1

Senator Peaden moved the following amendment:

2

3

     Senate Amendment (with title amendment)

4

     Delete everything after the enacting clause

5

and insert:

6

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

7

400.179, Florida Statutes, is amended to read:

8

     400.179  Liability for Medicaid underpayments and

9

overpayments.--

10

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

11

the fact that Medicaid may have underpaid or overpaid the

12

transferor, and because in most instances, any such underpayment

13

or overpayment can only be determined following a formal field

14

audit, the liabilities for any such underpayments or overpayments

15

shall be as follows:

16

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

17

leased by the transferor:

18

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

19

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

20

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

21

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

22

Medicaid payments to the facility computed on the basis of the

23

preceding 12-month average Medicaid payments to the facility.

24

     2.  A leasehold licensee may meet the requirements of

25

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

26

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

27

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

28

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

29

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

30

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

31

average is not available, projected Medicaid payments may be

32

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

33

and shall be accounted for separately as a Medicaid nursing home

34

overpayment account. These fees shall be used at the sole

35

discretion of the agency to repay nursing home Medicaid

36

overpayments. The agency may transfer funds to the Grants and

37

Donations Trust Fund for such repayments. Payment of this fee

38

shall not release the licensee from any liability for any

39

Medicaid overpayments, nor shall payment bar the agency from

40

seeking to recoup overpayments from the licensee and any other

41

liable party. As a condition of exercising this lease bond

42

alternative, licensees paying this fee must maintain an existing

43

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

44

bond. The agency is herein granted specific authority to

45

promulgate all rules pertaining to the administration and

46

management of this account, including withdrawals from the

47

account, subject to federal review and approval. This provision

48

shall take effect upon becoming law and shall apply to any

49

leasehold license application. The financial viability of the

50

Medicaid nursing home overpayment account shall be determined by

51

the agency through annual review of the account balance and the

52

amount of total outstanding, unpaid Medicaid overpayments owing

53

from leasehold licensees to the agency as determined by final

54

agency audits.

55

     3.  The leasehold licensee may meet the bond requirement

56

through other arrangements acceptable to the agency. The agency

57

is herein granted specific authority to promulgate rules

58

pertaining to lease bond arrangements.

59

     4.  All existing nursing facility licensees, operating the

60

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

61

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

62

1., above, on and after July 1, 1993, for each 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 acquire,

68

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

69

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

70

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

71

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

72

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

73

a receiver, deemed necessary to ensure compliance with this

74

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

75

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

76

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

77

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

78

county or municipality is not a leasehold for purposes of this

79

paragraph and is not subject to the bond requirement of this

80

paragraph.

81

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

82

Florida Statutes, are amended to read:

83

     409.904  Optional payments for eligible persons.--The agency

84

may make payments for medical assistance and related services on

85

behalf of the following persons who are determined to be eligible

86

subject to the income, assets, and categorical eligibility tests

87

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

88

Medicaid eligible persons is subject to the availability of

89

moneys and any limitations established by the General

90

Appropriations Act or chapter 216.

91

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

92

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

93

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

94

and whose assets do not exceed established limitations.

95

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

96

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

97

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

98

federal poverty level, whose assets do not exceed established

99

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

100

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

101

institutional care services, hospice services, or home and

102

community-based services. The agency shall seek federal

103

authorization through a waiver to provide this coverage. This

104

subsection expires October 31, 2008.

105

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

106

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

107

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

108

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

109

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

110

coverage groups, medical expenses are deductible from income in

111

accordance with federal requirements in order to make a

112

determination of eligibility. A family or person eligible under

113

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

114

receive the same services as other Medicaid recipients, with the

115

exception of services in skilled nursing facilities and

116

intermediate care facilities for the developmentally disabled.

117

This paragraph expires October 31, 2008.

118

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

119

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

120

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

121

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

122

these coverage groups, medical expenses are deductible from

123

income in accordance with federal requirements in order to made a

124

determination of eligibility. A person eligible under the

125

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

126

the same services as other Medicaid recipients, with the

127

exception of services in skilled nursing facilities and

128

intermediate care facilities for the developmentally disabled.

129

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

130

Florida Statutes, are amended to read:

131

     409.906  Optional Medicaid services.--Subject to specific

132

appropriations, the agency may make payments for services which

133

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

134

Act and are furnished by Medicaid providers to recipients who are

135

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

136

provided. Any optional service that is provided shall be provided

137

only when medically necessary and in accordance with state and

138

federal law. Optional services rendered by providers in mobile

139

units to Medicaid recipients may be restricted or prohibited by

140

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

141

or limit the agency from adjusting fees, reimbursement rates,

142

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

143

making any other adjustments necessary to comply with the

144

availability of moneys and any limitations or directions provided

145

for in the General Appropriations Act or chapter 216. If

146

necessary to safeguard the state's systems of providing services

147

to elderly and disabled persons and subject to the notice and

148

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

149

Agency for Health Care Administration to amend the Medicaid state

150

plan to delete the optional Medicaid service known as

151

"Intermediate Care Facilities for the Developmentally Disabled."

152

Optional services may include:

153

     (1)  ADULT DENTAL SERVICES.--

154

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

155

dental procedures to alleviate pain or infection. Emergency

156

dental care shall be limited to emergency oral examinations,

157

necessary radiographs, extractions, and incision and drainage of

158

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

159

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

160

partial dentures, the procedures required to seat full or partial

161

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

162

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

163

recipient who is 21 years of age or older.

164

     (c) However, Medicaid may will not provide reimbursement

165

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

166

a mobile dental unit:

167

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

168

with the Department of Health and complying with Medicaid's

169

county health department clinic services program specifications

170

as a county health department clinic services provider.

171

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

172

arrangement with a federally qualified health center and

173

complying with Medicaid's federally qualified health center

174

specifications as a federally qualified health center provider.

175

     3.  Rendering dental services to Medicaid recipients, 21

176

years of age and older, at nursing facilities.

177

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

178

with a state-approved dental educational institution.

179

     (d) This subsection expires September 30, 2008.

180

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

181

related services, including hearing evaluations, hearing aid

182

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

183

provided to a recipient by a licensed hearing aid specialist,

184

otolaryngologist, otologist, audiologist, or physician. Effective

185

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

186

services for adults.

187

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

188

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

189

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

190

     409.908  Reimbursement of Medicaid providers.--Subject to

191

specific appropriations, the agency shall reimburse Medicaid

192

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

193

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

194

manuals and handbooks incorporated by reference therein. These

195

methodologies may include fee schedules, reimbursement methods

196

based on cost reporting, negotiated fees, competitive bidding

197

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

198

efficient and effective for purchasing services or goods on

199

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

200

reporting and submits a cost report late and that cost report

201

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

202

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

203

retroactively calculated using the new cost report, and full

204

payment at the recalculated rate shall be effected retroactively.

205

Medicare-granted extensions for filing cost reports, if

206

applicable, shall also apply to Medicaid cost reports. Payment

207

for Medicaid compensable services made on behalf of Medicaid

208

eligible persons is subject to the availability of moneys and any

209

limitations or directions provided for in the General

210

Appropriations Act or chapter 216. Further, nothing in this

211

section shall be construed to prevent or limit the agency from

212

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

213

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

214

necessary to comply with the availability of moneys and any

215

limitations or directions provided for in the General

216

Appropriations Act, provided the adjustment is consistent with

217

legislative intent.

218

     (13)  Medicare premiums for persons eligible for both

219

Medicare and Medicaid coverage shall be paid at the rates

220

established by Title XVIII of the Social Security Act. For

221

Medicare services rendered to Medicaid-eligible persons, Medicaid

222

shall pay Medicare deductibles and coinsurance as follows:

223

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

224

     1.  Medicaid payments for Nursing Home Medicare part A

225

coinsurance are shall be limited to the Medicaid nursing home per

226

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

227

amount of Medicare coinsurance. The Medicaid per diem rate shall

228

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

229

claims and may not be subsequently adjusted due to subsequent per

230

diem rate adjustments.

231

     2.  Medicaid shall pay all deductibles and coinsurance for

232

Medicare-eligible recipients receiving freestanding end stage

233

renal dialysis center services.

234

     3.  Medicaid payments for general hospital inpatient

235

services are shall be limited to the Medicare deductible per

236

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

237

toward coinsurance for Medicare general hospital inpatient

238

services.

239

     4.  Medicaid shall pay all deductibles and coinsurance for

240

Medicare emergency transportation services provided by ambulances

241

licensed pursuant to chapter 401.

242

     5. Medicaid shall pay all deductibles and coinsurance for

243

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

244

home.

245

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

246

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

247

and customary charge, or the Medicaid maximum allowable fee

248

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

249

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

250

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

251

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

252

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

253

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

254

provider. Medicaid providers are required to dispense generic

255

drugs if available at lower cost and the agency has not

256

determined that the branded product is more cost-effective,

257

unless the prescriber has requested and received approval to

258

require the branded product. The agency is directed to implement

259

a variable dispensing fee for payments for prescribed medicines

260

while ensuring continued access for Medicaid recipients. The

261

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

262

either or both the volume of prescriptions dispensed by a

263

specific pharmacy provider, the volume of prescriptions dispensed

264

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

265

products. The agency may increase the pharmacy dispensing fee

266

authorized by statute and in the annual General Appropriations

267

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

268

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

269

dispensing of a Medicaid product that is not included on the

270

preferred drug list. The agency may establish a supplemental

271

pharmaceutical dispensing fee to be paid to providers returning

272

unused unit-dose packaged medications to stock and crediting the

273

Medicaid program for the ingredient cost of those medications if

274

the ingredient costs to be credited exceed the value of the

275

supplemental dispensing fee. The agency is authorized to limit

276

reimbursement for prescribed medicine in order to comply with any

277

limitations or directions provided for in the General

278

Appropriations Act, which may include implementing a prospective

279

or concurrent utilization review program.

280

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

281

provider reimbursement rates on a recurring basis as prescribed

282

in the general appropriations act for the following provider

283

types:

284

     1. Inpatient hospitals.

285

     2. Outpatient hospitals.

286

     3. Nursing homes.

287

     4. County health departments.

288

     5. Community intermediate care facilities for the

289

developmentally disabled.

290

     6. Prepaid health plans.

291

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

292

appropriation by the Legislature.

293

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

294

409.911, Florida Statutes, is amended to read:

295

     409.911  Disproportionate share program.--Subject to

296

specific allocations established within the General

297

Appropriations Act and any limitations established pursuant to

298

chapter 216, the agency shall distribute, pursuant to this

299

section, moneys to hospitals providing a disproportionate share

300

of Medicaid or charity care services by making quarterly Medicaid

301

payments as required. Notwithstanding the provisions of s.

302

409.915, counties are exempt from contributing toward the cost of

303

this special reimbursement for hospitals serving a

304

disproportionate share of low-income patients.

305

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

306

following actual audited data to determine the Medicaid days and

307

charity care to be used in calculating the disproportionate share

308

payment:

309

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

310

audited disproportionate share data to determine each hospital's

311

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

312

fiscal year.

313

     Section 6.  Section 409.9112, Florida Statutes, is amended

314

to read:

315

     409.9112  Disproportionate share program for regional

316

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

317

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

318

shall design and implement a system of making disproportionate

319

share payments to those hospitals that participate in the

320

regional perinatal intensive care center program established

321

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

322

with federal requirements and shall distribute funds in each

323

fiscal year for which an appropriation is made by making

324

quarterly Medicaid payments. Notwithstanding the provisions of s.

325

409.915, counties are exempt from contributing toward the cost of

326

this special reimbursement for hospitals serving a

327

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

328

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

329

moneys under the regional perinatal intensive care centers

330

disproportionate share program.

331

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

332

calculate the total amount earned for hospitals that participate

333

in the regional perinatal intensive care center program:

334

335

TAE = HDSP/THDSP

336

337

Where:

338

     TAE = total amount earned by a regional perinatal intensive

339

care center.

340

     HDSP = the prior state fiscal year regional perinatal

341

intensive care center disproportionate share payment to the

342

individual hospital.

343

     THDSP = the prior state fiscal year total regional perinatal

344

intensive care center disproportionate share payments to all

345

hospitals.

346

     (2)  The total additional payment for hospitals that

347

participate in the regional perinatal intensive care center

348

program shall be calculated by the agency as follows:

349

350

TAP = TAE x TA

351

352

Where:

353

     TAP = total additional payment for a regional perinatal

354

intensive care center.

355

     TAE = total amount earned by a regional perinatal intensive

356

care center.

357

     TA = total appropriation for the regional perinatal

358

intensive care center disproportionate share program.

359

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

360

hospital must be participating in the regional perinatal

361

intensive care center program pursuant to chapter 383 and must

362

meet the following additional requirements:

363

     (a)  Agree to conform to all departmental and agency

364

requirements to ensure high quality in the provision of services,

365

including criteria adopted by departmental and agency rule

366

concerning staffing ratios, medical records, standards of care,

367

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

368

department and agency deem appropriate as specified by rule.

369

     (b)  Agree to provide information to the department and

370

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

371

department and agency, concerning the care provided to all

372

patients in neonatal intensive care centers and high-risk

373

maternity care.

374

     (c)  Agree to accept all patients for neonatal intensive

375

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

376

on a functional space-available basis.

377

     (d)  Agree to develop arrangements with other maternity and

378

neonatal care providers in the hospital's region for the

379

appropriate receipt and transfer of patients in need of

380

specialized maternity and neonatal intensive care services.

381

     (e)  Agree to establish and provide a developmental

382

evaluation and services program for certain high-risk neonates,

383

as prescribed and defined by rule of the department.

384

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

385

perinatal care for health care professionals within the region of

386

the hospital, as specified by rule.

387

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

388

department's county health departments and other low-income

389

perinatal providers within the hospital's region, including the

390

development of written agreements between these organizations and

391

the hospital.

392

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

393

obstetrical patients and neonates in need of transfer from the

394

community to the hospital or from the hospital to another more

395

appropriate facility.

396

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

397

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

398

department and agency may shall not receive any payments under

399

this section until full compliance is achieved. A hospital which

400

is not in compliance in two or more consecutive quarters may

401

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

402

shall be distributed by the remaining participating regional

403

perinatal intensive care center program hospitals.

404

     Section 7.  Section 409.9113, Florida Statutes, is amended

405

to read:

406

     409.9113  Disproportionate share program for teaching

407

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

408

and 409.9112, the agency for Health Care Administration shall

409

make disproportionate share payments to statutorily defined

410

teaching hospitals for their increased costs associated with

411

medical education programs and for tertiary health care services

412

provided to the indigent. This system of payments shall conform

413

to with federal requirements and shall distribute funds in each

414

fiscal year for which an appropriation is made by making

415

quarterly Medicaid payments. Notwithstanding s. 409.915, counties

416

are exempt from contributing toward the cost of this special

417

reimbursement for hospitals serving a disproportionate share of

418

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

419

2007, the agency shall distribute the moneys provided in the

420

General Appropriations Act to statutorily defined teaching

421

hospitals and family practice teaching hospitals under the

422

teaching hospital disproportionate share program. The funds

423

provided for statutorily defined teaching hospitals shall be

424

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

425

2004 teaching hospital disproportionate share funds were

426

distributed or as otherwise provided in the General

427

Appropriations Act. The funds provided for family practice

428

teaching hospitals shall be distributed equally among family

429

practice teaching hospitals.

430

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

431

Health Care Administration shall calculate an allocation fraction

432

to be used for distributing funds to state statutory teaching

433

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

434

fiscal year, the agency shall distribute to each statutory

435

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

436

by multiplying one-fourth of the funds appropriated for this

437

purpose by the Legislature times such hospital's allocation

438

fraction. The allocation fraction for each such hospital shall be

439

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

440

The primary factors are:

441

     (a)  The number of nationally accredited graduate medical

442

education programs offered by the hospital, including programs

443

accredited by the Accreditation Council for Graduate Medical

444

Education and the combined Internal Medicine and Pediatrics

445

programs acceptable to both the American Board of Internal

446

Medicine and the American Board of Pediatrics at the beginning of

447

the state fiscal year preceding the date on which the allocation

448

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

449

fraction that the hospital represents of the total number of

450

programs, where the total is computed for all state statutory

451

teaching hospitals.

452

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

453

hospital, which comprises two components:

454

     1.  The number of trainees enrolled in nationally accredited

455

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

456

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

457

during which each trainee is primarily assigned to the given

458

institution, over the state fiscal year preceding the date on

459

which the allocation fraction is calculated. The numerical value

460

of this factor is the fraction that the hospital represents of

461

the total number of full-time equivalent trainees enrolled in

462

accredited graduate programs, where the total is computed for all

463

state statutory teaching hospitals.

464

     2.  The number of medical students enrolled in accredited

465

colleges of medicine and engaged in clinical activities,

466

including required clinical clerkships and clinical electives.

467

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

468

during which each trainee is primarily assigned to the given

469

institution, over the course of the state fiscal year preceding

470

the date on which the allocation fraction is calculated. The

471

numerical value of this factor is the fraction that the given

472

hospital represents of the total number of full-time equivalent

473

students enrolled in accredited colleges of medicine, where the

474

total is computed for all state statutory teaching hospitals.

475

476

The primary factor for full-time equivalent trainees is computed

477

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

478

     (c)  A service index that comprises three components:

479

     1.  The Agency for Health Care Administration Service Index,

480

computed by applying the standard Service Inventory Scores

481

established by the agency for Health Care Administration to

482

services offered by the given hospital, as reported on Worksheet

483

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

484

date on which the allocation fraction is calculated. The

485

numerical value of this factor is the fraction that the given

486

hospital represents of the total Agency for Health Care

487

Administration Service Index values, where the total is computed

488

for all state statutory teaching hospitals.

489

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

490

the standard Service Inventory Scores established by the agency

491

for Health Care Administration to the volume of each service,

492

expressed in terms of the standard units of measure reported on

493

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

494

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

495

numerical value of this factor is the fraction that the given

496

hospital represents of the total volume-weighted service index

497

values, where the total is computed for all state statutory

498

teaching hospitals.

499

     3.  Total Medicaid payments to each hospital for direct

500

inpatient and outpatient services during the fiscal year

501

preceding the date on which the allocation factor is calculated.

502

This includes payments made to each hospital for such services by

503

Medicaid prepaid health plans, whether the plan was administered

504

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

505

fraction that each hospital represents of the total of such

506

Medicaid payments, where the total is computed for all state

507

statutory teaching hospitals.

508

509

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

510

of these three components, divided by three.

511

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

512

following formula to calculate the maximum additional

513

disproportionate share payment for statutorily defined teaching

514

hospitals:

515

516

TAP = THAF x A

517

518

Where:

519

     TAP = total additional payment.

520

     THAF = teaching hospital allocation factor.

521

     A = amount appropriated for a teaching hospital

522

disproportionate share program.

523

     Section 8.  Section 409.9117, Florida Statutes, is amended

524

to read:

525

     409.9117  Primary care disproportionate share program.--For

526

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

527

not distribute moneys under the primary care disproportionate

528

share program.

529

     (1)  If federal funds are available for disproportionate

530

share programs in addition to those otherwise provided by law,

531

there shall be created a primary care disproportionate share

532

program.

533

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

534

calculate the total amount earned for hospitals that participate

535

in the primary care disproportionate share program:

536

537

TAE = HDSP/THDSP

538

539

Where:

540

     TAE = total amount earned by a hospital participating in the

541

primary care disproportionate share program.

542

     HDSP = the prior state fiscal year primary care

543

disproportionate share payment to the individual hospital.

544

     THDSP = the prior state fiscal year total primary care

545

disproportionate share payments to all hospitals.

546

     (3)  The total additional payment for hospitals that

547

participate in the primary care disproportionate share program

548

shall be calculated by the agency as follows:

549

550

TAP = TAE x TA

551

552

Where:

553

     TAP = total additional payment for a primary care hospital.

554

     TAE = total amount earned by a primary care hospital.

555

     TA = total appropriation for the primary care

556

disproportionate share program.

557

     (4) In establishing the establishment and funding of this

558

program, the agency shall use the following criteria in addition

559

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

560

a hospital unless the hospital agrees to:

561

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

562

exists in the community.

563

     (b)  Ensure the availability of primary and specialty care

564

physicians to Medicaid recipients who are not enrolled in a

565

prepaid capitated arrangement and who are in need of access to

566

such physicians.

567

     (c)  Coordinate and provide primary care services free of

568

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

569

percent of the federal poverty level who are not otherwise

570

covered by Medicaid or another program administered by a

571

governmental entity, and to provide such services based on a

572

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

573

of the federal poverty level who are not otherwise covered by

574

Medicaid or another program administered by a governmental

575

entity, except that eligibility may be limited to persons who

576

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

577

the hospital.

578

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

579

one exists within the agreed geopolitical boundaries, concerning

580

the provision of primary care services, in order to guarantee

581

delivery of services in a nonduplicative fashion, and to provide

582

for referral arrangements, privileges, and admissions, as

583

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

584

offsite facility primary care services within 24 hours to which

585

all Medicaid recipients and persons eligible under this paragraph

586

who do not require emergency room services are referred during

587

normal daylight hours.

588

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

589

entities to ensure the provision of certain public health

590

services, case management, referral and acceptance of patients,

591

and sharing of epidemiological data, as the agency and the

592

hospital find mutually necessary and desirable to promote and

593

protect the public health within the agreed geopolitical

594

boundaries.

595

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

596

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

597

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

598

and who reside within the area.

599

     (g)  Provide inpatient services to residents within the area

600

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

601

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

602

the basis of available space, except that nothing shall prevent

603

the hospital from establishing bill collection programs based on

604

ability to pay.

605

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

606

Florida Health Care Purchasing Cooperative, and business health

607

coalitions, as appropriate, to develop a feasibility study and

608

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

609

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

610

such a plan.

611

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

612

provide community health education and prevention activities

613

designed to promote healthy lifestyles and appropriate use of

614

health services.

615

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

616

for promoting access to affordable health care services for all

617

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

618

to, public health services, primary care services, inpatient

619

services, and affordable health insurance generally.

620

621

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

622

this subsection, or any other contractual condition, may not

623

receive payments under this section until full compliance is

624

achieved.

625

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

626

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

627

Florida Statutes, are amended to read:

628

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

629

agency shall purchase goods and services for Medicaid recipients

630

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

631

quality medical care. To ensure that medical services are

632

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

633

confirmation or second physician's opinion of the correct

634

diagnosis for purposes of authorizing future services under the

635

Medicaid program. This section does not restrict access to

636

emergency services or poststabilization care services as defined

637

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

638

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

639

shall maximize the use of prepaid per capita and prepaid

640

aggregate fixed-sum basis services when appropriate and other

641

alternative service delivery and reimbursement methodologies,

642

including competitive bidding pursuant to s. 287.057, designed to

643

facilitate the cost-effective purchase of a case-managed

644

continuum of care. The agency shall also require providers to

645

minimize the exposure of recipients to the need for acute

646

inpatient, custodial, and other institutional care and the

647

inappropriate or unnecessary use of high-cost services. The

648

agency shall contract with a vendor to monitor and evaluate the

649

clinical practice patterns of providers in order to identify

650

trends that are outside the normal practice patterns of a

651

provider's professional peers or the national guidelines of a

652

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

653

provide information and counseling to a provider whose practice

654

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

655

to improve patient care and reduce inappropriate utilization. The

656

agency may mandate prior authorization, drug therapy management,

657

or disease management participation for certain populations of

658

Medicaid beneficiaries, certain drug classes, or particular drugs

659

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

660

interactions. The Pharmaceutical and Therapeutics Committee shall

661

make recommendations to the agency on drugs for which prior

662

authorization is required. The agency shall inform the

663

Pharmaceutical and Therapeutics Committee of its decisions

664

regarding drugs subject to prior authorization. The agency is

665

authorized to limit the entities it contracts with or enrolls as

666

Medicaid providers by developing a provider network through

667

provider credentialing. The agency may competitively bid single-

668

source-provider contracts if procurement of goods or services

669

results in demonstrated cost savings to the state without

670

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

671

on the assessment of beneficiary access to care, provider

672

availability, provider quality standards, time and distance

673

standards for access to care, the cultural competence of the

674

provider network, demographic characteristics of Medicaid

675

beneficiaries, practice and provider-to-beneficiary standards,

676

appointment wait times, beneficiary use of services, provider

677

turnover, provider profiling, provider licensure history,

678

previous program integrity investigations and findings, peer

679

review, provider Medicaid policy and billing compliance records,

680

clinical and medical record audits, and other factors. Providers

681

shall not be entitled to enrollment in the Medicaid provider

682

network. The agency shall determine instances in which allowing

683

Medicaid beneficiaries to purchase durable medical equipment and

684

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

685

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

686

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

687

order to protect against fraud and abuse in the Medicaid program

688

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

689

necessary to administer these policies.

690

     (4)  The agency may contract with:

691

     (b)  An entity that is providing comprehensive behavioral

692

health care services to certain Medicaid recipients through a

693

capitated, prepaid arrangement pursuant to the federal waiver

694

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

695

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

696

the clinical systems and operational competence to manage risk

697

and provide comprehensive behavioral health care to Medicaid

698

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

699

behavioral health care services" means covered mental health and

700

substance abuse treatment services that are available to Medicaid

701

recipients. The secretary of the Department of Children and

702

Family Services shall approve provisions of procurements related

703

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

704

enrolling such children in a prepaid behavioral health plan. Any

705

contract awarded under this paragraph must be competitively

706

procured. In developing the behavioral health care prepaid plan

707

procurement document, the agency shall ensure that the

708

procurement document requires the contractor to develop and

709

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

710

services provided to residents of licensed assisted living

711

facilities that hold a limited mental health license. Except as

712

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

713

Medicaid managed care pilot program is authorized pursuant to s.

714

409.91211, the agency shall seek federal approval to contract

715

with a single entity meeting these requirements to provide

716

comprehensive behavioral health care services to all Medicaid

717

recipients not enrolled in a Medicaid managed care plan

718

authorized under s. 409.91211 or a Medicaid health maintenance

719

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

720

managed care pilot program is authorized pursuant to s. 409.91211

721

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

722

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

723

the remaining counties may be included with an adjacent AHCA area

724

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

725

sufficient choice of providers in its network to ensure recipient

726

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

727

they are satisfied. The network shall include all public mental

728

health hospitals. To ensure unimpaired access to behavioral

729

health care services by Medicaid recipients, all contracts issued

730

pursuant to this paragraph shall require 80 percent of the

731

capitation paid to the managed care plan, including health

732

maintenance organizations, to be expended for the provision of

733

behavioral health care services. In the event the managed care

734

plan expends less than 80 percent of the capitation paid pursuant

735

to this paragraph for the provision of behavioral health care

736

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

737

agency shall provide the managed care plan with a certification

738

letter indicating the amount of capitation paid during each

739

calendar year for the provision of behavioral health care

740

services pursuant to this section. The agency may reimburse for

741

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

742

until the agency finds that adequate funds are available for

743

capitated, prepaid arrangements.

744

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

745

contracts with the entities providing comprehensive inpatient and

746

outpatient mental health care services to Medicaid recipients in

747

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

748

include substance abuse treatment services.

749

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

750

Children and Family Services shall execute a written agreement

751

that requires collaboration and joint development of all policy,

752

budgets, procurement documents, contracts, and monitoring plans

753

that have an impact on the state and Medicaid community mental

754

health and targeted case management programs.

755

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

756

the agency and the Department of Children and Family Services

757

shall contract with managed care entities in each AHCA area

758

except area 6 or arrange to provide comprehensive inpatient and

759

outpatient mental health and substance abuse services through

760

capitated prepaid arrangements to all Medicaid recipients who are

761

eligible to participate in such plans under federal law and

762

regulation. In AHCA areas where eligible individuals number less

763

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

764

care plan to provide comprehensive behavioral health services to

765

all recipients who are not enrolled in a Medicaid health

766

maintenance organization or a Medicaid capitated managed care

767

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

768

more than one comprehensive behavioral health provider to provide

769

care to recipients who are not enrolled in a Medicaid capitated

770

managed care plan authorized under s. 409.91211 or a Medicaid

771

health maintenance organization in AHCA areas where the eligible

772

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

773

managed care pilot program is authorized pursuant to s. 409.91211

774

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

775

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

776

the remaining counties may be included with an adjacent AHCA area

777

and shall be subject to this paragraph. Contracts for

778

comprehensive behavioral health providers awarded pursuant to

779

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

780

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

781

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

782

provide and receive payment for the same comprehensive behavioral

783

health benefits as provided in AHCA rules, including handbooks

784

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

785

contract with at least two comprehensive behavioral health care

786

providers to provide behavioral health care to recipients in that

787

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

788

One of the behavioral health care contracts shall be with the

789

existing provider service network pilot project, as described in

790

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

791

effectiveness of the provision of quality mental health services

792

through a public hospital-operated managed care model. Payment

793

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

794

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

795

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

796

MediPass-enrolled recipients shall be assigned to the existing

797

provider service network in area 11 for their behavioral care.

798

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

799

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

800

the Speaker of the House of Representatives which provides for

801

the full implementation of capitated prepaid behavioral health

802

care in all areas of the state.

803

     a.  Implementation shall begin in 2003 in those AHCA areas

804

of the state where the agency is able to establish sufficient

805

capitation rates.

806

     b.  If the agency determines that the proposed capitation

807

rate in any area is insufficient to provide appropriate services,

808

the agency may adjust the capitation rate to ensure that care

809

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

810

general revenue to address any additional required match but may

811

not over-obligate existing funds on an annualized basis.

812

     c.  Subject to any limitations provided for in the General

813

Appropriations Act, the agency, in compliance with appropriate

814

federal authorization, shall develop policies and procedures that

815

allow for certification of local and state funds.

816

     5.  Children residing in a statewide inpatient psychiatric

817

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

818

of Children and Family Services residential program approved as a

819

Medicaid behavioral health overlay services provider shall not be

820

included in a behavioral health care prepaid health plan or any

821

other Medicaid managed care plan pursuant to this paragraph.

822

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

823

agency shall in its procurement document require an entity

824

providing only comprehensive behavioral health care services to

825

prevent the displacement of indigent care patients by enrollees

826

in the Medicaid prepaid health plan providing behavioral health

827

care services from facilities receiving state funding to provide

828

indigent behavioral health care, to facilities licensed under

829

chapter 395 which do not receive state funding for indigent

830

behavioral health care, or reimburse the unsubsidized facility

831

for the cost of behavioral health care provided to the displaced

832

indigent care patient.

833

     7.  Traditional community mental health providers under

834

contract with the Department of Children and Family Services

835

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

836

contract with the Department of Children and Family Services in

837

areas 1 and 6, and inpatient mental health providers licensed

838

pursuant to chapter 395 must be offered an opportunity to accept

839

or decline a contract to participate in any provider network for

840

prepaid behavioral health services.

841

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

842

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

843

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

844

welfare services in the HomeSafeNet system, shall be enrolled in

845

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

846

health care services including inpatient, outpatient psychiatric,

847

community mental health, and case management shall be reimbursed

848

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

849

children, who are open for child welfare services in the

850

HomeSafeNet system, shall receive their behavioral health care

851

services through a specialty prepaid plan operated by community-

852

based lead agencies either through a single agency or formal

853

agreements among several agencies. The specialty prepaid plan

854

must result in savings to the state comparable to savings

855

achieved in other Medicaid managed care and prepaid programs.

856

Such plan must provide mechanisms to maximize state and local

857

revenues. The specialty prepaid plan shall be developed by the

858

agency and the Department of Children and Family Services. The

859

agency is authorized to seek any federal waivers to implement

860

this initiative. Medicaid-eligible children whose cases are open

861

for child welfare services in the HomeSafeNet system and who

862

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

863

upon the development of a service delivery mechanism for children

864

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

865

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

866

drug spending-control program that includes the following

867

components:

868

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

869

of cost-effective therapeutic options recommended by the Medicaid

870

Pharmacy and Therapeutics Committee established pursuant to s.

871

409.91195 and adopted by the agency for each therapeutic class on

872

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

873

when feasible, the preferred drug list should include at least

874

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

875

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

876

Internet website without following the rulemaking procedures of

877

chapter 120. Antiretroviral agents are excluded from the

878

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

879

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

880

the drug products' smallest marketed package is greater than a

881

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

882

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

883

authorized. The agency is authorized to seek any federal waivers

884

necessary to implement these cost-control programs and to

885

continue participation in the federal Medicaid rebate program, or

886

alternatively to negotiate state-only manufacturer rebates. The

887

agency may adopt rules to implement this subparagraph. The agency

888

shall continue to provide unlimited contraceptive drugs and

889

items. The agency must establish procedures to ensure that:

890

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

891

consultation by telephone or other telecommunication device

892

within 24 hours after receipt of a request for prior

893

consultation; and

894

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

895

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

896

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

897

     2.  Reimbursement to pharmacies for Medicaid prescribed

898

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

899

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

900

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

901

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

902

(UAC) charge billed by the provider.

903

     3.  The agency shall develop and implement a process for

904

managing the drug therapies of Medicaid recipients who are using

905

significant numbers of prescribed drugs each month. The

906

management process may include, but is not limited to,

907

comprehensive, physician-directed medical-record reviews, claims

908

analyses, and case evaluations to determine the medical necessity

909

and appropriateness of a patient's treatment plan and drug

910

therapies. The agency may contract with a private organization to

911

provide drug-program-management services. The Medicaid drug

912

benefit management program shall include initiatives to manage

913

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

914

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

915

patients in annual spending. The agency shall enroll any Medicaid

916

recipient in the drug benefit management program if he or she

917

meets the specifications of this provision and is not enrolled in

918

a Medicaid health maintenance organization.

919

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

920

based on need, competitive bidding, price negotiations,

921

credentialing, or similar criteria. The agency shall give special

922

consideration to rural areas in determining the size and location

923

of pharmacies included in the Medicaid pharmacy network. A

924

pharmacy credentialing process may include criteria such as a

925

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

926

educational programs, patient consultation, disease management

927

services, and other characteristics. The agency may impose a

928

moratorium on Medicaid pharmacy enrollment when it is determined

929

that it has a sufficient number of Medicaid-participating

930

providers. The agency must allow dispensing practitioners to

931

participate as a part of the Medicaid pharmacy network regardless

932

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

933

dispensing prescription drugs under the Medicaid program. A

934

dispensing practitioner must meet all credentialing requirements

935

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

936

     5.  The agency shall develop and implement a program that

937

requires Medicaid practitioners who prescribe drugs to use a

938

counterfeit-proof prescription pad for Medicaid prescriptions.

939

The agency shall require the use of standardized counterfeit-

940

proof prescription pads by Medicaid-participating prescribers or

941

prescribers who write prescriptions for Medicaid recipients. The

942

agency may implement the program in targeted geographic areas or

943

statewide.

944

     6.  The agency may enter into arrangements that require

945

manufacturers of generic drugs prescribed to Medicaid recipients

946

to provide rebates of at least 15.1 percent of the average

947

manufacturer price for the manufacturer's generic products. These

948

arrangements shall require that if a generic-drug manufacturer

949

pays federal rebates for Medicaid-reimbursed drugs at a level

950

below 15.1 percent, the manufacturer must provide a supplemental

951

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

952

percent rebate level.

953

     7.  The agency may establish a preferred drug list as

954

described in this subsection, and, pursuant to the establishment

955

of such preferred drug list, it is authorized to negotiate

956

supplemental rebates from manufacturers that are in addition to

957

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

958

less than 14 percent of the average manufacturer price as defined

959

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

960

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

961

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

962

agency may negotiate. The agency may determine that specific

963

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

964

percentages. Agreement to pay the minimum supplemental rebate

965

percentage will guarantee a manufacturer that the Medicaid

966

Pharmaceutical and Therapeutics Committee will consider a product

967

for inclusion on the preferred drug list. However, a

968

pharmaceutical manufacturer is not guaranteed placement on the

969

preferred drug list by simply paying the minimum supplemental

970

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

971

a drug and recommendations of the Medicaid Pharmaceutical and

972

Therapeutics Committee, as well as the price of competing

973

products minus federal and state rebates. The agency is

974

authorized to contract with an outside agency or contractor to

975

conduct negotiations for supplemental rebates. For the purposes

976

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

977

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

978

substitution for supplemental rebates are prohibited. The agency

979

is authorized to seek any federal waivers to implement this

980

initiative.

981

     8.  The Agency for Health Care Administration shall expand

982

home delivery of pharmacy products. To assist Medicaid patients

983

in securing their prescriptions and reduce program costs, the

984

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

985

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

986

by Medicaid patients with diabetes. Medicaid recipients in the

987

current program may obtain nondiabetes drugs on a voluntary

988

basis. This initiative is limited to the geographic area covered

989

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

990

federal waivers necessary to implement this subparagraph.

991

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

992

prescribed to treat erectile dysfunction.

993

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

994

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

995

experience in operating behavioral drug management systems to

996

implement this program. The agency is authorized to seek federal

997

waivers to implement this program.

998

     b.  The agency, in conjunction with the Department of

999

Children and Family Services, may implement the Medicaid

1000

behavioral drug management system that is designed to improve the

1001

quality of care and behavioral health prescribing practices based

1002

on best practice guidelines, improve patient adherence to

1003

medication plans, reduce clinical risk, and lower prescribed drug

1004

costs and the rate of inappropriate spending on Medicaid

1005

behavioral drugs. The program may include the following elements:

1006

     (I)  Provide for the development and adoption of best

1007

practice guidelines for behavioral health-related drugs such as

1008

antipsychotics, antidepressants, and medications for treating

1009

bipolar disorders and other behavioral conditions; translate them

1010

into practice; review behavioral health prescribers and compare

1011

their prescribing patterns to a number of indicators that are

1012

based on national standards; and determine deviations from best

1013

practice guidelines.

1014

     (II)  Implement processes for providing feedback to and

1015

educating prescribers using best practice educational materials

1016

and peer-to-peer consultation.

1017

     (III)  Assess Medicaid beneficiaries who are outliers in

1018

their use of behavioral health drugs with regard to the numbers

1019

and types of drugs taken, drug dosages, combination drug

1020

therapies, and other indicators of improper use of behavioral

1021

health drugs.

1022

     (IV)  Alert prescribers to patients who fail to refill

1023

prescriptions in a timely fashion, are prescribed multiple same-

1024

class behavioral health drugs, and may have other potential

1025

medication problems.

1026

     (V)  Track spending trends for behavioral health drugs and

1027

deviation from best practice guidelines.

1028

     (VI)  Use educational and technological approaches to

1029

promote best practices, educate consumers, and train prescribers

1030

in the use of practice guidelines.

1031

     (VII)  Disseminate electronic and published materials.

1032

     (VIII)  Hold statewide and regional conferences.

1033

     (IX)  Implement a disease management program with a model

1034

quality-based medication component for severely mentally ill

1035

individuals and emotionally disturbed children who are high users

1036

of care.

1037

     11.a.  The agency shall implement a Medicaid prescription

1038

drug management system. The agency may contract with a vendor

1039

that has experience in operating prescription drug management

1040

systems in order to implement this system. Any management system

1041

that is implemented in accordance with this subparagraph must

1042

rely on cooperation between physicians and pharmacists to

1043

determine appropriate practice patterns and clinical guidelines

1044

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

1045

Medicaid program. The agency may seek federal waivers to

1046

implement this program.

1047

     b.  The drug management system must be designed to improve

1048

the quality of care and prescribing practices based on best

1049

practice guidelines, improve patient adherence to medication

1050

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

1051

the rate of inappropriate spending on Medicaid prescription

1052

drugs. The program must:

1053

     (I)  Provide for the development and adoption of best

1054

practice guidelines for the prescribing and use of drugs in the

1055

Medicaid program, including translating best practice guidelines

1056

into practice; reviewing prescriber patterns and comparing them

1057

to indicators that are based on national standards and practice

1058

patterns of clinical peers in their community, statewide, and

1059

nationally; and determine deviations from best practice

1060

guidelines.

1061

     (II)  Implement processes for providing feedback to and

1062

educating prescribers using best practice educational materials

1063

and peer-to-peer consultation.

1064

     (III)  Assess Medicaid recipients who are outliers in their

1065

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

1066

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

1067

therapies, and other indicators of improper use of prescription

1068

drugs.

1069

     (IV)  Alert prescribers to patients who fail to refill

1070

prescriptions in a timely fashion, are prescribed multiple drugs

1071

that may be redundant or contraindicated, or may have other

1072

potential medication problems.

1073

     (V)  Track spending trends for prescription drugs and

1074

deviation from best practice guidelines.

1075

     (VI)  Use educational and technological approaches to

1076

promote best practices, educate consumers, and train prescribers

1077

in the use of practice guidelines.

1078

     (VII)  Disseminate electronic and published materials.

1079

     (VIII)  Hold statewide and regional conferences.

1080

     (IX)  Implement disease management programs in cooperation

1081

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

1082

medication component for individuals having chronic medical

1083

conditions.

1084

     12.  The agency is authorized to contract for drug rebate

1085

administration, including, but not limited to, calculating rebate

1086

amounts, invoicing manufacturers, negotiating disputes with

1087

manufacturers, and maintaining a database of rebate collections.

1088

     13.  The agency may specify the preferred daily dosing form

1089

or strength for the purpose of promoting best practices with

1090

regard to the prescribing of certain drugs as specified in the

1091

General Appropriations Act and ensuring cost-effective

1092

prescribing practices.

1093

     14.  The agency may require prior authorization for

1094

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

1095

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

1096

     a.  For an indication not approved in labeling;

1097

     b.  To comply with certain clinical guidelines; or

1098

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

1099

abuse.

1100

1101

The agency may require the prescribing professional to provide

1102

information about the rationale and supporting medical evidence

1103

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

1104

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

1105

subject to prior authorization on an Internet website without

1106

amending its rule or engaging in additional rulemaking.

1107

     15.  The agency, in conjunction with the Pharmaceutical and

1108

Therapeutics Committee, may require age-related prior

1109

authorizations for certain prescribed drugs. The agency may

1110

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

1111

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

1112

of the this product as recommended by the manufacturer and

1113

approved by the Food and Drug Administration. Prior authorization

1114

may require the prescribing professional to provide information

1115

about the rationale and supporting medical evidence for the use

1116

of a drug.

1117

     16.  The agency shall implement a step-therapy prior

1118

authorization approval process for medications excluded from the

1119

preferred drug list. Medications listed on the preferred drug

1120

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

1121

alternative medications that are not listed. The step-therapy

1122

prior authorization may require the prescriber to use the

1123

medications of a similar drug class or for a similar medical

1124

indication unless contraindicated in the Food and Drug

1125

Administration labeling. The trial period between the specified

1126

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

1127

therapy approval process shall be developed in accordance with

1128

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

1129

product may be approved without meeting the step-therapy prior

1130

authorization criteria if the prescribing physician provides the

1131

agency with additional written medical or clinical documentation

1132

that the product is medically necessary because:

1133

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

1134

the disease or medical condition which is an acceptable clinical

1135

alternative;

1136

     b.  The alternatives have been ineffective in the treatment

1137

of the beneficiary's disease; or

1138

     c.  Based on historic evidence and known characteristics of

1139

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

1140

or the number of doses have been ineffective.

1141

1142

The agency shall work with the physician to determine the best

1143

alternative for the patient. The agency may adopt rules waiving

1144

the requirements for written clinical documentation for specific

1145

drugs in limited clinical situations.

1146

     17.  The agency shall implement a return and reuse program

1147

for drugs dispensed by pharmacies to institutional recipients,

1148

which includes payment of a $5 restocking fee for the

1149

implementation and operation of the program. The return and reuse

1150

program shall be implemented electronically and in a manner that

1151

promotes efficiency. The program must permit a pharmacy to

1152

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

1153

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

1154

return to inventory of drugs that cannot be credited or returned

1155

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

1156

program has reduced the amount of Medicaid prescription drugs

1157

which are destroyed on an annual basis and if there are

1158

additional ways to ensure more prescription drugs are not

1159

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

1160

and recommendations shall be reported to the Legislature by

1161

December 1, 2005.

1162

     (42) The agency may shall develop and implement a

1163

utilization management program for Medicaid-eligible recipients

1164

for the management of occupational, physical, respiratory, and

1165

speech therapies. The agency shall establish a utilization

1166

program that may require prior authorization in order to ensure

1167

medically necessary and cost-effective treatments. The program

1168

shall be operated in accordance with a federally approved waiver

1169

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

1170

waiver or state plan amendment to implement this program. The

1171

agency may also competitively procure these services from an

1172

outside vendor on a regional or statewide basis.

1173

     Section 10.  Section 409.91206, Florida Statutes, is created

1174

to read:

1175

     409.91206 Alternatives for health and long-term care

1176

reforms.--The Governor, the President of the Senate, and the

1177

Speaker of the House of Representatives may convene workgroups to

1178

propose alternatives for cost-effective health and long-term care

1179

reforms, including, but not limited to, reforms for Medicaid.

1180

     Section 11.  Paragraphs (c), (e), (f), and (i) of subsection

1181

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

1182

     409.9122  Mandatory Medicaid managed care enrollment;

1183

programs and procedures.--

1184

     (2)

1185

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

1186

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

1187

Department of Health, the Department of Children and Family

1188

Services, and the Department of Elderly Affairs shall cooperate

1189

to ensure that each Medicaid recipient receives clear and easily

1190

understandable information that meets the following requirements:

1191

     1.  Explains the concept of managed care, including

1192

MediPass.

1193

     2.  Provides information on the comparative performance of

1194

managed care plans and MediPass in the areas of quality,

1195

credentialing, preventive health programs, network size and

1196

availability, and patient satisfaction.

1197

     3.  Explains where additional information on each managed

1198

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

1199

     4.  Explains that recipients have the right to choose their

1200

own managed care coverage at the time they first enroll in

1201

Medicaid and again at regular intervals set by the agency plans

1202

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

1203

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

1204

managed care plan or MediPass according to the criteria specified

1205

in this section.

1206

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

1207

grievance, or change managed care plans or MediPass providers if

1208

the recipient is not satisfied with the managed care plan or

1209

MediPass.

1210

     (e)  Medicaid recipients who are already enrolled in a

1211

managed care plan or MediPass shall be offered the opportunity to

1212

change managed care plans or MediPass providers on a staggered

1213

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

1214

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

1215

MediPass providers. A recipient already enrolled in a managed

1216

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

1217

period shall remain enrolled in his or her current managed care

1218

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

1219

recipient already enrolled in MediPass who fails to make a choice

1220

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

1221

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

1222

The agency shall apply for a state plan amendment or federal

1223

waiver authority, if necessary, to implement the provisions of

1224

this paragraph. Those Medicaid recipients who do not make a

1225

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

1226

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

1227

for a Medicaid recipient who is also a recipient of Supplemental

1228

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

1229

managed care plan or MediPass, the agency shall determine whether

1230

the SSI recipient has an ongoing relationship with a MediPass

1231

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

1232

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

1233

If the SSI recipient has an ongoing relationship with a managed

1234

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

1235

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

1236

relationship shall be assigned to a managed care plan or MediPass

1237

provider in accordance with paragraph (f).

1238

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

1239

care plan or MediPass provider, the agency shall assign the

1240

Medicaid recipient to a managed care plan or MediPass provider.

1241

Medicaid recipients, eligible for managed care plan enrollment,

1242

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

1243

choice shall be assigned to managed care plans until an

1244

enrollment of 35 percent in MediPass and 65 percent in managed

1245

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

1246

achieved. Once this enrollment is achieved, the assignments shall

1247

be divided in order to maintain an enrollment in MediPass and

1248

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

1249

proportion, respectively. Thereafter, assignment of Medicaid

1250

recipients who fail to make a choice shall be based

1251

proportionally on the preferences of recipients who have made a

1252

choice in the previous period. Such proportions shall be revised

1253

at least quarterly to reflect an update of the preferences of

1254

Medicaid recipients. The agency shall disproportionately assign

1255

Medicaid-eligible recipients who are required to but have failed

1256

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

1257

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

1258

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

1259

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

1260

exclusive provider organizations, provider service networks,

1261

minority physician networks, and pediatric emergency department

1262

diversion programs authorized by this chapter or the General

1263

Appropriations Act, in such manner as the agency deems

1264

appropriate, until the agency has determined that the networks

1265

and programs have sufficient numbers to be operated economically

1266

operated. For purposes of this paragraph, when referring to

1267

assignment, the term "managed care plans" includes health

1268

maintenance organizations, exclusive provider organizations,

1269

provider service networks, minority physician networks,

1270

Children's Medical Services Network, and pediatric emergency

1271

department diversion programs authorized by this chapter or the

1272

General Appropriations Act. When making assignments, the agency

1273

shall take into account the following criteria:

1274

     1.  A managed care plan has sufficient network capacity to

1275

meet the need of members.

1276

     2.  The managed care plan or MediPass has previously

1277

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

1278

plan's primary care providers or MediPass providers has

1279

previously provided health care to the recipient.

1280

     3.  The agency has knowledge that the member has previously

1281

expressed a preference for a particular managed care plan or

1282

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

1283

data, but has failed to make a choice.

1284

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

1285

providers are geographically accessible to the recipient's

1286

residence.

1287

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

1288

selection or has been notified of his or her initial assignment

1289

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

1290

shall have 90 days to exercise the opportunity in which to

1291

voluntarily disenroll and select another managed care option plan

1292

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

1293

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

1294

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

1295

necessary specialty services, an unreasonable delay or denial of

1296

service, or fraudulent enrollment. The agency shall develop

1297

criteria for good cause disenrollment for chronically ill and

1298

disabled populations who are assigned to managed care plans if

1299

more appropriate care is available through the MediPass program.

1300

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

1301

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

1302

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

1303

determination of cause, except in cases in which immediate risk

1304

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

1305

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

1306

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

1307

of the second month after the month the disenrollment request was

1308

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

1309

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

1310

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

1311

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

1312

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

1313

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

1314

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

1315

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

1316

of the date agency action was required. Recipients who disagree

1317

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

1318

disenrollment shall be advised of their right to pursue a

1319

Medicaid fair hearing to dispute the agency's finding.

1320

     Section 12. Paragraph (c) of subsection (5) of section

1321

409.905 and section 430.83, Florida Statutes, are repealed.

1322

     Section 13.  This act shall take effect July 1, 2008.

1323

1324

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

1325

And the title is amended as follows:

1326

     Delete everything before the enacting clause

1327

and insert:

1328

A bill to be entitled

1329

An act relating to the Medicaid program; amending s.

1330

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

1331

Administration to transfer fees used to repay nursing home

1332

Medicaid overpayments to the Grants and Donations Trust

1333

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

1334

discontinuing optional Medicaid payments for certain

1335

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

1336

revising certain eligibility criteria for pregnant women

1337

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

1338

discontinuing adult dental services and adult hearing

1339

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

1340

requiring Medicaid to pay for all deductibles and

1341

coinsurance for portable X-ray Medicare Part B services

1342

provided in a nursing home; revising the factors used to

1343

determine the reimbursement rate to providers for Medicaid

1344

prescribed drugs; requiring the agency to reduce certain

1345

provider reimbursement rates as prescribed in the

1346

appropriations act; providing that any increases in rates

1347

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

1348

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

1349

to determine a hospital's Medicaid days and charity care

1350

during the 2008-2009 fiscal year; creating s. 409.91206,

1351

F.S.; authorizing the Governor and the Legislature to

1352

convene workgroups to propose alternatives for cost-

1353

effective health and long-term care reforms; amending s.

1354

409.9112, F.S.; prohibiting the Agency for Health Care

1355

Administration from distributing moneys under the regional

1356

perinatal intensive care disproportionate share program

1357

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

1358

F.S.; authorizing the agency to distribute

1359

disproportionate share funds to teaching hospital during

1360

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

1361

be distributed as provided in the appropriations act;

1362

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

1363

of funds under the primary disproportionate share program

1364

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

1365

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

1366

requirement of enrolling Medicaid eligible children in

1367

MediPass or Medicaid fee-for-service and behavioral health

1368

care services; revising the factors used to determine the

1369

reimbursement rate to pharmacies for Medicaid prescribed

1370

drugs; revising the requirement for the agency to develop

1371

a utilization management program for Medicaid recipients

1372

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

1373

revising enrollment requirements relating to Medicaid

1374

managed care programs and the agency's authority to assign

1375

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

1376

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

1377

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

1378

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

1379

Program; providing an effective date.

4/15/2008  9:16:00 AM     2-07459-08