee for primary care or as a
7 capitated rate provider for Medicaid services. Any savings
8 shall be shared with the federally qualified health center
9 networks under the contract.
10 (c) For purposes of this subsection, the term
11 "cost-effective" means that a network's per-member, per-month
12 costs to the state, including, but not limited to,
13 fee-for-service costs, administrative costs, and
14 case-management fees must be no greater than the state's costs
15 associated with contracts for Medicaid services, which shall
16 be actuarially adjusted for case mix, model, and service area.
17 The agency shall conduct actuarially sound audits adjusted for
18 case mix and model in order to ensure such cost-effectiveness
19 and shall publish the audit results on its Internet website
20 and submit the audit results annually to the Governor, the
21 President of the Senate, and the Speaker of the House of
22 Representatives no later than December 31.
23 (d) The agency may apply for any federal waivers
24 needed to administer this subsection.
25 (51) To the extent permitted by federal law and as
26 allowed under s. 409.906, the agency shall provide
27 reimbursement for emergency mental health care services for
28 Medicaid recipients in crisis-stabilization facilities
29 licensed under s. 394.875 as long as those services are less
30 expensive than the same services provided in a hospital
31 setting.
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1 Section 2. Section 409.91211, Florida Statutes, is
2 created to read:
3 409.91211 Medicaid managed care pilot program.--
4 (1) The agency is authorized to seek experimental,
5 pilot, or demonstration project waivers, pursuant to s. 1115
6 of the Social Security Act, to create a more efficient and
7 effective service delivery system that enhances quality of
8 care and client outcomes in the Florida Medicaid program
9 pursuant to this section in two geographic areas. One
10 demonstration site shall include only Broward County. A second
11 demonstration site shall initially include Duval County and
12 shall be expanded to include Baker, Clay, and Nassau Counties
13 within 1 year after the Duval County program becomes
14 operational. This waiver authority is contingent upon federal
15 approval to preserve the upper-payment-limit funding mechanism
16 for hospitals, including a guarantee of a reasonable growth
17 factor, a methodology to allow the use of a portion of these
18 funds to serve as a risk pool for demonstration sites,
19 provisions to preserve the state's ability to use
20 intergovernmental transfers, and provisions to protect the
21 disproportionate share program authorized pursuant to this
22 chapter.
23 (2) The Legislature intends for the capitated managed
24 care pilot program to:
25 (a) Provide recipients in Medicaid fee-for-service or
26 the MediPass program a comprehensive and coordinated capitated
27 managed care system for all health care services specified in
28 ss. 409.905 and 409.906.
29 (b) Stabilize Medicaid expenditures under the pilot
30 program compared to Medicaid expenditures in the pilot area
31
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1 for the 3 years before implementation of the pilot program,
2 while ensuring:
3 1. Consumer education and choice.
4 2. Access to medically necessary services.
5 3. Coordination of preventative, acute, and long-term
6 care.
7 4. Reductions in unnecessary service utilization.
8 (c) Provide an opportunity to evaluate the feasibility
9 of statewide implementation of capitated managed care networks
10 as a replacement for the current Medicaid fee-for-service and
11 MediPass systems.
12 (3) The agency shall have the following powers,
13 duties, and responsibilities with respect to the development
14 of a pilot program:
15 (a) To develop and recommend a system to deliver all
16 health care services specified in ss. 409.905 and 409.906,
17 which shall not vary in amount, duration, or scope beyond what
18 is allowed in current managed care contracts in the form of
19 capitated managed care networks under the Medicaid program.
20 (b) To recommend Medicaid-eligibility categories, from
21 those specified in ss. 409.903 and 409.904, which shall be
22 included in the pilot program.
23 (c) To determine and recommend how to design the
24 managed care pilot program in order to take maximum advantage
25 of all available state and federal funds, including those
26 obtained through intergovernmental transfers, the
27 upper-payment-level funding systems, and the disproportionate
28 share program.
29 (d) To determine and recommend actuarially sound,
30 risk-adjusted capitation rates for Medicaid recipients in the
31
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1 pilot program which can be separated to cover comprehensive
2 care, enhanced services, and catastrophic care.
3 (e) To determine and recommend policies and guidelines
4 for phasing in financial risk for approved provider service
5 networks over a 3-year period. These shall include an option
6 to pay fee-for-service rates that may include a
7 savings-settlement option for at least 2 years. This model may
8 be converted to a risk-adjusted capitated rate in the third
9 year of operation. Federally qualified health centers may be
10 offered an opportunity to accept or decline a contract to
11 participate in any provider network for prepaid primary care
12 services.
13 (f) To determine and recommend provisions related to
14 stop-loss requirements and the transfer of excess cost to
15 catastrophic coverage that accommodates the risks associated
16 with the development of the pilot program.
17 (g) To determine and recommend a process to be used by
18 the Social Services Estimating Conference to determine and
19 validate the rate of growth of the per-member costs of
20 providing Medicaid services under the managed care pilot
21 program.
22 (h) To determine and recommend program standards and
23 credentialing requirements for capitated managed care networks
24 to participate in the pilot program, including those related
25 to fiscal solvency, quality of care, and adequacy of access to
26 health care providers. It is the intent of the Legislature
27 that, to the extent possible, any pilot program authorized by
28 the state under this section include any federally qualified
29 health center, federally qualified rural health clinic, county
30 health department, or other federally, state, or locally
31 funded entity that serves the geographic areas within the
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1 boundaries of the pilot program that requests to participate.
2 This paragraph does not relieve an entity that qualifies as a
3 capitated managed care network under this section from any
4 other licensure or regulatory requirements contained in state
5 or federal law which would otherwise apply to the entity. The
6 standards and credentialing requirements shall be based upon,
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 9. The network's infrastructure capacity to manage
27 financial transactions, recordkeeping, data collection, and
28 other administrative functions.
29 10. The network's ability to submit any financial,
30 programmatic, or patient-encounter data or other information
31
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1 required by the agency to determine the actual services
2 provided and the cost of administering the plan.
3 (i) To develop and recommend a mechanism for providing
4 information to Medicaid recipients for the purpose of
5 selecting a capitated managed care plan. For each plan
6 available to a recipient, the agency, at a minimum shall
7 ensure that the recipient is provided with:
8 1. A list and description of the benefits provided.
9 2. Information about cost sharing.
10 3. Plan performance data, if available.
11 4. An explanation of benefit limitations.
12 5. Contact information, including identification of
13 providers participating in the network, geographic locations,
14 and transportation limitations.
15 6. Any other information the agency determines would
16 facilitate a recipient's understanding of the plan or
17 insurance that would best meet his or her needs.
18 (j) To develop and recommend a system to ensure that
19 there is a record of recipient acknowledgment that choice
20 counseling has been provided.
21 (k) To develop and recommend a choice counseling
22 system to ensure that the choice counseling process and
23 related material are designed to provide counseling through
24 face-to-face interaction, by telephone, and in writing and
25 through other forms of relevant media. Materials shall be
26 written at the fourth-grade reading level and available in a
27 language other than English when 5 percent of the county
28 speaks a language other than English. Choice counseling shall
29 also use language lines and other services for impaired
30 recipients, such as TTD/TTY.
31
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1 (l) To develop and recommend a system that prohibits
2 capitated managed care plans, their representatives, and
3 providers employed by or contracted with the capitated managed
4 care plans from recruiting persons eligible for or enrolled in
5 Medicaid, from providing inducements to Medicaid recipients to
6 select a particular capitated managed care plan, and from
7 prejudicing Medicaid recipients against other capitated
8 managed care plans. The system shall require the entity
9 performing choice counseling to determine if the recipient has
10 made a choice of a plan or has opted out because of duress,
11 threats, payment to the recipient, or incentives promised to
12 the recipient by a third party. If the choice counseling
13 entity determines that the decision to choose a plan was
14 unlawfully influenced or a plan violated any of the provisions
15 of s. 409.912(21), the choice counseling entity shall
16 immediately report the violation to the agency's program
17 integrity section for investigation.Verification of choice
18 counseling by the recipient shall include a stipulation that
19 the recipient acknowledges the provisions of this subsection.
20 (m) To develop and recommend a choice counseling
21 system that promotes health literacy and provides information
22 aimed to reduce minority health disparities through outreach
23 activities for Medicaid recipients.
24 (n) To develop and recommend a system for the agency
25 to contract with entities to perform choice counseling. The
26 agency may establish standards and performance contracts,
27 including standards requiring the contractor to hire choice
28 counselors who are representative of the state's diverse
29 population and to train choice counselors in working with
30 culturally diverse populations.
31
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1 (o) To determine and recommend descriptions of the
2 eligibility assignment processes which will be used to
3 facilitate client choice while ensuring pilot programs of
4 adequate enrollment levels. These processes shall ensure that
5 pilot sites have sufficient levels of enrollment to conduct a
6 valid test of the managed care pilot program within a 2-year
7 timeframe.
8 (p) To develop and recommend a system to monitor the
9 provision of health care services in the pilot program,
10 including utilization and quality of health care services for
11 the purpose of ensuring access to medically necessary
12 services. This system shall include an encounter
13 data-information system that collects and reports utilization
14 information. The system shall include a method for verifying
15 data integrity within the database and within the provider's
16 medical records.
17 (q) To recommend a grievance-resolution process for
18 Medicaid recipients enrolled in a capitated managed care
19 network under the pilot program modeled after the subscriber
20 assistance panel, as created in s. 408.7056. This process
21 shall include a mechanism for an expedited review of no
22 greater than 24 hours after notification of a grievance if the
23 life of a Medicaid recipient is in imminent and emergent
24 jeopardy.
25 (r) To recommend a grievance-resolution process for
26 health care providers employed by or contracted with a
27 capitated managed care network under the pilot program in
28 order to settle disputes among the provider and the managed
29 care network or the provider and the agency.
30 (s) To develop and recommend criteria to designate
31 health care providers as eligible to participate in the pilot
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1 program. The agency and capitated managed care networks must
2 follow national guidelines for selecting health care
3 providers, whenever available. These criteria must include at
4 a minimum those criteria specified in s. 409.907.
5 (t) To develop and recommend health care provider
6 agreements for participation in the pilot program.
7 (u) To require that all health care providers under
8 contract with the pilot program be duly licensed in the state,
9 if such licensure is available, and meet other criteria as may
10 be established by the agency. These criteria shall include at
11 a minimum those criteria specified in s. 409.907.
12 (v) To develop and recommend agreements with other
13 state or local governmental programs or institutions for the
14 coordination of health care to eligible individuals receiving
15 services from such programs or institutions.
16 (w) To develop and recommend a system to oversee the
17 activities of pilot program participants, health care
18 providers, capitated managed care networks, and their
19 representatives in order to prevent fraud or abuse,
20 overutilization or duplicative utilization, underutilization
21 or inappropriate denial of services, and neglect of
22 participants and to recover overpayments as appropriate. For
23 the purposes of this paragraph, the terms "abuse" and "fraud"
24 have the meanings as provided in s. 409.913. The agency must
25 refer incidents of suspected fraud, abuse, overutilization and
26 duplicative utilization, and underutilization or inappropriate
27 denial of services to the appropriate regulatory agency.
28 (x) To develop and provide actuarial and benefit
29 design analyses that indicate the effect on capitation rates
30 and benefits offered in the pilot program over a prospective
31 5-year period based on the following assumptions:
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1 1. Growth in capitation rates which is limited to the
2 estimated growth rate in general revenue.
3 2. Growth in capitation rates which is limited to the
4 average growth rate over the last 3 years in per-recipient
5 Medicaid expenditures.
6 3. Growth in capitation rates which is limited to the
7 growth rate of aggregate Medicaid expenditures between the
8 2003-2004 fiscal year and the 2004-2005 fiscal year.
9 (y) To develop a mechanism to require capitated
10 managed care plans to reimburse qualified emergency service
11 providers, including, but not limited to, ambulance services,
12 in accordance with ss. 409.908 and 409.9128. The pilot program
13 must include a provision for continuation of fee-for-service
14 payments for individuals who access emergency departments and
15 subsequently are determined eligible for Medicaid services.
16 The pilot program must include a provision for continuing
17 fee-for-service payments for emergency services, including but
18 not limited to, individuals who access ambulance services or
19 emergency departments and who are subsequently determined to
20 be eligible for Medicaid services.
21 (z) To develop a system whereby school districts
22 participating in the certified school match program pursuant
23 to ss. 409.908(21) and 1011.70 shall be reimbursed by
24 Medicaid, subject to the limitations of s. 1011.70(1), for a
25 Medicaid-eligible child participating in the services as
26 authorized in s. 1011.70, as provided for in s. 409.9071,
27 regardless of whether the child is enrolled in a capitated
28 managed care network. Capitated managed care networks must
29 make a good-faith effort to execute agreements with school
30 districts regarding the coordinated provision of services
31 authorized under s. 1011.70. County health departments
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1 delivering school-based services pursuant to ss. 381.0056 and
2 381.0057 must be reimbursed by Medicaid for the federal share
3 for a Medicaid-eligible child who receives Medicaid-covered
4 services in a school setting, regardless of whether the child
5 is enrolled in a capitated managed care network. Capitated
6 managed care networks must make a good-faith effort to execute
7 agreements with county health departments regarding the
8 coordinated provision of services to a Medicaid-eligible
9 child. To ensure continuity of care for Medicaid patients, the
10 agency, the Department of Health, and the Department of
11 Education shall develop procedures for ensuring that a
12 student's capitated managed care network provider receives
13 information relating to services provided in accordance with
14 ss. 381.0056, 381.0057, 409.9071, and 1011.70.
15 (aa) To develop and recommend a mechanism whereby
16 Medicaid recipients who are already enrolled in a managed care
17 plan or the MediPass program in the pilot areas shall be
18 offered the opportunity to change to capitated managed care
19 plans on a staggered basis, as defined by the agency. All
20 Medicaid recipients shall have 30 days in which to make a
21 choice of capitated managed care plans. Those Medicaid
22 recipients who do not make a choice shall be assigned to a
23 capitated managed care plan in accordance with paragraph
24 (4)(a). To facilitate continuity of care for a Medicaid
25 recipient who is also a recipient of Supplemental Security
26 Income (SSI), prior to assigning the SSI recipient to a
27 capitated managed care plan, the agency shall determine
28 whether the SSI recipient has an ongoing relationship with a
29 provider or capitated managed care plan, and if so, the agency
30 shall assign the SSI recipient to that provider or capitated
31 managed care plan where feasible. Those SSI recipients who do
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1 not have such a provider relationship shall be assigned to a
2 capitated managed care plan provider in accordance with
3 paragraph (4)(a).
4 (bb) To develop and recommend a service delivery
5 alternative for children having chronic medical conditions
6 which establishes a medical home project to provide primary
7 care services to this population. The project shall provide
8 community-based primary care services that are integrated with
9 other subspecialties to meet the medical, developmental, and
10 emotional needs for children and their families. This project
11 shall include an evaluation component to determine impacts on
12 hospitalizations, length of stays, emergency room visits,
13 costs, and access to care, including specialty care and
14 patient, and family satisfaction.
15 (cc) To develop and recommend service delivery
16 mechanisms within capitated managed care plans to provide
17 Medicaid services as specified in ss. 409.905 and 409.906 to
18 persons with developmental disabilities sufficient to meet the
19 medical, developmental, and emotional needs of these persons.
20 (dd) To develop and recommend service delivery
21 mechanisms within capitated managed care plans to provide
22 Medicaid services as specified in ss. 409.905 and 409.906 to
23 Medicaid-eligible children in foster care. These services must
24 be coordinated with community-based care providers as
25 specified in s. 409.1675, where available, and be sufficient
26 to meet the medical, developmental, and emotional needs of
27 these children.
28 (4)(a) A Medicaid recipient in the pilot area who is
29 not currently enrolled in a capitated managed care plan upon
30 implementation is not eligible for services as specified in
31 ss. 409.905 and 409.906, for the amount of time that the
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1 recipient does not enroll in a capitated managed care network.
2 If a Medicaid recipient has not enrolled in a capitated
3 managed care plan within 30 days after eligibility, the agency
4 shall assign the Medicaid recipient to a capitated managed
5 care plan based on the assessed needs of the recipient as
6 determined by the agency. When making assignments, the agency
7 shall take into account the following criteria:
8 1. A capitated managed care network has sufficient
9 network capacity to meet the need of members.
10 2. The capitated managed care network has previously
11 enrolled the recipient as a member, or one of the capitated
12 managed care network's primary care providers has previously
13 provided health care to the recipient.
14 3. The agency has knowledge that the member has
15 previously expressed a preference for a particular capitated
16 managed care network as indicated by Medicaid fee-for-service
17 claims data, but has failed to make a choice.
18 4. The capitated managed care network's primary care
19 providers are geographically accessible to the recipient's
20 residence.
21 (b) When more than one capitated managed care network
22 provider meets the criteria specified in paragraph (3)(j), the
23 agency shall make recipient assignments consecutively by
24 family unit.
25 (c) The agency may not engage in practices that are
26 designed to favor one capitated managed care plan over another
27 or that are designed to influence Medicaid recipients to
28 enroll in a particular capitated managed care network in order
29 to strengthen its particular fiscal viability.
30 (d) After a recipient has made a selection or has been
31 enrolled in a capitated managed care network, the recipient
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1 shall have 90 days in which to voluntarily disenroll and
2 select another capitated managed care network. After 90 days,
3 no further changes may be made except for cause. Cause shall
4 include, but not be limited to, poor quality of care, lack of
5 access to necessary specialty services, an unreasonable delay
6 or denial of service, inordinate or inappropriate changes of
7 primary care providers, service access impairments due to
8 significant changes in the geographic location of services, or
9 fraudulent enrollment. The agency may require a recipient to
10 use the capitated managed care network's grievance process as
11 specified in paragraph (3)(h) prior to the agency's
12 determination of cause, except in cases in which immediate
13 risk of permanent damage to the recipient's health is alleged.
14 The grievance process, when used, must be completed in time to
15 permit the recipient to disenroll no later than the first day
16 of the second month after the month the disenrollment request
17 was made. If the capitated managed care network, as a result
18 of the grievance process, approves an enrollee's request to
19 disenroll, the agency is not required to make a determination
20 in the case. The agency must make a determination and take
21 final action on a recipient's request so that disenrollment
22 occurs no later than the first day of the second month after
23 the month the request was made. If the agency fails to act
24 within the specified timeframe, the recipient's request to
25 disenroll is deemed to be approved as of the date agency
26 action was required. Recipients who disagree with the agency's
27 finding that cause does not exist for disenrollment shall be
28 advised of their right to pursue a Medicaid fair hearing to
29 dispute the agency's finding.
30 (e) The agency shall apply for federal waivers from
31 the Centers for Medicare and Medicaid Services to lock
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1 eligible Medicaid recipients into a capitated managed care
2 network for 12 months after an open enrollment period. After
3 12 months of enrollment, a recipient may select another
4 capitated managed care network. However, nothing shall prevent
5 a Medicaid recipient from changing primary care providers
6 within the capitated managed care network during the 12-month
7 period.
8 (f) The agency shall apply for federal waivers from
9 the Centers for Medicare and Medicaid Services to allow
10 recipients to purchase health care coverage through an
11 employer-sponsored health insurance plan instead of through a
12 Medicaid-certified plan. This provision shall be known as the
13 opt-out option.
14 1. A recipient who chooses the Medicaid opt-out option
15 shall have an opportunity for a specified period of time, as
16 authorized under a waiver granted by the Centers for Medicare
17 and Medicaid Services, to select and enroll in a
18 Medicaid-certified plan. If the recipient remains in the
19 employer-sponsored plan after the specified period, the
20 recipient shall remain in the opt-out program for at least 1
21 year or until the recipient no longer has access to
22 employer-sponsored coverage, until the employer's open
23 enrollment period for a person who opts out in order to
24 participate in employer-sponsored coverage, or until the
25 person is no longer eligible for Medicaid, whichever time
26 period is shorter.
27 2. Notwithstanding any other provision of this
28 section, coverage, cost sharing, and any other component of
29 employer-sponsored health insurance shall be governed by
30 applicable state and federal laws.
31
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1 (5) This section does not authorize the agency to
2 implement any provision of s. 1115 of the Social Security Act
3 experimental, pilot, or demonstration project waiver to reform
4 the state Medicaid program in any part of the state other than
5 the two geographic areas specified in this section unless
6 approved by the Legislature.
7 (6) The agency shall develop and submit for approval
8 applications for waivers of applicable federal laws and
9 regulations as necessary to implement the managed care pilot
10 project as defined in this section. The agency shall post all
11 waiver applications under this section on its Internet website
12 30 days before submitting the applications to the United
13 States Centers for Medicare and Medicaid Services. All waiver
14 applications shall be provided for review and comment to the
15 appropriate committees of the Senate and House of
16 Representatives for at least 10 working days prior to
17 submission. All waivers submitted to and approved by the
18 United States Centers for Medicare and Medicaid Services under
19 this section must be submitted to the appropriate committees
20 of the Senate and the House of Representatives in order to
21 obtain authority for implementation as required by s.
22 409.912(11), before program implementation. The appropriate
23 committees shall recommend whether to approve the
24 implementation of the waivers to the Legislature or to the
25 Legislative Budget Commission if the Legislature is not in
26 session. The agency shall submit a plan containing a detailed
27 timeline for implementation and budgetary projections of the
28 effect of the pilot program on the total Medicaid budget for
29 the 2006-2007 through 2009-2010 fiscal years.
30 (7) Upon review and approval of the applications for
31 waivers of applicable federal laws and regulations to
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1 implement the managed care pilot program by the Legislature,
2 the agency may initiate adoption of rules pursuant to ss.
3 120.536(1) and 120.54 to implement and administer the managed
4 care pilot program as provided in this section.
5 Section 3. The Office of Program Policy Analysis and
6 Government Accountability, in consultation with the Auditor
7 General, shall comprehensively evaluate the two managed care
8 pilot programs created under section 409.91211, Florida
9 Statutes. The evaluation shall begin with the implementation
10 of the managed care model in the pilot areas and continue for
11 24 months after the two pilot programs have enrolled Medicaid
12 recipients and started providing health care services. The
13 evaluation must include assessments of cost savings; consumer
14 education, choice, and access to services; coordination of
15 care; and quality of care by each eligibility category and
16 managed care plan in each pilot site. The evaluation must
17 describe administrative or legal barriers to the
18 implementation and operation of each pilot program and include
19 recommendations regarding statewide expansion of the managed
20 care pilot programs. The office shall submit an evaluation
21 report to the Governor, the President of the Senate, and the
22 Speaker of the House of Representatives no later than June 30,
23 2008. The managed care pilot program may not be expanded to
24 any additional counties that are not identified in this
25 section without the authorization of the Legislature.
26 Section 4. Paragraphs (a) and (j) of subsection (2) of
27 section 409.9122, Florida Statutes, are amended to read:
28 409.9122 Mandatory Medicaid managed care enrollment;
29 programs and procedures.--
30 (2)(a) The agency shall enroll in a managed care plan
31 or MediPass all Medicaid recipients, except those Medicaid
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1 recipients who are: in an institution; enrolled in the
2 Medicaid medically needy program; or eligible for both
3 Medicaid and Medicare. Upon enrollment, individuals will be
4 able to change their managed care option during the 90-day opt
5 out period required by federal Medicaid regulations. The
6 agency is authorized to seek the necessary Medicaid state plan
7 amendment to implement this policy. However, to the extent
8 permitted by federal law, the agency may enroll in a managed
9 care plan or MediPass a Medicaid recipient who is exempt from
10 mandatory managed care enrollment, provided that:
11 1. The recipient's decision to enroll in a managed
12 care plan or MediPass is voluntary;
13 2. If the recipient chooses to enroll in a managed
14 care plan, the agency has determined that the managed care
15 plan provides specific programs and services which address the
16 special health needs of the recipient; and
17 3. The agency receives any necessary waivers from the
18 federal Centers for Medicare and Medicaid Services Health Care
19 Financing Administration.
20
21 The agency shall develop rules to establish policies by which
22 exceptions to the mandatory managed care enrollment
23 requirement may be made on a case-by-case basis. The rules
24 shall include the specific criteria to be applied when making
25 a determination as to whether to exempt a recipient from
26 mandatory enrollment in a managed care plan or MediPass.
27 School districts participating in the certified school match
28 program pursuant to ss. 409.908(21) and 1011.70 shall be
29 reimbursed by Medicaid, subject to the limitations of s.
30 1011.70(1), for a Medicaid-eligible child participating in the
31 services as authorized in s. 1011.70, as provided for in s.
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1 409.9071, regardless of whether the child is enrolled in
2 MediPass or a managed care plan. Managed care plans shall make
3 a good faith effort to execute agreements with school
4 districts regarding the coordinated provision of services
5 authorized under s. 1011.70. County health departments
6 delivering school-based services pursuant to ss. 381.0056 and
7 381.0057 shall be reimbursed by Medicaid for the federal share
8 for a Medicaid-eligible child who receives Medicaid-covered
9 services in a school setting, regardless of whether the child
10 is enrolled in MediPass or a managed care plan. Managed care
11 plans shall make a good faith effort to execute agreements
12 with county health departments regarding the coordinated
13 provision of services to a Medicaid-eligible child. To ensure
14 continuity of care for Medicaid patients, the agency, the
15 Department of Health, and the Department of Education shall
16 develop procedures for ensuring that a student's managed care
17 plan or MediPass provider receives information relating to
18 services provided in accordance with ss. 381.0056, 381.0057,
19 409.9071, and 1011.70.
20 (j) The agency shall apply for a federal waiver from
21 the Centers for Medicare and Medicaid Services Health Care
22 Financing Administration to lock eligible Medicaid recipients
23 into a managed care plan or MediPass for 12 months after an
24 open enrollment period. After 12 months' enrollment, a
25 recipient may select another managed care plan or MediPass
26 provider. However, nothing shall prevent a Medicaid recipient
27 from changing primary care providers within the managed care
28 plan or MediPass program during the 12-month period.
29 Section 5. Subsection (2) of section 409.913, Florida
30 Statutes, is amended, and subsection (36) is added to that
31 section, to read:
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1 409.913 Oversight of the integrity of the Medicaid
2 program.--The agency shall operate a program to oversee the
3 activities of Florida Medicaid recipients, and providers and
4 their representatives, to ensure that fraudulent and abusive
5 behavior and neglect of recipients occur to the minimum extent
6 possible, and to recover overpayments and impose sanctions as
7 appropriate. Beginning January 1, 2003, and each year
8 thereafter, the agency and the Medicaid Fraud Control Unit of
9 the Department of Legal Affairs shall submit a joint report to
10 the Legislature documenting the effectiveness of the state's
11 efforts to control Medicaid fraud and abuse and to recover
12 Medicaid overpayments during the previous fiscal year. The
13 report must describe the number of cases opened and
14 investigated each year; the sources of the cases opened; the
15 disposition of the cases closed each year; the amount of
16 overpayments alleged in preliminary and final audit letters;
17 the number and amount of fines or penalties imposed; any
18 reductions in overpayment amounts negotiated in settlement
19 agreements or by other means; the amount of final agency
20 determinations of overpayments; the amount deducted from
21 federal claiming as a result of overpayments; the amount of
22 overpayments recovered each year; the amount of cost of
23 investigation recovered each year; the average length of time
24 to collect from the time the case was opened until the
25 overpayment is paid in full; the amount determined as
26 uncollectible and the portion of the uncollectible amount
27 subsequently reclaimed from the Federal Government; the number
28 of providers, by type, that are terminated from participation
29 in the Medicaid program as a result of fraud and abuse; and
30 all costs associated with discovering and prosecuting cases of
31 Medicaid overpayments and making recoveries in such cases. The
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1 report must also document actions taken to prevent
2 overpayments and the number of providers prevented from
3 enrolling in or reenrolling in the Medicaid program as a
4 result of documented Medicaid fraud and abuse and must
5 recommend changes necessary to prevent or recover
6 overpayments.
7 (2) The agency shall conduct, or cause to be conducted
8 by contract or otherwise, reviews, investigations, analyses,
9 audits, or any combination thereof, to determine possible
10 fraud, abuse, overpayment, or recipient neglect in the
11 Medicaid program and shall report the findings of any
12 overpayments in audit reports as appropriate. At least 5
13 percent of all audits shall be conducted on a random basis.
14 (36) The agency shall provide to each Medicaid
15 recipient or his or her representative an explanation of
16 benefits in the form of a letter that is mailed to the most
17 recent address of the recipient on the record with the
18 Department of Children and Family Services. The explanation of
19 benefits must include the patient's name, the name of the
20 health care provider and the address of the location where the
21 service was provided, a description of all services billed to
22 Medicaid in terminology that should be understood by a
23 reasonable person, and information on how to report
24 inappropriate or incorrect billing to the agency or other law
25 enforcement entities for review or investigation.
26 Section 6. The Agency for Health Care Administration
27 shall submit to the Legislature by December 15, 2005, a report
28 on the legal and administrative barriers to enforcing section
29 409.9081, Florida Statutes. The report must describe how many
30 services require copayments, which providers collect
31 copayments, and the total amount of copayments collected from
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1 recipients for all services required under section 409.9081,
2 Florida Statutes, by provider type for the 2001-2002 through
3 2004-2005 fiscal years. The agency shall recommend a mechanism
4 to enforce the requirement for Medicaid recipients to make
5 copayments which does not shift the copayment amount to the
6 provider. The agency shall also identify the federal or state
7 laws or regulations that permit Medicaid recipients to declare
8 impoverishment in order to avoid paying the copayment and
9 extent to which these statements of impoverishment are
10 verified. If claims of impoverishment are not currently
11 verified, the agency shall recommend a system for such
12 verification. The report must also identify any other
13 cost-sharing measures that could be imposed on Medicaid
14 recipients.
15 Section 7. The Agency for Health Care Administration
16 shall submit to the Legislature by January 15, 2006,
17 recommendations to ensure that Medicaid is the payer of last
18 resort as required by section 409.910, Florida Statutes. The
19 report must identify the public and private entities that are
20 liable for primary payment of health care services and
21 recommend methods to improve enforcement of third-party
22 liability responsibility and repayment of benefits to the
23 state Medicaid program. The report must estimate the potential
24 recoveries that may be achieved through third-party liability
25 efforts if administrative and legal barriers are removed. The
26 report must recommend whether modifications to the agency's
27 contingency-fee contract for third-party liability could
28 enhance third-party liability for benefits provided to
29 Medicaid recipients.
30 Section 8. By January 15, 2006, the Office of Program
31 Policy Analysis and Government Accountability shall submit to
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1 the Legislature a study of the long-term care community
2 diversion pilot project authorized under sections
3 430.701-430.709, Florida Statutes. The study may be conducted
4 by staff of the Office of Program Policy Analysis and
5 Government Accountability or by a consultant obtained through
6 a competitive bid pursuant to the provisions of chapter 287,
7 Florida Statutes. The study must use a statistically-valid
8 methodology to assess the percent of persons served in the
9 project over a 2-year period who would have required Medicaid
10 nursing home services without the diversion services, which
11 services are most frequently used, and which services are
12 least frequently used. The study must determine whether the
13 project is cost-effective or is an expansion of the Medicaid
14 program because a preponderance of the project enrollees would
15 not have required Medicaid nursing home services within a
16 2-year period regardless of the availability of the project or
17 that the enrollees could have been safely served through
18 another Medicaid program at a lower cost to the state.
19 Section 9. The Agency for Health Care Administration
20 shall identify how many individuals in the long-term care
21 diversion programs who receive care at home have a
22 patient-responsibility payment associated with their
23 participation in the diversion program. If no system is
24 available to assess this information, the agency shall
25 determine the cost of creating a system to identify and
26 collect these payments and whether the cost of developing a
27 system for this purpose is offset by the amount of
28 patient-responsibility payments which could be collected with
29 the system. The agency shall report this information to the
30 Legislature by December 1, 2005.
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1 Section 10. The Office of Program Policy Analysis and
2 Government Accountability shall conduct a study of state
3 programs that allow non-Medicaid eligible persons under a
4 certain income level to buy into the Medicaid program as if it
5 was private insurance. The study shall examine Medicaid buy-in
6 programs in other states to determine if there are any models
7 that can be implemented in Florida which would provide access
8 to uninsured Floridians and what effect this program would
9 have on Medicaid expenditures based on the experience of
10 similar states. The study must also examine whether the
11 Medically Needy program could be redesigned to be a Medicaid
12 buy-in program. The study must be submitted to the Legislature
13 by January 1, 2006.
14 Section 11. The Office of Program Policy Analysis and
15 Government Accountability, in consultation with the Office of
16 Attorney General, Medicaid Fraud Control Unit and the Auditor
17 General, shall conduct a study to examine issues related to
18 the amount of state and federal dollars lost due to fraud and
19 abuse in the Medicaid prescription drug program. The study
20 shall focus on examining whether pharmaceutical manufacturers
21 and their affiliates and wholesale pharmaceutical
22 manufacturers and their affiliates that participate in the
23 Medicaid program in this state, with respect to rebates for
24 prescription drugs, are inflating the average wholesale price
25 that is used in determining how much the state pays for
26 prescription drugs for Medicaid recipients. The study shall
27 also focus on examining whether the manufacturers and their
28 affiliates are committing other deceptive pricing practices
29 with regard to federal and state rebates for prescription
30 drugs in the Medicaid program in this state. The study,
31 including findings and recommendations, shall be submitted to
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1 the Governor, the President of the Senate, the Speaker of the
2 House of Representatives, the Minority Leader of the Senate,
3 and the Minority Leader of the House of Representatives by
4 January 1, 2006.
5 Section 12. The sums of $7,129,241 in recurring
6 General Revenue Funds, $9,076,875 in nonrecurring General
7 Revenue Funds, $8,608,242 in recurring funds from the
8 Administrative Trust Fund, and $9,076,874 in nonrecurring
9 funds from the Administrative Trust Fund are appropriated and
10 11 full time equivalent positions are authorized for the
11 purpose of implementing this act.
12 Section 13. This act shall take effect July 1, 2005.
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