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Senator Jones moved the following amendment:

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     Senate Amendment (with title amendment)

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     Delete line(s) 948-1081

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and insert:

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     Section 12.  Subsections (5) through (27) of section

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409.901, Florida Statutes, are redesignated as subsections (6)

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through (28), respectively, and a new subsection (5) is added to

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that section to read:

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     409.901  Definitions; ss. 409.901-409.920.--As used in ss.

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409.901-409.920, except as otherwise specifically provided, the

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term:

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     (5) "Change of ownership" means an event in which the

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provider changes to a different legal entity or in which 45

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percent or more of the ownership, voting shares, or controlling

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interest in a corporation whose shares are not publicly traded on

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a recognized stock exchange is transferred or assigned, including

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the final transfer or assignment of multiple transfers or

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assignments over a 2-year period that cumulatively total 45

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percent or more. A change solely in the management company or

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board of directors is not a change of ownership.

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     Section 13.  Subsections (6) and (9) of section 409.907,

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Florida Statutes, are amended to read:

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     409.907  Medicaid provider agreements.--The agency may make

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payments for medical assistance and related services rendered to

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Medicaid recipients only to an individual or entity who has a

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provider agreement in effect with the agency, who is performing

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services or supplying goods in accordance with federal, state,

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and local law, and who agrees that no person shall, on the

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grounds of handicap, race, color, or national origin, or for any

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other reason, be subjected to discrimination under any program or

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activity for which the provider receives payment from the agency.

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     (6)  A Medicaid provider agreement may be revoked, at the

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option of the agency, as the result of a change of ownership of

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any facility, association, partnership, or other entity named as

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the provider in the provider agreement. A provider shall give the

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agency 60 days' notice before making any change in ownership of

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the entity named in the provider agreement as the provider.

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     (a) In the event of a change of ownership, the transferor

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remains liable for all outstanding overpayments, administrative

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fines, and any other moneys owed to the agency before the

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effective date of the change of ownership. In addition to the

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continuing liability of the transferor, the transferee is liable

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to the agency for all outstanding overpayments identified by the

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agency on or before the effective date of the change of

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ownership. For purposes of this subsection, the term "outstanding

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overpayment" includes any amount identified in a preliminary

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audit report issued to the transferor by the agency on or before

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the effective date of the change of ownership. In the event of a

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change of ownership for a skilled nursing facility or

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intermediate care facility, the Medicaid provider agreement shall

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be assigned to the transferee if the transferee meets all other

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Medicaid provider qualifications. In the event of a change of

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ownership involving a skilled nursing facility licensed under

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part II of chapter 400, liability for all outstanding

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overpayments, administrative fines, and any moneys owed to the

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agency before the effective date of the change of ownership shall

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be determined in accordance with the provisions of s. 400.179.

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     (b) At least 60 days before the anticipated date of the

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change of ownership, the transferor shall notify the agency of

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the intended change of ownership and the transferee shall submit

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to the agency a Medicaid provider enrollment application. If a

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change of ownership occurs without compliance with the notice

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requirements of this subsection, the transferor and transferee

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shall be jointly and severally liable for all overpayments,

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administrative fines, and other moneys due to the agency,

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regardless of whether the agency identified the overpayments,

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administrative fines, or other moneys before or after the

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effective date of the change of ownership. The agency may not

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approve a transferee's Medicaid provider enrollment application

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if the transferee or transferor has not paid or agreed in writing

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to a payment plan for all outstanding overpayments,

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administrative fines, and other moneys due to the agency. This

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subsection does not preclude the agency from seeking any other

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legal or equitable remedies available to the agency for the

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recovery of moneys owed to the Medicaid program. In the event of

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a change of ownership involving a skilled nursing facility

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licensed under part II of chapter 400, liability for all

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outstanding overpayments, administrative fines, and any moneys

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owed to the agency before the effective date of the change of

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ownership shall be determined in accordance with the provisions

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of s. 400.179 if the Medicaid provider enrollment application for

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change of ownership is submitted before the change of ownership.

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     (9)  Upon receipt of a completed, signed, and dated

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application, and completion of any necessary background

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investigation and criminal history record check, the agency must

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either:

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     (a)  Enroll the applicant as a Medicaid provider upon

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approval of the provider application. The enrollment effective

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date shall be the date the agency receives the provider

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application. With respect to a provider that requires a Medicare

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certification survey, the enrollment effective date is the date

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the certification is awarded. With respect to a provider that

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completes a change of ownership, the effective date is the date

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the agency received the application, the date the change of

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ownership was complete, or the date the applicant became eligible

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to provide services under Medicaid, whichever date is later. With

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respect to a provider of emergency medical services

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transportation or emergency services and care, the effective date

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is the date the services were rendered. Payment for any claims

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for services provided to Medicaid recipients between the date of

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receipt of the application and the date of approval is contingent

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on applying any and all applicable audits and edits contained in

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the agency's claims adjudication and payment processing systems;

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or

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     (b)  Deny the application if the agency finds that it is in

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the best interest of the Medicaid program to do so. The agency

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may consider the factors listed in subsection (10), as well as

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any other factor that could affect the effective and efficient

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administration of the program, including, but not limited to, the

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applicant's demonstrated ability to provide services, conduct

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business, and operate a financially viable concern; the current

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availability of medical care, services, or supplies to

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recipients, taking into account geographic location and

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reasonable travel time; the number of providers of the same type

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already enrolled in the same geographic area; and the

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credentials, experience, success, and patient outcomes of the

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provider for the services that it is making application to

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provide in the Medicaid program. The agency shall deny the

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application if the agency finds that a provider; any officer,

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director, agent, managing employee, or affiliated person; or any

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partner or shareholder having an ownership interest equal to 5

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percent or greater in the provider if the provider is a

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corporation, partnership, or other business entity, has failed to

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pay all outstanding fines or overpayments assessed by final order

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of the agency or final order of the Centers for Medicare and

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Medicaid Services, not subject to further appeal, unless the

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provider agrees to a repayment plan that includes withholding

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Medicaid reimbursement until the amount due is paid in full.

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     Section 14.  Subsection (20) of section 409.910, Florida

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Statutes, is amended to read:

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     409.910  Responsibility for payments on behalf of Medicaid-

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eligible persons when other parties are liable.--

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     (20)  Entities providing health insurance as defined in s.

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624.603, health maintenance organizations and prepaid health

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clinics as defined in chapter 641, and, on behalf of their

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clients, third-party administrators and pharmacy benefits

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managers as defined in s. 409.901 (27) s. 409.901(26) shall

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provide such records and information as are necessary to

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accomplish the purpose of this section, unless such requirement

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results in an unreasonable burden.

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     (a)  The director of the agency and the Director of the

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Office of Insurance Regulation of the Financial Services

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Commission shall enter into a cooperative agreement for

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requesting and obtaining information necessary to effect the

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purpose and objective of this section.

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     1.  The agency shall request only that information necessary

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to determine whether health insurance as defined pursuant to s.

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624.603, or those health services provided pursuant to chapter

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641, could be, should be, or have been claimed and paid with

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respect to items of medical care and services furnished to any

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person eligible for services under this section.

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     2.  All information obtained pursuant to subparagraph 1. is

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confidential and exempt from s. 119.07(1).

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     3.  The cooperative agreement or rules adopted under this

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subsection may include financial arrangements to reimburse the

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reporting entities for reasonable costs or a portion thereof

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incurred in furnishing the requested information. Neither the

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cooperative agreement nor the rules shall require the automation

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of manual processes to provide the requested information.

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     (b)  The agency and the Financial Services Commission

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jointly shall adopt rules for the development and administration

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of the cooperative agreement. The rules shall include the

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following:

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     1.  A method for identifying those entities subject to

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furnishing information under the cooperative agreement.

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     2.  A method for furnishing requested information.

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     3.  Procedures for requesting exemption from the cooperative

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agreement based on an unreasonable burden to the reporting

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entity.

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     Section 15.  Subsection (48) of section 409.912, Florida

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Statutes, is amended to read:

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     409.912  Cost-effective purchasing of health care.--The

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agency shall purchase goods and services for Medicaid recipients

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in the most cost-effective manner consistent with the delivery of

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quality medical care. To ensure that medical services are

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effectively utilized, the agency may, in any case, require a

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confirmation or second physician's opinion of the correct

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diagnosis for purposes of authorizing future services under the

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Medicaid program. This section does not restrict access to

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emergency services or poststabilization care services as defined

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in 42 C.F.R. part 438.114. Such confirmation or second opinion

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shall be rendered in a manner approved by the agency. The agency

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shall maximize the use of prepaid per capita and prepaid

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aggregate fixed-sum basis services when appropriate and other

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alternative service delivery and reimbursement methodologies,

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including competitive bidding pursuant to s. 287.057, designed to

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facilitate the cost-effective purchase of a case-managed

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continuum of care. The agency shall also require providers to

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minimize the exposure of recipients to the need for acute

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inpatient, custodial, and other institutional care and the

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inappropriate or unnecessary use of high-cost services. The

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agency shall contract with a vendor to monitor and evaluate the

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clinical practice patterns of providers in order to identify

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trends that are outside the normal practice patterns of a

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provider's professional peers or the national guidelines of a

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provider's professional association. The vendor must be able to

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provide information and counseling to a provider whose practice

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patterns are outside the norms, in consultation with the agency,

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to improve patient care and reduce inappropriate utilization. The

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agency may mandate prior authorization, drug therapy management,

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or disease management participation for certain populations of

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Medicaid beneficiaries, certain drug classes, or particular drugs

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to prevent fraud, abuse, overuse, and possible dangerous drug

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interactions. The Pharmaceutical and Therapeutics Committee shall

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make recommendations to the agency on drugs for which prior

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authorization is required. The agency shall inform the

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Pharmaceutical and Therapeutics Committee of its decisions

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regarding drugs subject to prior authorization. The agency is

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authorized to limit the entities it contracts with or enrolls as

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Medicaid providers by developing a provider network through

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provider credentialing. The agency may competitively bid single-

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source-provider contracts if procurement of goods or services

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results in demonstrated cost savings to the state without

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limiting access to care. The agency may limit its network based

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on the assessment of beneficiary access to care, provider

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availability, provider quality standards, time and distance

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standards for access to care, the cultural competence of the

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provider network, demographic characteristics of Medicaid

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beneficiaries, practice and provider-to-beneficiary standards,

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appointment wait times, beneficiary use of services, provider

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turnover, provider profiling, provider licensure history,

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previous program integrity investigations and findings, peer

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review, provider Medicaid policy and billing compliance records,

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clinical and medical record audits, and other factors. Providers

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shall not be entitled to enrollment in the Medicaid provider

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network. The agency shall determine instances in which allowing

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Medicaid beneficiaries to purchase durable medical equipment and

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other goods is less expensive to the Medicaid program than long-

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term rental of the equipment or goods. The agency may establish

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rules to facilitate purchases in lieu of long-term rentals in

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order to protect against fraud and abuse in the Medicaid program

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as defined in s. 409.913. The agency may seek federal waivers

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necessary to administer these policies.

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     (48)(a) A provider is not entitled to enrollment in the

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Medicaid provider network. The agency may implement a Medicaid

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fee-for-service provider network controls, including, but not

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limited to, competitive procurement and provider credentialing.

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If a credentialing process is used, the agency may limit its

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provider network based upon the following considerations:

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beneficiary access to care, provider availability, provider

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quality standards and quality assurance processes, cultural

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competency, demographic characteristics of beneficiaries,

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practice standards, service wait times, provider turnover,

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provider licensure and accreditation history, program integrity

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history, peer review, Medicaid policy and billing compliance

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records, clinical and medical record audit findings, and such

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other areas that are considered necessary by the agency to ensure

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the integrity of the program.

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     (b) The agency shall limit its network of durable medical

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equipment and medical supply providers. For dates of service

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after January 1, 2009, the agency shall limit payment for durable

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medical equipment and supplies to providers that meet all the

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requirements of this paragraph.

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     1. Providers must be accredited by a Centers for Medicare

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and Medicaid Services deemed accreditation organization for

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suppliers of durable medical equipment, prosthetics, orthotics,

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and supplies. The provider must maintain accreditation and is

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subject to unannounced reviews by the accrediting organization.

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     2. Providers must provide the services or supplies directly

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to the Medicaid recipient or caregiver at the provider location

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or recipient's residence or send the supplies directly to the

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recipient's residence with receipt of mailed delivery.

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Subcontracting or consignment of the service or supply to a third

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party is prohibited.

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     3. Notwithstanding subparagraph 2., a durable medical

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equipment provider may store nebulizers at a physician's office

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for the purpose of having the physician's staff issue the

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equipment if it meets all of the following conditions:

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     a. The physician must document the medical necessity and

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need to prevent further deterioration of the patient's

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respiratory status by the timely delivery of the nebulizer in the

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physician's office.

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     b. The durable medical equipment provider must have written

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documentation of the competency and training by a Florida-

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licensed registered respiratory therapist of any durable medical

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equipment staff who participate in the training of physician

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office staff for the use of nebulizers, including cleaning,

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warranty, and special needs of patients.

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     c. The physician's office must have documented the training

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and competency of any staff member who initiates the delivery of

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nebulizers to patients. The durable medical equipment provider

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must maintain copies of all physician office training.

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     d. The physician's office must maintain inventory records

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of stored nebulizers, including documentation of the durable

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medical equipment provider source.

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     e. A physician contracted with a Medicaid durable medical

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equipment provider may not have a financial relationship with

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that provider or receive any financial gain from the delivery of

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nebulizers to patients.

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     4. Providers must have a physical business location and a

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functional landline business phone. The location must be within

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the state or not more than 50 miles from the Florida state line.

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The agency may make exceptions for providers of durable medical

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equipment or supplies not otherwise available from other enrolled

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providers located within the state.

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     5. Physical business locations must be clearly identified

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as a business that furnishes durable medical equipment or medical

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supplies by signage that can be read from 20 feet away. The

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location must be readily accessible to the public during normal,

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posted business hours and must operate no less than 5 hours per

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day and no less than 5 days per week, with the exception of

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scheduled and posted holidays. The location may not be located

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within or at the same numbered street address as another enrolled

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Medicaid durable medical equipment or medical supply provider or

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as an enrolled Medicaid pharmacy that is also enrolled as a

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durable medical equipment provider. A licensed orthotist or

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prosthetist that provides only orthotic or prosthetic devices as

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a Medicaid durable medical equipment provider is exempt from the

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provisions in this paragraph.

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     6. Providers must maintain a stock of durable medical

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equipment and medical supplies on site that is readily available

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to meet the needs of the durable medical equipment business

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location's customers.

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     7. Providers must provide a surety bond of $50,000 for each

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provider location, up to a maximum of 5 bonds statewide or an

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aggregate bond of $250,000 statewide, as identified by Federal

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Employer Identification Number. Providers who post a statewide or

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an aggregate bond must identify all of their locations in any

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Medicaid durable medical equipment and medical supply provider

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enrollment application or bond renewal. Each provider location's

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surety bond must be renewed annually and the provider must submit

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proof of renewal even if the original bond is a continuous bond.

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A licensed orthotist or prosthetist that provides only orthotic

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or prosthetic devices as a Medicaid durable medical equipment

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provider is exempt from the provisions in this paragraph.

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     8. Providers must obtain a level 2 background screening, as

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provided under s. 435.04, for each provider employee in direct

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contact with or providing direct services to recipients of

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durable medical equipment and medical supplies in their homes.

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This requirement includes, but is not limited to, repair and

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service technicians, fitters, and delivery staff. The provider

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shall pay for the cost of the background screening.

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     9. The following providers are exempt from the requirements

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of subparagraphs 1. and 6.:

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     a. Durable medical equipment providers owned and operated

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by a government entity.

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     b. Durable medical equipment providers that are operating

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within a pharmacy that is currently enrolled as a Medicaid

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pharmacy provider.

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     c. Active, Medicaid-enrolled orthopedic physician groups,

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primarily owned by physicians, which provide only orthotic and

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prosthetic devices.

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     Section 16. The Agency for Health Care Administration shall

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review the process, procedures, and contractor's performance for

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the prior authorization of home health agency visits that are in

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excess of 60 visits over the lifetime of a Medicaid recipient.

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The agency shall determine whether modifications are necessary in

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order to reduce Medicaid fraud and abuse related to home health

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services for a Medicaid recipient which are not medically

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necessary. If modifications to the prior authorization function

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are necessary, the agency shall amend the contract to require

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contractor performance that reduces potential Medicaid fraud and

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abuse with respect to home health agency visits.

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     Section 17. The Agency for Health Care Administration shall

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report to the Legislature by January 1, 2009, on the feasibility

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and costs of accessing the Medicare system to disallow Medicaid

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payment for home health services that are paid for under the

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Medicare prospective payment system for recipients who are dually

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eligible for Medicaid and Medicare.

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================ T I T L E  A M E N D M E N T ================

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And the title is amended as follows:

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     Delete line(s) 89-106

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and insert:

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exchange for patient referrals; amending s, 409.901, F.S.;

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defining the term "change of ownership"; amending s.

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409.907, F.S.; revising provisions relating to change of

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ownership of Medicaid provider agreements; providing for

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continuing financial liability of a transferor under

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certain circumstances; defining the term "outstanding

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overpayment"; requiring the transferor to provide notice

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of change of ownership to the agency within a specified

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time period; requiring the transferee to submit a Medicaid

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provider enrollment application to the agency; providing

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for joint and several liability under certain

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circumstances; requiring a written payment plan for

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certain outstanding financial obligations; providing

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conditions under which additional enrollment effective

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dates apply; amending s. 409.910, F.S.; conforming a

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cross-reference; amending s. 409.912, F.S.; requiring the

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agency to limit its network of Medicaid durable medical

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equipment and medical supply providers; prohibiting

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reimbursement for dates of service after a certain date;

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requiring accreditation; requiring direct provision of

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services or supplies; authorizing a provider to store

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nebulizers at a physician's office under certain

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circumstances; imposing certain physical location

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requirements; requiring a provider to maintain a certain

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stock of equipment and supplies; requiring a surety bond;

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requiring background screenings of employees; providing

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for certain exemptions; requiring the Agency for Health

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Care Administration to review the process for prior

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authorization of home health agency visits and determine

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whether modifications to the process are necessary;

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requiring the agency to report to the Legislature on the

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feasibility of accessing the Medicare system to determine

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recipient eligibility for home health services;

4/22/2008  9:24:00 AM     13-08208-08