Senate Bill sb2176c3
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By the Committees on Ways and Means; Health and Human Services
Appropriations; Health Care; and Senator Peaden
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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;
31 establishing requirements for the receipt of
1
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1 grant funding; requiring the Office of Rural
2 Health to monitor rural health networks;
3 authorizing the Department of Health to
4 establish rules governing rural health network
5 grant programs and performance standards;
6 amending s. 395.602, F.S.; defining the term
7 "critical access hospital"; deleting the
8 definitions of "emergency care hospital," and
9 "essential access community hospital"; revising
10 the definition of "rural primary care
11 hospital"; amending s. 395.603, F.S.; deleting
12 a requirement that the Agency for Health Care
13 Administration adopt a rule relating to
14 deactivation of rural hospital beds under
15 certain circumstances; requiring that critical
16 access hospitals and rural primary care
17 hospitals maintain a certain number of actively
18 licensed beds; amending s. 395.604, F.S.;
19 removing emergency care hospitals and essential
20 access community hospitals from certain
21 licensure requirements; specifying certain
22 special conditions for rural primary care
23 hospitals; amending s. 395.6061, F.S.;
24 specifying the purposes of rural hospital
25 capital improvement grants; modifying the
26 conditions for receiving a grant; authorizing
27 the Department of Health to award grants for
28 remaining funds to financially distressed rural
29 hospitals; requiring a financially distressed
30 rural hospital to be bound by certain terms of
31 a participation agreement in order to receive
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1 remaining funds; amending s. 409.908, F.S.;
2 requiring the Agency for Health Care
3 Administration to pay certain physicians a
4 bonus for Medicaid physician services provided
5 within a rural county; amending ss. 408.07,
6 409.9116, and 1009.65, F.S.; conforming
7 cross-references; requiring the Office of
8 Program Policy Analysis and Government
9 Accountability to contract for a study of the
10 financing options for replacing or changing the
11 use of certain rural hospitals; requiring a
12 report to the Legislature by a specified date;
13 repealing s. 395.605, F.S., relating to the
14 licensure of emergency care hospitals;
15 providing appropriations; providing an
16 effective date.
17
18 Be It Enacted by the Legislature of the State of Florida:
19
20 Section 1. Section 381.0405, Florida Statutes, is
21 amended to read:
22 381.0405 Office of Rural Health.--
23 (1) ESTABLISHMENT.--The Department of Health shall
24 establish an Office of Rural Health, which shall assist rural
25 health care providers in improving the health status and
26 health care of rural residents of this state and help rural
27 health care providers to integrate their efforts and prepare
28 for prepaid and at-risk reimbursement. The Office of Rural
29 Health shall coordinate its activities with rural health
30 networks established under s. 381.0406, local health councils
31 established under s. 408.033, the area health education center
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1 network established under pursuant to s. 381.0402, and with
2 any appropriate research and policy development centers within
3 universities that have state-approved medical schools. The
4 Office of Rural Health may enter into a formal relationship
5 with any center that designates the office as an affiliate of
6 the center.
7 (2) PURPOSE.--The Office of Rural Health shall
8 actively foster the development of service-delivery systems
9 and cooperative agreements to enhance the provision of
10 high-quality health care services in rural areas and serve as
11 a catalyst for improved health services to residents citizens
12 in rural areas of the state.
13 (3) GENERAL FUNCTIONS.--The office shall:
14 (a) Integrate policies related to physician workforce,
15 hospitals, public health, and state regulatory functions.
16 (b) Work with rural stakeholders in order to foster
17 the development of strategic planning that addresses Propose
18 solutions to problems affecting health care delivery in rural
19 areas.
20 (c) Develop, in coordination with the rural health
21 networks, standards, guidelines, and performance objectives
22 for rural health networks.
23 (d) Foster the expansion of rural health network
24 service areas to include rural counties that are not covered
25 by a rural health network.
26 (e)(c) Seek grant funds from foundations and the
27 Federal Government.
28 (f) Administer state grant programs for rural
29 hospitals and rural health networks.
30 (4) COORDINATION.--The office shall:
31
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1 (a) Identify federal and state rural health programs
2 and provide information and technical assistance to rural
3 providers regarding participation in such programs.
4 (b) Act as a clearinghouse for collecting and
5 disseminating information on rural health care issues,
6 research findings on rural health care, and innovative
7 approaches to the delivery of health care in rural areas.
8 (c) Foster the creation of regional health care
9 systems that promote cooperation through cooperative
10 agreements, rather than competition.
11 (d) Coordinate the department's rural health care
12 activities, programs, and policies.
13 (e) Design initiatives and promote cooperative
14 agreements in order to improve access to primary care,
15 prehospital emergency care, inpatient acute care, and
16 emergency medical services and promote the coordination of
17 such services in rural areas.
18 (f) Assume responsibility for state coordination of
19 the Rural Hospital Transition Grant Program, the Essential
20 Access Community Hospital Program, and other federal rural
21 hospital and rural health care grant programs.
22 (5) TECHNICAL ASSISTANCE.--The office shall:
23 (a) Assist Help rural health care providers in
24 recruiting obtain health care practitioners by promoting the
25 location and relocation of health care practitioners in rural
26 areas and promoting policies that create incentives for
27 practitioners to serve in rural areas.
28 (b) Provide technical assistance to hospitals,
29 community and migrant health centers, and other health care
30 providers that serve residents of rural areas.
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1 (c) Assist with the design of strategies to improve
2 health care workforce recruitment and placement programs.
3 (d) Provide technical assistance to rural health
4 networks in the development of their long-range development
5 plans.
6 (e) Provide links to best practices and other
7 technical-assistance resources on its website.
8 (6) RESEARCH PUBLICATIONS AND SPECIAL STUDIES.--The
9 office shall:
10 (a) Conduct policy and research studies.
11 (b) Conduct health status studies of rural residents.
12 (c) Collect relevant data on rural health care issues
13 for use in program planning and department policy development.
14 (7) ADVISORY COUNCIL.--The Secretary of Health and the
15 Secretary of Health Care Administration shall each appoint no
16 more than five members having relevant health care operations
17 management, practice, and policy experience to an advisory
18 council to advise the office regarding its responsibilities
19 under this section and ss. 381.0406 and 395.6061. Members
20 shall be appointed for 4-year staggered terms and may be
21 reappointed to a second term of office. Members shall serve
22 without compensation, but are entitled to reimbursement for
23 per diem and travel expenses as provided in s. 112.061. The
24 department shall provide staff and other administrative
25 assistance reasonably necessary to assist the advisory council
26 in carrying out its duties. The advisory council shall work
27 with stakeholders to develop recommendations that address
28 barriers and identify options for establishing provider
29 networks in rural counties.
30 (8) REPORTS.--Beginning January 1, 2007, and annually
31 thereafter, the Office of Rural Health shall submit a report
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1 to the Governor, the President of the Senate, and the Speaker
2 of the House of Representatives summarizing the activities of
3 the office, including the grants obtained or administered by
4 the office and the status of rural health networks and rural
5 hospitals in the state. The report must also include
6 recommendations that address barriers and identify options for
7 establishing provider networks in rural counties.
8 (9)(7) APPROPRIATION.--The Legislature shall
9 appropriate such sums as are necessary to support the Office
10 of Rural Health.
11 Section 2. Section 381.0406, Florida Statutes, is
12 amended to read:
13 381.0406 Rural health networks.--
14 (1) LEGISLATIVE FINDINGS AND INTENT.--
15 (a) The Legislature finds that, in rural areas, access
16 to health care is limited and the quality of health care is
17 negatively affected by inadequate financing, difficulty in
18 recruiting and retaining skilled health professionals, and the
19 because of a migration of patients to urban areas for general
20 acute care and specialty services.
21 (b) The Legislature further finds that the efficient
22 and effective delivery of health care services in rural areas
23 requires:
24 1. The integration of public and private resources;
25 2. The introduction of innovative outreach methods;
26 3. The adoption of quality improvement and
27 cost-effectiveness measures;
28 4. The organization of health care providers into
29 joint contracting entities;
30 5. Establishing referral linkages;
31
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1 6. The analysis of costs and services in order to
2 prepare health care providers for prepaid and at-risk
3 financing; and
4 7. The coordination of health care providers.
5 (c) The Legislature further finds that the
6 availability of a continuum of quality health care services,
7 including preventive, primary, secondary, tertiary, and
8 long-term care, is essential to the economic and social
9 vitality of rural communities.
10 (d) The Legislature further finds that health care
11 providers in rural areas are not prepared for market changes
12 such as the introduction of managed care and
13 capitation-reimbursement methodologies into health care
14 services.
15 (e)(d) The Legislature further finds that the creation
16 of rural health networks can help to alleviate these problems.
17 Rural health networks shall act in the broad public interest
18 and, to the extent possible, seek to improve the
19 accessibility, quality, and cost-effectiveness of rural health
20 care by planning, developing, coordinating, and providing be
21 structured to provide a continuum of quality health care
22 services for rural residents through the cooperative efforts
23 of rural health network members and other health care
24 providers.
25 (f)(e) The Legislature further finds that rural health
26 networks shall have the goal of increasing the financial
27 stability of statutory rural hospitals by linking rural
28 hospital services to other services in a continuum of health
29 care services and by increasing the utilization of statutory
30 rural hospitals whenever for appropriate health care services
31 whenever feasible, which shall help to ensure their survival
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1 and thereby support the economy and protect the health and
2 safety of rural residents.
3 (g)(f) Finally, the Legislature finds that rural
4 health networks may serve as "laboratories" to determine the
5 best way of organizing rural health services and linking to
6 out-of-area services that are not available locally in order,
7 to move the state closer to ensuring that everyone has access
8 to health care, and to promote cost containment efforts. The
9 ultimate goal of rural health networks shall be to ensure that
10 quality health care is available and efficiently delivered to
11 all persons in rural areas.
12 (2) DEFINITIONS.--
13 (a) "Rural" means an area having with a population
14 density of fewer less than 100 individuals per square mile or
15 an area defined by the most recent United States Census as
16 rural.
17 (b) "Health care provider" means any individual,
18 group, or entity, public or private, which that provides
19 health care, including: preventive health care, primary health
20 care, secondary and tertiary health care, hospital in-hospital
21 health care, public health care, and health promotion and
22 education.
23 (c) "Rural health network" or "network" means a
24 nonprofit legal entity whose principal place of business is in
25 a rural county, whose members consist consisting of rural and
26 urban health care providers and others, and which that is
27 established organized to plan, develop, organize, and deliver
28 health care services on a cooperative basis in a rural area,
29 except for some secondary and tertiary care services.
30 (3) NETWORK MEMBERSHIP.--
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1 (a) Because each rural area is unique, with a
2 different health care provider mix, health care provider
3 membership may vary, but all networks shall include members
4 that provide health promotion and disease-prevention services,
5 public health services, comprehensive primary care, emergency
6 medical care, and acute inpatient care.
7 (b) Each county health department shall be a member of
8 the rural health network whose service area includes the
9 county in which the county health department is located.
10 Federally qualified health centers and emergency medical
11 services providers are encouraged to become members of the
12 rural health networks in the areas in which their patients
13 reside or receive services.
14 (c)(4) Network membership shall be available to all
15 health care providers in the network service area if, provided
16 that they render care to all patients referred to them from
17 other network members;, comply with network quality assurance,
18 quality improvement, and utilization-management and risk
19 management requirements; and, abide by the terms and
20 conditions of network provider agreements in paragraph
21 (11)(c), and provide services at a rate or price equal to the
22 rate or price negotiated by the network.
23 (4)(5) NETWORK SERVICE AREAS.--Network service areas
24 are do not required need to conform to local political
25 boundaries or state administrative district boundaries. The
26 geographic area of one rural health network, however, may not
27 overlap the territory of any other rural health network.
28 (5)(6) NETWORK FUNCTIONS.-- Networks shall:
29 (a) Seek to develop linkages with provisions for
30 referral to tertiary inpatient care, specialty physician care,
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1 and to other services that are not available in rural service
2 areas.
3 (b)(7) Networks shall Make available health promotion,
4 disease prevention, and primary care services, in order to
5 improve the health status of rural residents and to contain
6 health care costs.
7 (8) Networks may have multiple points of entry, such
8 as through private physicians, community health centers,
9 county health departments, certified rural health clinics,
10 hospitals, or other providers; or they may have a single point
11 of entry.
12 (c)(9) Encourage members through training and
13 educational programs to adopt standards of care, and promote
14 the evidence-based practice of medicine. Networks shall
15 establish standard protocols, coordinate and share patient
16 records, and develop patient information exchange systems in
17 order to improve quality and access to services.
18 (d) Develop quality-improvement programs and train
19 network members and other health care providers in the use of
20 such programs.
21 (e) Develop disease-management systems and train
22 network members and other health care providers in the use of
23 such systems.
24 (f) Promote outreach to areas with a high need for
25 services.
26 (g) Seek to develop community care alternatives for
27 elders who would otherwise be placed in nursing homes.
28 (h) Emphasize community care alternatives for persons
29 with mental health and substance abuse disorders who are at
30 risk of being admitted to an institution.
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1 (i) Develop and implement a long-range development
2 plan for an integrated system of care that is responsive to
3 the unique local health needs and the area health care
4 services market. Each rural health network long-range
5 development plan must address strategies to improve access to
6 specialty care, train health care providers to use standards
7 of care for chronic illness, develop disease-management
8 capacity, and link to state and national quality-improvement
9 initiatives. The initial long-range development plan must be
10 submitted to the Office of Rural Health for review and
11 approval no later than July 1, 2007, and thereafter the plans
12 must be updated and submitted to the Office of Rural Health
13 every 3 years.
14 (10) Networks shall develop risk management and
15 quality assurance programs for network providers.
16 (6)(11) NETWORK GOVERNANCE AND ORGANIZATION.--
17 (a) Networks shall be incorporated as not-for-profit
18 corporations under chapter 617, with articles of incorporation
19 that set forth purposes consistent with this section the laws
20 of the state.
21 (b) Each network Networks shall have an independent a
22 board of directors that derives membership from local
23 government, health care providers, businesses, consumers,
24 advocacy groups, and others. Boards of other community health
25 care entities may not serve in whole as the board of a rural
26 health network; however, some overlap of board membership with
27 other community organizations is encouraged. Network staff
28 must provide an annual orientation and strategic planning
29 activity for board members.
30 (c) Network boards of directors shall have the
31 responsibility of determining the content of health care
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1 provider agreements that link network members. The written
2 agreements between the network and its health care provider
3 members must specify participation in the essential functions
4 of the network and 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 that can provide include the following core
26 services: disease prevention, health promotion, comprehensive
27 primary care, emergency medical care, and acute inpatient
28 care. Each network shall seek to ensure the availability of
29 comprehensive maternity care, including prenatal, delivery,
30 and postpartum care for uncomplicated pregnancies, either
31 directly, by contract, or through referral agreements.
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1 Networks shall, to the extent feasible, develop local services
2 and linkages among health care providers to also ensure the
3 availability of the following services: within the specified
4 timeframes, either directly, by contract, or through referral
5 agreements:
6 1. Services available in the home.
7 1.a. Home health care.
8 2.b. Hospice care.
9 2. Services accessible within 30 minutes travel time
10 or less.
11 3.a. Emergency medical services, including advanced
12 life support, ambulance, and basic emergency room services.
13 4.b. Primary care, including.
14 c. prenatal and postpartum care for uncomplicated
15 pregnancies.
16 5.d. Community-based services for elders, such as
17 adult day care and assistance with activities of daily living.
18 6.e. Public health services, including communicable
19 disease control, disease prevention, health education, and
20 health promotion.
21 7.f. Outpatient mental health psychiatric and
22 substance abuse services.
23 3. Services accessible within 45 minutes travel time
24 or less.
25 8.a. Hospital acute inpatient care for persons whose
26 illnesses or medical problems are not severe.
27 9.b. Level I obstetrical care, which is Labor and
28 delivery for low-risk patients.
29 10.c. Skilled nursing services and, long-term care,
30 including nursing home care.
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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 1.d. Dialysis.
5 2.e. Osteopathic and chiropractic manipulative
6 therapy.
7 4. Services accessible within 2 hours travel time or
8 less.
9 3.a. Specialist physician care.
10 4.b. Hospital acute inpatient care for severe
11 illnesses and medical problems.
12 5.c. Level II and III obstetrical care, which is Labor
13 and delivery care for high-risk patients and neonatal
14 intensive care.
15 6.d. Comprehensive medical rehabilitation.
16 7.e. Inpatient mental health psychiatric and substance
17 abuse services.
18 8.f. Magnetic resonance imaging, lithotripter
19 treatment, oncology, advanced radiology, and other
20 technologically advanced services.
21 9.g. Subacute care.
22 (8) COORDINATION WITH OTHER ENTITIES.--
23 (a) Area health education centers, health planning
24 councils, and regional education consortia shall participate
25 in the rural health networks' preparation of long-range
26 development plans. The Department of Health may require
27 written memoranda of agreement between a network and an area
28 health education center or health planning council.
29 (b) Rural health networks shall initiate activities,
30 in coordination with area health education centers, to carry
31 out the objectives of the adopted long-range development plan,
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1 including continuing education for health care practitioners
2 performing functions such as disease management, continuous
3 quality improvement, telemedicine, long-distance learning, and
4 the treatment of chronic illness using standards of care. As
5 used in this section, the term "telemedicine" means the use of
6 telecommunications to deliver or expedite the delivery of
7 health care services.
8 (c) Health planning councils shall support the
9 preparation of network long-range development plans through
10 data collection and analysis in order to assess the health
11 status of area residents and the capacity of local health
12 services.
13 (d) Regional education consortia that have the
14 technology available to assist rural health networks in
15 establishing systems for exchange of patient information and
16 for long-distance learning shall provide technical assistance
17 upon the request of a rural health network.
18 (e)(b) Networks shall actively participate with area
19 health education center programs, whenever feasible, in
20 developing and implementing recruitment, training, and
21 retention programs directed at positively influencing the
22 supply and distribution of health care professionals serving
23 in, or receiving training in, network areas.
24 (c) As funds become available, networks shall
25 emphasize community care alternatives for elders who would
26 otherwise be placed in nursing homes.
27 (d) To promote the most efficient use of resources,
28 networks shall emphasize disease prevention, early diagnosis
29 and treatment of medical problems, and community care
30 alternatives for persons with mental health and substance
31 abuse disorders who are at risk to be institutionalized.
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1 (f)(13) TRAUMA SERVICES.--In those network areas
2 having which have an established trauma agency approved by the
3 Department of Health, the network shall seek the participation
4 of that trauma agency must be a participant in the network.
5 Trauma services provided within the network area must comply
6 with s. 395.405.
7 (9)(14) NETWORK FINANCING.--
8 (a) Networks may use all sources of public and private
9 funds to support network activities. Nothing in this section
10 prohibits networks from becoming managed care providers.
11 (b) The Department of Health shall establish grant
12 programs to provide funding to support the administrative
13 costs of developing and operating rural health networks.
14 (10) NETWORK PERFORMANCE STANDARDS.--The Department of
15 Health shall develop and enforce performance standards for
16 rural health network operations grants and rural health
17 infrastructure development grants.
18 (a) Operations grant performance standards must
19 include, but are not limited to, standards that require the
20 rural health network to:
21 1. Have a qualified board of directors that meets at
22 least quarterly.
23 2. Have sufficient staff who have the qualifications
24 and experience to perform the requirements of this section, as
25 assessed by the Office of Rural Health, or a written plan to
26 obtain such staff.
27 3. Comply with the department's grant-management
28 standards in a timely and responsive manner.
29 4. Comply with the department's standards for the
30 administration of federal grant funding, including assistance
31 to rural hospitals.
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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 a network operations
11 grant program. As funds become available, certified networks
12 that meet performance standards shall be eligible to receive
13 grant funds to be used to help defray the costs of rural
14 health network infrastructure development, patient care, and
15 network administration. Rural health network infrastructure
16 development includes, but is not limited to: recruitment and
17 retention of primary care practitioners; enhancements of
18 primary care services through the use of mobile clinics;
19 development of preventive health care programs; linkage of
20 urban and rural health care systems; design and implementation
21 of automated patient records, outcome measurement, quality
22 assurance, and risk management systems; establishment of
23 one-stop service delivery sites; upgrading of medical
24 technology available to network providers; enhancement of
25 emergency medical systems; enhancement of medical
26 transportation; formation of joint contracting entities
27 composed of rural physicians, rural hospitals, and other rural
28 health care providers; establishment of comprehensive
29 disease-management programs that meet Medicaid requirements;
30 establishment of regional quality-improvement programs
31 involving physicians and hospitals consistent with state and
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1 national initiatives; establishment of speciality networks
2 connecting rural primary care physicians and urban
3 specialists; development of regional broadband
4 telecommunications systems that have the capacity to share
5 patient information in a secure network, telemedicine, and
6 long-distance learning capacity; and linkage between training
7 programs for health care practitioners and the delivery of
8 health care services in rural areas and development of
9 telecommunication capabilities. A Phase II award may occur in
10 the same fiscal year as a Phase I award.
11 (12)(16) CERTIFICATION.--For the purpose of certifying
12 networks that are eligible for Phase II funding, the
13 Department of Health shall certify networks that meet the
14 criteria delineated in this section and the rules governing
15 rural health networks. The Office of Rural Health in the
16 Department of Health shall monitor rural health networks in
17 order to ensure continued compliance with established
18 certification and performance standards.
19 (13)(17) RULES.--The Department of Health shall
20 establish rules that govern the creation and certification of
21 networks, the provision of grant funds under Phase I and Phase
22 II, and the establishment of performance standards including
23 establishing outcome measures for networks.
24 Section 3. Subsection (2) of section 395.602, Florida
25 Statutes, is amended to read:
26 395.602 Rural hospitals.--
27 (2) DEFINITIONS.--As used in this part:
28 (a) "Critical access hospital" means a hospital that
29 meets the definition of rural hospital in paragraph (d) and
30 meets the requirements for reimbursement by Medicare and
31
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1 Medicaid under 42 C.F.R. ss. 485.601-485.647. "Emergency care
2 hospital" means a medical facility which provides:
3 1. Emergency medical treatment; and
4 2. Inpatient care to ill or injured persons prior to
5 their transportation to another hospital or provides inpatient
6 medical care to persons needing care for a period of up to 96
7 hours. The 96-hour limitation on inpatient care does not
8 apply to respite, skilled nursing, hospice, or other nonacute
9 care patients.
10 (b) "Essential access community hospital" means any
11 facility which:
12 1. Has at least 100 beds;
13 2. Is located more than 35 miles from any other
14 essential access community hospital, rural referral center, or
15 urban hospital meeting criteria for classification as a
16 regional referral center;
17 3. Is part of a network that includes rural primary
18 care hospitals;
19 4. Provides emergency and medical backup services to
20 rural primary care hospitals in its rural health network;
21 5. Extends staff privileges to rural primary care
22 hospital physicians in its network; and
23 6. Accepts patients transferred from rural primary
24 care hospitals in its network.
25 (b)(c) "Inactive rural hospital bed" means a licensed
26 acute care hospital bed, as defined in s. 395.002(14), that is
27 inactive in that it cannot be occupied by acute care
28 inpatients.
29 (c)(d) "Rural area health education center" means an
30 area health education center (AHEC), as authorized by Pub. L.
31 No. 94-484, which provides services in a county with a
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1 population density of no greater than 100 persons per square
2 mile.
3 (d)(e) "Rural hospital" means an acute care hospital
4 licensed under this chapter, having 100 or fewer licensed beds
5 and an emergency room, which is:
6 1. The sole provider within a county with a population
7 density of no greater than 100 persons per square mile;
8 2. An acute care hospital, in a county with a
9 population density of no greater than 100 persons per square
10 mile, which is at least 30 minutes of travel time, on normally
11 traveled roads under normal traffic conditions, from any other
12 acute care hospital within the same county;
13 3. A hospital supported by a tax district or
14 subdistrict whose boundaries encompass a population of 100
15 persons or fewer per square mile;
16 4. A hospital in a constitutional charter county with
17 a population of over 1 million persons that has imposed a
18 local option health service tax pursuant to law and in an area
19 that was directly impacted by a catastrophic event on August
20 24, 1992, for which the Governor of Florida declared a state
21 of emergency pursuant to chapter 125, and has 120 beds or less
22 that serves an agricultural community with an emergency room
23 utilization of no less than 20,000 visits and a Medicaid
24 inpatient utilization rate greater than 15 percent;
25 5. A hospital with a service area that has a
26 population of 100 persons or fewer per square mile. As used in
27 this subparagraph, the term "service area" means the fewest
28 number of zip codes that account for 75 percent of the
29 hospital's discharges for the most recent 5-year period, based
30 on information available from the hospital inpatient discharge
31
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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 may shall annually be
5 disbursed to financially distressed rural hospitals in
6 accordance with this section. The Department of Health shall
7 establish, by rule, criteria for awarding grants for any
8 remaining funds, which must be used exclusively for the
9 support and assistance of rural hospitals as defined in s.
10 395.602, including criteria relating to the level of charity
11 uncompensated care rendered by the hospital, the financial
12 status of the hospital, the performance standards of the
13 hospital, the hospital's participation in a rural health
14 network as defined in s. 381.0406, and the proposed use of the
15 grant by the rural hospital to resolve a specific problem. The
16 department must consider any information submitted in an
17 application for the grants in accordance with subsection (1)
18 in determining eligibility for and the amount of the grant,
19 and none of the individual items of information by itself may
20 be used to deny grant eligibility.
21 (4) To receive any of the remaining funds, a
22 financially distressed rural hospital must agree to be bound
23 by the terms of a participation agreement with the department,
24 which may include:
25 (a) The appointment of a health care expert under
26 contract with the department to analyze and monitor the
27 hospital's operations during the period of distress.
28 (b) The establishment of minimum standards for the
29 education and experience of the managers and administrators of
30 the hospital.
31
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1 (c) The oversight and monitoring of a strategic plan
2 to restore the hospital to an economically stable condition or
3 to effect a transition to an alternative means of providing
4 services.
5 (d) The establishment of an orientation and
6 development program for members of the board.
7 (e) The approval of any facility relocation plans.
8 (5)(4) The department shall ensure that the funds are
9 used solely for the purposes specified in this section. The
10 total grants awarded pursuant to this section shall not exceed
11 the amount appropriated for this program.
12 Section 7. Subsection (12) of section 409.908, Florida
13 Statutes, is amended to read:
14 409.908 Reimbursement of Medicaid providers.--Subject
15 to specific appropriations, the agency shall reimburse
16 Medicaid providers, in accordance with state and federal law,
17 according to methodologies set forth in the rules of the
18 agency and in policy manuals and handbooks incorporated by
19 reference therein. These methodologies may include fee
20 schedules, reimbursement methods based on cost reporting,
21 negotiated fees, competitive bidding pursuant to s. 287.057,
22 and other mechanisms the agency considers efficient and
23 effective for purchasing services or goods on behalf of
24 recipients. If a provider is reimbursed based on cost
25 reporting and submits a cost report late and that cost report
26 would have been used to set a lower reimbursement rate for a
27 rate semester, then the provider's rate for that semester
28 shall be retroactively calculated using the new cost report,
29 and full payment at the recalculated rate shall be effected
30 retroactively. Medicare-granted extensions for filing cost
31 reports, if applicable, shall also apply to Medicaid cost
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1 reports. Payment for Medicaid compensable services made on
2 behalf of Medicaid eligible persons is subject to the
3 availability of moneys and any limitations or directions
4 provided for in the General Appropriations Act or chapter 216.
5 Further, nothing in this section shall be construed to prevent
6 or limit the agency from adjusting fees, reimbursement rates,
7 lengths of stay, number of visits, or number of services, or
8 making any other adjustments necessary to comply with the
9 availability of moneys and any limitations or directions
10 provided for in the General Appropriations Act, provided the
11 adjustment is consistent with legislative intent.
12 (12)(a) A physician shall be reimbursed the lesser of
13 the amount billed by the provider or the Medicaid maximum
14 allowable fee established by the agency.
15 (b) The agency shall adopt a fee schedule, subject to
16 any limitations or directions provided for in the General
17 Appropriations Act, based on a resource-based relative value
18 scale for pricing Medicaid physician services. Under this fee
19 schedule, physicians shall be paid a dollar amount for each
20 service based on the average resources required to provide the
21 service, including, but not limited to, estimates of average
22 physician time and effort, practice expense, and the costs of
23 professional liability insurance. The fee schedule shall
24 provide increased reimbursement for preventive and primary
25 care services and lowered reimbursement for specialty services
26 by using at least two conversion factors, one for cognitive
27 services and another for procedural services. The fee schedule
28 shall not increase total Medicaid physician expenditures
29 unless moneys are available, and shall be phased in over a
30 2-year period beginning on July 1, 1994. The Agency for Health
31 Care Administration shall seek the advice of a 16-member
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1 advisory panel in formulating and adopting the fee schedule.
2 The panel shall consist of Medicaid physicians licensed under
3 chapters 458 and 459 and shall be composed of 50 percent
4 primary care physicians and 50 percent specialty care
5 physicians.
6 (c) Notwithstanding paragraph (b), reimbursement fees
7 to physicians for providing total obstetrical services to
8 Medicaid recipients, which include prenatal, delivery, and
9 postpartum care, shall be at least $1,500 per delivery for a
10 pregnant woman with low medical risk and at least $2,000 per
11 delivery for a pregnant woman with high medical risk. However,
12 reimbursement to physicians working in Regional Perinatal
13 Intensive Care Centers designated pursuant to chapter 383, for
14 services to certain pregnant Medicaid recipients with a high
15 medical risk, may be made according to obstetrical care and
16 neonatal care groupings and rates established by the agency.
17 Nurse midwives licensed under part I of chapter 464 or
18 midwives licensed under chapter 467 shall be reimbursed at no
19 less than 80 percent of the low medical risk fee. The agency
20 shall by rule determine, for the purpose of this paragraph,
21 what constitutes a high or low medical risk pregnant woman and
22 shall not pay more based solely on the fact that a caesarean
23 section was performed, rather than a vaginal delivery. The
24 agency shall by rule determine a prorated payment for
25 obstetrical services in cases where only part of the total
26 prenatal, delivery, or postpartum care was performed. The
27 Department of Health shall adopt rules for appropriate
28 insurance coverage for midwives licensed under chapter 467.
29 Prior to the issuance and renewal of an active license, or
30 reactivation of an inactive license for midwives licensed
31
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1 under chapter 467, such licensees shall submit proof of
2 coverage with each application.
3 (d) Notwithstanding other provisions of this
4 subsection, physicians licensed under chapter 458 or chapter
5 459 who have a provider agreement with a rural health network
6 as established in s. 381.0406 shall be paid a 10-percent bonus
7 over the Medicaid physician fee schedule for any physician
8 service provided within the geographic boundary of a rural
9 county as defined by the most recent United States Census as
10 rural.
11 Section 8. Subsection (43) of section 408.07, Florida
12 Statutes, is amended to read:
13 408.07 Definitions.--As used in this chapter, with the
14 exception of ss. 408.031-408.045, the term:
15 (43) "Rural hospital" means an acute care hospital
16 licensed under chapter 395, having 100 or fewer licensed beds
17 and an emergency room, and which is:
18 (a) The sole provider within a county with a
19 population density of no greater than 100 persons per square
20 mile;
21 (b) An acute care hospital, in a county with a
22 population density of no greater than 100 persons per square
23 mile, which is at least 30 minutes of travel time, on normally
24 traveled roads under normal traffic conditions, from another
25 acute care hospital within the same county;
26 (c) A hospital supported by a tax district or
27 subdistrict whose boundaries encompass a population of 100
28 persons or fewer per square mile;
29 (d) A hospital with a service area that has a
30 population of 100 persons or fewer per square mile. As used
31 in this paragraph, the term "service area" means the fewest
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1 number of zip codes that account for 75 percent of the
2 hospital's discharges for the most recent 5-year period, based
3 on information available from the hospital inpatient discharge
4 database in the State Center for Health Statistics at the
5 Agency for Health Care Administration; or
6 (e) A critical access hospital.
7
8 Population densities used in this subsection must be based
9 upon the most recently completed United States census. A
10 hospital that received funds under s. 409.9116 for a quarter
11 beginning no later than July 1, 2002, is deemed to have been
12 and shall continue to be a rural hospital from that date
13 through June 30, 2012, if the hospital continues to have 100
14 or fewer licensed beds and an emergency room, or meets the
15 criteria of s. 395.602(2)(d)4. s. 395.602(2)(e)4. An acute
16 care hospital that has not previously been designated as a
17 rural hospital and that meets the criteria of this subsection
18 shall be granted such designation upon application, including
19 supporting documentation, to the Agency for Health Care
20 Administration.
21 Section 9. Subsection (6) of section 409.9116, Florida
22 Statutes, is amended to read:
23 409.9116 Disproportionate share/financial assistance
24 program for rural hospitals.--In addition to the payments made
25 under s. 409.911, the Agency for Health Care Administration
26 shall administer a federally matched disproportionate share
27 program and a state-funded financial assistance program for
28 statutory rural hospitals. The agency shall make
29 disproportionate share payments to statutory rural hospitals
30 that qualify for such payments and financial assistance
31 payments to statutory rural hospitals that do not qualify for
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1 disproportionate share payments. The disproportionate share
2 program payments shall be limited by and conform with federal
3 requirements. Funds shall be distributed quarterly in each
4 fiscal year for which an appropriation is made.
5 Notwithstanding the provisions of s. 409.915, counties are
6 exempt from contributing toward the cost of this special
7 reimbursement for hospitals serving a disproportionate share
8 of low-income patients.
9 (6) This section applies only to hospitals that were
10 defined as statutory rural hospitals, or their
11 successor-in-interest hospital, prior to January 1, 2001. Any
12 additional hospital that is defined as a statutory rural
13 hospital, or its successor-in-interest hospital, on or after
14 January 1, 2001, is not eligible for programs under this
15 section unless additional funds are appropriated each fiscal
16 year specifically to the rural hospital disproportionate share
17 and financial assistance programs in an amount necessary to
18 prevent any hospital, or its successor-in-interest hospital,
19 eligible for the programs prior to January 1, 2001, from
20 incurring a reduction in payments because of the eligibility
21 of an additional hospital to participate in the programs. A
22 hospital, or its successor-in-interest hospital, which
23 received funds pursuant to this section before January 1,
24 2001, and which qualifies under s. 395.602(2)(d) s.
25 395.602(2)(e), shall be included in the programs under this
26 section and is not required to seek additional appropriations
27 under this subsection.
28 Section 10. Paragraph (b) of subsection (2) of section
29 1009.65, Florida Statutes, is amended to read:
30 1009.65 Medical Education Reimbursement and Loan
31 Repayment Program.--
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1 (2) From the funds available, the Department of Health
2 shall make payments to selected medical professionals as
3 follows:
4 (b) All payments shall be contingent on continued
5 proof of primary care practice in an area defined in s.
6 395.602(2)(d) s. 395.602(2)(e), or an underserved area
7 designated by the Department of Health, provided the
8 practitioner accepts Medicaid reimbursement if eligible for
9 such reimbursement. Correctional facilities, state hospitals,
10 and other state institutions that employ medical personnel
11 shall be designated by the Department of Health as underserved
12 locations. Locations with high incidences of infant mortality,
13 high morbidity, or low Medicaid participation by health care
14 professionals may be designated as underserved.
15 Section 11. The Office of Program Policy Analysis and
16 Government Accountability shall contract with an entity having
17 expertise in the financing of rural hospital capital
18 improvement projects to study the financing options for
19 replacing or changing the use of rural hospital facilities
20 having 55 or fewer beds which were built before 1985 and which
21 have not had major renovations since 1985. For each such
22 hospital, the contractor shall assess the need to replace or
23 convert the facility, identify all available sources of
24 financing for such replacement or conversion and assess each
25 community's capacity to maximize these funding options,
26 propose a model replacement facility if a facility should be
27 replaced, and propose alternative uses of the facility if
28 continued operation of the hospital is not financially
29 feasible. Based on the results of the contract study, the
30 Office of Program Policy Analysis and Government
31 Accountability shall submit recommendations to the Legislature
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1 by February 1, 2007, regarding whether the state should
2 provide financial assistance to replace or convert these rural
3 hospital facilities and what form that assistance should take.
4 Section 12. Section 395.605, Florida Statutes, is
5 repealed.
6 Section 13. The sum of $440,000 from nonrecurring
7 general revenue funds is appropriated to the Office of Program
8 Policy Analysis and Government Accountability to implement
9 section 11 of this act.
10 Section 14. The sums of $3,638,709 in recurring
11 general revenue funds and $5,067,392 in recurring funds from
12 the Medical Care Trust Fund are appropriated to the Agency for
13 Health Care Administration to implement the 10-percent
14 Medicaid fee schedule bonus payment as provided in this act.
15 Section 15. The sum of $3 million in recurring general
16 revenue funds is appropriated to the Department of Health to
17 implement rural health network infrastructure development as
18 provided in section 2 of this act.
19 Section 16. The sum of $3 million in nonrecurring
20 general revenue funds is appropriated to the Department of
21 Health to implement the rural hospital capital improvement
22 grant program as provided in section 6 of this act.
23 Section 17. The sums of $196,818 in recurring general
24 revenue funds and $17,556 in nonrecurring general revenue
25 funds are appropriated to the Department of Health, and three
26 full-time equivalent positions and associated salary rate of
27 121,619 are authorized to implement this act.
28 Section 18. This act shall take effect July 1, 2006.
29
30
31
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS/CS Senate Bill 2176
3
4 -- Deletes a new requirement in the bill for the Office of
Rural Health to conduct research on best practices in the
5 delivery of health care services in rural areas.
6 -- Requires the advisory council to develop recommendations
that address barriers and identify options for
7 establishing provider networks in rural counties.
8 -- Restores current statutory language that is struck in the
bill relating to rural health networks directly providing
9 health care services.
10 -- Deletes a requirement for rural health networks to
collect data and conduct studies to measure resident's
11 health status.
12 -- Deletes a section that created a new rural health
infrastructure development grant program, and instead,
13 expands the existing Phase II funding of rural health
networks to include rural health network infrastructure
14 development grants.
15 -- Authorizes the Department of Health to disburse any
remaining funds, after each rural hospital gets a
16 $100,000 capital improvement grant, to financially
distressed rural hospitals.
17
-- Establishes requirements for a financially distressed
18 rural hospital to receive funding. These include a
participation agreement with the Department of Health,
19 which can impose certain requirements for the managers,
administrators, and board of the hospital or the
20 appointment of an expert to analyze and monitor the
hospital operations during the period of distress.
21
-- Provides an appropriation.
22
23
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26
27
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31
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