HB 5007

1	A bill to be entitled
2	An act relating to health care; amending s. 400.23, F.S.;
3	revising minimum staffing requirements for nursing homes;
4	amending s. 409.904, F.S.; revising requirements relating
5	to eligibility of certain women for family planning
6	services; amending s. 409.905, F.S.; revising requirements
7	for the hospitalist program; removing a provision
8	authorizing the Agency for Health Care Administration to
9	seek certain waivers to implement the program; amending s.
10	409.906, F.S.; revising provisions relating to optional
11	adult dental and visual services covered by Medicaid;
12	amending s. 409.907, F.S.; revising the enrollment
13	effective date for Medicaid providers; providing
14	procedures for payment for certain claims for services;
15	amending s. 409.9081, F.S.; revising the limitation on
16	Medicaid recipient copayments for emergency room services;
17	amending s. 409.911, F.S., relating to the hospital
18	disproportionate share program; revising the method for
19	calculating disproportionate share payments to hospitals;
20	deleting obsolete provisions; amending s. 409.9113, F.S.;
21	providing guidelines for distribution of disproportionate
22	share funds to certain teaching hospitals; amending s.
23	409.9117, F.S., relating to the primary care
24	disproportionate share program; revising the time period
25	during which the agency shall not distribute certain
26	moneys; amending s. 409.912, F.S., relating to cost-
27	effective purchasing of health care; providing that
28	adjustments for health status be considered in agency
29	evaluations of the cost-effectiveness of Medicaid managed
30	care plans; providing requirements for Medicaid capitation
31	payments for managed long-term care programs and payments
32	for Medicaid home and community-based services; amending
33	s. 409.9122, F.S.; revising enrollment limits for Medicaid
34	recipients who are subject to mandatory assignment to
35	managed care plans and MediPass; amending s. 624.91, F.S.;
36	requiring the Florida Healthy Kids Corporation to return
37	certain unspent funds based on a formula developed by the
38	corporation; amending s. 430.705, F.S., relating to
39	implementation of the long-term care community diversion
40	pilot projects; providing requirements for Medicaid
41	capitation payments for managed long-term care programs
42	and payments for Medicaid home and community-based
43	services; providing an effective date.
44
45	Be It Enacted by the Legislature of the State of Florida:
46
47	Section 1.  Paragraph (a) of subsection (3) of section
48	400.23, Florida Statutes, is amended to read:
49	400.23  Rules; evaluation and deficiencies; licensure
50	status.--
51	(3)(a)  The agency shall adopt rules providing minimum
52	staffing requirements for nursing homes. These requirements
53	shall include, for each nursing home facility, a minimum
54	certified nursing assistant staffing of 2.3 hours of direct care
55	per resident per day beginning January 1, 2002, increasing to
56	2.6 hours of direct care per resident per day beginning January
57	1, 2003, and increasing to 2.9 hours of direct care per resident
58	per day beginning July 1, 2006. Beginning January 1, 2002, no
59	facility shall staff below one certified nursing assistant per
60	20 residents, and a minimum licensed nursing staffing of 1.0
61	hour of direct resident care per resident per day but never
62	below one licensed nurse per 40 residents. Nursing assistants
63	employed under s. 400.211(2) may be included in computing the
64	staffing ratio for certified nursing assistants only if they
65	provide nursing assistance services to residents on a full-time
66	basis. Each nursing home must document compliance with staffing
67	standards as required under this paragraph and post daily the
68	names of staff on duty for the benefit of facility residents and
69	the public. The agency shall recognize the use of licensed
70	nurses for compliance with minimum staffing requirements for
71	certified nursing assistants, provided that the facility
72	otherwise meets the minimum staffing requirements for licensed
73	nurses and that the licensed nurses are performing the duties of
74	a certified nursing assistant. Unless otherwise approved by the
75	agency, licensed nurses counted toward the minimum staffing
76	requirements for certified nursing assistants must exclusively
77	perform the duties of a certified nursing assistant for the
78	entire shift and not also be counted toward the minimum staffing
79	requirements for licensed nurses. If the agency approved a
80	facility's request to use a licensed nurse to perform both
81	licensed nursing and certified nursing assistant duties, the
82	facility must allocate the amount of staff time specifically
83	spent on certified nursing assistant duties for the purpose of
84	documenting compliance with minimum staffing requirements for
85	certified and licensed nursing staff. In no event may the hours
86	of a licensed nurse with dual job responsibilities be counted
87	twice.
88	Section 2.  Subsection (5) of section 409.904, Florida
89	Statutes, is amended to read:
90	409.904  Optional payments for eligible persons.--The
91	agency may make payments for medical assistance and related
92	services on behalf of the following persons who are determined
93	to be eligible subject to the income, assets, and categorical
94	eligibility tests set forth in federal and state law. Payment on
95	behalf of these Medicaid eligible persons is subject to the
96	availability of moneys and any limitations established by the
97	General Appropriations Act or chapter 216.
98	(5)  Subject to specific federal authorization, a
99	postpartum woman living in a family that has an income that is
100	at or below 185 percent of the most current federal poverty
101	level is eligible for family planning services as specified in
102	s. 409.905(3) for a period of up to 24 months following a loss
103	of Medicaid benefits pregnancy for which Medicaid paid for
104	pregnancy-related services.
105	Section 3.  Paragraph (d) of subsection (5) of section
106	409.905, Florida Statutes, is amended to read:
107	409.905  Mandatory Medicaid services.--The agency may make
108	payments for the following services, which are required of the
109	state by Title XIX of the Social Security Act, furnished by
110	Medicaid providers to recipients who are determined to be
111	eligible on the dates on which the services were provided. Any
112	service under this section shall be provided only when medically
113	necessary and in accordance with state and federal law.
114	Mandatory services rendered by providers in mobile units to
115	Medicaid recipients may be restricted by the agency. Nothing in
116	this section shall be construed to prevent or limit the agency
117	from adjusting fees, reimbursement rates, lengths of stay,
118	number of visits, number of services, or any other adjustments
119	necessary to comply with the availability of moneys and any
120	limitations or directions provided for in the General
121	Appropriations Act or chapter 216.
122	(5)  HOSPITAL INPATIENT SERVICES.--The agency shall pay for
123	all covered services provided for the medical care and treatment
124	of a recipient who is admitted as an inpatient by a licensed
125	physician or dentist to a hospital licensed under part I of
126	chapter 395. However, the agency shall limit the payment for
127	inpatient hospital services for a Medicaid recipient 21 years of
128	age or older to 45 days or the number of days necessary to
129	comply with the General Appropriations Act.
130	(d)  The agency shall implement a hospitalist program in
131	certain high-volume participating hospitals, select counties, or
132	statewide. The program shall require hospitalists to authorize
133	and manage Medicaid recipients' hospital admissions and lengths
134	of stay. Individuals who are dually eligible for Medicare and
135	Medicaid are exempted from this requirement. Medicaid
136	participating physicians and other practitioners with hospital
137	admitting privileges shall coordinate and review admissions of
138	Medicaid recipients with the hospitalist. The agency may
139	competitively bid a contract for selection of a qualified
140	organization to provide hospitalist services. The qualified
141	organization shall employ board certified physicians who are
142	full-time dedicated employees of the contractor and have no
143	outside practice. Where used, the hospitalist program shall
144	replace the existing hospital utilization review program. The
145	agency is authorized to seek federal waivers to implement this
146	program.
147	Section 4.  Paragraph (b) of subsection (1) and subsection
148	(23) of section 409.906, Florida Statutes, are amended to read:
149	409.906  Optional Medicaid services.--Subject to specific
150	appropriations, the agency may make payments for services which
151	are optional to the state under Title XIX of the Social Security
152	Act and are furnished by Medicaid providers to recipients who
153	are determined to be eligible on the dates on which the services
154	were provided. Any optional service that is provided shall be
155	provided only when medically necessary and in accordance with
156	state and federal law. Optional services rendered by providers
157	in mobile units to Medicaid recipients may be restricted or
158	prohibited by the agency. Nothing in this section shall be
159	construed to prevent or limit the agency from adjusting fees,
160	reimbursement rates, lengths of stay, number of visits, or
161	number of services, or making any other adjustments necessary to
162	comply with the availability of moneys and any limitations or
163	directions provided for in the General Appropriations Act or
164	chapter 216. If necessary to safeguard the state's systems of
165	providing services to elderly and disabled persons and subject
166	to the notice and review provisions of s. 216.177, the Governor
167	may direct the Agency for Health Care Administration to amend
168	the Medicaid state plan to delete the optional Medicaid service
169	known as "Intermediate Care Facilities for the Developmentally
170	Disabled." Optional services may include:
171	(1)  ADULT DENTAL SERVICES.--
172	(b)  Beginning January 1, 2005, the agency may pay for
173	partial dentures and full dentures, the procedures required to
174	seat dentures, and the repair and reline of dentures, provided
175	by or under the direction of a licensed dentist, for a recipient
176	who is 21 years of age or older.
177	(23)  CHILDREN'S VISUAL SERVICES.--The agency may pay for
178	visual examinations, eyeglasses, and eyeglass repairs for a
179	recipient younger than 21 years of age, if they are prescribed
180	by a licensed physician specializing in diseases of the eye or
181	by a licensed optometrist. Eyeglasses for adult recipients shall
182	be limited to one pair every 2 years.
183	Section 5.  Paragraph (a) of subsection (9) of section
184	409.907, Florida Statutes, is amended to read:
185	409.907  Medicaid provider agreements.--The agency may make
186	payments for medical assistance and related services rendered to
187	Medicaid recipients only to an individual or entity who has a
188	provider agreement in effect with the agency, who is performing
189	services or supplying goods in accordance with federal, state,
190	and local law, and who agrees that no person shall, on the
191	grounds of handicap, race, color, or national origin, or for any
192	other reason, be subjected to discrimination under any program
193	or activity for which the provider receives payment from the
194	agency.
195	(9)  Upon receipt of a completed, signed, and dated
196	application, and completion of any necessary background
197	investigation and criminal history record check, the agency must
198	either:
199	(a)  Enroll the applicant as a Medicaid provider no earlier
200	than the effective date of the approval of the provider
201	application. With respect to providers who were recently granted
202	a change of ownership and those who primarily provide emergency
203	medical services transportation or emergency services and care
204	pursuant to s. 395.1041 or s. 401.45, or services provided by
205	entities under s. 409.91255, and out-of-state providers, upon
206	approval of the provider application., The enrollment effective
207	date shall be of approval is considered to be the date the
208	agency receives the provider application. Payment for any claims
209	for services provided to Medicaid recipients between the date of
210	receipt of the application and the date of approval is
211	contingent on applying any and all applicable audits and edits
212	contained in the agency's claims adjudication and payment
213	processing systems; or
214	Section 6.  Paragraph (c) of subsection (1) of section
215	409.9081, Florida Statutes, is amended to read:
216	409.9081  Copayments.--
217	(1)  The agency shall require, subject to federal
218	regulations and limitations, each Medicaid recipient to pay at
219	the time of service a nominal copayment for the following
220	Medicaid services:
221	(c)  Hospital emergency department visits for nonemergency
222	care: 5 percent of up to the first $300 of the Medicaid payment
223	for emergency room services, not to exceed $15 for each
224	emergency department visit.
225	Section 7.  Subsections (2), (3), and (4) of section
226	409.911, Florida Statutes, are amended to read:
227	409.911  Disproportionate share program.--Subject to
228	specific allocations established within the General
229	Appropriations Act and any limitations established pursuant to
230	chapter 216, the agency shall distribute, pursuant to this
231	section, moneys to hospitals providing a disproportionate share
232	of Medicaid or charity care services by making quarterly
233	Medicaid payments as required. Notwithstanding the provisions of
234	s. 409.915, counties are exempt from contributing toward the
235	cost of this special reimbursement for hospitals serving a
236	disproportionate share of low-income patients.
237	(2)  The Agency for Health Care Administration shall use
238	the following actual audited data to determine the Medicaid days
239	and charity care to be used in calculating the disproportionate
240	share payment:
241	(a)  The average of the 1998, 1999, and 2000, 2001, and
242	2002 audited disproportionate share data to determine each
243	hospital's Medicaid days and charity care for the 2006-2007
244	2004-2005 state fiscal year and the average of the 1999, 2000,
245	and 2001 audited disproportionate share data to determine the
246	Medicaid days and charity care for the 2005-2006 state fiscal
247	year.
248	(b)  If the Agency for Health Care Administration does not
249	have the prescribed 3 years of audited disproportionate share
250	data as noted in paragraph (a) for a hospital, the agency shall
251	use the average of the years of the audited disproportionate
252	share data as noted in paragraph (a) which is available.
253	(c)  In accordance with s. 1923(b) of the Social Security
254	Act, a hospital with a Medicaid inpatient utilization rate
255	greater than one standard deviation above the statewide mean or
256	a hospital with a low-income utilization rate of 25 percent or
257	greater shall qualify for reimbursement.
258	(3)  Hospitals that qualify for a disproportionate share
259	payment solely under paragraph (2)(c) shall have their payment
260	calculated in accordance with the following formulas:
261
262	DSHP = (HMD/TMSD) x $1 million
263
264	Where:
265	DSHP = disproportionate share hospital payment.
266	HMD = hospital Medicaid days.
267	TSD = total state Medicaid days.
268
269	Any funds not allocated to hospitals qualifying under this
270	section shall be redistributed to the non-state government owned
271	or operated hospitals with greater than 3,100 3,300 Medicaid
272	days.
273	(4)  The following formulas shall be used to pay
274	disproportionate share dollars to public hospitals:
275	(a)  For state mental health hospitals:
276
277	DSHP = (HMD/TMDMH) x TAAMH
278
279	shall be the difference between the federal cap for Institutions
280	for Mental Diseases and the amounts paid under the mental health
281	disproportionate share program.
282
283	Where:
284	DSHP = disproportionate share hospital payment.
285	HMD = hospital Medicaid days.
286	TMDHH = total Medicaid days for state mental health
287	hospitals.
288	TAAMH = total amount available for mental health hospitals.
289	(b)  For non-state government owned or operated hospitals
290	with 3,100 3,300 or more Medicaid days:
291
292	DSHP = [(.82 x HCCD/TCCD) + (.18 x HMD/TMD)]
293	x TAAPH
294	TAAPH = TAA - TAAMH
295
296	Where:
297	TAA = total available appropriation.
298	TAAPH = total amount available for public hospitals.
299	DSHP = disproportionate share hospital payments.
300	HMD = hospital Medicaid days.
301	TMD = total state Medicaid days for public hospitals.
302	HCCD = hospital charity care dollars.
303	TCCD = total state charity care dollars for public non-
304	state hospitals.
305
306	1.  For the 2005-2006 state fiscal year only, the DSHP for
307	the public nonstate hospitals shall be computed using a weighted
308	average of the disproportionate share payments for the 2004-2005
309	state fiscal year which uses an average of the 1998, 1999, and
310	2000 audited disproportionate share data and the
311	disproportionate share payments for the 2005-2006 state fiscal
312	year as computed using the formula above and using the average
313	of the 1999, 2000, and 2001 audited disproportionate share data.
314	The final DSHP for the public nonstate hospitals shall be
315	computed as an average using the calculated payments for the
316	2005-2006 state fiscal year weighted at 65 percent and the
317	disproportionate share payments for the 2004-2005 state fiscal
318	year weighted at 35 percent.
319	2.  The TAAPH shall be reduced by $6,365,257 before
320	computing the DSHP for each public hospital. The $6,365,257
321	shall be distributed equally between the public hospitals that
322	are also designated statutory teaching hospitals.
323	(c)  For non-state government owned or operated hospitals
324	with less than 3,100 3,300 Medicaid days, a total of $750,000
325	shall be distributed equally among these hospitals.
326	Section 8.  Section 409.9113, Florida Statutes, is amended
327	to read:
328	409.9113  Disproportionate share program for teaching
329	hospitals.--In addition to the payments made under ss. 409.911
330	and 409.9112, the Agency for Health Care Administration shall
331	make disproportionate share payments to statutorily defined
332	teaching hospitals for their increased costs associated with
333	medical education programs and for tertiary health care services
334	provided to the indigent. This system of payments shall conform
335	with federal requirements and shall distribute funds in each
336	fiscal year for which an appropriation is made by making
337	quarterly Medicaid payments. Notwithstanding s. 409.915,
338	counties are exempt from contributing toward the cost of this
339	special reimbursement for hospitals serving a disproportionate
340	share of low-income patients. For the state fiscal year 2006-
341	2007 2005-2006, the agency shall not distribute the moneys
342	provided in the General Appropriations Act to statutorily
343	defined teaching hospitals and family practice teaching
344	hospitals under the teaching hospital disproportionate share
345	program. The funds provided for statutorily defined teaching
346	hospitals shall be distributed in the same proportion as the
347	state fiscal year 2003-2004 teaching hospital disproportionate
348	share funds were distributed. The funds provided for family
349	practice teaching hospitals shall be distributed equally among
350	family practice teaching hospitals.
351	(1)  On or before September 15 of each year, the Agency for
352	Health Care Administration shall calculate an allocation
353	fraction to be used for distributing funds to state statutory
354	teaching hospitals. Subsequent to the end of each quarter of the
355	state fiscal year, the agency shall distribute to each statutory
356	teaching hospital, as defined in s. 408.07, an amount determined
357	by multiplying one-fourth of the funds appropriated for this
358	purpose by the Legislature times such hospital's allocation
359	fraction. The allocation fraction for each such hospital shall
360	be determined by the sum of three primary factors, divided by
361	three. The primary factors are:
362	(a)  The number of nationally accredited graduate medical
363	education programs offered by the hospital, including programs
364	accredited by the Accreditation Council for Graduate Medical
365	Education and the combined Internal Medicine and Pediatrics
366	programs acceptable to both the American Board of Internal
367	Medicine and the American Board of Pediatrics at the beginning
368	of the state fiscal year preceding the date on which the
369	allocation fraction is calculated. The numerical value of this
370	factor is the fraction that the hospital represents of the total
371	number of programs, where the total is computed for all state
372	statutory teaching hospitals.
373	(b)  The number of full-time equivalent trainees in the
374	hospital, which comprises two components:
375	1.  The number of trainees enrolled in nationally
376	accredited graduate medical education programs, as defined in
377	paragraph (a). Full-time equivalents are computed using the
378	fraction of the year during which each trainee is primarily
379	assigned to the given institution, over the state fiscal year
380	preceding the date on which the allocation fraction is
381	calculated. The numerical value of this factor is the fraction
382	that the hospital represents of the total number of full-time
383	equivalent trainees enrolled in accredited graduate programs,
384	where the total is computed for all state statutory teaching
385	hospitals.
386	2.  The number of medical students enrolled in accredited
387	colleges of medicine and engaged in clinical activities,
388	including required clinical clerkships and clinical electives.
389	Full-time equivalents are computed using the fraction of the
390	year during which each trainee is primarily assigned to the
391	given institution, over the course of the state fiscal year
392	preceding the date on which the allocation fraction is
393	calculated. The numerical value of this factor is the fraction
394	that the given hospital represents of the total number of full-
395	time equivalent students enrolled in accredited colleges of
396	medicine, where the total is computed for all state statutory
397	teaching hospitals.
398
399	The primary factor for full-time equivalent trainees is computed
400	as the sum of these two components, divided by two.
401	(c)  A service index that comprises three components:
402	1.  The Agency for Health Care Administration Service
403	Index, computed by applying the standard Service Inventory
404	Scores established by the Agency for Health Care Administration
405	to services offered by the given hospital, as reported on
406	Worksheet A-2 for the last fiscal year reported to the agency
407	before the date on which the allocation fraction is calculated.
408	The numerical value of this factor is the fraction that the
409	given hospital represents of the total Agency for Health Care
410	Administration Service Index values, where the total is computed
411	for all state statutory teaching hospitals.
412	2.  A volume-weighted service index, computed by applying
413	the standard Service Inventory Scores established by the Agency
414	for Health Care Administration to the volume of each service,
415	expressed in terms of the standard units of measure reported on
416	Worksheet A-2 for the last fiscal year reported to the agency
417	before the date on which the allocation factor is calculated.
418	The numerical value of this factor is the fraction that the
419	given hospital represents of the total volume-weighted service
420	index values, where the total is computed for all state
421	statutory teaching hospitals.
422	3.  Total Medicaid payments to each hospital for direct
423	inpatient and outpatient services during the fiscal year
424	preceding the date on which the allocation factor is calculated.
425	This includes payments made to each hospital for such services
426	by Medicaid prepaid health plans, whether the plan was
427	administered by the hospital or not. The numerical value of this
428	factor is the fraction that each hospital represents of the
429	total of such Medicaid payments, where the total is computed for
430	all state statutory teaching hospitals.
431
432	The primary factor for the service index is computed as the sum
433	of these three components, divided by three.
434	(2)  By October 1 of each year, the agency shall use the
435	following formula to calculate the maximum additional
436	disproportionate share payment for statutorily defined teaching
437	hospitals:
438
439	TAP = THAF x A
440
441	Where:
442	TAP = total additional payment.
443	THAF = teaching hospital allocation factor.
444	A = amount appropriated for a teaching hospital
445	disproportionate share program.
446	Section 9.  Section 409.9117, Florida Statutes, is amended
447	to read:
448	409.9117  Primary care disproportionate share program.--For
449	the state fiscal year 2006-2007 2005-2006, the agency shall not
450	distribute moneys under the primary care disproportionate share
451	program.
452	(1)  If federal funds are available for disproportionate
453	share programs in addition to those otherwise provided by law,
454	there shall be created a primary care disproportionate share
455	program.
456	(2)  The following formula shall be used by the agency to
457	calculate the total amount earned for hospitals that participate
458	in the primary care disproportionate share program:
459
460	TAE = HDSP/THDSP
461
462	Where:
463	TAE = total amount earned by a hospital participating in
464	the primary care disproportionate share program.
465	HDSP = the prior state fiscal year primary care
466	disproportionate share payment to the individual hospital.
467	THDSP = the prior state fiscal year total primary care
468	disproportionate share payments to all hospitals.
469	(3)  The total additional payment for hospitals that
470	participate in the primary care disproportionate share program
471	shall be calculated by the agency as follows:
472
473	TAP = TAE x TA
474
475	Where:
476	TAP = total additional payment for a primary care hospital.
477	TAE = total amount earned by a primary care hospital.
478	TA = total appropriation for the primary care
479	disproportionate share program.
480	(4)  In the establishment and funding of this program, the
481	agency shall use the following criteria in addition to those
482	specified in s. 409.911, payments may not be made to a hospital
483	unless the hospital agrees to:
484	(a)  Cooperate with a Medicaid prepaid health plan, if one
485	exists in the community.
486	(b)  Ensure the availability of primary and specialty care
487	physicians to Medicaid recipients who are not enrolled in a
488	prepaid capitated arrangement and who are in need of access to
489	such physicians.
490	(c)  Coordinate and provide primary care services free of
491	charge, except copayments, to all persons with incomes up to 100
492	percent of the federal poverty level who are not otherwise
493	covered by Medicaid or another program administered by a
494	governmental entity, and to provide such services based on a
495	sliding fee scale to all persons with incomes up to 200 percent
496	of the federal poverty level who are not otherwise covered by
497	Medicaid or another program administered by a governmental
498	entity, except that eligibility may be limited to persons who
499	reside within a more limited area, as agreed to by the agency
500	and the hospital.
501	(d)  Contract with any federally qualified health center,
502	if one exists within the agreed geopolitical boundaries,
503	concerning the provision of primary care services, in order to
504	guarantee delivery of services in a nonduplicative fashion, and
505	to provide for referral arrangements, privileges, and
506	admissions, as appropriate. The hospital shall agree to provide
507	at an onsite or offsite facility primary care services within 24
508	hours to which all Medicaid recipients and persons eligible
509	under this paragraph who do not require emergency room services
510	are referred during normal daylight hours.
511	(e)  Cooperate with the agency, the county, and other
512	entities to ensure the provision of certain public health
513	services, case management, referral and acceptance of patients,
514	and sharing of epidemiological data, as the agency and the
515	hospital find mutually necessary and desirable to promote and
516	protect the public health within the agreed geopolitical
517	boundaries.
518	(f)  In cooperation with the county in which the hospital
519	resides, develop a low-cost, outpatient, prepaid health care
520	program to persons who are not eligible for the Medicaid
521	program, and who reside within the area.
522	(g)  Provide inpatient services to residents within the
523	area who are not eligible for Medicaid or Medicare, and who do
524	not have private health insurance, regardless of ability to pay,
525	on the basis of available space, except that nothing shall
526	prevent the hospital from establishing bill collection programs
527	based on ability to pay.
528	(h)  Work with the Florida Healthy Kids Corporation, the
529	Florida Health Care Purchasing Cooperative, and business health
530	coalitions, as appropriate, to develop a feasibility study and
531	plan to provide a low-cost comprehensive health insurance plan
532	to persons who reside within the area and who do not have access
533	to such a plan.
534	(i)  Work with public health officials and other experts to
535	provide community health education and prevention activities
536	designed to promote healthy lifestyles and appropriate use of
537	health services.
538	(j)  Work with the local health council to develop a plan
539	for promoting access to affordable health care services for all
540	persons who reside within the area, including, but not limited
541	to, public health services, primary care services, inpatient
542	services, and affordable health insurance generally.
543
544	Any hospital that fails to comply with any of the provisions of
545	this subsection, or any other contractual condition, may not
546	receive payments under this section until full compliance is
547	achieved.
548	Section 10.  Subsection (44) of section 409.912, Florida
549	Statutes, is amended, and subsection (53) is added to that
550	section, to read:
551	409.912  Cost-effective purchasing of health care.--The
552	agency shall purchase goods and services for Medicaid recipients
553	in the most cost-effective manner consistent with the delivery
554	of quality medical care. To ensure that medical services are
555	effectively utilized, the agency may, in any case, require a
556	confirmation or second physician's opinion of the correct
557	diagnosis for purposes of authorizing future services under the
558	Medicaid program. This section does not restrict access to
559	emergency services or poststabilization care services as defined
560	in 42 C.F.R. part 438.114. Such confirmation or second opinion
561	shall be rendered in a manner approved by the agency. The agency
562	shall maximize the use of prepaid per capita and prepaid
563	aggregate fixed-sum basis services when appropriate and other
564	alternative service delivery and reimbursement methodologies,
565	including competitive bidding pursuant to s. 287.057, designed
566	to facilitate the cost-effective purchase of a case-managed
567	continuum of care. The agency shall also require providers to
568	minimize the exposure of recipients to the need for acute
569	inpatient, custodial, and other institutional care and the
570	inappropriate or unnecessary use of high-cost services. The
571	agency shall contract with a vendor to monitor and evaluate the
572	clinical practice patterns of providers in order to identify
573	trends that are outside the normal practice patterns of a
574	provider's professional peers or the national guidelines of a
575	provider's professional association. The vendor must be able to
576	provide information and counseling to a provider whose practice
577	patterns are outside the norms, in consultation with the agency,
578	to improve patient care and reduce inappropriate utilization.
579	The agency may mandate prior authorization, drug therapy
580	management, or disease management participation for certain
581	populations of Medicaid beneficiaries, certain drug classes, or
582	particular drugs to prevent fraud, abuse, overuse, and possible
583	dangerous drug interactions. The Pharmaceutical and Therapeutics
584	Committee shall make recommendations to the agency on drugs for
585	which prior authorization is required. The agency shall inform
586	the Pharmaceutical and Therapeutics Committee of its decisions
587	regarding drugs subject to prior authorization. The agency is
588	authorized to limit the entities it contracts with or enrolls as
589	Medicaid providers by developing a provider network through
590	provider credentialing. The agency may competitively bid single-
591	source-provider contracts if procurement of goods or services
592	results in demonstrated cost savings to the state without
593	limiting access to care. The agency may limit its network based
594	on the assessment of beneficiary access to care, provider
595	availability, provider quality standards, time and distance
596	standards for access to care, the cultural competence of the
597	provider network, demographic characteristics of Medicaid
598	beneficiaries, practice and provider-to-beneficiary standards,
599	appointment wait times, beneficiary use of services, provider
600	turnover, provider profiling, provider licensure history,
601	previous program integrity investigations and findings, peer
602	review, provider Medicaid policy and billing compliance records,
603	clinical and medical record audits, and other factors. Providers
604	shall not be entitled to enrollment in the Medicaid provider
605	network. The agency shall determine instances in which allowing
606	Medicaid beneficiaries to purchase durable medical equipment and
607	other goods is less expensive to the Medicaid program than long-
608	term rental of the equipment or goods. The agency may establish
609	rules to facilitate purchases in lieu of long-term rentals in
610	order to protect against fraud and abuse in the Medicaid program
611	as defined in s. 409.913. The agency may seek federal waivers
612	necessary to administer these policies.
613	(44)  The Agency for Health Care Administration shall
614	ensure that any Medicaid managed care plan as defined in s.
615	409.9122(2)(f)(h), whether paid on a capitated basis or a shared
616	savings basis, is cost-effective. For purposes of this
617	subsection, the term "cost-effective" means that a network's
618	per-member, per-month costs to the state, including, but not
619	limited to, fee-for-service costs, administrative costs, and
620	case-management fees, if any, must be no greater than the
621	state's costs associated with contracts for Medicaid services
622	established under subsection (3), which may shall be actuarially
623	adjusted for health status case mix, model, and service area.
624	The agency shall conduct actuarially sound adjustments for
625	health status audits adjusted for case mix and model in order to
626	ensure such cost-effectiveness and shall publish the audit
627	results on its Internet website and submit the audit results
628	annually to the Governor, the President of the Senate, and the
629	Speaker of the House of Representatives no later than December
630	31 of each year. Contracts established pursuant to this
631	subsection which are not cost-effective may not be renewed.
632	(53)  In accordance with s. 430.705 and 42 C.F.R. s. 438,
633	Medicaid capitation payments for managed long-term care programs
634	shall be risk adjusted by plan and reflect members' level of
635	chronic illness, functional limitations, and risk of
636	institutional placement, as determined by expenditures for a
637	comparable fee-for-service population. Payments for Medicaid
638	home and community-based services shall be at least actuarially
639	equivalent to and shall be trended from the greater of fee-for-
640	service levels or plan experience to reflect the increased
641	services required to maintain people in community settings under
642	managed care.
643	Section 11.  Paragraphs (f) and (k) of subsection (2) of
644	section 409.9122, Florida Statutes, are amended to read:
645	409.9122  Mandatory Medicaid managed care enrollment;
646	programs and procedures.--
647	(2)
648	(f)  When a Medicaid recipient does not choose a managed
649	care plan or MediPass provider, the agency shall assign the
650	Medicaid recipient to a managed care plan or MediPass provider.
651	Medicaid recipients who are subject to mandatory assignment but
652	who fail to make a choice shall be assigned to managed care
653	plans until an enrollment of 35 40 percent in MediPass and 65 60
654	percent in managed care plans, of all those eligible to choose
655	managed care, is achieved. Once this enrollment is achieved, the
656	assignments shall be divided in order to maintain an enrollment
657	in MediPass and managed care plans which is in a 35 40 percent
658	and 65 60 percent proportion, respectively. Thereafter,
659	assignment of Medicaid recipients who fail to make a choice
660	shall be based proportionally on the preferences of recipients
661	who have made a choice in the previous period. Such proportions
662	shall be revised at least quarterly to reflect an update of the
663	preferences of Medicaid recipients. The agency shall
664	disproportionately assign Medicaid-eligible recipients who are
665	required to but have failed to make a choice of managed care
666	plan or MediPass, including children, and who are to be assigned
667	to the MediPass program to children's networks as described in
668	s. 409.912(4)(g), Children's Medical Services Network as defined
669	in s. 391.021, exclusive provider organizations, provider
670	service networks, minority physician networks, and pediatric
671	emergency department diversion programs authorized by this
672	chapter or the General Appropriations Act, in such manner as the
673	agency deems appropriate, until the agency has determined that
674	the networks and programs have sufficient numbers to be
675	economically operated. For purposes of this paragraph, when
676	referring to assignment, the term "managed care plans" includes
677	health maintenance organizations, exclusive provider
678	organizations, provider service networks, minority physician
679	networks, Children's Medical Services Network, and pediatric
680	emergency department diversion programs authorized by this
681	chapter or the General Appropriations Act. When making
682	assignments, the agency shall take into account the following
683	criteria:
684	1.  A managed care plan has sufficient network capacity to
685	meet the need of members.
686	2.  The managed care plan or MediPass has previously
687	enrolled the recipient as a member, or one of the managed care
688	plan's primary care providers or MediPass providers has
689	previously provided health care to the recipient.
690	3.  The agency has knowledge that the member has previously
691	expressed a preference for a particular managed care plan or
692	MediPass provider as indicated by Medicaid fee-for-service
693	claims data, but has failed to make a choice.
694	4.  The managed care plan's or MediPass primary care
695	providers are geographically accessible to the recipient's
696	residence.
697	(k)  When a Medicaid recipient does not choose a managed
698	care plan or MediPass provider, the agency shall assign the
699	Medicaid recipient to a managed care plan, except in those
700	counties in which there are fewer than two managed care plans
701	accepting Medicaid enrollees, in which case assignment shall be
702	to a managed care plan or a MediPass provider. Medicaid
703	recipients in counties with fewer than two managed care plans
704	accepting Medicaid enrollees who are subject to mandatory
705	assignment but who fail to make a choice shall be assigned to
706	managed care plans until an enrollment of 35 40 percent in
707	MediPass and 65 60 percent in managed care plans, of all those
708	eligible to choose managed care, is achieved. Once that
709	enrollment is achieved, the assignments shall be divided in
710	order to maintain an enrollment in MediPass and managed care
711	plans which is in a 35 40 percent and 65 60 percent proportion,
712	respectively. In service areas 1 and 6 of the Agency for Health
713	Care Administration where the agency is contracting for the
714	provision of comprehensive behavioral health services through a
715	capitated prepaid arrangement, recipients who fail to make a
716	choice shall be assigned equally to MediPass or a managed care
717	plan. For purposes of this paragraph, when referring to
718	assignment, the term "managed care plans" includes exclusive
719	provider organizations, provider service networks, Children's
720	Medical Services Network, minority physician networks, and
721	pediatric emergency department diversion programs authorized by
722	this chapter or the General Appropriations Act. When making
723	assignments, the agency shall take into account the following
724	criteria:
725	1.  A managed care plan has sufficient network capacity to
726	meet the need of members.
727	2.  The managed care plan or MediPass has previously
728	enrolled the recipient as a member, or one of the managed care
729	plan's primary care providers or MediPass providers has
730	previously provided health care to the recipient.
731	3.  The agency has knowledge that the member has previously
732	expressed a preference for a particular managed care plan or
733	MediPass provider as indicated by Medicaid fee-for-service
734	claims data, but has failed to make a choice.
735	4.  The managed care plan's or MediPass primary care
736	providers are geographically accessible to the recipient's
737	residence.
738	5.  The agency has authority to make mandatory assignments
739	based on quality of service and performance of managed care
740	plans.
741	Section 12.  Paragraph (b) of subsection (5) of section
742	624.91, Florida Statutes, is amended to read:
743	624.91  The Florida Healthy Kids Corporation Act.--
744	(5)  CORPORATION AUTHORIZATION, DUTIES, POWERS.--
745	(b)  The Florida Healthy Kids Corporation shall:
746	1.  Arrange for the collection of any family, local
747	contributions, or employer payment or premium, in an amount to
748	be determined by the board of directors, to provide for payment
749	of premiums for comprehensive insurance coverage and for the
750	actual or estimated administrative expenses.
751	2.  Arrange for the collection of any voluntary
752	contributions to provide for payment of premiums for children
753	who are not eligible for medical assistance under Title XXI of
754	the Social Security Act. Each fiscal year, the corporation shall
755	establish a local match policy for the enrollment of non-Title-
756	XXI-eligible children in the Healthy Kids program. By May 1 of
757	each year, the corporation shall provide written notification of
758	the amount to be remitted to the corporation for the following
759	fiscal year under that policy. Local match sources may include,
760	but are not limited to, funds provided by municipalities,
761	counties, school boards, hospitals, health care providers,
762	charitable organizations, special taxing districts, and private
763	organizations. The minimum local match cash contributions
764	required each fiscal year and local match credits shall be
765	determined by the General Appropriations Act. The corporation
766	shall calculate a county's local match rate based upon that
767	county's percentage of the state's total non-Title-XXI
768	expenditures as reported in the corporation's most recently
769	audited financial statement. In awarding the local match
770	credits, the corporation may consider factors including, but not
771	limited to, population density, per capita income, and existing
772	child-health-related expenditures and services. If local match
773	amounts collected exceed expenditures during any fiscal year,
774	including the 2005-2006 fiscal year, the corporation shall
775	return unspent local funds collected based on a formula
776	developed by the corporation.
777	3.  Subject to the provisions of s. 409.8134, accept
778	voluntary supplemental local match contributions that comply
779	with the requirements of Title XXI of the Social Security Act
780	for the purpose of providing additional coverage in contributing
781	counties under Title XXI.
782	4.  Establish the administrative and accounting procedures
783	for the operation of the corporation.
784	5.  Establish, with consultation from appropriate
785	professional organizations, standards for preventive health
786	services and providers and comprehensive insurance benefits
787	appropriate to children, provided that such standards for rural
788	areas shall not limit primary care providers to board-certified
789	pediatricians.
790	6.  Determine eligibility for children seeking to
791	participate in the Title XXI-funded components of the Florida
792	KidCare program consistent with the requirements specified in s.
793	409.814, as well as the non-Title-XXI-eligible children as
794	provided in subsection (3).
795	7.  Establish procedures under which providers of local
796	match to, applicants to and participants in the program may have
797	grievances reviewed by an impartial body and reported to the
798	board of directors of the corporation.
799	8.  Establish participation criteria and, if appropriate,
800	contract with an authorized insurer, health maintenance
801	organization, or third-party administrator to provide
802	administrative services to the corporation.
803	9.  Establish enrollment criteria which shall include
804	penalties or waiting periods of not fewer than 60 days for
805	reinstatement of coverage upon voluntary cancellation for
806	nonpayment of family premiums.
807	10.  Contract with authorized insurers or any provider of
808	health care services, meeting standards established by the
809	corporation, for the provision of comprehensive insurance
810	coverage to participants. Such standards shall include criteria
811	under which the corporation may contract with more than one
812	provider of health care services in program sites. Health plans
813	shall be selected through a competitive bid process. The Florida
814	Healthy Kids Corporation shall purchase goods and services in
815	the most cost-effective manner consistent with the delivery of
816	quality medical care. The maximum administrative cost for a
817	Florida Healthy Kids Corporation contract shall be 15 percent.
818	For health care contracts, the minimum medical loss ratio for a
819	Florida Healthy Kids Corporation contract shall be 85 percent.
820	For dental contracts, the remaining compensation to be paid to
821	the authorized insurer or provider under a Florida Healthy Kids
822	Corporation contract shall be no less than an amount which is 85
823	percent of premium; to the extent any contract provision does
824	not provide for this minimum compensation, this section shall
825	prevail. The health plan selection criteria and scoring system,
826	and the scoring results, shall be available upon request for
827	inspection after the bids have been awarded.
828	11.  Establish disenrollment criteria in the event local
829	matching funds are insufficient to cover enrollments.
830	12.  Develop and implement a plan to publicize the Florida
831	Healthy Kids Corporation, the eligibility requirements of the
832	program, and the procedures for enrollment in the program and to
833	maintain public awareness of the corporation and the program.
834	13.  Secure staff necessary to properly administer the
835	corporation. Staff costs shall be funded from state and local
836	matching funds and such other private or public funds as become
837	available. The board of directors shall determine the number of
838	staff members necessary to administer the corporation.
839	14.  Provide a report annually to the Governor, Chief
840	Financial Officer, Commissioner of Education, Senate President,
841	Speaker of the House of Representatives, and Minority Leaders of
842	the Senate and the House of Representatives.
843	15.  Establish benefit packages which conform to the
844	provisions of the Florida KidCare program, as created in ss.
845	409.810-409.820.
846	Section 13.  Subsection (4) of section 430.705, Florida
847	Statutes, is amended to read:
848	430.705  Implementation of the long-term care community
849	diversion pilot projects.--
850	(4)  Pursuant to 42 C.F.R. s. 438.6(c), the agency, in
851	consultation with the department, shall annually reevaluate and
852	recertify the capitation rates for the diversion pilot projects.
853	The agency, in consultation with the department, shall secure
854	the utilization and cost data for Medicaid and Medicare
855	beneficiaries served by the program which shall be used in
856	developing rates for the diversion pilot projects. The
857	capitation rates shall be risk adjusted by plan and reflect
858	members' level of chronic illness, functional limitations, and
859	risk of institutional placement, as determined by expenditures
860	for a comparable fee-for-service population. Payments for
861	Medicaid home and community-based services shall be at least
862	actuarially equivalent to and shall be trended from the greater
863	of fee-for-service levels or plan experience to reflect the
864	increased services required to maintain people in community
865	settings under managed care.
866	Section 14.  This act shall take effect July 1, 2006.

CODING: Words stricken are deletions; words underlined are additions.