Amendment
Bill No. HB 5085

Amendment No. 100637

CHAMBER ACTION
Senate		House
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1	The Conference Committee on HB 5085 offered the following:
2
3	Conference Committee Amendment (with title amendment)
4	Remove everything after the enacting clause and insert:
5	Section 1.  Paragraph (d) of subsection (2) of section
6	400.179, Florida Statutes, is amended to read:
7	400.179  Liability for Medicaid underpayments and
8	overpayments.--
9	(2)  Because any transfer of a nursing facility may expose
10	the fact that Medicaid may have underpaid or overpaid the
11	transferor, and because in most instances, any such underpayment
12	or overpayment can only be determined following a formal field
13	audit, the liabilities for any such underpayments or
14	overpayments shall be as follows:
15	(d)  Where the transfer involves a facility that has been
16	leased by the transferor:
17	1.  The transferee shall, as a condition to being issued a
18	license by the agency, acquire, maintain, and provide proof to
19	the agency of a bond with a term of 30 months, renewable
20	annually, in an amount not less than the total of 3 months'
21	Medicaid payments to the facility computed on the basis of the
22	preceding 12-month average Medicaid payments to the facility.
23	2.  A leasehold licensee may meet the requirements of
24	subparagraph 1. by payment of a nonrefundable fee, paid at
25	initial licensure, paid at the time of any subsequent change of
26	ownership, and paid annually thereafter, in the amount of 1
27	percent of the total of 3 months' Medicaid payments to the
28	facility computed on the basis of the preceding 12-month average
29	Medicaid payments to the facility. If a preceding 12-month
30	average is not available, projected Medicaid payments may be
31	used. The fee shall be deposited into the Health Care Trust Fund
32	and shall be accounted for separately as a Medicaid nursing home
33	overpayment account. These fees shall be used at the sole
34	discretion of the agency to repay nursing home Medicaid
35	overpayments. The agency is authorized to transfer funds to the
36	Grants and Donations Trust Fund for such repayments. Payment of
37	this fee shall not release the licensee from any liability for
38	any Medicaid overpayments, nor shall payment bar the agency from
39	seeking to recoup overpayments from the licensee and any other
40	liable party. As a condition of exercising this lease bond
41	alternative, licensees paying this fee must maintain an existing
42	lease bond through the end of the 30-month term period of that
43	bond. The agency is herein granted specific authority to
44	promulgate all rules pertaining to the administration and
45	management of this account, including withdrawals from the
46	account, subject to federal review and approval. This provision
47	shall take effect upon becoming law and shall apply to any
48	leasehold license application. The financial viability of the
49	Medicaid nursing home overpayment account shall be determined by
50	the agency through annual review of the account balance and the
51	amount of total outstanding, unpaid Medicaid overpayments owing
52	from leasehold licensees to the agency as determined by final
53	agency audits.
54	3.  The leasehold licensee may meet the bond requirement
55	through other arrangements acceptable to the agency. The agency
56	is herein granted specific authority to promulgate rules
57	pertaining to lease bond arrangements.
58	4.  All existing nursing facility licensees, operating the
59	facility as a leasehold, shall acquire, maintain, and provide
60	proof to the agency of the 30-month bond required in
61	subparagraph 1., above, on and after July 1, 1993, for each
62	license renewal.
63	5.  It shall be the responsibility of all nursing facility
64	operators, operating the facility as a leasehold, to renew the
65	30-month bond and to provide proof of such renewal to the agency
66	annually.
67	6.  Any failure of the nursing facility operator to
68	acquire, maintain, renew annually, or provide proof to the
69	agency shall be grounds for the agency to deny, revoke, and
70	suspend the facility license to operate such facility and to
71	take any further action, including, but not limited to,
72	enjoining the facility, asserting a moratorium pursuant to part
73	II of chapter 408, or applying for a receiver, deemed necessary
74	to ensure compliance with this section and to safeguard and
75	protect the health, safety, and welfare of the facility's
76	residents. A lease agreement required as a condition of bond
77	financing or refinancing under s. 154.213 by a health facilities
78	authority or required under s. 159.30 by a county or
79	municipality is not a leasehold for purposes of this paragraph
80	and is not subject to the bond requirement of this paragraph.
81	Section 2.  Section 409.017, Florida Statutes, is amended
82	to read:
83	409.017  Local Funding Revenue Maximization Act;
84	legislative intent; revenue maximization program.--
85	(1)  SHORT TITLE.--This section may be cited as the "Local
86	Funding Revenue Maximization Act."
87	(2)  LEGISLATIVE INTENT.--
88	(a)  The Legislature recognizes that state funds do not
89	fully utilize federal funding matching opportunities for health
90	and human services needs. It is the intent of the Legislature to
91	authorize the use of certified local funding for federal
92	matching programs to the fullest extent possible to maximize
93	federal funding of local preventive services and local child
94	development programs in this state. To that end, the Legislature
95	expects that state agencies will take a proactive approach in
96	implementing this legislative priority. It is the further intent
97	of the Legislature that this act shall be revenue neutral with
98	respect to state funds.
99	(b)  It is the intent of the Legislature that revenue
100	maximization opportunities using certified local funding shall
101	occur only after available state funds have been utilized to
102	generate matching federal funding for the state.
103	(c)  It is the intent of the Legislature that participation
104	in revenue maximization is to be voluntary for local political
105	subdivisions.
106	(d)  Except for funds expended pursuant to Title XIX of the
107	Social Security Act, it is the intent of the Legislature that
108	certified local funding for federal matching programs not
109	supplant or replace state funds. Beginning July 1, 2004, any
110	state funds supplanted or replaced with local tax revenues for
111	Title XIX funds shall be expressly approved in the General
112	Appropriations Act or by the Legislative Budget Commission
113	pursuant to chapter 216.
114	(e)  It is the intent of the Legislature that revenue
115	maximization shall not divert existing funds from state agencies
116	that are currently using local funds to maximize matching
117	federal and state funds to the greatest extent possible.
118	(f)  It is the intent of the legislature to encourage and
119	allow any agency to engage, through a competitive procurement
120	process, an entity with expertise in claiming justifiable and
121	appropriate federal funds through revenue maximization efforts
122	both retrospectively and prospectively. This claiming may
123	include, but not be limited to, administrative and services
124	activities that are eligible under federal matching programs.
125	(3)  REVENUE MAXIMIZATION PROGRAM.--
126	(a)  For purposes of this section, the term "agency" means
127	any state agency or department that is involved in providing
128	health, social, or human services, including, but not limited
129	to, the Agency for Health Care Administration, the Agency for
130	Workforce Innovation, the Department of Children and Family
131	Services, the Department of Elderly Affairs, the Department of
132	Juvenile Justice, the Department of Education, and the State
133	Board of Education.
134	(b)  The Agency for Health Care Administration may develop
135	a procurement document and procedure to claim administrative
136	federal matching funds for state provided educational services.
137	The agency shall then competitively procure an entity with
138	appropriate expertise and experience to retrospectively and
139	prospectively maximize federal revenues through administrative
140	claims for federal matching funds for state provided educational
141	services.
142	(c)(b)  Each agency shall establish programs and mechanisms
143	designed to maximize the use of local funding for federal
144	programs in accordance with this section.
145	(d)(c)  The use of local matching funds under this section
146	must be limited to public revenue funds of local political
147	subdivisions, including, but not limited to, counties,
148	municipalities, and special districts. To the extent permitted
149	by federal law, funds donated to such local political
150	subdivisions by private entities, such as, but not limited to,
151	the United Way, community foundations or other foundations, and
152	businesses, or by individuals are considered to be public
153	revenue funds available for matching federal funding.
154	(e)(d)  Subject to paragraph (g) (f), any federal
155	reimbursement received as a result of the certification of local
156	matching funds must, unless specifically prohibited by federal
157	law or state law, including the General Appropriations Act, and
158	subject to the availability of specific appropriation and
159	release authority, be returned within 30 days after receipt by
160	the agency by the most expedient means possible to the local
161	political subdivision providing such funding, and the local
162	political subdivision must be provided an annual accounting of
163	federal reimbursements received by the state or its agencies as
164	a result of the certification of the local political
165	subdivision's matching funds. The receipt by a local political
166	subdivision of such matching funds must not in any way influence
167	or be used as a factor in developing any agency's annual
168	operating budget allocation methodology or formula or any
169	subsequent budget amendment allocations or formulas. If
170	necessary, agreements must be made between an agency and the
171	local political subdivision to accomplish that purpose. Such an
172	agreement may provide that the local political subdivision must:
173	verify the eligibility of the local program or programs and the
174	individuals served thereby to qualify for federal matching
175	funds; shall develop and maintain the financial records
176	necessary for documenting the appropriate use of federal funds;
177	shall comply with all applicable state and federal laws,
178	regulations, and rules that regulate such federal services; and
179	shall reimburse the cost of any disallowance of federal funding
180	previously provided to a local political subdivision resulting
181	from the failure of that local political subdivision to comply
182	with applicable state or federal laws, rules, or regulations.
183	(f)(e)  Each agency, as applicable, shall work with local
184	political subdivisions to modify any state plans and to seek and
185	implement any federal waivers necessary to implement this
186	section. If such modifications or waivers require the approval
187	of the Legislature, the agency, as applicable, shall draft such
188	legislation and present it to the President of the Senate and
189	the Speaker of the House of Representatives and to the
190	respective committee chairs of the Senate and the House of
191	Representatives by January 1, 2004, and, as applicable, annually
192	thereafter.
193	(g)(f)  Each agency, as applicable, before funds generated
194	under this section are distributed to any local political
195	subdivision, may deduct the actual administrative cost for
196	implementing and monitoring the local match program; however,
197	such administrative costs may not exceed 5 percent of the total
198	federal reimbursement funding to be provided to the local
199	political subdivision under paragraph (e) (d). To the extent
200	that any other provision of state law applies to the
201	certification of local matching funds for a specific program,
202	the provisions of that statute which relate to administrative
203	costs apply in lieu of the provisions of this paragraph. The
204	failure to remit reimbursement to the local political
205	subdivision will result in the payment of interest, in addition
206	to the amount to be reimbursed at a rate pursuant to s. 55.03(1)
207	on the unpaid amount from the expiration of the 30-day period
208	until payment is received.
209	(h)(g)  Each agency, respectively, shall annually submit to
210	the Governor, the President of the Senate, and the Speaker of
211	the House of Representatives, no later than January 1, a report
212	that documents the specific activities undertaken during the
213	previous fiscal year under this section. The report must
214	include, but is not limited to, a statement of the total amount
215	of federal matching funds generated by local matching funds
216	under this section, reported by federal funding source; the
217	total amount of block grant funds expended during the previous
218	fiscal year, reported by federal funding source; the total
219	amount for federal matching fund programs, including, but not
220	limited to, Temporary Assistance for Needy Families and Child
221	Care and Development Fund, of unobligated funds and unliquidated
222	funds, both as of the close of the previous federal fiscal year;
223	the amount of unliquidated funds that is in danger of being
224	returned to the Federal Government at the end of the current
225	federal fiscal year; and a detailed plan and timeline for
226	spending any unobligated and unliquidated funds by the end of
227	the current federal fiscal year.
228	Section 3.  Subsections (1) and (2) of section 409.904,
229	Florida Statutes, are amended to read:
230	409.904  Optional payments for eligible persons.--The
231	agency may make payments for medical assistance and related
232	services on behalf of the following persons who are determined
233	to be eligible subject to the income, assets, and categorical
234	eligibility tests set forth in federal and state law. Payment on
235	behalf of these Medicaid eligible persons is subject to the
236	availability of moneys and any limitations established by the
237	General Appropriations Act or chapter 216.
238	(1)(a)  From July 1, 2005, through December 31, 2005, a
239	person who is age 65 or older or is determined to be disabled,
240	whose income is at or below 88 percent of federal poverty level,
241	and whose assets do not exceed established limitations.
242	(b)  Effective January 1, 2006, and subject to federal
243	waiver approval, a person who is age 65 or older or is
244	determined to be disabled, whose income is at or below 88
245	percent of the federal poverty level, whose assets do not exceed
246	established limitations, and who is not eligible for Medicare
247	or, if eligible for Medicare, is also eligible for and receiving
248	Medicaid-covered institutional care services, hospice services,
249	or home and community-based services. The agency shall seek
250	federal authorization through a waiver to provide this coverage.
251	This subsection expires June 30, 2009.
252	(2)(a)  A family, a pregnant woman, a child under age 21, a
253	person age 65 or over, or a blind or disabled person, who would
254	be eligible under any group listed in s. 409.903(1), (2), or
255	(3), except that the income or assets of such family or person
256	exceed established limitations. For a family or person in one of
257	these coverage groups, medical expenses are deductible from
258	income in accordance with federal requirements in order to make
259	a determination of eligibility. A family or person eligible
260	under the coverage known as the "medically needy," is eligible
261	to receive the same services as other Medicaid recipients, with
262	the exception of services in skilled nursing facilities and
263	intermediate care facilities for the developmentally disabled.
264	This subsection expires June 30, 2009.
265	(b)  Effective July 1, 2009, a pregnant woman or a child
266	younger than 21 years of age who would be eligible under any
267	group listed in s. 409.903, except that the income or assets of
268	such group exceed established limitations. For a person in one
269	of these coverage groups, medical expenses are deductible from
270	income in accordance with federal requirements in order to make
271	a determination of eligibility. A person eligible under the
272	coverage known as the "medically needy" is eligible to receive
273	the same services as other Medicaid recipients, with the
274	exception of services in skilled nursing facilities and
275	intermediate care facilities for the developmentally disabled.
276	Section 4.  Subsection (26) is added to section 409.906,
277	Florida Statutes, to read:
278	409.906  Optional Medicaid services.--Subject to specific
279	appropriations, the agency may make payments for services which
280	are optional to the state under Title XIX of the Social Security
281	Act and are furnished by Medicaid providers to recipients who
282	are determined to be eligible on the dates on which the services
283	were provided. Any optional service that is provided shall be
284	provided only when medically necessary and in accordance with
285	state and federal law. Optional services rendered by providers
286	in mobile units to Medicaid recipients may be restricted or
287	prohibited by the agency. Nothing in this section shall be
288	construed to prevent or limit the agency from adjusting fees,
289	reimbursement rates, lengths of stay, number of visits, or
290	number of services, or making any other adjustments necessary to
291	comply with the availability of moneys and any limitations or
292	directions provided for in the General Appropriations Act or
293	chapter 216. If necessary to safeguard the state's systems of
294	providing services to elderly and disabled persons and subject
295	to the notice and review provisions of s. 216.177, the Governor
296	may direct the Agency for Health Care Administration to amend
297	the Medicaid state plan to delete the optional Medicaid service
298	known as "Intermediate Care Facilities for the Developmentally
299	Disabled." Optional services may include:
300	(26)  ANESTHESIOLOGIST ASSISTANT SERVICES.--The agency may
301	pay for all services provided to a recipient by an
302	anesthesiologist assistant licensed under s. 458.3475 or s.
303	459.023. Reimbursement for such services must be not less than
304	80 percent of the reimbursement that would be paid to a
305	physician who provided the same services.
306	Section 5.  Subsections (13) and (14) of section 409.908,
307	Florida Statutes, as amended by chapter 2007-331, Laws of
308	Florida, are amended, and subsection (23) is added to that
309	section, to read:
310	409.908  Reimbursement of Medicaid providers.--Subject to
311	specific appropriations, the agency shall reimburse Medicaid
312	providers, in accordance with state and federal law, according
313	to methodologies set forth in the rules of the agency and in
314	policy manuals and handbooks incorporated by reference therein.
315	These methodologies may include fee schedules, reimbursement
316	methods based on cost reporting, negotiated fees, competitive
317	bidding pursuant to s. 287.057, and other mechanisms the agency
318	considers efficient and effective for purchasing services or
319	goods on behalf of recipients. If a provider is reimbursed based
320	on cost reporting and submits a cost report late and that cost
321	report would have been used to set a lower reimbursement rate
322	for a rate semester, then the provider's rate for that semester
323	shall be retroactively calculated using the new cost report, and
324	full payment at the recalculated rate shall be effected
325	retroactively. Medicare-granted extensions for filing cost
326	reports, if applicable, shall also apply to Medicaid cost
327	reports. Payment for Medicaid compensable services made on
328	behalf of Medicaid eligible persons is subject to the
329	availability of moneys and any limitations or directions
330	provided for in the General Appropriations Act or chapter 216.
331	Further, nothing in this section shall be construed to prevent
332	or limit the agency from adjusting fees, reimbursement rates,
333	lengths of stay, number of visits, or number of services, or
334	making any other adjustments necessary to comply with the
335	availability of moneys and any limitations or directions
336	provided for in the General Appropriations Act, provided the
337	adjustment is consistent with legislative intent.
338	(13)  Medicare premiums for persons eligible for both
339	Medicare and Medicaid coverage shall be paid at the rates
340	established by Title XVIII of the Social Security Act. For
341	Medicare services rendered to Medicaid-eligible persons,
342	Medicaid shall pay Medicare deductibles and coinsurance as
343	follows:
344	(a)  Medicaid shall make no payment toward deductibles and
345	coinsurance for any service that is not covered by Medicaid.
346	(a)(b)  Medicaid's financial obligation for deductibles and
347	coinsurance payments shall be based on Medicare allowable fees,
348	not on a provider's billed charges.
349	(b)(c)  Medicaid will pay no portion of Medicare
350	deductibles and coinsurance when payment that Medicare has made
351	for the service equals or exceeds what Medicaid would have paid
352	if it had been the sole payor. The combined payment of Medicare
353	and Medicaid shall not exceed the amount Medicaid would have
354	paid had it been the sole payor. The Legislature finds that
355	there has been confusion regarding the reimbursement for
356	services rendered to dually eligible Medicare beneficiaries.
357	Accordingly, the Legislature clarifies that it has always been
358	the intent of the Legislature before and after 1991 that, in
359	reimbursing in accordance with fees established by Title XVIII
360	for premiums, deductibles, and coinsurance for Medicare services
361	rendered by physicians to Medicaid eligible persons, physicians
362	be reimbursed at the lesser of the amount billed by the
363	physician or the Medicaid maximum allowable fee established by
364	the Agency for Health Care Administration, as is permitted by
365	federal law. It has never been the intent of the Legislature
366	with regard to such services rendered by physicians that
367	Medicaid be required to provide any payment for deductibles,
368	coinsurance, or copayments for Medicare cost sharing, or any
369	expenses incurred relating thereto, in excess of the payment
370	amount provided for under the State Medicaid plan for such
371	service. This payment methodology is applicable even in those
372	situations in which the payment for Medicare cost sharing for a
373	qualified Medicare beneficiary with respect to an item or
374	service is reduced or eliminated. This expression of the
375	Legislature is in clarification of existing law and shall apply
376	to payment for, and with respect to provider agreements with
377	respect to, items or services furnished on or after the
378	effective date of this act. This paragraph applies to payment by
379	Medicaid for items and services furnished before the effective
380	date of this act if such payment is the subject of a lawsuit
381	that is based on the provisions of this section, and that is
382	pending as of, or is initiated after, the effective date of this
383	act.
384	(c)(d)  Notwithstanding paragraphs (a) and (b) (a)-(c):
385	1.  Medicaid payments for Nursing Home Medicare part A
386	coinsurance are shall be limited to the Medicaid nursing home
387	per diem rate less any amounts paid by Medicare, but only up to
388	the amount of Medicare coinsurance. The Medicaid per diem rate
389	shall be the rate in effect for the dates of service of the
390	crossover claims and may not be subsequently adjusted due to
391	subsequent per diem rate adjustments.
392	2.  Medicaid shall pay all deductibles and coinsurance for
393	Medicare-eligible recipients receiving freestanding end stage
394	renal dialysis center services.
395	3.  Medicaid payments for general and specialty hospital
396	inpatient services are shall be limited to the Medicare
397	deductible and coinsurance per spell of illness. Medicaid
398	payments for hospital Medicare Part A coinsurance shall be
399	limited to the Medicaid hospital per diem rate less any amounts
400	paid by Medicare, but only up to the amount of Medicare
401	coinsurance. Medicaid payments for coinsurance shall be limited
402	to the Medicaid per diem rate in effect for the dates of service
403	of the crossover claims and may not be subsequently adjusted due
404	to subsequent per diem adjustments. Medicaid shall make no
405	payment toward coinsurance for Medicare general hospital
406	inpatient services.
407	4.  Medicaid shall pay all deductibles and coinsurance for
408	Medicare emergency transportation services provided by
409	ambulances licensed pursuant to chapter 401.
410	5.  Medicaid shall pay all deductibles and coinsurance for
411	portable X-ray Medicare Part B services provided in a nursing
412	home.
413	(14)  A provider of prescribed drugs shall be reimbursed
414	the least of the amount billed by the provider, the provider's
415	usual and customary charge, or the Medicaid maximum allowable
416	fee established by the agency, plus a dispensing fee. The
417	Medicaid maximum allowable fee for ingredient cost will be based
418	on the lower of: average wholesale price (AWP) minus 16.4 15.4
419	percent, wholesaler acquisition cost (WAC) plus 4.75 5.75
420	percent, the federal upper limit (FUL), the state maximum
421	allowable cost (SMAC), or the usual and customary (UAC) charge
422	billed by the provider. Medicaid providers are required to
423	dispense generic drugs if available at lower cost and the agency
424	has not determined that the branded product is more cost-
425	effective, unless the prescriber has requested and received
426	approval to require the branded product. The agency is directed
427	to implement a variable dispensing fee for payments for
428	prescribed medicines while ensuring continued access for
429	Medicaid recipients. The variable dispensing fee may be based
430	upon, but not limited to, either or both the volume of
431	prescriptions dispensed by a specific pharmacy provider, the
432	volume of prescriptions dispensed to an individual recipient,
433	and dispensing of preferred-drug-list products. The agency may
434	increase the pharmacy dispensing fee authorized by statute and
435	in the annual General Appropriations Act by $0.50 for the
436	dispensing of a Medicaid preferred-drug-list product and reduce
437	the pharmacy dispensing fee by $0.50 for the dispensing of a
438	Medicaid product that is not included on the preferred drug
439	list. The agency may establish a supplemental pharmaceutical
440	dispensing fee to be paid to providers returning unused unit-
441	dose packaged medications to stock and crediting the Medicaid
442	program for the ingredient cost of those medications if the
443	ingredient costs to be credited exceed the value of the
444	supplemental dispensing fee. The agency is authorized to limit
445	reimbursement for prescribed medicine in order to comply with
446	any limitations or directions provided for in the General
447	Appropriations Act, which may include implementing a prospective
448	or concurrent utilization review program.
449	(23)(a)  The agency shall establish rates at a level that
450	ensures no increase in statewide expenditures resulting from a
451	change in unit costs for 2 fiscal years effective July 1, 2009.
452	Reimbursement rates for the 2 fiscal years shall be as provided
453	in the General Appropriations Act.
454	(b)  This subsection applies to the following provider
455	types:
456	1.  Inpatient hospitals.
457	2.  Outpatient hospitals.
458	3.  Nursing homes.
459	4.  County health departments.
460	5.  Community intermediate care facilities for the
461	developmentally disabled.
462	6.  Prepaid health plans.
463
464	The agency shall apply the effect of this subsection to the
465	reimbursement rates for nursing home diversion programs.
466	(c)  The agency shall create a workgroup on hospital
467	reimbursement, a workgroup on nursing facility reimbursement,
468	and a workgroup on managed care plan payment. The workgroups
469	shall evaluate alternative reimbursement and payment
470	methodologies for hospitals, nursing facilities, and managed
471	care plans, including prospective payment methodologies for
472	hospitals and nursing facilities. The nursing facility workgroup
473	shall also consider price-based methodologies for indirect care
474	and acuity adjustments for direct care. The agency shall submit
475	a report on the evaluated alternative reimbursement
476	methodologies to the relevant committees of the Senate and the
477	House of Representatives by November 1, 2009.
478	(d)  This subsection expires June 30, 2011.
479	Section 6.  Paragraph (a) of subsection (2) of section
480	409.911, Florida Statutes, is amended to read:
481	409.911  Disproportionate share program.--Subject to
482	specific allocations established within the General
483	Appropriations Act and any limitations established pursuant to
484	chapter 216, the agency shall distribute, pursuant to this
485	section, moneys to hospitals providing a disproportionate share
486	of Medicaid or charity care services by making quarterly
487	Medicaid payments as required. Notwithstanding the provisions of
488	s. 409.915, counties are exempt from contributing toward the
489	cost of this special reimbursement for hospitals serving a
490	disproportionate share of low-income patients.
491	(2)  The Agency for Health Care Administration shall use
492	the following actual audited data to determine the Medicaid days
493	and charity care to be used in calculating the disproportionate
494	share payment:
495	(a)  The average of the 2002, 2003, and 2004 2000, 2001,
496	and 2002 audited disproportionate share data to determine each
497	hospital's Medicaid days and charity care for the 2008-2009
498	2006-2007 state fiscal year.
499	Section 7.  Section 409.9112, Florida Statutes, is amended
500	to read:
501	409.9112  Disproportionate share program for regional
502	perinatal intensive care centers.--In addition to the payments
503	made under s. 409.911, the Agency for Health Care Administration
504	shall design and implement a system of making disproportionate
505	share payments to those hospitals that participate in the
506	regional perinatal intensive care center program established
507	pursuant to chapter 383. This system of payments shall conform
508	with federal requirements and shall distribute funds in each
509	fiscal year for which an appropriation is made by making
510	quarterly Medicaid payments. Notwithstanding the provisions of
511	s. 409.915, counties are exempt from contributing toward the
512	cost of this special reimbursement for hospitals serving a
513	disproportionate share of low-income patients. For the state
514	fiscal year 2008-2009 2005-2006, the agency shall not distribute
515	moneys under the regional perinatal intensive care centers
516	disproportionate share program.
517	(1)  The following formula shall be used by the agency to
518	calculate the total amount earned for hospitals that participate
519	in the regional perinatal intensive care center program:
520
521	TAE = HDSP/THDSP
522
523	Where:
524	TAE = total amount earned by a regional perinatal intensive
525	care center.
526	HDSP = the prior state fiscal year regional perinatal
527	intensive care center disproportionate share payment to the
528	individual hospital.
529	THDSP = the prior state fiscal year total regional
530	perinatal intensive care center disproportionate share payments
531	to all hospitals.
532	(2)  The total additional payment for hospitals that
533	participate in the regional perinatal intensive care center
534	program shall be calculated by the agency as follows:
535
536	TAP = TAE x TA
537
538	Where:
539	TAP = total additional payment for a regional perinatal
540	intensive care center.
541	TAE = total amount earned by a regional perinatal intensive
542	care center.
543	TA = total appropriation for the regional perinatal
544	intensive care center disproportionate share program.
545	(3)  In order to receive payments under this section, a
546	hospital must be participating in the regional perinatal
547	intensive care center program pursuant to chapter 383 and must
548	meet the following additional requirements:
549	(a)  Agree to conform to all departmental and agency
550	requirements to ensure high quality in the provision of
551	services, including criteria adopted by departmental and agency
552	rule concerning staffing ratios, medical records, standards of
553	care, equipment, space, and such other standards and criteria as
554	the department and agency deem appropriate as specified by rule.
555	(b)  Agree to provide information to the department and
556	agency, in a form and manner to be prescribed by rule of the
557	department and agency, concerning the care provided to all
558	patients in neonatal intensive care centers and high-risk
559	maternity care.
560	(c)  Agree to accept all patients for neonatal intensive
561	care and high-risk maternity care, regardless of ability to pay,
562	on a functional space-available basis.
563	(d)  Agree to develop arrangements with other maternity and
564	neonatal care providers in the hospital's region for the
565	appropriate receipt and transfer of patients in need of
566	specialized maternity and neonatal intensive care services.
567	(e)  Agree to establish and provide a developmental
568	evaluation and services program for certain high-risk neonates,
569	as prescribed and defined by rule of the department.
570	(f)  Agree to sponsor a program of continuing education in
571	perinatal care for health care professionals within the region
572	of the hospital, as specified by rule.
573	(g)  Agree to provide backup and referral services to the
574	department's county health departments and other low-income
575	perinatal providers within the hospital's region, including the
576	development of written agreements between these organizations
577	and the hospital.
578	(h)  Agree to arrange for transportation for high-risk
579	obstetrical patients and neonates in need of transfer from the
580	community to the hospital or from the hospital to another more
581	appropriate facility.
582	(4)  Hospitals which fail to comply with any of the
583	conditions in subsection (3) or the applicable rules of the
584	department and agency shall not receive any payments under this
585	section until full compliance is achieved. A hospital which is
586	not in compliance in two or more consecutive quarters shall not
587	receive its share of the funds. Any forfeited funds shall be
588	distributed by the remaining participating regional perinatal
589	intensive care center program hospitals.
590	Section 8.  Section 409.9113, Florida Statutes, is amended
591	to read:
592	409.9113  Disproportionate share program for teaching
593	hospitals.--In addition to the payments made under ss. 409.911
594	and 409.9112, the Agency for Health Care Administration shall
595	make disproportionate share payments to statutorily defined
596	teaching hospitals for their increased costs associated with
597	medical education programs and for tertiary health care services
598	provided to the indigent. This system of payments shall conform
599	with federal requirements and shall distribute funds in each
600	fiscal year for which an appropriation is made by making
601	quarterly Medicaid payments. Notwithstanding s. 409.915,
602	counties are exempt from contributing toward the cost of this
603	special reimbursement for hospitals serving a disproportionate
604	share of low-income patients. For the state fiscal year 2008-
605	2009 2006-2007, the agency shall distribute the moneys provided
606	in the General Appropriations Act to statutorily defined
607	teaching hospitals and family practice teaching hospitals under
608	the teaching hospital disproportionate share program. The funds
609	provided for statutorily defined teaching hospitals shall be
610	distributed in the same proportion as the state fiscal year
611	2003-2004 teaching hospital disproportionate share funds were
612	distributed or as otherwise provided in the General
613	Appropriations Act. The funds provided for family practice
614	teaching hospitals shall be distributed equally among family
615	practice teaching hospitals.
616	(1)  On or before September 15 of each year, the Agency for
617	Health Care Administration shall calculate an allocation
618	fraction to be used for distributing funds to state statutory
619	teaching hospitals. Subsequent to the end of each quarter of the
620	state fiscal year, the agency shall distribute to each statutory
621	teaching hospital, as defined in s. 408.07, an amount determined
622	by multiplying one-fourth of the funds appropriated for this
623	purpose by the Legislature times such hospital's allocation
624	fraction. The allocation fraction for each such hospital shall
625	be determined by the sum of three primary factors, divided by
626	three. The primary factors are:
627	(a)  The number of nationally accredited graduate medical
628	education programs offered by the hospital, including programs
629	accredited by the Accreditation Council for Graduate Medical
630	Education and the combined Internal Medicine and Pediatrics
631	programs acceptable to both the American Board of Internal
632	Medicine and the American Board of Pediatrics at the beginning
633	of the state fiscal year preceding the date on which the
634	allocation fraction is calculated. The numerical value of this
635	factor is the fraction that the hospital represents of the total
636	number of programs, where the total is computed for all state
637	statutory teaching hospitals.
638	(b)  The number of full-time equivalent trainees in the
639	hospital, which comprises two components:
640	1.  The number of trainees enrolled in nationally
641	accredited graduate medical education programs, as defined in
642	paragraph (a). Full-time equivalents are computed using the
643	fraction of the year during which each trainee is primarily
644	assigned to the given institution, over the state fiscal year
645	preceding the date on which the allocation fraction is
646	calculated. The numerical value of this factor is the fraction
647	that the hospital represents of the total number of full-time
648	equivalent trainees enrolled in accredited graduate programs,
649	where the total is computed for all state statutory teaching
650	hospitals.
651	2.  The number of medical students enrolled in accredited
652	colleges of medicine and engaged in clinical activities,
653	including required clinical clerkships and clinical electives.
654	Full-time equivalents are computed using the fraction of the
655	year during which each trainee is primarily assigned to the
656	given institution, over the course of the state fiscal year
657	preceding the date on which the allocation fraction is
658	calculated. The numerical value of this factor is the fraction
659	that the given hospital represents of the total number of full-
660	time equivalent students enrolled in accredited colleges of
661	medicine, where the total is computed for all state statutory
662	teaching hospitals.
663
664	The primary factor for full-time equivalent trainees is computed
665	as the sum of these two components, divided by two.
666	(c)  A service index that comprises three components:
667	1.  The Agency for Health Care Administration Service
668	Index, computed by applying the standard Service Inventory
669	Scores established by the Agency for Health Care Administration
670	to services offered by the given hospital, as reported on
671	Worksheet A-2 for the last fiscal year reported to the agency
672	before the date on which the allocation fraction is calculated.
673	The numerical value of this factor is the fraction that the
674	given hospital represents of the total Agency for Health Care
675	Administration Service Index values, where the total is computed
676	for all state statutory teaching hospitals.
677	2.  A volume-weighted service index, computed by applying
678	the standard Service Inventory Scores established by the Agency
679	for Health Care Administration to the volume of each service,
680	expressed in terms of the standard units of measure reported on
681	Worksheet A-2 for the last fiscal year reported to the agency
682	before the date on which the allocation factor is calculated.
683	The numerical value of this factor is the fraction that the
684	given hospital represents of the total volume-weighted service
685	index values, where the total is computed for all state
686	statutory teaching hospitals.
687	3.  Total Medicaid payments to each hospital for direct
688	inpatient and outpatient services during the fiscal year
689	preceding the date on which the allocation factor is calculated.
690	This includes payments made to each hospital for such services
691	by Medicaid prepaid health plans, whether the plan was
692	administered by the hospital or not. The numerical value of this
693	factor is the fraction that each hospital represents of the
694	total of such Medicaid payments, where the total is computed for
695	all state statutory teaching hospitals.
696
697	The primary factor for the service index is computed as the sum
698	of these three components, divided by three.
699	(2)  By October 1 of each year, the agency shall use the
700	following formula to calculate the maximum additional
701	disproportionate share payment for statutorily defined teaching
702	hospitals:
703
704	TAP = THAF x A
705
706	Where:
707	TAP = total additional payment.
708	THAF = teaching hospital allocation factor.
709	A = amount appropriated for a teaching hospital
710	disproportionate share program.
711	Section 9.  Section 409.9117, Florida Statutes, is amended
712	to read:
713	409.9117  Primary care disproportionate share program.--For
714	the state fiscal year 2008-2009 2006-2007, the agency shall not
715	distribute moneys under the primary care disproportionate share
716	program.
717	(1)  If federal funds are available for disproportionate
718	share programs in addition to those otherwise provided by law,
719	there shall be created a primary care disproportionate share
720	program.
721	(2)  The following formula shall be used by the agency to
722	calculate the total amount earned for hospitals that participate
723	in the primary care disproportionate share program:
724
725	TAE = HDSP/THDSP
726
727	Where:
728	TAE = total amount earned by a hospital participating in
729	the primary care disproportionate share program.
730	HDSP = the prior state fiscal year primary care
731	disproportionate share payment to the individual hospital.
732	THDSP = the prior state fiscal year total primary care
733	disproportionate share payments to all hospitals.
734	(3)  The total additional payment for hospitals that
735	participate in the primary care disproportionate share program
736	shall be calculated by the agency as follows:
737
738	TAP = TAE x TA
739
740	Where:
741	TAP = total additional payment for a primary care hospital.
742	TAE = total amount earned by a primary care hospital.
743	TA = total appropriation for the primary care
744	disproportionate share program.
745	(4)  In the establishment and funding of this program, the
746	agency shall use the following criteria in addition to those
747	specified in s. 409.911, payments may not be made to a hospital
748	unless the hospital agrees to:
749	(a)  Cooperate with a Medicaid prepaid health plan, if one
750	exists in the community.
751	(b)  Ensure the availability of primary and specialty care
752	physicians to Medicaid recipients who are not enrolled in a
753	prepaid capitated arrangement and who are in need of access to
754	such physicians.
755	(c)  Coordinate and provide primary care services free of
756	charge, except copayments, to all persons with incomes up to 100
757	percent of the federal poverty level who are not otherwise
758	covered by Medicaid or another program administered by a
759	governmental entity, and to provide such services based on a
760	sliding fee scale to all persons with incomes up to 200 percent
761	of the federal poverty level who are not otherwise covered by
762	Medicaid or another program administered by a governmental
763	entity, except that eligibility may be limited to persons who
764	reside within a more limited area, as agreed to by the agency
765	and the hospital.
766	(d)  Contract with any federally qualified health center,
767	if one exists within the agreed geopolitical boundaries,
768	concerning the provision of primary care services, in order to
769	guarantee delivery of services in a nonduplicative fashion, and
770	to provide for referral arrangements, privileges, and
771	admissions, as appropriate. The hospital shall agree to provide
772	at an onsite or offsite facility primary care services within 24
773	hours to which all Medicaid recipients and persons eligible
774	under this paragraph who do not require emergency room services
775	are referred during normal daylight hours.
776	(e)  Cooperate with the agency, the county, and other
777	entities to ensure the provision of certain public health
778	services, case management, referral and acceptance of patients,
779	and sharing of epidemiological data, as the agency and the
780	hospital find mutually necessary and desirable to promote and
781	protect the public health within the agreed geopolitical
782	boundaries.
783	(f)  In cooperation with the county in which the hospital
784	resides, develop a low-cost, outpatient, prepaid health care
785	program to persons who are not eligible for the Medicaid
786	program, and who reside within the area.
787	(g)  Provide inpatient services to residents within the
788	area who are not eligible for Medicaid or Medicare, and who do
789	not have private health insurance, regardless of ability to pay,
790	on the basis of available space, except that nothing shall
791	prevent the hospital from establishing bill collection programs
792	based on ability to pay.
793	(h)  Work with the Florida Healthy Kids Corporation, the
794	Florida Health Care Purchasing Cooperative, and business health
795	coalitions, as appropriate, to develop a feasibility study and
796	plan to provide a low-cost comprehensive health insurance plan
797	to persons who reside within the area and who do not have access
798	to such a plan.
799	(i)  Work with public health officials and other experts to
800	provide community health education and prevention activities
801	designed to promote healthy lifestyles and appropriate use of
802	health services.
803	(j)  Work with the local health council to develop a plan
804	for promoting access to affordable health care services for all
805	persons who reside within the area, including, but not limited
806	to, public health services, primary care services, inpatient
807	services, and affordable health insurance generally.
808
809	Any hospital that fails to comply with any of the provisions of
810	this subsection, or any other contractual condition, may not
811	receive payments under this section until full compliance is
812	achieved.
813	Section 10.  Paragraph (b) of subsection (4) and paragraph
814	(a) of subsection (39) of section 409.912, Florida Statutes, as
815	amended by chapter 2007-331, Laws of Florida, are amended, and
816	subsection (53) is added to that section, to read:
817	409.912  Cost-effective purchasing of health care.--The
818	agency shall purchase goods and services for Medicaid recipients
819	in the most cost-effective manner consistent with the delivery
820	of quality medical care. To ensure that medical services are
821	effectively utilized, the agency may, in any case, require a
822	confirmation or second physician's opinion of the correct
823	diagnosis for purposes of authorizing future services under the
824	Medicaid program. This section does not restrict access to
825	emergency services or poststabilization care services as defined
826	in 42 C.F.R. part 438.114. Such confirmation or second opinion
827	shall be rendered in a manner approved by the agency. The agency
828	shall maximize the use of prepaid per capita and prepaid
829	aggregate fixed-sum basis services when appropriate and other
830	alternative service delivery and reimbursement methodologies,
831	including competitive bidding pursuant to s. 287.057, designed
832	to facilitate the cost-effective purchase of a case-managed
833	continuum of care. The agency shall also require providers to
834	minimize the exposure of recipients to the need for acute
835	inpatient, custodial, and other institutional care and the
836	inappropriate or unnecessary use of high-cost services. The
837	agency shall contract with a vendor to monitor and evaluate the
838	clinical practice patterns of providers in order to identify
839	trends that are outside the normal practice patterns of a
840	provider's professional peers or the national guidelines of a
841	provider's professional association. The vendor must be able to
842	provide information and counseling to a provider whose practice
843	patterns are outside the norms, in consultation with the agency,
844	to improve patient care and reduce inappropriate utilization.
845	The agency may mandate prior authorization, drug therapy
846	management, or disease management participation for certain
847	populations of Medicaid beneficiaries, certain drug classes, or
848	particular drugs to prevent fraud, abuse, overuse, and possible
849	dangerous drug interactions. The Pharmaceutical and Therapeutics
850	Committee shall make recommendations to the agency on drugs for
851	which prior authorization is required. The agency shall inform
852	the Pharmaceutical and Therapeutics Committee of its decisions
853	regarding drugs subject to prior authorization. The agency is
854	authorized to limit the entities it contracts with or enrolls as
855	Medicaid providers by developing a provider network through
856	provider credentialing. The agency may competitively bid single-
857	source-provider contracts if procurement of goods or services
858	results in demonstrated cost savings to the state without
859	limiting access to care. The agency may limit its network based
860	on the assessment of beneficiary access to care, provider
861	availability, provider quality standards, time and distance
862	standards for access to care, the cultural competence of the
863	provider network, demographic characteristics of Medicaid
864	beneficiaries, practice and provider-to-beneficiary standards,
865	appointment wait times, beneficiary use of services, provider
866	turnover, provider profiling, provider licensure history,
867	previous program integrity investigations and findings, peer
868	review, provider Medicaid policy and billing compliance records,
869	clinical and medical record audits, and other factors. Providers
870	shall not be entitled to enrollment in the Medicaid provider
871	network. The agency shall determine instances in which allowing
872	Medicaid beneficiaries to purchase durable medical equipment and
873	other goods is less expensive to the Medicaid program than long-
874	term rental of the equipment or goods. The agency may establish
875	rules to facilitate purchases in lieu of long-term rentals in
876	order to protect against fraud and abuse in the Medicaid program
877	as defined in s. 409.913. The agency may seek federal waivers
878	necessary to administer these policies.
879	(4)  The agency may contract with:
880	(b)  An entity that is providing comprehensive behavioral
881	health care services to certain Medicaid recipients through a
882	capitated, prepaid arrangement pursuant to the federal waiver
883	provided for by s. 409.905(5). Such an entity must be licensed
884	under chapter 624, chapter 636, or chapter 641 and must possess
885	the clinical systems and operational competence to manage risk
886	and provide comprehensive behavioral health care to Medicaid
887	recipients. As used in this paragraph, the term "comprehensive
888	behavioral health care services" means covered mental health and
889	substance abuse treatment services that are available to
890	Medicaid recipients. The secretary of the Department of Children
891	and Family Services shall approve provisions of procurements
892	related to children in the department's care or custody prior to
893	enrolling such children in a prepaid behavioral health plan. Any
894	contract awarded under this paragraph must be competitively
895	procured. In developing the behavioral health care prepaid plan
896	procurement document, the agency shall ensure that the
897	procurement document requires the contractor to develop and
898	implement a plan to ensure compliance with s. 394.4574 related
899	to services provided to residents of licensed assisted living
900	facilities that hold a limited mental health license. Except as
901	provided in subparagraph 8., and except in counties where the
902	Medicaid managed care pilot program is authorized pursuant to s.
903	409.91211, the agency shall seek federal approval to contract
904	with a single entity meeting these requirements to provide
905	comprehensive behavioral health care services to all Medicaid
906	recipients not enrolled in a Medicaid managed care plan
907	authorized under s. 409.91211 or a Medicaid health maintenance
908	organization in an AHCA area. In an AHCA area where the Medicaid
909	managed care pilot program is authorized pursuant to s.
910	409.91211 in one or more counties, the agency may procure a
911	contract with a single entity to serve the remaining counties as
912	an AHCA area or the remaining counties may be included with an
913	adjacent AHCA area and shall be subject to this paragraph. Each
914	entity must offer sufficient choice of providers in its network
915	to ensure recipient access to care and the opportunity to select
916	a provider with whom they are satisfied. The network shall
917	include all public mental health hospitals. To ensure unimpaired
918	access to behavioral health care services by Medicaid
919	recipients, all contracts issued pursuant to this paragraph
920	shall require 80 percent of the capitation paid to the managed
921	care plan, including health maintenance organizations, to be
922	expended for the provision of behavioral health care services.
923	In the event the managed care plan expends less than 80 percent
924	of the capitation paid pursuant to this paragraph for the
925	provision of behavioral health care services, the difference
926	shall be returned to the agency. The agency shall provide the
927	managed care plan with a certification letter indicating the
928	amount of capitation paid during each calendar year for the
929	provision of behavioral health care services pursuant to this
930	section. The agency may reimburse for substance abuse treatment
931	services on a fee-for-service basis until the agency finds that
932	adequate funds are available for capitated, prepaid
933	arrangements.
934	1.  By January 1, 2001, the agency shall modify the
935	contracts with the entities providing comprehensive inpatient
936	and outpatient mental health care services to Medicaid
937	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
938	Counties, to include substance abuse treatment services.
939	2.  By July 1, 2003, the agency and the Department of
940	Children and Family Services shall execute a written agreement
941	that requires collaboration and joint development of all policy,
942	budgets, procurement documents, contracts, and monitoring plans
943	that have an impact on the state and Medicaid community mental
944	health and targeted case management programs.
945	3.  Except as provided in subparagraph 8., by July 1, 2006,
946	the agency and the Department of Children and Family Services
947	shall contract with managed care entities in each AHCA area
948	except area 6 or arrange to provide comprehensive inpatient and
949	outpatient mental health and substance abuse services through
950	capitated prepaid arrangements to all Medicaid recipients who
951	are eligible to participate in such plans under federal law and
952	regulation. In AHCA areas where eligible individuals number less
953	than 150,000, the agency shall contract with a single managed
954	care plan to provide comprehensive behavioral health services to
955	all recipients who are not enrolled in a Medicaid health
956	maintenance organization or a Medicaid capitated managed care
957	plan authorized under s. 409.91211. The agency may contract with
958	more than one comprehensive behavioral health provider to
959	provide care to recipients who are not enrolled in a Medicaid
960	capitated managed care plan authorized under s. 409.91211 or a
961	Medicaid health maintenance organization in AHCA areas where the
962	eligible population exceeds 150,000. In an AHCA area where the
963	Medicaid managed care pilot program is authorized pursuant to s.
964	409.91211 in one or more counties, the agency may procure a
965	contract with a single entity to serve the remaining counties as
966	an AHCA area or the remaining counties may be included with an
967	adjacent AHCA area and shall be subject to this paragraph.
968	Contracts for comprehensive behavioral health providers awarded
969	pursuant to this section shall be competitively procured. Both
970	for-profit and not-for-profit corporations shall be eligible to
971	compete. Managed care plans contracting with the agency under
972	subsection (3) shall provide and receive payment for the same
973	comprehensive behavioral health benefits as provided in AHCA
974	rules, including handbooks incorporated by reference. In AHCA
975	area 11, the agency shall contract with at least two
976	comprehensive behavioral health care providers to provide
977	behavioral health care to recipients in that area who are
978	enrolled in, or assigned to, the MediPass program. One of the
979	behavioral health care contracts shall be with the existing
980	provider service network pilot project, as described in
981	paragraph (d), for the purpose of demonstrating the cost-
982	effectiveness of the provision of quality mental health services
983	through a public hospital-operated managed care model. Payment
984	shall be at an agreed-upon capitated rate to ensure cost
985	savings. Of the recipients in area 11 who are assigned to
986	MediPass under the provisions of s. 409.9122(2)(k), a minimum of
987	50,000 of those MediPass-enrolled recipients shall be assigned
988	to the existing provider service network in area 11 for their
989	behavioral care.
990	4.  By October 1, 2003, the agency and the department shall
991	submit a plan to the Governor, the President of the Senate, and
992	the Speaker of the House of Representatives which provides for
993	the full implementation of capitated prepaid behavioral health
994	care in all areas of the state.
995	a.  Implementation shall begin in 2003 in those AHCA areas
996	of the state where the agency is able to establish sufficient
997	capitation rates.
998	b.  If the agency determines that the proposed capitation
999	rate in any area is insufficient to provide appropriate
1000	services, the agency may adjust the capitation rate to ensure
1001	that care will be available. The agency and the department may
1002	use existing general revenue to address any additional required
1003	match but may not over-obligate existing funds on an annualized
1004	basis.
1005	c.  Subject to any limitations provided for in the General
1006	Appropriations Act, the agency, in compliance with appropriate
1007	federal authorization, shall develop policies and procedures
1008	that allow for certification of local and state funds.
1009	5.  Children residing in a statewide inpatient psychiatric
1010	program, or in a Department of Juvenile Justice or a Department
1011	of Children and Family Services residential program approved as
1012	a Medicaid behavioral health overlay services provider shall not
1013	be included in a behavioral health care prepaid health plan or
1014	any other Medicaid managed care plan pursuant to this paragraph.
1015	6.  In converting to a prepaid system of delivery, the
1016	agency shall in its procurement document require an entity
1017	providing only comprehensive behavioral health care services to
1018	prevent the displacement of indigent care patients by enrollees
1019	in the Medicaid prepaid health plan providing behavioral health
1020	care services from facilities receiving state funding to provide
1021	indigent behavioral health care, to facilities licensed under
1022	chapter 395 which do not receive state funding for indigent
1023	behavioral health care, or reimburse the unsubsidized facility
1024	for the cost of behavioral health care provided to the displaced
1025	indigent care patient.
1026	7.  Traditional community mental health providers under
1027	contract with the Department of Children and Family Services
1028	pursuant to part IV of chapter 394, child welfare providers
1029	under contract with the Department of Children and Family
1030	Services in areas 1 and 6, and inpatient mental health providers
1031	licensed pursuant to chapter 395 must be offered an opportunity
1032	to accept or decline a contract to participate in any provider
1033	network for prepaid behavioral health services.
1034	8.  All Medicaid-eligible children, except children in area
1035	1 and children in Highlands, Hardee, Polk, or Manatee County of
1036	area 6 For fiscal year 2004-2005, all Medicaid eligible
1037	children, except children in areas 1 and 6, whose cases are open
1038	for child welfare services in the HomeSafeNet system, shall be
1039	enrolled in MediPass or in Medicaid fee-for-service and all
1040	their behavioral health care services including inpatient,
1041	outpatient psychiatric, community mental health, and case
1042	management shall be reimbursed on a fee-for-service basis.
1043	Beginning July 1, 2005, such children, who are open for child
1044	welfare services in the HomeSafeNet system, shall receive their
1045	behavioral health care services through a specialty prepaid plan
1046	operated by community-based lead agencies either through a
1047	single agency or formal agreements among several agencies. The
1048	specialty prepaid plan must result in savings to the state
1049	comparable to savings achieved in other Medicaid managed care
1050	and prepaid programs. Such plan must provide mechanisms to
1051	maximize state and local revenues. The specialty prepaid plan
1052	shall be developed by the agency and the Department of Children
1053	and Family Services. The agency is authorized to seek any
1054	federal waivers to implement this initiative. Medicaid-eligible
1055	children whose cases are open for child welfare services in the
1056	HomeSafeNet system and who reside in AHCA area 10 are exempt
1057	from the specialty prepaid plan upon the development of a
1058	service delivery mechanism for children who reside in area 10 as
1059	specified in s. 409.91211(3)(dd).
1060	(39)(a)  The agency shall implement a Medicaid prescribed-
1061	drug spending-control program that includes the following
1062	components:
1063	1.  A Medicaid preferred drug list, which shall be a
1064	listing of cost-effective therapeutic options recommended by the
1065	Medicaid Pharmacy and Therapeutics Committee established
1066	pursuant to s. 409.91195 and adopted by the agency for each
1067	therapeutic class on the preferred drug list. At the discretion
1068	of the committee, and when feasible, the preferred drug list
1069	should include at least two products in a therapeutic class. The
1070	agency may post the preferred drug list and updates to the
1071	preferred drug list on an Internet website without following the
1072	rulemaking procedures of chapter 120. Antiretroviral agents are
1073	excluded from the preferred drug list. The agency shall also
1074	limit the amount of a prescribed drug dispensed to no more than
1075	a 34-day supply unless the drug products' smallest marketed
1076	package is greater than a 34-day supply, or the drug is
1077	determined by the agency to be a maintenance drug in which case
1078	a 100-day maximum supply may be authorized. The agency is
1079	authorized to seek any federal waivers necessary to implement
1080	these cost-control programs and to continue participation in the
1081	federal Medicaid rebate program, or alternatively to negotiate
1082	state-only manufacturer rebates. The agency may adopt rules to
1083	implement this subparagraph. The agency shall continue to
1084	provide unlimited contraceptive drugs and items. The agency must
1085	establish procedures to ensure that:
1086	a.  There is will be a response to a request for prior
1087	consultation by telephone or other telecommunication device
1088	within 24 hours after receipt of a request for prior
1089	consultation; and
1090	b.  A 72-hour supply of the drug prescribed is will be
1091	provided in an emergency or when the agency does not provide a
1092	response within 24 hours as required by sub-subparagraph a.
1093	2.  Reimbursement to pharmacies for Medicaid prescribed
1094	drugs shall be set at the lesser of: the average wholesale price
1095	(AWP) minus 16.4 15.4 percent, the wholesaler acquisition cost
1096	(WAC) plus 4.75 5.75 percent, the federal upper limit (FUL), the
1097	state maximum allowable cost (SMAC), or the usual and customary
1098	(UAC) charge billed by the provider.
1099	3.  The agency shall develop and implement a process for
1100	managing the drug therapies of Medicaid recipients who are using
1101	significant numbers of prescribed drugs each month. The
1102	management process may include, but is not limited to,
1103	comprehensive, physician-directed medical-record reviews, claims
1104	analyses, and case evaluations to determine the medical
1105	necessity and appropriateness of a patient's treatment plan and
1106	drug therapies. The agency may contract with a private
1107	organization to provide drug-program-management services. The
1108	Medicaid drug benefit management program shall include
1109	initiatives to manage drug therapies for HIV/AIDS patients,
1110	patients using 20 or more unique prescriptions in a 180-day
1111	period, and the top 1,000 patients in annual spending. The
1112	agency shall enroll any Medicaid recipient in the drug benefit
1113	management program if he or she meets the specifications of this
1114	provision and is not enrolled in a Medicaid health maintenance
1115	organization.
1116	4.  The agency may limit the size of its pharmacy network
1117	based on need, competitive bidding, price negotiations,
1118	credentialing, or similar criteria. The agency shall give
1119	special consideration to rural areas in determining the size and
1120	location of pharmacies included in the Medicaid pharmacy
1121	network. A pharmacy credentialing process may include criteria
1122	such as a pharmacy's full-service status, location, size,
1123	patient educational programs, patient consultation, disease
1124	management services, and other characteristics. The agency may
1125	impose a moratorium on Medicaid pharmacy enrollment when it is
1126	determined that it has a sufficient number of Medicaid-
1127	participating providers. The agency must allow dispensing
1128	practitioners to participate as a part of the Medicaid pharmacy
1129	network regardless of the practitioner's proximity to any other
1130	entity that is dispensing prescription drugs under the Medicaid
1131	program. A dispensing practitioner must meet all credentialing
1132	requirements applicable to his or her practice, as determined by
1133	the agency.
1134	5.  The agency shall develop and implement a program that
1135	requires Medicaid practitioners who prescribe drugs to use a
1136	counterfeit-proof prescription pad for Medicaid prescriptions.
1137	The agency shall require the use of standardized counterfeit-
1138	proof prescription pads by Medicaid-participating prescribers or
1139	prescribers who write prescriptions for Medicaid recipients. The
1140	agency may implement the program in targeted geographic areas or
1141	statewide.
1142	6.  The agency may enter into arrangements that require
1143	manufacturers of generic drugs prescribed to Medicaid recipients
1144	to provide rebates of at least 15.1 percent of the average
1145	manufacturer price for the manufacturer's generic products.
1146	These arrangements shall require that if a generic-drug
1147	manufacturer pays federal rebates for Medicaid-reimbursed drugs
1148	at a level below 15.1 percent, the manufacturer must provide a
1149	supplemental rebate to the state in an amount necessary to
1150	achieve a 15.1-percent rebate level.
1151	7.  The agency may establish a preferred drug list as
1152	described in this subsection, and, pursuant to the establishment
1153	of such preferred drug list, it is authorized to negotiate
1154	supplemental rebates from manufacturers that are in addition to
1155	those required by Title XIX of the Social Security Act and at no
1156	less than 14 percent of the average manufacturer price as
1157	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
1158	the federal or supplemental rebate, or both, equals or exceeds
1159	29 percent. There is no upper limit on the supplemental rebates
1160	the agency may negotiate. The agency may determine that specific
1161	products, brand-name or generic, are competitive at lower rebate
1162	percentages. Agreement to pay the minimum supplemental rebate
1163	percentage will guarantee a manufacturer that the Medicaid
1164	Pharmaceutical and Therapeutics Committee will consider a
1165	product for inclusion on the preferred drug list. However, a
1166	pharmaceutical manufacturer is not guaranteed placement on the
1167	preferred drug list by simply paying the minimum supplemental
1168	rebate. Agency decisions will be made on the clinical efficacy
1169	of a drug and recommendations of the Medicaid Pharmaceutical and
1170	Therapeutics Committee, as well as the price of competing
1171	products minus federal and state rebates. The agency is
1172	authorized to contract with an outside agency or contractor to
1173	conduct negotiations for supplemental rebates. For the purposes
1174	of this section, the term "supplemental rebates" means cash
1175	rebates. Effective July 1, 2004, value-added programs as a
1176	substitution for supplemental rebates are prohibited. The agency
1177	is authorized to seek any federal waivers to implement this
1178	initiative.
1179	8.  The Agency for Health Care Administration shall expand
1180	home delivery of pharmacy products. To assist Medicaid patients
1181	in securing their prescriptions and reduce program costs, the
1182	agency shall expand its current mail-order-pharmacy diabetes-
1183	supply program to include all generic and brand-name drugs used
1184	by Medicaid patients with diabetes. Medicaid recipients in the
1185	current program may obtain nondiabetes drugs on a voluntary
1186	basis. This initiative is limited to the geographic area covered
1187	by the current contract. The agency may seek and implement any
1188	federal waivers necessary to implement this subparagraph.
1189	9.  The agency shall limit to one dose per month any drug
1190	prescribed to treat erectile dysfunction.
1191	10.a.  The agency may implement a Medicaid behavioral drug
1192	management system. The agency may contract with a vendor that
1193	has experience in operating behavioral drug management systems
1194	to implement this program. The agency is authorized to seek
1195	federal waivers to implement this program.
1196	b.  The agency, in conjunction with the Department of
1197	Children and Family Services, may implement the Medicaid
1198	behavioral drug management system that is designed to improve
1199	the quality of care and behavioral health prescribing practices
1200	based on best practice guidelines, improve patient adherence to
1201	medication plans, reduce clinical risk, and lower prescribed
1202	drug costs and the rate of inappropriate spending on Medicaid
1203	behavioral drugs. The program may include the following
1204	elements:
1205	(I)  Provide for the development and adoption of best
1206	practice guidelines for behavioral health-related drugs such as
1207	antipsychotics, antidepressants, and medications for treating
1208	bipolar disorders and other behavioral conditions; translate
1209	them into practice; review behavioral health prescribers and
1210	compare their prescribing patterns to a number of indicators
1211	that are based on national standards; and determine deviations
1212	from best practice guidelines.
1213	(II)  Implement processes for providing feedback to and
1214	educating prescribers using best practice educational materials
1215	and peer-to-peer consultation.
1216	(III)  Assess Medicaid beneficiaries who are outliers in
1217	their use of behavioral health drugs with regard to the numbers
1218	and types of drugs taken, drug dosages, combination drug
1219	therapies, and other indicators of improper use of behavioral
1220	health drugs.
1221	(IV)  Alert prescribers to patients who fail to refill
1222	prescriptions in a timely fashion, are prescribed multiple same-
1223	class behavioral health drugs, and may have other potential
1224	medication problems.
1225	(V)  Track spending trends for behavioral health drugs and
1226	deviation from best practice guidelines.
1227	(VI)  Use educational and technological approaches to
1228	promote best practices, educate consumers, and train prescribers
1229	in the use of practice guidelines.
1230	(VII)  Disseminate electronic and published materials.
1231	(VIII)  Hold statewide and regional conferences.
1232	(IX)  Implement a disease management program with a model
1233	quality-based medication component for severely mentally ill
1234	individuals and emotionally disturbed children who are high
1235	users of care.
1236	11.a.  The agency shall implement a Medicaid prescription
1237	drug management system. The agency may contract with a vendor
1238	that has experience in operating prescription drug management
1239	systems in order to implement this system. Any management system
1240	that is implemented in accordance with this subparagraph must
1241	rely on cooperation between physicians and pharmacists to
1242	determine appropriate practice patterns and clinical guidelines
1243	to improve the prescribing, dispensing, and use of drugs in the
1244	Medicaid program. The agency may seek federal waivers to
1245	implement this program.
1246	b.  The drug management system must be designed to improve
1247	the quality of care and prescribing practices based on best
1248	practice guidelines, improve patient adherence to medication
1249	plans, reduce clinical risk, and lower prescribed drug costs and
1250	the rate of inappropriate spending on Medicaid prescription
1251	drugs. The program must:
1252	(I)  Provide for the development and adoption of best
1253	practice guidelines for the prescribing and use of drugs in the
1254	Medicaid program, including translating best practice guidelines
1255	into practice; reviewing prescriber patterns and comparing them
1256	to indicators that are based on national standards and practice
1257	patterns of clinical peers in their community, statewide, and
1258	nationally; and determine deviations from best practice
1259	guidelines.
1260	(II)  Implement processes for providing feedback to and
1261	educating prescribers using best practice educational materials
1262	and peer-to-peer consultation.
1263	(III)  Assess Medicaid recipients who are outliers in their
1264	use of a single or multiple prescription drugs with regard to
1265	the numbers and types of drugs taken, drug dosages, combination
1266	drug therapies, and other indicators of improper use of
1267	prescription drugs.
1268	(IV)  Alert prescribers to patients who fail to refill
1269	prescriptions in a timely fashion, are prescribed multiple drugs
1270	that may be redundant or contraindicated, or may have other
1271	potential medication problems.
1272	(V)  Track spending trends for prescription drugs and
1273	deviation from best practice guidelines.
1274	(VI)  Use educational and technological approaches to
1275	promote best practices, educate consumers, and train prescribers
1276	in the use of practice guidelines.
1277	(VII)  Disseminate electronic and published materials.
1278	(VIII)  Hold statewide and regional conferences.
1279	(IX)  Implement disease management programs in cooperation
1280	with physicians and pharmacists, along with a model quality-
1281	based medication component for individuals having chronic
1282	medical conditions.
1283	12.  The agency is authorized to contract for drug rebate
1284	administration, including, but not limited to, calculating
1285	rebate amounts, invoicing manufacturers, negotiating disputes
1286	with manufacturers, and maintaining a database of rebate
1287	collections.
1288	13.  The agency may specify the preferred daily dosing form
1289	or strength for the purpose of promoting best practices with
1290	regard to the prescribing of certain drugs as specified in the
1291	General Appropriations Act and ensuring cost-effective
1292	prescribing practices.
1293	14.  The agency may require prior authorization for
1294	Medicaid-covered prescribed drugs. The agency may, but is not
1295	required to, prior-authorize the use of a product:
1296	a.  For an indication not approved in labeling;
1297	b.  To comply with certain clinical guidelines; or
1298	c.  If the product has the potential for overuse, misuse,
1299	or abuse.
1300
1301	The agency may require the prescribing professional to provide
1302	information about the rationale and supporting medical evidence
1303	for the use of a drug. The agency may post prior authorization
1304	criteria and protocol and updates to the list of drugs that are
1305	subject to prior authorization on an Internet website without
1306	amending its rule or engaging in additional rulemaking.
1307	15.  The agency, in conjunction with the Pharmaceutical and
1308	Therapeutics Committee, may require age-related prior
1309	authorizations for certain prescribed drugs. The agency may
1310	preauthorize the use of a drug for a recipient who may not meet
1311	the age requirement or may exceed the length of therapy for use
1312	of this product as recommended by the manufacturer and approved
1313	by the Food and Drug Administration. Prior authorization may
1314	require the prescribing professional to provide information
1315	about the rationale and supporting medical evidence for the use
1316	of a drug.
1317	16.  The agency shall implement a step-therapy prior
1318	authorization approval process for medications excluded from the
1319	preferred drug list. Medications listed on the preferred drug
1320	list must be used within the previous 12 months prior to the
1321	alternative medications that are not listed. The step-therapy
1322	prior authorization may require the prescriber to use the
1323	medications of a similar drug class or for a similar medical
1324	indication unless contraindicated in the Food and Drug
1325	Administration labeling. The trial period between the specified
1326	steps may vary according to the medical indication. The step-
1327	therapy approval process shall be developed in accordance with
1328	the committee as stated in s. 409.91195(7) and (8). A drug
1329	product may be approved without meeting the step-therapy prior
1330	authorization criteria if the prescribing physician provides the
1331	agency with additional written medical or clinical documentation
1332	that the product is medically necessary because:
1333	a.  There is not a drug on the preferred drug list to treat
1334	the disease or medical condition which is an acceptable clinical
1335	alternative;
1336	b.  The alternatives have been ineffective in the treatment
1337	of the beneficiary's disease; or
1338	c.  Based on historic evidence and known characteristics of
1339	the patient and the drug, the drug is likely to be ineffective,
1340	or the number of doses have been ineffective.
1341
1342	The agency shall work with the physician to determine the best
1343	alternative for the patient. The agency may adopt rules waiving
1344	the requirements for written clinical documentation for specific
1345	drugs in limited clinical situations.
1346	17.  The agency shall implement a return and reuse program
1347	for drugs dispensed by pharmacies to institutional recipients,
1348	which includes payment of a $5 restocking fee for the
1349	implementation and operation of the program. The return and
1350	reuse program shall be implemented electronically and in a
1351	manner that promotes efficiency. The program must permit a
1352	pharmacy to exclude drugs from the program if it is not
1353	practical or cost-effective for the drug to be included and must
1354	provide for the return to inventory of drugs that cannot be
1355	credited or returned in a cost-effective manner. The agency
1356	shall determine if the program has reduced the amount of
1357	Medicaid prescription drugs which are destroyed on an annual
1358	basis and if there are additional ways to ensure more
1359	prescription drugs are not destroyed which could safely be
1360	reused. The agency's conclusion and recommendations shall be
1361	reported to the Legislature by December 1, 2005.
1362	(53)  Before seeking an amendment to the state plan for
1363	purposes of implementing programs authorized by the Deficit
1364	Reduction Act of 2005, the agency shall notify the Legislature.
1365	Section 11.  Section 409.91206, Florida Statutes, is
1366	created to read:
1367	409.91206  Alternatives for health and long-term care
1368	reforms.--The Governor, the President of the Senate, and the
1369	Speaker of the House of Representatives may convene workgroups
1370	to propose alternatives for cost-effective health and long-term
1371	care reforms, including, but not limited to, reforms for
1372	Medicaid.
1373	Section 12.  Paragraphs (c), (e), (f), and (i) of
1374	subsection (2) of section 409.9122, Florida Statutes, are
1375	amended to read:
1376	409.9122  Mandatory Medicaid managed care enrollment;
1377	programs and procedures.--
1378	(2)
1379	(c)  Medicaid recipients shall have a choice of managed
1380	care plans or MediPass. The Agency for Health Care
1381	Administration, the Department of Health, the Department of
1382	Children and Family Services, and the Department of Elderly
1383	Affairs shall cooperate to ensure that each Medicaid recipient
1384	receives clear and easily understandable information that meets
1385	the following requirements:
1386	1.  Explains the concept of managed care, including
1387	MediPass.
1388	2.  Provides information on the comparative performance of
1389	managed care plans and MediPass in the areas of quality,
1390	credentialing, preventive health programs, network size and
1391	availability, and patient satisfaction.
1392	3.  Explains where additional information on each managed
1393	care plan and MediPass in the recipient's area can be obtained.
1394	4.  Explains that recipients have the right to choose their
1395	own managed care coverage at the time they first enroll in
1396	Medicaid and again at regular intervals set by the agency plans
1397	or MediPass. However, if a recipient does not choose a managed
1398	care plan or MediPass, the agency will assign the recipient to a
1399	managed care plan or MediPass according to the criteria
1400	specified in this section.
1401	5.  Explains the recipient's right to complain, file a
1402	grievance, or change managed care plans or MediPass providers if
1403	the recipient is not satisfied with the managed care plan or
1404	MediPass.
1405	(e)  Medicaid recipients who are already enrolled in a
1406	managed care plan or MediPass shall be offered the opportunity
1407	to change managed care plans or MediPass providers on a
1408	staggered basis, as defined by the agency. All Medicaid
1409	recipients shall have 30 days in which to make a choice of
1410	managed care plans or MediPass providers. In counties that have
1411	two or more managed care plans, a recipient already enrolled in
1412	MediPass who fails to make a choice during the annual period
1413	shall be assigned to a managed care plan if he or she is
1414	eligible for enrollment in the managed care plan. The agency
1415	shall apply for a state plan amendment or federal waiver
1416	authority, if necessary, to implement the provisions of this
1417	paragraph.  All newly eligible Medicaid recipients shall have 30
1418	days in which to make a choice of managed care plans or Medipass
1419	providers. Those Medicaid recipients who do not make a choice
1420	shall be assigned to a managed care plan or MediPass in
1421	accordance with paragraph (f). To facilitate continuity of care,
1422	for a Medicaid recipient who is also a recipient of Supplemental
1423	Security Income (SSI), prior to assigning the SSI recipient to a
1424	managed care plan or MediPass, the agency shall determine
1425	whether the SSI recipient has an ongoing relationship with a
1426	MediPass provider or managed care plan, and if so, the agency
1427	shall assign the SSI recipient to that MediPass provider or
1428	managed care plan. If the SSI recipient has an ongoing
1429	relationship with a managed care plan, the agency shall assign
1430	the recipient to that managed care plan. Those SSI recipients
1431	who do not have such a provider relationship shall be assigned
1432	to a managed care plan or MediPass provider in accordance with
1433	paragraph (f).
1434	(f)  If When a Medicaid recipient does not choose a managed
1435	care plan or MediPass provider, the agency shall assign the
1436	Medicaid recipient to a managed care plan or MediPass provider.
1437	Medicaid recipients eligible for managed care plan enrollment
1438	who are subject to mandatory assignment but who fail to make a
1439	choice shall be assigned to managed care plans until an
1440	enrollment of 35 percent in MediPass and 65 percent in managed
1441	care plans, of all those eligible to choose managed care, is
1442	achieved. Once this enrollment is achieved, the assignments
1443	shall be divided in order to maintain an enrollment in MediPass
1444	and managed care plans which is in a 35 percent and 65 percent
1445	proportion, respectively. Thereafter, assignment of Medicaid
1446	recipients who fail to make a choice shall be based
1447	proportionally on the preferences of recipients who have made a
1448	choice in the previous period. Such proportions shall be revised
1449	at least quarterly to reflect an update of the preferences of
1450	Medicaid recipients. The agency shall disproportionately assign
1451	Medicaid-eligible recipients who are required to but have failed
1452	to make a choice of managed care plan or MediPass, including
1453	children, and who would are to be assigned to the MediPass
1454	program to children's networks as described in s. 409.912(4)(g),
1455	Children's Medical Services Network as defined in s. 391.021,
1456	exclusive provider organizations, provider service networks,
1457	minority physician networks, and pediatric emergency department
1458	diversion programs authorized by this chapter or the General
1459	Appropriations Act, in such manner as the agency deems
1460	appropriate, until the agency has determined that the networks
1461	and programs have sufficient numbers to be operated economically
1462	operated. For purposes of this paragraph, when referring to
1463	assignment, the term "managed care plans" includes health
1464	maintenance organizations, exclusive provider organizations,
1465	provider service networks, minority physician networks,
1466	Children's Medical Services Network, and pediatric emergency
1467	department diversion programs authorized by this chapter or the
1468	General Appropriations Act. When making assignments, the agency
1469	shall take into account the following criteria:
1470	1.  A managed care plan has sufficient network capacity to
1471	meet the need of members.
1472	2.  The managed care plan or MediPass has previously
1473	enrolled the recipient as a member, or one of the managed care
1474	plan's primary care providers or MediPass providers has
1475	previously provided health care to the recipient.
1476	3.  The agency has knowledge that the member has previously
1477	expressed a preference for a particular managed care plan or
1478	MediPass provider as indicated by Medicaid fee-for-service
1479	claims data, but has failed to make a choice.
1480	4.  The managed care plan's or MediPass primary care
1481	providers are geographically accessible to the recipient's
1482	residence.
1483	(i)  After a recipient has made his or her a selection or
1484	has been enrolled in a managed care plan or MediPass, the
1485	recipient shall have 90 days to exercise the opportunity in
1486	which to voluntarily disenroll and select another managed care
1487	plan or MediPass provider. After 90 days, no further changes may
1488	be made except for good cause. Good cause includes shall
1489	include, but is not be limited to, poor quality of care, lack of
1490	access to necessary specialty services, an unreasonable delay or
1491	denial of service, or fraudulent enrollment. The agency shall
1492	develop criteria for good cause disenrollment for chronically
1493	ill and disabled populations who are assigned to managed care
1494	plans if more appropriate care is available through the MediPass
1495	program. The agency must make a determination as to whether
1496	cause exists. However, the agency may require a recipient to use
1497	the managed care plan's or MediPass grievance process prior to
1498	the agency's determination of cause, except in cases in which
1499	immediate risk of permanent damage to the recipient's health is
1500	alleged. The grievance process, when utilized, must be completed
1501	in time to permit the recipient to disenroll by no later than
1502	the first day of the second month after the month the
1503	disenrollment request was made. If the managed care plan or
1504	MediPass, as a result of the grievance process, approves an
1505	enrollee's request to disenroll, the agency is not required to
1506	make a determination in the case. The agency must make a
1507	determination and take final action on a recipient's request so
1508	that disenrollment occurs no later than the first day of the
1509	second month after the month the request was made. If the agency
1510	fails to act within the specified timeframe, the recipient's
1511	request to disenroll is deemed to be approved as of the date
1512	agency action was required. Recipients who disagree with the
1513	agency's finding that cause does not exist for disenrollment
1514	shall be advised of their right to pursue a Medicaid fair
1515	hearing to dispute the agency's finding.
1516	Section 13.  Subsection (2) of section 409.9124, Florida
1517	Statutes, is amended to read:
1518	409.9124  Managed care reimbursement.--The agency shall
1519	develop and adopt by rule a methodology for reimbursing managed
1520	care plans.
1521	(2)  Each year prior to establishing new managed care
1522	rates, the agency shall review all prior year adjustments for
1523	changes in trend, and shall reduce or eliminate those
1524	adjustments which are not reasonable and which reflect policies
1525	or programs which are not in effect. In addition, the agency
1526	shall apply only those policy reductions applicable to the
1527	fiscal year for which the rates are being set, which can be
1528	accurately estimated and verified by an independent actuary, and
1529	which have been implemented prior to or will be implemented
1530	during the fiscal year. The agency shall pay rates at per-
1531	member, per-month averages that do not exceed the amounts
1532	allowed for in the General Appropriations Act applicable to the
1533	fiscal year for which the rates will be in effect.
1534	Section 14.  Subsection (36) of section 409.913, Florida
1535	Statutes, is amended to read:
1536	409.913  Oversight of the integrity of the Medicaid
1537	program.--The agency shall operate a program to oversee the
1538	activities of Florida Medicaid recipients, and providers and
1539	their representatives, to ensure that fraudulent and abusive
1540	behavior and neglect of recipients occur to the minimum extent
1541	possible, and to recover overpayments and impose sanctions as
1542	appropriate. Beginning January 1, 2003, and each year
1543	thereafter, the agency and the Medicaid Fraud Control Unit of
1544	the Department of Legal Affairs shall submit a joint report to
1545	the Legislature documenting the effectiveness of the state's
1546	efforts to control Medicaid fraud and abuse and to recover
1547	Medicaid overpayments during the previous fiscal year. The
1548	report must describe the number of cases opened and investigated
1549	each year; the sources of the cases opened; the disposition of
1550	the cases closed each year; the amount of overpayments alleged
1551	in preliminary and final audit letters; the number and amount of
1552	fines or penalties imposed; any reductions in overpayment
1553	amounts negotiated in settlement agreements or by other means;
1554	the amount of final agency determinations of overpayments; the
1555	amount deducted from federal claiming as a result of
1556	overpayments; the amount of overpayments recovered each year;
1557	the amount of cost of investigation recovered each year; the
1558	average length of time to collect from the time the case was
1559	opened until the overpayment is paid in full; the amount
1560	determined as uncollectible and the portion of the uncollectible
1561	amount subsequently reclaimed from the Federal Government; the
1562	number of providers, by type, that are terminated from
1563	participation in the Medicaid program as a result of fraud and
1564	abuse; and all costs associated with discovering and prosecuting
1565	cases of Medicaid overpayments and making recoveries in such
1566	cases. The report must also document actions taken to prevent
1567	overpayments and the number of providers prevented from
1568	enrolling in or reenrolling in the Medicaid program as a result
1569	of documented Medicaid fraud and abuse and must recommend
1570	changes necessary to prevent or recover overpayments.
1571	(36)  The agency shall provide to each Medicaid recipient
1572	or his or her representative an explanation of benefits in the
1573	form of a letter that is mailed to the most recent address of
1574	the recipient on the record with the Department of Children and
1575	Family Services. The explanation of benefits must include the
1576	patient's name, the name of the health care provider and the
1577	address of the location where the service was provided, a
1578	description of all services billed to Medicaid in terminology
1579	that should be understood by a reasonable person, and
1580	information on how to report inappropriate or incorrect billing
1581	to the agency or other law enforcement entities for review or
1582	investigation. The explanation of benefits may not be mailed for
1583	Medicaid independent laboratory services as described in s.
1584	409.905(7) or for Medicaid certified match services as described
1585	in ss. 409.9071 and 1011.70.
1586	Section 15.  Sections 409.9061 and 430.83, Florida
1587	Statutes, are repealed.
1588	Section 16.  This act shall take effect July 1, 2008.
1589
1590
1591	-----------------------------------------------------
1592	T I T L E  A M E N D M E N T
1593	Remove the entire title and insert:
1594	A bill to be entitled
1595	An act relating to health care; amending s. 400.179, F.S.;
1596	authorizing the Agency for Health Care Administration to
1597	transfer funds to the Grants and Donations Trust Fund for
1598	certain repayments; amending s. 409.017, F.S.; revising
1599	the short title; providing additional legislative intent;
1600	requiring the agency to develop a procurement document and
1601	procedure to claim certain federal matching funds;
1602	amending s. 409.904, F.S.; discontinuing optional Medicaid
1603	payments for certain persons age 65 or over or who are
1604	blind or disabled; revising certain eligibility criteria
1605	for pregnant women and children younger than age 21;
1606	amending s. 409.906, F.S.; authorizing payment of a
1607	specified amount for Medicaid services provided by an
1608	anesthesiologist assistant; amending s. 409.908, F.S.;
1609	deleting a provision prohibiting Medicaid from making any
1610	payment toward deductibles and coinsurance for services
1611	not covered by Medicaid; providing limitations on Medicaid
1612	payments for coinsurance; providing for Medicaid to pay
1613	for certain X-ray services in a nursing home; revising
1614	reimbursement rates for providers of Medicaid prescribed
1615	drugs; requiring the agency to revise reimbursement rates
1616	for hospitals, nursing homes, county health departments,
1617	and community intermediate care facilities for the
1618	developmentally disabled for 2 fiscal years; requiring the
1619	agency to apply the effect of the revised reimbursement
1620	rates to set payment rates for managed care plans and
1621	nursing home diversion programs; requiring the agency to
1622	establish workgroups to evaluate alternative reimbursement
1623	and payment methodologies for hospitals, nursing
1624	facilities, and managed care plans; requiring a report;
1625	providing for future repeal of the suspension of the use
1626	of cost data to set certain rates; amending s. 409.911,
1627	F.S.; revising the share data used to calculate
1628	disproportionate share payments to hospitals; amending s.
1629	409.9112, F.S.; revising the time period during which the
1630	agency is prohibited from distributing disproportionate
1631	share payments to regional perinatal intensive care
1632	centers; amending s. 409.9113, F.S.; requiring the agency
1633	to distribute moneys provided in the General
1634	Appropriations Act to statutorily defined teaching
1635	hospitals and family practice teaching hospitals under the
1636	teaching hospital disproportionate share program for the
1637	2008-2009 fiscal year; amending s. 409.9117, F.S.;
1638	prohibiting the agency from distributing moneys under the
1639	primary care disproportionate share program for the 2008-
1640	2009 fiscal year; amending s. 409.912, F.S.; adding a
1641	county for participation in the Medicaid behavioral health
1642	care services specialty prepaid plan; revising
1643	reimbursement rates to pharmacies for Medicaid prescribed
1644	drugs; requiring the agency to notify the Legislature
1645	before seeking an amendment to the state plan in order to
1646	implement programs authorized by the Deficit Reduction Act
1647	of 2005; creating s. 409.91206, F.S.; providing for
1648	proposed alternatives for health and long-term care
1649	reforms; amending s. 409.9122, F.S.; revising enrollment
1650	requirements relating to Medicaid managed care programs
1651	and the agency's authority to assign persons to MediPass
1652	or a managed care plan; amending s. 409.9124, F.S.;
1653	removing the limitation on the application of certain
1654	rates and rate reductions used by the agency to reimburse
1655	managed care plans; amending s. 409.913, F.S.; prohibiting
1656	mailing of the explanation of benefits for certain
1657	Medicaid services; repealing s. 409.9061, F.S., relating
1658	to authority for a statewide laboratory services contract;
1659	repealing s. 430.83, F.S., relating to the Sunshine for
1660	Seniors Program; providing an effective date.

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