Senate Bill sb2176c2

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    Florida Senate - 2006                    CS for CS for SB 2176

    By the Committees on Health and Human Services Appropriations;
    Health Care; and Senator Peaden




    603-2139-06

  1                      A bill to be entitled

  2         An act relating to rural health care; amending

  3         s. 381.0405, F.S.; revising the purpose and

  4         functions of the Office of Rural Health in the

  5         Department of Health; requiring the Secretary

  6         of Health and the Secretary of Health Care

  7         Administration to appoint an advisory council

  8         to advise the Office of Rural Health; providing

  9         for terms of office of the members of the

10         advisory council; authorizing per diem and

11         travel reimbursement for members of the

12         advisory council; requiring the Office of Rural

13         Health to submit an annual report to the

14         Governor and the Legislature; amending s.

15         381.0406, F.S.; revising legislative findings

16         and intent with respect to rural health

17         networks; redefining the term "rural health

18         network"; establishing requirements for

19         membership in rural health networks; adding

20         functions for the rural health networks;

21         revising requirements for the governance and

22         organization of rural health networks; revising

23         the services to be provided by provider members

24         of rural health networks; requiring

25         coordination among rural health networks and

26         area health education centers, health planning

27         councils, and regional education consortia;

28         establishing requirements for funding rural

29         health networks; establishing performance

30         standards for rural health networks; creating a

31         rural health infrastructure development grant

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 1         program; defining projects that may be funded

 2         through the grant program; requiring the Office

 3         of Rural Health to monitor rural health

 4         networks; authorizing the Department of Health

 5         to establish rules governing rural health

 6         network grant programs and performance

 7         standards; amending s. 395.602, F.S.; defining

 8         the term "critical access hospital"; deleting

 9         the definitions of "emergency care hospital,"

10         and "essential access community hospital";

11         revising the definition of "rural primary care

12         hospital"; amending s. 395.603, F.S.; deleting

13         a requirement that the Agency for Health Care

14         Administration adopt a rule relating to

15         deactivation of rural hospital beds under

16         certain circumstances; requiring that critical

17         access hospitals and rural primary care

18         hospitals maintain a certain number of actively

19         licensed beds; amending s. 395.604, F.S.;

20         removing emergency care hospitals and essential

21         access community hospitals from certain

22         licensure requirements; specifying certain

23         special conditions for rural primary care

24         hospitals; amending s. 395.6061, F.S.;

25         specifying the purposes of rural hospital

26         capital improvement grants; modifying the

27         conditions for receiving a grant; amending s.

28         409.908, F.S.; requiring the Agency for Health

29         Care Administration to pay certain physicians a

30         bonus for Medicaid physician services provided

31         within a rural county; amending ss. 408.07,

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 1         409.9116, and 1009.65, F.S.; conforming

 2         cross-references; requiring the Office of

 3         Program Policy Analysis and Government

 4         Accountability to contract for a study of the

 5         financing options for replacing or changing the

 6         use of certain rural hospitals; requiring a

 7         report to the Legislature by a specified date;

 8         repealing s. 395.605, F.S., relating to the

 9         licensure of emergency care hospitals;

10         providing an effective date.

11  

12  Be It Enacted by the Legislature of the State of Florida:

13  

14         Section 1.  Section 381.0405, Florida Statutes, is

15  amended to read:

16         381.0405  Office of Rural Health.--

17         (1)  ESTABLISHMENT.--The Department of Health shall

18  establish an Office of Rural Health, which shall assist rural

19  health care providers in improving the health status and

20  health care of rural residents of this state and help rural

21  health care providers to integrate their efforts and prepare

22  for prepaid and at-risk reimbursement. The Office of Rural

23  Health shall coordinate its activities with rural health

24  networks established under s. 381.0406, local health councils

25  established under s. 408.033, the area health education center

26  network established under pursuant to s. 381.0402, and with

27  any appropriate research and policy development centers within

28  universities that have state-approved medical schools.  The

29  Office of Rural Health may enter into a formal relationship

30  with any center that designates the office as an affiliate of

31  the center.

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 1         (2)  PURPOSE.--The Office of Rural Health shall

 2  actively foster the development of service-delivery systems

 3  and cooperative agreements to enhance the provision of

 4  high-quality health care services in rural areas and serve as

 5  a catalyst for improved health services to residents citizens

 6  in rural areas of the state.

 7         (3)  GENERAL FUNCTIONS.--The office shall:

 8         (a)  Integrate policies related to physician workforce,

 9  hospitals, public health, and state regulatory functions.

10         (b)  Work with rural stakeholders in order to foster

11  the development of strategic planning that addresses Propose

12  solutions to problems affecting health care delivery in rural

13  areas.

14         (c)  Develop, in coordination with the rural health

15  networks, standards, guidelines, and performance objectives

16  for rural health networks.

17         (d)  Foster the expansion of rural health network

18  service areas to include rural counties that are not covered

19  by a rural health network.

20         (e)(c)  Seek grant funds from foundations and the

21  Federal Government.

22         (f)  Administer state grant programs for rural

23  hospitals and rural health networks.

24         (4)  COORDINATION.--The office shall:

25         (a)  Identify federal and state rural health programs

26  and provide information and technical assistance to rural

27  providers regarding participation in such programs.

28         (b)  Act as a clearinghouse for collecting and

29  disseminating information on rural health care issues,

30  research findings on rural health care, and innovative

31  approaches to the delivery of health care in rural areas.

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 1         (c)  Foster the creation of regional health care

 2  systems that promote cooperation through cooperative

 3  agreements, rather than competition.

 4         (d)  Coordinate the department's rural health care

 5  activities, programs, and policies.

 6         (e)  Design initiatives and promote cooperative

 7  agreements in order to improve access to primary care,

 8  prehospital emergency care, inpatient acute care, and

 9  emergency medical services and promote the coordination of

10  such services in rural areas.

11         (f)  Assume responsibility for state coordination of

12  the Rural Hospital Transition Grant Program, the Essential

13  Access Community Hospital Program, and other federal rural

14  hospital and rural health care grant programs.

15         (5)  TECHNICAL ASSISTANCE.--The office shall:

16         (a)  Assist Help rural health care providers in

17  recruiting obtain health care practitioners by promoting the

18  location and relocation of health care practitioners in rural

19  areas and promoting policies that create incentives for

20  practitioners to serve in rural areas.

21         (b)  Provide technical assistance to hospitals,

22  community and migrant health centers, and other health care

23  providers that serve residents of rural areas.

24         (c)  Assist with the design of strategies to improve

25  health care workforce recruitment and placement programs.

26         (d)  Provide technical assistance to rural health

27  networks in the development of their long-range development

28  plans.

29         (e)  Provide links to best practices and other

30  technical-assistance resources on its website.

31  

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 1         (6)  RESEARCH PUBLICATIONS AND SPECIAL STUDIES.--The

 2  office shall:

 3         (a)  Conduct policy and research studies.

 4         (b)  Conduct health status studies of rural residents.

 5         (c)  Collect relevant data on rural health care issues

 6  for use in program planning and department policy development.

 7         (d)  Conduct research on best practices in the delivery

 8  of health care services in rural areas.

 9         (7)  ADVISORY COUNCIL.--The Secretary of Health and the

10  Secretary of Health Care Administration shall each appoint no

11  more than five members having relevant management and practice

12  experience in health care operations to an advisory council to

13  advise the office regarding its responsibilities under this

14  section and ss. 381.0406 and 395.6061. Members must be

15  appointed for 4-year staggered terms and may be reappointed to

16  a second term of office. Members shall serve without

17  compensation, but are entitled to reimbursement for per diem

18  and travel expenses as provided in s. 112.061.

19         (8)  REPORTS.--Beginning January 1, 2007, and annually

20  thereafter, the Office of Rural Health shall submit a report

21  to the Governor, the President of the Senate, and the Speaker

22  of the House of Representatives summarizing the activities of

23  the office, including the grants obtained or administered by

24  the office and the status of rural health networks and rural

25  hospitals in the state. The report must also include

26  recommendations for improvements in health care delivery in

27  rural areas of the state.

28         (9)(7)  APPROPRIATION.--The Legislature shall

29  appropriate such sums as are necessary to support the Office

30  of Rural Health.

31  

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 1         Section 2.  Section 381.0406, Florida Statutes, is

 2  amended to read:

 3         381.0406  Rural health networks.--

 4         (1)  LEGISLATIVE FINDINGS AND INTENT.--

 5         (a)  The Legislature finds that, in rural areas, access

 6  to health care is limited and the quality of health care is

 7  negatively affected by inadequate financing, difficulty in

 8  recruiting and retaining skilled health professionals, and

 9  because of a migration of patients to urban areas for general

10  acute care and specialty services.

11         (b)  The Legislature further finds that the efficient

12  and effective delivery of health care services in rural areas

13  requires:

14         1.  The integration of public and private resources;

15         2.  The introduction of innovative outreach methods;

16         3.  The adoption of quality improvement and

17  cost-effectiveness measures;

18         4.  The organization of health care providers into

19  joint contracting entities;

20         5.  An agreement on clinical pathways and establishing

21  referral linkages;

22         6.  The analysis of costs and services in order to

23  prepare health care providers for prepaid and at-risk

24  financing; and

25         7.  The coordination of health care providers.

26         (c)  The Legislature further finds that the

27  availability of a continuum of quality health care services,

28  including preventive, primary, secondary, tertiary, and

29  long-term care, is essential to the economic and social

30  vitality of rural communities.

31  

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 1         (d)  The Legislature further finds that health care

 2  providers in rural areas are not prepared for market changes

 3  such as the move to managed care and capitation-reimbursement

 4  methodologies.

 5         (e)(d)  The Legislature further finds that the creation

 6  of rural health networks can help to alleviate these problems.

 7  Rural health networks shall act in the broad public interest

 8  and, to the extent possible, seek to improve the

 9  accessibility, quality, and cost-effectiveness of rural health

10  care by planning, developing, and coordinating be structured

11  to provide a continuum of quality health care services for

12  rural residents through the cooperative efforts of rural

13  health network members and other health care providers.

14         (f)(e)  The Legislature further finds that rural health

15  networks shall have the goal of increasing the financial

16  stability of statutory rural hospitals by linking rural

17  hospital services to other services in a continuum of health

18  care services and by increasing the utilization of statutory

19  rural hospitals whenever for appropriate health care services

20  whenever feasible, which shall help to ensure their survival

21  and thereby support the economy and protect the health and

22  safety of rural residents.

23         (g)(f)  Finally, the Legislature finds that rural

24  health networks may serve as "laboratories" to determine the

25  best way of organizing rural health services and linking to

26  out-of-area services that are not available locally in order,

27  to move the state closer to ensuring that everyone has access

28  to health care, and to promote cost containment efforts.  The

29  ultimate goal of rural health networks shall be to ensure that

30  quality health care is available and efficiently delivered to

31  all persons in rural areas.

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 1         (2)  DEFINITIONS.--

 2         (a)  "Rural" means an area having with a population

 3  density of fewer less than 100 individuals per square mile or

 4  an area defined by the most recent United States Census as

 5  rural.

 6         (b)  "Health care provider" means any individual,

 7  group, or entity, public or private, which that provides

 8  health care, including: preventive health care, primary health

 9  care, secondary and tertiary health care, hospital in-hospital

10  health care, public health care, and health promotion and

11  education.

12         (c)  "Rural health network" or "network" means a

13  nonprofit legal entity whose principal place of business is in

14  a rural county, whose members consist consisting of rural and

15  urban health care providers and others, and which that is

16  established organized to plan, develop, and organize the

17  delivery of and deliver health care services on a cooperative

18  basis in a rural area, except for some secondary and tertiary

19  care services.

20         (3)  NETWORK MEMBERSHIP.--

21         (a)  Because each rural area is unique, with a

22  different health care provider mix, health care provider

23  membership may vary, but all networks shall include members

24  that provide health promotion and disease-prevention services,

25  public health services, comprehensive primary care, emergency

26  medical care, and acute inpatient care.

27         (b)  Each county health department shall be a member of

28  the rural health network whose service area includes the

29  county in which the county health department is located.

30  Federally qualified health centers and emergency medical

31  services providers are encouraged to become members of the

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 1  rural health networks in the areas in which their patients

 2  reside or receive services.

 3         (c)(4)  Network membership shall be available to all

 4  health care providers in the network service area if, provided

 5  that they render care to all patients referred to them from

 6  other network members;, comply with network quality assurance,

 7  quality improvement, and utilization-management and risk

 8  management  requirements; and, abide by the terms and

 9  conditions of network provider agreements in paragraph

10  (11)(c), and provide services at a rate or price equal to the

11  rate or price negotiated by the network.

12         (4)(5)  NETWORK SERVICE AREAS.--Network service areas

13  do not need to conform to local political boundaries or state

14  administrative district boundaries.  The geographic area of

15  one rural health network, however, may not overlap the

16  territory of any other rural health network.

17         (5)(6)  NETWORK FUNCTIONS.-- Networks shall:

18         (a)  Seek to develop linkages with provisions for

19  referral to tertiary inpatient care, specialty physician care,

20  and to other services that are not available in rural service

21  areas.

22         (b)(7)  Seek to Networks shall make accessible to all

23  residents available health promotion, disease prevention, and

24  primary care services, in order to improve the health status

25  of rural residents and to contain health care costs.

26         (8)  Networks may have multiple points of entry, such

27  as through private physicians, community health centers,

28  county health departments, certified rural health clinics,

29  hospitals, or other providers; or they may have a single point

30  of entry.

31  

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 1         (c)(9)  Encourage members through training and

 2  educational programs to adopt standards of care, promote

 3  evidence-based practice of medicine Networks shall establish

 4  standard protocols, coordinate and share patient records, and

 5  develop patient information exchange systems in order to

 6  improve quality and access to services.

 7         (d)  Develop continuous quality-improvement programs

 8  and train network members and other health care providers in

 9  the use of such programs.

10         (e)  Develop disease-management systems and train

11  network members and other health care providers in the use of

12  such systems.

13         (f)  Promote outreach to targeted areas of high service

14  need.

15         (g)  Seek to develop community care alternatives for

16  elders who would otherwise be placed in nursing homes.

17         (h)  Emphasize community care alternatives for persons

18  with mental health and substance abuse disorders who are at

19  risk of being admitted to an institution.

20         (i)  Collect data and conduct analyses and studies to

21  measure area residents' health status and the adequacy of the

22  health care delivery system in the network service area,

23  including the needs of medically indigent persons. Whenever

24  feasible, the network shall use data collected by state and

25  federal agencies to avoid duplication of data reporting by

26  health care providers.

27         (j)  Design and implement a long-range development plan

28  for an integrated system of care that provides for adequate

29  financing and reimbursement, including strategies and

30  priorities for implementation, and that is responsive to the

31  unique local health needs and the area health services market.

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 1  Each rural health network development plan must address

 2  strategies to improve access to specialty care, provide for

 3  training health care providers to use standards of care for

 4  chronic illness, provide for developing disease-management

 5  capacity, and provide for developing regional

 6  quality-improvement initiatives. The initial long-range

 7  development plan must be submitted to the Office of Rural

 8  Health for review and approval no later than July 1, 2007, and

 9  thereafter the plans must be updated and submitted to the

10  Office of Rural Health every 3 years.

11         (10)  Networks shall develop risk management and

12  quality assurance programs for network providers.

13         (6)(11)  NETWORK GOVERNANCE AND ORGANIZATION.--

14         (a)  Networks shall be incorporated as not-for-profit

15  corporations under chapter 617, with articles of incorporation

16  that set forth purposes consistent with this section the laws

17  of the state.

18         (b)  Networks shall have an independent a board of

19  directors that derives membership from local government,

20  health care providers, businesses, consumers, advocacy groups,

21  and others. Boards of other community health care entities may

22  not serve in whole as the board of a rural health network;

23  however, some overlap of board membership with other community

24  organizations is encouraged. Network staff must provide an

25  annual orientation and strategic planning activity for board

26  members.

27         (c)  Network boards of directors shall have the

28  responsibility of determining the content of health care

29  provider agreements that link network members.  The written

30  agreements between the network and its health care provider

31  members must specify participation in the essential functions

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 1  of the network, which include disease-management initiatives,

 2  systems for exchanging patient information, specialty-referral

 3  agreements, and quality-assurance and quality-improvement

 4  programs. shall specify:

 5         1.  Who provides what services.

 6         2.  The extent to which the health care provider

 7  provides care to persons who lack health insurance or are

 8  otherwise unable to pay for care.

 9         3.  The procedures for transfer of medical records.

10         4.  The method used for the transportation of patients

11  between providers.

12         5.  Referral and patient flow including appointments

13  and scheduling.

14         6.  Payment arrangements for the transfer or referral

15  of patients.

16         (d)  There shall be no liability on the part of, and no

17  cause of action of any nature shall arise against, any member

18  of a network board of directors, or its employees or agents,

19  for any lawful action taken by them in the performance of

20  their administrative powers and duties under this subsection.

21         (7)(12)  NETWORK PROVIDER MEMBER SERVICES.--

22         (a)  Networks, to the extent feasible, shall seek to

23  develop services that provide for a continuum of care for all

24  residents patients served by the network.  Each network shall

25  recruit members providing include the following core services:

26  disease prevention, health promotion, comprehensive primary

27  care, emergency medical care, and acute inpatient care. Each

28  network shall seek to ensure the availability of comprehensive

29  maternity care, including prenatal, delivery, and postpartum

30  care for uncomplicated pregnancies, either directly, by

31  contract, or through referral agreements. Networks shall, to

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 1  the extent feasible, develop local services and linkages among

 2  health care providers to also ensure the availability of the

 3  following services: within the specified timeframes, either

 4  directly, by contract, or through referral agreements:

 5         1.  Services available in the home.

 6         1.a.  Home health care.

 7         2.b.  Hospice care.

 8         2.  Services accessible within 30 minutes travel time

 9  or less.

10         3.a.  Emergency medical services, including advanced

11  life support, ambulance, and basic emergency room services.

12         4.b.  Primary care, including.

13         c.  prenatal and postpartum care for uncomplicated

14  pregnancies.

15         5.d.  Community-based services for elders, such as

16  adult day care and assistance with activities of daily living.

17         6.e.  Public health services, including communicable

18  disease control, disease prevention, health education, and

19  health promotion.

20         7.f.  Outpatient mental health psychiatric and

21  substance abuse services.

22         3.  Services accessible within 45 minutes travel time

23  or less.

24         8.a.  Hospital acute inpatient care for persons whose

25  illnesses or medical problems are not severe.

26         9.b.  Level I obstetrical care, which is Labor and

27  delivery for low-risk patients.

28         10.c.  Skilled nursing services and, long-term care,

29  including nursing home care.

30  

31  

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 1         (b)  Networks shall seek to foster linkages with

 2  out-of-area services to the extent feasible to ensure the

 3  availability of:

 4         d.  Dialysis.

 5         e.  Osteopathic and chiropractic manipulative therapy.

 6         4.  Services accessible within 2 hours travel time or

 7  less.

 8         1.a.  Specialist physician care.

 9         2.b.  Hospital acute inpatient care for severe

10  illnesses and medical problems.

11         3.c.  Level II and III obstetrical care, which is Labor

12  and delivery care for high-risk patients and neonatal

13  intensive care.

14         4.d.  Comprehensive medical rehabilitation.

15         5.e.  Inpatient mental health psychiatric and substance

16  abuse services.

17         6.f.  Magnetic resonance imaging, lithotripter

18  treatment, oncology, advanced radiology, and other

19  technologically advanced services.

20         g.  Subacute care.

21         (8)  COORDINATION WITH OTHER ENTITIES.--

22         (a)  Area health education centers, health planning

23  councils, and regional education consortia shall participate

24  in the rural health networks' preparation of rural

25  infrastructure development plans. The Department of Health may

26  require written memoranda of agreement between a network and

27  an area health education center or health planning council.

28         (b)  Rural health networks shall initiate activities,

29  in coordination with area health education centers, to carry

30  out the objectives of the adopted development plan, including

31  continuing education for health care practitioners performing

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 1  functions such as disease management, continuous quality

 2  improvement, telehealth, long-distance learning, and the

 3  treatment of chronic illness using standards of care.

 4         (c)  Health planning councils shall support the

 5  preparation of network rural infrastructure development plans

 6  through data collection and analysis in order to assess the

 7  health status of area residents and the capacity of local

 8  health services.

 9         (d)  Regional education consortia that have technology

10  available to assist rural health networks in establishing

11  systems for exchange of patient information and for

12  long-distance learning shall provide technical assistance upon

13  the request of a rural health network.

14         (b)  Networks shall actively participate with area

15  health education center programs, whenever feasible, in

16  developing and implementing recruitment, training, and

17  retention programs directed at positively influencing the

18  supply and distribution of health care professionals serving

19  in, or receiving training in, network areas.

20         (c)  As funds become available, networks shall

21  emphasize community care alternatives for elders who would

22  otherwise be placed in nursing homes.

23         (d)  To promote the most efficient use of resources,

24  networks shall emphasize disease prevention, early diagnosis

25  and treatment of medical problems, and community care

26  alternatives for persons with mental health and substance

27  abuse disorders who are at risk to be institutionalized.

28         (e)(13)  TRAUMA SERVICES.--In those network areas

29  having which have an established trauma agency approved by the

30  Department of Health, the network shall seek the participation

31  of that trauma agency must be a participant in the network.

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 1  Trauma services provided within the network area must comply

 2  with s. 395.405.

 3         (9)(14)  NETWORK FINANCING.--

 4         (a)  Networks may use all sources of public and private

 5  funds to support network activities. Nothing in this section

 6  prohibits networks from becoming managed care providers.

 7         (b)  The Department of Health shall provide funding to

 8  support the administrative costs of operating rural health

 9  networks. Rural health networks may apply for funding for

10  network operations and for rural health infrastructure

11  development.

12         (10)  NETWORK PERFORMANCE STANDARDS.--The Department of

13  Health shall develop and enforce performance standards for

14  rural health network operations grants and rural health

15  infrastructure development grants.

16         (a)  Operations grant performance standards must

17  include, but are not limited to, standards that require the

18  rural health network to:

19         1.  Have a qualified board of directors that meets at

20  least quarterly.

21         2.  Have sufficient staff who have the qualifications

22  and experience to perform the requirements of this section, as

23  assessed by the Office of Rural Health, or a written plan to

24  obtain such staff.

25         3.  Comply with the department's grant-management

26  standards in a timely and responsive manner.

27         4.  Comply with the department's standards for the

28  administration of federal grant funding, including assistance

29  to rural hospitals.

30  

31  

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 1         5.  Demonstrate a commitment to network activities from

 2  area health care providers and other stakeholders, as

 3  described in letters of support.

 4         (b)  Rural health infrastructure development grant

 5  performance standards must include, but are not limited to,

 6  standards that require the rural health network to:

 7         1.  During the 2006-2007 fiscal year develop a

 8  long-range development plan and, after July 1, 2007, have a

 9  long-range development plan that has been reviewed and

10  approved by the Office of Rural Health.

11         2.  Have two or more successful network-development

12  activities, such as:

13         a.  Management of a network-development or outreach

14  grant from the federal Office of Rural Health Policy;

15         b.  Implementation of outreach programs to address

16  chronic disease, infant mortality, or assistance with

17  prescription medication;

18         c.  Development of partnerships with community and

19  faith-based organizations to address area health problems;

20         d.  Provision of direct services, such as clinics or

21  mobile units;

22         e.  Operation of credentialing services for health care

23  providers or quality-assurance and quality-improvement

24  initiatives that, whenever possible, are consistent with state

25  or federal quality initiatives;

26         f.  Support for the development of community health

27  centers, local community health councils, federal designation

28  as a rural critical access hospital, or comprehensive

29  community health planning initiatives; and

30         g.  Development of the capacity to obtain federal,

31  state, and foundation grants.

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 1         (11)(15)  NETWORK IMPLEMENTATION.--As funds become

 2  available, networks shall be developed and implemented in two

 3  phases.

 4         (a)  Phase I shall consist of a network planning and

 5  development grant program. Planning grants shall be used to

 6  organize networks, incorporate network boards, and develop

 7  formal provider agreements as provided for in this section.

 8  The Department of Health shall develop a request-for-proposal

 9  process to solicit grant applications.

10         (b)  Phase II shall consist of network operations.  As

11  funds become available, certified networks that meet

12  performance standards shall be eligible to receive grant

13  funds, including rural health infrastructure development

14  grants under subsection (12), to be used to help defray the

15  costs of network infrastructure development, patient care, and

16  network administration.  Infrastructure development includes,

17  but is not limited to: recruitment and retention of primary

18  care practitioners; enhancements of primary care services

19  through the use of mobile clinics; development of preventive

20  health care programs; linkage of urban and rural health care

21  systems; design and implementation of automated patient

22  records, outcome measurement, quality assurance, quality

23  improvement, and utilization-management and risk management

24  systems; establishment of one-stop service delivery sites;

25  upgrading of medical technology available to network

26  providers; enhancement of emergency medical systems;

27  enhancement of medical transportation; and development of

28  telecommunication capabilities.  A Phase II award may occur in

29  the same fiscal year as a Phase I award.

30         (12)  RURAL HEALTH INFRASTRUCTURE DEVELOPMENT

31  GRANTS.--There is established a rural health infrastructure

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 1  development grant program. The Department of Health shall make

 2  available, subject to legislative appropriations, grants to

 3  rural health networks that meet performance standards. Each

 4  rural health network that applies for grant funding under this

 5  subsection must develop detailed plans to build clinical and

 6  administrative infrastructures in its service area which meet

 7  or exceed standards for Medicaid contracting.

 8         (a)  For purposes of this grant program, building

 9  clinical infrastructure means establishing:

10         1.  Specialty networks, such as linking rural

11  physicians, hospitals, specialty physicians, and regional

12  tertiary hospitals, which are supported by broadband

13  telecommunication networks, including wireless services, to

14  enable patient care referrals, sharing of patient health

15  information, consultation among providers, and followup on

16  patient care.

17         2.  Regional continuous quality-management systems

18  consistent with state and federal quality initiatives.

19         3.  Comprehensive disease-management programs that

20  address the characteristics of the local area and meet

21  Medicaid standards.

22         (b)  For purposes of this grant program, building

23  administrative infrastructure means:

24         1.  Developing telecommunications infrastructure that

25  provides broadband communication, including wireless service,

26  between rural and urban health care providers for the purpose

27  of sharing health information. Developing telecommunications

28  infrastructure includes participating in regional health

29  information network grant programs and regional health

30  information organizations and obtaining funding from federal

31  funding sources.

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 1         2.  Developing telehealth and long-distance learning

 2  systems that use a telecommunications infrastructure to

 3  support links with specialists and regional hospitals and the

 4  training of medical students and other health care

 5  professionals.

 6         3.  Forming entities to encourage joint contracting by

 7  rural physicians and hospitals enabling them to negotiate and

 8  contract with health plans.

 9         4.  Forming, or joining, entities that would enable

10  rural health care providers to take advantage of economies of

11  scale in purchasing supplies and equipment, billing services,

12  and personnel services.

13         (13)(16)  CERTIFICATION.--For the purpose of certifying

14  networks that are eligible for Phase II funding, the

15  Department of Health shall certify networks that meet the

16  criteria delineated in this section and the rules governing

17  rural health networks. The Office of Rural Health in the

18  Department of Health shall monitor rural health networks in

19  order to ensure continued compliance with established

20  certification and performance standards.

21         (14)(17)  RULES.--The Department of Health shall

22  establish rules that govern the creation and certification of

23  networks, the provision of grant funds under Phase I and Phase

24  II, and the establishment of performance standards including

25  establishing outcome measures for networks.

26         Section 3.  Subsection (2) of section 395.602, Florida

27  Statutes, is amended to read:

28         395.602  Rural hospitals.--

29         (2)  DEFINITIONS.--As used in this part:

30         (a)  "Critical access hospital" means a hospital that

31  meets the definition of rural hospital in paragraph (d) and

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 1  meets the requirements for reimbursement by Medicare and

 2  Medicaid under 42 C.F.R. ss. 485.601-485.647. "Emergency care

 3  hospital" means a medical facility which provides:

 4         1.  Emergency medical treatment; and

 5         2.  Inpatient care to ill or injured persons prior to

 6  their transportation to another hospital or provides inpatient

 7  medical care to persons needing care for a period of up to 96

 8  hours.  The 96-hour limitation on inpatient care does not

 9  apply to respite, skilled nursing, hospice, or other nonacute

10  care patients.

11         (b)  "Essential access community hospital" means any

12  facility which:

13         1.  Has at least 100 beds;

14         2.  Is located more than 35 miles from any other

15  essential access community hospital, rural referral center, or

16  urban hospital meeting criteria for classification as a

17  regional referral center;

18         3.  Is part of a network that includes rural primary

19  care hospitals;

20         4.  Provides emergency and medical backup services to

21  rural primary care hospitals in its rural health network;

22         5.  Extends staff privileges to rural primary care

23  hospital physicians in its network; and

24         6.  Accepts patients transferred from rural primary

25  care hospitals in its network.

26         (b)(c)  "Inactive rural hospital bed" means a licensed

27  acute care hospital bed, as defined in s. 395.002(14), that is

28  inactive in that it cannot be occupied by acute care

29  inpatients.

30         (c)(d)  "Rural area health education center" means an

31  area health education center (AHEC), as authorized by Pub. L.

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 1  No. 94-484, which provides services in a county with a

 2  population density of no greater than 100 persons per square

 3  mile.

 4         (d)(e)  "Rural hospital" means an acute care hospital

 5  licensed under this chapter, having 100 or fewer licensed beds

 6  and an emergency room, which is:

 7         1.  The sole provider within a county with a population

 8  density of no greater than 100 persons per square mile;

 9         2.  An acute care hospital, in a county with a

10  population density of no greater than 100 persons per square

11  mile, which is at least 30 minutes of travel time, on normally

12  traveled roads under normal traffic conditions, from any other

13  acute care hospital within the same county;

14         3.  A hospital supported by a tax district or

15  subdistrict whose boundaries encompass a population of 100

16  persons or fewer per square mile;

17         4.  A hospital in a constitutional charter county with

18  a population of over 1 million persons that has imposed a

19  local option health service tax pursuant to law and in an area

20  that was directly impacted by a catastrophic event on August

21  24, 1992, for which the Governor of Florida declared a state

22  of emergency pursuant to chapter 125, and has 120 beds or less

23  that serves an agricultural community with an emergency room

24  utilization of no less than 20,000 visits and a Medicaid

25  inpatient utilization rate greater than 15 percent;

26         5.  A hospital with a service area that has a

27  population of 100 persons or fewer per square mile. As used in

28  this subparagraph, the term "service area" means the fewest

29  number of zip codes that account for 75 percent of the

30  hospital's discharges for the most recent 5-year period, based

31  on information available from the hospital inpatient discharge

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 1  database in the State Center for Health Statistics at the

 2  Agency for Health Care Administration; or

 3         6.  A hospital designated as a critical access

 4  hospital, as defined in s. 408.07(15).

 5  

 6  Population densities used in this paragraph must be based upon

 7  the most recently completed United States census. A hospital

 8  that received funds under s. 409.9116 for a quarter beginning

 9  no later than July 1, 2002, is deemed to have been and shall

10  continue to be a rural hospital from that date through June

11  30, 2012, if the hospital continues to have 100 or fewer

12  licensed beds and an emergency room, or meets the criteria of

13  subparagraph 4. An acute care hospital that has not previously

14  been designated as a rural hospital and that meets the

15  criteria of this paragraph shall be granted such designation

16  upon application, including supporting documentation to the

17  Agency for Health Care Administration.

18         (e)(f)  "Rural primary care hospital" means any

19  facility that meeting the criteria in paragraph (e) or s.

20  395.605 which provides:

21         1.  Twenty-four-hour emergency medical care;

22         2.  Temporary inpatient care for periods of 96 72 hours

23  or less to patients requiring stabilization before discharge

24  or transfer to another hospital. The 96-hour 72-hour

25  limitation does not apply to respite, skilled nursing,

26  hospice, or other nonacute care patients; and

27         3.  Has at least no more than six licensed acute care

28  inpatient beds.

29         (f)(g)  "Swing-bed" means a bed which can be used

30  interchangeably as either a hospital, skilled nursing facility

31  

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 1  (SNF), or intermediate care facility (ICF) bed pursuant to 42

 2  C.F.R. parts 405, 435, 440, 442, and 447.

 3         Section 4.  Subsection (1) of section 395.603, Florida

 4  Statutes, is amended to read:

 5         395.603  Deactivation of general hospital beds; rural

 6  hospital impact statement.--

 7         (1)  The agency shall establish, by rule, a process by

 8  which A rural hospital, as defined in s. 395.602, which that

 9  seeks licensure as a rural primary care hospital or as an

10  emergency care hospital, or becomes a certified rural health

11  clinic as defined in Pub. L. No. 95-210, or becomes a primary

12  care program such as a county health department, community

13  health center, or other similar outpatient program that

14  provides preventive and curative services, may deactivate

15  general hospital beds. A critical access hospital or a rural

16  primary care hospital hospitals and emergency care hospitals

17  shall maintain the number of actively licensed general

18  hospital beds necessary for the facility to be certified for

19  Medicare reimbursement. Hospitals that discontinue inpatient

20  care to become rural health care clinics or primary care

21  programs shall deactivate all licensed general hospital beds.

22  All hospitals, clinics, and programs with inactive beds shall

23  provide 24-hour emergency medical care by staffing an

24  emergency room. Providers with inactive beds shall be subject

25  to the criteria in s. 395.1041. The agency shall specify in

26  rule requirements for making 24-hour emergency care available.

27  Inactive general hospital beds shall be included in the acute

28  care bed inventory, maintained by the agency for

29  certificate-of-need purposes, for 10 years from the date of

30  deactivation of the beds. After 10 years have elapsed,

31  inactive beds shall be excluded from the inventory. The agency

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 1  shall, at the request of the licensee, reactivate the inactive

 2  general beds upon a showing by the licensee that licensure

 3  requirements for the inactive general beds are met.

 4         Section 5.  Section 395.604, Florida Statutes, is

 5  amended to read:

 6         395.604  Other Rural primary care hospitals hospital

 7  programs.--

 8         (1)  The agency may license rural primary care

 9  hospitals subject to federal approval for participation in the

10  Medicare and Medicaid programs. Rural primary care hospitals

11  shall be treated in the same manner as emergency care

12  hospitals and rural hospitals with respect to ss.

13  395.605(2)-(8)(a), 408.033(2)(b)3., and 408.038.

14         (2)  The agency may designate essential access

15  community hospitals.

16         (3)  The agency may adopt licensure rules for rural

17  primary care hospitals and essential access community

18  hospitals. Such rules must conform to s. 395.1055.

19         (3)  For the purpose of Medicaid swing-bed

20  reimbursement pursuant to the Medicaid program, the agency

21  shall treat rural primary care hospitals in the same manner as

22  rural hospitals.

23         (4)  For the purpose of participation in the Medical

24  Education Reimbursement and Loan Repayment Program as defined

25  in s. 1009.65 or other loan repayment or incentive programs

26  designed to relieve medical workforce shortages, the

27  department shall treat rural primary care hospitals in the

28  same manner as rural hospitals.

29         (5)  For the purpose of coordinating primary care

30  services described in s. 154.011(1)(c)10., the department

31  

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 1  shall treat rural primary care hospitals in the same manner as

 2  rural hospitals.

 3         (6)  Rural hospitals that make application under the

 4  certificate-of-need program to be licensed as rural primary

 5  care hospitals shall receive expedited review as defined in s.

 6  408.032. Rural primary care hospitals seeking relicensure as

 7  acute care general hospitals shall also receive expedited

 8  review.

 9         (7)  Rural primary care hospitals are exempt from

10  certificate-of-need requirements for home health and hospice

11  services and for swing beds in a number that does not exceed

12  one-half of the facility's licensed beds.

13         (8)  Rural primary care hospitals shall have agreements

14  with other hospitals, skilled nursing facilities, home health

15  agencies, and with providers of diagnostic-imaging and

16  laboratory services that are not provided on site but are

17  needed by patients.

18         (4)  The department may seek federal recognition of

19  emergency care hospitals authorized by s. 395.605 under the

20  essential access community hospital program authorized by the

21  Omnibus Budget Reconciliation Act of 1989.

22         Section 6.  Section 395.6061, Florida Statutes, is

23  amended to read:

24         395.6061  Rural hospital capital improvement.--There is

25  established a rural hospital capital improvement grant

26  program.

27         (1)  A rural hospital as defined in s. 395.602 may

28  apply to the department for a grant to acquire, repair,

29  improve, or upgrade systems, facilities, or equipment. The

30  grant application must provide information that includes:

31  

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 1         (a)  A statement indicating the problem the rural

 2  hospital proposes to solve with the grant funds;

 3         (b)  The strategy proposed to resolve the problem;

 4         (c)  The organizational structure, financial system,

 5  and facilities that are essential to the proposed solution;

 6         (d)  The projected longevity of the proposed solution

 7  after the grant funds are expended;

 8         (e)  Evidence of participation in a rural health

 9  network as defined in s. 381.0406 and evidence that, after

10  July 1, 2007, the application is consistent with the rural

11  health network long-range development plan;

12         (f)  Evidence that the rural hospital has difficulty in

13  obtaining funding or that funds available for the proposed

14  solution are inadequate;

15         (g)  Evidence that the grant funds will assist in

16  maintaining or returning the hospital to an economically

17  stable condition or that any plan for closure of the hospital

18  or realignment of services will involve development of

19  innovative alternatives for the provision of needed

20  discontinued services;

21         (h)  Evidence of a satisfactory record-keeping system

22  to account for grant fund expenditures within the rural

23  county; and

24         (i)  A rural health network plan that includes a

25  description of how the plan was developed, the goals of the

26  plan, the links with existing health care providers under the

27  plan, Indicators quantifying the hospital's financial status

28  well-being, measurable outcome targets, and the current

29  physical and operational condition of the hospital.

30         (2)  Each rural hospital as defined in s. 395.602 shall

31  receive a minimum of $100,000 annually, subject to legislative

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 1  appropriation, upon application to the Department of Health,

 2  for projects to acquire, repair, improve, or upgrade systems,

 3  facilities, or equipment.

 4         (3)  Any remaining funds shall annually be disbursed to

 5  rural hospitals in accordance with this section. The

 6  Department of Health shall establish, by rule, criteria for

 7  awarding grants for any remaining funds, which must be used

 8  exclusively for the support and assistance of rural hospitals

 9  as defined in s. 395.602, including criteria relating to the

10  level of charity uncompensated care rendered by the hospital,

11  indicators quantifying the hospital's financial status,

12  measurable outcome objectives, the participation in a rural

13  health network as defined in s. 381.0406, and the proposed use

14  of the grant by the rural hospital to resolve a specific

15  problem. The department must consider any information

16  submitted in an application for the grants in accordance with

17  subsection (1) in determining eligibility for and the amount

18  of the grant, and none of the individual items of information

19  by itself may be used to deny grant eligibility.

20         (4)  The department shall ensure that the funds are

21  used solely for the purposes specified in this section. The

22  total grants awarded pursuant to this section shall not exceed

23  the amount appropriated for this program.

24         Section 7.  Subsection (12) of section 409.908, Florida

25  Statutes, is amended to read:

26         409.908  Reimbursement of Medicaid providers.--Subject

27  to specific appropriations, the agency shall reimburse

28  Medicaid providers, in accordance with state and federal law,

29  according to methodologies set forth in the rules of the

30  agency and in policy manuals and handbooks incorporated by

31  reference therein.  These methodologies may include fee

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 1  schedules, reimbursement methods based on cost reporting,

 2  negotiated fees, competitive bidding pursuant to s. 287.057,

 3  and other mechanisms the agency considers efficient and

 4  effective for purchasing services or goods on behalf of

 5  recipients. If a provider is reimbursed based on cost

 6  reporting and submits a cost report late and that cost report

 7  would have been used to set a lower reimbursement rate for a

 8  rate semester, then the provider's rate for that semester

 9  shall be retroactively calculated using the new cost report,

10  and full payment at the recalculated rate shall be effected

11  retroactively. Medicare-granted extensions for filing cost

12  reports, if applicable, shall also apply to Medicaid cost

13  reports. Payment for Medicaid compensable services made on

14  behalf of Medicaid eligible persons is subject to the

15  availability of moneys and any limitations or directions

16  provided for in the General Appropriations Act or chapter 216.

17  Further, nothing in this section shall be construed to prevent

18  or limit the agency from adjusting fees, reimbursement rates,

19  lengths of stay, number of visits, or number of services, or

20  making any other adjustments necessary to comply with the

21  availability of moneys and any limitations or directions

22  provided for in the General Appropriations Act, provided the

23  adjustment is consistent with legislative intent.

24         (12)(a)  A physician shall be reimbursed the lesser of

25  the amount billed by the provider or the Medicaid maximum

26  allowable fee established by the agency.

27         (b)  The agency shall adopt a fee schedule, subject to

28  any limitations or directions provided for in the General

29  Appropriations Act, based on a resource-based relative value

30  scale for pricing Medicaid physician services. Under this fee

31  schedule, physicians shall be paid a dollar amount for each

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 1  service based on the average resources required to provide the

 2  service, including, but not limited to, estimates of average

 3  physician time and effort, practice expense, and the costs of

 4  professional liability insurance.  The fee schedule shall

 5  provide increased reimbursement for preventive and primary

 6  care services and lowered reimbursement for specialty services

 7  by using at least two conversion factors, one for cognitive

 8  services and another for procedural services. The fee schedule

 9  shall not increase total Medicaid physician expenditures

10  unless moneys are available, and shall be phased in over a

11  2-year period beginning on July 1, 1994. The Agency for Health

12  Care Administration shall seek the advice of a 16-member

13  advisory panel in formulating and adopting the fee schedule.

14  The panel shall consist of Medicaid physicians licensed under

15  chapters 458 and 459 and shall be composed of 50 percent

16  primary care physicians and 50 percent specialty care

17  physicians.

18         (c)  Notwithstanding paragraph (b), reimbursement fees

19  to physicians for providing total obstetrical services to

20  Medicaid recipients, which include prenatal, delivery, and

21  postpartum care, shall be at least $1,500 per delivery for a

22  pregnant woman with low medical risk and at least $2,000 per

23  delivery for a pregnant woman with high medical risk. However,

24  reimbursement to physicians working in Regional Perinatal

25  Intensive Care Centers designated pursuant to chapter 383, for

26  services to certain pregnant Medicaid recipients with a high

27  medical risk, may be made according to obstetrical care and

28  neonatal care groupings and rates established by the agency.

29  Nurse midwives licensed under part I of chapter 464 or

30  midwives licensed under chapter 467 shall be reimbursed at no

31  less than 80 percent of the low medical risk fee. The agency

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 1  shall by rule determine, for the purpose of this paragraph,

 2  what constitutes a high or low medical risk pregnant woman and

 3  shall not pay more based solely on the fact that a caesarean

 4  section was performed, rather than a vaginal delivery. The

 5  agency shall by rule determine a prorated payment for

 6  obstetrical services in cases where only part of the total

 7  prenatal, delivery, or postpartum care was performed. The

 8  Department of Health shall adopt rules for appropriate

 9  insurance coverage for midwives licensed under chapter 467.

10  Prior to the issuance and renewal of an active license, or

11  reactivation of an inactive license for midwives licensed

12  under chapter 467, such licensees shall submit proof of

13  coverage with each application.

14         (d)  Notwithstanding other provisions of this

15  subsection, physicians licensed under chapter 458 or chapter

16  459 who have a provider agreement with a rural health network

17  as established in s. 381.0406 shall be paid a 10-percent bonus

18  over the Medicaid physician fee schedule for any physician

19  service provided within the geographic boundary of a rural

20  county as defined by the most recent United States Census as

21  rural.

22         Section 8.  Subsection (43) of section 408.07, Florida

23  Statutes, is amended to read:

24         408.07  Definitions.--As used in this chapter, with the

25  exception of ss. 408.031-408.045, the term:

26         (43)  "Rural hospital" means an acute care hospital

27  licensed under chapter 395, having 100 or fewer licensed beds

28  and an emergency room, and which is:

29         (a)  The sole provider within a county with a

30  population density of no greater than 100 persons per square

31  mile;

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 1         (b)  An acute care hospital, in a county with a

 2  population density of no greater than 100 persons per square

 3  mile, which is at least 30 minutes of travel time, on normally

 4  traveled roads under normal traffic conditions, from another

 5  acute care hospital within the same county;

 6         (c)  A hospital supported by a tax district or

 7  subdistrict whose boundaries encompass a population of 100

 8  persons or fewer per square mile;

 9         (d)  A hospital with a service area that has a

10  population of 100 persons or fewer per square mile.  As used

11  in this paragraph, the term "service area" means the fewest

12  number of zip codes that account for 75 percent of the

13  hospital's discharges for the most recent 5-year period, based

14  on information available from the hospital inpatient discharge

15  database in the State Center for Health Statistics at the

16  Agency for Health Care Administration; or

17         (e)  A critical access hospital.

18  

19  Population densities used in this subsection must be based

20  upon the most recently completed United States census. A

21  hospital that received funds under s. 409.9116 for a quarter

22  beginning no later than July 1, 2002, is deemed to have been

23  and shall continue to be a rural hospital from that date

24  through June 30, 2012, if the hospital continues to have 100

25  or fewer licensed beds and an emergency room, or meets the

26  criteria of s. 395.602(2)(d)4. s. 395.602(2)(e)4. An acute

27  care hospital that has not previously been designated as a

28  rural hospital and that meets the criteria of this subsection

29  shall be granted such designation upon application, including

30  supporting documentation, to the Agency for Health Care

31  Administration.

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 1         Section 9.  Subsection (6) of section 409.9116, Florida

 2  Statutes, is amended to read:

 3         409.9116  Disproportionate share/financial assistance

 4  program for rural hospitals.--In addition to the payments made

 5  under s. 409.911, the Agency for Health Care Administration

 6  shall administer a federally matched disproportionate share

 7  program and a state-funded financial assistance program for

 8  statutory rural hospitals. The agency shall make

 9  disproportionate share payments to statutory rural hospitals

10  that qualify for such payments and financial assistance

11  payments to statutory rural hospitals that do not qualify for

12  disproportionate share payments. The disproportionate share

13  program payments shall be limited by and conform with federal

14  requirements. Funds shall be distributed quarterly in each

15  fiscal year for which an appropriation is made.

16  Notwithstanding the provisions of s. 409.915, counties are

17  exempt from contributing toward the cost of this special

18  reimbursement for hospitals serving a disproportionate share

19  of low-income patients.

20         (6)  This section applies only to hospitals that were

21  defined as statutory rural hospitals, or their

22  successor-in-interest hospital, prior to January 1, 2001. Any

23  additional hospital that is defined as a statutory rural

24  hospital, or its successor-in-interest hospital, on or after

25  January 1, 2001, is not eligible for programs under this

26  section unless additional funds are appropriated each fiscal

27  year specifically to the rural hospital disproportionate share

28  and financial assistance programs in an amount necessary to

29  prevent any hospital, or its successor-in-interest hospital,

30  eligible for the programs prior to January 1, 2001, from

31  incurring a reduction in payments because of the eligibility

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    Florida Senate - 2006                    CS for CS for SB 2176
    603-2139-06




 1  of an additional hospital to participate in the programs. A

 2  hospital, or its successor-in-interest hospital, which

 3  received funds pursuant to this section before January 1,

 4  2001, and which qualifies under s. 395.602(2)(d) s.

 5  395.602(2)(e), shall be included in the programs under this

 6  section and is not required to seek additional appropriations

 7  under this subsection.

 8         Section 10.  Paragraph (b) of subsection (2) of section

 9  1009.65, Florida Statutes, is amended to read:

10         1009.65  Medical Education Reimbursement and Loan

11  Repayment Program.--

12         (2)  From the funds available, the Department of Health

13  shall make payments to selected medical professionals as

14  follows:

15         (b)  All payments shall be contingent on continued

16  proof of primary care practice in an area defined in s.

17  395.602(2)(d) s. 395.602(2)(e), or an underserved area

18  designated by the Department of Health, provided the

19  practitioner accepts Medicaid reimbursement if eligible for

20  such reimbursement. Correctional facilities, state hospitals,

21  and other state institutions that employ medical personnel

22  shall be designated by the Department of Health as underserved

23  locations. Locations with high incidences of infant mortality,

24  high morbidity, or low Medicaid participation by health care

25  professionals may be designated as underserved.

26         Section 11.  The Office of Program Policy Analysis and

27  Government Accountability shall contract with an entity having

28  expertise in the financing of rural hospital capital

29  improvement projects to study the financing options for

30  replacing or changing the use of rural hospital facilities

31  having 55 or fewer beds which were built before 1985 and which

                                  35

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    Florida Senate - 2006                    CS for CS for SB 2176
    603-2139-06




 1  have not had major renovations since 1985. For each such

 2  hospital, the contractor shall assess the need to replace or

 3  convert the facility, identify all available sources of

 4  financing for such replacement or conversion and assess each

 5  community's capacity to maximize these funding options,

 6  propose a model replacement facility if a facility should be

 7  replaced, and propose alternative uses of the facility if

 8  continued operation of the hospital is not financially

 9  feasible. Based on the results of the contract study, the

10  Office of Program Policy Analysis and Government

11  Accountability shall submit recommendations to the Legislature

12  by February 1, 2007, regarding whether the state should

13  provide financial assistance to replace or convert these rural

14  hospital facilities and what form that assistance should take.

15         Section 12.  Section 395.605, Florida Statutes, is

16  repealed.

17         Section 13.  This act shall take effect July 1, 2006.

18  

19          STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
                       COMMITTEE SUBSTITUTE FOR
20                          CS for SB 2176

21                                 

22  Restores current law related to the rural hospital capital
    improvement grant program that requires each rural hospital to
23  receive a minimum of $100,000 annually and requires any
    remaining funds to be annually disbursed to rural hospitals.
24  

25  

26  

27  

28  

29  

30  

31  

                                  36

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