HB 5085

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

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