Florida Senate - 2009 PROPOSED COMMITTEE SUBSTITUTE
Bill No. SB 1658
Barcode 426188
603-03123A-09
Proposed Committee Substitute by the Committee on Health and
Human Services Appropriations
1 A bill to be entitled
2 An act relating to the health care; amending s.
3 408.040, F.S.; conforming a cross-reference; amending
4 s. 409.814, F.S.; requiring an applicant for the
5 Florida Kidcare program to provide verification of the
6 child’s citizenship status; amending s. 409.815, F.S.;
7 revising behavioral health services and dental
8 services coverage under the Kidcare program; revising
9 methods by which payments are made to federally
10 qualified health centers and rural health clinics;
11 amending s. 409.818, F.S.; revising the manner by
12 which quality assurance and access standards are
13 monitored in the Kidcare program; amending s. 409.904,
14 F.S.; extending the date that certain persons are
15 eligible to receive optional Medicaid services;
16 amending s. 409.905, F.S.; requiring prior
17 authorization for certain home health services;
18 establishing requirements for Medicaid reimbursed home
19 health services; amending s. 409.908, F.S.; requiring
20 increases in certain Medicaid provider rates to be
21 authorized in the appropriations act; amending s.
22 409.9082, F.S.; deleting an option for discontinuing
23 the nursing home quality assessment; amending s.
24 409.911, F.S.; updating the data to be used in
25 calculating disproportionate share; amending s.
26 409.9112, F.S.; continuing the prohibition against
27 distributing moneys under the perinatal intensive care
28 centers disproportionate share program; amending s.
29 409.9113, F.S.; continuing authorization for the
30 distribution of moneys to teaching hospitals under the
31 disproportionate share program; amending s. 409.9117,
32 F.S.; continuing the prohibition against distributing
33 moneys for the primary care disproportionate share
34 program; amending ss. 409.91195 and 409.91196, F.S.;
35 conforming cross-references; amending s. 409.912,
36 F.S.; deleting the fixed payment for delivery program
37 for Medicaid recipients 60 years of age or older;
38 requiring that a Medicaid managed care plan’s costs to
39 the state be adjusted for health status; amending s.
40 409.91211, F.S.; revising the timeline for phasing in
41 financial risk for provider service networks;
42 conforming cross-references; amending s. 430.04, F.S.;
43 requiring the Department of Elderly Affairs to
44 administer all Medicaid waivers and programs relating
45 to elders; amending s. 641.386, F.S.; conforming a
46 cross-reference; directing the Agency for Health Care
47 Administration to establish pilot projects in Miami
48 Dade County relating to home health services;
49 providing an effective date.
50
51 Be It Enacted by the Legislature of the State of Florida:
52
53 Section 1. Paragraph (d) of subsection (1) of section
54 408.040, Florida Statutes, is amended to read:
55 408.040 Conditions and monitoring.—
56 (1)
57 (d) If a nursing home is located in a county in which a
58 long-term care community diversion pilot project has been
59 implemented under s. 430.705 or in a county in which an
60 integrated, fixed-payment delivery program for Medicaid
61 recipients who are 60 years of age or older or dually eligible
62 for Medicare and Medicaid has been implemented under s.
63 409.912(5), the nursing home may request a reduction in the
64 percentage of annual patient days used by residents who are
65 eligible for care under Title XIX of the Social Security Act,
66 which is a condition of the nursing home’s certificate of need.
67 The agency shall automatically grant the nursing home’s request
68 if the reduction is not more than 15 percent of the nursing
69 home’s annual Medicaid-patient-days condition. A nursing home
70 may submit only one request every 2 years for an automatic
71 reduction. A requesting nursing home must notify the agency in
72 writing at least 60 days in advance of its intent to reduce its
73 annual Medicaid-patient-days condition by not more than 15
74 percent. The agency must acknowledge the request in writing and
75 must change its records to reflect the revised certificate-of
76 need condition. This paragraph expires June 30, 2011.
77 Section 2. Paragraph (c) is added to subsection (8) of
78 section 409.814, Florida Statutes, to read:
79 409.814 Eligibility.—A child who has not reached 19 years
80 of age whose family income is equal to or below 200 percent of
81 the federal poverty level is eligible for the Florida Kidcare
82 program as provided in this section. For enrollment in the
83 Children’s Medical Services Network, a complete application
84 includes the medical or behavioral health screening. If,
85 subsequently, an individual is determined to be ineligible for
86 coverage, he or she must immediately be disenrolled from the
87 respective Florida Kidcare program component.
88 (8) In determining the eligibility of a child, an assets
89 test is not required. Each applicant shall provide written
90 documentation during the application process and the
91 redetermination process, including, but not limited to, the
92 following:
93 (c) Effective January 1, 2010, verification of the child’s
94 citizenship status as required under Title XXI of the Social
95 Security Act.
96 Section 3. Paragraphs (g) and (q) of section (2) of
97 section 409.815, Florida Statutes, are amended, and paragraph
98 (w) is added to that section, to read:
99 409.815 Health benefits coverage; limitations.—
100 (2) BENCHMARK BENEFITS.—In order for health benefits
101 coverage to qualify for premium assistance payments for an
102 eligible child under ss. 409.810-409.820, the health benefits
103 coverage, except for coverage under Medicaid and Medikids, must
104 include the following minimum benefits, as medically necessary.
105 (g) Behavioral health services.—
106 1. Mental health benefits include:
107 a. Inpatient services, limited to not more than 30
108 inpatient days per contract year for psychiatric admissions, or
109 residential services in facilities licensed under s. 394.875(6)
110 or s. 395.003 in lieu of inpatient psychiatric admissions;
111 however, a minimum of 10 of the 30 days shall be available only
112 for inpatient psychiatric services if when authorized by a
113 physician; and
114 b. Outpatient services, including outpatient visits for
115 psychological or psychiatric evaluation, diagnosis, and
116 treatment by a licensed mental health professional, limited to a
117 maximum of 40 outpatient visits each contract year.
118 2. Substance abuse services include:
119 a. Inpatient services, limited to not more than 7 inpatient
120 days per contract year for medical detoxification only and 30
121 days of residential services; and
122 b. Outpatient services, including evaluation, diagnosis,
123 and treatment by a licensed practitioner, limited to a maximum
124 of 40 outpatient visits per contract year.
125
126 Effective October 1, 2009, covered services include inpatient
127 and outpatient services for mental and nervous disorders as
128 defined in the most recent edition of the Diagnostic and
129 Statistical Manual of Mental Disorders published by the American
130 Psychiatric Association. Such benefits include psychological or
131 psychiatric evaluation, diagnosis, and treatment by a licensed
132 mental health professional, and inpatient, outpatient, and
133 residential treatment services for the diagnosis and treatment
134 of substance abuse disorders. Any benefit limitations, including
135 duration of services, number of visits, or number of days for
136 hospitalization or residential services may not be any less
137 favorable than those for physical illnesses generally for the
138 care and treatment of schizophrenia and psychotic disorders,
139 mood disorders, anxiety disorders, substance abuse disorders,
140 eating disorders, and childhood attention deficit disorders. The
141 program may also implement appropriate financial incentives,
142 peer review, utilization requirements, and other methods used
143 for the management of benefits provided for other medical
144 conditions in order to reduce service costs and utilization
145 without compromising quality of care.
146 (q) Dental services.—Effective October 1, 2009, dental
147 services shall be covered as required under federal law and may
148 also include those dental benefits provided to children by the
149 Florida Medicaid program under s. 409.906(6).
150 (w) Reimbursement of federally qualified health centers and
151 rural health clinics.—Effective October 1, 2009, payments for
152 services provided to enrollees by federally qualified health
153 centers and rural health clinics under this section shall be
154 reimbursed using the Medicaid Prospective Payment System as
155 provided for under s. 2107(e)(1)(D) of the Social Security Act,
156 as added by subsection (a). If such services are paid for by
157 health insurers or health care providers under contract with the
158 Florida Healthy Kids Corporation, such entities are responsible
159 for this payment. The agency may seek any available federal
160 grants to assist with this transition.
161 Section 4. Paragraph (c) of subsection (3) of section
162 409.818, Florida Statutes, is amended to read:
163 409.818 Administration.—In order to implement ss. 409.810
164 409.820, the following agencies shall have the following duties:
165 (3) The Agency for Health Care Administration, under the
166 authority granted in s. 409.914(1), shall:
167 (c) Monitor compliance with quality assurance and access
168 standards developed under s. 409.820 and in accordance with s.
169 2103(f) of the Social Security Act, 42 U.S.C. 1397bb(f).
170
171 The agency is designated the lead state agency for Title XXI of
172 the Social Security Act for purposes of receipt of federal
173 funds, for reporting purposes, and for ensuring compliance with
174 federal and state regulations and rules.
175 Section 5. Subsection (1) and paragraph (a) of subsection
176 (2) of section 409.904, Florida Statutes, are amended to read:
177 409.904 Optional payments for eligible persons.—The agency
178 may make payments for medical assistance and related services on
179 behalf of the following persons who are determined to be
180 eligible subject to the income, assets, and categorical
181 eligibility tests set forth in federal and state law. Payment on
182 behalf of these Medicaid eligible persons is subject to the
183 availability of moneys and any limitations established by the
184 General Appropriations Act or chapter 216.
185 (1) Effective January 1, 2006, and Subject to federal
186 waiver approval, a person who is age 65 or older or is
187 determined to be disabled, whose income is at or below 88
188 percent of the federal poverty level, whose assets do not exceed
189 established limitations, and who is not eligible for Medicare
190 or, if eligible for Medicare, is also eligible for and receiving
191 Medicaid-covered institutional care services, hospice services,
192 or home and community-based services. The agency shall seek
193 federal authorization through a waiver to provide this coverage.
194 This subsection expires December 31, 2010 June 30, 2009.
195 (2)(a) A family, a pregnant woman, a child under age 21, a
196 person age 65 or over, or a blind or disabled person, who would
197 be eligible under any group listed in s. 409.903(1), (2), or
198 (3), except that the income or assets of such family or person
199 exceed established limitations. For a family or person in one of
200 these coverage groups, medical expenses are deductible from
201 income in accordance with federal requirements in order to make
202 a determination of eligibility. A family or person eligible
203 under the coverage known as the “medically needy,” is eligible
204 to receive the same services as other Medicaid recipients, with
205 the exception of services in skilled nursing facilities and
206 intermediate care facilities for the developmentally disabled.
207 This subsection expires December 31, 2010 June 30, 2009.
208 Section 6. Subsection (4) of section 409.905, Florida
209 Statutes, is amended to read:
210 409.905 Mandatory Medicaid services.—The agency may make
211 payments for the following services, which are required of the
212 state by Title XIX of the Social Security Act, furnished by
213 Medicaid providers to recipients who are determined to be
214 eligible on the dates on which the services were provided. Any
215 service under this section shall be provided only when medically
216 necessary and in accordance with state and federal law.
217 Mandatory services rendered by providers in mobile units to
218 Medicaid recipients may be restricted by the agency. Nothing in
219 this section shall be construed to prevent or limit the agency
220 from adjusting fees, reimbursement rates, lengths of stay,
221 number of visits, number of services, or any other adjustments
222 necessary to comply with the availability of moneys and any
223 limitations or directions provided for in the General
224 Appropriations Act or chapter 216.
225 (4) HOME HEALTH CARE SERVICES.—The agency shall pay for
226 nursing and home health aide services, supplies, appliances, and
227 durable medical equipment, necessary to assist a recipient
228 living at home. An entity that provides services pursuant to
229 this subsection must shall be licensed under part III of chapter
230 400. These services, equipment, and supplies, or reimbursement
231 therefor, may be limited as provided in the General
232 Appropriations Act and do not include services, equipment, or
233 supplies provided to a person residing in a hospital or nursing
234 facility.
235 (a) In providing home health care services, the agency may
236 require prior authorization of care based on diagnosis or
237 utilization rates. Prior authorization is required for home
238 health services visits not associated with a skilled nursing
239 visit if the home health agency’s utilization rates exceed the
240 state average by 50 percent or more. The home health agency must
241 submit documentation that supports the recipient’s diagnosis and
242 the recipient’s plan of care to the agency when requesting prior
243 authorization.
244 (b) The agency shall implement a comprehensive utilization
245 management program that requires prior authorization of all
246 private duty nursing services, an individualized treatment plan
247 that includes information about medication and treatment orders,
248 treatment goals, methods of care to be used, and plans for care
249 coordination by nurses and other health professionals. The
250 utilization management program shall also include a process for
251 periodically reviewing the ongoing use of private duty nursing
252 services. For a child, the assessment of need shall be based on
253 a child’s condition, family support and care supplements, a
254 family’s ability to provide care, and a family’s and child’s
255 schedule regarding work, school, sleep, and care for other
256 family dependents. When implemented, the private duty nursing
257 utilization management program shall replace the current
258 authorization program used by the agency for Health Care
259 Administration and the Children’s Medical Services program of
260 the Department of Health. The agency may competitively bid on a
261 contract to select a qualified organization to provide
262 utilization management of private duty nursing services. The
263 agency is authorized to seek federal waivers to implement this
264 initiative.
265 (c) The agency may provide reimbursement for only those
266 home health services that are medically necessary and if:
267 1. The services are ordered by a physician.
268 2. The written prescription for services is signed and
269 dated by the recipient’s physician before the development of a
270 plan of care and before any required request for prior
271 authorization.
272 3. The physician ordering the services is not employed,
273 under contract with, or otherwise affiliated with the home
274 health agency rendering the services.
275 4. The physician ordering the services has examined the
276 recipient within 30 days before the initial request for services
277 and biannually thereafter.
278 5. The written prescription for the services includes the
279 recipient’s acute or chronic medical condition or diagnosis; the
280 home health service required, including the minimum skill level
281 required to perform the service; and the frequency and duration
282 of services.
283 6. The national provider identifier, Medicaid
284 identification number, or medical practitioner license number of
285 the physician ordering the services is listed on the written
286 prescription for the services, the claim for home health
287 reimbursement, and the prior authorization request.
288 Section 7. Subsection (23) of section 409.908, Florida
289 Statutes, is amended to read:
290 409.908 Reimbursement of Medicaid providers.—Subject to
291 specific appropriations, the agency shall reimburse Medicaid
292 providers, in accordance with state and federal law, according
293 to methodologies set forth in the rules of the agency and in
294 policy manuals and handbooks incorporated by reference therein.
295 These methodologies may include fee schedules, reimbursement
296 methods based on cost reporting, negotiated fees, competitive
297 bidding pursuant to s. 287.057, and other mechanisms the agency
298 considers efficient and effective for purchasing services or
299 goods on behalf of recipients. If a provider is reimbursed based
300 on cost reporting and submits a cost report late and that cost
301 report would have been used to set a lower reimbursement rate
302 for a rate semester, then the provider’s rate for that semester
303 shall be retroactively calculated using the new cost report, and
304 full payment at the recalculated rate shall be effected
305 retroactively. Medicare-granted extensions for filing cost
306 reports, if applicable, shall also apply to Medicaid cost
307 reports. Payment for Medicaid compensable services made on
308 behalf of Medicaid eligible persons is subject to the
309 availability of moneys and any limitations or directions
310 provided for in the General Appropriations Act or chapter 216.
311 Further, nothing in this section shall be construed to prevent
312 or limit the agency from adjusting fees, reimbursement rates,
313 lengths of stay, number of visits, or number of services, or
314 making any other adjustments necessary to comply with the
315 availability of moneys and any limitations or directions
316 provided for in the General Appropriations Act, provided the
317 adjustment is consistent with legislative intent.
318 (23)(a) The agency shall establish rates at a level that
319 ensures no increase in statewide expenditures resulting from a
320 change in unit costs for 2 fiscal years effective July 1, 2009.
321 Reimbursement rates for the 2 fiscal years shall be as provided
322 in the General Appropriations Act.
323 (a)(b) This subsection applies to The following provider
324 types may not receive an increase in reimbursement rate due to a
325 change in unit cost unless specifically appropriated in the
326 General Appropriations Act:
327 1. Inpatient hospitals.
328 2. Outpatient hospitals.
329 3. Nursing homes.
330 4. County health departments.
331 5. Community intermediate care facilities for the
332 developmentally disabled.
333 6. Prepaid health plans.
334 7. Nursing home diversion programs.
335
336 The agency shall apply the effect of this subsection to the
337 reimbursement rates for nursing home diversion programs.
338 (b)(c) The agency shall create a workgroup on hospital
339 reimbursement, a workgroup on nursing facility reimbursement,
340 and a workgroup on managed care plan payment. The workgroups
341 shall evaluate alternative reimbursement and payment
342 methodologies for hospitals, nursing facilities, and managed
343 care plans, including prospective payment methodologies for
344 hospitals and nursing facilities. The nursing facility workgroup
345 shall also consider price-based methodologies for indirect care
346 and acuity adjustments for direct care. The agency shall submit
347 a report on the evaluated alternative reimbursement
348 methodologies to the relevant committees of the Senate and the
349 House of Representatives by November 1, 2009.
350 (c)(d) This subsection expires June 30, 2011.
351 Section 8. Subsection (6) of section 409.9082, Florida
352 Statutes, is amended to read:
353 409.9082 Quality assessment on nursing home facility
354 providers; exemptions; purpose; federal approval required;
355 remedies.—
356 (6) The quality assessment shall terminate and the agency
357 shall discontinue the imposition, assessment, and collection of
358 the nursing facility quality assessment if any of the following
359 occur:
360 (a) the agency does not obtain necessary federal approval
361 for the nursing home facility quality assessment or the payment
362 rates required by subsection (4); or
363 (b) The weighted average Medicaid rate paid to nursing home
364 facilities is reduced below the weighted average Medicaid rate
365 to nursing home facilities in effect on December 31, 2008, plus
366 any future annual amount of the quality assessment and the
367 applicable matching federal funds. Upon termination of the
368 quality assessment, all collected assessment revenues, less any
369 amounts expended by the agency, shall be returned on a pro rata
370 basis to the nursing facilities that paid them.
371 Section 9. Paragraph (a) of subsection (2) of section
372 409.911, Florida Statutes, is amended to read:
373 409.911 Disproportionate share program.—Subject to specific
374 allocations established within the General Appropriations Act
375 and any limitations established pursuant to chapter 216, the
376 agency shall distribute, pursuant to this section, moneys to
377 hospitals providing a disproportionate share of Medicaid or
378 charity care services by making quarterly Medicaid payments as
379 required. Notwithstanding the provisions of s. 409.915, counties
380 are exempt from contributing toward the cost of this special
381 reimbursement for hospitals serving a disproportionate share of
382 low-income patients.
383 (2) The agency for Health Care Administration shall use the
384 following actual audited data to determine the Medicaid days and
385 charity care to be used in calculating the disproportionate
386 share payment:
387 (a) The average of the 2002, 2003, and 2004, and 2005
388 audited disproportionate share data to determine each hospital’s
389 Medicaid days and charity care for the 2009-2010 2008-2009 state
390 fiscal year.
391 Section 10. Section 409.9112, Florida Statutes, is amended
392 to read:
393 409.9112 Disproportionate share program for regional
394 perinatal intensive care centers.—In addition to the payments
395 made under s. 409.911, the agency for Health Care Administration
396 shall design and implement a system for of making
397 disproportionate share payments to those hospitals that
398 participate in the regional perinatal intensive care center
399 program established pursuant to chapter 383. The This system of
400 payments must shall conform to with federal requirements and
401 shall distribute funds in each fiscal year for which an
402 appropriation is made by making quarterly Medicaid payments.
403 Notwithstanding the provisions of s. 409.915, counties are
404 exempt from contributing toward the cost of this special
405 reimbursement for hospitals serving a disproportionate share of
406 low-income patients. For the 2009-2010 state fiscal year 2008
407 2009, the agency may shall not distribute moneys under the
408 regional perinatal intensive care centers disproportionate share
409 program.
410 (1) The following formula shall be used by the agency to
411 calculate the total amount earned for hospitals that participate
412 in the regional perinatal intensive care center program:
413 TAE = HDSP/THDSP
414
415 Where:
416 TAE = total amount earned by a regional perinatal intensive
417 care center.
418 HDSP = the prior state fiscal year regional perinatal
419 intensive care center disproportionate share payment to the
420 individual hospital.
421 THDSP = the prior state fiscal year total regional
422 perinatal intensive care center disproportionate share payments
423 to all hospitals.
424 (2) The total additional payment for hospitals that
425 participate in the regional perinatal intensive care center
426 program shall be calculated by the agency as follows:
427 TAP = TAE x TA
428
429 Where:
430 TAP = total additional payment for a regional perinatal
431 intensive care center.
432 TAE = total amount earned by a regional perinatal intensive
433 care center.
434 TA = total appropriation for the regional perinatal
435 intensive care center disproportionate share program.
436 (3) In order to receive payments under this section, a
437 hospital must be participating in the regional perinatal
438 intensive care center program pursuant to chapter 383 and must
439 meet the following additional requirements:
440 (a) Agree to conform to all departmental and agency
441 requirements to ensure high quality in the provision of
442 services, including criteria adopted by departmental and agency
443 rule concerning staffing ratios, medical records, standards of
444 care, equipment, space, and such other standards and criteria as
445 the department and agency deem appropriate as specified by rule.
446 (b) Agree to provide information to the department and
447 agency, in a form and manner to be prescribed by rule of the
448 department and agency, concerning the care provided to all
449 patients in neonatal intensive care centers and high-risk
450 maternity care.
451 (c) Agree to accept all patients for neonatal intensive
452 care and high-risk maternity care, regardless of ability to pay,
453 on a functional space-available basis.
454 (d) Agree to develop arrangements with other maternity and
455 neonatal care providers in the hospital’s region for the
456 appropriate receipt and transfer of patients in need of
457 specialized maternity and neonatal intensive care services.
458 (e) Agree to establish and provide a developmental
459 evaluation and services program for certain high-risk neonates,
460 as prescribed and defined by rule of the department.
461 (f) Agree to sponsor a program of continuing education in
462 perinatal care for health care professionals within the region
463 of the hospital, as specified by rule.
464 (g) Agree to provide backup and referral services to the
465 department’s county health departments and other low-income
466 perinatal providers within the hospital’s region, including the
467 development of written agreements between these organizations
468 and the hospital.
469 (h) Agree to arrange for transportation for high-risk
470 obstetrical patients and neonates in need of transfer from the
471 community to the hospital or from the hospital to another more
472 appropriate facility.
473 (4) Hospitals which fail to comply with any of the
474 conditions in subsection (3) or the applicable rules of the
475 department and agency may shall not receive any payments under
476 this section until full compliance is achieved. A hospital which
477 is not in compliance in two or more consecutive quarters may
478 shall not receive its share of the funds. Any forfeited funds
479 shall be distributed by the remaining participating regional
480 perinatal intensive care center program hospitals.
481 Section 11. Section 409.9113, Florida Statutes, is amended
482 to read:
483 409.9113 Disproportionate share program for teaching
484 hospitals.—In addition to the payments made under ss. 409.911
485 and 409.9112, the agency for Health Care Administration shall
486 make disproportionate share payments to statutorily defined
487 teaching hospitals for their increased costs associated with
488 medical education programs and for tertiary health care services
489 provided to the indigent. This system of payments must shall
490 conform to with federal requirements and shall distribute funds
491 in each fiscal year for which an appropriation is made by making
492 quarterly Medicaid payments. Notwithstanding s. 409.915,
493 counties are exempt from contributing toward the cost of this
494 special reimbursement for hospitals serving a disproportionate
495 share of low-income patients. For the 2009-2010 state fiscal
496 year 2008-2009, the agency shall distribute the moneys provided
497 in the General Appropriations Act to statutorily defined
498 teaching hospitals and family practice teaching hospitals under
499 the teaching hospital disproportionate share program. The funds
500 provided for statutorily defined teaching hospitals shall be
501 distributed in the same proportion as the state fiscal year
502 2003-2004 teaching hospital disproportionate share funds were
503 distributed or as otherwise provided in the General
504 Appropriations Act. The funds provided for family practice
505 teaching hospitals shall be distributed equally among family
506 practice teaching hospitals.
507 (1) On or before September 15 of each year, the agency for
508 Health Care Administration shall calculate an allocation
509 fraction to be used for distributing funds to state statutory
510 teaching hospitals. Subsequent to the end of each quarter of the
511 state fiscal year, the agency shall distribute to each statutory
512 teaching hospital, as defined in s. 408.07, an amount determined
513 by multiplying one-fourth of the funds appropriated for this
514 purpose by the Legislature times such hospital’s allocation
515 fraction. The allocation fraction for each such hospital shall
516 be determined by the sum of the following three primary factors,
517 divided by three. The primary factors are:
518 (a) The number of nationally accredited graduate medical
519 education programs offered by the hospital, including programs
520 accredited by the Accreditation Council for Graduate Medical
521 Education and the combined Internal Medicine and Pediatrics
522 programs acceptable to both the American Board of Internal
523 Medicine and the American Board of Pediatrics at the beginning
524 of the state fiscal year preceding the date on which the
525 allocation fraction is calculated. The numerical value of this
526 factor is the fraction that the hospital represents of the total
527 number of programs, where the total is computed for all state
528 statutory teaching hospitals.
529 (b) The number of full-time equivalent trainees in the
530 hospital, which comprises two components:
531 1. The number of trainees enrolled in nationally accredited
532 graduate medical education programs, as defined in paragraph
533 (a). Full-time equivalents are computed using the fraction of
534 the year during which each trainee is primarily assigned to the
535 given institution, over the state fiscal year preceding the date
536 on which the allocation fraction is calculated. The numerical
537 value of this factor is the fraction that the hospital
538 represents of the total number of full-time equivalent trainees
539 enrolled in accredited graduate programs, where the total is
540 computed for all state statutory teaching hospitals.
541 2. The number of medical students enrolled in accredited
542 colleges of medicine and engaged in clinical activities,
543 including required clinical clerkships and clinical electives.
544 Full-time equivalents are computed using the fraction of the
545 year during which each trainee is primarily assigned to the
546 given institution, over the course of the state fiscal year
547 preceding the date on which the allocation fraction is
548 calculated. The numerical value of this factor is the fraction
549 that the given hospital represents of the total number of full
550 time equivalent students enrolled in accredited colleges of
551 medicine, where the total is computed for all state statutory
552 teaching hospitals.
553
554 The primary factor for full-time equivalent trainees is computed
555 as the sum of these two components, divided by two.
556 (c) A service index that comprises three components:
557 1. The Agency for Health Care Administration Service Index,
558 computed by applying the standard Service Inventory Scores
559 established by the agency for Health Care Administration to
560 services offered by the given hospital, as reported on Worksheet
561 A-2 for the last fiscal year reported to the agency before the
562 date on which the allocation fraction is calculated. The
563 numerical value of this factor is the fraction that the given
564 hospital represents of the total Agency for Health Care
565 Administration Service Index values, where the total is computed
566 for all state statutory teaching hospitals.
567 2. A volume-weighted service index, computed by applying
568 the standard Service Inventory Scores established by the Agency
569 for Health Care Administration to the volume of each service,
570 expressed in terms of the standard units of measure reported on
571 Worksheet A-2 for the last fiscal year reported to the agency
572 before the date on which the allocation factor is calculated.
573 The numerical value of this factor is the fraction that the
574 given hospital represents of the total volume-weighted service
575 index values, where the total is computed for all state
576 statutory teaching hospitals.
577 3. Total Medicaid payments to each hospital for direct
578 inpatient and outpatient services during the fiscal year
579 preceding the date on which the allocation factor is calculated.
580 This includes payments made to each hospital for such services
581 by Medicaid prepaid health plans, whether the plan was
582 administered by the hospital or not. The numerical value of this
583 factor is the fraction that each hospital represents of the
584 total of such Medicaid payments, where the total is computed for
585 all state statutory teaching hospitals.
586
587 The primary factor for the service index is computed as the sum
588 of these three components, divided by three.
589 (2) By October 1 of each year, the agency shall use the
590 following formula to calculate the maximum additional
591 disproportionate share payment for statutorily defined teaching
592 hospitals:
593 TAP = THAF x A
594
595 Where:
596 TAP = total additional payment.
597 THAF = teaching hospital allocation factor.
598 A = amount appropriated for a teaching hospital
599 disproportionate share program.
600 Section 12. Section 409.9117, Florida Statutes, is amended
601 to read:
602 409.9117 Primary care disproportionate share program.—For
603 the 2009-2010 state fiscal year 2008-2009, the agency shall not
604 distribute moneys under the primary care disproportionate share
605 program.
606 (1) If federal funds are available for disproportionate
607 share programs in addition to those otherwise provided by law,
608 there shall be created a primary care disproportionate share
609 program.
610 (2) The following formula shall be used by the agency to
611 calculate the total amount earned for hospitals that participate
612 in the primary care disproportionate share program:
613 TAE = HDSP/THDSP
614
615 Where:
616 TAE = total amount earned by a hospital participating in
617 the primary care disproportionate share program.
618 HDSP = the prior state fiscal year primary care
619 disproportionate share payment to the individual hospital.
620 THDSP = the prior state fiscal year total primary care
621 disproportionate share payments to all hospitals.
622 (3) The total additional payment for hospitals that
623 participate in the primary care disproportionate share program
624 shall be calculated by the agency as follows:
625 TAP = TAE x TA
626
627 Where:
628 TAP = total additional payment for a primary care hospital.
629 TAE = total amount earned by a primary care hospital.
630 TA = total appropriation for the primary care
631 disproportionate share program.
632 (4) In the establishment and funding of this program, the
633 agency shall use the following criteria in addition to those
634 specified in s. 409.911, and payments may not be made to a
635 hospital unless the hospital agrees to:
636 (a) Cooperate with a Medicaid prepaid health plan, if one
637 exists in the community.
638 (b) Ensure the availability of primary and specialty care
639 physicians to Medicaid recipients who are not enrolled in a
640 prepaid capitated arrangement and who are in need of access to
641 such physicians.
642 (c) Coordinate and provide primary care services free of
643 charge, except copayments, to all persons with incomes up to 100
644 percent of the federal poverty level who are not otherwise
645 covered by Medicaid or another program administered by a
646 governmental entity, and to provide such services based on a
647 sliding fee scale to all persons with incomes up to 200 percent
648 of the federal poverty level who are not otherwise covered by
649 Medicaid or another program administered by a governmental
650 entity, except that eligibility may be limited to persons who
651 reside within a more limited area, as agreed to by the agency
652 and the hospital.
653 (d) Contract with any federally qualified health center, if
654 one exists within the agreed geopolitical boundaries, concerning
655 the provision of primary care services, in order to guarantee
656 delivery of services in a nonduplicative fashion, and to provide
657 for referral arrangements, privileges, and admissions, as
658 appropriate. The hospital shall agree to provide at an onsite or
659 offsite facility primary care services within 24 hours to which
660 all Medicaid recipients and persons eligible under this
661 paragraph who do not require emergency room services are
662 referred during normal daylight hours.
663 (e) Cooperate with the agency, the county, and other
664 entities to ensure the provision of certain public health
665 services, case management, referral and acceptance of patients,
666 and sharing of epidemiological data, as the agency and the
667 hospital find mutually necessary and desirable to promote and
668 protect the public health within the agreed geopolitical
669 boundaries.
670 (f) In cooperation with the county in which the hospital
671 resides, develop a low-cost, outpatient, prepaid health care
672 program to persons who are not eligible for the Medicaid
673 program, and who reside within the area.
674 (g) Provide inpatient services to residents within the area
675 who are not eligible for Medicaid or Medicare, and who do not
676 have private health insurance, regardless of ability to pay, on
677 the basis of available space, except that hospitals may not be
678 prevented nothing shall prevent the hospital from establishing
679 bill collection programs based on ability to pay.
680 (h) Work with the Florida Healthy Kids Corporation, the
681 Florida Health Care Purchasing Cooperative, and business health
682 coalitions, as appropriate, to develop a feasibility study and
683 plan to provide a low-cost comprehensive health insurance plan
684 to persons who reside within the area and who do not have access
685 to such a plan.
686 (i) Work with public health officials and other experts to
687 provide community health education and prevention activities
688 designed to promote healthy lifestyles and appropriate use of
689 health services.
690 (j) Work with the local health council to develop a plan
691 for promoting access to affordable health care services for all
692 persons who reside within the area, including, but not limited
693 to, public health services, primary care services, inpatient
694 services, and affordable health insurance generally.
695
696 Any hospital that fails to comply with any of the provisions of
697 this subsection, or any other contractual condition, may not
698 receive payments under this section until full compliance is
699 achieved.
700 Section 13. Subsection (4) of section 409.91195, Florida
701 Statutes, is amended to read:
702 409.91195 Medicaid Pharmaceutical and Therapeutics
703 Committee.—There is created a Medicaid Pharmaceutical and
704 Therapeutics Committee within the agency for the purpose of
705 developing a Medicaid preferred drug list.
706 (4) Upon recommendation of the committee, the agency shall
707 adopt a preferred drug list as described in s. 409.912(38) s.
708 409.912(39). If To the extent feasible, the committee shall
709 review all drug classes included on the preferred drug list
710 every 12 months, and may recommend additions to and deletions
711 from the preferred drug list, such that the preferred drug list
712 provides for medically appropriate drug therapies for Medicaid
713 patients which achieve cost savings contained in the General
714 Appropriations Act.
715 Section 14. Subsection (1) of section 409.91196, Florida
716 Statutes, is amended to read:
717 409.91196 Supplemental rebate agreements; public records
718 and public meetings exemption.—
719 (1) The rebate amount, percent of rebate, manufacturer’s
720 pricing, and supplemental rebate, and other trade secrets as
721 defined in s. 688.002 that the agency has identified for use in
722 negotiations, held by the agency for Health Care Administration
723 under s. 409.912(38)(a)7. s. 409.912(39)(a)7. are confidential
724 and exempt from s. 119.07(1) and s. 24(a), Art. I of the State
725 Constitution.
726 Section 15. Present subsections (6) through (53) of section
727 409.912, Florida Statutes, are redesignated as subsections (5)
728 through (52), respectively, and present subsections (5), (21),
729 and (29) of that section, are amended to read:
730 409.912 Cost-effective purchasing of health care.—The
731 agency shall purchase goods and services for Medicaid recipients
732 in the most cost-effective manner consistent with the delivery
733 of quality medical care. To ensure that medical services are
734 effectively utilized, the agency may, in any case, require a
735 confirmation or second physician’s opinion of the correct
736 diagnosis for purposes of authorizing future services under the
737 Medicaid program. This section does not restrict access to
738 emergency services or poststabilization care services as defined
739 in 42 C.F.R. part 438.114. Such confirmation or second opinion
740 shall be rendered in a manner approved by the agency. The agency
741 shall maximize the use of prepaid per capita and prepaid
742 aggregate fixed-sum basis services when appropriate and other
743 alternative service delivery and reimbursement methodologies,
744 including competitive bidding pursuant to s. 287.057, designed
745 to facilitate the cost-effective purchase of a case-managed
746 continuum of care. The agency shall also require providers to
747 minimize the exposure of recipients to the need for acute
748 inpatient, custodial, and other institutional care and the
749 inappropriate or unnecessary use of high-cost services. The
750 agency shall contract with a vendor to monitor and evaluate the
751 clinical practice patterns of providers in order to identify
752 trends that are outside the normal practice patterns of a
753 provider’s professional peers or the national guidelines of a
754 provider’s professional association. The vendor must be able to
755 provide information and counseling to a provider whose practice
756 patterns are outside the norms, in consultation with the agency,
757 to improve patient care and reduce inappropriate utilization.
758 The agency may mandate prior authorization, drug therapy
759 management, or disease management participation for certain
760 populations of Medicaid beneficiaries, certain drug classes, or
761 particular drugs to prevent fraud, abuse, overuse, and possible
762 dangerous drug interactions. The Pharmaceutical and Therapeutics
763 Committee shall make recommendations to the agency on drugs for
764 which prior authorization is required. The agency shall inform
765 the Pharmaceutical and Therapeutics Committee of its decisions
766 regarding drugs subject to prior authorization. The agency is
767 authorized to limit the entities it contracts with or enrolls as
768 Medicaid providers by developing a provider network through
769 provider credentialing. The agency may competitively bid single
770 source-provider contracts if procurement of goods or services
771 results in demonstrated cost savings to the state without
772 limiting access to care. The agency may limit its network based
773 on the assessment of beneficiary access to care, provider
774 availability, provider quality standards, time and distance
775 standards for access to care, the cultural competence of the
776 provider network, demographic characteristics of Medicaid
777 beneficiaries, practice and provider-to-beneficiary standards,
778 appointment wait times, beneficiary use of services, provider
779 turnover, provider profiling, provider licensure history,
780 previous program integrity investigations and findings, peer
781 review, provider Medicaid policy and billing compliance records,
782 clinical and medical record audits, and other factors. Providers
783 shall not be entitled to enrollment in the Medicaid provider
784 network. The agency shall determine instances in which allowing
785 Medicaid beneficiaries to purchase durable medical equipment and
786 other goods is less expensive to the Medicaid program than long
787 term rental of the equipment or goods. The agency may establish
788 rules to facilitate purchases in lieu of long-term rentals in
789 order to protect against fraud and abuse in the Medicaid program
790 as defined in s. 409.913. The agency may seek federal waivers
791 necessary to administer these policies.
792 (5) The Agency for Health Care Administration, in
793 partnership with the Department of Elderly Affairs, shall create
794 an integrated, fixed-payment delivery program for Medicaid
795 recipients who are 60 years of age or older or dually eligible
796 for Medicare and Medicaid. The Agency for Health Care
797 Administration shall implement the integrated program initially
798 on a pilot basis in two areas of the state. The pilot areas
799 shall be Area 7 and Area 11 of the Agency for Health Care
800 Administration. Enrollment in the pilot areas shall be on a
801 voluntary basis and in accordance with approved federal waivers
802 and this section. The agency and its program contractors and
803 providers shall not enroll any individual in the integrated
804 program because the individual or the person legally responsible
805 for the individual fails to choose to enroll in the integrated
806 program. Enrollment in the integrated program shall be
807 exclusively by affirmative choice of the eligible individual or
808 by the person legally responsible for the individual. The
809 integrated program must transfer all Medicaid services for
810 eligible elderly individuals who choose to participate into an
811 integrated-care management model designed to serve Medicaid
812 recipients in the community. The integrated program must combine
813 all funding for Medicaid services provided to individuals who
814 are 60 years of age or older or dually eligible for Medicare and
815 Medicaid into the integrated program, including funds for
816 Medicaid home and community-based waiver services; all Medicaid
817 services authorized in ss. 409.905 and 409.906, excluding funds
818 for Medicaid nursing home services unless the agency is able to
819 demonstrate how the integration of the funds will improve
820 coordinated care for these services in a less costly manner; and
821 Medicare coinsurance and deductibles for persons dually eligible
822 for Medicaid and Medicare as prescribed in s. 409.908(13).
823 (a) Individuals who are 60 years of age or older or dually
824 eligible for Medicare and Medicaid and enrolled in the
825 developmental disabilities waiver program, the family and
826 supported-living waiver program, the project AIDS care waiver
827 program, the traumatic brain injury and spinal cord injury
828 waiver program, the consumer-directed care waiver program, and
829 the program of all-inclusive care for the elderly program, and
830 residents of institutional care facilities for the
831 developmentally disabled, must be excluded from the integrated
832 program.
833 (b) Managed care entities who meet or exceed the agency’s
834 minimum standards are eligible to operate the integrated
835 program. Entities eligible to participate include managed care
836 organizations licensed under chapter 641, including entities
837 eligible to participate in the nursing home diversion program,
838 other qualified providers as defined in s. 430.703(7), community
839 care for the elderly lead agencies, and other state-certified
840 community service networks that meet comparable standards as
841 defined by the agency, in consultation with the Department of
842 Elderly Affairs and the Office of Insurance Regulation, to be
843 financially solvent and able to take on financial risk for
844 managed care. Community service networks that are certified
845 pursuant to the comparable standards defined by the agency are
846 not required to be licensed under chapter 641. Managed care
847 entities who operate the integrated program shall be subject to
848 s. 408.7056. Eligible entities shall choose to serve enrollees
849 who are dually eligible for Medicare and Medicaid, enrollees who
850 are 60 years of age or older, or both.
851 (c) The agency must ensure that the capitation-rate-setting
852 methodology for the integrated program is actuarially sound and
853 reflects the intent to provide quality care in the least
854 restrictive setting. The agency must also require integrated
855 program providers to develop a credentialing system for service
856 providers and to contract with all Gold Seal nursing homes,
857 where feasible, and exclude, where feasible, chronically poor
858 performing facilities and providers as defined by the agency.
859 The integrated program must develop and maintain an informal
860 provider grievance system that addresses provider payment and
861 contract problems. The agency shall also establish a formal
862 grievance system to address those issues that were not resolved
863 through the informal grievance system. The integrated program
864 must provide that if the recipient resides in a noncontracted
865 residential facility licensed under chapter 400 or chapter 429
866 at the time of enrollment in the integrated program, the
867 recipient must be permitted to continue to reside in the
868 noncontracted facility as long as the recipient desires. The
869 integrated program must also provide that, in the absence of a
870 contract between the integrated-program provider and the
871 residential facility licensed under chapter 400 or chapter 429,
872 current Medicaid rates must prevail. The integrated-program
873 provider must ensure that electronic nursing home claims that
874 contain sufficient information for processing are paid within 10
875 business days after receipt. Alternately, the integrated-program
876 provider may establish a capitated payment mechanism to
877 prospectively pay nursing homes at the beginning of each month.
878 The agency and the Department of Elderly Affairs must jointly
879 develop procedures to manage the services provided through the
880 integrated program in order to ensure quality and recipient
881 choice.
882 (d) The Office of Program Policy Analysis and Government
883 Accountability, in consultation with the Auditor General, shall
884 comprehensively evaluate the pilot project for the integrated,
885 fixed-payment delivery program for Medicaid recipients created
886 under this subsection. The evaluation shall begin as soon as
887 Medicaid recipients are enrolled in the managed care pilot
888 program plans and shall continue for 24 months thereafter. The
889 evaluation must include assessments of each managed care plan in
890 the integrated program with regard to cost savings; consumer
891 education, choice, and access to services; coordination of care;
892 and quality of care. The evaluation must describe administrative
893 or legal barriers to the implementation and operation of the
894 pilot program and include recommendations regarding statewide
895 expansion of the pilot program. The office shall submit its
896 evaluation report to the Governor, the President of the Senate,
897 and the Speaker of the House of Representatives no later than
898 December 31, 2009.
899 (e) The agency may seek federal waivers or Medicaid state
900 plan amendments and adopt rules as necessary to administer the
901 integrated program. The agency may implement the approved
902 federal waivers and other provisions as specified in this
903 subsection.
904 (f) No later than December 31, 2007, the agency shall
905 provide a report to the Governor, the President of the Senate,
906 and the Speaker of the House of Representatives containing an
907 analysis of the merits and challenges of seeking a waiver to
908 implement a voluntary program that integrates payments and
909 services for dually enrolled Medicare and Medicaid recipients
910 who are 65 years of age or older.
911 (20)(21) Any entity contracting with the agency pursuant to
912 this section to provide health care services to Medicaid
913 recipients is prohibited from engaging in any of the following
914 practices or activities:
915 (c) Granting or offering of any monetary or other valuable
916 consideration for enrollment, except as authorized by subsection
917 (23) (24).
918 (28)(29) The agency shall perform enrollments and
919 disenrollments for Medicaid recipients who are eligible for
920 MediPass or managed care plans. Notwithstanding the prohibition
921 contained in paragraph (20)(f) (21)(f), managed care plans may
922 perform preenrollments of Medicaid recipients under the
923 supervision of the agency or its agents. For the purposes of
924 this section, “preenrollment” means the provision of marketing
925 and educational materials to a Medicaid recipient and assistance
926 in completing the application forms, but does shall not include
927 actual enrollment into a managed care plan. An application for
928 enrollment is shall not be deemed complete until the agency or
929 its agent verifies that the recipient made an informed,
930 voluntary choice. The agency, in cooperation with the Department
931 of Children and Family Services, may test new marketing
932 initiatives to inform Medicaid recipients about their managed
933 care options at selected sites. The agency shall report to the
934 Legislature on the effectiveness of such initiatives. The agency
935 may contract with a third party to perform managed care plan and
936 MediPass enrollment and disenrollment services for Medicaid
937 recipients and may is authorized to adopt rules to implement
938 such services. The agency may adjust the capitation rate only to
939 cover the costs of a third-party enrollment and disenrollment
940 contract, and for agency supervision and management of the
941 managed care plan enrollment and disenrollment contract.
942 Section 16. Paragraphs (e), (l), (p), and (w) of subsection
943 (3) and subsection (12) of section 409.91211, Florida Statutes,
944 are amended to read:
945 409.91211 Medicaid managed care pilot program.—
946 (3) The agency shall have the following powers, duties, and
947 responsibilities with respect to the pilot program:
948 (e) To implement policies and guidelines for phasing in
949 financial risk for approved provider service networks over a 5-
950 year 3-year period. These policies and guidelines must include
951 an option for a provider service network to be paid fee-for
952 service rates. For any provider service network established in a
953 managed care pilot area, the option to be paid fee-for-service
954 rates must shall include a savings-settlement mechanism that is
955 consistent with s. 409.912(44). This model must shall be
956 converted to a risk-adjusted capitated rate by no later than the
957 beginning of the sixth fourth year of operation, and may be
958 converted earlier at the option of the provider service network.
959 Federally qualified health centers may be offered an opportunity
960 to accept or decline a contract to participate in any provider
961 network for prepaid primary care services.
962 (l) To implement a system that prohibits capitated managed
963 care plans, their representatives, and providers employed by or
964 contracted with the capitated managed care plans from recruiting
965 persons eligible for or enrolled in Medicaid, from providing
966 inducements to Medicaid recipients to select a particular
967 capitated managed care plan, and from prejudicing Medicaid
968 recipients against other capitated managed care plans. The
969 system must shall require the entity performing choice
970 counseling to determine if the recipient has made a choice of a
971 plan or has opted out because of duress, threats, payment to the
972 recipient, or incentives promised to the recipient by a third
973 party. If the choice counseling entity determines that the
974 decision to choose a plan was unlawfully influenced or a plan
975 violated any of the provisions of s. 409.912(20) s. 409.912(21),
976 the choice counseling entity shall immediately report the
977 violation to the agency’s program integrity section for
978 investigation. Verification of choice counseling by the
979 recipient must shall include a stipulation that the recipient
980 acknowledges the provisions of this subsection.
981 (p) To implement standards for plan compliance, including,
982 but not limited to, standards for quality assurance and
983 performance improvement, standards for peer or professional
984 reviews, grievance policies, and policies for maintaining
985 program integrity. The agency shall develop a data-reporting
986 system, seek input from managed care plans in order to establish
987 requirements for patient-encounter reporting, and ensure that
988 the data reported is accurate and complete.
989 1. In performing the duties required under this section,
990 the agency shall work with managed care plans to establish a
991 uniform system to measure and monitor outcomes for a recipient
992 of Medicaid services.
993 2. The system must shall use financial, clinical, and other
994 criteria based on pharmacy, medical services, and other data
995 that is related to the provision of Medicaid services,
996 including, but not limited to:
997 a. The Health Plan Employer Data and Information Set
998 (HEDIS) or measures that are similar to HEDIS.
999 b. Member satisfaction.
1000 c. Provider satisfaction.
1001 d. Report cards on plan performance and best practices.
1002 e. Compliance with the requirements for prompt payment of
1003 claims under ss. 627.613, 641.3155, and 641.513.
1004 f. Utilization and quality data for the purpose of ensuring
1005 access to medically necessary services, including
1006 underutilization or inappropriate denial of services.
1007 3. The agency shall require the managed care plans that
1008 have contracted with the agency to establish a quality assurance
1009 system that incorporates the provisions of s. 409.912(26) s.
1010 409.912(27) and any standards, rules, and guidelines developed
1011 by the agency.
1012 4. The agency shall establish an encounter database in
1013 order to compile data on health services rendered by health care
1014 practitioners who provide services to patients enrolled in
1015 managed care plans in the demonstration sites. The encounter
1016 database shall:
1017 a. Collect the following for each type of patient encounter
1018 with a health care practitioner or facility, including:
1019 (I) The demographic characteristics of the patient.
1020 (II) The principal, secondary, and tertiary diagnosis.
1021 (III) The procedure performed.
1022 (IV) The date and location where the procedure was
1023 performed.
1024 (V) The payment for the procedure, if any.
1025 (VI) If applicable, the health care practitioner’s
1026 universal identification number.
1027 (VII) If the health care practitioner rendering the service
1028 is a dependent practitioner, the modifiers appropriate to
1029 indicate that the service was delivered by the dependent
1030 practitioner.
1031 b. Collect appropriate information relating to prescription
1032 drugs for each type of patient encounter.
1033 c. Collect appropriate information related to health care
1034 costs and utilization from managed care plans participating in
1035 the demonstration sites.
1036 5. If To the extent practicable, when collecting the data
1037 the agency shall use a standardized claim form or electronic
1038 transfer system that is used by health care practitioners,
1039 facilities, and payors.
1040 6. Health care practitioners and facilities in the
1041 demonstration sites shall electronically submit, and managed
1042 care plans participating in the demonstration sites shall
1043 electronically receive, information concerning claims payments
1044 and any other information reasonably related to the encounter
1045 database using a standard format as required by the agency.
1046 7. The agency shall establish reasonable deadlines for
1047 phasing in the electronic transmittal of full encounter data.
1048 8. The system must ensure that the data reported is
1049 accurate and complete.
1050 (w) To implement procedures to minimize the risk of
1051 Medicaid fraud and abuse in all plans operating in the Medicaid
1052 managed care pilot program authorized in this section.
1053 1. The agency shall ensure that applicable provisions of
1054 this chapter and chapters 414, 626, 641, and 932 which relate to
1055 Medicaid fraud and abuse are applied and enforced at the
1056 demonstration project sites.
1057 2. Providers must have the certification, license, and
1058 credentials that are required by law and waiver requirements.
1059 3. The agency shall ensure that the plan is in compliance
1060 with s. 409.912(20) and (21) s. 409.912(21) and (22).
1061 4. The agency shall require that each plan establish
1062 functions and activities governing program integrity in order to
1063 reduce the incidence of fraud and abuse. Plans must report
1064 instances of fraud and abuse pursuant to chapter 641.
1065 5. The plan must shall have written administrative and
1066 management arrangements or procedures, including a mandatory
1067 compliance plan, which are designed to guard against fraud and
1068 abuse. The plan shall designate a compliance officer who has
1069 sufficient experience in health care.
1070 6.a. The agency shall require all managed care plan
1071 contractors in the pilot program to report all instances of
1072 suspected fraud and abuse. A failure to report instances of
1073 suspected fraud and abuse is a violation of law and subject to
1074 the penalties provided by law.
1075 b. An instance of fraud and abuse in the managed care plan,
1076 including, but not limited to, defrauding the state health care
1077 benefit program by misrepresentation of fact in reports, claims,
1078 certifications, enrollment claims, demographic statistics, or
1079 patient-encounter data; misrepresentation of the qualifications
1080 of persons rendering health care and ancillary services; bribery
1081 and false statements relating to the delivery of health care;
1082 unfair and deceptive marketing practices; and false claims
1083 actions in the provision of managed care, is a violation of law
1084 and subject to the penalties provided by law.
1085 c. The agency shall require that all contractors make all
1086 files and relevant billing and claims data accessible to state
1087 regulators and investigators and that all such data is linked
1088 into a unified system to ensure consistent reviews and
1089 investigations.
1090 (12) For purposes of this section, the term “capitated
1091 managed care plan” includes health insurers authorized under
1092 chapter 624, exclusive provider organizations authorized under
1093 chapter 627, health maintenance organizations authorized under
1094 chapter 641, the Children’s Medical Services Network under
1095 chapter 391, and provider service networks that elect to be paid
1096 fee-for-service for up to 5 3 years as authorized under this
1097 section.
1098 Section 17. Subsection (18) is added to section 430.04,
1099 Florida Statutes, to read:
1100 430.04 Duties and responsibilities of the Department of
1101 Elderly Affairs.—The Department of Elderly Affairs shall:
1102 (18) Administer all Medicaid waivers and programs relating
1103 to elders and their appropriations. The waivers include, but are
1104 not limited to:
1105 (a) The Alzheimer’s Dementia-Specific Medicaid Waiver as
1106 established in s. 430.502(7), (8), and (9).
1107 (b) The Assisted Living for the Frail Elderly Waiver.
1108 (c) The Aged and Disabled Adult Waiver.
1109 (d) The Adult Day Health Care Waiver.
1110 (e) The Consumer Directed Care Plus Program as defined in
1111 s. 409.221.
1112 (f) The Program for All-inclusive Care for the Elderly.
1113 (g) The Long-Term Care Community-Based Diversion Pilot
1114 Project as described in s. 430.705.
1115 (h) The Channeling Services Waiver for Frail Elders.
1116 Section 18. Subsection (4) of section 641.386, Florida
1117 Statutes, is amended to read:
1118 641.386 Agent licensing and appointment required;
1119 exceptions.—
1120 (4) All agents and health maintenance organizations must
1121 shall comply with and be subject to the applicable provisions of
1122 ss. 641.309 and 409.912(20) 409.912(21), and all companies and
1123 entities appointing agents must shall comply with s. 626.451,
1124 when marketing for any health maintenance organization licensed
1125 pursuant to this part, including those organizations under
1126 contract with the Agency for Health Care Administration to
1127 provide health care services to Medicaid recipients or any
1128 private entity providing health care services to Medicaid
1129 recipients pursuant to a prepaid health plan contract with the
1130 Agency for Health Care Administration.
1131 Section 19. The Agency for Health Care Administration shall
1132 develop and implement a home health agency monitoring pilot
1133 project in Miami-Dade County by January 1, 2010. The agency
1134 shall contract with a vendor to verify the utilization and the
1135 delivery of home health services and provide an electronic
1136 billing interface for such services. The contract must require
1137 the creation of a program to submit claims for the home health
1138 services electronically. The program must verify visits for the
1139 delivery of home health services telephonically using voice
1140 biometrics. The agency may seek amendments to the Medicaid state
1141 plan and waivers of federal laws, as necessary, to implement the
1142 pilot project. Notwithstanding s. 287.057(5)(f), Florida
1143 Statutes, the agency must award the contract through the
1144 competitive solicitation process. The agency shall submit a
1145 report to the Governor, the President of the Senate, and the
1146 Speaker of the House of Representatives evaluating the pilot
1147 project by February 1, 2011.
1148 Section 20. The Agency for Health Care Administration shall
1149 implement a comprehensive care management pilot project in
1150 Miami-Dade County for home health services by January 1, 2010,
1151 which includes face-to-face assessments by a state-licensed
1152 nurse, consultation with physicians ordering services to
1153 substantiate the medical necessity for services, and on-site or
1154 desk reviews of recipients’ medical records. The agency may
1155 enter into a contract with a qualified organization to implement
1156 the pilot project. The agency may seek amendments to the
1157 Medicaid state plan and waivers of federal laws, as necessary,
1158 to implement the pilot project.
1159 Section 21. This act shall take effect upon becoming a law.