HB 1575

1	A bill to be entitled
2	An act relating to rural health care; amending s.
3	381.0405, F.S.; revising the purpose and functions of the
4	Office of Rural Health in the Department of Health;
5	requiring the Secretary of Health and the Secretary of
6	Health Care Administration to appoint an advisory council
7	to advise the Office of Rural Health; providing for terms
8	of office of the members of the advisory council;
9	authorizing per diem and travel reimbursement for members
10	of the advisory council; requiring the Office of Rural
11	Health to submit an annual report to the Governor and the
12	Legislature; amending s. 381.0406, F.S.; revising
13	legislative findings and intent with respect to rural
14	health networks; redefining the term "rural health
15	network"; establishing requirements for membership in
16	rural health networks; adding functions for the rural
17	health networks; revising requirements for the governance
18	and organization of rural health networks; revising the
19	services to be provided by provider members of rural
20	health networks; requiring coordination among rural health
21	networks and area health education centers, health
22	planning councils, and regional education consortia;
23	establishing requirements for funding rural health
24	networks; establishing performance standards for rural
25	health networks; establishing requirements for the receipt
26	of grant funding; requiring the Office of Rural Health to
27	monitor rural health networks; authorizing the Department
28	of Health to establish rules governing rural health
29	network grant programs and performance standards; amending
30	s. 395.602, F.S.; defining the term "critical access
31	hospital"; deleting the definitions of "emergency care
32	hospital," and "essential access community hospital";
33	revising the definition of "rural primary care hospital";
34	amending s. 395.603, F.S.; deleting a requirement that the
35	Agency for Health Care Administration adopt a rule
36	relating to deactivation of rural hospital beds under
37	certain circumstances; requiring that critical access
38	hospitals and rural primary care hospitals maintain a
39	certain number of actively licensed beds; amending s.
40	395.604, F.S.; removing emergency care hospitals and
41	essential access community hospitals from certain
42	licensure requirements; specifying certain special
43	conditions for rural primary care hospitals; amending s.
44	395.6061, F.S.; specifying the purposes of capital
45	improvement grants for rural hospitals; modifying the
46	conditions for receiving a grant; authorizing the
47	Department of Health to award grants for remaining funds
48	to certain rural hospitals; requiring a rural hospital
49	that receives any remaining funds to be bound by certain
50	terms of a participation agreement in order to receive
51	remaining funds; amending s. 409.908, F.S.; requiring the
52	Agency for Health Care Administration to pay certain
53	physicians a bonus for Medicaid physician services
54	provided within a rural county; amending ss. 408.07,
55	409.9116, and 1009.65, F.S.; conforming cross-references;
56	requiring the Office of Program Policy Analysis and
57	Government Accountability to contract for a study of the
58	financing options for replacing or changing the use of
59	certain rural hospitals; requiring a report to the
60	Legislature by a specified date; repealing s. 395.605,
61	F.S., relating to the licensure of emergency care
62	hospitals; providing appropriations and authorizing
63	additional positions; providing an effective date.
64
65	Be It Enacted by the Legislature of the State of Florida:
66
67	Section 1.  Section 381.0405, Florida Statutes, is amended
68	to read:
69	381.0405  Office of Rural Health.--
70	(1)  ESTABLISHMENT.--The Department of Health shall
71	establish an Office of Rural Health, which shall assist rural
72	health care providers in improving the health status and health
73	care of rural residents of this state and help rural health care
74	providers to integrate their efforts and prepare for prepaid and
75	at-risk reimbursement. The Office of Rural Health shall
76	coordinate its activities with rural health networks established
77	under s. 381.0406, local health councils established under s.
78	408.033, the area health education center network established
79	under pursuant to s. 381.0402, and with any appropriate research
80	and policy development centers within universities that have
81	state-approved medical schools. The Office of Rural Health may
82	enter into a formal relationship with any center that designates
83	the office as an affiliate of the center.
84	(2)  PURPOSE.--The Office of Rural Health shall actively
85	foster the development of service-delivery systems and
86	cooperative agreements to enhance the provision of high-quality
87	health care services in rural areas and serve as a catalyst for
88	improved health services to residents citizens in rural areas of
89	the state.
90	(3)  GENERAL FUNCTIONS.--The office shall:
91	(a)  Integrate policies related to physician workforce,
92	hospitals, public health, and state regulatory functions.
93	(b)  Work with rural stakeholders in order to foster the
94	development of strategic planning that addresses Propose
95	solutions to problems affecting health care delivery in rural
96	areas.
97	(c)  Develop, in coordination with the rural health
98	networks, standards, guidelines, and performance objectives for
99	rural health networks.
100	(d)  Foster the expansion of rural health network service
101	areas to include rural counties that are not covered by a rural
102	health network.
103	(e)(c)  Seek grant funds from foundations and the Federal
104	Government.
105	(f)  Administer state grant programs for rural hospitals
106	and rural health networks.
107	(4)  COORDINATION.--The office shall:
108	(a)  Identify federal and state rural health programs and
109	provide information and technical assistance to rural providers
110	regarding participation in such programs.
111	(b)  Act as a clearinghouse for collecting and
112	disseminating information on rural health care issues, research
113	findings on rural health care, and innovative approaches to the
114	delivery of health care in rural areas.
115	(c)  Foster the creation of regional health care systems
116	that promote cooperation through cooperative agreements, rather
117	than competition.
118	(d)  Coordinate the department's rural health care
119	activities, programs, and policies.
120	(e)  Design initiatives and promote cooperative agreements
121	in order to improve access to primary care, prehospital
122	emergency care, inpatient acute care, and emergency medical
123	services and promote the coordination of such services in rural
124	areas.
125	(f)  Assume responsibility for state coordination of the
126	Rural Hospital Transition Grant Program, the Essential Access
127	Community Hospital Program, and other federal rural hospital and
128	rural health care grant programs.
129	(5)  TECHNICAL ASSISTANCE.--The office shall:
130	(a)  Assist Help rural health care providers in recruiting
131	obtain health care practitioners by promoting the location and
132	relocation of health care practitioners in rural areas and
133	promoting policies that create incentives for practitioners to
134	serve in rural areas.
135	(b)  Provide technical assistance to hospitals, community
136	and migrant health centers, and other health care providers that
137	serve residents of rural areas.
138	(c)  Assist with the design of strategies to improve health
139	care workforce recruitment and placement programs.
140	(d)  Provide technical assistance to rural health networks
141	in the development of their long-range development plans.
142	(e)  Provide links to best practices and other technical-
143	assistance resources on its website.
144	(6)  RESEARCH PUBLICATIONS AND SPECIAL STUDIES.--The office
145	shall:
146	(a)  Conduct policy and research studies.
147	(b)  Conduct health status studies of rural residents.
148	(c)  Collect relevant data on rural health care issues for
149	use in program planning and department policy development.
150	(7)  ADVISORY COUNCIL.--The Secretary of Health and the
151	Secretary of Health Care Administration shall each appoint no
152	more than five members having relevant health care operations
153	management, practice, and policy experience to an advisory
154	council to advise the office regarding its responsibilities
155	under this section and ss. 381.0406 and 395.6061. Members shall
156	be appointed for 4-year staggered terms and may be reappointed
157	to a second term of office. Members shall serve without
158	compensation, but are entitled to reimbursement for per diem and
159	travel expenses as provided in s. 112.061. The department shall
160	provide staff and other administrative assistance reasonably
161	necessary to assist the advisory council in carrying out its
162	duties. The advisory council shall work with stakeholders to
163	develop recommendations that address barriers and identify
164	options for establishing provider networks in rural counties.
165	(8)  REPORTS.--Beginning January 1, 2008, and annually
166	thereafter, the Office of Rural Health shall submit a report to
167	the Governor, the President of the Senate, and the Speaker of
168	the House of Representatives summarizing the activities of the
169	office, including the grants obtained or administered by the
170	office and the status of rural health networks and rural
171	hospitals in the state. The report must also include
172	recommendations that address barriers and identify options for
173	establishing provider networks in rural counties.
174	(9)(7)  APPROPRIATION.--The Legislature shall appropriate
175	such sums as are necessary to support the Office of Rural
176	Health.
177	Section 2.  Section 381.0406, Florida Statutes, is amended
178	to read:
179	381.0406  Rural health networks.--
180	(1)  LEGISLATIVE FINDINGS AND INTENT.--
181	(a)  The Legislature finds that, in rural areas, access to
182	health care is limited and the quality of health care is
183	negatively affected by inadequate financing, difficulty in
184	recruiting and retaining skilled health professionals, and the
185	because of a migration of patients to urban areas for general
186	acute care and specialty services.
187	(b)  The Legislature further finds that the efficient and
188	effective delivery of health care services in rural areas
189	requires:
190	1.  The integration of public and private resources;
191	2.  The introduction of innovative outreach methods;
192	3.  The adoption of quality improvement and cost-
193	effectiveness measures;
194	4.  The organization of health care providers into joint
195	contracting entities;
196	5.  Establishing referral linkages;
197	6.  The analysis of costs and services in order to prepare
198	health care providers for prepaid and at-risk financing; and
199	7.  The coordination of health care providers.
200	(c)  The Legislature further finds that the availability of
201	a continuum of quality health care services, including
202	preventive, primary, secondary, tertiary, and long-term care, is
203	essential to the economic and social vitality of rural
204	communities.
205	(d)  The Legislature further finds that health care
206	providers in rural areas are not prepared for market changes
207	such as the introduction of managed care and capitation-
208	reimbursement methodologies into health care services.
209	(e)(d)  The Legislature further finds that the creation of
210	rural health networks can help to alleviate these problems.
211	Rural health networks shall act in the broad public interest
212	and, to the extent possible, seek to improve the accessibility,
213	quality, and cost-effectiveness of rural health care by
214	planning, developing, coordinating, and providing be structured
215	to provide a continuum of quality health care services for rural
216	residents through the cooperative efforts of rural health
217	network members and other health care providers.
218	(f)(e)  The Legislature further finds that rural health
219	networks shall have the goal of increasing the financial
220	stability of statutory rural hospitals by linking rural hospital
221	services to other services in a continuum of health care
222	services and by increasing the utilization of statutory rural
223	hospitals whenever for appropriate health care services whenever
224	feasible, which shall help to ensure their survival and thereby
225	support the economy and protect the health and safety of rural
226	residents.
227	(g)(f)  Finally, the Legislature finds that rural health
228	networks may serve as "laboratories" to determine the best way
229	of organizing rural health services and linking to out-of-area
230	services that are not available locally in order, to move the
231	state closer to ensuring that everyone has access to health
232	care, and to promote cost-containment cost containment efforts.
233	The ultimate goal of rural health networks shall be to ensure
234	that quality health care is available and efficiently delivered
235	to all persons in rural areas.
236	(2)  DEFINITIONS.--
237	(a)  "Rural" means an area having with a population density
238	of fewer less than 100 individuals per square mile or an area
239	defined by the most recent United States Census as rural.
240	(b)  "Health care provider" means any individual, group, or
241	entity, public or private, which that provides health care,
242	including: preventive health care, primary health care,
243	secondary and tertiary health care, hospital in-hospital health
244	care, public health care, and health promotion and education.
245	(c)  "Rural health network" or "network" means a nonprofit
246	legal entity whose principal place of business is in a rural
247	area, whose members consist consisting of rural and urban health
248	care providers and others, and which that is established
249	organized to plan, develop, organize, and deliver health care
250	services on a cooperative basis in a rural area, except for some
251	secondary and tertiary care services.
252	(3)  NETWORK MEMBERSHIP.--
253	(a)  Because each rural area is unique, with a different
254	health care provider mix, health care provider membership may
255	vary, but all networks shall include members that provide health
256	promotion and disease-prevention services, public health
257	services, comprehensive primary care, emergency medical care,
258	and acute inpatient care.
259	(b)  Each county health department shall be a member of the
260	rural health network whose service area includes the county in
261	which the county health department is located. Federally
262	qualified health centers and emergency medical services
263	providers are encouraged to become members of the rural health
264	networks in the areas in which their patients reside or receive
265	services.
266	(c)(4)  Network membership shall be available to all health
267	care providers in the network service area if, provided that
268	they render care to all patients referred to them from other
269	network members;, comply with network quality assurance, quality
270	improvement, and utilization-management and risk management
271	requirements; and, abide by the terms and conditions of network
272	provider agreements in paragraph (11)(c), and provide services
273	at a rate or price equal to the rate or price negotiated by the
274	network.
275	(4)(5)  NETWORK SERVICE AREAS.--Network service areas are
276	do not required need to conform to local political boundaries or
277	state administrative district boundaries. The geographic area of
278	one rural health network, however, may not overlap the territory
279	of any other rural health network.
280	(5)(6)  NETWORK FUNCTIONS.--Networks shall:
281	(a)  Seek to develop linkages with provisions for referral
282	to tertiary inpatient care, specialty physician care, and to
283	other services that are not available in rural service areas.
284	(b)(7)  Networks shall Make available health promotion,
285	disease prevention, and primary care services, in order to
286	improve the health status of rural residents and to contain
287	health care costs.
288	(8)  Networks may have multiple points of entry, such as
289	through private physicians, community health centers, county
290	health departments, certified rural health clinics, hospitals,
291	or other providers; or they may have a single point of entry.
292	(c)(9)  Encourage members through training and educational
293	programs to adopt standards of care and promote the evidence-
294	based practice of medicine. Networks shall establish standard
295	protocols, coordinate and share patient records, and develop
296	patient information exchange systems in order to improve the
297	quality of and access to services.
298	(d)  Develop quality-improvement programs and train network
299	members and other health care providers in the use of such
300	programs.
301	(e)  Develop disease-management systems and train network
302	members and other health care providers in the use of such
303	systems.
304	(f)  Promote outreach to areas that have a high need for
305	services.
306	(g)  Seek to develop community care alternatives for elders
307	who would otherwise be placed in nursing homes.
308	(h)  Emphasize community care alternatives for persons with
309	mental health and substance abuse disorders who are at risk of
310	being admitted to an institution.
311	(i)  Develop and implement a long-range development plan
312	for an integrated system of care that is responsive to the
313	unique local health needs and the area health care services
314	market. Each rural health network long-range development plan
315	must address strategies to improve access to specialty care,
316	train health care providers to use standards of care for chronic
317	illness, develop disease-management capacity, and link to state
318	and national quality-improvement initiatives. The initial long-
319	range development plan must be submitted to the Office of Rural
320	Health for review and approval no later than July 1, 2008, and
321	thereafter the plans must be updated and submitted to the Office
322	of Rural Health every 3 years.
323	(10)  Networks shall develop risk management and quality
324	assurance programs for network providers.
325	(6)(11)  NETWORK GOVERNANCE AND ORGANIZATION.--
326	(a)  Networks shall be incorporated as not-for-profit
327	corporations under chapter 617, with articles of incorporation
328	that set forth purposes consistent with this section the laws of
329	the state.
330	(b)  Each network Networks shall have an independent a
331	board of directors that derives membership from local
332	government, health care providers, businesses, consumers,
333	advocacy groups, and others. Boards of other community health
334	care entities may not serve in whole as the board of a rural
335	health network; however, some overlap of board membership with
336	other community organizations is encouraged. Network staff must
337	provide an annual orientation and strategic planning activity
338	for board members.
339	(c)  Network boards of directors shall have the
340	responsibility of determining the content of health care
341	provider agreements that link network members. The written
342	agreements between the network and its health care provider
343	members must specify participation in the essential functions of
344	the network and shall specify:
345	1.  Who provides what services.
346	2.  The extent to which the health care provider provides
347	care to persons who lack health insurance or are otherwise
348	unable to pay for care.
349	3.  The procedures for transfer of medical records.
350	4.  The method used for the transportation of patients
351	between providers.
352	5.  Referral and patient flow including appointments and
353	scheduling.
354	6.  Payment arrangements for the transfer or referral of
355	patients.
356	(d)  There shall be no liability on the part of, and no
357	cause of action of any nature shall arise against, any member of
358	a network board of directors, or its employees or agents, for
359	any lawful action taken by them in the performance of their
360	administrative powers and duties under this subsection.
361	(7)(12)  NETWORK PROVIDER MEMBER SERVICES.--
362	(a)  Networks, to the extent feasible, shall seek to
363	develop services that provide for a continuum of care for all
364	residents patients served by the network. Each network shall
365	recruit members that can provide include the following core
366	services:  disease prevention, health promotion, comprehensive
367	primary care, emergency medical care, and acute inpatient care.
368	Each network shall seek to ensure the availability of
369	comprehensive maternity care, including prenatal, delivery, and
370	postpartum care for uncomplicated pregnancies, either directly,
371	by contract, or through referral agreements. Networks shall, to
372	the extent feasible, develop local services and linkages among
373	health care providers in order to also ensure the availability
374	of the following services: within the specified timeframes,
375	either directly, by contract, or through referral agreements:
376	1.  Services available in the home.
377	1.a.  Home health care.
378	2.b.  Hospice care.
379	2.  Services accessible within 30 minutes travel time or
380	less.
381	3.a.  Emergency medical services, including advanced life
382	support, ambulance, and basic emergency room services.
383	4.b.  Primary care, including.
384	c.  prenatal and postpartum care for uncomplicated
385	pregnancies.
386	5.d.  Community-based services for elders, such as adult
387	day care and assistance with activities of daily living.
388	6.e.  Public health services, including communicable
389	disease control, disease prevention, health education, and
390	health promotion.
391	7.f.  Outpatient mental health psychiatric and substance
392	abuse treatment services.
393	3.  Services accessible within 45 minutes travel time or
394	less.
395	8.a.  Hospital acute inpatient care for persons whose
396	illnesses or medical problems are not severe.
397	9.b.  Level I obstetrical care, which is Labor and delivery
398	for low-risk patients.
399	10.c.  Skilled nursing services and, long-term care,
400	including nursing home care.
401	(b)  Networks shall seek to foster linkages with out-of-
402	area services to the extent feasible in order to ensure the
403	availability of:
404	1.d.  Dialysis.
405	2.e.  Osteopathic and chiropractic manipulative therapy.
406	4.  Services accessible within 2 hours travel time or less.
407	3.a.  Specialist physician care.
408	4.b.  Hospital acute inpatient care for severe illnesses
409	and medical problems.
410	5.c.  Level II and III obstetrical care, which is Labor and
411	delivery care for high-risk patients and neonatal intensive
412	care.
413	6.d.  Comprehensive medical rehabilitation.
414	7.e.  Inpatient mental health psychiatric and substance
415	abuse treatment services.
416	8.f.  Magnetic resonance imaging, lithotripter treatment,
417	oncology, advanced radiology, and other technologically advanced
418	services.
419	9.g.  Subacute care.
420	(8)  COORDINATION WITH OTHER ENTITIES.--
421	(a)  Area health education centers, health planning
422	councils, and regional education consortia having technological
423	expertise in continuing education shall participate in the rural
424	health networks' preparation of long-range development plans.
425	The Department of Health may require written memoranda of
426	agreement between a network and an area health education center
427	or health planning council.
428	(b)  Rural health networks shall initiate activities, in
429	coordination with area health education centers, to carry out
430	the objectives of the adopted long-range development plan,
431	including continuing education for health care practitioners
432	performing functions such as disease management, continuous
433	quality improvement, telemedicine, long-distance learning, and
434	the treatment of chronic illness using standards of care. As
435	used in this section, the term "telemedicine" means the use of
436	telecommunications to deliver or expedite the delivery of health
437	care services.
438	(c)  Health planning councils shall support the preparation
439	of network long-range development plans through data collection
440	and analysis in order to assess the health status of area
441	residents and the capacity of local health services.
442	(d)  Regional education consortia that have the technology
443	available to assist rural health networks in establishing
444	systems for the exchange of patient information and for long-
445	distance learning are encouraged to provide technical assistance
446	upon the request of a rural health network.
447	(e)(b)  Networks shall actively participate with area
448	health education center programs, whenever feasible, in
449	developing and implementing recruitment, training, and retention
450	programs directed at positively influencing the supply and
451	distribution of health care professionals serving in, or
452	receiving training in, network areas.
453	(c)  As funds become available, networks shall emphasize
454	community care alternatives for elders who would otherwise be
455	placed in nursing homes.
456	(d)  To promote the most efficient use of resources,
457	networks shall emphasize disease prevention, early diagnosis and
458	treatment of medical problems, and community care alternatives
459	for persons with mental health and substance abuse disorders who
460	are at risk to be institutionalized.
461	(f)(13)  TRAUMA SERVICES.--In those network areas having
462	which have an established trauma agency approved by the
463	Department of Health, the network shall seek the participation
464	of that trauma agency must be a participant in the network.
465	Trauma services provided within the network area must comply
466	with s. 395.405.
467	(9)(14)  NETWORK FINANCING.--
468	(a)  Networks may use all sources of public and private
469	funds to support network activities. Nothing in this section
470	prohibits networks from becoming managed care providers.
471	(b)  The Department of Health shall establish grant
472	programs to provide funding to support the administrative costs
473	of developing and operating rural health networks.
474	(10)  NETWORK PERFORMANCE STANDARDS.--The Department of
475	Health shall develop and enforce performance standards for rural
476	health network operations grants and rural health infrastructure
477	development grants.
478	(a)  Operations grant performance standards must include,
479	but are not limited to, standards that require the rural health
480	network to:
481	1.  Have a qualified board of directors that meets at least
482	quarterly.
483	2.  Have sufficient staff who have the qualifications and
484	experience to perform the requirements of this section, as
485	assessed by the Office of Rural Health, or a written plan to
486	obtain such staff.
487	3.  Comply with the department's grant-management standards
488	in a timely and responsive manner.
489	4.  Comply with the department's standards for the
490	administration of federal grant funding, including assistance to
491	rural hospitals.
492	5.  Demonstrate a commitment to network activities from
493	area health care providers and other stakeholders, as described
494	in letters of support.
495	(b)  Rural health infrastructure development grant
496	performance standards must include, but are not limited to,
497	standards that require the rural health network to:
498	1.  During the 2007-2008 fiscal year, develop a long-range
499	development plan and, after July 1, 2008, have a long-range
500	development plan that has been reviewed and approved by the
501	Office of Rural Health.
502	2.  Have two or more successful network-development
503	activities, such as:
504	a.  Management of a network-development or outreach grant
505	from the federal Office of Rural Health Policy;
506	b.  Implementation of outreach programs to address chronic
507	disease, infant mortality, or assistance with prescription
508	medication;
509	c.  Development of partnerships with community and faith-
510	based organizations to address area health problems;
511	d.  Provision of direct services, such as clinics or mobile
512	units;
513	e.  Operation of credentialing services for health care
514	providers or quality-assurance and quality-improvement
515	initiatives that, whenever possible, are consistent with state
516	or federal quality initiatives;
517	f.  Support for the development of community health
518	centers, local community health councils, federal designation as
519	a rural critical access hospital, or comprehensive community
520	health planning initiatives; and
521	g.  Development of the capacity to obtain federal, state,
522	and foundation grants.
523	(11)(15)  NETWORK IMPLEMENTATION.--As funds become
524	available, networks shall be developed and implemented in two
525	phases.
526	(a)  Phase I shall consist of a network planning and
527	development grant program. Planning grants shall be used to
528	organize networks, incorporate network boards, and develop
529	formal provider agreements as provided for in this section. The
530	Department of Health shall develop a request-for-proposal
531	process to solicit grant applications.
532	(b)  Phase II shall consist of a network operations grant
533	program. As funds become available, certified networks that meet
534	performance standards shall be eligible to receive grant funds
535	to be used to help defray the costs of rural health network
536	infrastructure development, patient care, and network
537	administration. Rural health network infrastructure development
538	includes, but is not limited to: recruitment and retention of
539	primary care practitioners; enhancement of primary care services
540	through the use of mobile clinics; development of preventive
541	health care programs; linkage of urban and rural health care
542	systems; design and implementation of automated patient records,
543	outcome measurement, quality assurance, and risk management
544	systems; establishment of one-stop service delivery sites;
545	upgrading of medical technology available to network providers;
546	enhancement of emergency medical systems; enhancement of medical
547	transportation; formation of joint contracting entities composed
548	of rural physicians, rural hospitals, and other rural health
549	care providers; establishment of comprehensive disease-
550	management programs that meet Medicaid requirements;
551	establishment of regional quality-improvement programs involving
552	physicians and hospitals consistent with state and national
553	initiatives; establishment of specialty networks connecting
554	rural primary care physicians and urban specialists; development
555	of regional broadband telecommunications systems that have the
556	capacity to share patient information in a secure network,
557	telemedicine, and long-distance learning capacity; and linkage
558	between training programs for health care practitioners and the
559	delivery of health care services in rural areas and development
560	of telecommunication capabilities. A Phase II award may occur in
561	the same fiscal year as a Phase I award.
562	(12)(16)  CERTIFICATION.--For the purpose of certifying
563	networks that are eligible for Phase II funding, the Department
564	of Health shall certify networks that meet the criteria
565	delineated in this section and the rules governing rural health
566	networks. The Office of Rural Health in the Department of Health
567	shall monitor rural health networks in order to ensure continued
568	compliance with established certification and performance
569	standards.
570	(13)(17)  RULES.--The Department of Health shall establish
571	rules that govern the creation and certification of networks,
572	the provision of grant funds under Phase I and Phase II, and the
573	establishment of performance standards including establishing
574	outcome measures for networks.
575	Section 3.  Subsection (2) of section 395.602, Florida
576	Statutes, is amended to read:
577	395.602  Rural hospitals.--
578	(2)  DEFINITIONS.--As used in this part:
579	(a)  "Critical access hospital" means a hospital that meets
580	the definition of rural hospital in paragraph (d) and meets the
581	requirements for reimbursement by Medicare and Medicaid under 42
582	C.F.R. ss. 485.601-485.647. "Emergency care hospital" means a
583	medical facility which provides:
584	1.  Emergency medical treatment; and
585	2.  Inpatient care to ill or injured persons prior to their
586	transportation to another hospital or provides inpatient medical
587	care to persons needing care for a period of up to 96 hours. The
588	96-hour limitation on inpatient care does not apply to respite,
589	skilled nursing, hospice, or other nonacute care patients.
590	(b)  "Essential access community hospital" means any
591	facility which:
592	1.  Has at least 100 beds;
593	2.  Is located more than 35 miles from any other essential
594	access community hospital, rural referral center, or urban
595	hospital meeting criteria for classification as a regional
596	referral center;
597	3.  Is part of a network that includes rural primary care
598	hospitals;
599	4.  Provides emergency and medical backup services to rural
600	primary care hospitals in its rural health network;
601	5.  Extends staff privileges to rural primary care hospital
602	physicians in its network; and
603	6.  Accepts patients transferred from rural primary care
604	hospitals in its network.
605	(b)(c)  "Inactive rural hospital bed" means a licensed
606	acute care hospital bed, as defined in s. 395.002(14), that is
607	inactive in that it cannot be occupied by acute care inpatients.
608	(c)(d)  "Rural area health education center" means an area
609	health education center (AHEC), as authorized by Pub. L. No. 94-
610	484, which provides services in a county with a population
611	density of no greater than 100 persons per square mile.
612	(d)(e)  "Rural hospital" means an acute care hospital
613	licensed under this chapter, having 100 or fewer licensed beds
614	and an emergency room, which is:
615	1.  The sole provider within a county with a population
616	density of no greater than 100 persons per square mile;
617	2.  An acute care hospital, in a county with a population
618	density of no greater than 100 persons per square mile, which is
619	at least 30 minutes of travel time, on normally traveled roads
620	under normal traffic conditions, from any other acute care
621	hospital within the same county;
622	3.  A hospital supported by a tax district or subdistrict
623	whose boundaries encompass a population of 100 persons or fewer
624	per square mile;
625	4.  A hospital in a constitutional charter county with a
626	population of over 1 million persons that has imposed a local
627	option health service tax pursuant to law and in an area that
628	was directly impacted by a catastrophic event on August 24,
629	1992, for which the Governor of Florida declared a state of
630	emergency pursuant to chapter 125, and has 120 beds or less that
631	serves an agricultural community with an emergency room
632	utilization of no less than 20,000 visits and a Medicaid
633	inpatient utilization rate greater than 15 percent;
634	5.  A hospital with a service area that has a population of
635	100 persons or fewer per square mile. As used in this
636	subparagraph, the term "service area" means the fewest number of
637	zip codes that account for 75 percent of the hospital's
638	discharges for the most recent 5-year period, based on
639	information available from the hospital inpatient discharge
640	database in the Florida Center for Health Information and Policy
641	Analysis at the Agency for Health Care Administration; or
642	6.  A hospital designated as a critical access hospital, as
643	defined in s. 408.07(15).
644
645	Population densities used in this paragraph must be based upon
646	the most recently completed United States census. A hospital
647	that received funds under s. 409.9116 for a quarter beginning no
648	later than July 1, 2002, is deemed to have been and shall
649	continue to be a rural hospital from that date through June 30,
650	2012, if the hospital continues to have 100 or fewer licensed
651	beds and an emergency room, or meets the criteria of
652	subparagraph 4. An acute care hospital that has not previously
653	been designated as a rural hospital and that meets the criteria
654	of this paragraph shall be granted such designation upon
655	application, including supporting documentation to the Agency
656	for Health Care Administration.
657	(e)(f)  "Rural primary care hospital" means any facility
658	that meeting the criteria in paragraph (e) or s. 395.605 which
659	provides:
660	1.  Twenty-four-hour emergency medical care;
661	2.  Temporary inpatient care for periods of 96 72 hours or
662	less to patients requiring stabilization before discharge or
663	transfer to another hospital. The 96-hour 72-hour limitation
664	does not apply to respite, skilled nursing, hospice, or other
665	nonacute care patients; and
666	3.  Has at least no more than six licensed acute care
667	inpatient beds.
668	(f)(g)  "Swing-bed" means a bed which can be used
669	interchangeably as either a hospital, skilled nursing facility
670	(SNF), or intermediate care facility (ICF) bed pursuant to 42
671	C.F.R. parts 405, 435, 440, 442, and 447.
672	Section 4.  Subsection (1) of section 395.603, Florida
673	Statutes, is amended to read:
674	395.603  Deactivation of general hospital beds; rural
675	hospital impact statement.--
676	(1)  The agency shall establish, by rule, a process by
677	which A rural hospital, as defined in s. 395.602, which that
678	seeks licensure as a rural primary care hospital or as an
679	emergency care hospital, or becomes a certified rural health
680	clinic as defined in Pub. L. No. 95-210, or becomes a primary
681	care program such as a county health department, community
682	health center, or other similar outpatient program that provides
683	preventive and curative services, may deactivate general
684	hospital beds. A critical access hospital or a rural primary
685	care hospital hospitals and emergency care hospitals shall
686	maintain the number of actively licensed general hospital beds
687	necessary for the facility to be certified for Medicare
688	reimbursement. Hospitals that discontinue inpatient care to
689	become rural health care clinics or primary care programs shall
690	deactivate all licensed general hospital beds. All hospitals,
691	clinics, and programs with inactive beds shall provide 24-hour
692	emergency medical care by staffing an emergency room. Providers
693	with inactive beds shall be subject to the criteria in s.
694	395.1041. The agency shall specify in rule requirements for
695	making 24-hour emergency care available. Inactive general
696	hospital beds shall be included in the acute care bed inventory,
697	maintained by the agency for certificate-of-need purposes, for
698	10 years from the date of deactivation of the beds. After 10
699	years have elapsed, inactive beds shall be excluded from the
700	inventory. The agency shall, at the request of the licensee,
701	reactivate the inactive general beds upon a showing by the
702	licensee that licensure requirements for the inactive general
703	beds are met.
704	Section 5.  Section 395.604, Florida Statutes, is amended
705	to read:
706	395.604  Other Rural primary care hospitals hospital
707	programs.--
708	(1)  The agency may license rural primary care hospitals
709	subject to federal approval for participation in the Medicare
710	and Medicaid programs. Rural primary care hospitals shall be
711	treated in the same manner as emergency care hospitals and rural
712	hospitals with respect to ss. 395.605(2)-(8)(a),
713	408.033(2)(b)3., and 408.038.
714	(2)  The agency may designate essential access community
715	hospitals.
716	(3)  The agency may adopt licensure rules for rural primary
717	care hospitals and essential access community hospitals. Such
718	rules must conform to s. 395.1055.
719	(3)  For the purpose of Medicaid swing-bed reimbursement
720	pursuant to the Medicaid program, the agency shall treat rural
721	primary care hospitals in the same manner as rural hospitals.
722	(4)  For the purpose of participation in the Medical
723	Education Reimbursement and Loan Repayment Program as defined in
724	s. 1009.65 or other loan repayment or incentive programs
725	designed to relieve medical workforce shortages, the department
726	shall treat rural primary care hospitals in the same manner as
727	rural hospitals.
728	(5)  For the purpose of coordinating primary care services
729	described in s. 154.011(1)(c)10., the department shall treat
730	rural primary care hospitals in the same manner as rural
731	hospitals.
732	(6)  Rural hospitals that make application under the
733	certificate-of-need program to be licensed as rural primary care
734	hospitals shall receive expedited review as defined in s.
735	408.032. Rural primary care hospitals seeking relicensure as
736	acute care general hospitals shall also receive expedited
737	review.
738	(7)  Rural primary care hospitals are exempt from
739	certificate-of-need requirements for home health and hospice
740	services and for swing beds in a number that does not exceed
741	one-half of the facility's licensed beds.
742	(8)  Rural primary care hospitals shall have agreements
743	with other hospitals, skilled nursing facilities, home health
744	agencies, and providers of diagnostic-imaging and laboratory
745	services that are not provided on site but are needed by
746	patients.
747	(4)  The department may seek federal recognition of
748	emergency care hospitals authorized by s. 395.605 under the
749	essential access community hospital program authorized by the
750	Omnibus Budget Reconciliation Act of 1989.
751	Section 6.  Section 395.6061, Florida Statutes, is amended
752	to read:
753	395.6061  Rural hospital capital improvement.--There is
754	established a rural hospital capital improvement grant program.
755	(1)  A rural hospital as defined in s. 395.602 may apply to
756	the department for a grant to acquire, repair, improve, or
757	upgrade systems, facilities, or equipment. The grant application
758	must provide information that includes:
759	(a)  A statement indicating the problem the rural hospital
760	proposes to solve with the grant funds;
761	(b)  The strategy proposed to resolve the problem;
762	(c)  The organizational structure, financial system, and
763	facilities that are essential to the proposed solution;
764	(d)  The projected longevity of the proposed solution after
765	the grant funds are expended;
766	(e)  Evidence of participation in a rural health network as
767	defined in s. 381.0406 and evidence that, after July 1, 2008,
768	the application is consistent with the rural health network's
769	long-range development plan;
770	(f)  Evidence that the rural hospital has difficulty in
771	obtaining funding or that funds available for the proposed
772	solution are inadequate;
773	(g)  Evidence that the grant funds will assist in
774	maintaining or returning the hospital to an economically stable
775	condition or that any plan for closure of the hospital or
776	realignment of services will involve development of innovative
777	alternatives for the provision of needed discontinued services;
778	(h)  Evidence of a satisfactory record-keeping system to
779	account for grant fund expenditures within the rural county; and
780	(i)  A rural health network plan that includes a
781	description of how the plan was developed, the goals of the
782	plan, the links with existing health care providers under the
783	plan, Indicators quantifying the hospital's financial status
784	well-being, measurable outcome targets, and the current physical
785	and operational condition of the hospital.
786	(2)  Each rural hospital as defined in s. 395.602 shall
787	receive a minimum of $200,000 $100,000 annually, subject to
788	legislative appropriation, upon application to the Department of
789	Health, for projects to acquire, repair, improve, or upgrade
790	systems, facilities, or equipment.
791	(3)  Any remaining funds may shall annually be disbursed to
792	rural hospitals in accordance with this section. The Department
793	of Health shall establish, by rule, criteria for awarding grants
794	for any remaining funds, which must be used exclusively for the
795	support and assistance of rural hospitals as defined in s.
796	395.602, including criteria relating to the level of charity
797	uncompensated care rendered by the hospital, the financial
798	stability of the hospital, financial and quality indicators for
799	the hospital, whether the project is sustainable beyond the
800	funding period, the hospital's ability to improve or expand
801	services, the hospital's participation in a rural health network
802	as defined in s. 381.0406, and the proposed use of the grant by
803	the rural hospital to resolve a specific problem. The department
804	must consider any information submitted in an application for
805	the grants in accordance with subsection (1) in determining
806	eligibility for and the amount of the grant, and none of the
807	individual items of information by itself may be used to deny
808	grant eligibility.
809	(4)  To receive any of the remaining funds, a rural
810	hospital must agree to be bound by the terms of a participation
811	agreement with the department, which may include:
812	(a)  The appointment of a health care expert under contract
813	with the department to analyze and monitor the hospital's
814	operations.
815	(b)  The establishment of an orientation and development
816	program for members of the board.
817	(c)  The approval of any facility relocation plans.
818	(5)(4)  The department shall ensure that the funds are used
819	solely for the purposes specified in this section. The total
820	grants awarded pursuant to this section shall not exceed the
821	amount appropriated for this program.
822	Section 7.  Subsection (12) of section 409.908, Florida
823	Statutes, is amended to read:
824	409.908  Reimbursement of Medicaid providers.--Subject to
825	specific appropriations, the agency shall reimburse Medicaid
826	providers, in accordance with state and federal law, according
827	to methodologies set forth in the rules of the agency and in
828	policy manuals and handbooks incorporated by reference therein.
829	These methodologies may include fee schedules, reimbursement
830	methods based on cost reporting, negotiated fees, competitive
831	bidding pursuant to s. 287.057, and other mechanisms the agency
832	considers efficient and effective for purchasing services or
833	goods on behalf of recipients. If a provider is reimbursed based
834	on cost reporting and submits a cost report late and that cost
835	report would have been used to set a lower reimbursement rate
836	for a rate semester, then the provider's rate for that semester
837	shall be retroactively calculated using the new cost report, and
838	full payment at the recalculated rate shall be effected
839	retroactively. Medicare-granted extensions for filing cost
840	reports, if applicable, shall also apply to Medicaid cost
841	reports. Payment for Medicaid compensable services made on
842	behalf of Medicaid eligible persons is subject to the
843	availability of moneys and any limitations or directions
844	provided for in the General Appropriations Act or chapter 216.
845	Further, nothing in this section shall be construed to prevent
846	or limit the agency from adjusting fees, reimbursement rates,
847	lengths of stay, number of visits, or number of services, or
848	making any other adjustments necessary to comply with the
849	availability of moneys and any limitations or directions
850	provided for in the General Appropriations Act, provided the
851	adjustment is consistent with legislative intent.
852	(12)(a)  A physician shall be reimbursed the lesser of the
853	amount billed by the provider or the Medicaid maximum allowable
854	fee established by the agency.
855	(b)  The agency shall adopt a fee schedule, subject to any
856	limitations or directions provided for in the General
857	Appropriations Act, based on a resource-based relative value
858	scale for pricing Medicaid physician services. Under this fee
859	schedule, physicians shall be paid a dollar amount for each
860	service based on the average resources required to provide the
861	service, including, but not limited to, estimates of average
862	physician time and effort, practice expense, and the costs of
863	professional liability insurance. The fee schedule shall provide
864	increased reimbursement for preventive and primary care services
865	and lowered reimbursement for specialty services by using at
866	least two conversion factors, one for cognitive services and
867	another for procedural services. The fee schedule shall not
868	increase total Medicaid physician expenditures unless moneys are
869	available, and shall be phased in over a 2-year period beginning
870	on July 1, 1994. The Agency for Health Care Administration shall
871	seek the advice of a 16-member advisory panel in formulating and
872	adopting the fee schedule. The panel shall consist of Medicaid
873	physicians licensed under chapters 458 and 459 and shall be
874	composed of 50 percent primary care physicians and 50 percent
875	specialty care physicians.
876	(c)  Notwithstanding paragraph (b), reimbursement fees to
877	physicians for providing total obstetrical services to Medicaid
878	recipients, which include prenatal, delivery, and postpartum
879	care, shall be at least $1,500 per delivery for a pregnant woman
880	with low medical risk and at least $2,000 per delivery for a
881	pregnant woman with high medical risk. However, reimbursement to
882	physicians working in Regional Perinatal Intensive Care Centers
883	designated pursuant to chapter 383, for services to certain
884	pregnant Medicaid recipients with a high medical risk, may be
885	made according to obstetrical care and neonatal care groupings
886	and rates established by the agency. Nurse midwives licensed
887	under part I of chapter 464 or midwives licensed under chapter
888	467 shall be reimbursed at no less than 80 percent of the low
889	medical risk fee. The agency shall by rule determine, for the
890	purpose of this paragraph, what constitutes a high or low
891	medical risk pregnant woman and shall not pay more based solely
892	on the fact that a caesarean section was performed, rather than
893	a vaginal delivery. The agency shall by rule determine a
894	prorated payment for obstetrical services in cases where only
895	part of the total prenatal, delivery, or postpartum care was
896	performed. The Department of Health shall adopt rules for
897	appropriate insurance coverage for midwives licensed under
898	chapter 467. Prior to the issuance and renewal of an active
899	license, or reactivation of an inactive license for midwives
900	licensed under chapter 467, such licensees shall submit proof of
901	coverage with each application.
902	(d)  Notwithstanding other provisions of this subsection,
903	physicians licensed under chapter 458 or chapter 459 who have a
904	provider agreement with a rural health network as established in
905	s. 381.0406 shall be paid a 10-percent bonus over the Medicaid
906	physician fee schedule for any physician service provided within
907	the geographic boundary of a rural county as defined by the most
908	recent United States Census as rural.
909	Section 8.  Subsection (43) of section 408.07, Florida
910	Statutes, is amended to read:
911	408.07  Definitions.--As used in this chapter, with the
912	exception of ss. 408.031-408.045, the term:
913	(43)  "Rural hospital" means an acute care hospital
914	licensed under chapter 395, having 100 or fewer licensed beds
915	and an emergency room, and which is:
916	(a)  The sole provider within a county with a population
917	density of no greater than 100 persons per square mile;
918	(b)  An acute care hospital, in a county with a population
919	density of no greater than 100 persons per square mile, which is
920	at least 30 minutes of travel time, on normally traveled roads
921	under normal traffic conditions, from another acute care
922	hospital within the same county;
923	(c)  A hospital supported by a tax district or subdistrict
924	whose boundaries encompass a population of 100 persons or fewer
925	per square mile;
926	(d)  A hospital with a service area that has a population
927	of 100 persons or fewer per square mile. As used in this
928	paragraph, the term "service area" means the fewest number of
929	zip codes that account for 75 percent of the hospital's
930	discharges for the most recent 5-year period, based on
931	information available from the hospital inpatient discharge
932	database in the Florida Center for Health Information and Policy
933	Analysis at the Agency for Health Care Administration; or
934	(e)  A critical access hospital.
935
936	Population densities used in this subsection must be based upon
937	the most recently completed United States census. A hospital
938	that received funds under s. 409.9116 for a quarter beginning no
939	later than July 1, 2002, is deemed to have been and shall
940	continue to be a rural hospital from that date through June 30,
941	2012, if the hospital continues to have 100 or fewer licensed
942	beds and an emergency room, or meets the criteria of s.
943	395.602(2)(d)4. s. 395.602(2)(e)4. An acute care hospital that
944	has not previously been designated as a rural hospital and that
945	meets the criteria of this subsection shall be granted such
946	designation upon application, including supporting
947	documentation, to the Agency for Health Care Administration.
948	Section 9.  Subsection (6) of section 409.9116, Florida
949	Statutes, is amended to read:
950	409.9116  Disproportionate share/financial assistance
951	program for rural hospitals.--In addition to the payments made
952	under s. 409.911, the Agency for Health Care Administration
953	shall administer a federally matched disproportionate share
954	program and a state-funded financial assistance program for
955	statutory rural hospitals. The agency shall make
956	disproportionate share payments to statutory rural hospitals
957	that qualify for such payments and financial assistance payments
958	to statutory rural hospitals that do not qualify for
959	disproportionate share payments. The disproportionate share
960	program payments shall be limited by and conform with federal
961	requirements. Funds shall be distributed quarterly in each
962	fiscal year for which an appropriation is made. Notwithstanding
963	the provisions of s. 409.915, counties are exempt from
964	contributing toward the cost of this special reimbursement for
965	hospitals serving a disproportionate share of low-income
966	patients.
967	(6)  This section applies only to hospitals that were
968	defined as statutory rural hospitals, or their successor-in-
969	interest hospital, prior to January 1, 2001. Any additional
970	hospital that is defined as a statutory rural hospital, or its
971	successor-in-interest hospital, on or after January 1, 2001, is
972	not eligible for programs under this section unless additional
973	funds are appropriated each fiscal year specifically to the
974	rural hospital disproportionate share and financial assistance
975	programs in an amount necessary to prevent any hospital, or its
976	successor-in-interest hospital, eligible for the programs prior
977	to January 1, 2001, from incurring a reduction in payments
978	because of the eligibility of an additional hospital to
979	participate in the programs. A hospital, or its successor-in-
980	interest hospital, which received funds pursuant to this section
981	before January 1, 2001, and which qualifies under s.
982	395.602(2)(d) s. 395.602(2)(e), shall be included in the
983	programs under this section and is not required to seek
984	additional appropriations under this subsection.
985	Section 10.  Paragraph (b) of subsection (2) of section
986	1009.65, Florida Statutes, is amended to read:
987	1009.65  Medical Education Reimbursement and Loan Repayment
988	Program.--
989	(2)  From the funds available, the Department of Health
990	shall make payments to selected medical professionals as
991	follows:
992	(b)  All payments shall be contingent on continued proof of
993	primary care practice in an area defined in s. 395.602(2)(d) s.
994	395.602(2)(e), or an underserved area designated by the
995	Department of Health, provided the practitioner accepts Medicaid
996	reimbursement if eligible for such reimbursement. Correctional
997	facilities, state hospitals, and other state institutions that
998	employ medical personnel shall be designated by the Department
999	of Health as underserved locations. Locations with high
1000	incidences of infant mortality, high morbidity, or low Medicaid
1001	participation by health care professionals may be designated as
1002	underserved.
1003	Section 11.  The Office of Program Policy Analysis and
1004	Government Accountability shall contract with an entity having
1005	expertise in the financing of rural hospital capital improvement
1006	projects to study the financing options for replacing or
1007	changing the use of rural hospital facilities having 55 or fewer
1008	beds which were built before 1985 and which have not had major
1009	renovations since 1985. For each such hospital, the contractor
1010	shall assess the need to replace or convert the facility,
1011	identify all available sources of financing for such replacement
1012	or conversion and assess each community's capacity to maximize
1013	these funding options, propose a model replacement facility if a
1014	facility should be replaced, and propose alternative uses of the
1015	facility if continued operation of the hospital is not
1016	financially feasible. Based on the results of the contract
1017	study, the Office of Program Policy Analysis and Government
1018	Accountability shall submit recommendations to the Legislature
1019	by February 1, 2008, regarding whether the state should provide
1020	financial assistance to replace or convert these rural hospital
1021	facilities and what form that assistance should take.
1022	Section 12.  Section 395.605, Florida Statutes, is
1023	repealed.
1024	Section 13.  The sum of $440,000 in nonrecurring general
1025	revenue is appropriated from the General Revenue Fund to the
1026	Office of Program Policy Analysis and Government Accountability
1027	for the 2007-2008 fiscal year to implement section 11 of this
1028	act.
1029	Section 14.  The sums of $3,638,709 in recurring revenue
1030	from the General Revenue Fund and $5,067,392 in recurring
1031	revenue from the Medical Care Trust Fund are appropriated to the
1032	Agency for Health Care Administration for the 2007-2008 fiscal
1033	year to implement the 10-percent Medicaid fee schedule bonus
1034	payment as provided in s. 409.908, Florida Statutes, as amended
1035	by this act.
1036	Section 15.  The sum of $3 million in recurring revenue is
1037	appropriated from the General Revenue Fund to the Department of
1038	Health for the 2007-2008 fiscal year to implement rural health
1039	network infrastructure development as provided in s. 381.0406,
1040	Florida Statutes, as amended by this act.
1041	Section 16.  The sum of $7.5 million in nonrecurring
1042	revenue is appropriated from the General Revenue Fund to the
1043	Department of Health for the 2007-2008 fiscal year to implement
1044	the rural hospital capital improvement grant program as provided
1045	in s. 395.6061, Florida Statutes, as amended by this act.
1046	Section 17.  The sums of $196,818 in recurring revenue from
1047	the General Revenue Fund and $17,556 in nonrecurring revenue
1048	from the General Revenue Fund  are appropriated to the
1049	Department of Health, and three full-time equivalent positions
1050	and associated salary rate of 121,619 are authorized to
1051	implement this act.
1052	Section 18.  This act shall take effect July 1, 2007.

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