CS for SB 1854 First Engrossed
20081854e1
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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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400.179, F.S.; authorizing the Agency for Health Care
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Administration to transfer fees used to repay nursing home
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Medicaid overpayments to the Grants and Donations Trust
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Fund within the agency; amending s. 409.904, F.S.;
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discontinuing optional Medicaid payments for certain
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persons age 65 or over or who are blind or disabled;
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revising certain eligibility criteria for pregnant women
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and children younger than 21; amending s. 409.906, F.S.;
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discontinuing adult dental services and adult hearing
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services on a certain date; amending s. 409.908, F.S.;
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requiring Medicaid to pay for all deductibles and
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coinsurance for portable X-ray Medicare Part B services
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provided in a nursing home; revising the factors used to
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determine the reimbursement rate to providers for Medicaid
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prescribed drugs; requiring the agency to reduce certain
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provider reimbursement rates as prescribed in the
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appropriations act; providing that any increases in rates
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as subject to the appropriations act; amending s. 409.911,
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F.S.; revising which year's disproportionate data is used
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to determine a hospital's Medicaid days and charity care
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during the 2008-2009 fiscal year; creating s. 409.91206,
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F.S.; authorizing the Governor and the Legislature to
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convene workgroups to propose alternatives for cost-
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effective health and long-term care reforms; amending s.
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409.9112, F.S.; prohibiting the Agency for Health Care
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Administration from distributing moneys under the regional
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perinatal intensive care disproportionate share program
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during the 2008-2009 fiscal year; amending s. 409.9113,
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F.S.; authorizing the agency to distribute
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disproportionate share funds to teaching hospital during
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the 2008-2009 fiscal year; providing that such funds may
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be distributed as provided in the appropriations act;
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amending s. 409.9117, F.S.; prohibiting the distribution
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of funds under the primary disproportionate share program
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during the 2008-2009 fiscal year; amending s. 409.912,
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F.S.; specifying certain counties that are exempt from the
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requirement of enrolling Medicaid eligible children in
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MediPass or Medicaid fee-for-service and behavioral health
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care services; revising the factors used to determine the
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reimbursement rate to pharmacies for Medicaid prescribed
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drugs; revising the requirement for the agency to develop
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a utilization management program for Medicaid recipients
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for certain therapies; amending s. 409.9122, F.S.;
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revising enrollment requirements relating to Medicaid
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managed care programs and the agency's authority to assign
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persons to MediPass or a managed care plan; repealing s.
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409.905(5)(c), F.S., relating to the agency's authority to
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adjust a hospital's inpatient per diem rate; repealing s.
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430.83, F.S., relating to the Sunshine for Seniors
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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. Paragraph (d) of subsection (2) of section
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400.179, Florida Statutes, is amended to read:
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400.179 Liability for Medicaid underpayments and
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overpayments.--
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(2) Because any transfer of a nursing facility may expose
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the fact that Medicaid may have underpaid or overpaid the
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transferor, and because in most instances, any such underpayment
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or overpayment can only be determined following a formal field
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audit, the liabilities for any such underpayments or overpayments
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shall be as follows:
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(d) Where the transfer involves a facility that has been
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leased by the transferor:
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1. The transferee shall, as a condition to being issued a
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license by the agency, acquire, maintain, and provide proof to
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the agency of a bond with a term of 30 months, renewable
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annually, in an amount not less than the total of 3 months'
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Medicaid payments to the facility computed on the basis of the
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preceding 12-month average Medicaid payments to the facility.
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2. A leasehold licensee may meet the requirements of
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subparagraph 1. by payment of a nonrefundable fee, paid at
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initial licensure, paid at the time of any subsequent change of
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ownership, and paid annually thereafter, in the amount of 1
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percent of the total of 3 months' Medicaid payments to the
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facility computed on the basis of the preceding 12-month average
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Medicaid payments to the facility. If a preceding 12-month
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average is not available, projected Medicaid payments may be
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used. The fee shall be deposited into the Health Care Trust Fund
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and shall be accounted for separately as a Medicaid nursing home
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overpayment account. These fees shall be used at the sole
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discretion of the agency to repay nursing home Medicaid
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overpayments. The agency may transfer funds to the Grants and
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Donations Trust Fund for such repayments. Payment of this fee
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shall not release the licensee from any liability for any
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Medicaid overpayments, nor shall payment bar the agency from
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seeking to recoup overpayments from the licensee and any other
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liable party. As a condition of exercising this lease bond
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alternative, licensees paying this fee must maintain an existing
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lease bond through the end of the 30-month term period of that
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bond. The agency is herein granted specific authority to
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promulgate all rules pertaining to the administration and
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management of this account, including withdrawals from the
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account, subject to federal review and approval. This provision
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shall take effect upon becoming law and shall apply to any
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leasehold license application. The financial viability of the
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Medicaid nursing home overpayment account shall be determined by
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the agency through annual review of the account balance and the
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amount of total outstanding, unpaid Medicaid overpayments owing
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from leasehold licensees to the agency as determined by final
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agency audits.
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3. The leasehold licensee may meet the bond requirement
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through other arrangements acceptable to the agency. The agency
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is herein granted specific authority to promulgate rules
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pertaining to lease bond arrangements.
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4. All existing nursing facility licensees, operating the
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facility as a leasehold, shall acquire, maintain, and provide
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proof to the agency of the 30-month bond required in subparagraph
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1., above, on and after July 1, 1993, for each license renewal.
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5. It shall be the responsibility of all nursing facility
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operators, operating the facility as a leasehold, to renew the
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30-month bond and to provide proof of such renewal to the agency
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annually.
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6. Any failure of the nursing facility operator to acquire,
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maintain, renew annually, or provide proof to the agency shall be
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grounds for the agency to deny, revoke, and suspend the facility
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license to operate such facility and to take any further action,
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including, but not limited to, enjoining the facility, asserting
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a moratorium pursuant to part II of chapter 408, or applying for
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a receiver, deemed necessary to ensure compliance with this
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section and to safeguard and protect the health, safety, and
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welfare of the facility's residents. A lease agreement required
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as a condition of bond financing or refinancing under s. 154.213
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by a health facilities authority or required under s. 159.30 by a
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county or municipality is not a leasehold for purposes of this
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paragraph and is not subject to the bond requirement of this
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paragraph.
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Section 2. 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 3. 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 and related
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services for adults.
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Section 4. 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 5. 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 6. 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 7. 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.
514
2. The number of medical students enrolled in accredited
515
colleges of medicine and engaged in clinical activities,
516
including required clinical clerkships and clinical electives.
517
Full-time equivalents are computed using the fraction of the year
518
during which each trainee is primarily assigned to the given
519
institution, over the course of the state fiscal year preceding
520
the date on which the allocation fraction is calculated. The
521
numerical value of this factor is the fraction that the given
522
hospital represents of the total number of full-time equivalent
523
students enrolled in accredited colleges of medicine, where the
524
total is computed for all state statutory teaching hospitals.
525
526
The primary factor for full-time equivalent trainees is computed
527
as the sum of these two components, divided by two.
528
(c) A service index that comprises three components:
529
1. The Agency for Health Care Administration Service Index,
530
computed by applying the standard Service Inventory Scores
531
established by the agency for Health Care Administration to
532
services offered by the given hospital, as reported on Worksheet
533
A-2 for the last fiscal year reported to the agency before the
534
date on which the allocation fraction is calculated. The
535
numerical value of this factor is the fraction that the given
536
hospital represents of the total Agency for Health Care
537
Administration Service Index values, where the total is computed
538
for all state statutory teaching hospitals.
539
2. A volume-weighted service index, computed by applying
540
the standard Service Inventory Scores established by the agency
541
for Health Care Administration to the volume of each service,
542
expressed in terms of the standard units of measure reported on
543
Worksheet A-2 for the last fiscal year reported to the agency
544
before the date on which the allocation factor is calculated. The
545
numerical value of this factor is the fraction that the given
546
hospital represents of the total volume-weighted service index
547
values, where the total is computed for all state statutory
548
teaching hospitals.
549
3. Total Medicaid payments to each hospital for direct
550
inpatient and outpatient services during the fiscal year
551
preceding the date on which the allocation factor is calculated.
552
This includes payments made to each hospital for such services by
553
Medicaid prepaid health plans, whether the plan was administered
554
by the hospital or not. The numerical value of this factor is the
555
fraction that each hospital represents of the total of such
556
Medicaid payments, where the total is computed for all state
557
statutory teaching hospitals.
558
559
The primary factor for the service index is computed as the sum
560
of these three components, divided by three.
561
(2) By October 1 of each year, the agency shall use the
562
following formula to calculate the maximum additional
563
disproportionate share payment for statutorily defined teaching
564
hospitals:
565
566
TAP = THAF x A
567
568
Where:
569
TAP = total additional payment.
570
THAF = teaching hospital allocation factor.
571
A = amount appropriated for a teaching hospital
572
disproportionate share program.
573
Section 8. Section 409.9117, Florida Statutes, is amended
574
to read:
575
409.9117 Primary care disproportionate share program.--For
576
the 2008-2009 state fiscal year 2006-2007, the agency may shall
577
not distribute moneys under the primary care disproportionate
578
share program.
579
(1) If federal funds are available for disproportionate
580
share programs in addition to those otherwise provided by law,
581
there shall be created a primary care disproportionate share
582
program.
583
(2) The following formula shall be used by the agency to
584
calculate the total amount earned for hospitals that participate
585
in the primary care disproportionate share program:
586
587
TAE = HDSP/THDSP
588
589
Where:
590
TAE = total amount earned by a hospital participating in the
591
primary care disproportionate share program.
592
HDSP = the prior state fiscal year primary care
593
disproportionate share payment to the individual hospital.
594
THDSP = the prior state fiscal year total primary care
595
disproportionate share payments to all hospitals.
596
(3) The total additional payment for hospitals that
597
participate in the primary care disproportionate share program
598
shall be calculated by the agency as follows:
599
600
TAP = TAE x TA
601
602
Where:
603
TAP = total additional payment for a primary care hospital.
604
TAE = total amount earned by a primary care hospital.
605
TA = total appropriation for the primary care
606
disproportionate share program.
607
(4) In establishing the establishment and funding of this
608
program, the agency shall use the following criteria in addition
609
to those specified in s. 409.911, and payments may not be made to
610
a hospital unless the hospital agrees to:
611
(a) Cooperate with a Medicaid prepaid health plan, if one
612
exists in the community.
613
(b) Ensure the availability of primary and specialty care
614
physicians to Medicaid recipients who are not enrolled in a
615
prepaid capitated arrangement and who are in need of access to
616
such physicians.
617
(c) Coordinate and provide primary care services free of
618
charge, except copayments, to all persons with incomes up to 100
619
percent of the federal poverty level who are not otherwise
620
covered by Medicaid or another program administered by a
621
governmental entity, and to provide such services based on a
622
sliding fee scale to all persons with incomes up to 200 percent
623
of the federal poverty level who are not otherwise covered by
624
Medicaid or another program administered by a governmental
625
entity, except that eligibility may be limited to persons who
626
reside within a more limited area, as agreed to by the agency and
627
the hospital.
628
(d) Contract with any federally qualified health center, if
629
one exists within the agreed geopolitical boundaries, concerning
630
the provision of primary care services, in order to guarantee
631
delivery of services in a nonduplicative fashion, and to provide
632
for referral arrangements, privileges, and admissions, as
633
appropriate. The hospital shall agree to provide at an onsite or
634
offsite facility primary care services within 24 hours to which
635
all Medicaid recipients and persons eligible under this paragraph
636
who do not require emergency room services are referred during
637
normal daylight hours.
638
(e) Cooperate with the agency, the county, and other
639
entities to ensure the provision of certain public health
640
services, case management, referral and acceptance of patients,
641
and sharing of epidemiological data, as the agency and the
642
hospital find mutually necessary and desirable to promote and
643
protect the public health within the agreed geopolitical
644
boundaries.
645
(f) In cooperation with the county in which the hospital
646
resides, develop a low-cost, outpatient, prepaid health care
647
program to persons who are not eligible for the Medicaid program,
648
and who reside within the area.
649
(g) Provide inpatient services to residents within the area
650
who are not eligible for Medicaid or Medicare, and who do not
651
have private health insurance, regardless of ability to pay, on
652
the basis of available space, except that nothing shall prevent
653
the hospital from establishing bill collection programs based on
654
ability to pay.
655
(h) Work with the Florida Healthy Kids Corporation, the
656
Florida Health Care Purchasing Cooperative, and business health
657
coalitions, as appropriate, to develop a feasibility study and
658
plan to provide a low-cost comprehensive health insurance plan to
659
persons who reside within the area and who do not have access to
660
such a plan.
661
(i) Work with public health officials and other experts to
662
provide community health education and prevention activities
663
designed to promote healthy lifestyles and appropriate use of
664
health services.
665
(j) Work with the local health council to develop a plan
666
for promoting access to affordable health care services for all
667
persons who reside within the area, including, but not limited
668
to, public health services, primary care services, inpatient
669
services, and affordable health insurance generally.
670
671
Any hospital that fails to comply with any of the provisions of
672
this subsection, or any other contractual condition, may not
673
receive payments under this section until full compliance is
674
achieved.
675
Section 9. Paragraph (b) of subsection (4), paragraph (a)
676
of subsection (39), and subsection (42) of section 409.912,
677
Florida Statutes, are amended to read:
678
409.912 Cost-effective purchasing of health care.--The
679
agency shall purchase goods and services for Medicaid recipients
680
in the most cost-effective manner consistent with the delivery of
681
quality medical care. To ensure that medical services are
682
effectively utilized, the agency may, in any case, require a
683
confirmation or second physician's opinion of the correct
684
diagnosis for purposes of authorizing future services under the
685
Medicaid program. This section does not restrict access to
686
emergency services or poststabilization care services as defined
687
in 42 C.F.R. part 438.114. Such confirmation or second opinion
688
shall be rendered in a manner approved by the agency. The agency
689
shall maximize the use of prepaid per capita and prepaid
690
aggregate fixed-sum basis services when appropriate and other
691
alternative service delivery and reimbursement methodologies,
692
including competitive bidding pursuant to s. 287.057, designed to
693
facilitate the cost-effective purchase of a case-managed
694
continuum of care. The agency shall also require providers to
695
minimize the exposure of recipients to the need for acute
696
inpatient, custodial, and other institutional care and the
697
inappropriate or unnecessary use of high-cost services. The
698
agency shall contract with a vendor to monitor and evaluate the
699
clinical practice patterns of providers in order to identify
700
trends that are outside the normal practice patterns of a
701
provider's professional peers or the national guidelines of a
702
provider's professional association. The vendor must be able to
703
provide information and counseling to a provider whose practice
704
patterns are outside the norms, in consultation with the agency,
705
to improve patient care and reduce inappropriate utilization. The
706
agency may mandate prior authorization, drug therapy management,
707
or disease management participation for certain populations of
708
Medicaid beneficiaries, certain drug classes, or particular drugs
709
to prevent fraud, abuse, overuse, and possible dangerous drug
710
interactions. The Pharmaceutical and Therapeutics Committee shall
711
make recommendations to the agency on drugs for which prior
712
authorization is required. The agency shall inform the
713
Pharmaceutical and Therapeutics Committee of its decisions
714
regarding drugs subject to prior authorization. The agency is
715
authorized to limit the entities it contracts with or enrolls as
716
Medicaid providers by developing a provider network through
717
provider credentialing. The agency may competitively bid single-
718
source-provider contracts if procurement of goods or services
719
results in demonstrated cost savings to the state without
720
limiting access to care. The agency may limit its network based
721
on the assessment of beneficiary access to care, provider
722
availability, provider quality standards, time and distance
723
standards for access to care, the cultural competence of the
724
provider network, demographic characteristics of Medicaid
725
beneficiaries, practice and provider-to-beneficiary standards,
726
appointment wait times, beneficiary use of services, provider
727
turnover, provider profiling, provider licensure history,
728
previous program integrity investigations and findings, peer
729
review, provider Medicaid policy and billing compliance records,
730
clinical and medical record audits, and other factors. Providers
731
shall not be entitled to enrollment in the Medicaid provider
732
network. The agency shall determine instances in which allowing
733
Medicaid beneficiaries to purchase durable medical equipment and
734
other goods is less expensive to the Medicaid program than long-
735
term rental of the equipment or goods. The agency may establish
736
rules to facilitate purchases in lieu of long-term rentals in
737
order to protect against fraud and abuse in the Medicaid program
738
as defined in s. 409.913. The agency may seek federal waivers
739
necessary to administer these policies.
740
(4) The agency may contract with:
741
(b) An entity that is providing comprehensive behavioral
742
health care services to certain Medicaid recipients through a
743
capitated, prepaid arrangement pursuant to the federal waiver
744
provided for by s. 409.905(5). Such an entity must be licensed
745
under chapter 624, chapter 636, or chapter 641 and must possess
746
the clinical systems and operational competence to manage risk
747
and provide comprehensive behavioral health care to Medicaid
748
recipients. As used in this paragraph, the term "comprehensive
749
behavioral health care services" means covered mental health and
750
substance abuse treatment services that are available to Medicaid
751
recipients. The secretary of the Department of Children and
752
Family Services shall approve provisions of procurements related
753
to children in the department's care or custody prior to
754
enrolling such children in a prepaid behavioral health plan. Any
755
contract awarded under this paragraph must be competitively
756
procured. In developing the behavioral health care prepaid plan
757
procurement document, the agency shall ensure that the
758
procurement document requires the contractor to develop and
759
implement a plan to ensure compliance with s. 394.4574 related to
760
services provided to residents of licensed assisted living
761
facilities that hold a limited mental health license. Except as
762
provided in subparagraph 8., and except in counties where the
763
Medicaid managed care pilot program is authorized pursuant to s.
764
409.91211, the agency shall seek federal approval to contract
765
with a single entity meeting these requirements to provide
766
comprehensive behavioral health care services to all Medicaid
767
recipients not enrolled in a Medicaid managed care plan
768
authorized under s. 409.91211 or a Medicaid health maintenance
769
organization in an AHCA area. In an AHCA area where the Medicaid
770
managed care pilot program is authorized pursuant to s. 409.91211
771
in one or more counties, the agency may procure a contract with a
772
single entity to serve the remaining counties as an AHCA area or
773
the remaining counties may be included with an adjacent AHCA area
774
and shall be subject to this paragraph. Each entity must offer
775
sufficient choice of providers in its network to ensure recipient
776
access to care and the opportunity to select a provider with whom
777
they are satisfied. The network shall include all public mental
778
health hospitals. To ensure unimpaired access to behavioral
779
health care services by Medicaid recipients, all contracts issued
780
pursuant to this paragraph shall require 80 percent of the
781
capitation paid to the managed care plan, including health
782
maintenance organizations, to be expended for the provision of
783
behavioral health care services. In the event the managed care
784
plan expends less than 80 percent of the capitation paid pursuant
785
to this paragraph for the provision of behavioral health care
786
services, the difference shall be returned to the agency. The
787
agency shall provide the managed care plan with a certification
788
letter indicating the amount of capitation paid during each
789
calendar year for the provision of behavioral health care
790
services pursuant to this section. The agency may reimburse for
791
substance abuse treatment services on a fee-for-service basis
792
until the agency finds that adequate funds are available for
793
capitated, prepaid arrangements.
794
1. By January 1, 2001, the agency shall modify the
795
contracts with the entities providing comprehensive inpatient and
796
outpatient mental health care services to Medicaid recipients in
797
Hillsborough, Highlands, Hardee, Manatee, and Polk Counties, to
798
include substance abuse treatment services.
799
2. By July 1, 2003, the agency and the Department of
800
Children and Family Services shall execute a written agreement
801
that requires collaboration and joint development of all policy,
802
budgets, procurement documents, contracts, and monitoring plans
803
that have an impact on the state and Medicaid community mental
804
health and targeted case management programs.
805
3. Except as provided in subparagraph 8., by July 1, 2006,
806
the agency and the Department of Children and Family Services
807
shall contract with managed care entities in each AHCA area
808
except area 6 or arrange to provide comprehensive inpatient and
809
outpatient mental health and substance abuse services through
810
capitated prepaid arrangements to all Medicaid recipients who are
811
eligible to participate in such plans under federal law and
812
regulation. In AHCA areas where eligible individuals number less
813
than 150,000, the agency shall contract with a single managed
814
care plan to provide comprehensive behavioral health services to
815
all recipients who are not enrolled in a Medicaid health
816
maintenance organization or a Medicaid capitated managed care
817
plan authorized under s. 409.91211. The agency may contract with
818
more than one comprehensive behavioral health provider to provide
819
care to recipients who are not enrolled in a Medicaid capitated
820
managed care plan authorized under s. 409.91211 or a Medicaid
821
health maintenance organization in AHCA areas where the eligible
822
population exceeds 150,000. In an AHCA area where the Medicaid
823
managed care pilot program is authorized pursuant to s. 409.91211
824
in one or more counties, the agency may procure a contract with a
825
single entity to serve the remaining counties as an AHCA area or
826
the remaining counties may be included with an adjacent AHCA area
827
and shall be subject to this paragraph. Contracts for
828
comprehensive behavioral health providers awarded pursuant to
829
this section shall be competitively procured. Both for-profit and
830
not-for-profit corporations shall be eligible to compete. Managed
831
care plans contracting with the agency under subsection (3) shall
832
provide and receive payment for the same comprehensive behavioral
833
health benefits as provided in AHCA rules, including handbooks
834
incorporated by reference. In AHCA area 11, the agency shall
835
contract with at least two comprehensive behavioral health care
836
providers to provide behavioral health care to recipients in that
837
area who are enrolled in, or assigned to, the MediPass program.
838
One of the behavioral health care contracts shall be with the
839
existing provider service network pilot project, as described in
840
paragraph (d), for the purpose of demonstrating the cost-
841
effectiveness of the provision of quality mental health services
842
through a public hospital-operated managed care model. Payment
843
shall be at an agreed-upon capitated rate to ensure cost savings.
844
Of the recipients in area 11 who are assigned to MediPass under
845
the provisions of s. 409.9122(2)(k), a minimum of 50,000 of those
846
MediPass-enrolled recipients shall be assigned to the existing
847
provider service network in area 11 for their behavioral care.
848
4. By October 1, 2003, the agency and the department shall
849
submit a plan to the Governor, the President of the Senate, and
850
the Speaker of the House of Representatives which provides for
851
the full implementation of capitated prepaid behavioral health
852
care in all areas of the state.
853
a. Implementation shall begin in 2003 in those AHCA areas
854
of the state where the agency is able to establish sufficient
855
capitation rates.
856
b. If the agency determines that the proposed capitation
857
rate in any area is insufficient to provide appropriate services,
858
the agency may adjust the capitation rate to ensure that care
859
will be available. The agency and the department may use existing
860
general revenue to address any additional required match but may
861
not over-obligate existing funds on an annualized basis.
862
c. Subject to any limitations provided for in the General
863
Appropriations Act, the agency, in compliance with appropriate
864
federal authorization, shall develop policies and procedures that
865
allow for certification of local and state funds.
866
5. Children residing in a statewide inpatient psychiatric
867
program, or in a Department of Juvenile Justice or a Department
868
of Children and Family Services residential program approved as a
869
Medicaid behavioral health overlay services provider shall not be
870
included in a behavioral health care prepaid health plan or any
871
other Medicaid managed care plan pursuant to this paragraph.
872
6. In converting to a prepaid system of delivery, the
873
agency shall in its procurement document require an entity
874
providing only comprehensive behavioral health care services to
875
prevent the displacement of indigent care patients by enrollees
876
in the Medicaid prepaid health plan providing behavioral health
877
care services from facilities receiving state funding to provide
878
indigent behavioral health care, to facilities licensed under
879
chapter 395 which do not receive state funding for indigent
880
behavioral health care, or reimburse the unsubsidized facility
881
for the cost of behavioral health care provided to the displaced
882
indigent care patient.
883
7. Traditional community mental health providers under
884
contract with the Department of Children and Family Services
885
pursuant to part IV of chapter 394, child welfare providers under
886
contract with the Department of Children and Family Services in
887
areas 1 and 6, and inpatient mental health providers licensed
888
pursuant to chapter 395 must be offered an opportunity to accept
889
or decline a contract to participate in any provider network for
890
prepaid behavioral health services.
891
8. For fiscal year 2004-2005, all Medicaid eligible
892
children, except children in areas 1 and Highland, Hardee, Polk,
893
and Manatee counties of area 6, whose cases are open for child
894
welfare services in the HomeSafeNet system, shall be enrolled in
895
MediPass or in Medicaid fee-for-service and all their behavioral
896
health care services including inpatient, outpatient psychiatric,
897
community mental health, and case management shall be reimbursed
898
on a fee-for-service basis. Beginning July 1, 2005, such
899
children, who are open for child welfare services in the
900
HomeSafeNet system, shall receive their behavioral health care
901
services through a specialty prepaid plan operated by community-
902
based lead agencies either through a single agency or formal
903
agreements among several agencies. The specialty prepaid plan
904
must result in savings to the state comparable to savings
905
achieved in other Medicaid managed care and prepaid programs.
906
Such plan must provide mechanisms to maximize state and local
907
revenues. The specialty prepaid plan shall be developed by the
908
agency and the Department of Children and Family Services. The
909
agency is authorized to seek any federal waivers to implement
910
this initiative. Medicaid-eligible children whose cases are open
911
for child welfare services in the HomeSafeNet system and who
912
reside in AHCA area 10 are exempt from the specialty prepaid plan
913
upon the development of a service delivery mechanism for children
914
who reside in area 10 as specified in s. 409.91211(3)(dd).
915
(39)(a) The agency shall implement a Medicaid prescribed-
916
drug spending-control program that includes the following
917
components:
918
1. A Medicaid preferred drug list, which shall be a listing
919
of cost-effective therapeutic options recommended by the Medicaid
920
Pharmacy and Therapeutics Committee established pursuant to s.
921
409.91195 and adopted by the agency for each therapeutic class on
922
the preferred drug list. At the discretion of the committee, and
923
when feasible, the preferred drug list should include at least
924
two products in a therapeutic class. The agency may post the
925
preferred drug list and updates to the preferred drug list on an
926
Internet website without following the rulemaking procedures of
927
chapter 120. Antiretroviral agents are excluded from the
928
preferred drug list. The agency shall also limit the amount of a
929
prescribed drug dispensed to no more than a 34-day supply unless
930
the drug products' smallest marketed package is greater than a
931
34-day supply, or the drug is determined by the agency to be a
932
maintenance drug in which case a 100-day maximum supply may be
933
authorized. The agency is authorized to seek any federal waivers
934
necessary to implement these cost-control programs and to
935
continue participation in the federal Medicaid rebate program, or
936
alternatively to negotiate state-only manufacturer rebates. The
937
agency may adopt rules to implement this subparagraph. The agency
938
shall continue to provide unlimited contraceptive drugs and
939
items. The agency must establish procedures to ensure that:
940
a. There is will be a response to a request for prior
941
consultation by telephone or other telecommunication device
942
within 24 hours after receipt of a request for prior
943
consultation; and
944
b. A 72-hour supply of the drug prescribed is will be
945
provided in an emergency or when the agency does not provide a
946
response within 24 hours as required by sub-subparagraph a.
947
2. Reimbursement to pharmacies for Medicaid prescribed
948
drugs shall be set at the lesser of: the average wholesale price
949
(AWP) minus 16.4 15.4 percent, the wholesaler acquisition cost
950
(WAC) plus 4.75 5.75 percent, the federal upper limit (FUL), the
951
state maximum allowable cost (SMAC), or the usual and customary
952
(UAC) charge billed by the provider.
953
3. The agency shall develop and implement a process for
954
managing the drug therapies of Medicaid recipients who are using
955
significant numbers of prescribed drugs each month. The
956
management process may include, but is not limited to,
957
comprehensive, physician-directed medical-record reviews, claims
958
analyses, and case evaluations to determine the medical necessity
959
and appropriateness of a patient's treatment plan and drug
960
therapies. The agency may contract with a private organization to
961
provide drug-program-management services. The Medicaid drug
962
benefit management program shall include initiatives to manage
963
drug therapies for HIV/AIDS patients, patients using 20 or more
964
unique prescriptions in a 180-day period, and the top 1,000
965
patients in annual spending. The agency shall enroll any Medicaid
966
recipient in the drug benefit management program if he or she
967
meets the specifications of this provision and is not enrolled in
968
a Medicaid health maintenance organization.
969
4. The agency may limit the size of its pharmacy network
970
based on need, competitive bidding, price negotiations,
971
credentialing, or similar criteria. The agency shall give special
972
consideration to rural areas in determining the size and location
973
of pharmacies included in the Medicaid pharmacy network. A
974
pharmacy credentialing process may include criteria such as a
975
pharmacy's full-service status, location, size, patient
976
educational programs, patient consultation, disease management
977
services, and other characteristics. The agency may impose a
978
moratorium on Medicaid pharmacy enrollment when it is determined
979
that it has a sufficient number of Medicaid-participating
980
providers. The agency must allow dispensing practitioners to
981
participate as a part of the Medicaid pharmacy network regardless
982
of the practitioner's proximity to any other entity that is
983
dispensing prescription drugs under the Medicaid program. A
984
dispensing practitioner must meet all credentialing requirements
985
applicable to his or her practice, as determined by the agency.
986
5. The agency shall develop and implement a program that
987
requires Medicaid practitioners who prescribe drugs to use a
988
counterfeit-proof prescription pad for Medicaid prescriptions.
989
The agency shall require the use of standardized counterfeit-
990
proof prescription pads by Medicaid-participating prescribers or
991
prescribers who write prescriptions for Medicaid recipients. The
992
agency may implement the program in targeted geographic areas or
993
statewide.
994
6. The agency may enter into arrangements that require
995
manufacturers of generic drugs prescribed to Medicaid recipients
996
to provide rebates of at least 15.1 percent of the average
997
manufacturer price for the manufacturer's generic products. These
998
arrangements shall require that if a generic-drug manufacturer
999
pays federal rebates for Medicaid-reimbursed drugs at a level
1000
below 15.1 percent, the manufacturer must provide a supplemental
1001
rebate to the state in an amount necessary to achieve a 15.1-
1002
percent rebate level.
1003
7. The agency may establish a preferred drug list as
1004
described in this subsection, and, pursuant to the establishment
1005
of such preferred drug list, it is authorized to negotiate
1006
supplemental rebates from manufacturers that are in addition to
1007
those required by Title XIX of the Social Security Act and at no
1008
less than 14 percent of the average manufacturer price as defined
1009
in 42 U.S.C. s. 1936 on the last day of a quarter unless the
1010
federal or supplemental rebate, or both, equals or exceeds 29
1011
percent. There is no upper limit on the supplemental rebates the
1012
agency may negotiate. The agency may determine that specific
1013
products, brand-name or generic, are competitive at lower rebate
1014
percentages. Agreement to pay the minimum supplemental rebate
1015
percentage will guarantee a manufacturer that the Medicaid
1016
Pharmaceutical and Therapeutics Committee will consider a product
1017
for inclusion on the preferred drug list. However, a
1018
pharmaceutical manufacturer is not guaranteed placement on the
1019
preferred drug list by simply paying the minimum supplemental
1020
rebate. Agency decisions will be made on the clinical efficacy of
1021
a drug and recommendations of the Medicaid Pharmaceutical and
1022
Therapeutics Committee, as well as the price of competing
1023
products minus federal and state rebates. The agency is
1024
authorized to contract with an outside agency or contractor to
1025
conduct negotiations for supplemental rebates. For the purposes
1026
of this section, the term "supplemental rebates" means cash
1027
rebates. Effective July 1, 2004, value-added programs as a
1028
substitution for supplemental rebates are prohibited. The agency
1029
is authorized to seek any federal waivers to implement this
1030
initiative.
1031
8. The Agency for Health Care Administration shall expand
1032
home delivery of pharmacy products. To assist Medicaid patients
1033
in securing their prescriptions and reduce program costs, the
1034
agency shall expand its current mail-order-pharmacy diabetes-
1035
supply program to include all generic and brand-name drugs used
1036
by Medicaid patients with diabetes. Medicaid recipients in the
1037
current program may obtain nondiabetes drugs on a voluntary
1038
basis. This initiative is limited to the geographic area covered
1039
by the current contract. The agency may seek and implement any
1040
federal waivers necessary to implement this subparagraph.
1041
9. The agency shall limit to one dose per month any drug
1042
prescribed to treat erectile dysfunction.
1043
10.a. The agency may implement a Medicaid behavioral drug
1044
management system. The agency may contract with a vendor that has
1045
experience in operating behavioral drug management systems to
1046
implement this program. The agency is authorized to seek federal
1047
waivers to implement this program.
1048
b. The agency, in conjunction with the Department of
1049
Children and Family Services, may implement the Medicaid
1050
behavioral drug management system that is designed to improve the
1051
quality of care and behavioral health prescribing practices based
1052
on best practice guidelines, improve patient adherence to
1053
medication plans, reduce clinical risk, and lower prescribed drug
1054
costs and the rate of inappropriate spending on Medicaid
1055
behavioral drugs. The program may include the following elements:
1056
(I) Provide for the development and adoption of best
1057
practice guidelines for behavioral health-related drugs such as
1058
antipsychotics, antidepressants, and medications for treating
1059
bipolar disorders and other behavioral conditions; translate them
1060
into practice; review behavioral health prescribers and compare
1061
their prescribing patterns to a number of indicators that are
1062
based on national standards; and determine deviations from best
1063
practice guidelines.
1064
(II) Implement processes for providing feedback to and
1065
educating prescribers using best practice educational materials
1066
and peer-to-peer consultation.
1067
(III) Assess Medicaid beneficiaries who are outliers in
1068
their use of behavioral health drugs with regard to the numbers
1069
and types of drugs taken, drug dosages, combination drug
1070
therapies, and other indicators of improper use of behavioral
1071
health drugs.
1072
(IV) Alert prescribers to patients who fail to refill
1073
prescriptions in a timely fashion, are prescribed multiple same-
1074
class behavioral health drugs, and may have other potential
1075
medication problems.
1076
(V) Track spending trends for behavioral health drugs and
1077
deviation from best practice guidelines.
1078
(VI) Use educational and technological approaches to
1079
promote best practices, educate consumers, and train prescribers
1080
in the use of practice guidelines.
1081
(VII) Disseminate electronic and published materials.
1082
(VIII) Hold statewide and regional conferences.
1083
(IX) Implement a disease management program with a model
1084
quality-based medication component for severely mentally ill
1085
individuals and emotionally disturbed children who are high users
1086
of care.
1087
11.a. The agency shall implement a Medicaid prescription
1088
drug management system. The agency may contract with a vendor
1089
that has experience in operating prescription drug management
1090
systems in order to implement this system. Any management system
1091
that is implemented in accordance with this subparagraph must
1092
rely on cooperation between physicians and pharmacists to
1093
determine appropriate practice patterns and clinical guidelines
1094
to improve the prescribing, dispensing, and use of drugs in the
1095
Medicaid program. The agency may seek federal waivers to
1096
implement this program.
1097
b. The drug management system must be designed to improve
1098
the quality of care and prescribing practices based on best
1099
practice guidelines, improve patient adherence to medication
1100
plans, reduce clinical risk, and lower prescribed drug costs and
1101
the rate of inappropriate spending on Medicaid prescription
1102
drugs. The program must:
1103
(I) Provide for the development and adoption of best
1104
practice guidelines for the prescribing and use of drugs in the
1105
Medicaid program, including translating best practice guidelines
1106
into practice; reviewing prescriber patterns and comparing them
1107
to indicators that are based on national standards and practice
1108
patterns of clinical peers in their community, statewide, and
1109
nationally; and determine deviations from best practice
1110
guidelines.
1111
(II) Implement processes for providing feedback to and
1112
educating prescribers using best practice educational materials
1113
and peer-to-peer consultation.
1114
(III) Assess Medicaid recipients who are outliers in their
1115
use of a single or multiple prescription drugs with regard to the
1116
numbers and types of drugs taken, drug dosages, combination drug
1117
therapies, and other indicators of improper use of prescription
1118
drugs.
1119
(IV) Alert prescribers to patients who fail to refill
1120
prescriptions in a timely fashion, are prescribed multiple drugs
1121
that may be redundant or contraindicated, or may have other
1122
potential medication problems.
1123
(V) Track spending trends for prescription drugs and
1124
deviation from best practice guidelines.
1125
(VI) Use educational and technological approaches to
1126
promote best practices, educate consumers, and train prescribers
1127
in the use of practice guidelines.
1128
(VII) Disseminate electronic and published materials.
1129
(VIII) Hold statewide and regional conferences.
1130
(IX) Implement disease management programs in cooperation
1131
with physicians and pharmacists, along with a model quality-based
1132
medication component for individuals having chronic medical
1133
conditions.
1134
12. The agency is authorized to contract for drug rebate
1135
administration, including, but not limited to, calculating rebate
1136
amounts, invoicing manufacturers, negotiating disputes with
1137
manufacturers, and maintaining a database of rebate collections.
1138
13. The agency may specify the preferred daily dosing form
1139
or strength for the purpose of promoting best practices with
1140
regard to the prescribing of certain drugs as specified in the
1141
General Appropriations Act and ensuring cost-effective
1142
prescribing practices.
1143
14. The agency may require prior authorization for
1144
Medicaid-covered prescribed drugs. The agency may, but is not
1145
required to, prior-authorize the use of a product:
1146
a. For an indication not approved in labeling;
1147
b. To comply with certain clinical guidelines; or
1148
c. If the product has the potential for overuse, misuse, or
1149
abuse.
1150
1151
The agency may require the prescribing professional to provide
1152
information about the rationale and supporting medical evidence
1153
for the use of a drug. The agency may post prior authorization
1154
criteria and protocol and updates to the list of drugs that are
1155
subject to prior authorization on an Internet website without
1156
amending its rule or engaging in additional rulemaking.
1157
15. The agency, in conjunction with the Pharmaceutical and
1158
Therapeutics Committee, may require age-related prior
1159
authorizations for certain prescribed drugs. The agency may
1160
preauthorize the use of a drug for a recipient who may not meet
1161
the age requirement or may exceed the length of therapy for use
1162
of the this product as recommended by the manufacturer and
1163
approved by the Food and Drug Administration. Prior authorization
1164
may require the prescribing professional to provide information
1165
about the rationale and supporting medical evidence for the use
1166
of a drug.
1167
16. The agency shall implement a step-therapy prior
1168
authorization approval process for medications excluded from the
1169
preferred drug list. Medications listed on the preferred drug
1170
list must be used within the previous 12 months prior to the
1171
alternative medications that are not listed. The step-therapy
1172
prior authorization may require the prescriber to use the
1173
medications of a similar drug class or for a similar medical
1174
indication unless contraindicated in the Food and Drug
1175
Administration labeling. The trial period between the specified
1176
steps may vary according to the medical indication. The step-
1177
therapy approval process shall be developed in accordance with
1178
the committee as stated in s. 409.91195(7) and (8). A drug
1179
product may be approved without meeting the step-therapy prior
1180
authorization criteria if the prescribing physician provides the
1181
agency with additional written medical or clinical documentation
1182
that the product is medically necessary because:
1183
a. There is not a drug on the preferred drug list to treat
1184
the disease or medical condition which is an acceptable clinical
1185
alternative;
1186
b. The alternatives have been ineffective in the treatment
1187
of the beneficiary's disease; or
1188
c. Based on historic evidence and known characteristics of
1189
the patient and the drug, the drug is likely to be ineffective,
1190
or the number of doses have been ineffective.
1191
1192
The agency shall work with the physician to determine the best
1193
alternative for the patient. The agency may adopt rules waiving
1194
the requirements for written clinical documentation for specific
1195
drugs in limited clinical situations.
1196
17. The agency shall implement a return and reuse program
1197
for drugs dispensed by pharmacies to institutional recipients,
1198
which includes payment of a $5 restocking fee for the
1199
implementation and operation of the program. The return and reuse
1200
program shall be implemented electronically and in a manner that
1201
promotes efficiency. The program must permit a pharmacy to
1202
exclude drugs from the program if it is not practical or cost-
1203
effective for the drug to be included and must provide for the
1204
return to inventory of drugs that cannot be credited or returned
1205
in a cost-effective manner. The agency shall determine if the
1206
program has reduced the amount of Medicaid prescription drugs
1207
which are destroyed on an annual basis and if there are
1208
additional ways to ensure more prescription drugs are not
1209
destroyed which could safely be reused. The agency's conclusion
1210
and recommendations shall be reported to the Legislature by
1211
December 1, 2005.
1212
(42) The agency may shall develop and implement a
1213
utilization management program for Medicaid-eligible recipients
1214
for the management of occupational, physical, respiratory, and
1215
speech therapies. The agency shall establish a utilization
1216
program that may require prior authorization in order to ensure
1217
medically necessary and cost-effective treatments. The program
1218
shall be operated in accordance with a federally approved waiver
1219
program or state plan amendment. The agency may seek a federal
1220
waiver or state plan amendment to implement this program. The
1221
agency may also competitively procure these services from an
1222
outside vendor on a regional or statewide basis.
1223
Section 10. Section 409.91206, Florida Statutes, is created
1224
to read:
1225
409.91206 Alternatives for health and long-term care
1226
reforms.--The Governor, the President of the Senate, and the
1227
Speaker of the House of Representatives may convene workgroups to
1228
propose alternatives for cost-effective health and long-term care
1229
reforms, including, but not limited to, reforms for Medicaid.
1230
Section 11. Paragraphs (c), (e), (f), and (i) of subsection
1231
(2) of section 409.9122, Florida Statutes, are amended to read:
1232
409.9122 Mandatory Medicaid managed care enrollment;
1233
programs and procedures.--
1234
(2)
1235
(c) Medicaid recipients shall have a choice of managed care
1236
plans or MediPass. The agency for Health Care Administration, the
1237
Department of Health, the Department of Children and Family
1238
Services, and the Department of Elderly Affairs shall cooperate
1239
to ensure that each Medicaid recipient receives clear and easily
1240
understandable information that meets the following requirements:
1241
1. Explains the concept of managed care, including
1242
MediPass.
1243
2. Provides information on the comparative performance of
1244
managed care plans and MediPass in the areas of quality,
1245
credentialing, preventive health programs, network size and
1246
availability, and patient satisfaction.
1247
3. Explains where additional information on each managed
1248
care plan and MediPass in the recipient's area can be obtained.
1249
4. Explains that recipients have the right to choose their
1250
own managed care coverage at the time they first enroll in
1251
Medicaid and again at regular intervals set by the agency plans
1252
or MediPass. However, if a recipient does not choose a managed
1253
care plan or MediPass, the agency will assign the recipient to a
1254
managed care plan or MediPass according to the criteria specified
1255
in this section.
1256
5. Explains the recipient's right to complain, file a
1257
grievance, or change managed care plans or MediPass providers if
1258
the recipient is not satisfied with the managed care plan or
1259
MediPass.
1260
(e) Medicaid recipients who are already enrolled in a
1261
managed care plan or MediPass shall be offered the opportunity to
1262
change managed care plans or MediPass providers on a staggered
1263
basis, as defined by the agency. All Medicaid recipients shall
1264
have 30 days in which to make a choice of managed care plans or
1265
MediPass providers. A recipient already enrolled in a managed
1266
care plan who fails to make a choice during the 30-day choice
1267
period shall remain enrolled in his or her current managed care
1268
plan. In counties that have two or more managed care plans, a
1269
recipient already enrolled in MediPass who fails to make a choice
1270
during the annual period shall be assigned to a managed care plan
1271
if he or she is eligible for enrollment in the managed care plan.
1272
The agency shall apply for a state plan amendment or federal
1273
waiver authority, if necessary, to implement the provisions of
1274
this paragraph. Those Medicaid recipients who do not make a
1275
choice shall be assigned to a managed care plan or MediPass in
1276
accordance with paragraph (f). To facilitate continuity of care,
1277
for a Medicaid recipient who is also a recipient of Supplemental
1278
Security Income (SSI), prior to assigning the SSI recipient to a
1279
managed care plan or MediPass, the agency shall determine whether
1280
the SSI recipient has an ongoing relationship with a MediPass
1281
provider or managed care plan, and if so, the agency shall assign
1282
the SSI recipient to that MediPass provider or managed care plan.
1283
If the SSI recipient has an ongoing relationship with a managed
1284
care plan, the agency shall assign the recipient to that managed
1285
care plan. Those SSI recipients who do not have such a provider
1286
relationship shall be assigned to a managed care plan or MediPass
1287
provider in accordance with paragraph (f).
1288
(f) If When a Medicaid recipient does not choose a managed
1289
care plan or MediPass provider, the agency shall assign the
1290
Medicaid recipient to a managed care plan or MediPass provider.
1291
Medicaid recipients, eligible for managed care plan enrollment,
1292
who are subject to mandatory assignment but who fail to make a
1293
choice shall be assigned to managed care plans until an
1294
enrollment of 35 percent in MediPass and 65 percent in managed
1295
care plans, of all those eligible to choose managed care, is
1296
achieved. Once this enrollment is achieved, the assignments shall
1297
be divided in order to maintain an enrollment in MediPass and
1298
managed care plans which is in a 35 percent and 65 percent
1299
proportion, respectively. Thereafter, assignment of Medicaid
1300
recipients who fail to make a choice shall be based
1301
proportionally on the preferences of recipients who have made a
1302
choice in the previous period. Such proportions shall be revised
1303
at least quarterly to reflect an update of the preferences of
1304
Medicaid recipients. The agency shall disproportionately assign
1305
Medicaid-eligible recipients who are required to but have failed
1306
to make a choice of managed care plan or MediPass, including
1307
children, and who would are to be assigned to the MediPass
1308
program to children's networks as described in s. 409.912(4)(g),
1309
Children's Medical Services Network as defined in s. 391.021,
1310
exclusive provider organizations, provider service networks,
1311
minority physician networks, and pediatric emergency department
1312
diversion programs authorized by this chapter or the General
1313
Appropriations Act, in such manner as the agency deems
1314
appropriate, until the agency has determined that the networks
1315
and programs have sufficient numbers to be operated economically
1316
operated. For purposes of this paragraph, when referring to
1317
assignment, the term "managed care plans" includes health
1318
maintenance organizations, exclusive provider organizations,
1319
provider service networks, minority physician networks,
1320
Children's Medical Services Network, and pediatric emergency
1321
department diversion programs authorized by this chapter or the
1322
General Appropriations Act. When making assignments, the agency
1323
shall take into account the following criteria:
1324
1. A managed care plan has sufficient network capacity to
1325
meet the need of members.
1326
2. The managed care plan or MediPass has previously
1327
enrolled the recipient as a member, or one of the managed care
1328
plan's primary care providers or MediPass providers has
1329
previously provided health care to the recipient.
1330
3. The agency has knowledge that the member has previously
1331
expressed a preference for a particular managed care plan or
1332
MediPass provider as indicated by Medicaid fee-for-service claims
1333
data, but has failed to make a choice.
1334
4. The managed care plan's or MediPass primary care
1335
providers are geographically accessible to the recipient's
1336
residence.
1337
(i) After a recipient has made his or her initial a
1338
selection or has been notified of his or her initial assignment
1339
to enrolled in a managed care plan or MediPass, the recipient
1340
shall have 90 days to exercise the opportunity in which to
1341
voluntarily disenroll and select another managed care option plan
1342
or MediPass provider. After 90 days, no further changes may be
1343
made except for cause. Good cause includes shall include, but is
1344
not be limited to, poor quality of care, lack of access to
1345
necessary specialty services, an unreasonable delay or denial of
1346
service, or fraudulent enrollment. The agency shall develop
1347
criteria for good cause disenrollment for chronically ill and
1348
disabled populations who are assigned to managed care plans if
1349
more appropriate care is available through the MediPass program.
1350
The agency must make a determination as to whether cause exists.
1351
However, the agency may require a recipient to use the managed
1352
care plan's or MediPass grievance process prior to the agency's
1353
determination of cause, except in cases in which immediate risk
1354
of permanent damage to the recipient's health is alleged. The
1355
grievance process, when utilized, must be completed in time to
1356
permit the recipient to disenroll by no later than the first day
1357
of the second month after the month the disenrollment request was
1358
made. If the managed care plan or MediPass, as a result of the
1359
grievance process, approves an enrollee's request to disenroll,
1360
the agency is not required to make a determination in the case.
1361
The agency must make a determination and take final action on a
1362
recipient's request so that disenrollment occurs by no later than
1363
the first day of the second month after the month the request was
1364
made. If the agency fails to act within the specified timeframe,
1365
the recipient's request to disenroll is deemed to be approved as
1366
of the date agency action was required. Recipients who disagree
1367
with the agency's finding that cause does not exist for
1368
disenrollment shall be advised of their right to pursue a
1369
Medicaid fair hearing to dispute the agency's finding.
1370
Section 12. Paragraph (c) of subsection (5) of section
1372
Section 13. This act shall take effect July 1, 2008.
CODING: Words stricken are deletions; words underlined are additions.