Florida Senate - 2008 PROPOSED COMMITTEE SUBSTITUTE
Bill No. SB 1854
800184
603-05957C-08
Proposed Committee Substitute by the Committee on Health and Human
Services Appropriations
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A bill to be entitled
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An act relating to the Medicaid program; amending s.
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409.904, F.S.; discontinuing optional Medicaid payments
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for certain persons age 65 or over or who are blind or
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disabled; revising certain eligibility criteria for
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pregnant women and children younger than 21; amending s.
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409.906, F.S.; discontinuing adult dental services and
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adult hearing services on a certain date; amending s.
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409.908, F.S.; requiring Medicaid to pay for all
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deductibles and coinsurance for portable X-ray Medicare
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Part B services provided in a nursing home; revising the
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factors used to determine the reimbursement rate to
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providers for Medicaid prescribed drugs; requiring the
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agency to reduce certain provider reimbursement rates as
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prescribed in the appropriations act; providing that any
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increases in rates as subject to the appropriations act;
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amending s. 409.911, F.S.; revising which year's
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disproportionate data is used to determine a hospital's
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Medicaid days and charity care during the 2008-2009 fiscal
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year; amending s. 409.9112, F.S.; prohibiting the Agency
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for Health Care Administration from distributing moneys
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under the regional perinatal intensive care
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disproportionate share program during the 2008-2009 fiscal
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year; amending s. 409.9113, F.S.; authorizing the agency
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to distribute disproportionate share funds to teaching
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hospital during the 2008-2009 fiscal year; providing that
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such funds may be distributed as provided in the
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appropriations act; amending s. 409.9117, F.S.;
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prohibiting the distribution of funds under the primary
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disproportionate share program during the 2008-2009 fiscal
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year; amending s. 409.912, F.S.; revising the factors used
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to determine the reimbursement rate to pharmacies for
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Medicaid prescribed drugs; revising the requirement for
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the agency to develop a utilization management program for
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Medicaid recipients for certain therapies; amending s.
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409.9122, F.S.; revising enrollment requirements relating
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to Medicaid managed care programs and the agency's
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authority to assign persons to MediPass or a managed care
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plan; repealing s. 409.905(5)(c), F.S., relating to the
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agency's authority to adjust a hospital's inpatient per
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diem rate; repealing s. 430.83, F.S., relating to the
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Sunshine for Seniors Program; providing an effective date.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Subsections (1) and (2) of section 409.904,
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Florida Statutes, are amended to read:
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409.904 Optional payments for eligible persons.--The agency
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may make payments for medical assistance and related services on
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behalf of the following persons who are determined to be eligible
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subject to the income, assets, and categorical eligibility tests
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set forth in federal and state law. Payment on behalf of these
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Medicaid eligible persons is subject to the availability of
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moneys and any limitations established by the General
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Appropriations Act or chapter 216.
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(1)(a) From July 1, 2005, through December 31, 2005, a
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person who is age 65 or older or is determined to be disabled,
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whose income is at or below 88 percent of federal poverty level,
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and whose assets do not exceed established limitations.
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(b) Effective January 1, 2006, and subject to federal
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waiver approval, a person who is age 65 or older or is determined
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to be disabled, whose income is at or below 88 percent of the
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federal poverty level, whose assets do not exceed established
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limitations, and who is not eligible for Medicare or, if eligible
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for Medicare, is also eligible for and receiving Medicaid-covered
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institutional care services, hospice services, or home and
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community-based services. The agency shall seek federal
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authorization through a waiver to provide this coverage. This
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subsection expires October 31, 2008.
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(2)(a) A family, a pregnant woman, a child under age 21, a
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person age 65 or over, or a blind or disabled person, who would
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be eligible under any group listed in s. 409.903(1), (2), or (3),
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except that the income or assets of such family or person exceed
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established limitations. For a family or person in one of these
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coverage groups, medical expenses are deductible from income in
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accordance with federal requirements in order to make a
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determination of eligibility. A family or person eligible under
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the coverage known as the "medically needy," is eligible to
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receive the same services as other Medicaid recipients, with the
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exception of services in skilled nursing facilities and
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intermediate care facilities for the developmentally disabled.
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This paragraph expires October 31, 2008.
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(b) Effective November 1, 2008, a pregnant woman or a child
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younger than 21 years of age who would be eligible under any
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group listed in s. 409.903, except that the income or assets of
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such group exceed established limitations. For a person in one of
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these coverage groups, medical expenses are deductible from
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income in accordance with federal requirements in order to made a
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determination of eligibility. A person eligible under the
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coverage known as the "medically needy" is eligible to receive
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the same services as other Medicaid recipients, with the
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exception of services in skilled nursing facilities and
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intermediate care facilities for the developmentally disabled.
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Section 2. Subsections (1) and (12) of section 409.906,
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Florida Statutes, are amended to read:
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409.906 Optional Medicaid services.--Subject to specific
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appropriations, the agency may make payments for services which
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are optional to the state under Title XIX of the Social Security
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Act and are furnished by Medicaid providers to recipients who are
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determined to be eligible on the dates on which the services were
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provided. Any optional service that is provided shall be provided
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only when medically necessary and in accordance with state and
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federal law. Optional services rendered by providers in mobile
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units to Medicaid recipients may be restricted or prohibited by
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the agency. Nothing in this section shall be construed to prevent
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or limit the agency from adjusting fees, reimbursement rates,
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lengths of stay, number of visits, or number of services, or
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making any other adjustments necessary to comply with the
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availability of moneys and any limitations or directions provided
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for in the General Appropriations Act or chapter 216. If
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necessary to safeguard the state's systems of providing services
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to elderly and disabled persons and subject to the notice and
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review provisions of s. 216.177, the Governor may direct the
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Agency for Health Care Administration to amend the Medicaid state
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plan to delete the optional Medicaid service known as
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"Intermediate Care Facilities for the Developmentally Disabled."
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Optional services may include:
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(1) ADULT DENTAL SERVICES.--
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(a) The agency may pay for medically necessary, emergency
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dental procedures to alleviate pain or infection. Emergency
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dental care shall be limited to emergency oral examinations,
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necessary radiographs, extractions, and incision and drainage of
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abscess, for a recipient who is 21 years of age or older.
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(b) Beginning July 1, 2006, the agency may pay for full or
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partial dentures, the procedures required to seat full or partial
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dentures, and the repair and reline of full or partial dentures,
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provided by or under the direction of a licensed dentist, for a
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recipient who is 21 years of age or older.
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(c) However, Medicaid may will not provide reimbursement
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for dental services provided in a mobile dental unit, except for
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a mobile dental unit:
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1. Owned by, operated by, or having a contractual agreement
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with the Department of Health and complying with Medicaid's
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county health department clinic services program specifications
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as a county health department clinic services provider.
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2. Owned by, operated by, or having a contractual
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arrangement with a federally qualified health center and
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complying with Medicaid's federally qualified health center
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specifications as a federally qualified health center provider.
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3. Rendering dental services to Medicaid recipients, 21
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years of age and older, at nursing facilities.
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4. Owned by, operated by, or having a contractual agreement
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with a state-approved dental educational institution.
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(d) This subsection expires September 30, 2008.
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(12) HEARING SERVICES.--The agency may pay for hearing and
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related services, including hearing evaluations, hearing aid
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devices, dispensing of the hearing aid, and related repairs, if
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provided to a recipient by a licensed hearing aid specialist,
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otolaryngologist, otologist, audiologist, or physician. Effective
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October 1, 2008, the agency may not pay for hearing services for
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adults.
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Section 3. Paragraph (d) of subsection (13) and subsection
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(14) of section 409.908, Florida Statutes, are amended, and
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subsection (23) is added to that section, to read:
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409.908 Reimbursement of Medicaid providers.--Subject to
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specific appropriations, the agency shall reimburse Medicaid
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providers, in accordance with state and federal law, according to
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methodologies set forth in the rules of the agency and in policy
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manuals and handbooks incorporated by reference therein. These
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methodologies may include fee schedules, reimbursement methods
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based on cost reporting, negotiated fees, competitive bidding
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pursuant to s. 287.057, and other mechanisms the agency considers
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efficient and effective for purchasing services or goods on
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behalf of recipients. If a provider is reimbursed based on cost
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reporting and submits a cost report late and that cost report
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would have been used to set a lower reimbursement rate for a rate
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semester, then the provider's rate for that semester shall be
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retroactively calculated using the new cost report, and full
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payment at the recalculated rate shall be effected retroactively.
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Medicare-granted extensions for filing cost reports, if
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applicable, shall also apply to Medicaid cost reports. Payment
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for Medicaid compensable services made on behalf of Medicaid
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eligible persons is subject to the availability of moneys and any
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limitations or directions provided for in the General
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Appropriations Act or chapter 216. Further, nothing in this
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section shall be construed to prevent or limit the agency from
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adjusting fees, reimbursement rates, lengths of stay, number of
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visits, or number of services, or making any other adjustments
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necessary to comply with the availability of moneys and any
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limitations or directions provided for in the General
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Appropriations Act, provided the adjustment is consistent with
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legislative intent.
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(13) Medicare premiums for persons eligible for both
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Medicare and Medicaid coverage shall be paid at the rates
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established by Title XVIII of the Social Security Act. For
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Medicare services rendered to Medicaid-eligible persons, Medicaid
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shall pay Medicare deductibles and coinsurance as follows:
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(d) Notwithstanding paragraphs (a)-(c):
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1. Medicaid payments for Nursing Home Medicare part A
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coinsurance are shall be limited to the Medicaid nursing home per
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diem rate less any amounts paid by Medicare, but only up to the
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amount of Medicare coinsurance. The Medicaid per diem rate shall
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be the rate in effect for the dates of service of the crossover
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claims and may not be subsequently adjusted due to subsequent per
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diem rate adjustments.
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2. Medicaid shall pay all deductibles and coinsurance for
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Medicare-eligible recipients receiving freestanding end stage
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renal dialysis center services.
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3. Medicaid payments for general hospital inpatient
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services are shall be limited to the Medicare deductible per
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spell of illness. Medicaid may not pay for shall make no payment
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toward coinsurance for Medicare general hospital inpatient
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services.
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4. Medicaid shall pay all deductibles and coinsurance for
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Medicare emergency transportation services provided by ambulances
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licensed pursuant to chapter 401.
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5. Medicaid shall pay all deductibles and coinsurance for
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portable X-ray Medicare Part B services provided in a nursing
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home.
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(14) A provider of prescribed drugs shall be reimbursed the
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least of the amount billed by the provider, the provider's usual
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and customary charge, or the Medicaid maximum allowable fee
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established by the agency, plus a dispensing fee. The Medicaid
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maximum allowable fee for ingredient cost is will be based on the
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lower of: average wholesale price (AWP) minus 16.4 15.4 percent,
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wholesaler acquisition cost (WAC) plus 4.75 5.75 percent, the
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federal upper limit (FUL), the state maximum allowable cost
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(SMAC), or the usual and customary (UAC) charge billed by the
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provider. Medicaid providers are required to dispense generic
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drugs if available at lower cost and the agency has not
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determined that the branded product is more cost-effective,
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unless the prescriber has requested and received approval to
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require the branded product. The agency is directed to implement
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a variable dispensing fee for payments for prescribed medicines
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while ensuring continued access for Medicaid recipients. The
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variable dispensing fee may be based upon, but not limited to,
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either or both the volume of prescriptions dispensed by a
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specific pharmacy provider, the volume of prescriptions dispensed
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to an individual recipient, and dispensing of preferred-drug-list
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products. The agency may increase the pharmacy dispensing fee
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authorized by statute and in the annual General Appropriations
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Act by $0.50 for the dispensing of a Medicaid preferred-drug-list
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product and reduce the pharmacy dispensing fee by $0.50 for the
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dispensing of a Medicaid product that is not included on the
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preferred drug list. The agency may establish a supplemental
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pharmaceutical dispensing fee to be paid to providers returning
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unused unit-dose packaged medications to stock and crediting the
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Medicaid program for the ingredient cost of those medications if
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the ingredient costs to be credited exceed the value of the
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supplemental dispensing fee. The agency is authorized to limit
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reimbursement for prescribed medicine in order to comply with any
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limitations or directions provided for in the General
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Appropriations Act, which may include implementing a prospective
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or concurrent utilization review program.
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(23)(a) Effective July 1, 2008, the agency shall reduce
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provider reimbursement rates on a recurring basis as prescribed
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in the general appropriations act for the following provider
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types:
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1. Inpatient hospitals.
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2. Outpatient hospitals.
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3. Nursing homes.
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4. County health departments.
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5. Community intermediate care facilities for the
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developmentally disabled.
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6. Prepaid health plans.
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(b) Any increase in reimbursement is subject to a specific
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appropriation by the Legislature.
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Section 4. Paragraph (a) of subsection (2) of section
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409.911, Florida Statutes, is amended to read:
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409.911 Disproportionate share program.--Subject to
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specific allocations established within the General
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Appropriations Act and any limitations established pursuant to
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chapter 216, the agency shall distribute, pursuant to this
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section, moneys to hospitals providing a disproportionate share
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of Medicaid or charity care services by making quarterly Medicaid
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payments as required. Notwithstanding the provisions of s.
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409.915, counties are exempt from contributing toward the cost of
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this special reimbursement for hospitals serving a
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disproportionate share of low-income patients.
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(2) The Agency for Health Care Administration shall use the
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following actual audited data to determine the Medicaid days and
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charity care to be used in calculating the disproportionate share
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payment:
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(a) The average of the 2000, 2001, and 2002, 2003, and 2004
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audited disproportionate share data to determine each hospital's
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Medicaid days and charity care for the 2008-2009 2006-2007 state
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fiscal year.
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Section 5. Section 409.9112, Florida Statutes, is amended
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to read:
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409.9112 Disproportionate share program for regional
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perinatal intensive care centers.--In addition to the payments
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made under s. 409.911, the agency for Health Care Administration
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shall design and implement a system of making disproportionate
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share payments to those hospitals that participate in the
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regional perinatal intensive care center program established
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pursuant to chapter 383. This system of payments shall conform to
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with federal requirements and shall distribute funds in each
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fiscal year for which an appropriation is made by making
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quarterly Medicaid payments. Notwithstanding the provisions of s.
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409.915, counties are exempt from contributing toward the cost of
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this special reimbursement for hospitals serving a
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disproportionate share of low-income patients. For the 2008-2009
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state fiscal year 2005-2006, the agency may shall not distribute
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moneys under the regional perinatal intensive care centers
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disproportionate share program.
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(1) The following formula shall be used by the agency to
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calculate the total amount earned for hospitals that participate
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in the regional perinatal intensive care center program:
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TAE = HDSP/THDSP
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Where:
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TAE = total amount earned by a regional perinatal intensive
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care center.
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HDSP = the prior state fiscal year regional perinatal
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intensive care center disproportionate share payment to the
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individual hospital.
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THDSP = the prior state fiscal year total regional perinatal
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intensive care center disproportionate share payments to all
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hospitals.
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(2) The total additional payment for hospitals that
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participate in the regional perinatal intensive care center
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program shall be calculated by the agency as follows:
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TAP = TAE x TA
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Where:
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TAP = total additional payment for a regional perinatal
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intensive care center.
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TAE = total amount earned by a regional perinatal intensive
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care center.
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TA = total appropriation for the regional perinatal
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intensive care center disproportionate share program.
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(3) In order to receive payments under this section, a
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hospital must be participating in the regional perinatal
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intensive care center program pursuant to chapter 383 and must
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meet the following additional requirements:
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(a) Agree to conform to all departmental and agency
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requirements to ensure high quality in the provision of services,
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including criteria adopted by departmental and agency rule
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concerning staffing ratios, medical records, standards of care,
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equipment, space, and such other standards and criteria as the
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department and agency deem appropriate as specified by rule.
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(b) Agree to provide information to the department and
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agency, in a form and manner to be prescribed by rule of the
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department and agency, concerning the care provided to all
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patients in neonatal intensive care centers and high-risk
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maternity care.
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(c) Agree to accept all patients for neonatal intensive
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care and high-risk maternity care, regardless of ability to pay,
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on a functional space-available basis.
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(d) Agree to develop arrangements with other maternity and
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neonatal care providers in the hospital's region for the
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appropriate receipt and transfer of patients in need of
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specialized maternity and neonatal intensive care services.
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(e) Agree to establish and provide a developmental
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evaluation and services program for certain high-risk neonates,
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as prescribed and defined by rule of the department.
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(f) Agree to sponsor a program of continuing education in
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perinatal care for health care professionals within the region of
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the hospital, as specified by rule.
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(g) Agree to provide backup and referral services to the
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department's county health departments and other low-income
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perinatal providers within the hospital's region, including the
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development of written agreements between these organizations and
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the hospital.
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(h) Agree to arrange for transportation for high-risk
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obstetrical patients and neonates in need of transfer from the
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community to the hospital or from the hospital to another more
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appropriate facility.
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(4) Hospitals which fail to comply with any of the
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conditions in subsection (3) or the applicable rules of the
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department and agency may shall not receive any payments under
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this section until full compliance is achieved. A hospital which
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is not in compliance in two or more consecutive quarters may
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shall not receive its share of the funds. Any forfeited funds
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shall be distributed by the remaining participating regional
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perinatal intensive care center program hospitals.
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Section 6. Section 409.9113, Florida Statutes, is amended
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to read:
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409.9113 Disproportionate share program for teaching
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hospitals.--In addition to the payments made under ss. 409.911
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and 409.9112, the agency for Health Care Administration shall
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make disproportionate share payments to statutorily defined
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teaching hospitals for their increased costs associated with
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medical education programs and for tertiary health care services
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provided to the indigent. This system of payments shall conform
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to with federal requirements and shall distribute funds in each
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fiscal year for which an appropriation is made by making
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quarterly Medicaid payments. Notwithstanding s. 409.915, counties
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are exempt from contributing toward the cost of this special
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reimbursement for hospitals serving a disproportionate share of
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low-income patients. For the 2008-2009 state fiscal year 2006-
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2007, the agency shall distribute the moneys provided in the
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General Appropriations Act to statutorily defined teaching
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hospitals and family practice teaching hospitals under the
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teaching hospital disproportionate share program. The funds
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provided for statutorily defined teaching hospitals shall be
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distributed in the same proportion as the state fiscal year 2003-
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2004 teaching hospital disproportionate share funds were
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distributed or as otherwise provided in the General
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Appropriations Act. The funds provided for family practice
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teaching hospitals shall be distributed equally among family
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practice teaching hospitals.
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(1) On or before September 15 of each year, the agency for
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Health Care Administration shall calculate an allocation fraction
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to be used for distributing funds to state statutory teaching
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hospitals. Subsequent to the end of each quarter of the state
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fiscal year, the agency shall distribute to each statutory
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teaching hospital, as defined in s. 408.07, an amount determined
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by multiplying one-fourth of the funds appropriated for this
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purpose by the Legislature times such hospital's allocation
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fraction. The allocation fraction for each such hospital shall be
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determined by the sum of three primary factors, divided by three.
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The primary factors are:
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(a) The number of nationally accredited graduate medical
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education programs offered by the hospital, including programs
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accredited by the Accreditation Council for Graduate Medical
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Education and the combined Internal Medicine and Pediatrics
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programs acceptable to both the American Board of Internal
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Medicine and the American Board of Pediatrics at the beginning of
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the state fiscal year preceding the date on which the allocation
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fraction is calculated. The numerical value of this factor is the
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fraction that the hospital represents of the total number of
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programs, where the total is computed for all state statutory
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teaching hospitals.
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(b) The number of full-time equivalent trainees in the
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hospital, which comprises two components:
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1. The number of trainees enrolled in nationally accredited
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graduate medical education programs, as defined in paragraph (a).
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Full-time equivalents are computed using the fraction of the year
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during which each trainee is primarily assigned to the given
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institution, over the state fiscal year preceding the date on
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which the allocation fraction is calculated. The numerical value
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of this factor is the fraction that the hospital represents of
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the total number of full-time equivalent trainees enrolled in
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accredited graduate programs, where the total is computed for all
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state statutory teaching hospitals.
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2. The number of medical students enrolled in accredited
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colleges of medicine and engaged in clinical activities,
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including required clinical clerkships and clinical electives.
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Full-time equivalents are computed using the fraction of the year
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during which each trainee is primarily assigned to the given
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institution, over the course of the state fiscal year preceding
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the date on which the allocation fraction is calculated. The
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numerical value of this factor is the fraction that the given
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hospital represents of the total number of full-time equivalent
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students enrolled in accredited colleges of medicine, where the
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total is computed for all state statutory teaching hospitals.
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The primary factor for full-time equivalent trainees is computed
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as the sum of these two components, divided by two.
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(c) A service index that comprises three components:
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1. The Agency for Health Care Administration Service Index,
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computed by applying the standard Service Inventory Scores
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established by the agency for Health Care Administration to
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services offered by the given hospital, as reported on Worksheet
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A-2 for the last fiscal year reported to the agency before the
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date on which the allocation fraction is calculated. The
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numerical value of this factor is the fraction that the given
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hospital represents of the total Agency for Health Care
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Administration Service Index values, where the total is computed
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for all state statutory teaching hospitals.
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2. A volume-weighted service index, computed by applying
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the standard Service Inventory Scores established by the agency
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for Health Care Administration to the volume of each service,
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expressed in terms of the standard units of measure reported on
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Worksheet A-2 for the last fiscal year reported to the agency
459
before the date on which the allocation factor is calculated. The
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numerical value of this factor is the fraction that the given
461
hospital represents of the total volume-weighted service index
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values, where the total is computed for all state statutory
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teaching hospitals.
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3. Total Medicaid payments to each hospital for direct
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inpatient and outpatient services during the fiscal year
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preceding the date on which the allocation factor is calculated.
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This includes payments made to each hospital for such services by
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Medicaid prepaid health plans, whether the plan was administered
469
by the hospital or not. The numerical value of this factor is the
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fraction that each hospital represents of the total of such
471
Medicaid payments, where the total is computed for all state
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statutory teaching hospitals.
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The primary factor for the service index is computed as the sum
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of these three components, divided by three.
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(2) By October 1 of each year, the agency shall use the
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following formula to calculate the maximum additional
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disproportionate share payment for statutorily defined teaching
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hospitals:
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TAP = THAF x A
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Where:
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TAP = total additional payment.
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THAF = teaching hospital allocation factor.
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A = amount appropriated for a teaching hospital
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disproportionate share program.
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Section 7. Section 409.9117, Florida Statutes, is amended
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to read:
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409.9117 Primary care disproportionate share program.--For
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the 2008-2009 state fiscal year 2006-2007, the agency may shall
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not distribute moneys under the primary care disproportionate
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share program.
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(1) If federal funds are available for disproportionate
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share programs in addition to those otherwise provided by law,
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there shall be created a primary care disproportionate share
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program.
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(2) The following formula shall be used by the agency to
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calculate the total amount earned for hospitals that participate
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in the primary care disproportionate share program:
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TAE = HDSP/THDSP
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Where:
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TAE = total amount earned by a hospital participating in the
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primary care disproportionate share program.
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HDSP = the prior state fiscal year primary care
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disproportionate share payment to the individual hospital.
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THDSP = the prior state fiscal year total primary care
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disproportionate share payments to all hospitals.
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(3) The total additional payment for hospitals that
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participate in the primary care disproportionate share program
513
shall be calculated by the agency as follows:
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TAP = TAE x TA
516
517
Where:
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TAP = total additional payment for a primary care hospital.
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TAE = total amount earned by a primary care hospital.
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TA = total appropriation for the primary care
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disproportionate share program.
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(4) In establishing the establishment and funding of this
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program, the agency shall use the following criteria in addition
524
to those specified in s. 409.911, and payments may not be made to
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a hospital unless the hospital agrees to:
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(a) Cooperate with a Medicaid prepaid health plan, if one
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exists in the community.
528
(b) Ensure the availability of primary and specialty care
529
physicians to Medicaid recipients who are not enrolled in a
530
prepaid capitated arrangement and who are in need of access to
531
such physicians.
532
(c) Coordinate and provide primary care services free of
533
charge, except copayments, to all persons with incomes up to 100
534
percent of the federal poverty level who are not otherwise
535
covered by Medicaid or another program administered by a
536
governmental entity, and to provide such services based on a
537
sliding fee scale to all persons with incomes up to 200 percent
538
of the federal poverty level who are not otherwise covered by
539
Medicaid or another program administered by a governmental
540
entity, except that eligibility may be limited to persons who
541
reside within a more limited area, as agreed to by the agency and
542
the hospital.
543
(d) Contract with any federally qualified health center, if
544
one exists within the agreed geopolitical boundaries, concerning
545
the provision of primary care services, in order to guarantee
546
delivery of services in a nonduplicative fashion, and to provide
547
for referral arrangements, privileges, and admissions, as
548
appropriate. The hospital shall agree to provide at an onsite or
549
offsite facility primary care services within 24 hours to which
550
all Medicaid recipients and persons eligible under this paragraph
551
who do not require emergency room services are referred during
552
normal daylight hours.
553
(e) Cooperate with the agency, the county, and other
554
entities to ensure the provision of certain public health
555
services, case management, referral and acceptance of patients,
556
and sharing of epidemiological data, as the agency and the
557
hospital find mutually necessary and desirable to promote and
558
protect the public health within the agreed geopolitical
559
boundaries.
560
(f) In cooperation with the county in which the hospital
561
resides, develop a low-cost, outpatient, prepaid health care
562
program to persons who are not eligible for the Medicaid program,
563
and who reside within the area.
564
(g) Provide inpatient services to residents within the area
565
who are not eligible for Medicaid or Medicare, and who do not
566
have private health insurance, regardless of ability to pay, on
567
the basis of available space, except that nothing shall prevent
568
the hospital from establishing bill collection programs based on
569
ability to pay.
570
(h) Work with the Florida Healthy Kids Corporation, the
571
Florida Health Care Purchasing Cooperative, and business health
572
coalitions, as appropriate, to develop a feasibility study and
573
plan to provide a low-cost comprehensive health insurance plan to
574
persons who reside within the area and who do not have access to
575
such a plan.
576
(i) Work with public health officials and other experts to
577
provide community health education and prevention activities
578
designed to promote healthy lifestyles and appropriate use of
579
health services.
580
(j) Work with the local health council to develop a plan
581
for promoting access to affordable health care services for all
582
persons who reside within the area, including, but not limited
583
to, public health services, primary care services, inpatient
584
services, and affordable health insurance generally.
585
586
Any hospital that fails to comply with any of the provisions of
587
this subsection, or any other contractual condition, may not
588
receive payments under this section until full compliance is
589
achieved.
590
Section 8. Paragraph (a) of subsection (39) and subsection
591
(42) of section 409.912, Florida Statutes, are amended to read:
592
409.912 Cost-effective purchasing of health care.--The
593
agency shall purchase goods and services for Medicaid recipients
594
in the most cost-effective manner consistent with the delivery of
595
quality medical care. To ensure that medical services are
596
effectively utilized, the agency may, in any case, require a
597
confirmation or second physician's opinion of the correct
598
diagnosis for purposes of authorizing future services under the
599
Medicaid program. This section does not restrict access to
600
emergency services or poststabilization care services as defined
601
in 42 C.F.R. part 438.114. Such confirmation or second opinion
602
shall be rendered in a manner approved by the agency. The agency
603
shall maximize the use of prepaid per capita and prepaid
604
aggregate fixed-sum basis services when appropriate and other
605
alternative service delivery and reimbursement methodologies,
606
including competitive bidding pursuant to s. 287.057, designed to
607
facilitate the cost-effective purchase of a case-managed
608
continuum of care. The agency shall also require providers to
609
minimize the exposure of recipients to the need for acute
610
inpatient, custodial, and other institutional care and the
611
inappropriate or unnecessary use of high-cost services. The
612
agency shall contract with a vendor to monitor and evaluate the
613
clinical practice patterns of providers in order to identify
614
trends that are outside the normal practice patterns of a
615
provider's professional peers or the national guidelines of a
616
provider's professional association. The vendor must be able to
617
provide information and counseling to a provider whose practice
618
patterns are outside the norms, in consultation with the agency,
619
to improve patient care and reduce inappropriate utilization. The
620
agency may mandate prior authorization, drug therapy management,
621
or disease management participation for certain populations of
622
Medicaid beneficiaries, certain drug classes, or particular drugs
623
to prevent fraud, abuse, overuse, and possible dangerous drug
624
interactions. The Pharmaceutical and Therapeutics Committee shall
625
make recommendations to the agency on drugs for which prior
626
authorization is required. The agency shall inform the
627
Pharmaceutical and Therapeutics Committee of its decisions
628
regarding drugs subject to prior authorization. The agency is
629
authorized to limit the entities it contracts with or enrolls as
630
Medicaid providers by developing a provider network through
631
provider credentialing. The agency may competitively bid single-
632
source-provider contracts if procurement of goods or services
633
results in demonstrated cost savings to the state without
634
limiting access to care. The agency may limit its network based
635
on the assessment of beneficiary access to care, provider
636
availability, provider quality standards, time and distance
637
standards for access to care, the cultural competence of the
638
provider network, demographic characteristics of Medicaid
639
beneficiaries, practice and provider-to-beneficiary standards,
640
appointment wait times, beneficiary use of services, provider
641
turnover, provider profiling, provider licensure history,
642
previous program integrity investigations and findings, peer
643
review, provider Medicaid policy and billing compliance records,
644
clinical and medical record audits, and other factors. Providers
645
shall not be entitled to enrollment in the Medicaid provider
646
network. The agency shall determine instances in which allowing
647
Medicaid beneficiaries to purchase durable medical equipment and
648
other goods is less expensive to the Medicaid program than long-
649
term rental of the equipment or goods. The agency may establish
650
rules to facilitate purchases in lieu of long-term rentals in
651
order to protect against fraud and abuse in the Medicaid program
652
as defined in s. 409.913. The agency may seek federal waivers
653
necessary to administer these policies.
654
(39)(a) The agency shall implement a Medicaid prescribed-
655
drug spending-control program that includes the following
656
components:
657
1. A Medicaid preferred drug list, which shall be a listing
658
of cost-effective therapeutic options recommended by the Medicaid
659
Pharmacy and Therapeutics Committee established pursuant to s.
660
409.91195 and adopted by the agency for each therapeutic class on
661
the preferred drug list. At the discretion of the committee, and
662
when feasible, the preferred drug list should include at least
663
two products in a therapeutic class. The agency may post the
664
preferred drug list and updates to the preferred drug list on an
665
Internet website without following the rulemaking procedures of
666
chapter 120. Antiretroviral agents are excluded from the
667
preferred drug list. The agency shall also limit the amount of a
668
prescribed drug dispensed to no more than a 34-day supply unless
669
the drug products' smallest marketed package is greater than a
670
34-day supply, or the drug is determined by the agency to be a
671
maintenance drug in which case a 100-day maximum supply may be
672
authorized. The agency is authorized to seek any federal waivers
673
necessary to implement these cost-control programs and to
674
continue participation in the federal Medicaid rebate program, or
675
alternatively to negotiate state-only manufacturer rebates. The
676
agency may adopt rules to implement this subparagraph. The agency
677
shall continue to provide unlimited contraceptive drugs and
678
items. The agency must establish procedures to ensure that:
679
a. There is will be a response to a request for prior
680
consultation by telephone or other telecommunication device
681
within 24 hours after receipt of a request for prior
682
consultation; and
683
b. A 72-hour supply of the drug prescribed is will be
684
provided in an emergency or when the agency does not provide a
685
response within 24 hours as required by sub-subparagraph a.
686
2. Reimbursement to pharmacies for Medicaid prescribed
687
drugs shall be set at the lesser of: the average wholesale price
688
(AWP) minus 16.4 15.4 percent, the wholesaler acquisition cost
689
(WAC) plus 4.75 5.75 percent, the federal upper limit (FUL), the
690
state maximum allowable cost (SMAC), or the usual and customary
691
(UAC) charge billed by the provider.
692
3. The agency shall develop and implement a process for
693
managing the drug therapies of Medicaid recipients who are using
694
significant numbers of prescribed drugs each month. The
695
management process may include, but is not limited to,
696
comprehensive, physician-directed medical-record reviews, claims
697
analyses, and case evaluations to determine the medical necessity
698
and appropriateness of a patient's treatment plan and drug
699
therapies. The agency may contract with a private organization to
700
provide drug-program-management services. The Medicaid drug
701
benefit management program shall include initiatives to manage
702
drug therapies for HIV/AIDS patients, patients using 20 or more
703
unique prescriptions in a 180-day period, and the top 1,000
704
patients in annual spending. The agency shall enroll any Medicaid
705
recipient in the drug benefit management program if he or she
706
meets the specifications of this provision and is not enrolled in
707
a Medicaid health maintenance organization.
708
4. The agency may limit the size of its pharmacy network
709
based on need, competitive bidding, price negotiations,
710
credentialing, or similar criteria. The agency shall give special
711
consideration to rural areas in determining the size and location
712
of pharmacies included in the Medicaid pharmacy network. A
713
pharmacy credentialing process may include criteria such as a
714
pharmacy's full-service status, location, size, patient
715
educational programs, patient consultation, disease management
716
services, and other characteristics. The agency may impose a
717
moratorium on Medicaid pharmacy enrollment when it is determined
718
that it has a sufficient number of Medicaid-participating
719
providers. The agency must allow dispensing practitioners to
720
participate as a part of the Medicaid pharmacy network regardless
721
of the practitioner's proximity to any other entity that is
722
dispensing prescription drugs under the Medicaid program. A
723
dispensing practitioner must meet all credentialing requirements
724
applicable to his or her practice, as determined by the agency.
725
5. The agency shall develop and implement a program that
726
requires Medicaid practitioners who prescribe drugs to use a
727
counterfeit-proof prescription pad for Medicaid prescriptions.
728
The agency shall require the use of standardized counterfeit-
729
proof prescription pads by Medicaid-participating prescribers or
730
prescribers who write prescriptions for Medicaid recipients. The
731
agency may implement the program in targeted geographic areas or
732
statewide.
733
6. The agency may enter into arrangements that require
734
manufacturers of generic drugs prescribed to Medicaid recipients
735
to provide rebates of at least 15.1 percent of the average
736
manufacturer price for the manufacturer's generic products. These
737
arrangements shall require that if a generic-drug manufacturer
738
pays federal rebates for Medicaid-reimbursed drugs at a level
739
below 15.1 percent, the manufacturer must provide a supplemental
740
rebate to the state in an amount necessary to achieve a 15.1-
741
percent rebate level.
742
7. The agency may establish a preferred drug list as
743
described in this subsection, and, pursuant to the establishment
744
of such preferred drug list, it is authorized to negotiate
745
supplemental rebates from manufacturers that are in addition to
746
those required by Title XIX of the Social Security Act and at no
747
less than 14 percent of the average manufacturer price as defined
748
in 42 U.S.C. s. 1936 on the last day of a quarter unless the
749
federal or supplemental rebate, or both, equals or exceeds 29
750
percent. There is no upper limit on the supplemental rebates the
751
agency may negotiate. The agency may determine that specific
752
products, brand-name or generic, are competitive at lower rebate
753
percentages. Agreement to pay the minimum supplemental rebate
754
percentage will guarantee a manufacturer that the Medicaid
755
Pharmaceutical and Therapeutics Committee will consider a product
756
for inclusion on the preferred drug list. However, a
757
pharmaceutical manufacturer is not guaranteed placement on the
758
preferred drug list by simply paying the minimum supplemental
759
rebate. Agency decisions will be made on the clinical efficacy of
760
a drug and recommendations of the Medicaid Pharmaceutical and
761
Therapeutics Committee, as well as the price of competing
762
products minus federal and state rebates. The agency is
763
authorized to contract with an outside agency or contractor to
764
conduct negotiations for supplemental rebates. For the purposes
765
of this section, the term "supplemental rebates" means cash
766
rebates. Effective July 1, 2004, value-added programs as a
767
substitution for supplemental rebates are prohibited. The agency
768
is authorized to seek any federal waivers to implement this
769
initiative.
770
8. The Agency for Health Care Administration shall expand
771
home delivery of pharmacy products. To assist Medicaid patients
772
in securing their prescriptions and reduce program costs, the
773
agency shall expand its current mail-order-pharmacy diabetes-
774
supply program to include all generic and brand-name drugs used
775
by Medicaid patients with diabetes. Medicaid recipients in the
776
current program may obtain nondiabetes drugs on a voluntary
777
basis. This initiative is limited to the geographic area covered
778
by the current contract. The agency may seek and implement any
779
federal waivers necessary to implement this subparagraph.
780
9. The agency shall limit to one dose per month any drug
781
prescribed to treat erectile dysfunction.
782
10.a. The agency may implement a Medicaid behavioral drug
783
management system. The agency may contract with a vendor that has
784
experience in operating behavioral drug management systems to
785
implement this program. The agency is authorized to seek federal
786
waivers to implement this program.
787
b. The agency, in conjunction with the Department of
788
Children and Family Services, may implement the Medicaid
789
behavioral drug management system that is designed to improve the
790
quality of care and behavioral health prescribing practices based
791
on best practice guidelines, improve patient adherence to
792
medication plans, reduce clinical risk, and lower prescribed drug
793
costs and the rate of inappropriate spending on Medicaid
794
behavioral drugs. The program may include the following elements:
795
(I) Provide for the development and adoption of best
796
practice guidelines for behavioral health-related drugs such as
797
antipsychotics, antidepressants, and medications for treating
798
bipolar disorders and other behavioral conditions; translate them
799
into practice; review behavioral health prescribers and compare
800
their prescribing patterns to a number of indicators that are
801
based on national standards; and determine deviations from best
802
practice guidelines.
803
(II) Implement processes for providing feedback to and
804
educating prescribers using best practice educational materials
805
and peer-to-peer consultation.
806
(III) Assess Medicaid beneficiaries who are outliers in
807
their use of behavioral health drugs with regard to the numbers
808
and types of drugs taken, drug dosages, combination drug
809
therapies, and other indicators of improper use of behavioral
810
health drugs.
811
(IV) Alert prescribers to patients who fail to refill
812
prescriptions in a timely fashion, are prescribed multiple same-
813
class behavioral health drugs, and may have other potential
814
medication problems.
815
(V) Track spending trends for behavioral health drugs and
816
deviation from best practice guidelines.
817
(VI) Use educational and technological approaches to
818
promote best practices, educate consumers, and train prescribers
819
in the use of practice guidelines.
820
(VII) Disseminate electronic and published materials.
821
(VIII) Hold statewide and regional conferences.
822
(IX) Implement a disease management program with a model
823
quality-based medication component for severely mentally ill
824
individuals and emotionally disturbed children who are high users
825
of care.
826
11.a. The agency shall implement a Medicaid prescription
827
drug management system. The agency may contract with a vendor
828
that has experience in operating prescription drug management
829
systems in order to implement this system. Any management system
830
that is implemented in accordance with this subparagraph must
831
rely on cooperation between physicians and pharmacists to
832
determine appropriate practice patterns and clinical guidelines
833
to improve the prescribing, dispensing, and use of drugs in the
834
Medicaid program. The agency may seek federal waivers to
835
implement this program.
836
b. The drug management system must be designed to improve
837
the quality of care and prescribing practices based on best
838
practice guidelines, improve patient adherence to medication
839
plans, reduce clinical risk, and lower prescribed drug costs and
840
the rate of inappropriate spending on Medicaid prescription
841
drugs. The program must:
842
(I) Provide for the development and adoption of best
843
practice guidelines for the prescribing and use of drugs in the
844
Medicaid program, including translating best practice guidelines
845
into practice; reviewing prescriber patterns and comparing them
846
to indicators that are based on national standards and practice
847
patterns of clinical peers in their community, statewide, and
848
nationally; and determine deviations from best practice
849
guidelines.
850
(II) Implement processes for providing feedback to and
851
educating prescribers using best practice educational materials
852
and peer-to-peer consultation.
853
(III) Assess Medicaid recipients who are outliers in their
854
use of a single or multiple prescription drugs with regard to the
855
numbers and types of drugs taken, drug dosages, combination drug
856
therapies, and other indicators of improper use of prescription
857
drugs.
858
(IV) Alert prescribers to patients who fail to refill
859
prescriptions in a timely fashion, are prescribed multiple drugs
860
that may be redundant or contraindicated, or may have other
861
potential medication problems.
862
(V) Track spending trends for prescription drugs and
863
deviation from best practice guidelines.
864
(VI) Use educational and technological approaches to
865
promote best practices, educate consumers, and train prescribers
866
in the use of practice guidelines.
867
(VII) Disseminate electronic and published materials.
868
(VIII) Hold statewide and regional conferences.
869
(IX) Implement disease management programs in cooperation
870
with physicians and pharmacists, along with a model quality-based
871
medication component for individuals having chronic medical
872
conditions.
873
12. The agency is authorized to contract for drug rebate
874
administration, including, but not limited to, calculating rebate
875
amounts, invoicing manufacturers, negotiating disputes with
876
manufacturers, and maintaining a database of rebate collections.
877
13. The agency may specify the preferred daily dosing form
878
or strength for the purpose of promoting best practices with
879
regard to the prescribing of certain drugs as specified in the
880
General Appropriations Act and ensuring cost-effective
881
prescribing practices.
882
14. The agency may require prior authorization for
883
Medicaid-covered prescribed drugs. The agency may, but is not
884
required to, prior-authorize the use of a product:
885
a. For an indication not approved in labeling;
886
b. To comply with certain clinical guidelines; or
887
c. If the product has the potential for overuse, misuse, or
888
abuse.
889
890
The agency may require the prescribing professional to provide
891
information about the rationale and supporting medical evidence
892
for the use of a drug. The agency may post prior authorization
893
criteria and protocol and updates to the list of drugs that are
894
subject to prior authorization on an Internet website without
895
amending its rule or engaging in additional rulemaking.
896
15. The agency, in conjunction with the Pharmaceutical and
897
Therapeutics Committee, may require age-related prior
898
authorizations for certain prescribed drugs. The agency may
899
preauthorize the use of a drug for a recipient who may not meet
900
the age requirement or may exceed the length of therapy for use
901
of the this product as recommended by the manufacturer and
902
approved by the Food and Drug Administration. Prior authorization
903
may require the prescribing professional to provide information
904
about the rationale and supporting medical evidence for the use
905
of a drug.
906
16. The agency shall implement a step-therapy prior
907
authorization approval process for medications excluded from the
908
preferred drug list. Medications listed on the preferred drug
909
list must be used within the previous 12 months prior to the
910
alternative medications that are not listed. The step-therapy
911
prior authorization may require the prescriber to use the
912
medications of a similar drug class or for a similar medical
913
indication unless contraindicated in the Food and Drug
914
Administration labeling. The trial period between the specified
915
steps may vary according to the medical indication. The step-
916
therapy approval process shall be developed in accordance with
917
the committee as stated in s. 409.91195(7) and (8). A drug
918
product may be approved without meeting the step-therapy prior
919
authorization criteria if the prescribing physician provides the
920
agency with additional written medical or clinical documentation
921
that the product is medically necessary because:
922
a. There is not a drug on the preferred drug list to treat
923
the disease or medical condition which is an acceptable clinical
924
alternative;
925
b. The alternatives have been ineffective in the treatment
926
of the beneficiary's disease; or
927
c. Based on historic evidence and known characteristics of
928
the patient and the drug, the drug is likely to be ineffective,
929
or the number of doses have been ineffective.
930
931
The agency shall work with the physician to determine the best
932
alternative for the patient. The agency may adopt rules waiving
933
the requirements for written clinical documentation for specific
934
drugs in limited clinical situations.
935
17. The agency shall implement a return and reuse program
936
for drugs dispensed by pharmacies to institutional recipients,
937
which includes payment of a $5 restocking fee for the
938
implementation and operation of the program. The return and reuse
939
program shall be implemented electronically and in a manner that
940
promotes efficiency. The program must permit a pharmacy to
941
exclude drugs from the program if it is not practical or cost-
942
effective for the drug to be included and must provide for the
943
return to inventory of drugs that cannot be credited or returned
944
in a cost-effective manner. The agency shall determine if the
945
program has reduced the amount of Medicaid prescription drugs
946
which are destroyed on an annual basis and if there are
947
additional ways to ensure more prescription drugs are not
948
destroyed which could safely be reused. The agency's conclusion
949
and recommendations shall be reported to the Legislature by
950
December 1, 2005.
951
(42) The agency may shall develop and implement a
952
utilization management program for Medicaid-eligible recipients
953
for the management of occupational, physical, respiratory, and
954
speech therapies. The agency shall establish a utilization
955
program that may require prior authorization in order to ensure
956
medically necessary and cost-effective treatments. The program
957
shall be operated in accordance with a federally approved waiver
958
program or state plan amendment. The agency may seek a federal
959
waiver or state plan amendment to implement this program. The
960
agency may also competitively procure these services from an
961
outside vendor on a regional or statewide basis.
962
Section 9. Paragraphs (c), (e), (f), and (i) of subsection
963
(2) of section 409.9122, Florida Statutes, are amended to read:
964
409.9122 Mandatory Medicaid managed care enrollment;
965
programs and procedures.--
966
(2)
967
(c) Medicaid recipients shall have a choice of managed care
968
plans or MediPass. The agency for Health Care Administration, the
969
Department of Health, the Department of Children and Family
970
Services, and the Department of Elderly Affairs shall cooperate
971
to ensure that each Medicaid recipient receives clear and easily
972
understandable information that meets the following requirements:
973
1. Explains the concept of managed care, including
974
MediPass.
975
2. Provides information on the comparative performance of
976
managed care plans and MediPass in the areas of quality,
977
credentialing, preventive health programs, network size and
978
availability, and patient satisfaction.
979
3. Explains where additional information on each managed
980
care plan and MediPass in the recipient's area can be obtained.
981
4. Explains that recipients have the right to choose their
982
own managed care coverage at the time they first enroll in
983
Medicaid and again at regular intervals set by the agency plans
984
or MediPass. However, if a recipient does not choose a managed
985
care plan or MediPass, the agency will assign the recipient to a
986
managed care plan or MediPass according to the criteria specified
987
in this section.
988
5. Explains the recipient's right to complain, file a
989
grievance, or change managed care plans or MediPass providers if
990
the recipient is not satisfied with the managed care plan or
991
MediPass.
992
(e) Medicaid recipients who are already enrolled in a
993
managed care plan or MediPass shall be offered the opportunity to
994
change managed care plans or MediPass providers on a staggered
995
basis, as defined by the agency. All Medicaid recipients shall
996
have 30 days in which to make a choice of managed care plans or
997
MediPass providers. A recipient already enrolled in a managed
998
care plan who fails to make a choice during the 30-day choice
999
period shall remain enrolled in his or her current managed care
1000
plan. In counties with two or more managed care plans, a
1001
recipient already enrolled in MediPass who fails to make a choice
1002
during the annual period shall be assigned to a managed care plan
1003
if he or she is eligible for enrollment in the managed care plan.
1004
The agency shall apply for a state plan amendment or federal
1005
waiver authority, if necessary, to implement the provisions of
1006
this paragraph. Those Medicaid recipients who do not make a
1007
choice shall be assigned to a managed care plan or MediPass in
1008
accordance with paragraph (f). To facilitate continuity of care,
1009
for a Medicaid recipient who is also a recipient of Supplemental
1010
Security Income (SSI), prior to assigning the SSI recipient to a
1011
managed care plan or MediPass, the agency shall determine whether
1012
the SSI recipient has an ongoing relationship with a MediPass
1013
provider or managed care plan, and if so, the agency shall assign
1014
the SSI recipient to that MediPass provider or managed care plan.
1015
If the SSI recipient has an ongoing relationship with a managed
1016
care plan, the agency shall assign the recipient to that managed
1017
care plan. Those SSI recipients who do not have such a provider
1018
relationship shall be assigned to a managed care plan or MediPass
1019
provider in accordance with paragraph (f).
1020
(f) If When a Medicaid recipient does not choose a managed
1021
care plan or MediPass provider, the agency shall assign the
1022
Medicaid recipient to a managed care plan or MediPass provider.
1023
Medicaid recipients, eligible for managed care plan enrollment,
1024
who are subject to mandatory assignment but who fail to make a
1025
choice shall be assigned to managed care plans until an
1026
enrollment of 35 percent in MediPass and 65 percent in managed
1027
care plans, of all those eligible to choose managed care, is
1028
achieved. Once this enrollment is achieved, the assignments shall
1029
be divided in order to maintain an enrollment in MediPass and
1030
managed care plans which is in a 35 percent and 65 percent
1031
proportion, respectively. Thereafter, assignment of Medicaid
1032
recipients who fail to make a choice shall be based
1033
proportionally on the preferences of recipients who have made a
1034
choice in the previous period. Such proportions shall be revised
1035
at least quarterly to reflect an update of the preferences of
1036
Medicaid recipients. The agency shall disproportionately assign
1037
Medicaid-eligible recipients who are required to but have failed
1038
to make a choice of managed care plan or MediPass, including
1039
children, and who would are to be assigned to the MediPass
1040
program to children's networks as described in s. 409.912(4)(g),
1041
Children's Medical Services Network as defined in s. 391.021,
1042
exclusive provider organizations, provider service networks,
1043
minority physician networks, and pediatric emergency department
1044
diversion programs authorized by this chapter or the General
1045
Appropriations Act, in such manner as the agency deems
1046
appropriate, until the agency has determined that the networks
1047
and programs have sufficient numbers to be operated economically
1048
operated. For purposes of this paragraph, when referring to
1049
assignment, the term "managed care plans" includes health
1050
maintenance organizations, exclusive provider organizations,
1051
provider service networks, minority physician networks,
1052
Children's Medical Services Network, and pediatric emergency
1053
department diversion programs authorized by this chapter or the
1054
General Appropriations Act. When making assignments, the agency
1055
shall take into account the following criteria:
1056
1. A managed care plan has sufficient network capacity to
1057
meet the need of members.
1058
2. The managed care plan or MediPass has previously
1059
enrolled the recipient as a member, or one of the managed care
1060
plan's primary care providers or MediPass providers has
1061
previously provided health care to the recipient.
1062
3. The agency has knowledge that the member has previously
1063
expressed a preference for a particular managed care plan or
1064
MediPass provider as indicated by Medicaid fee-for-service claims
1065
data, but has failed to make a choice.
1066
4. The managed care plan's or MediPass primary care
1067
providers are geographically accessible to the recipient's
1068
residence.
1069
(i) After a recipient has made his or her initial a
1070
selection or has been notified of his or her initial assignment
1071
to enrolled in a managed care plan or MediPass, the recipient
1072
shall have 90 days to exercise the opportunity in which to
1073
voluntarily disenroll and select another managed care option plan
1074
or MediPass provider. After 90 days, no further changes may be
1075
made except for cause. Good cause includes shall include, but is
1076
not be limited to, poor quality of care, lack of access to
1077
necessary specialty services, an unreasonable delay or denial of
1078
service, or fraudulent enrollment. The agency shall develop
1079
criteria for good cause disenrollment for chronically ill and
1080
disabled populations who are assigned to managed care plans if
1081
more appropriate care is available through the MediPass program.
1082
The agency must make a determination as to whether cause exists.
1083
However, the agency may require a recipient to use the managed
1084
care plan's or MediPass grievance process prior to the agency's
1085
determination of cause, except in cases in which immediate risk
1086
of permanent damage to the recipient's health is alleged. The
1087
grievance process, when utilized, must be completed in time to
1088
permit the recipient to disenroll by no later than the first day
1089
of the second month after the month the disenrollment request was
1090
made. If the managed care plan or MediPass, as a result of the
1091
grievance process, approves an enrollee's request to disenroll,
1092
the agency is not required to make a determination in the case.
1093
The agency must make a determination and take final action on a
1094
recipient's request so that disenrollment occurs by no later than
1095
the first day of the second month after the month the request was
1096
made. If the agency fails to act within the specified timeframe,
1097
the recipient's request to disenroll is deemed to be approved as
1098
of the date agency action was required. Recipients who disagree
1099
with the agency's finding that cause does not exist for
1100
disenrollment shall be advised of their right to pursue a
1101
Medicaid fair hearing to dispute the agency's finding.
1102
Section 10. Paragraph (c) of subsection (5) of section
1103
409.905 and section 430.83, Florida Statutes, are repealed.
1104
Section 11. This act shall take effect July 1, 2008.