HB 5085

1
A bill to be entitled
2An act relating to health care; amending s. 400.179, F.S.;
3authorizing the Agency for Health Care Administration to
4transfer funds to the Grants and Donations Trust Fund for
5certain repayments; amending s. 409.017, F.S.; revising
6the short title; providing additional legislative intent;
7requiring the agency to develop a procurement document and
8procedure to claim certain federal matching funds;
9amending s. 409.904, F.S.; discontinuing optional Medicaid
10payments for certain persons age 65 or over or who are
11blind or disabled; revising certain eligibility criteria
12for pregnant women and children younger than age 21;
13amending s. 409.906, F.S.; authorizing payment of a
14specified amount for Medicaid services provided by an
15anesthesiologist assistant; amending s. 409.908, F.S.;
16deleting a provision prohibiting Medicaid from making any
17payment toward deductibles and coinsurance for services
18not covered by Medicaid; providing limitations on Medicaid
19payments for coinsurance; providing for Medicaid to pay
20for certain X-ray services in a nursing home; revising
21reimbursement rates for providers of Medicaid prescribed
22drugs; requiring the agency to revise reimbursement rates
23for hospitals, nursing homes, county health departments,
24and community intermediate care facilities for the
25developmentally disabled for 2 fiscal years; requiring the
26agency to apply the effect of the revised reimbursement
27rates to set payment rates for managed care plans and
28nursing home diversion programs; requiring the agency to
29establish workgroups to evaluate alternative reimbursement
30and payment methodologies for hospitals, nursing
31facilities, and managed care plans; requiring a report;
32providing for future repeal of the suspension of the use
33of cost data to set certain rates; amending s. 409.911,
34F.S.; revising the share data used to calculate
35disproportionate share payments to hospitals; amending s.
36409.9112, F.S.; revising the time period during which the
37agency is prohibited from distributing disproportionate
38share payments to regional perinatal intensive care
39centers; amending s. 409.9113, F.S.; requiring the agency
40to distribute moneys provided in the General
41Appropriations Act to statutorily defined teaching
42hospitals and family practice teaching hospitals under the
43teaching hospital disproportionate share program for the
442008-2009 fiscal year; amending s. 409.9117, F.S.;
45prohibiting the agency from distributing moneys under the
46primary care disproportionate share program for the 2008-
472009 fiscal year; amending s. 409.912, F.S.; adding a
48county for participation in the Medicaid behavioral health
49care services specialty prepaid plan; revising
50reimbursement rates to pharmacies for Medicaid prescribed
51drugs; requiring the agency to notify the Legislature
52before seeking an amendment to the state plan in order to
53implement programs authorized by the Deficit Reduction Act
54of 2005; creating s. 409.91206, F.S.; providing for
55proposed alternatives for health and long-term care
56reforms; amending s. 409.9122, F.S.; revising enrollment
57requirements relating to Medicaid managed care programs
58and the agency's authority to assign persons to MediPass
59or a managed care plan; amending s. 409.9124, F.S.;
60removing the limitation on the application of certain
61rates and rate reductions used by the agency to reimburse
62managed care plans; amending s. 409.913, F.S.; prohibiting
63mailing of the explanation of benefits for certain
64Medicaid services; repealing s. 409.9061, F.S., relating
65to authority for a statewide laboratory services contract;
66repealing s. 430.83, F.S., relating to the Sunshine for
67Seniors Program; providing an effective date.
68
69Be It Enacted by the Legislature of the State of Florida:
70
71     Section 1.  Paragraph (d) of subsection (2) of section
72400.179, Florida Statutes, is amended to read:
73     400.179  Liability for Medicaid underpayments and
74overpayments.--
75     (2)  Because any transfer of a nursing facility may expose
76the fact that Medicaid may have underpaid or overpaid the
77transferor, and because in most instances, any such underpayment
78or overpayment can only be determined following a formal field
79audit, the liabilities for any such underpayments or
80overpayments shall be as follows:
81     (d)  Where the transfer involves a facility that has been
82leased by the transferor:
83     1.  The transferee shall, as a condition to being issued a
84license by the agency, acquire, maintain, and provide proof to
85the agency of a bond with a term of 30 months, renewable
86annually, in an amount not less than the total of 3 months'
87Medicaid payments to the facility computed on the basis of the
88preceding 12-month average Medicaid payments to the facility.
89     2.  A leasehold licensee may meet the requirements of
90subparagraph 1. by payment of a nonrefundable fee, paid at
91initial licensure, paid at the time of any subsequent change of
92ownership, and paid annually thereafter, in the amount of 1
93percent of the total of 3 months' Medicaid payments to the
94facility computed on the basis of the preceding 12-month average
95Medicaid payments to the facility. If a preceding 12-month
96average is not available, projected Medicaid payments may be
97used. The fee shall be deposited into the Health Care Trust Fund
98and shall be accounted for separately as a Medicaid nursing home
99overpayment account. These fees shall be used at the sole
100discretion of the agency to repay nursing home Medicaid
101overpayments. The agency is authorized to transfer funds to the
102Grants and Donations Trust Fund for such repayments. Payment of
103this fee shall not release the licensee from any liability for
104any Medicaid overpayments, nor shall payment bar the agency from
105seeking to recoup overpayments from the licensee and any other
106liable party. As a condition of exercising this lease bond
107alternative, licensees paying this fee must maintain an existing
108lease bond through the end of the 30-month term period of that
109bond. The agency is herein granted specific authority to
110promulgate all rules pertaining to the administration and
111management of this account, including withdrawals from the
112account, subject to federal review and approval. This provision
113shall take effect upon becoming law and shall apply to any
114leasehold license application. The financial viability of the
115Medicaid nursing home overpayment account shall be determined by
116the agency through annual review of the account balance and the
117amount of total outstanding, unpaid Medicaid overpayments owing
118from leasehold licensees to the agency as determined by final
119agency audits.
120     3.  The leasehold licensee may meet the bond requirement
121through other arrangements acceptable to the agency. The agency
122is herein granted specific authority to promulgate rules
123pertaining to lease bond arrangements.
124     4.  All existing nursing facility licensees, operating the
125facility as a leasehold, shall acquire, maintain, and provide
126proof to the agency of the 30-month bond required in
127subparagraph 1., above, on and after July 1, 1993, for each
128license renewal.
129     5.  It shall be the responsibility of all nursing facility
130operators, operating the facility as a leasehold, to renew the
13130-month bond and to provide proof of such renewal to the agency
132annually.
133     6.  Any failure of the nursing facility operator to
134acquire, maintain, renew annually, or provide proof to the
135agency shall be grounds for the agency to deny, revoke, and
136suspend the facility license to operate such facility and to
137take any further action, including, but not limited to,
138enjoining the facility, asserting a moratorium pursuant to part
139II of chapter 408, or applying for a receiver, deemed necessary
140to ensure compliance with this section and to safeguard and
141protect the health, safety, and welfare of the facility's
142residents. A lease agreement required as a condition of bond
143financing or refinancing under s. 154.213 by a health facilities
144authority or required under s. 159.30 by a county or
145municipality is not a leasehold for purposes of this paragraph
146and is not subject to the bond requirement of this paragraph.
147     Section 2.  Section 409.017, Florida Statutes, is amended
148to read:
149     409.017  Local Funding Revenue Maximization Act;
150legislative intent; revenue maximization program.--
151     (1)  SHORT TITLE.--This section may be cited as the "Local
152Funding Revenue Maximization Act."
153     (2)  LEGISLATIVE INTENT.--
154     (a)  The Legislature recognizes that state funds do not
155fully utilize federal funding matching opportunities for health
156and human services needs. It is the intent of the Legislature to
157authorize the use of certified local funding for federal
158matching programs to the fullest extent possible to maximize
159federal funding of local preventive services and local child
160development programs in this state. To that end, the Legislature
161expects that state agencies will take a proactive approach in
162implementing this legislative priority. It is the further intent
163of the Legislature that this act shall be revenue neutral with
164respect to state funds.
165     (b)  It is the intent of the Legislature that revenue
166maximization opportunities using certified local funding shall
167occur only after available state funds have been utilized to
168generate matching federal funding for the state.
169     (c)  It is the intent of the Legislature that participation
170in revenue maximization is to be voluntary for local political
171subdivisions.
172     (d)  Except for funds expended pursuant to Title XIX of the
173Social Security Act, it is the intent of the Legislature that
174certified local funding for federal matching programs not
175supplant or replace state funds. Beginning July 1, 2004, any
176state funds supplanted or replaced with local tax revenues for
177Title XIX funds shall be expressly approved in the General
178Appropriations Act or by the Legislative Budget Commission
179pursuant to chapter 216.
180     (e)  It is the intent of the Legislature that revenue
181maximization shall not divert existing funds from state agencies
182that are currently using local funds to maximize matching
183federal and state funds to the greatest extent possible.
184     (f)  It is the intent of the legislature to encourage and
185allow any agency to engage, through a competitive procurement
186process, an entity with expertise in claiming justifiable and
187appropriate federal funds through revenue maximization efforts
188both retrospectively and prospectively. This claiming may
189include, but not be limited to, administrative and services
190activities that are eligible under federal matching programs.
191     (3)  REVENUE MAXIMIZATION PROGRAM.--
192     (a)  For purposes of this section, the term "agency" means
193any state agency or department that is involved in providing
194health, social, or human services, including, but not limited
195to, the Agency for Health Care Administration, the Agency for
196Workforce Innovation, the Department of Children and Family
197Services, the Department of Elderly Affairs, the Department of
198Juvenile Justice, the Department of Education, and the State
199Board of Education.
200     (b)  The Agency for Health Care Administration may develop
201a procurement document and procedure to claim administrative
202federal matching funds for state provided educational services.
203The agency shall then competitively procure an entity with
204appropriate expertise and experience to retrospectively and
205prospectively maximize federal revenues through administrative
206claims for federal matching funds for state provided educational
207services.
208     (c)(b)  Each agency shall establish programs and mechanisms
209designed to maximize the use of local funding for federal
210programs in accordance with this section.
211     (d)(c)  The use of local matching funds under this section
212must be limited to public revenue funds of local political
213subdivisions, including, but not limited to, counties,
214municipalities, and special districts. To the extent permitted
215by federal law, funds donated to such local political
216subdivisions by private entities, such as, but not limited to,
217the United Way, community foundations or other foundations, and
218businesses, or by individuals are considered to be public
219revenue funds available for matching federal funding.
220     (e)(d)  Subject to paragraph (g) (f), any federal
221reimbursement received as a result of the certification of local
222matching funds must, unless specifically prohibited by federal
223law or state law, including the General Appropriations Act, and
224subject to the availability of specific appropriation and
225release authority, be returned within 30 days after receipt by
226the agency by the most expedient means possible to the local
227political subdivision providing such funding, and the local
228political subdivision must be provided an annual accounting of
229federal reimbursements received by the state or its agencies as
230a result of the certification of the local political
231subdivision's matching funds. The receipt by a local political
232subdivision of such matching funds must not in any way influence
233or be used as a factor in developing any agency's annual
234operating budget allocation methodology or formula or any
235subsequent budget amendment allocations or formulas. If
236necessary, agreements must be made between an agency and the
237local political subdivision to accomplish that purpose. Such an
238agreement may provide that the local political subdivision must:
239verify the eligibility of the local program or programs and the
240individuals served thereby to qualify for federal matching
241funds; shall develop and maintain the financial records
242necessary for documenting the appropriate use of federal funds;
243shall comply with all applicable state and federal laws,
244regulations, and rules that regulate such federal services; and
245shall reimburse the cost of any disallowance of federal funding
246previously provided to a local political subdivision resulting
247from the failure of that local political subdivision to comply
248with applicable state or federal laws, rules, or regulations.
249     (f)(e)  Each agency, as applicable, shall work with local
250political subdivisions to modify any state plans and to seek and
251implement any federal waivers necessary to implement this
252section. If such modifications or waivers require the approval
253of the Legislature, the agency, as applicable, shall draft such
254legislation and present it to the President of the Senate and
255the Speaker of the House of Representatives and to the
256respective committee chairs of the Senate and the House of
257Representatives by January 1, 2004, and, as applicable, annually
258thereafter.
259     (g)(f)  Each agency, as applicable, before funds generated
260under this section are distributed to any local political
261subdivision, may deduct the actual administrative cost for
262implementing and monitoring the local match program; however,
263such administrative costs may not exceed 5 percent of the total
264federal reimbursement funding to be provided to the local
265political subdivision under paragraph (e) (d). To the extent
266that any other provision of state law applies to the
267certification of local matching funds for a specific program,
268the provisions of that statute which relate to administrative
269costs apply in lieu of the provisions of this paragraph. The
270failure to remit reimbursement to the local political
271subdivision will result in the payment of interest, in addition
272to the amount to be reimbursed at a rate pursuant to s. 55.03(1)
273on the unpaid amount from the expiration of the 30-day period
274until payment is received.
275     (h)(g)  Each agency, respectively, shall annually submit to
276the Governor, the President of the Senate, and the Speaker of
277the House of Representatives, no later than January 1, a report
278that documents the specific activities undertaken during the
279previous fiscal year under this section. The report must
280include, but is not limited to, a statement of the total amount
281of federal matching funds generated by local matching funds
282under this section, reported by federal funding source; the
283total amount of block grant funds expended during the previous
284fiscal year, reported by federal funding source; the total
285amount for federal matching fund programs, including, but not
286limited to, Temporary Assistance for Needy Families and Child
287Care and Development Fund, of unobligated funds and unliquidated
288funds, both as of the close of the previous federal fiscal year;
289the amount of unliquidated funds that is in danger of being
290returned to the Federal Government at the end of the current
291federal fiscal year; and a detailed plan and timeline for
292spending any unobligated and unliquidated funds by the end of
293the current federal fiscal year.
294     Section 3.  Subsections (1) and (2) of section 409.904,
295Florida Statutes, are amended to read:
296     409.904  Optional payments for eligible persons.--The
297agency may make payments for medical assistance and related
298services on behalf of the following persons who are determined
299to be eligible subject to the income, assets, and categorical
300eligibility tests set forth in federal and state law. Payment on
301behalf of these Medicaid eligible persons is subject to the
302availability of moneys and any limitations established by the
303General Appropriations Act or chapter 216.
304     (1)(a)  From July 1, 2005, through December 31, 2005, a
305person who is age 65 or older or is determined to be disabled,
306whose income is at or below 88 percent of federal poverty level,
307and whose assets do not exceed established limitations.
308     (b)  Effective January 1, 2006, and subject to federal
309waiver approval, a person who is age 65 or older or is
310determined to be disabled, whose income is at or below 88
311percent of the federal poverty level, whose assets do not exceed
312established limitations, and who is not eligible for Medicare
313or, if eligible for Medicare, is also eligible for and receiving
314Medicaid-covered institutional care services, hospice services,
315or home and community-based services. The agency shall seek
316federal authorization through a waiver to provide this coverage.
317This subsection expires June 30, 2009.
318     (2)(a)  A family, a pregnant woman, a child under age 21, a
319person age 65 or over, or a blind or disabled person, who would
320be eligible under any group listed in s. 409.903(1), (2), or
321(3), except that the income or assets of such family or person
322exceed established limitations. For a family or person in one of
323these coverage groups, medical expenses are deductible from
324income in accordance with federal requirements in order to make
325a determination of eligibility. A family or person eligible
326under the coverage known as the "medically needy," is eligible
327to receive the same services as other Medicaid recipients, with
328the exception of services in skilled nursing facilities and
329intermediate care facilities for the developmentally disabled.
330This subsection expires June 30, 2009.
331     (b)  Effective July 1, 2009, a pregnant woman or a child
332younger than 21 years of age who would be eligible under any
333group listed in s. 409.903, except that the income or assets of
334such group exceed established limitations. For a person in one
335of these coverage groups, medical expenses are deductible from
336income in accordance with federal requirements in order to make
337a determination of eligibility. A person eligible under the
338coverage known as the "medically needy" is eligible to receive
339the same services as other Medicaid recipients, with the
340exception of services in skilled nursing facilities and
341intermediate care facilities for the developmentally disabled.
342     Section 4.  Subsection (26) is added to section 409.906,
343Florida Statutes, to read:
344     409.906  Optional Medicaid services.--Subject to specific
345appropriations, the agency may make payments for services which
346are optional to the state under Title XIX of the Social Security
347Act and are furnished by Medicaid providers to recipients who
348are determined to be eligible on the dates on which the services
349were provided. Any optional service that is provided shall be
350provided only when medically necessary and in accordance with
351state and federal law. Optional services rendered by providers
352in mobile units to Medicaid recipients may be restricted or
353prohibited by the agency. Nothing in this section shall be
354construed to prevent or limit the agency from adjusting fees,
355reimbursement rates, lengths of stay, number of visits, or
356number of services, or making any other adjustments necessary to
357comply with the availability of moneys and any limitations or
358directions provided for in the General Appropriations Act or
359chapter 216. If necessary to safeguard the state's systems of
360providing services to elderly and disabled persons and subject
361to the notice and review provisions of s. 216.177, the Governor
362may direct the Agency for Health Care Administration to amend
363the Medicaid state plan to delete the optional Medicaid service
364known as "Intermediate Care Facilities for the Developmentally
365Disabled." Optional services may include:
366     (26)  ANESTHESIOLOGIST ASSISTANT SERVICES.--The agency may
367pay for all services provided to a recipient by an
368anesthesiologist assistant licensed under s. 458.3475 or s.
369459.023. Reimbursement for such services must be not less than
37080 percent of the reimbursement that would be paid to a
371physician who provided the same services.
372     Section 5.  Subsections (13) and (14) of section 409.908,
373Florida Statutes, as amended by chapter 2007-331, Laws of
374Florida, are amended, and subsection (23) is added to that
375section, to read:
376     409.908  Reimbursement of Medicaid providers.--Subject to
377specific appropriations, the agency shall reimburse Medicaid
378providers, in accordance with state and federal law, according
379to methodologies set forth in the rules of the agency and in
380policy manuals and handbooks incorporated by reference therein.
381These methodologies may include fee schedules, reimbursement
382methods based on cost reporting, negotiated fees, competitive
383bidding pursuant to s. 287.057, and other mechanisms the agency
384considers efficient and effective for purchasing services or
385goods on behalf of recipients. If a provider is reimbursed based
386on cost reporting and submits a cost report late and that cost
387report would have been used to set a lower reimbursement rate
388for a rate semester, then the provider's rate for that semester
389shall be retroactively calculated using the new cost report, and
390full payment at the recalculated rate shall be effected
391retroactively. Medicare-granted extensions for filing cost
392reports, if applicable, shall also apply to Medicaid cost
393reports. Payment for Medicaid compensable services made on
394behalf of Medicaid eligible persons is subject to the
395availability of moneys and any limitations or directions
396provided for in the General Appropriations Act or chapter 216.
397Further, nothing in this section shall be construed to prevent
398or limit the agency from adjusting fees, reimbursement rates,
399lengths of stay, number of visits, or number of services, or
400making any other adjustments necessary to comply with the
401availability of moneys and any limitations or directions
402provided for in the General Appropriations Act, provided the
403adjustment is consistent with legislative intent.
404     (13)  Medicare premiums for persons eligible for both
405Medicare and Medicaid coverage shall be paid at the rates
406established by Title XVIII of the Social Security Act. For
407Medicare services rendered to Medicaid-eligible persons,
408Medicaid shall pay Medicare deductibles and coinsurance as
409follows:
410     (a)  Medicaid shall make no payment toward deductibles and
411coinsurance for any service that is not covered by Medicaid.
412     (a)(b)  Medicaid's financial obligation for deductibles and
413coinsurance payments shall be based on Medicare allowable fees,
414not on a provider's billed charges.
415     (b)(c)  Medicaid will pay no portion of Medicare
416deductibles and coinsurance when payment that Medicare has made
417for the service equals or exceeds what Medicaid would have paid
418if it had been the sole payor. The combined payment of Medicare
419and Medicaid shall not exceed the amount Medicaid would have
420paid had it been the sole payor. The Legislature finds that
421there has been confusion regarding the reimbursement for
422services rendered to dually eligible Medicare beneficiaries.
423Accordingly, the Legislature clarifies that it has always been
424the intent of the Legislature before and after 1991 that, in
425reimbursing in accordance with fees established by Title XVIII
426for premiums, deductibles, and coinsurance for Medicare services
427rendered by physicians to Medicaid eligible persons, physicians
428be reimbursed at the lesser of the amount billed by the
429physician or the Medicaid maximum allowable fee established by
430the Agency for Health Care Administration, as is permitted by
431federal law. It has never been the intent of the Legislature
432with regard to such services rendered by physicians that
433Medicaid be required to provide any payment for deductibles,
434coinsurance, or copayments for Medicare cost sharing, or any
435expenses incurred relating thereto, in excess of the payment
436amount provided for under the State Medicaid plan for such
437service. This payment methodology is applicable even in those
438situations in which the payment for Medicare cost sharing for a
439qualified Medicare beneficiary with respect to an item or
440service is reduced or eliminated. This expression of the
441Legislature is in clarification of existing law and shall apply
442to payment for, and with respect to provider agreements with
443respect to, items or services furnished on or after the
444effective date of this act. This paragraph applies to payment by
445Medicaid for items and services furnished before the effective
446date of this act if such payment is the subject of a lawsuit
447that is based on the provisions of this section, and that is
448pending as of, or is initiated after, the effective date of this
449act.
450     (c)(d)  Notwithstanding paragraphs (a) and (b) (a)-(c):
451     1.  Medicaid payments for Nursing Home Medicare part A
452coinsurance are shall be limited to the Medicaid nursing home
453per diem rate less any amounts paid by Medicare, but only up to
454the amount of Medicare coinsurance. The Medicaid per diem rate
455shall be the rate in effect for the dates of service of the
456crossover claims and may not be subsequently adjusted due to
457subsequent per diem rate adjustments.
458     2.  Medicaid shall pay all deductibles and coinsurance for
459Medicare-eligible recipients receiving freestanding end stage
460renal dialysis center services.
461     3.  Medicaid payments for general and specialty hospital
462inpatient services are shall be limited to the Medicare
463deductible and coinsurance per spell of illness. Medicaid
464payments for hospital Medicare Part A coinsurance shall be
465limited to the Medicaid hospital per diem rate less any amounts
466paid by Medicare, but only up to the amount of Medicare
467coinsurance. Medicaid payments for coinsurance shall be limited
468to the Medicaid per diem rate in effect for the dates of service
469of the crossover claims and may not be subsequently adjusted due
470to subsequent per diem adjustments. Medicaid shall make no
471payment toward coinsurance for Medicare general hospital
472inpatient services.
473     4.  Medicaid shall pay all deductibles and coinsurance for
474Medicare emergency transportation services provided by
475ambulances licensed pursuant to chapter 401.
476     5.  Medicaid shall pay all deductibles and coinsurance for
477portable X-ray Medicare Part B services provided in a nursing
478home.
479     (14)  A provider of prescribed drugs shall be reimbursed
480the least of the amount billed by the provider, the provider's
481usual and customary charge, or the Medicaid maximum allowable
482fee established by the agency, plus a dispensing fee. The
483Medicaid maximum allowable fee for ingredient cost will be based
484on the lower of: average wholesale price (AWP) minus 16.4 15.4
485percent, wholesaler acquisition cost (WAC) plus 4.75 5.75
486percent, the federal upper limit (FUL), the state maximum
487allowable cost (SMAC), or the usual and customary (UAC) charge
488billed by the provider. Medicaid providers are required to
489dispense generic drugs if available at lower cost and the agency
490has not determined that the branded product is more cost-
491effective, unless the prescriber has requested and received
492approval to require the branded product. The agency is directed
493to implement a variable dispensing fee for payments for
494prescribed medicines while ensuring continued access for
495Medicaid recipients. The variable dispensing fee may be based
496upon, but not limited to, either or both the volume of
497prescriptions dispensed by a specific pharmacy provider, the
498volume of prescriptions dispensed to an individual recipient,
499and dispensing of preferred-drug-list products. The agency may
500increase the pharmacy dispensing fee authorized by statute and
501in the annual General Appropriations Act by $0.50 for the
502dispensing of a Medicaid preferred-drug-list product and reduce
503the pharmacy dispensing fee by $0.50 for the dispensing of a
504Medicaid product that is not included on the preferred drug
505list. The agency may establish a supplemental pharmaceutical
506dispensing fee to be paid to providers returning unused unit-
507dose packaged medications to stock and crediting the Medicaid
508program for the ingredient cost of those medications if the
509ingredient costs to be credited exceed the value of the
510supplemental dispensing fee. The agency is authorized to limit
511reimbursement for prescribed medicine in order to comply with
512any limitations or directions provided for in the General
513Appropriations Act, which may include implementing a prospective
514or concurrent utilization review program.
515     (23)(a)  The agency shall establish rates at a level that
516ensures no increase in statewide expenditures resulting from a
517change in unit costs for 2 fiscal years effective July 1, 2009.
518Reimbursement rates for the 2 fiscal years shall be as provided
519in the General Appropriations Act.
520     (b)  This subsection applies to the following provider
521types:
522     1.  Inpatient hospitals.
523     2.  Outpatient hospitals.
524     3.  Nursing homes.
525     4.  County health departments.
526     5.  Community intermediate care facilities for the
527developmentally disabled.
528     6.  Prepaid health plans.
529
530The agency shall apply the effect of this subsection to the
531reimbursement rates for nursing home diversion programs.
532     (c)  The agency shall create a workgroup on hospital
533reimbursement, a workgroup on nursing facility reimbursement,
534and a workgroup on managed care plan payment. The workgroups
535shall evaluate alternative reimbursement and payment
536methodologies for hospitals, nursing facilities, and managed
537care plans, including prospective payment methodologies for
538hospitals and nursing facilities. The nursing facility workgroup
539shall also consider price-based methodologies for indirect care
540and acuity adjustments for direct care. The agency shall submit
541a report on the evaluated alternative reimbursement
542methodologies to the relevant committees of the Senate and the
543House of Representatives by November 1, 2009.
544     (d)  This subsection expires June 30, 2011.
545     Section 6.  Paragraph (a) of subsection (2) of section
546409.911, Florida Statutes, is amended to read:
547     409.911  Disproportionate share program.--Subject to
548specific allocations established within the General
549Appropriations Act and any limitations established pursuant to
550chapter 216, the agency shall distribute, pursuant to this
551section, moneys to hospitals providing a disproportionate share
552of Medicaid or charity care services by making quarterly
553Medicaid payments as required. Notwithstanding the provisions of
554s. 409.915, counties are exempt from contributing toward the
555cost of this special reimbursement for hospitals serving a
556disproportionate share of low-income patients.
557     (2)  The Agency for Health Care Administration shall use
558the following actual audited data to determine the Medicaid days
559and charity care to be used in calculating the disproportionate
560share payment:
561     (a)  The average of the 2002, 2003, and 2004 2000, 2001,
562and 2002 audited disproportionate share data to determine each
563hospital's Medicaid days and charity care for the 2008-2009
5642006-2007 state fiscal year.
565     Section 7.  Section 409.9112, Florida Statutes, is amended
566to read:
567     409.9112  Disproportionate share program for regional
568perinatal intensive care centers.--In addition to the payments
569made under s. 409.911, the Agency for Health Care Administration
570shall design and implement a system of making disproportionate
571share payments to those hospitals that participate in the
572regional perinatal intensive care center program established
573pursuant to chapter 383. This system of payments shall conform
574with federal requirements and shall distribute funds in each
575fiscal year for which an appropriation is made by making
576quarterly Medicaid payments. Notwithstanding the provisions of
577s. 409.915, counties are exempt from contributing toward the
578cost of this special reimbursement for hospitals serving a
579disproportionate share of low-income patients. For the state
580fiscal year 2008-2009 2005-2006, the agency shall not distribute
581moneys under the regional perinatal intensive care centers
582disproportionate share program.
583     (1)  The following formula shall be used by the agency to
584calculate the total amount earned for hospitals that participate
585in the regional perinatal intensive care center program:
586
587TAE = HDSP/THDSP
588
589Where:
590     TAE = total amount earned by a regional perinatal intensive
591care center.
592     HDSP = the prior state fiscal year regional perinatal
593intensive care center disproportionate share payment to the
594individual hospital.
595     THDSP = the prior state fiscal year total regional
596perinatal intensive care center disproportionate share payments
597to all hospitals.
598     (2)  The total additional payment for hospitals that
599participate in the regional perinatal intensive care center
600program shall be calculated by the agency as follows:
601
602TAP = TAE x TA
603
604Where:
605     TAP = total additional payment for a regional perinatal
606intensive care center.
607     TAE = total amount earned by a regional perinatal intensive
608care center.
609     TA = total appropriation for the regional perinatal
610intensive care center disproportionate share program.
611     (3)  In order to receive payments under this section, a
612hospital must be participating in the regional perinatal
613intensive care center program pursuant to chapter 383 and must
614meet the following additional requirements:
615     (a)  Agree to conform to all departmental and agency
616requirements to ensure high quality in the provision of
617services, including criteria adopted by departmental and agency
618rule concerning staffing ratios, medical records, standards of
619care, equipment, space, and such other standards and criteria as
620the department and agency deem appropriate as specified by rule.
621     (b)  Agree to provide information to the department and
622agency, in a form and manner to be prescribed by rule of the
623department and agency, concerning the care provided to all
624patients in neonatal intensive care centers and high-risk
625maternity care.
626     (c)  Agree to accept all patients for neonatal intensive
627care and high-risk maternity care, regardless of ability to pay,
628on a functional space-available basis.
629     (d)  Agree to develop arrangements with other maternity and
630neonatal care providers in the hospital's region for the
631appropriate receipt and transfer of patients in need of
632specialized maternity and neonatal intensive care services.
633     (e)  Agree to establish and provide a developmental
634evaluation and services program for certain high-risk neonates,
635as prescribed and defined by rule of the department.
636     (f)  Agree to sponsor a program of continuing education in
637perinatal care for health care professionals within the region
638of the hospital, as specified by rule.
639     (g)  Agree to provide backup and referral services to the
640department's county health departments and other low-income
641perinatal providers within the hospital's region, including the
642development of written agreements between these organizations
643and the hospital.
644     (h)  Agree to arrange for transportation for high-risk
645obstetrical patients and neonates in need of transfer from the
646community to the hospital or from the hospital to another more
647appropriate facility.
648     (4)  Hospitals which fail to comply with any of the
649conditions in subsection (3) or the applicable rules of the
650department and agency shall not receive any payments under this
651section until full compliance is achieved. A hospital which is
652not in compliance in two or more consecutive quarters shall not
653receive its share of the funds. Any forfeited funds shall be
654distributed by the remaining participating regional perinatal
655intensive care center program hospitals.
656     Section 8.  Section 409.9113, Florida Statutes, is amended
657to read:
658     409.9113  Disproportionate share program for teaching
659hospitals.--In addition to the payments made under ss. 409.911
660and 409.9112, the Agency for Health Care Administration shall
661make disproportionate share payments to statutorily defined
662teaching hospitals for their increased costs associated with
663medical education programs and for tertiary health care services
664provided to the indigent. This system of payments shall conform
665with federal requirements and shall distribute funds in each
666fiscal year for which an appropriation is made by making
667quarterly Medicaid payments. Notwithstanding s. 409.915,
668counties are exempt from contributing toward the cost of this
669special reimbursement for hospitals serving a disproportionate
670share of low-income patients. For the state fiscal year 2008-
6712009 2006-2007, the agency shall distribute the moneys provided
672in the General Appropriations Act to statutorily defined
673teaching hospitals and family practice teaching hospitals under
674the teaching hospital disproportionate share program. The funds
675provided for statutorily defined teaching hospitals shall be
676distributed in the same proportion as the state fiscal year
6772003-2004 teaching hospital disproportionate share funds were
678distributed or as otherwise provided in the General
679Appropriations Act. The funds provided for family practice
680teaching hospitals shall be distributed equally among family
681practice teaching hospitals.
682     (1)  On or before September 15 of each year, the Agency for
683Health Care Administration shall calculate an allocation
684fraction to be used for distributing funds to state statutory
685teaching hospitals. Subsequent to the end of each quarter of the
686state fiscal year, the agency shall distribute to each statutory
687teaching hospital, as defined in s. 408.07, an amount determined
688by multiplying one-fourth of the funds appropriated for this
689purpose by the Legislature times such hospital's allocation
690fraction. The allocation fraction for each such hospital shall
691be determined by the sum of three primary factors, divided by
692three. The primary factors are:
693     (a)  The number of nationally accredited graduate medical
694education programs offered by the hospital, including programs
695accredited by the Accreditation Council for Graduate Medical
696Education and the combined Internal Medicine and Pediatrics
697programs acceptable to both the American Board of Internal
698Medicine and the American Board of Pediatrics at the beginning
699of the state fiscal year preceding the date on which the
700allocation fraction is calculated. The numerical value of this
701factor is the fraction that the hospital represents of the total
702number of programs, where the total is computed for all state
703statutory teaching hospitals.
704     (b)  The number of full-time equivalent trainees in the
705hospital, which comprises two components:
706     1.  The number of trainees enrolled in nationally
707accredited graduate medical education programs, as defined in
708paragraph (a). Full-time equivalents are computed using the
709fraction of the year during which each trainee is primarily
710assigned to the given institution, over the state fiscal year
711preceding the date on which the allocation fraction is
712calculated. The numerical value of this factor is the fraction
713that the hospital represents of the total number of full-time
714equivalent trainees enrolled in accredited graduate programs,
715where the total is computed for all state statutory teaching
716hospitals.
717     2.  The number of medical students enrolled in accredited
718colleges of medicine and engaged in clinical activities,
719including required clinical clerkships and clinical electives.
720Full-time equivalents are computed using the fraction of the
721year during which each trainee is primarily assigned to the
722given institution, over the course of the state fiscal year
723preceding the date on which the allocation fraction is
724calculated. The numerical value of this factor is the fraction
725that the given hospital represents of the total number of full-
726time equivalent students enrolled in accredited colleges of
727medicine, where the total is computed for all state statutory
728teaching hospitals.
729
730The primary factor for full-time equivalent trainees is computed
731as the sum of these two components, divided by two.
732     (c)  A service index that comprises three components:
733     1.  The Agency for Health Care Administration Service
734Index, computed by applying the standard Service Inventory
735Scores established by the Agency for Health Care Administration
736to services offered by the given hospital, as reported on
737Worksheet A-2 for the last fiscal year reported to the agency
738before the date on which the allocation fraction is calculated.
739The numerical value of this factor is the fraction that the
740given hospital represents of the total Agency for Health Care
741Administration Service Index values, where the total is computed
742for all state statutory teaching hospitals.
743     2.  A volume-weighted service index, computed by applying
744the standard Service Inventory Scores established by the Agency
745for Health Care Administration to the volume of each service,
746expressed in terms of the standard units of measure reported on
747Worksheet A-2 for the last fiscal year reported to the agency
748before the date on which the allocation factor is calculated.
749The numerical value of this factor is the fraction that the
750given hospital represents of the total volume-weighted service
751index values, where the total is computed for all state
752statutory teaching hospitals.
753     3.  Total Medicaid payments to each hospital for direct
754inpatient and outpatient services during the fiscal year
755preceding the date on which the allocation factor is calculated.
756This includes payments made to each hospital for such services
757by Medicaid prepaid health plans, whether the plan was
758administered by the hospital or not. The numerical value of this
759factor is the fraction that each hospital represents of the
760total of such Medicaid payments, where the total is computed for
761all state statutory teaching hospitals.
762
763The primary factor for the service index is computed as the sum
764of these three components, divided by three.
765     (2)  By October 1 of each year, the agency shall use the
766following formula to calculate the maximum additional
767disproportionate share payment for statutorily defined teaching
768hospitals:
769
770TAP = THAF x A
771
772Where:
773     TAP = total additional payment.
774     THAF = teaching hospital allocation factor.
775     A = amount appropriated for a teaching hospital
776disproportionate share program.
777     Section 9.  Section 409.9117, Florida Statutes, is amended
778to read:
779     409.9117  Primary care disproportionate share program.--For
780the state fiscal year 2008-2009 2006-2007, the agency shall not
781distribute moneys under the primary care disproportionate share
782program.
783     (1)  If federal funds are available for disproportionate
784share programs in addition to those otherwise provided by law,
785there shall be created a primary care disproportionate share
786program.
787     (2)  The following formula shall be used by the agency to
788calculate the total amount earned for hospitals that participate
789in the primary care disproportionate share program:
790
791TAE = HDSP/THDSP
792
793Where:
794     TAE = total amount earned by a hospital participating in
795the primary care disproportionate share program.
796     HDSP = the prior state fiscal year primary care
797disproportionate share payment to the individual hospital.
798     THDSP = the prior state fiscal year total primary care
799disproportionate share payments to all hospitals.
800     (3)  The total additional payment for hospitals that
801participate in the primary care disproportionate share program
802shall be calculated by the agency as follows:
803
804TAP = TAE x TA
805
806Where:
807     TAP = total additional payment for a primary care hospital.
808     TAE = total amount earned by a primary care hospital.
809     TA = total appropriation for the primary care
810disproportionate share program.
811     (4)  In the establishment and funding of this program, the
812agency shall use the following criteria in addition to those
813specified in s. 409.911, payments may not be made to a hospital
814unless the hospital agrees to:
815     (a)  Cooperate with a Medicaid prepaid health plan, if one
816exists in the community.
817     (b)  Ensure the availability of primary and specialty care
818physicians to Medicaid recipients who are not enrolled in a
819prepaid capitated arrangement and who are in need of access to
820such physicians.
821     (c)  Coordinate and provide primary care services free of
822charge, except copayments, to all persons with incomes up to 100
823percent of the federal poverty level who are not otherwise
824covered by Medicaid or another program administered by a
825governmental entity, and to provide such services based on a
826sliding fee scale to all persons with incomes up to 200 percent
827of the federal poverty level who are not otherwise covered by
828Medicaid or another program administered by a governmental
829entity, except that eligibility may be limited to persons who
830reside within a more limited area, as agreed to by the agency
831and the hospital.
832     (d)  Contract with any federally qualified health center,
833if one exists within the agreed geopolitical boundaries,
834concerning the provision of primary care services, in order to
835guarantee delivery of services in a nonduplicative fashion, and
836to provide for referral arrangements, privileges, and
837admissions, as appropriate. The hospital shall agree to provide
838at an onsite or offsite facility primary care services within 24
839hours to which all Medicaid recipients and persons eligible
840under this paragraph who do not require emergency room services
841are referred during normal daylight hours.
842     (e)  Cooperate with the agency, the county, and other
843entities to ensure the provision of certain public health
844services, case management, referral and acceptance of patients,
845and sharing of epidemiological data, as the agency and the
846hospital find mutually necessary and desirable to promote and
847protect the public health within the agreed geopolitical
848boundaries.
849     (f)  In cooperation with the county in which the hospital
850resides, develop a low-cost, outpatient, prepaid health care
851program to persons who are not eligible for the Medicaid
852program, and who reside within the area.
853     (g)  Provide inpatient services to residents within the
854area who are not eligible for Medicaid or Medicare, and who do
855not have private health insurance, regardless of ability to pay,
856on the basis of available space, except that nothing shall
857prevent the hospital from establishing bill collection programs
858based on ability to pay.
859     (h)  Work with the Florida Healthy Kids Corporation, the
860Florida Health Care Purchasing Cooperative, and business health
861coalitions, as appropriate, to develop a feasibility study and
862plan to provide a low-cost comprehensive health insurance plan
863to persons who reside within the area and who do not have access
864to such a plan.
865     (i)  Work with public health officials and other experts to
866provide community health education and prevention activities
867designed to promote healthy lifestyles and appropriate use of
868health services.
869     (j)  Work with the local health council to develop a plan
870for promoting access to affordable health care services for all
871persons who reside within the area, including, but not limited
872to, public health services, primary care services, inpatient
873services, and affordable health insurance generally.
874
875Any hospital that fails to comply with any of the provisions of
876this subsection, or any other contractual condition, may not
877receive payments under this section until full compliance is
878achieved.
879     Section 10.  Paragraph (b) of subsection (4) and paragraph
880(a) of subsection (39) of section 409.912, Florida Statutes, as
881amended by chapter 2007-331, Laws of Florida, are amended, and
882subsection (53) is added to that section, to read:
883     409.912  Cost-effective purchasing of health care.--The
884agency shall purchase goods and services for Medicaid recipients
885in the most cost-effective manner consistent with the delivery
886of quality medical care. To ensure that medical services are
887effectively utilized, the agency may, in any case, require a
888confirmation or second physician's opinion of the correct
889diagnosis for purposes of authorizing future services under the
890Medicaid program. This section does not restrict access to
891emergency services or poststabilization care services as defined
892in 42 C.F.R. part 438.114. Such confirmation or second opinion
893shall be rendered in a manner approved by the agency. The agency
894shall maximize the use of prepaid per capita and prepaid
895aggregate fixed-sum basis services when appropriate and other
896alternative service delivery and reimbursement methodologies,
897including competitive bidding pursuant to s. 287.057, designed
898to facilitate the cost-effective purchase of a case-managed
899continuum of care. The agency shall also require providers to
900minimize the exposure of recipients to the need for acute
901inpatient, custodial, and other institutional care and the
902inappropriate or unnecessary use of high-cost services. The
903agency shall contract with a vendor to monitor and evaluate the
904clinical practice patterns of providers in order to identify
905trends that are outside the normal practice patterns of a
906provider's professional peers or the national guidelines of a
907provider's professional association. The vendor must be able to
908provide information and counseling to a provider whose practice
909patterns are outside the norms, in consultation with the agency,
910to improve patient care and reduce inappropriate utilization.
911The agency may mandate prior authorization, drug therapy
912management, or disease management participation for certain
913populations of Medicaid beneficiaries, certain drug classes, or
914particular drugs to prevent fraud, abuse, overuse, and possible
915dangerous drug interactions. The Pharmaceutical and Therapeutics
916Committee shall make recommendations to the agency on drugs for
917which prior authorization is required. The agency shall inform
918the Pharmaceutical and Therapeutics Committee of its decisions
919regarding drugs subject to prior authorization. The agency is
920authorized to limit the entities it contracts with or enrolls as
921Medicaid providers by developing a provider network through
922provider credentialing. The agency may competitively bid single-
923source-provider contracts if procurement of goods or services
924results in demonstrated cost savings to the state without
925limiting access to care. The agency may limit its network based
926on the assessment of beneficiary access to care, provider
927availability, provider quality standards, time and distance
928standards for access to care, the cultural competence of the
929provider network, demographic characteristics of Medicaid
930beneficiaries, practice and provider-to-beneficiary standards,
931appointment wait times, beneficiary use of services, provider
932turnover, provider profiling, provider licensure history,
933previous program integrity investigations and findings, peer
934review, provider Medicaid policy and billing compliance records,
935clinical and medical record audits, and other factors. Providers
936shall not be entitled to enrollment in the Medicaid provider
937network. The agency shall determine instances in which allowing
938Medicaid beneficiaries to purchase durable medical equipment and
939other goods is less expensive to the Medicaid program than long-
940term rental of the equipment or goods. The agency may establish
941rules to facilitate purchases in lieu of long-term rentals in
942order to protect against fraud and abuse in the Medicaid program
943as defined in s. 409.913. The agency may seek federal waivers
944necessary to administer these policies.
945     (4)  The agency may contract with:
946     (b)  An entity that is providing comprehensive behavioral
947health care services to certain Medicaid recipients through a
948capitated, prepaid arrangement pursuant to the federal waiver
949provided for by s. 409.905(5). Such an entity must be licensed
950under chapter 624, chapter 636, or chapter 641 and must possess
951the clinical systems and operational competence to manage risk
952and provide comprehensive behavioral health care to Medicaid
953recipients. As used in this paragraph, the term "comprehensive
954behavioral health care services" means covered mental health and
955substance abuse treatment services that are available to
956Medicaid recipients. The secretary of the Department of Children
957and Family Services shall approve provisions of procurements
958related to children in the department's care or custody prior to
959enrolling such children in a prepaid behavioral health plan. Any
960contract awarded under this paragraph must be competitively
961procured. In developing the behavioral health care prepaid plan
962procurement document, the agency shall ensure that the
963procurement document requires the contractor to develop and
964implement a plan to ensure compliance with s. 394.4574 related
965to services provided to residents of licensed assisted living
966facilities that hold a limited mental health license. Except as
967provided in subparagraph 8., and except in counties where the
968Medicaid managed care pilot program is authorized pursuant to s.
969409.91211, the agency shall seek federal approval to contract
970with a single entity meeting these requirements to provide
971comprehensive behavioral health care services to all Medicaid
972recipients not enrolled in a Medicaid managed care plan
973authorized under s. 409.91211 or a Medicaid health maintenance
974organization in an AHCA area. In an AHCA area where the Medicaid
975managed care pilot program is authorized pursuant to s.
976409.91211 in one or more counties, the agency may procure a
977contract with a single entity to serve the remaining counties as
978an AHCA area or the remaining counties may be included with an
979adjacent AHCA area and shall be subject to this paragraph. Each
980entity must offer sufficient choice of providers in its network
981to ensure recipient access to care and the opportunity to select
982a provider with whom they are satisfied. The network shall
983include all public mental health hospitals. To ensure unimpaired
984access to behavioral health care services by Medicaid
985recipients, all contracts issued pursuant to this paragraph
986shall require 80 percent of the capitation paid to the managed
987care plan, including health maintenance organizations, to be
988expended for the provision of behavioral health care services.
989In the event the managed care plan expends less than 80 percent
990of the capitation paid pursuant to this paragraph for the
991provision of behavioral health care services, the difference
992shall be returned to the agency. The agency shall provide the
993managed care plan with a certification letter indicating the
994amount of capitation paid during each calendar year for the
995provision of behavioral health care services pursuant to this
996section. The agency may reimburse for substance abuse treatment
997services on a fee-for-service basis until the agency finds that
998adequate funds are available for capitated, prepaid
999arrangements.
1000     1.  By January 1, 2001, the agency shall modify the
1001contracts with the entities providing comprehensive inpatient
1002and outpatient mental health care services to Medicaid
1003recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
1004Counties, to include substance abuse treatment services.
1005     2.  By July 1, 2003, the agency and the Department of
1006Children and Family Services shall execute a written agreement
1007that requires collaboration and joint development of all policy,
1008budgets, procurement documents, contracts, and monitoring plans
1009that have an impact on the state and Medicaid community mental
1010health and targeted case management programs.
1011     3.  Except as provided in subparagraph 8., by July 1, 2006,
1012the agency and the Department of Children and Family Services
1013shall contract with managed care entities in each AHCA area
1014except area 6 or arrange to provide comprehensive inpatient and
1015outpatient mental health and substance abuse services through
1016capitated prepaid arrangements to all Medicaid recipients who
1017are eligible to participate in such plans under federal law and
1018regulation. In AHCA areas where eligible individuals number less
1019than 150,000, the agency shall contract with a single managed
1020care plan to provide comprehensive behavioral health services to
1021all recipients who are not enrolled in a Medicaid health
1022maintenance organization or a Medicaid capitated managed care
1023plan authorized under s. 409.91211. The agency may contract with
1024more than one comprehensive behavioral health provider to
1025provide care to recipients who are not enrolled in a Medicaid
1026capitated managed care plan authorized under s. 409.91211 or a
1027Medicaid health maintenance organization in AHCA areas where the
1028eligible population exceeds 150,000. In an AHCA area where the
1029Medicaid managed care pilot program is authorized pursuant to s.
1030409.91211 in one or more counties, the agency may procure a
1031contract with a single entity to serve the remaining counties as
1032an AHCA area or the remaining counties may be included with an
1033adjacent AHCA area and shall be subject to this paragraph.
1034Contracts for comprehensive behavioral health providers awarded
1035pursuant to this section shall be competitively procured. Both
1036for-profit and not-for-profit corporations shall be eligible to
1037compete. Managed care plans contracting with the agency under
1038subsection (3) shall provide and receive payment for the same
1039comprehensive behavioral health benefits as provided in AHCA
1040rules, including handbooks incorporated by reference. In AHCA
1041area 11, the agency shall contract with at least two
1042comprehensive behavioral health care providers to provide
1043behavioral health care to recipients in that area who are
1044enrolled in, or assigned to, the MediPass program. One of the
1045behavioral health care contracts shall be with the existing
1046provider service network pilot project, as described in
1047paragraph (d), for the purpose of demonstrating the cost-
1048effectiveness of the provision of quality mental health services
1049through a public hospital-operated managed care model. Payment
1050shall be at an agreed-upon capitated rate to ensure cost
1051savings. Of the recipients in area 11 who are assigned to
1052MediPass under the provisions of s. 409.9122(2)(k), a minimum of
105350,000 of those MediPass-enrolled recipients shall be assigned
1054to the existing provider service network in area 11 for their
1055behavioral care.
1056     4.  By October 1, 2003, the agency and the department shall
1057submit a plan to the Governor, the President of the Senate, and
1058the Speaker of the House of Representatives which provides for
1059the full implementation of capitated prepaid behavioral health
1060care in all areas of the state.
1061     a.  Implementation shall begin in 2003 in those AHCA areas
1062of the state where the agency is able to establish sufficient
1063capitation rates.
1064     b.  If the agency determines that the proposed capitation
1065rate in any area is insufficient to provide appropriate
1066services, the agency may adjust the capitation rate to ensure
1067that care will be available. The agency and the department may
1068use existing general revenue to address any additional required
1069match but may not over-obligate existing funds on an annualized
1070basis.
1071     c.  Subject to any limitations provided for in the General
1072Appropriations Act, the agency, in compliance with appropriate
1073federal authorization, shall develop policies and procedures
1074that allow for certification of local and state funds.
1075     5.  Children residing in a statewide inpatient psychiatric
1076program, or in a Department of Juvenile Justice or a Department
1077of Children and Family Services residential program approved as
1078a Medicaid behavioral health overlay services provider shall not
1079be included in a behavioral health care prepaid health plan or
1080any other Medicaid managed care plan pursuant to this paragraph.
1081     6.  In converting to a prepaid system of delivery, the
1082agency shall in its procurement document require an entity
1083providing only comprehensive behavioral health care services to
1084prevent the displacement of indigent care patients by enrollees
1085in the Medicaid prepaid health plan providing behavioral health
1086care services from facilities receiving state funding to provide
1087indigent behavioral health care, to facilities licensed under
1088chapter 395 which do not receive state funding for indigent
1089behavioral health care, or reimburse the unsubsidized facility
1090for the cost of behavioral health care provided to the displaced
1091indigent care patient.
1092     7.  Traditional community mental health providers under
1093contract with the Department of Children and Family Services
1094pursuant to part IV of chapter 394, child welfare providers
1095under contract with the Department of Children and Family
1096Services in areas 1 and 6, and inpatient mental health providers
1097licensed pursuant to chapter 395 must be offered an opportunity
1098to accept or decline a contract to participate in any provider
1099network for prepaid behavioral health services.
1100     8.  All Medicaid-eligible children, except children in area
11011 and children in Highlands, Hardee, Polk, or Manatee County of
1102area 6 For fiscal year 2004-2005, all Medicaid eligible
1103children, except children in areas 1 and 6, whose cases are open
1104for child welfare services in the HomeSafeNet system, shall be
1105enrolled in MediPass or in Medicaid fee-for-service and all
1106their behavioral health care services including inpatient,
1107outpatient psychiatric, community mental health, and case
1108management shall be reimbursed on a fee-for-service basis.
1109Beginning July 1, 2005, such children, who are open for child
1110welfare services in the HomeSafeNet system, shall receive their
1111behavioral health care services through a specialty prepaid plan
1112operated by community-based lead agencies either through a
1113single agency or formal agreements among several agencies. The
1114specialty prepaid plan must result in savings to the state
1115comparable to savings achieved in other Medicaid managed care
1116and prepaid programs. Such plan must provide mechanisms to
1117maximize state and local revenues. The specialty prepaid plan
1118shall be developed by the agency and the Department of Children
1119and Family Services. The agency is authorized to seek any
1120federal waivers to implement this initiative. Medicaid-eligible
1121children whose cases are open for child welfare services in the
1122HomeSafeNet system and who reside in AHCA area 10 are exempt
1123from the specialty prepaid plan upon the development of a
1124service delivery mechanism for children who reside in area 10 as
1125specified in s. 409.91211(3)(dd).
1126     (39)(a)  The agency shall implement a Medicaid prescribed-
1127drug spending-control program that includes the following
1128components:
1129     1.  A Medicaid preferred drug list, which shall be a
1130listing of cost-effective therapeutic options recommended by the
1131Medicaid Pharmacy and Therapeutics Committee established
1132pursuant to s. 409.91195 and adopted by the agency for each
1133therapeutic class on the preferred drug list. At the discretion
1134of the committee, and when feasible, the preferred drug list
1135should include at least two products in a therapeutic class. The
1136agency may post the preferred drug list and updates to the
1137preferred drug list on an Internet website without following the
1138rulemaking procedures of chapter 120. Antiretroviral agents are
1139excluded from the preferred drug list. The agency shall also
1140limit the amount of a prescribed drug dispensed to no more than
1141a 34-day supply unless the drug products' smallest marketed
1142package is greater than a 34-day supply, or the drug is
1143determined by the agency to be a maintenance drug in which case
1144a 100-day maximum supply may be authorized. The agency is
1145authorized to seek any federal waivers necessary to implement
1146these cost-control programs and to continue participation in the
1147federal Medicaid rebate program, or alternatively to negotiate
1148state-only manufacturer rebates. The agency may adopt rules to
1149implement this subparagraph. The agency shall continue to
1150provide unlimited contraceptive drugs and items. The agency must
1151establish procedures to ensure that:
1152     a.  There is will be a response to a request for prior
1153consultation by telephone or other telecommunication device
1154within 24 hours after receipt of a request for prior
1155consultation; and
1156     b.  A 72-hour supply of the drug prescribed is will be
1157provided in an emergency or when the agency does not provide a
1158response within 24 hours as required by sub-subparagraph a.
1159     2.  Reimbursement to pharmacies for Medicaid prescribed
1160drugs shall be set at the lesser of: the average wholesale price
1161(AWP) minus 16.4 15.4 percent, the wholesaler acquisition cost
1162(WAC) plus 4.75 5.75 percent, the federal upper limit (FUL), the
1163state maximum allowable cost (SMAC), or the usual and customary
1164(UAC) charge billed by the provider.
1165     3.  The agency shall develop and implement a process for
1166managing the drug therapies of Medicaid recipients who are using
1167significant numbers of prescribed drugs each month. The
1168management process may include, but is not limited to,
1169comprehensive, physician-directed medical-record reviews, claims
1170analyses, and case evaluations to determine the medical
1171necessity and appropriateness of a patient's treatment plan and
1172drug therapies. The agency may contract with a private
1173organization to provide drug-program-management services. The
1174Medicaid drug benefit management program shall include
1175initiatives to manage drug therapies for HIV/AIDS patients,
1176patients using 20 or more unique prescriptions in a 180-day
1177period, and the top 1,000 patients in annual spending. The
1178agency shall enroll any Medicaid recipient in the drug benefit
1179management program if he or she meets the specifications of this
1180provision and is not enrolled in a Medicaid health maintenance
1181organization.
1182     4.  The agency may limit the size of its pharmacy network
1183based on need, competitive bidding, price negotiations,
1184credentialing, or similar criteria. The agency shall give
1185special consideration to rural areas in determining the size and
1186location of pharmacies included in the Medicaid pharmacy
1187network. A pharmacy credentialing process may include criteria
1188such as a pharmacy's full-service status, location, size,
1189patient educational programs, patient consultation, disease
1190management services, and other characteristics. The agency may
1191impose a moratorium on Medicaid pharmacy enrollment when it is
1192determined that it has a sufficient number of Medicaid-
1193participating providers. The agency must allow dispensing
1194practitioners to participate as a part of the Medicaid pharmacy
1195network regardless of the practitioner's proximity to any other
1196entity that is dispensing prescription drugs under the Medicaid
1197program. A dispensing practitioner must meet all credentialing
1198requirements applicable to his or her practice, as determined by
1199the agency.
1200     5.  The agency shall develop and implement a program that
1201requires Medicaid practitioners who prescribe drugs to use a
1202counterfeit-proof prescription pad for Medicaid prescriptions.
1203The agency shall require the use of standardized counterfeit-
1204proof prescription pads by Medicaid-participating prescribers or
1205prescribers who write prescriptions for Medicaid recipients. The
1206agency may implement the program in targeted geographic areas or
1207statewide.
1208     6.  The agency may enter into arrangements that require
1209manufacturers of generic drugs prescribed to Medicaid recipients
1210to provide rebates of at least 15.1 percent of the average
1211manufacturer price for the manufacturer's generic products.
1212These arrangements shall require that if a generic-drug
1213manufacturer pays federal rebates for Medicaid-reimbursed drugs
1214at a level below 15.1 percent, the manufacturer must provide a
1215supplemental rebate to the state in an amount necessary to
1216achieve a 15.1-percent rebate level.
1217     7.  The agency may establish a preferred drug list as
1218described in this subsection, and, pursuant to the establishment
1219of such preferred drug list, it is authorized to negotiate
1220supplemental rebates from manufacturers that are in addition to
1221those required by Title XIX of the Social Security Act and at no
1222less than 14 percent of the average manufacturer price as
1223defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
1224the federal or supplemental rebate, or both, equals or exceeds
122529 percent. There is no upper limit on the supplemental rebates
1226the agency may negotiate. The agency may determine that specific
1227products, brand-name or generic, are competitive at lower rebate
1228percentages. Agreement to pay the minimum supplemental rebate
1229percentage will guarantee a manufacturer that the Medicaid
1230Pharmaceutical and Therapeutics Committee will consider a
1231product for inclusion on the preferred drug list. However, a
1232pharmaceutical manufacturer is not guaranteed placement on the
1233preferred drug list by simply paying the minimum supplemental
1234rebate. Agency decisions will be made on the clinical efficacy
1235of a drug and recommendations of the Medicaid Pharmaceutical and
1236Therapeutics Committee, as well as the price of competing
1237products minus federal and state rebates. The agency is
1238authorized to contract with an outside agency or contractor to
1239conduct negotiations for supplemental rebates. For the purposes
1240of this section, the term "supplemental rebates" means cash
1241rebates. Effective July 1, 2004, value-added programs as a
1242substitution for supplemental rebates are prohibited. The agency
1243is authorized to seek any federal waivers to implement this
1244initiative.
1245     8.  The Agency for Health Care Administration shall expand
1246home delivery of pharmacy products. To assist Medicaid patients
1247in securing their prescriptions and reduce program costs, the
1248agency shall expand its current mail-order-pharmacy diabetes-
1249supply program to include all generic and brand-name drugs used
1250by Medicaid patients with diabetes. Medicaid recipients in the
1251current program may obtain nondiabetes drugs on a voluntary
1252basis. This initiative is limited to the geographic area covered
1253by the current contract. The agency may seek and implement any
1254federal waivers necessary to implement this subparagraph.
1255     9.  The agency shall limit to one dose per month any drug
1256prescribed to treat erectile dysfunction.
1257     10.a.  The agency may implement a Medicaid behavioral drug
1258management system. The agency may contract with a vendor that
1259has experience in operating behavioral drug management systems
1260to implement this program. The agency is authorized to seek
1261federal waivers to implement this program.
1262     b.  The agency, in conjunction with the Department of
1263Children and Family Services, may implement the Medicaid
1264behavioral drug management system that is designed to improve
1265the quality of care and behavioral health prescribing practices
1266based on best practice guidelines, improve patient adherence to
1267medication plans, reduce clinical risk, and lower prescribed
1268drug costs and the rate of inappropriate spending on Medicaid
1269behavioral drugs. The program may include the following
1270elements:
1271     (I)  Provide for the development and adoption of best
1272practice guidelines for behavioral health-related drugs such as
1273antipsychotics, antidepressants, and medications for treating
1274bipolar disorders and other behavioral conditions; translate
1275them into practice; review behavioral health prescribers and
1276compare their prescribing patterns to a number of indicators
1277that are based on national standards; and determine deviations
1278from best practice guidelines.
1279     (II)  Implement processes for providing feedback to and
1280educating prescribers using best practice educational materials
1281and peer-to-peer consultation.
1282     (III)  Assess Medicaid beneficiaries who are outliers in
1283their use of behavioral health drugs with regard to the numbers
1284and types of drugs taken, drug dosages, combination drug
1285therapies, and other indicators of improper use of behavioral
1286health drugs.
1287     (IV)  Alert prescribers to patients who fail to refill
1288prescriptions in a timely fashion, are prescribed multiple same-
1289class behavioral health drugs, and may have other potential
1290medication problems.
1291     (V)  Track spending trends for behavioral health drugs and
1292deviation from best practice guidelines.
1293     (VI)  Use educational and technological approaches to
1294promote best practices, educate consumers, and train prescribers
1295in the use of practice guidelines.
1296     (VII)  Disseminate electronic and published materials.
1297     (VIII)  Hold statewide and regional conferences.
1298     (IX)  Implement a disease management program with a model
1299quality-based medication component for severely mentally ill
1300individuals and emotionally disturbed children who are high
1301users of care.
1302     11.a.  The agency shall implement a Medicaid prescription
1303drug management system. The agency may contract with a vendor
1304that has experience in operating prescription drug management
1305systems in order to implement this system. Any management system
1306that is implemented in accordance with this subparagraph must
1307rely on cooperation between physicians and pharmacists to
1308determine appropriate practice patterns and clinical guidelines
1309to improve the prescribing, dispensing, and use of drugs in the
1310Medicaid program. The agency may seek federal waivers to
1311implement this program.
1312     b.  The drug management system must be designed to improve
1313the quality of care and prescribing practices based on best
1314practice guidelines, improve patient adherence to medication
1315plans, reduce clinical risk, and lower prescribed drug costs and
1316the rate of inappropriate spending on Medicaid prescription
1317drugs. The program must:
1318     (I)  Provide for the development and adoption of best
1319practice guidelines for the prescribing and use of drugs in the
1320Medicaid program, including translating best practice guidelines
1321into practice; reviewing prescriber patterns and comparing them
1322to indicators that are based on national standards and practice
1323patterns of clinical peers in their community, statewide, and
1324nationally; and determine deviations from best practice
1325guidelines.
1326     (II)  Implement processes for providing feedback to and
1327educating prescribers using best practice educational materials
1328and peer-to-peer consultation.
1329     (III)  Assess Medicaid recipients who are outliers in their
1330use of a single or multiple prescription drugs with regard to
1331the numbers and types of drugs taken, drug dosages, combination
1332drug therapies, and other indicators of improper use of
1333prescription drugs.
1334     (IV)  Alert prescribers to patients who fail to refill
1335prescriptions in a timely fashion, are prescribed multiple drugs
1336that may be redundant or contraindicated, or may have other
1337potential medication problems.
1338     (V)  Track spending trends for prescription drugs and
1339deviation from best practice guidelines.
1340     (VI)  Use educational and technological approaches to
1341promote best practices, educate consumers, and train prescribers
1342in the use of practice guidelines.
1343     (VII)  Disseminate electronic and published materials.
1344     (VIII)  Hold statewide and regional conferences.
1345     (IX)  Implement disease management programs in cooperation
1346with physicians and pharmacists, along with a model quality-
1347based medication component for individuals having chronic
1348medical conditions.
1349     12.  The agency is authorized to contract for drug rebate
1350administration, including, but not limited to, calculating
1351rebate amounts, invoicing manufacturers, negotiating disputes
1352with manufacturers, and maintaining a database of rebate
1353collections.
1354     13.  The agency may specify the preferred daily dosing form
1355or strength for the purpose of promoting best practices with
1356regard to the prescribing of certain drugs as specified in the
1357General Appropriations Act and ensuring cost-effective
1358prescribing practices.
1359     14.  The agency may require prior authorization for
1360Medicaid-covered prescribed drugs. The agency may, but is not
1361required to, prior-authorize the use of a product:
1362     a.  For an indication not approved in labeling;
1363     b.  To comply with certain clinical guidelines; or
1364     c.  If the product has the potential for overuse, misuse,
1365or abuse.
1366
1367The agency may require the prescribing professional to provide
1368information about the rationale and supporting medical evidence
1369for the use of a drug. The agency may post prior authorization
1370criteria and protocol and updates to the list of drugs that are
1371subject to prior authorization on an Internet website without
1372amending its rule or engaging in additional rulemaking.
1373     15.  The agency, in conjunction with the Pharmaceutical and
1374Therapeutics Committee, may require age-related prior
1375authorizations for certain prescribed drugs. The agency may
1376preauthorize the use of a drug for a recipient who may not meet
1377the age requirement or may exceed the length of therapy for use
1378of this product as recommended by the manufacturer and approved
1379by the Food and Drug Administration. Prior authorization may
1380require the prescribing professional to provide information
1381about the rationale and supporting medical evidence for the use
1382of a drug.
1383     16.  The agency shall implement a step-therapy prior
1384authorization approval process for medications excluded from the
1385preferred drug list. Medications listed on the preferred drug
1386list must be used within the previous 12 months prior to the
1387alternative medications that are not listed. The step-therapy
1388prior authorization may require the prescriber to use the
1389medications of a similar drug class or for a similar medical
1390indication unless contraindicated in the Food and Drug
1391Administration labeling. The trial period between the specified
1392steps may vary according to the medical indication. The step-
1393therapy approval process shall be developed in accordance with
1394the committee as stated in s. 409.91195(7) and (8). A drug
1395product may be approved without meeting the step-therapy prior
1396authorization criteria if the prescribing physician provides the
1397agency with additional written medical or clinical documentation
1398that the product is medically necessary because:
1399     a.  There is not a drug on the preferred drug list to treat
1400the disease or medical condition which is an acceptable clinical
1401alternative;
1402     b.  The alternatives have been ineffective in the treatment
1403of the beneficiary's disease; or
1404     c.  Based on historic evidence and known characteristics of
1405the patient and the drug, the drug is likely to be ineffective,
1406or the number of doses have been ineffective.
1407
1408The agency shall work with the physician to determine the best
1409alternative for the patient. The agency may adopt rules waiving
1410the requirements for written clinical documentation for specific
1411drugs in limited clinical situations.
1412     17.  The agency shall implement a return and reuse program
1413for drugs dispensed by pharmacies to institutional recipients,
1414which includes payment of a $5 restocking fee for the
1415implementation and operation of the program. The return and
1416reuse program shall be implemented electronically and in a
1417manner that promotes efficiency. The program must permit a
1418pharmacy to exclude drugs from the program if it is not
1419practical or cost-effective for the drug to be included and must
1420provide for the return to inventory of drugs that cannot be
1421credited or returned in a cost-effective manner. The agency
1422shall determine if the program has reduced the amount of
1423Medicaid prescription drugs which are destroyed on an annual
1424basis and if there are additional ways to ensure more
1425prescription drugs are not destroyed which could safely be
1426reused. The agency's conclusion and recommendations shall be
1427reported to the Legislature by December 1, 2005.
1428     (53)  Before seeking an amendment to the state plan for
1429purposes of implementing programs authorized by the Deficit
1430Reduction Act of 2005, the agency shall notify the Legislature.
1431     Section 11.  Section 409.91206, Florida Statutes, is
1432created to read:
1433     409.91206  Alternatives for health and long-term care
1434reforms.--The Governor, the President of the Senate, and the
1435Speaker of the House of Representatives may convene workgroups
1436to propose alternatives for cost-effective health and long-term
1437care reforms, including, but not limited to, reforms for
1438Medicaid.
1439     Section 12.  Paragraphs (c), (e), (f), and (i) of
1440subsection (2) of section 409.9122, Florida Statutes, are
1441amended to read:
1442     409.9122  Mandatory Medicaid managed care enrollment;
1443programs and procedures.--
1444     (2)
1445     (c)  Medicaid recipients shall have a choice of managed
1446care plans or MediPass. The Agency for Health Care
1447Administration, the Department of Health, the Department of
1448Children and Family Services, and the Department of Elderly
1449Affairs shall cooperate to ensure that each Medicaid recipient
1450receives clear and easily understandable information that meets
1451the following requirements:
1452     1.  Explains the concept of managed care, including
1453MediPass.
1454     2.  Provides information on the comparative performance of
1455managed care plans and MediPass in the areas of quality,
1456credentialing, preventive health programs, network size and
1457availability, and patient satisfaction.
1458     3.  Explains where additional information on each managed
1459care plan and MediPass in the recipient's area can be obtained.
1460     4.  Explains that recipients have the right to choose their
1461own managed care coverage at the time they first enroll in
1462Medicaid and again at regular intervals set by the agency plans
1463or MediPass. However, if a recipient does not choose a managed
1464care plan or MediPass, the agency will assign the recipient to a
1465managed care plan or MediPass according to the criteria
1466specified in this section.
1467     5.  Explains the recipient's right to complain, file a
1468grievance, or change managed care plans or MediPass providers if
1469the recipient is not satisfied with the managed care plan or
1470MediPass.
1471     (e)  Medicaid recipients who are already enrolled in a
1472managed care plan or MediPass shall be offered the opportunity
1473to change managed care plans or MediPass providers on a
1474staggered basis, as defined by the agency. All Medicaid
1475recipients shall have 30 days in which to make a choice of
1476managed care plans or MediPass providers. In counties that have
1477two or more managed care plans, a recipient already enrolled in
1478MediPass who fails to make a choice during the annual period
1479shall be assigned to a managed care plan if he or she is
1480eligible for enrollment in the managed care plan. The agency
1481shall apply for a state plan amendment or federal waiver
1482authority, if necessary, to implement the provisions of this
1483paragraph.  All newly eligible Medicaid recipients shall have 30
1484days in which to make a choice of managed care plans or Medipass
1485providers. Those Medicaid recipients who do not make a choice
1486shall be assigned to a managed care plan or MediPass in
1487accordance with paragraph (f). To facilitate continuity of care,
1488for a Medicaid recipient who is also a recipient of Supplemental
1489Security Income (SSI), prior to assigning the SSI recipient to a
1490managed care plan or MediPass, the agency shall determine
1491whether the SSI recipient has an ongoing relationship with a
1492MediPass provider or managed care plan, and if so, the agency
1493shall assign the SSI recipient to that MediPass provider or
1494managed care plan. If the SSI recipient has an ongoing
1495relationship with a managed care plan, the agency shall assign
1496the recipient to that managed care plan. Those SSI recipients
1497who do not have such a provider relationship shall be assigned
1498to a managed care plan or MediPass provider in accordance with
1499paragraph (f).
1500     (f)  If When a Medicaid recipient does not choose a managed
1501care plan or MediPass provider, the agency shall assign the
1502Medicaid recipient to a managed care plan or MediPass provider.
1503Medicaid recipients eligible for managed care plan enrollment
1504who are subject to mandatory assignment but who fail to make a
1505choice shall be assigned to managed care plans until an
1506enrollment of 35 percent in MediPass and 65 percent in managed
1507care plans, of all those eligible to choose managed care, is
1508achieved. Once this enrollment is achieved, the assignments
1509shall be divided in order to maintain an enrollment in MediPass
1510and managed care plans which is in a 35 percent and 65 percent
1511proportion, respectively. Thereafter, assignment of Medicaid
1512recipients who fail to make a choice shall be based
1513proportionally on the preferences of recipients who have made a
1514choice in the previous period. Such proportions shall be revised
1515at least quarterly to reflect an update of the preferences of
1516Medicaid recipients. The agency shall disproportionately assign
1517Medicaid-eligible recipients who are required to but have failed
1518to make a choice of managed care plan or MediPass, including
1519children, and who would are to be assigned to the MediPass
1520program to children's networks as described in s. 409.912(4)(g),
1521Children's Medical Services Network as defined in s. 391.021,
1522exclusive provider organizations, provider service networks,
1523minority physician networks, and pediatric emergency department
1524diversion programs authorized by this chapter or the General
1525Appropriations Act, in such manner as the agency deems
1526appropriate, until the agency has determined that the networks
1527and programs have sufficient numbers to be operated economically
1528operated. For purposes of this paragraph, when referring to
1529assignment, the term "managed care plans" includes health
1530maintenance organizations, exclusive provider organizations,
1531provider service networks, minority physician networks,
1532Children's Medical Services Network, and pediatric emergency
1533department diversion programs authorized by this chapter or the
1534General Appropriations Act. When making assignments, the agency
1535shall take into account the following criteria:
1536     1.  A managed care plan has sufficient network capacity to
1537meet the need of members.
1538     2.  The managed care plan or MediPass has previously
1539enrolled the recipient as a member, or one of the managed care
1540plan's primary care providers or MediPass providers has
1541previously provided health care to the recipient.
1542     3.  The agency has knowledge that the member has previously
1543expressed a preference for a particular managed care plan or
1544MediPass provider as indicated by Medicaid fee-for-service
1545claims data, but has failed to make a choice.
1546     4.  The managed care plan's or MediPass primary care
1547providers are geographically accessible to the recipient's
1548residence.
1549     (i)  After a recipient has made his or her a selection or
1550has been enrolled in a managed care plan or MediPass, the
1551recipient shall have 90 days to exercise the opportunity in
1552which to voluntarily disenroll and select another managed care
1553plan or MediPass provider. After 90 days, no further changes may
1554be made except for good cause. Good cause includes shall
1555include, but is not be limited to, poor quality of care, lack of
1556access to necessary specialty services, an unreasonable delay or
1557denial of service, or fraudulent enrollment. The agency shall
1558develop criteria for good cause disenrollment for chronically
1559ill and disabled populations who are assigned to managed care
1560plans if more appropriate care is available through the MediPass
1561program. The agency must make a determination as to whether
1562cause exists. However, the agency may require a recipient to use
1563the managed care plan's or MediPass grievance process prior to
1564the agency's determination of cause, except in cases in which
1565immediate risk of permanent damage to the recipient's health is
1566alleged. The grievance process, when utilized, must be completed
1567in time to permit the recipient to disenroll by no later than
1568the first day of the second month after the month the
1569disenrollment request was made. If the managed care plan or
1570MediPass, as a result of the grievance process, approves an
1571enrollee's request to disenroll, the agency is not required to
1572make a determination in the case. The agency must make a
1573determination and take final action on a recipient's request so
1574that disenrollment occurs no later than the first day of the
1575second month after the month the request was made. If the agency
1576fails to act within the specified timeframe, the recipient's
1577request to disenroll is deemed to be approved as of the date
1578agency action was required. Recipients who disagree with the
1579agency's finding that cause does not exist for disenrollment
1580shall be advised of their right to pursue a Medicaid fair
1581hearing to dispute the agency's finding.
1582     Section 13.  Subsection (2) of section 409.9124, Florida
1583Statutes, is amended to read:
1584     409.9124  Managed care reimbursement.--The agency shall
1585develop and adopt by rule a methodology for reimbursing managed
1586care plans.
1587     (2)  Each year prior to establishing new managed care
1588rates, the agency shall review all prior year adjustments for
1589changes in trend, and shall reduce or eliminate those
1590adjustments which are not reasonable and which reflect policies
1591or programs which are not in effect. In addition, the agency
1592shall apply only those policy reductions applicable to the
1593fiscal year for which the rates are being set, which can be
1594accurately estimated and verified by an independent actuary, and
1595which have been implemented prior to or will be implemented
1596during the fiscal year. The agency shall pay rates at per-
1597member, per-month averages that do not exceed the amounts
1598allowed for in the General Appropriations Act applicable to the
1599fiscal year for which the rates will be in effect.
1600     Section 14.  Subsection (36) of section 409.913, Florida
1601Statutes, is amended to read:
1602     409.913  Oversight of the integrity of the Medicaid
1603program.--The agency shall operate a program to oversee the
1604activities of Florida Medicaid recipients, and providers and
1605their representatives, to ensure that fraudulent and abusive
1606behavior and neglect of recipients occur to the minimum extent
1607possible, and to recover overpayments and impose sanctions as
1608appropriate. Beginning January 1, 2003, and each year
1609thereafter, the agency and the Medicaid Fraud Control Unit of
1610the Department of Legal Affairs shall submit a joint report to
1611the Legislature documenting the effectiveness of the state's
1612efforts to control Medicaid fraud and abuse and to recover
1613Medicaid overpayments during the previous fiscal year. The
1614report must describe the number of cases opened and investigated
1615each year; the sources of the cases opened; the disposition of
1616the cases closed each year; the amount of overpayments alleged
1617in preliminary and final audit letters; the number and amount of
1618fines or penalties imposed; any reductions in overpayment
1619amounts negotiated in settlement agreements or by other means;
1620the amount of final agency determinations of overpayments; the
1621amount deducted from federal claiming as a result of
1622overpayments; the amount of overpayments recovered each year;
1623the amount of cost of investigation recovered each year; the
1624average length of time to collect from the time the case was
1625opened until the overpayment is paid in full; the amount
1626determined as uncollectible and the portion of the uncollectible
1627amount subsequently reclaimed from the Federal Government; the
1628number of providers, by type, that are terminated from
1629participation in the Medicaid program as a result of fraud and
1630abuse; and all costs associated with discovering and prosecuting
1631cases of Medicaid overpayments and making recoveries in such
1632cases. The report must also document actions taken to prevent
1633overpayments and the number of providers prevented from
1634enrolling in or reenrolling in the Medicaid program as a result
1635of documented Medicaid fraud and abuse and must recommend
1636changes necessary to prevent or recover overpayments.
1637     (36)  The agency shall provide to each Medicaid recipient
1638or his or her representative an explanation of benefits in the
1639form of a letter that is mailed to the most recent address of
1640the recipient on the record with the Department of Children and
1641Family Services. The explanation of benefits must include the
1642patient's name, the name of the health care provider and the
1643address of the location where the service was provided, a
1644description of all services billed to Medicaid in terminology
1645that should be understood by a reasonable person, and
1646information on how to report inappropriate or incorrect billing
1647to the agency or other law enforcement entities for review or
1648investigation. The explanation of benefits may not be mailed for
1649Medicaid independent laboratory services as described in s.
1650409.905(7) or for Medicaid certified match services as described
1651in ss. 409.9071 and 1011.70.
1652     Section 15.  Sections 409.9061 and 430.83, Florida
1653Statutes, are repealed.
1654     Section 16.  This act shall take effect July 1, 2008.


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