1

A bill to be entitled

2

An act relating to the Medicaid program; amending s.

3

400.179, F.S.; authorizing the Agency for Health Care

4

Administration to transfer fees used to repay nursing home

5

Medicaid overpayments to the Grants and Donations Trust

6

Fund within the agency; amending s. 409.904, F.S.;

7

discontinuing optional Medicaid payments for certain

8

persons age 65 or over or who are blind or disabled;

9

revising certain eligibility criteria for pregnant women

10

and children younger than 21; amending s. 409.906, F.S.;

11

discontinuing adult dental services and adult hearing

12

services on a certain date; amending s. 409.908, F.S.;

13

requiring Medicaid to pay for all deductibles and

14

coinsurance for portable X-ray Medicare Part B services

15

provided in a nursing home; revising the factors used to

16

determine the reimbursement rate to providers for Medicaid

17

prescribed drugs; requiring the agency to reduce certain

18

provider reimbursement rates as prescribed in the

19

appropriations act; providing that any increases in rates

20

as subject to the appropriations act; amending s. 409.911,

21

F.S.; revising which year's disproportionate data is used

22

to determine a hospital's Medicaid days and charity care

23

during the 2008-2009 fiscal year; amending s. 409.9112,

24

F.S.; prohibiting the Agency for Health Care

25

Administration from distributing moneys under the regional

26

perinatal intensive care disproportionate share program

27

during the 2008-2009 fiscal year; amending s. 409.9113,

28

F.S.; authorizing the agency to distribute

29

disproportionate share funds to teaching hospital during

30

the 2008-2009 fiscal year; providing that such funds may

31

be distributed as provided in the appropriations act;

32

amending s. 409.9117, F.S.; prohibiting the distribution

33

of funds under the primary disproportionate share program

34

during the 2008-2009 fiscal year; amending s. 409.912,

35

F.S.; specifying certain counties that are exempt from the

36

requirement of enrolling Medicaid eligible children in

37

MediPass or Medicaid fee-for-service and behavioral health

38

care services; revising the factors used to determine the

39

reimbursement rate to pharmacies for Medicaid prescribed

40

drugs; revising the requirement for the agency to develop

41

a utilization management program for Medicaid recipients

42

for certain therapies; amending s. 409.9122, F.S.;

43

revising enrollment requirements relating to Medicaid

44

managed care programs and the agency's authority to assign

45

persons to MediPass or a managed care plan; repealing s.

46

409.905(5)(c), F.S., relating to the agency's authority to

47

adjust a hospital's inpatient per diem rate; repealing s.

48

430.83, F.S., relating to the Sunshine for Seniors

49

Program; providing an effective date.

50

51

Be It Enacted by the Legislature of the State of Florida:

52

53

     Section 1.  Paragraph (d) of subsection (2) of section

54

400.179, Florida Statutes, is amended to read:

55

     400.179  Liability for Medicaid underpayments and

56

overpayments.--

57

     (2)  Because any transfer of a nursing facility may expose

58

the fact that Medicaid may have underpaid or overpaid the

59

transferor, and because in most instances, any such underpayment

60

or overpayment can only be determined following a formal field

61

audit, the liabilities for any such underpayments or overpayments

62

shall be as follows:

63

     (d)  Where the transfer involves a facility that has been

64

leased by the transferor:

65

     1.  The transferee shall, as a condition to being issued a

66

license by the agency, acquire, maintain, and provide proof to

67

the agency of a bond with a term of 30 months, renewable

68

annually, in an amount not less than the total of 3 months'

69

Medicaid payments to the facility computed on the basis of the

70

preceding 12-month average Medicaid payments to the facility.

71

     2.  A leasehold licensee may meet the requirements of

72

subparagraph 1. by payment of a nonrefundable fee, paid at

73

initial licensure, paid at the time of any subsequent change of

74

ownership, and paid annually thereafter, in the amount of 1

75

percent of the total of 3 months' Medicaid payments to the

76

facility computed on the basis of the preceding 12-month average

77

Medicaid payments to the facility. If a preceding 12-month

78

average is not available, projected Medicaid payments may be

79

used. The fee shall be deposited into the Health Care Trust Fund

80

and shall be accounted for separately as a Medicaid nursing home

81

overpayment account. These fees shall be used at the sole

82

discretion of the agency to repay nursing home Medicaid

83

overpayments. The agency may transfer funds to the Grants and

84

Donations Trust Fund for such repayments. Payment of this fee

85

shall not release the licensee from any liability for any

86

Medicaid overpayments, nor shall payment bar the agency from

87

seeking to recoup overpayments from the licensee and any other

88

liable party. As a condition of exercising this lease bond

89

alternative, licensees paying this fee must maintain an existing

90

lease bond through the end of the 30-month term period of that

91

bond. The agency is herein granted specific authority to

92

promulgate all rules pertaining to the administration and

93

management of this account, including withdrawals from the

94

account, subject to federal review and approval. This provision

95

shall take effect upon becoming law and shall apply to any

96

leasehold license application. The financial viability of the

97

Medicaid nursing home overpayment account shall be determined by

98

the agency through annual review of the account balance and the

99

amount of total outstanding, unpaid Medicaid overpayments owing

100

from leasehold licensees to the agency as determined by final

101

agency audits.

102

     3.  The leasehold licensee may meet the bond requirement

103

through other arrangements acceptable to the agency. The agency

104

is herein granted specific authority to promulgate rules

105

pertaining to lease bond arrangements.

106

     4.  All existing nursing facility licensees, operating the

107

facility as a leasehold, shall acquire, maintain, and provide

108

proof to the agency of the 30-month bond required in subparagraph

109

1., above, on and after July 1, 1993, for each license renewal.

110

     5.  It shall be the responsibility of all nursing facility

111

operators, operating the facility as a leasehold, to renew the

112

30-month bond and to provide proof of such renewal to the agency

113

annually.

114

     6.  Any failure of the nursing facility operator to acquire,

115

maintain, renew annually, or provide proof to the agency shall be

116

grounds for the agency to deny, revoke, and suspend the facility

117

license to operate such facility and to take any further action,

118

including, but not limited to, enjoining the facility, asserting

119

a moratorium pursuant to part II of chapter 408, or applying for

120

a receiver, deemed necessary to ensure compliance with this

121

section and to safeguard and protect the health, safety, and

122

welfare of the facility's residents. A lease agreement required

123

as a condition of bond financing or refinancing under s. 154.213

124

by a health facilities authority or required under s. 159.30 by a

125

county or municipality is not a leasehold for purposes of this

126

paragraph and is not subject to the bond requirement of this

127

paragraph.

128

     Section 2.  Subsections (1) and (2) of section 409.904,

129

Florida Statutes, are amended to read:

130

     409.904  Optional payments for eligible persons.--The agency

131

may make payments for medical assistance and related services on

132

behalf of the following persons who are determined to be eligible

133

subject to the income, assets, and categorical eligibility tests

134

set forth in federal and state law. Payment on behalf of these

135

Medicaid eligible persons is subject to the availability of

136

moneys and any limitations established by the General

137

Appropriations Act or chapter 216.

138

     (1)(a) From July 1, 2005, through December 31, 2005, a

139

person who is age 65 or older or is determined to be disabled,

140

whose income is at or below 88 percent of federal poverty level,

141

and whose assets do not exceed established limitations.

142

     (b) Effective January 1, 2006, and subject to federal

143

waiver approval, a person who is age 65 or older or is determined

144

to be disabled, whose income is at or below 88 percent of the

145

federal poverty level, whose assets do not exceed established

146

limitations, and who is not eligible for Medicare or, if eligible

147

for Medicare, is also eligible for and receiving Medicaid-covered

148

institutional care services, hospice services, or home and

149

community-based services. The agency shall seek federal

150

authorization through a waiver to provide this coverage. This

151

subsection expires October 31, 2008.

152

     (2)(a) A family, a pregnant woman, a child under age 21, a

153

person age 65 or over, or a blind or disabled person, who would

154

be eligible under any group listed in s. 409.903(1), (2), or (3),

155

except that the income or assets of such family or person exceed

156

established limitations. For a family or person in one of these

157

coverage groups, medical expenses are deductible from income in

158

accordance with federal requirements in order to make a

159

determination of eligibility. A family or person eligible under

160

the coverage known as the "medically needy," is eligible to

161

receive the same services as other Medicaid recipients, with the

162

exception of services in skilled nursing facilities and

163

intermediate care facilities for the developmentally disabled.

164

This paragraph expires October 31, 2008.

165

     (b) Effective November 1, 2008, a pregnant woman or a child

166

younger than 21 years of age who would be eligible under any

167

group listed in s. 409.903, except that the income or assets of

168

such group exceed established limitations. For a person in one of

169

these coverage groups, medical expenses are deductible from

170

income in accordance with federal requirements in order to made a

171

determination of eligibility. A person eligible under the

172

coverage known as the "medically needy" is eligible to receive

173

the same services as other Medicaid recipients, with the

174

exception of services in skilled nursing facilities and

175

intermediate care facilities for the developmentally disabled.

176

     Section 3.  Subsections (1) and (12) of section 409.906,

177

Florida Statutes, are amended to read:

178

     409.906  Optional Medicaid services.--Subject to specific

179

appropriations, the agency may make payments for services which

180

are optional to the state under Title XIX of the Social Security

181

Act and are furnished by Medicaid providers to recipients who are

182

determined to be eligible on the dates on which the services were

183

provided. Any optional service that is provided shall be provided

184

only when medically necessary and in accordance with state and

185

federal law. Optional services rendered by providers in mobile

186

units to Medicaid recipients may be restricted or prohibited by

187

the agency. Nothing in this section shall be construed to prevent

188

or limit the agency from adjusting fees, reimbursement rates,

189

lengths of stay, number of visits, or number of services, or

190

making any other adjustments necessary to comply with the

191

availability of moneys and any limitations or directions provided

192

for in the General Appropriations Act or chapter 216. If

193

necessary to safeguard the state's systems of providing services

194

to elderly and disabled persons and subject to the notice and

195

review provisions of s. 216.177, the Governor may direct the

196

Agency for Health Care Administration to amend the Medicaid state

197

plan to delete the optional Medicaid service known as

198

"Intermediate Care Facilities for the Developmentally Disabled."

199

Optional services may include:

200

     (1)  ADULT DENTAL SERVICES.--

201

     (a)  The agency may pay for medically necessary, emergency

202

dental procedures to alleviate pain or infection. Emergency

203

dental care shall be limited to emergency oral examinations,

204

necessary radiographs, extractions, and incision and drainage of

205

abscess, for a recipient who is 21 years of age or older.

206

     (b)  Beginning July 1, 2006, the agency may pay for full or

207

partial dentures, the procedures required to seat full or partial

208

dentures, and the repair and reline of full or partial dentures,

209

provided by or under the direction of a licensed dentist, for a

210

recipient who is 21 years of age or older.

211

     (c) However, Medicaid may will not provide reimbursement

212

for dental services provided in a mobile dental unit, except for

213

a mobile dental unit:

214

     1.  Owned by, operated by, or having a contractual agreement

215

with the Department of Health and complying with Medicaid's

216

county health department clinic services program specifications

217

as a county health department clinic services provider.

218

     2.  Owned by, operated by, or having a contractual

219

arrangement with a federally qualified health center and

220

complying with Medicaid's federally qualified health center

221

specifications as a federally qualified health center provider.

222

     3.  Rendering dental services to Medicaid recipients, 21

223

years of age and older, at nursing facilities.

224

     4.  Owned by, operated by, or having a contractual agreement

225

with a state-approved dental educational institution.

226

     (d) This subsection expires September 30, 2008.

227

     (12)  HEARING SERVICES.--The agency may pay for hearing and

228

related services, including hearing evaluations, hearing aid

229

devices, dispensing of the hearing aid, and related repairs, if

230

provided to a recipient by a licensed hearing aid specialist,

231

otolaryngologist, otologist, audiologist, or physician. Effective

232

October 1, 2008, the agency may not pay for hearing and related

233

services for adults.

234

     Section 4.  Paragraph (d) of subsection (13) and subsection

235

(14) of section 409.908, Florida Statutes, are amended, and

236

subsection (23) is added to that section, to read:

237

     409.908  Reimbursement of Medicaid providers.--Subject to

238

specific appropriations, the agency shall reimburse Medicaid

239

providers, in accordance with state and federal law, according to

240

methodologies set forth in the rules of the agency and in policy

241

manuals and handbooks incorporated by reference therein. These

242

methodologies may include fee schedules, reimbursement methods

243

based on cost reporting, negotiated fees, competitive bidding

244

pursuant to s. 287.057, and other mechanisms the agency considers

245

efficient and effective for purchasing services or goods on

246

behalf of recipients. If a provider is reimbursed based on cost

247

reporting and submits a cost report late and that cost report

248

would have been used to set a lower reimbursement rate for a rate

249

semester, then the provider's rate for that semester shall be

250

retroactively calculated using the new cost report, and full

251

payment at the recalculated rate shall be effected retroactively.

252

Medicare-granted extensions for filing cost reports, if

253

applicable, shall also apply to Medicaid cost reports. Payment

254

for Medicaid compensable services made on behalf of Medicaid

255

eligible persons is subject to the availability of moneys and any

256

limitations or directions provided for in the General

257

Appropriations Act or chapter 216. Further, nothing in this

258

section shall be construed to prevent or limit the agency from

259

adjusting fees, reimbursement rates, lengths of stay, number of

260

visits, or number of services, or making any other adjustments

261

necessary to comply with the availability of moneys and any

262

limitations or directions provided for in the General

263

Appropriations Act, provided the adjustment is consistent with

264

legislative intent.

265

     (13)  Medicare premiums for persons eligible for both

266

Medicare and Medicaid coverage shall be paid at the rates

267

established by Title XVIII of the Social Security Act. For

268

Medicare services rendered to Medicaid-eligible persons, Medicaid

269

shall pay Medicare deductibles and coinsurance as follows:

270

     (d)  Notwithstanding paragraphs (a)-(c):

271

     1.  Medicaid payments for Nursing Home Medicare part A

272

coinsurance are shall be limited to the Medicaid nursing home per

273

diem rate less any amounts paid by Medicare, but only up to the

274

amount of Medicare coinsurance. The Medicaid per diem rate shall

275

be the rate in effect for the dates of service of the crossover

276

claims and may not be subsequently adjusted due to subsequent per

277

diem rate adjustments.

278

     2.  Medicaid shall pay all deductibles and coinsurance for

279

Medicare-eligible recipients receiving freestanding end stage

280

renal dialysis center services.

281

     3.  Medicaid payments for general hospital inpatient

282

services are shall be limited to the Medicare deductible per

283

spell of illness. Medicaid may not pay for shall make no payment

284

toward coinsurance for Medicare general hospital inpatient

285

services.

286

     4.  Medicaid shall pay all deductibles and coinsurance for

287

Medicare emergency transportation services provided by ambulances

288

licensed pursuant to chapter 401.

289

     5. Medicaid shall pay all deductibles and coinsurance for

290

portable X-ray Medicare Part B services provided in a nursing

291

home.

292

     (14)  A provider of prescribed drugs shall be reimbursed the

293

least of the amount billed by the provider, the provider's usual

294

and customary charge, or the Medicaid maximum allowable fee

295

established by the agency, plus a dispensing fee. The Medicaid

296

maximum allowable fee for ingredient cost is will be based on the

297

lower of: average wholesale price (AWP) minus 16.4 15.4 percent,

298

wholesaler acquisition cost (WAC) plus 4.75 5.75 percent, the

299

federal upper limit (FUL), the state maximum allowable cost

300

(SMAC), or the usual and customary (UAC) charge billed by the

301

provider. Medicaid providers are required to dispense generic

302

drugs if available at lower cost and the agency has not

303

determined that the branded product is more cost-effective,

304

unless the prescriber has requested and received approval to

305

require the branded product. The agency is directed to implement

306

a variable dispensing fee for payments for prescribed medicines

307

while ensuring continued access for Medicaid recipients. The

308

variable dispensing fee may be based upon, but not limited to,

309

either or both the volume of prescriptions dispensed by a

310

specific pharmacy provider, the volume of prescriptions dispensed

311

to an individual recipient, and dispensing of preferred-drug-list

312

products. The agency may increase the pharmacy dispensing fee

313

authorized by statute and in the annual General Appropriations

314

Act by $0.50 for the dispensing of a Medicaid preferred-drug-list

315

product and reduce the pharmacy dispensing fee by $0.50 for the

316

dispensing of a Medicaid product that is not included on the

317

preferred drug list. The agency may establish a supplemental

318

pharmaceutical dispensing fee to be paid to providers returning

319

unused unit-dose packaged medications to stock and crediting the

320

Medicaid program for the ingredient cost of those medications if

321

the ingredient costs to be credited exceed the value of the

322

supplemental dispensing fee. The agency is authorized to limit

323

reimbursement for prescribed medicine in order to comply with any

324

limitations or directions provided for in the General

325

Appropriations Act, which may include implementing a prospective

326

or concurrent utilization review program.

327

     (23)(a) Effective July 1, 2008, the agency shall reduce

328

provider reimbursement rates on a recurring basis as prescribed

329

in the general appropriations act for the following provider

330

types:

331

     1. Inpatient hospitals.

332

     2. Outpatient hospitals.

333

     3. Nursing homes.

334

     4. County health departments.

335

     5. Community intermediate care facilities for the

336

developmentally disabled.

337

     6. Prepaid health plans.

338

     (b) Any increase in reimbursement is subject to a specific

339

appropriation by the Legislature.

340

     Section 5.  Paragraph (a) of subsection (2) of section

341

409.911, Florida Statutes, is amended to read:

342

     409.911  Disproportionate share program.--Subject to

343

specific allocations established within the General

344

Appropriations Act and any limitations established pursuant to

345

chapter 216, the agency shall distribute, pursuant to this

346

section, moneys to hospitals providing a disproportionate share

347

of Medicaid or charity care services by making quarterly Medicaid

348

payments as required. Notwithstanding the provisions of s.

349

409.915, counties are exempt from contributing toward the cost of

350

this special reimbursement for hospitals serving a

351

disproportionate share of low-income patients.

352

     (2)  The Agency for Health Care Administration shall use the

353

following actual audited data to determine the Medicaid days and

354

charity care to be used in calculating the disproportionate share

355

payment:

356

     (a) The average of the 2000, 2001, and 2002, 2003, and 2004

357

audited disproportionate share data to determine each hospital's

358

Medicaid days and charity care for the 2008-2009 2006-2007 state

359

fiscal year.

360

     Section 6.  Section 409.9112, Florida Statutes, is amended

361

to read:

362

     409.9112  Disproportionate share program for regional

363

perinatal intensive care centers.--In addition to the payments

364

made under s. 409.911, the agency for Health Care Administration

365

shall design and implement a system of making disproportionate

366

share payments to those hospitals that participate in the

367

regional perinatal intensive care center program established

368

pursuant to chapter 383. This system of payments shall conform to

369

with federal requirements and shall distribute funds in each

370

fiscal year for which an appropriation is made by making

371

quarterly Medicaid payments. Notwithstanding the provisions of s.

372

409.915, counties are exempt from contributing toward the cost of

373

this special reimbursement for hospitals serving a

374

disproportionate share of low-income patients. For the 2008-2009

375

state fiscal year 2005-2006, the agency may shall not distribute

376

moneys under the regional perinatal intensive care centers

377

disproportionate share program.

378

     (1)  The following formula shall be used by the agency to

379

calculate the total amount earned for hospitals that participate

380

in the regional perinatal intensive care center program:

381

382

TAE = HDSP/THDSP

383

384

Where:

385

     TAE = total amount earned by a regional perinatal intensive

386

care center.

387

     HDSP = the prior state fiscal year regional perinatal

388

intensive care center disproportionate share payment to the

389

individual hospital.

390

     THDSP = the prior state fiscal year total regional perinatal

391

intensive care center disproportionate share payments to all

392

hospitals.

393

     (2)  The total additional payment for hospitals that

394

participate in the regional perinatal intensive care center

395

program shall be calculated by the agency as follows:

396

397

TAP = TAE x TA

398

399

Where:

400

     TAP = total additional payment for a regional perinatal

401

intensive care center.

402

     TAE = total amount earned by a regional perinatal intensive

403

care center.

404

     TA = total appropriation for the regional perinatal

405

intensive care center disproportionate share program.

406

     (3)  In order to receive payments under this section, a

407

hospital must be participating in the regional perinatal

408

intensive care center program pursuant to chapter 383 and must

409

meet the following additional requirements:

410

     (a)  Agree to conform to all departmental and agency

411

requirements to ensure high quality in the provision of services,

412

including criteria adopted by departmental and agency rule

413

concerning staffing ratios, medical records, standards of care,

414

equipment, space, and such other standards and criteria as the

415

department and agency deem appropriate as specified by rule.

416

     (b)  Agree to provide information to the department and

417

agency, in a form and manner to be prescribed by rule of the

418

department and agency, concerning the care provided to all

419

patients in neonatal intensive care centers and high-risk

420

maternity care.

421

     (c)  Agree to accept all patients for neonatal intensive

422

care and high-risk maternity care, regardless of ability to pay,

423

on a functional space-available basis.

424

     (d)  Agree to develop arrangements with other maternity and

425

neonatal care providers in the hospital's region for the

426

appropriate receipt and transfer of patients in need of

427

specialized maternity and neonatal intensive care services.

428

     (e)  Agree to establish and provide a developmental

429

evaluation and services program for certain high-risk neonates,

430

as prescribed and defined by rule of the department.

431

     (f)  Agree to sponsor a program of continuing education in

432

perinatal care for health care professionals within the region of

433

the hospital, as specified by rule.

434

     (g)  Agree to provide backup and referral services to the

435

department's county health departments and other low-income

436

perinatal providers within the hospital's region, including the

437

development of written agreements between these organizations and

438

the hospital.

439

     (h)  Agree to arrange for transportation for high-risk

440

obstetrical patients and neonates in need of transfer from the

441

community to the hospital or from the hospital to another more

442

appropriate facility.

443

     (4)  Hospitals which fail to comply with any of the

444

conditions in subsection (3) or the applicable rules of the

445

department and agency may shall not receive any payments under

446

this section until full compliance is achieved. A hospital which

447

is not in compliance in two or more consecutive quarters may

448

shall not receive its share of the funds. Any forfeited funds

449

shall be distributed by the remaining participating regional

450

perinatal intensive care center program hospitals.

451

     Section 7.  Section 409.9113, Florida Statutes, is amended

452

to read:

453

     409.9113  Disproportionate share program for teaching

454

hospitals.--In addition to the payments made under ss. 409.911

455

and 409.9112, the agency for Health Care Administration shall

456

make disproportionate share payments to statutorily defined

457

teaching hospitals for their increased costs associated with

458

medical education programs and for tertiary health care services

459

provided to the indigent. This system of payments shall conform

460

to with federal requirements and shall distribute funds in each

461

fiscal year for which an appropriation is made by making

462

quarterly Medicaid payments. Notwithstanding s. 409.915, counties

463

are exempt from contributing toward the cost of this special

464

reimbursement for hospitals serving a disproportionate share of

465

low-income patients. For the 2008-2009 state fiscal year 2006-

466

2007, the agency shall distribute the moneys provided in the

467

General Appropriations Act to statutorily defined teaching

468

hospitals and family practice teaching hospitals under the

469

teaching hospital disproportionate share program. The funds

470

provided for statutorily defined teaching hospitals shall be

471

distributed in the same proportion as the state fiscal year 2003-

472

2004 teaching hospital disproportionate share funds were

473

distributed or as otherwise provided in the General

474

Appropriations Act. The funds provided for family practice

475

teaching hospitals shall be distributed equally among family

476

practice teaching hospitals.

477

     (1) On or before September 15 of each year, the agency for

478

Health Care Administration shall calculate an allocation fraction

479

to be used for distributing funds to state statutory teaching

480

hospitals. Subsequent to the end of each quarter of the state

481

fiscal year, the agency shall distribute to each statutory

482

teaching hospital, as defined in s. 408.07, an amount determined

483

by multiplying one-fourth of the funds appropriated for this

484

purpose by the Legislature times such hospital's allocation

485

fraction. The allocation fraction for each such hospital shall be

486

determined by the sum of three primary factors, divided by three.

487

The primary factors are:

488

     (a)  The number of nationally accredited graduate medical

489

education programs offered by the hospital, including programs

490

accredited by the Accreditation Council for Graduate Medical

491

Education and the combined Internal Medicine and Pediatrics

492

programs acceptable to both the American Board of Internal

493

Medicine and the American Board of Pediatrics at the beginning of

494

the state fiscal year preceding the date on which the allocation

495

fraction is calculated. The numerical value of this factor is the

496

fraction that the hospital represents of the total number of

497

programs, where the total is computed for all state statutory

498

teaching hospitals.

499

     (b)  The number of full-time equivalent trainees in the

500

hospital, which comprises two components:

501

     1.  The number of trainees enrolled in nationally accredited

502

graduate medical education programs, as defined in paragraph (a).

503

Full-time equivalents are computed using the fraction of the year

504

during which each trainee is primarily assigned to the given

505

institution, over the state fiscal year preceding the date on

506

which the allocation fraction is calculated. The numerical value

507

of this factor is the fraction that the hospital represents of

508

the total number of full-time equivalent trainees enrolled in

509

accredited graduate programs, where the total is computed for all

510

state statutory teaching hospitals.

511

     2.  The number of medical students enrolled in accredited

512

colleges of medicine and engaged in clinical activities,

513

including required clinical clerkships and clinical electives.

514

Full-time equivalents are computed using the fraction of the year

515

during which each trainee is primarily assigned to the given

516

institution, over the course of the state fiscal year preceding

517

the date on which the allocation fraction is calculated. The

518

numerical value of this factor is the fraction that the given

519

hospital represents of the total number of full-time equivalent

520

students enrolled in accredited colleges of medicine, where the

521

total is computed for all state statutory teaching hospitals.

522

523

The primary factor for full-time equivalent trainees is computed

524

as the sum of these two components, divided by two.

525

     (c)  A service index that comprises three components:

526

     1.  The Agency for Health Care Administration Service Index,

527

computed by applying the standard Service Inventory Scores

528

established by the agency for Health Care Administration to

529

services offered by the given hospital, as reported on Worksheet

530

A-2 for the last fiscal year reported to the agency before the

531

date on which the allocation fraction is calculated. The

532

numerical value of this factor is the fraction that the given

533

hospital represents of the total Agency for Health Care

534

Administration Service Index values, where the total is computed

535

for all state statutory teaching hospitals.

536

     2.  A volume-weighted service index, computed by applying

537

the standard Service Inventory Scores established by the agency

538

for Health Care Administration to the volume of each service,

539

expressed in terms of the standard units of measure reported on

540

Worksheet A-2 for the last fiscal year reported to the agency

541

before the date on which the allocation factor is calculated. The

542

numerical value of this factor is the fraction that the given

543

hospital represents of the total volume-weighted service index

544

values, where the total is computed for all state statutory

545

teaching hospitals.

546

     3.  Total Medicaid payments to each hospital for direct

547

inpatient and outpatient services during the fiscal year

548

preceding the date on which the allocation factor is calculated.

549

This includes payments made to each hospital for such services by

550

Medicaid prepaid health plans, whether the plan was administered

551

by the hospital or not. The numerical value of this factor is the

552

fraction that each hospital represents of the total of such

553

Medicaid payments, where the total is computed for all state

554

statutory teaching hospitals.

555

556

The primary factor for the service index is computed as the sum

557

of these three components, divided by three.

558

     (2)  By October 1 of each year, the agency shall use the

559

following formula to calculate the maximum additional

560

disproportionate share payment for statutorily defined teaching

561

hospitals:

562

563

TAP = THAF x A

564

565

Where:

566

     TAP = total additional payment.

567

     THAF = teaching hospital allocation factor.

568

     A = amount appropriated for a teaching hospital

569

disproportionate share program.

570

     Section 8.  Section 409.9117, Florida Statutes, is amended

571

to read:

572

     409.9117  Primary care disproportionate share program.--For

573

the 2008-2009 state fiscal year 2006-2007, the agency may shall

574

not distribute moneys under the primary care disproportionate

575

share program.

576

     (1)  If federal funds are available for disproportionate

577

share programs in addition to those otherwise provided by law,

578

there shall be created a primary care disproportionate share

579

program.

580

     (2)  The following formula shall be used by the agency to

581

calculate the total amount earned for hospitals that participate

582

in the primary care disproportionate share program:

583

584

TAE = HDSP/THDSP

585

586

Where:

587

     TAE = total amount earned by a hospital participating in the

588

primary care disproportionate share program.

589

     HDSP = the prior state fiscal year primary care

590

disproportionate share payment to the individual hospital.

591

     THDSP = the prior state fiscal year total primary care

592

disproportionate share payments to all hospitals.

593

     (3)  The total additional payment for hospitals that

594

participate in the primary care disproportionate share program

595

shall be calculated by the agency as follows:

596

597

TAP = TAE x TA

598

599

Where:

600

     TAP = total additional payment for a primary care hospital.

601

     TAE = total amount earned by a primary care hospital.

602

     TA = total appropriation for the primary care

603

disproportionate share program.

604

     (4) In establishing the establishment and funding of this

605

program, the agency shall use the following criteria in addition

606

to those specified in s. 409.911, and payments may not be made to

607

a hospital unless the hospital agrees to:

608

     (a)  Cooperate with a Medicaid prepaid health plan, if one

609

exists in the community.

610

     (b)  Ensure the availability of primary and specialty care

611

physicians to Medicaid recipients who are not enrolled in a

612

prepaid capitated arrangement and who are in need of access to

613

such physicians.

614

     (c)  Coordinate and provide primary care services free of

615

charge, except copayments, to all persons with incomes up to 100

616

percent of the federal poverty level who are not otherwise

617

covered by Medicaid or another program administered by a

618

governmental entity, and to provide such services based on a

619

sliding fee scale to all persons with incomes up to 200 percent

620

of the federal poverty level who are not otherwise covered by

621

Medicaid or another program administered by a governmental

622

entity, except that eligibility may be limited to persons who

623

reside within a more limited area, as agreed to by the agency and

624

the hospital.

625

     (d)  Contract with any federally qualified health center, if

626

one exists within the agreed geopolitical boundaries, concerning

627

the provision of primary care services, in order to guarantee

628

delivery of services in a nonduplicative fashion, and to provide

629

for referral arrangements, privileges, and admissions, as

630

appropriate. The hospital shall agree to provide at an onsite or

631

offsite facility primary care services within 24 hours to which

632

all Medicaid recipients and persons eligible under this paragraph

633

who do not require emergency room services are referred during

634

normal daylight hours.

635

     (e)  Cooperate with the agency, the county, and other

636

entities to ensure the provision of certain public health

637

services, case management, referral and acceptance of patients,

638

and sharing of epidemiological data, as the agency and the

639

hospital find mutually necessary and desirable to promote and

640

protect the public health within the agreed geopolitical

641

boundaries.

642

     (f)  In cooperation with the county in which the hospital

643

resides, develop a low-cost, outpatient, prepaid health care

644

program to persons who are not eligible for the Medicaid program,

645

and who reside within the area.

646

     (g)  Provide inpatient services to residents within the area

647

who are not eligible for Medicaid or Medicare, and who do not

648

have private health insurance, regardless of ability to pay, on

649

the basis of available space, except that nothing shall prevent

650

the hospital from establishing bill collection programs based on

651

ability to pay.

652

     (h)  Work with the Florida Healthy Kids Corporation, the

653

Florida Health Care Purchasing Cooperative, and business health

654

coalitions, as appropriate, to develop a feasibility study and

655

plan to provide a low-cost comprehensive health insurance plan to

656

persons who reside within the area and who do not have access to

657

such a plan.

658

     (i)  Work with public health officials and other experts to

659

provide community health education and prevention activities

660

designed to promote healthy lifestyles and appropriate use of

661

health services.

662

     (j)  Work with the local health council to develop a plan

663

for promoting access to affordable health care services for all

664

persons who reside within the area, including, but not limited

665

to, public health services, primary care services, inpatient

666

services, and affordable health insurance generally.

667

668

Any hospital that fails to comply with any of the provisions of

669

this subsection, or any other contractual condition, may not

670

receive payments under this section until full compliance is

671

achieved.

672

     Section 9.  Paragraph (b) of subsection (4), paragraph (a)

673

of subsection (39), and subsection (42) of section 409.912,

674

Florida Statutes, are amended to read:

675

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

676

agency shall purchase goods and services for Medicaid recipients

677

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

678

quality medical care. To ensure that medical services are

679

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

680

confirmation or second physician's opinion of the correct

681

diagnosis for purposes of authorizing future services under the

682

Medicaid program. This section does not restrict access to

683

emergency services or poststabilization care services as defined

684

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

685

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

686

shall maximize the use of prepaid per capita and prepaid

687

aggregate fixed-sum basis services when appropriate and other

688

alternative service delivery and reimbursement methodologies,

689

including competitive bidding pursuant to s. 287.057, designed to

690

facilitate the cost-effective purchase of a case-managed

691

continuum of care. The agency shall also require providers to

692

minimize the exposure of recipients to the need for acute

693

inpatient, custodial, and other institutional care and the

694

inappropriate or unnecessary use of high-cost services. The

695

agency shall contract with a vendor to monitor and evaluate the

696

clinical practice patterns of providers in order to identify

697

trends that are outside the normal practice patterns of a

698

provider's professional peers or the national guidelines of a

699

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

700

provide information and counseling to a provider whose practice

701

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

702

to improve patient care and reduce inappropriate utilization. The

703

agency may mandate prior authorization, drug therapy management,

704

or disease management participation for certain populations of

705

Medicaid beneficiaries, certain drug classes, or particular drugs

706

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

707

interactions. The Pharmaceutical and Therapeutics Committee shall

708

make recommendations to the agency on drugs for which prior

709

authorization is required. The agency shall inform the

710

Pharmaceutical and Therapeutics Committee of its decisions

711

regarding drugs subject to prior authorization. The agency is

712

authorized to limit the entities it contracts with or enrolls as

713

Medicaid providers by developing a provider network through

714

provider credentialing. The agency may competitively bid single-

715

source-provider contracts if procurement of goods or services

716

results in demonstrated cost savings to the state without

717

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

718

on the assessment of beneficiary access to care, provider

719

availability, provider quality standards, time and distance

720

standards for access to care, the cultural competence of the

721

provider network, demographic characteristics of Medicaid

722

beneficiaries, practice and provider-to-beneficiary standards,

723

appointment wait times, beneficiary use of services, provider

724

turnover, provider profiling, provider licensure history,

725

previous program integrity investigations and findings, peer

726

review, provider Medicaid policy and billing compliance records,

727

clinical and medical record audits, and other factors. Providers

728

shall not be entitled to enrollment in the Medicaid provider

729

network. The agency shall determine instances in which allowing

730

Medicaid beneficiaries to purchase durable medical equipment and

731

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

732

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

733

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

734

order to protect against fraud and abuse in the Medicaid program

735

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

736

necessary to administer these policies.

737

     (4)  The agency may contract with:

738

     (b)  An entity that is providing comprehensive behavioral

739

health care services to certain Medicaid recipients through a

740

capitated, prepaid arrangement pursuant to the federal waiver

741

provided for by s. 409.905(5). Such an entity must be licensed

742

under chapter 624, chapter 636, or chapter 641 and must possess

743

the clinical systems and operational competence to manage risk

744

and provide comprehensive behavioral health care to Medicaid

745

recipients. As used in this paragraph, the term "comprehensive

746

behavioral health care services" means covered mental health and

747

substance abuse treatment services that are available to Medicaid

748

recipients. The secretary of the Department of Children and

749

Family Services shall approve provisions of procurements related

750

to children in the department's care or custody prior to

751

enrolling such children in a prepaid behavioral health plan. Any

752

contract awarded under this paragraph must be competitively

753

procured. In developing the behavioral health care prepaid plan

754

procurement document, the agency shall ensure that the

755

procurement document requires the contractor to develop and

756

implement a plan to ensure compliance with s. 394.4574 related to

757

services provided to residents of licensed assisted living

758

facilities that hold a limited mental health license. Except as

759

provided in subparagraph 8., and except in counties where the

760

Medicaid managed care pilot program is authorized pursuant to s.

761

409.91211, the agency shall seek federal approval to contract

762

with a single entity meeting these requirements to provide

763

comprehensive behavioral health care services to all Medicaid

764

recipients not enrolled in a Medicaid managed care plan

765

authorized under s. 409.91211 or a Medicaid health maintenance

766

organization in an AHCA area. In an AHCA area where the Medicaid

767

managed care pilot program is authorized pursuant to s. 409.91211

768

in one or more counties, the agency may procure a contract with a

769

single entity to serve the remaining counties as an AHCA area or

770

the remaining counties may be included with an adjacent AHCA area

771

and shall be subject to this paragraph. Each entity must offer

772

sufficient choice of providers in its network to ensure recipient

773

access to care and the opportunity to select a provider with whom

774

they are satisfied. The network shall include all public mental

775

health hospitals. To ensure unimpaired access to behavioral

776

health care services by Medicaid recipients, all contracts issued

777

pursuant to this paragraph shall require 80 percent of the

778

capitation paid to the managed care plan, including health

779

maintenance organizations, to be expended for the provision of

780

behavioral health care services. In the event the managed care

781

plan expends less than 80 percent of the capitation paid pursuant

782

to this paragraph for the provision of behavioral health care

783

services, the difference shall be returned to the agency. The

784

agency shall provide the managed care plan with a certification

785

letter indicating the amount of capitation paid during each

786

calendar year for the provision of behavioral health care

787

services pursuant to this section. The agency may reimburse for

788

substance abuse treatment services on a fee-for-service basis

789

until the agency finds that adequate funds are available for

790

capitated, prepaid arrangements.

791

     1.  By January 1, 2001, the agency shall modify the

792

contracts with the entities providing comprehensive inpatient and

793

outpatient mental health care services to Medicaid recipients in

794

Hillsborough, Highlands, Hardee, Manatee, and Polk Counties, to

795

include substance abuse treatment services.

796

     2.  By July 1, 2003, the agency and the Department of

797

Children and Family Services shall execute a written agreement

798

that requires collaboration and joint development of all policy,

799

budgets, procurement documents, contracts, and monitoring plans

800

that have an impact on the state and Medicaid community mental

801

health and targeted case management programs.

802

     3.  Except as provided in subparagraph 8., by July 1, 2006,

803

the agency and the Department of Children and Family Services

804

shall contract with managed care entities in each AHCA area

805

except area 6 or arrange to provide comprehensive inpatient and

806

outpatient mental health and substance abuse services through

807

capitated prepaid arrangements to all Medicaid recipients who are

808

eligible to participate in such plans under federal law and

809

regulation. In AHCA areas where eligible individuals number less

810

than 150,000, the agency shall contract with a single managed

811

care plan to provide comprehensive behavioral health services to

812

all recipients who are not enrolled in a Medicaid health

813

maintenance organization or a Medicaid capitated managed care

814

plan authorized under s. 409.91211. The agency may contract with

815

more than one comprehensive behavioral health provider to provide

816

care to recipients who are not enrolled in a Medicaid capitated

817

managed care plan authorized under s. 409.91211 or a Medicaid

818

health maintenance organization in AHCA areas where the eligible

819

population exceeds 150,000. In an AHCA area where the Medicaid

820

managed care pilot program is authorized pursuant to s. 409.91211

821

in one or more counties, the agency may procure a contract with a

822

single entity to serve the remaining counties as an AHCA area or

823

the remaining counties may be included with an adjacent AHCA area

824

and shall be subject to this paragraph. Contracts for

825

comprehensive behavioral health providers awarded pursuant to

826

this section shall be competitively procured. Both for-profit and

827

not-for-profit corporations shall be eligible to compete. Managed

828

care plans contracting with the agency under subsection (3) shall

829

provide and receive payment for the same comprehensive behavioral

830

health benefits as provided in AHCA rules, including handbooks

831

incorporated by reference. In AHCA area 11, the agency shall

832

contract with at least two comprehensive behavioral health care

833

providers to provide behavioral health care to recipients in that

834

area who are enrolled in, or assigned to, the MediPass program.

835

One of the behavioral health care contracts shall be with the

836

existing provider service network pilot project, as described in

837

paragraph (d), for the purpose of demonstrating the cost-

838

effectiveness of the provision of quality mental health services

839

through a public hospital-operated managed care model. Payment

840

shall be at an agreed-upon capitated rate to ensure cost savings.

841

Of the recipients in area 11 who are assigned to MediPass under

842

the provisions of s. 409.9122(2)(k), a minimum of 50,000 of those

843

MediPass-enrolled recipients shall be assigned to the existing

844

provider service network in area 11 for their behavioral care.

845

     4.  By October 1, 2003, the agency and the department shall

846

submit a plan to the Governor, the President of the Senate, and

847

the Speaker of the House of Representatives which provides for

848

the full implementation of capitated prepaid behavioral health

849

care in all areas of the state.

850

     a.  Implementation shall begin in 2003 in those AHCA areas

851

of the state where the agency is able to establish sufficient

852

capitation rates.

853

     b.  If the agency determines that the proposed capitation

854

rate in any area is insufficient to provide appropriate services,

855

the agency may adjust the capitation rate to ensure that care

856

will be available. The agency and the department may use existing

857

general revenue to address any additional required match but may

858

not over-obligate existing funds on an annualized basis.

859

     c.  Subject to any limitations provided for in the General

860

Appropriations Act, the agency, in compliance with appropriate

861

federal authorization, shall develop policies and procedures that

862

allow for certification of local and state funds.

863

     5.  Children residing in a statewide inpatient psychiatric

864

program, or in a Department of Juvenile Justice or a Department

865

of Children and Family Services residential program approved as a

866

Medicaid behavioral health overlay services provider shall not be

867

included in a behavioral health care prepaid health plan or any

868

other Medicaid managed care plan pursuant to this paragraph.

869

     6.  In converting to a prepaid system of delivery, the

870

agency shall in its procurement document require an entity

871

providing only comprehensive behavioral health care services to

872

prevent the displacement of indigent care patients by enrollees

873

in the Medicaid prepaid health plan providing behavioral health

874

care services from facilities receiving state funding to provide

875

indigent behavioral health care, to facilities licensed under

876

chapter 395 which do not receive state funding for indigent

877

behavioral health care, or reimburse the unsubsidized facility

878

for the cost of behavioral health care provided to the displaced

879

indigent care patient.

880

     7.  Traditional community mental health providers under

881

contract with the Department of Children and Family Services

882

pursuant to part IV of chapter 394, child welfare providers under

883

contract with the Department of Children and Family Services in

884

areas 1 and 6, and inpatient mental health providers licensed

885

pursuant to chapter 395 must be offered an opportunity to accept

886

or decline a contract to participate in any provider network for

887

prepaid behavioral health services.

888

     8.  For fiscal year 2004-2005, all Medicaid eligible

889

children, except children in areas 1 and Highland, Hardee, Polk,

890

and Manatee counties of area 6, whose cases are open for child

891

welfare services in the HomeSafeNet system, shall be enrolled in

892

MediPass or in Medicaid fee-for-service and all their behavioral

893

health care services including inpatient, outpatient psychiatric,

894

community mental health, and case management shall be reimbursed

895

on a fee-for-service basis. Beginning July 1, 2005, such

896

children, who are open for child welfare services in the

897

HomeSafeNet system, shall receive their behavioral health care

898

services through a specialty prepaid plan operated by community-

899

based lead agencies either through a single agency or formal

900

agreements among several agencies. The specialty prepaid plan

901

must result in savings to the state comparable to savings

902

achieved in other Medicaid managed care and prepaid programs.

903

Such plan must provide mechanisms to maximize state and local

904

revenues. The specialty prepaid plan shall be developed by the

905

agency and the Department of Children and Family Services. The

906

agency is authorized to seek any federal waivers to implement

907

this initiative. Medicaid-eligible children whose cases are open

908

for child welfare services in the HomeSafeNet system and who

909

reside in AHCA area 10 are exempt from the specialty prepaid plan

910

upon the development of a service delivery mechanism for children

911

who reside in area 10 as specified in s. 409.91211(3)(dd).

912

     (39)(a)  The agency shall implement a Medicaid prescribed-

913

drug spending-control program that includes the following

914

components:

915

     1.  A Medicaid preferred drug list, which shall be a listing

916

of cost-effective therapeutic options recommended by the Medicaid

917

Pharmacy and Therapeutics Committee established pursuant to s.

918

409.91195 and adopted by the agency for each therapeutic class on

919

the preferred drug list. At the discretion of the committee, and

920

when feasible, the preferred drug list should include at least

921

two products in a therapeutic class. The agency may post the

922

preferred drug list and updates to the preferred drug list on an

923

Internet website without following the rulemaking procedures of

924

chapter 120. Antiretroviral agents are excluded from the

925

preferred drug list. The agency shall also limit the amount of a

926

prescribed drug dispensed to no more than a 34-day supply unless

927

the drug products' smallest marketed package is greater than a

928

34-day supply, or the drug is determined by the agency to be a

929

maintenance drug in which case a 100-day maximum supply may be

930

authorized. The agency is authorized to seek any federal waivers

931

necessary to implement these cost-control programs and to

932

continue participation in the federal Medicaid rebate program, or

933

alternatively to negotiate state-only manufacturer rebates. The

934

agency may adopt rules to implement this subparagraph. The agency

935

shall continue to provide unlimited contraceptive drugs and

936

items. The agency must establish procedures to ensure that:

937

     a. There is will be a response to a request for prior

938

consultation by telephone or other telecommunication device

939

within 24 hours after receipt of a request for prior

940

consultation; and

941

     b. A 72-hour supply of the drug prescribed is will be

942

provided in an emergency or when the agency does not provide a

943

response within 24 hours as required by sub-subparagraph a.

944

     2.  Reimbursement to pharmacies for Medicaid prescribed

945

drugs shall be set at the lesser of: the average wholesale price

946

(AWP) minus 16.4 15.4 percent, the wholesaler acquisition cost

947

(WAC) plus 4.75 5.75 percent, the federal upper limit (FUL), the

948

state maximum allowable cost (SMAC), or the usual and customary

949

(UAC) charge billed by the provider.

950

     3.  The agency shall develop and implement a process for

951

managing the drug therapies of Medicaid recipients who are using

952

significant numbers of prescribed drugs each month. The

953

management process may include, but is not limited to,

954

comprehensive, physician-directed medical-record reviews, claims

955

analyses, and case evaluations to determine the medical necessity

956

and appropriateness of a patient's treatment plan and drug

957

therapies. The agency may contract with a private organization to

958

provide drug-program-management services. The Medicaid drug

959

benefit management program shall include initiatives to manage

960

drug therapies for HIV/AIDS patients, patients using 20 or more

961

unique prescriptions in a 180-day period, and the top 1,000

962

patients in annual spending. The agency shall enroll any Medicaid

963

recipient in the drug benefit management program if he or she

964

meets the specifications of this provision and is not enrolled in

965

a Medicaid health maintenance organization.

966

     4.  The agency may limit the size of its pharmacy network

967

based on need, competitive bidding, price negotiations,

968

credentialing, or similar criteria. The agency shall give special

969

consideration to rural areas in determining the size and location

970

of pharmacies included in the Medicaid pharmacy network. A

971

pharmacy credentialing process may include criteria such as a

972

pharmacy's full-service status, location, size, patient

973

educational programs, patient consultation, disease management

974

services, and other characteristics. The agency may impose a

975

moratorium on Medicaid pharmacy enrollment when it is determined

976

that it has a sufficient number of Medicaid-participating

977

providers. The agency must allow dispensing practitioners to

978

participate as a part of the Medicaid pharmacy network regardless

979

of the practitioner's proximity to any other entity that is

980

dispensing prescription drugs under the Medicaid program. A

981

dispensing practitioner must meet all credentialing requirements

982

applicable to his or her practice, as determined by the agency.

983

     5.  The agency shall develop and implement a program that

984

requires Medicaid practitioners who prescribe drugs to use a

985

counterfeit-proof prescription pad for Medicaid prescriptions.

986

The agency shall require the use of standardized counterfeit-

987

proof prescription pads by Medicaid-participating prescribers or

988

prescribers who write prescriptions for Medicaid recipients. The

989

agency may implement the program in targeted geographic areas or

990

statewide.

991

     6.  The agency may enter into arrangements that require

992

manufacturers of generic drugs prescribed to Medicaid recipients

993

to provide rebates of at least 15.1 percent of the average

994

manufacturer price for the manufacturer's generic products. These

995

arrangements shall require that if a generic-drug manufacturer

996

pays federal rebates for Medicaid-reimbursed drugs at a level

997

below 15.1 percent, the manufacturer must provide a supplemental

998

rebate to the state in an amount necessary to achieve a 15.1-

999

percent rebate level.

1000

     7.  The agency may establish a preferred drug list as

1001

described in this subsection, and, pursuant to the establishment

1002

of such preferred drug list, it is authorized to negotiate

1003

supplemental rebates from manufacturers that are in addition to

1004

those required by Title XIX of the Social Security Act and at no

1005

less than 14 percent of the average manufacturer price as defined

1006

in 42 U.S.C. s. 1936 on the last day of a quarter unless the

1007

federal or supplemental rebate, or both, equals or exceeds 29

1008

percent. There is no upper limit on the supplemental rebates the

1009

agency may negotiate. The agency may determine that specific

1010

products, brand-name or generic, are competitive at lower rebate

1011

percentages. Agreement to pay the minimum supplemental rebate

1012

percentage will guarantee a manufacturer that the Medicaid

1013

Pharmaceutical and Therapeutics Committee will consider a product

1014

for inclusion on the preferred drug list. However, a

1015

pharmaceutical manufacturer is not guaranteed placement on the

1016

preferred drug list by simply paying the minimum supplemental

1017

rebate. Agency decisions will be made on the clinical efficacy of

1018

a drug and recommendations of the Medicaid Pharmaceutical and

1019

Therapeutics Committee, as well as the price of competing

1020

products minus federal and state rebates. The agency is

1021

authorized to contract with an outside agency or contractor to

1022

conduct negotiations for supplemental rebates. For the purposes

1023

of this section, the term "supplemental rebates" means cash

1024

rebates. Effective July 1, 2004, value-added programs as a

1025

substitution for supplemental rebates are prohibited. The agency

1026

is authorized to seek any federal waivers to implement this

1027

initiative.

1028

     8.  The Agency for Health Care Administration shall expand

1029

home delivery of pharmacy products. To assist Medicaid patients

1030

in securing their prescriptions and reduce program costs, the

1031

agency shall expand its current mail-order-pharmacy diabetes-

1032

supply program to include all generic and brand-name drugs used

1033

by Medicaid patients with diabetes. Medicaid recipients in the

1034

current program may obtain nondiabetes drugs on a voluntary

1035

basis. This initiative is limited to the geographic area covered

1036

by the current contract. The agency may seek and implement any

1037

federal waivers necessary to implement this subparagraph.

1038

     9.  The agency shall limit to one dose per month any drug

1039

prescribed to treat erectile dysfunction.

1040

     10.a.  The agency may implement a Medicaid behavioral drug

1041

management system. The agency may contract with a vendor that has

1042

experience in operating behavioral drug management systems to

1043

implement this program. The agency is authorized to seek federal

1044

waivers to implement this program.

1045

     b.  The agency, in conjunction with the Department of

1046

Children and Family Services, may implement the Medicaid

1047

behavioral drug management system that is designed to improve the

1048

quality of care and behavioral health prescribing practices based

1049

on best practice guidelines, improve patient adherence to

1050

medication plans, reduce clinical risk, and lower prescribed drug

1051

costs and the rate of inappropriate spending on Medicaid

1052

behavioral drugs. The program may include the following elements:

1053

     (I)  Provide for the development and adoption of best

1054

practice guidelines for behavioral health-related drugs such as

1055

antipsychotics, antidepressants, and medications for treating

1056

bipolar disorders and other behavioral conditions; translate them

1057

into practice; review behavioral health prescribers and compare

1058

their prescribing patterns to a number of indicators that are

1059

based on national standards; and determine deviations from best

1060

practice guidelines.

1061

     (II)  Implement processes for providing feedback to and

1062

educating prescribers using best practice educational materials

1063

and peer-to-peer consultation.

1064

     (III)  Assess Medicaid beneficiaries who are outliers in

1065

their use of behavioral health drugs with regard to the numbers

1066

and types of drugs taken, drug dosages, combination drug

1067

therapies, and other indicators of improper use of behavioral

1068

health drugs.

1069

     (IV)  Alert prescribers to patients who fail to refill

1070

prescriptions in a timely fashion, are prescribed multiple same-

1071

class behavioral health drugs, and may have other potential

1072

medication problems.

1073

     (V)  Track spending trends for behavioral health drugs and

1074

deviation from best practice guidelines.

1075

     (VI)  Use educational and technological approaches to

1076

promote best practices, educate consumers, and train prescribers

1077

in the use of practice guidelines.

1078

     (VII)  Disseminate electronic and published materials.

1079

     (VIII)  Hold statewide and regional conferences.

1080

     (IX)  Implement a disease management program with a model

1081

quality-based medication component for severely mentally ill

1082

individuals and emotionally disturbed children who are high users

1083

of care.

1084

     11.a.  The agency shall implement a Medicaid prescription

1085

drug management system. The agency may contract with a vendor

1086

that has experience in operating prescription drug management

1087

systems in order to implement this system. Any management system

1088

that is implemented in accordance with this subparagraph must

1089

rely on cooperation between physicians and pharmacists to

1090

determine appropriate practice patterns and clinical guidelines

1091

to improve the prescribing, dispensing, and use of drugs in the

1092

Medicaid program. The agency may seek federal waivers to

1093

implement this program.

1094

     b.  The drug management system must be designed to improve

1095

the quality of care and prescribing practices based on best

1096

practice guidelines, improve patient adherence to medication

1097

plans, reduce clinical risk, and lower prescribed drug costs and

1098

the rate of inappropriate spending on Medicaid prescription

1099

drugs. The program must:

1100

     (I)  Provide for the development and adoption of best

1101

practice guidelines for the prescribing and use of drugs in the

1102

Medicaid program, including translating best practice guidelines

1103

into practice; reviewing prescriber patterns and comparing them

1104

to indicators that are based on national standards and practice

1105

patterns of clinical peers in their community, statewide, and

1106

nationally; and determine deviations from best practice

1107

guidelines.

1108

     (II)  Implement processes for providing feedback to and

1109

educating prescribers using best practice educational materials

1110

and peer-to-peer consultation.

1111

     (III)  Assess Medicaid recipients who are outliers in their

1112

use of a single or multiple prescription drugs with regard to the

1113

numbers and types of drugs taken, drug dosages, combination drug

1114

therapies, and other indicators of improper use of prescription

1115

drugs.

1116

     (IV)  Alert prescribers to patients who fail to refill

1117

prescriptions in a timely fashion, are prescribed multiple drugs

1118

that may be redundant or contraindicated, or may have other

1119

potential medication problems.

1120

     (V)  Track spending trends for prescription drugs and

1121

deviation from best practice guidelines.

1122

     (VI)  Use educational and technological approaches to

1123

promote best practices, educate consumers, and train prescribers

1124

in the use of practice guidelines.

1125

     (VII)  Disseminate electronic and published materials.

1126

     (VIII)  Hold statewide and regional conferences.

1127

     (IX)  Implement disease management programs in cooperation

1128

with physicians and pharmacists, along with a model quality-based

1129

medication component for individuals having chronic medical

1130

conditions.

1131

     12.  The agency is authorized to contract for drug rebate

1132

administration, including, but not limited to, calculating rebate

1133

amounts, invoicing manufacturers, negotiating disputes with

1134

manufacturers, and maintaining a database of rebate collections.

1135

     13.  The agency may specify the preferred daily dosing form

1136

or strength for the purpose of promoting best practices with

1137

regard to the prescribing of certain drugs as specified in the

1138

General Appropriations Act and ensuring cost-effective

1139

prescribing practices.

1140

     14.  The agency may require prior authorization for

1141

Medicaid-covered prescribed drugs. The agency may, but is not

1142

required to, prior-authorize the use of a product:

1143

     a.  For an indication not approved in labeling;

1144

     b.  To comply with certain clinical guidelines; or

1145

     c.  If the product has the potential for overuse, misuse, or

1146

abuse.

1147

1148

The agency may require the prescribing professional to provide

1149

information about the rationale and supporting medical evidence

1150

for the use of a drug. The agency may post prior authorization

1151

criteria and protocol and updates to the list of drugs that are

1152

subject to prior authorization on an Internet website without

1153

amending its rule or engaging in additional rulemaking.

1154

     15.  The agency, in conjunction with the Pharmaceutical and

1155

Therapeutics Committee, may require age-related prior

1156

authorizations for certain prescribed drugs. The agency may

1157

preauthorize the use of a drug for a recipient who may not meet

1158

the age requirement or may exceed the length of therapy for use

1159

of the this product as recommended by the manufacturer and

1160

approved by the Food and Drug Administration. Prior authorization

1161

may require the prescribing professional to provide information

1162

about the rationale and supporting medical evidence for the use

1163

of a drug.

1164

     16.  The agency shall implement a step-therapy prior

1165

authorization approval process for medications excluded from the

1166

preferred drug list. Medications listed on the preferred drug

1167

list must be used within the previous 12 months prior to the

1168

alternative medications that are not listed. The step-therapy

1169

prior authorization may require the prescriber to use the

1170

medications of a similar drug class or for a similar medical

1171

indication unless contraindicated in the Food and Drug

1172

Administration labeling. The trial period between the specified

1173

steps may vary according to the medical indication. The step-

1174

therapy approval process shall be developed in accordance with

1175

the committee as stated in s. 409.91195(7) and (8). A drug

1176

product may be approved without meeting the step-therapy prior

1177

authorization criteria if the prescribing physician provides the

1178

agency with additional written medical or clinical documentation

1179

that the product is medically necessary because:

1180

     a.  There is not a drug on the preferred drug list to treat

1181

the disease or medical condition which is an acceptable clinical

1182

alternative;

1183

     b.  The alternatives have been ineffective in the treatment

1184

of the beneficiary's disease; or

1185

     c.  Based on historic evidence and known characteristics of

1186

the patient and the drug, the drug is likely to be ineffective,

1187

or the number of doses have been ineffective.

1188

1189

The agency shall work with the physician to determine the best

1190

alternative for the patient. The agency may adopt rules waiving

1191

the requirements for written clinical documentation for specific

1192

drugs in limited clinical situations.

1193

     17.  The agency shall implement a return and reuse program

1194

for drugs dispensed by pharmacies to institutional recipients,

1195

which includes payment of a $5 restocking fee for the

1196

implementation and operation of the program. The return and reuse

1197

program shall be implemented electronically and in a manner that

1198

promotes efficiency. The program must permit a pharmacy to

1199

exclude drugs from the program if it is not practical or cost-

1200

effective for the drug to be included and must provide for the

1201

return to inventory of drugs that cannot be credited or returned

1202

in a cost-effective manner. The agency shall determine if the

1203

program has reduced the amount of Medicaid prescription drugs

1204

which are destroyed on an annual basis and if there are

1205

additional ways to ensure more prescription drugs are not

1206

destroyed which could safely be reused. The agency's conclusion

1207

and recommendations shall be reported to the Legislature by

1208

December 1, 2005.

1209

     (42) The agency may shall develop and implement a

1210

utilization management program for Medicaid-eligible recipients

1211

for the management of occupational, physical, respiratory, and

1212

speech therapies. The agency shall establish a utilization

1213

program that may require prior authorization in order to ensure

1214

medically necessary and cost-effective treatments. The program

1215

shall be operated in accordance with a federally approved waiver

1216

program or state plan amendment. The agency may seek a federal

1217

waiver or state plan amendment to implement this program. The

1218

agency may also competitively procure these services from an

1219

outside vendor on a regional or statewide basis.

1220

     Section 10.  Paragraphs (c), (e), (f), and (i) of subsection

1221

(2) of section 409.9122, Florida Statutes, are amended to read:

1222

     409.9122  Mandatory Medicaid managed care enrollment;

1223

programs and procedures.--

1224

     (2)

1225

     (c)  Medicaid recipients shall have a choice of managed care

1226

plans or MediPass. The agency for Health Care Administration, the

1227

Department of Health, the Department of Children and Family

1228

Services, and the Department of Elderly Affairs shall cooperate

1229

to ensure that each Medicaid recipient receives clear and easily

1230

understandable information that meets the following requirements:

1231

     1.  Explains the concept of managed care, including

1232

MediPass.

1233

     2.  Provides information on the comparative performance of

1234

managed care plans and MediPass in the areas of quality,

1235

credentialing, preventive health programs, network size and

1236

availability, and patient satisfaction.

1237

     3.  Explains where additional information on each managed

1238

care plan and MediPass in the recipient's area can be obtained.

1239

     4.  Explains that recipients have the right to choose their

1240

own managed care coverage at the time they first enroll in

1241

Medicaid and again at regular intervals set by the agency plans

1242

or MediPass. However, if a recipient does not choose a managed

1243

care plan or MediPass, the agency will assign the recipient to a

1244

managed care plan or MediPass according to the criteria specified

1245

in this section.

1246

     5.  Explains the recipient's right to complain, file a

1247

grievance, or change managed care plans or MediPass providers if

1248

the recipient is not satisfied with the managed care plan or

1249

MediPass.

1250

     (e)  Medicaid recipients who are already enrolled in a

1251

managed care plan or MediPass shall be offered the opportunity to

1252

change managed care plans or MediPass providers on a staggered

1253

basis, as defined by the agency. All Medicaid recipients shall

1254

have 30 days in which to make a choice of managed care plans or

1255

MediPass providers. A recipient already enrolled in a managed

1256

care plan who fails to make a choice during the 30-day choice

1257

period shall remain enrolled in his or her current managed care

1258

plan. In counties that have two or more managed care plans, a

1259

recipient already enrolled in MediPass who fails to make a choice

1260

during the annual period shall be assigned to a managed care plan

1261

if he or she is eligible for enrollment in the managed care plan.

1262

The agency shall apply for a state plan amendment or federal

1263

waiver authority, if necessary, to implement the provisions of

1264

this paragraph. Those Medicaid recipients who do not make a

1265

choice shall be assigned to a managed care plan or MediPass in

1266

accordance with paragraph (f). To facilitate continuity of care,

1267

for a Medicaid recipient who is also a recipient of Supplemental

1268

Security Income (SSI), prior to assigning the SSI recipient to a

1269

managed care plan or MediPass, the agency shall determine whether

1270

the SSI recipient has an ongoing relationship with a MediPass

1271

provider or managed care plan, and if so, the agency shall assign

1272

the SSI recipient to that MediPass provider or managed care plan.

1273

If the SSI recipient has an ongoing relationship with a managed

1274

care plan, the agency shall assign the recipient to that managed

1275

care plan. Those SSI recipients who do not have such a provider

1276

relationship shall be assigned to a managed care plan or MediPass

1277

provider in accordance with paragraph (f).

1278

     (f) If When a Medicaid recipient does not choose a managed

1279

care plan or MediPass provider, the agency shall assign the

1280

Medicaid recipient to a managed care plan or MediPass provider.

1281

Medicaid recipients, eligible for managed care plan enrollment,

1282

who are subject to mandatory assignment but who fail to make a

1283

choice shall be assigned to managed care plans until an

1284

enrollment of 35 percent in MediPass and 65 percent in managed

1285

care plans, of all those eligible to choose managed care, is

1286

achieved. Once this enrollment is achieved, the assignments shall

1287

be divided in order to maintain an enrollment in MediPass and

1288

managed care plans which is in a 35 percent and 65 percent

1289

proportion, respectively. Thereafter, assignment of Medicaid

1290

recipients who fail to make a choice shall be based

1291

proportionally on the preferences of recipients who have made a

1292

choice in the previous period. Such proportions shall be revised

1293

at least quarterly to reflect an update of the preferences of

1294

Medicaid recipients. The agency shall disproportionately assign

1295

Medicaid-eligible recipients who are required to but have failed

1296

to make a choice of managed care plan or MediPass, including

1297

children, and who would are to be assigned to the MediPass

1298

program to children's networks as described in s. 409.912(4)(g),

1299

Children's Medical Services Network as defined in s. 391.021,

1300

exclusive provider organizations, provider service networks,

1301

minority physician networks, and pediatric emergency department

1302

diversion programs authorized by this chapter or the General

1303

Appropriations Act, in such manner as the agency deems

1304

appropriate, until the agency has determined that the networks

1305

and programs have sufficient numbers to be operated economically

1306

operated. For purposes of this paragraph, when referring to

1307

assignment, the term "managed care plans" includes health

1308

maintenance organizations, exclusive provider organizations,

1309

provider service networks, minority physician networks,

1310

Children's Medical Services Network, and pediatric emergency

1311

department diversion programs authorized by this chapter or the

1312

General Appropriations Act. When making assignments, the agency

1313

shall take into account the following criteria:

1314

     1.  A managed care plan has sufficient network capacity to

1315

meet the need of members.

1316

     2.  The managed care plan or MediPass has previously

1317

enrolled the recipient as a member, or one of the managed care

1318

plan's primary care providers or MediPass providers has

1319

previously provided health care to the recipient.

1320

     3.  The agency has knowledge that the member has previously

1321

expressed a preference for a particular managed care plan or

1322

MediPass provider as indicated by Medicaid fee-for-service claims

1323

data, but has failed to make a choice.

1324

     4.  The managed care plan's or MediPass primary care

1325

providers are geographically accessible to the recipient's

1326

residence.

1327

     (i) After a recipient has made his or her initial a

1328

selection or has been notified of his or her initial assignment

1329

to enrolled in a managed care plan or MediPass, the recipient

1330

shall have 90 days to exercise the opportunity in which to

1331

voluntarily disenroll and select another managed care option plan

1332

or MediPass provider. After 90 days, no further changes may be

1333

made except for cause. Good cause includes shall include, but is

1334

not be limited to, poor quality of care, lack of access to

1335

necessary specialty services, an unreasonable delay or denial of

1336

service, or fraudulent enrollment. The agency shall develop

1337

criteria for good cause disenrollment for chronically ill and

1338

disabled populations who are assigned to managed care plans if

1339

more appropriate care is available through the MediPass program.

1340

The agency must make a determination as to whether cause exists.

1341

However, the agency may require a recipient to use the managed

1342

care plan's or MediPass grievance process prior to the agency's

1343

determination of cause, except in cases in which immediate risk

1344

of permanent damage to the recipient's health is alleged. The

1345

grievance process, when utilized, must be completed in time to

1346

permit the recipient to disenroll by no later than the first day

1347

of the second month after the month the disenrollment request was

1348

made. If the managed care plan or MediPass, as a result of the

1349

grievance process, approves an enrollee's request to disenroll,

1350

the agency is not required to make a determination in the case.

1351

The agency must make a determination and take final action on a

1352

recipient's request so that disenrollment occurs by no later than

1353

the first day of the second month after the month the request was

1354

made. If the agency fails to act within the specified timeframe,

1355

the recipient's request to disenroll is deemed to be approved as

1356

of the date agency action was required. Recipients who disagree

1357

with the agency's finding that cause does not exist for

1358

disenrollment shall be advised of their right to pursue a

1359

Medicaid fair hearing to dispute the agency's finding.

1360

     Section 11. Paragraph (c) of subsection (5) of section

1361

409.905 and section 430.83, Florida Statutes, are repealed.

1362

     Section 12.  This act shall take effect July 1, 2008.