Florida Senate - 2009 CS for SB 1658
By the Committee on Health and Human Services Appropriations;
and Senator Peaden
603-03992-09 20091658c1
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; revising the criteria for adjusting a
20 hospital’s inpatient per diem rate; amending s.
21 409.908, F.S.; requiring increases in certain Medicaid
22 provider rates to be authorized in the appropriations
23 act; amending s. 409.9082, F.S.; authorizing an
24 exemption from the nursing home quality assessment to
25 a nursing facility that has a certain number of
26 indigent census days; deleting an option for
27 discontinuing the nursing home quality assessment;
28 amending s. 409.911, F.S.; updating the data to be
29 used in calculating disproportionate share; amending
30 s. 409.9112, F.S.; continuing the prohibition against
31 distributing moneys under the perinatal intensive care
32 centers disproportionate share program; amending s.
33 409.9113, F.S.; continuing authorization for the
34 distribution of moneys to teaching hospitals under the
35 disproportionate share program; amending s. 409.9117,
36 F.S.; continuing the prohibition against distributing
37 moneys for the primary care disproportionate share
38 program; amending ss. 409.91195 and 409.91196, F.S.;
39 conforming cross-references; amending s. 409.912,
40 F.S.; deleting the fixed payment for delivery program
41 for Medicaid recipients 60 years of age or older;
42 requiring that a Medicaid managed care plan’s costs to
43 the state be adjusted for health status; amending s.
44 409.91211, F.S.; revising the timeline for phasing in
45 financial risk for provider service networks;
46 conforming cross-references; amending s. 430.04, F.S.;
47 requiring the Department of Elderly Affairs to
48 administer all Medicaid waivers and programs relating
49 to elders; amending s. 641.386, F.S.; conforming a
50 cross-reference; directing the Agency for Health Care
51 Administration to establish pilot projects in Miami
52 Dade County relating to home health services;
53 providing an effective date.
54
55 Be It Enacted by the Legislature of the State of Florida:
56
57 Section 1. Paragraph (d) of subsection (1) of section
58 408.040, Florida Statutes, is amended to read:
59 408.040 Conditions and monitoring.—
60 (1)
61 (d) If a nursing home is located in a county in which a
62 long-term care community diversion pilot project has been
63 implemented under s. 430.705 or in a county in which an
64 integrated, fixed-payment delivery program for Medicaid
65 recipients who are 60 years of age or older or dually eligible
66 for Medicare and Medicaid has been implemented under s.
67 409.912(5), the nursing home may request a reduction in the
68 percentage of annual patient days used by residents who are
69 eligible for care under Title XIX of the Social Security Act,
70 which is a condition of the nursing home’s certificate of need.
71 The agency shall automatically grant the nursing home’s request
72 if the reduction is not more than 15 percent of the nursing
73 home’s annual Medicaid-patient-days condition. A nursing home
74 may submit only one request every 2 years for an automatic
75 reduction. A requesting nursing home must notify the agency in
76 writing at least 60 days in advance of its intent to reduce its
77 annual Medicaid-patient-days condition by not more than 15
78 percent. The agency must acknowledge the request in writing and
79 must change its records to reflect the revised certificate-of
80 need condition. This paragraph expires June 30, 2011.
81 Section 2. Paragraph (c) is added to subsection (8) of
82 section 409.814, Florida Statutes, to read:
83 409.814 Eligibility.—A child who has not reached 19 years
84 of age whose family income is equal to or below 200 percent of
85 the federal poverty level is eligible for the Florida Kidcare
86 program as provided in this section. For enrollment in the
87 Children’s Medical Services Network, a complete application
88 includes the medical or behavioral health screening. If,
89 subsequently, an individual is determined to be ineligible for
90 coverage, he or she must immediately be disenrolled from the
91 respective Florida Kidcare program component.
92 (8) In determining the eligibility of a child, an assets
93 test is not required. Each applicant shall provide written
94 documentation during the application process and the
95 redetermination process, including, but not limited to, the
96 following:
97 (c) Effective January 1, 2010, verification of the child’s
98 citizenship status as required under Title XXI of the Social
99 Security Act.
100 Section 3. Paragraphs (g) and (q) of section (2) of
101 section 409.815, Florida Statutes, are amended, and paragraph
102 (w) is added to that section, to read:
103 409.815 Health benefits coverage; limitations.—
104 (2) BENCHMARK BENEFITS.—In order for health benefits
105 coverage to qualify for premium assistance payments for an
106 eligible child under ss. 409.810-409.820, the health benefits
107 coverage, except for coverage under Medicaid and Medikids, must
108 include the following minimum benefits, as medically necessary.
109 (g) Behavioral health services.—
110 1. Mental health benefits include:
111 a. Inpatient services, limited to not more than 30
112 inpatient days per contract year for psychiatric admissions, or
113 residential services in facilities licensed under s. 394.875(6)
114 or s. 395.003 in lieu of inpatient psychiatric admissions;
115 however, a minimum of 10 of the 30 days shall be available only
116 for inpatient psychiatric services if when authorized by a
117 physician; and
118 b. Outpatient services, including outpatient visits for
119 psychological or psychiatric evaluation, diagnosis, and
120 treatment by a licensed mental health professional, limited to a
121 maximum of 40 outpatient visits each contract year.
122 2. Substance abuse services include:
123 a. Inpatient services, limited to not more than 7 inpatient
124 days per contract year for medical detoxification only and 30
125 days of residential services; and
126 b. Outpatient services, including evaluation, diagnosis,
127 and treatment by a licensed practitioner, limited to a maximum
128 of 40 outpatient visits per contract year.
129
130 Effective October 1, 2009, covered services include inpatient
131 and outpatient services for mental and nervous disorders as
132 defined in the most recent edition of the Diagnostic and
133 Statistical Manual of Mental Disorders published by the American
134 Psychiatric Association. Such benefits include psychological or
135 psychiatric evaluation, diagnosis, and treatment by a licensed
136 mental health professional, and inpatient, outpatient, and
137 residential treatment services for the diagnosis and treatment
138 of substance abuse disorders. Any benefit limitations, including
139 duration of services, number of visits, or number of days for
140 hospitalization or residential services may not be any less
141 favorable than those for physical illnesses generally for the
142 care and treatment of schizophrenia and psychotic disorders,
143 mood disorders, anxiety disorders, substance abuse disorders,
144 eating disorders, and childhood attention deficit disorders. The
145 program may also implement appropriate financial incentives,
146 peer review, utilization requirements, and other methods used
147 for the management of benefits provided for other medical
148 conditions in order to reduce service costs and utilization
149 without compromising quality of care.
150 (q) Dental services.—Effective October 1, 2009, dental
151 services shall be covered as required under federal law and may
152 also include those dental benefits provided to children by the
153 Florida Medicaid program under s. 409.906(6).
154 (w) Reimbursement of federally qualified health centers and
155 rural health clinics.—Effective October 1, 2009, payments for
156 services provided to enrollees by federally qualified health
157 centers and rural health clinics under this section shall be
158 reimbursed using the Medicaid Prospective Payment System as
159 provided for under s. 2107(e)(1)(D) of the Social Security Act,
160 as added by subsection (a). If such services are paid for by
161 health insurers or health care providers under contract with the
162 Florida Healthy Kids Corporation, such entities are responsible
163 for this payment. The agency may seek any available federal
164 grants to assist with this transition.
165 Section 4. Paragraph (c) of subsection (3) of section
166 409.818, Florida Statutes, is amended to read:
167 409.818 Administration.—In order to implement ss. 409.810
168 409.820, the following agencies shall have the following duties:
169 (3) The Agency for Health Care Administration, under the
170 authority granted in s. 409.914(1), shall:
171 (c) Monitor compliance with quality assurance and access
172 standards developed under s. 409.820 and in accordance with s.
173 2103(f) of the Social Security Act, 42 U.S.C. 1397bb(f).
174
175 The agency is designated the lead state agency for Title XXI of
176 the Social Security Act for purposes of receipt of federal
177 funds, for reporting purposes, and for ensuring compliance with
178 federal and state regulations and rules.
179 Section 5. Subsection (1) and paragraph (a) of subsection
180 (2) of section 409.904, Florida Statutes, are amended to read:
181 409.904 Optional payments for eligible persons.—The agency
182 may make payments for medical assistance and related services on
183 behalf of the following persons who are determined to be
184 eligible subject to the income, assets, and categorical
185 eligibility tests set forth in federal and state law. Payment on
186 behalf of these Medicaid eligible persons is subject to the
187 availability of moneys and any limitations established by the
188 General Appropriations Act or chapter 216.
189 (1) Effective January 1, 2006, and Subject to federal
190 waiver approval, a person who is age 65 or older or is
191 determined to be disabled, whose income is at or below 88
192 percent of the federal poverty level, whose assets do not exceed
193 established limitations, and who is not eligible for Medicare
194 or, if eligible for Medicare, is also eligible for and receiving
195 Medicaid-covered institutional care services, hospice services,
196 or home and community-based services. The agency shall seek
197 federal authorization through a waiver to provide this coverage.
198 This subsection expires December 31, 2010 June 30, 2009.
199 (2)(a) A family, a pregnant woman, a child under age 21, a
200 person age 65 or over, or a blind or disabled person, who would
201 be eligible under any group listed in s. 409.903(1), (2), or
202 (3), except that the income or assets of such family or person
203 exceed established limitations. For a family or person in one of
204 these coverage groups, medical expenses are deductible from
205 income in accordance with federal requirements in order to make
206 a determination of eligibility. A family or person eligible
207 under the coverage known as the “medically needy,” is eligible
208 to receive the same services as other Medicaid recipients, with
209 the exception of services in skilled nursing facilities and
210 intermediate care facilities for the developmentally disabled.
211 This subsection expires December 31, 2010 June 30, 2009.
212 Section 6. Subsection (4) and paragraph (c) of subsection
213 (5) of section 409.905, Florida Statutes, are amended to read:
214 409.905 Mandatory Medicaid services.—The agency may make
215 payments for the following services, which are required of the
216 state by Title XIX of the Social Security Act, furnished by
217 Medicaid providers to recipients who are determined to be
218 eligible on the dates on which the services were provided. Any
219 service under this section shall be provided only when medically
220 necessary and in accordance with state and federal law.
221 Mandatory services rendered by providers in mobile units to
222 Medicaid recipients may be restricted by the agency. Nothing in
223 this section shall be construed to prevent or limit the agency
224 from adjusting fees, reimbursement rates, lengths of stay,
225 number of visits, number of services, or any other adjustments
226 necessary to comply with the availability of moneys and any
227 limitations or directions provided for in the General
228 Appropriations Act or chapter 216.
229 (4) HOME HEALTH CARE SERVICES.—The agency shall pay for
230 nursing and home health aide services, supplies, appliances, and
231 durable medical equipment, necessary to assist a recipient
232 living at home. An entity that provides services pursuant to
233 this subsection must shall be licensed under part III of chapter
234 400. These services, equipment, and supplies, or reimbursement
235 therefor, may be limited as provided in the General
236 Appropriations Act and do not include services, equipment, or
237 supplies provided to a person residing in a hospital or nursing
238 facility.
239 (a) In providing home health care services, the agency may
240 require prior authorization of care based on diagnosis or
241 utilization rates. Prior authorization is required for home
242 health services visits not associated with a skilled nursing
243 visit if the home health agency’s utilization rates exceed the
244 state average by 50 percent or more. The home health agency must
245 submit documentation that supports the recipient’s diagnosis and
246 the recipient’s plan of care to the agency when requesting prior
247 authorization.
248 (b) The agency shall implement a comprehensive utilization
249 management program that requires prior authorization of all
250 private duty nursing services, an individualized treatment plan
251 that includes information about medication and treatment orders,
252 treatment goals, methods of care to be used, and plans for care
253 coordination by nurses and other health professionals. The
254 utilization management program shall also include a process for
255 periodically reviewing the ongoing use of private duty nursing
256 services. For a child, the assessment of need shall be based on
257 a child’s condition, family support and care supplements, a
258 family’s ability to provide care, and a family’s and child’s
259 schedule regarding work, school, sleep, and care for other
260 family dependents. When implemented, the private duty nursing
261 utilization management program shall replace the current
262 authorization program used by the agency for Health Care
263 Administration and the Children’s Medical Services program of
264 the Department of Health. The agency may competitively bid on a
265 contract to select a qualified organization to provide
266 utilization management of private duty nursing services. The
267 agency is authorized to seek federal waivers to implement this
268 initiative.
269 (c) The agency may provide reimbursement for only those
270 home health services that are medically necessary and if:
271 1. The services are ordered by a physician.
272 2. The written prescription for services is signed and
273 dated by the recipient’s physician before the development of a
274 plan of care and before any required request for prior
275 authorization.
276 3. The physician ordering the services is not employed,
277 under contract with, or otherwise affiliated with the home
278 health agency rendering the services.
279 4. The physician ordering the services has examined the
280 recipient within 30 days before the initial request for services
281 and biannually thereafter.
282 5. The written prescription for the services includes the
283 recipient’s acute or chronic medical condition or diagnosis; the
284 home health service required, including the minimum skill level
285 required to perform the service; and the frequency and duration
286 of services.
287 6. The national provider identifier, Medicaid
288 identification number, or medical practitioner license number of
289 the physician ordering the services is listed on the written
290 prescription for the services, the claim for home health
291 reimbursement, and the prior authorization request.
292 (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
293 all covered services provided for the medical care and treatment
294 of a recipient who is admitted as an inpatient by a licensed
295 physician or dentist to a hospital licensed under part I of
296 chapter 395. However, the agency shall limit the payment for
297 inpatient hospital services for a Medicaid recipient 21 years of
298 age or older to 45 days or the number of days necessary to
299 comply with the General Appropriations Act.
300 (c) The agency for Health Care Administration shall adjust
301 a hospital’s current inpatient per diem rate to reflect the cost
302 of serving the Medicaid population at that institution if:
303 1. The hospital experiences an increase in Medicaid
304 caseload by more than 25 percent in any year, primarily
305 resulting from the closure of a hospital in the same service
306 area occurring after July 1, 1995;
307 2. The hospital’s Medicaid per diem rate is at least 25
308 percent below the Medicaid per patient cost for that year; or
309 3. The hospital is located in a county that has six five or
310 fewer general acute care hospitals, began offering obstetrical
311 services on or after September 1999, and has submitted a request
312 in writing to the agency for a rate adjustment after July 1,
313 2000, but before September 30, 2000, in which case such
314 hospital’s Medicaid inpatient per diem rate shall be adjusted to
315 cost, effective July 1, 2002.
316
317 By No later than October 1 of each year, the agency must provide
318 estimated costs for any adjustment in a hospital inpatient per
319 diem rate pursuant to this paragraph to the Executive Office of
320 the Governor, the House of Representatives General
321 Appropriations Committee, and the Senate Appropriations
322 Committee. Before the agency implements a change in a hospital’s
323 inpatient per diem rate pursuant to this paragraph, the
324 Legislature must have specifically appropriated sufficient funds
325 in the General Appropriations Act to support the increase in
326 cost as estimated by the agency.
327 Section 7. Subsection (23) of section 409.908, Florida
328 Statutes, is amended to read:
329 409.908 Reimbursement of Medicaid providers.—Subject to
330 specific appropriations, the agency shall reimburse Medicaid
331 providers, in accordance with state and federal law, according
332 to methodologies set forth in the rules of the agency and in
333 policy manuals and handbooks incorporated by reference therein.
334 These methodologies may include fee schedules, reimbursement
335 methods based on cost reporting, negotiated fees, competitive
336 bidding pursuant to s. 287.057, and other mechanisms the agency
337 considers efficient and effective for purchasing services or
338 goods on behalf of recipients. If a provider is reimbursed based
339 on cost reporting and submits a cost report late and that cost
340 report would have been used to set a lower reimbursement rate
341 for a rate semester, then the provider’s rate for that semester
342 shall be retroactively calculated using the new cost report, and
343 full payment at the recalculated rate shall be effected
344 retroactively. Medicare-granted extensions for filing cost
345 reports, if applicable, shall also apply to Medicaid cost
346 reports. Payment for Medicaid compensable services made on
347 behalf of Medicaid eligible persons is subject to the
348 availability of moneys and any limitations or directions
349 provided for in the General Appropriations Act or chapter 216.
350 Further, nothing in this section shall be construed to prevent
351 or limit the agency from adjusting fees, reimbursement rates,
352 lengths of stay, number of visits, or number of services, or
353 making any other adjustments necessary to comply with the
354 availability of moneys and any limitations or directions
355 provided for in the General Appropriations Act, provided the
356 adjustment is consistent with legislative intent.
357 (23)(a) The agency shall establish rates at a level that
358 ensures no increase in statewide expenditures resulting from a
359 change in unit costs for 2 fiscal years effective July 1, 2009.
360 Reimbursement rates for the 2 fiscal years shall be as provided
361 in the General Appropriations Act.
362 (a)(b) This subsection applies to The following provider
363 types may not receive an increase in reimbursement rate due to a
364 change in unit cost unless specifically appropriated in the
365 General Appropriations Act:
366 1. Inpatient hospitals.
367 2. Outpatient hospitals.
368 3. Nursing homes.
369 4. County health departments.
370 5. Community intermediate care facilities for the
371 developmentally disabled.
372 6. Prepaid health plans.
373 7. Nursing home diversion programs.
374
375 The agency shall apply the effect of this subsection to the
376 reimbursement rates for nursing home diversion programs.
377 (b)(c) The agency shall create a workgroup on hospital
378 reimbursement, a workgroup on nursing facility reimbursement,
379 and a workgroup on managed care plan payment. The workgroups
380 shall evaluate alternative reimbursement and payment
381 methodologies for hospitals, nursing facilities, and managed
382 care plans, including prospective payment methodologies for
383 hospitals and nursing facilities. The nursing facility workgroup
384 shall also consider price-based methodologies for indirect care
385 and acuity adjustments for direct care. The agency shall submit
386 a report on the evaluated alternative reimbursement
387 methodologies to the relevant committees of the Senate and the
388 House of Representatives by November 1, 2009.
389 (c)(d) This subsection expires June 30, 2011.
390 Section 8. Paragraph (d) is added to subsection (3) of
391 section 409.9082, Florida Statutes, as created by section 1 of
392 chapter 2009-4, Laws of Florida, and subsection (6) of that
393 section is amended, to read:
394 409.9082 Quality assessment on nursing home facility
395 providers; exemptions; purpose; federal approval required;
396 remedies.—
397 (3)
398 (d) Effective July 1, 2009, the agency may exempt from the
399 quality assessment or apply a lower quality assessment rate to a
400 qualified public, nonstate owned or operated nursing home
401 facility whose total annual indigent census days are greater
402 than 25 percent of the facility’s total annual census days.
403 (6) The quality assessment shall terminate and the agency
404 shall discontinue the imposition, assessment, and collection of
405 the nursing facility quality assessment if any of the following
406 occur:
407 (a) the agency does not obtain necessary federal approval
408 for the nursing home facility quality assessment or the payment
409 rates required by subsection (4); or
410 (b) The weighted average Medicaid rate paid to nursing home
411 facilities is reduced below the weighted average Medicaid rate
412 to nursing home facilities in effect on December 31, 2008, plus
413 any future annual amount of the quality assessment and the
414 applicable matching federal funds. Upon termination of the
415 quality assessment, all collected assessment revenues, less any
416 amounts expended by the agency, shall be returned on a pro rata
417 basis to the nursing facilities that paid them.
418 Section 9. Paragraph (a) of subsection (2) of section
419 409.911, Florida Statutes, is amended to read:
420 409.911 Disproportionate share program.—Subject to specific
421 allocations established within the General Appropriations Act
422 and any limitations established pursuant to chapter 216, the
423 agency shall distribute, pursuant to this section, moneys to
424 hospitals providing a disproportionate share of Medicaid or
425 charity care services by making quarterly Medicaid payments as
426 required. Notwithstanding the provisions of s. 409.915, counties
427 are exempt from contributing toward the cost of this special
428 reimbursement for hospitals serving a disproportionate share of
429 low-income patients.
430 (2) The agency for Health Care Administration shall use the
431 following actual audited data to determine the Medicaid days and
432 charity care to be used in calculating the disproportionate
433 share payment:
434 (a) The average of the 2002, 2003, and 2004, and 2005
435 audited disproportionate share data to determine each hospital’s
436 Medicaid days and charity care for the 2009-2010 2008-2009 state
437 fiscal year.
438 Section 10. Section 409.9112, Florida Statutes, is amended
439 to read:
440 409.9112 Disproportionate share program for regional
441 perinatal intensive care centers.—In addition to the payments
442 made under s. 409.911, the agency for Health Care Administration
443 shall design and implement a system for of making
444 disproportionate share payments to those hospitals that
445 participate in the regional perinatal intensive care center
446 program established pursuant to chapter 383. The This system of
447 payments must shall conform to with federal requirements and
448 shall distribute funds in each fiscal year for which an
449 appropriation is made by making quarterly Medicaid payments.
450 Notwithstanding the provisions of s. 409.915, counties are
451 exempt from contributing toward the cost of this special
452 reimbursement for hospitals serving a disproportionate share of
453 low-income patients. For the 2009-2010 state fiscal year 2008
454 2009, the agency may shall not distribute moneys under the
455 regional perinatal intensive care centers disproportionate share
456 program.
457 (1) The following formula shall be used by the agency to
458 calculate the total amount earned for hospitals that participate
459 in the regional perinatal intensive care center program:
460 TAE = HDSP/THDSP
461
462 Where:
463 TAE = total amount earned by a regional perinatal intensive
464 care center.
465 HDSP = the prior state fiscal year regional perinatal
466 intensive care center disproportionate share payment to the
467 individual hospital.
468 THDSP = the prior state fiscal year total regional
469 perinatal intensive care center disproportionate share payments
470 to all hospitals.
471 (2) The total additional payment for hospitals that
472 participate in the regional perinatal intensive care center
473 program shall be calculated by the agency as follows:
474 TAP = TAE x TA
475
476 Where:
477 TAP = total additional payment for a regional perinatal
478 intensive care center.
479 TAE = total amount earned by a regional perinatal intensive
480 care center.
481 TA = total appropriation for the regional perinatal
482 intensive care center disproportionate share program.
483 (3) In order to receive payments under this section, a
484 hospital must be participating in the regional perinatal
485 intensive care center program pursuant to chapter 383 and must
486 meet the following additional requirements:
487 (a) Agree to conform to all departmental and agency
488 requirements to ensure high quality in the provision of
489 services, including criteria adopted by departmental and agency
490 rule concerning staffing ratios, medical records, standards of
491 care, equipment, space, and such other standards and criteria as
492 the department and agency deem appropriate as specified by rule.
493 (b) Agree to provide information to the department and
494 agency, in a form and manner to be prescribed by rule of the
495 department and agency, concerning the care provided to all
496 patients in neonatal intensive care centers and high-risk
497 maternity care.
498 (c) Agree to accept all patients for neonatal intensive
499 care and high-risk maternity care, regardless of ability to pay,
500 on a functional space-available basis.
501 (d) Agree to develop arrangements with other maternity and
502 neonatal care providers in the hospital’s region for the
503 appropriate receipt and transfer of patients in need of
504 specialized maternity and neonatal intensive care services.
505 (e) Agree to establish and provide a developmental
506 evaluation and services program for certain high-risk neonates,
507 as prescribed and defined by rule of the department.
508 (f) Agree to sponsor a program of continuing education in
509 perinatal care for health care professionals within the region
510 of the hospital, as specified by rule.
511 (g) Agree to provide backup and referral services to the
512 department’s county health departments and other low-income
513 perinatal providers within the hospital’s region, including the
514 development of written agreements between these organizations
515 and the hospital.
516 (h) Agree to arrange for transportation for high-risk
517 obstetrical patients and neonates in need of transfer from the
518 community to the hospital or from the hospital to another more
519 appropriate facility.
520 (4) Hospitals which fail to comply with any of the
521 conditions in subsection (3) or the applicable rules of the
522 department and agency may shall not receive any payments under
523 this section until full compliance is achieved. A hospital which
524 is not in compliance in two or more consecutive quarters may
525 shall not receive its share of the funds. Any forfeited funds
526 shall be distributed by the remaining participating regional
527 perinatal intensive care center program hospitals.
528 Section 11. Section 409.9113, Florida Statutes, is amended
529 to read:
530 409.9113 Disproportionate share program for teaching
531 hospitals.—In addition to the payments made under ss. 409.911
532 and 409.9112, the agency for Health Care Administration shall
533 make disproportionate share payments to statutorily defined
534 teaching hospitals for their increased costs associated with
535 medical education programs and for tertiary health care services
536 provided to the indigent. This system of payments must shall
537 conform to with federal requirements and shall distribute funds
538 in each fiscal year for which an appropriation is made by making
539 quarterly Medicaid payments. Notwithstanding s. 409.915,
540 counties are exempt from contributing toward the cost of this
541 special reimbursement for hospitals serving a disproportionate
542 share of low-income patients. For the 2009-2010 state fiscal
543 year 2008-2009, the agency shall distribute the moneys provided
544 in the General Appropriations Act to statutorily defined
545 teaching hospitals and family practice teaching hospitals under
546 the teaching hospital disproportionate share program. The funds
547 provided for statutorily defined teaching hospitals shall be
548 distributed in the same proportion as the state fiscal year
549 2003-2004 teaching hospital disproportionate share funds were
550 distributed or as otherwise provided in the General
551 Appropriations Act. The funds provided for family practice
552 teaching hospitals shall be distributed equally among family
553 practice teaching hospitals.
554 (1) On or before September 15 of each year, the agency for
555 Health Care Administration shall calculate an allocation
556 fraction to be used for distributing funds to state statutory
557 teaching hospitals. Subsequent to the end of each quarter of the
558 state fiscal year, the agency shall distribute to each statutory
559 teaching hospital, as defined in s. 408.07, an amount determined
560 by multiplying one-fourth of the funds appropriated for this
561 purpose by the Legislature times such hospital’s allocation
562 fraction. The allocation fraction for each such hospital shall
563 be determined by the sum of the following three primary factors,
564 divided by three. The primary factors are:
565 (a) The number of nationally accredited graduate medical
566 education programs offered by the hospital, including programs
567 accredited by the Accreditation Council for Graduate Medical
568 Education and the combined Internal Medicine and Pediatrics
569 programs acceptable to both the American Board of Internal
570 Medicine and the American Board of Pediatrics at the beginning
571 of the state fiscal year preceding the date on which the
572 allocation fraction is calculated. The numerical value of this
573 factor is the fraction that the hospital represents of the total
574 number of programs, where the total is computed for all state
575 statutory teaching hospitals.
576 (b) The number of full-time equivalent trainees in the
577 hospital, which comprises two components:
578 1. The number of trainees enrolled in nationally accredited
579 graduate medical education programs, as defined in paragraph
580 (a). Full-time equivalents are computed using the fraction of
581 the year during which each trainee is primarily assigned to the
582 given institution, over the state fiscal year preceding the date
583 on which the allocation fraction is calculated. The numerical
584 value of this factor is the fraction that the hospital
585 represents of the total number of full-time equivalent trainees
586 enrolled in accredited graduate programs, where the total is
587 computed for all state statutory teaching hospitals.
588 2. The number of medical students enrolled in accredited
589 colleges of medicine and engaged in clinical activities,
590 including required clinical clerkships and clinical electives.
591 Full-time equivalents are computed using the fraction of the
592 year during which each trainee is primarily assigned to the
593 given institution, over the course of the state fiscal year
594 preceding the date on which the allocation fraction is
595 calculated. The numerical value of this factor is the fraction
596 that the given hospital represents of the total number of full
597 time equivalent students enrolled in accredited colleges of
598 medicine, where the total is computed for all state statutory
599 teaching hospitals.
600
601 The primary factor for full-time equivalent trainees is computed
602 as the sum of these two components, divided by two.
603 (c) A service index that comprises three components:
604 1. The Agency for Health Care Administration Service Index,
605 computed by applying the standard Service Inventory Scores
606 established by the agency for Health Care Administration to
607 services offered by the given hospital, as reported on Worksheet
608 A-2 for the last fiscal year reported to the agency before the
609 date on which the allocation fraction is calculated. The
610 numerical value of this factor is the fraction that the given
611 hospital represents of the total Agency for Health Care
612 Administration Service Index values, where the total is computed
613 for all state statutory teaching hospitals.
614 2. A volume-weighted service index, computed by applying
615 the standard Service Inventory Scores established by the Agency
616 for Health Care Administration to the volume of each service,
617 expressed in terms of the standard units of measure reported on
618 Worksheet A-2 for the last fiscal year reported to the agency
619 before the date on which the allocation factor is calculated.
620 The numerical value of this factor is the fraction that the
621 given hospital represents of the total volume-weighted service
622 index values, where the total is computed for all state
623 statutory teaching hospitals.
624 3. Total Medicaid payments to each hospital for direct
625 inpatient and outpatient services during the fiscal year
626 preceding the date on which the allocation factor is calculated.
627 This includes payments made to each hospital for such services
628 by Medicaid prepaid health plans, whether the plan was
629 administered by the hospital or not. The numerical value of this
630 factor is the fraction that each hospital represents of the
631 total of such Medicaid payments, where the total is computed for
632 all state statutory teaching hospitals.
633
634 The primary factor for the service index is computed as the sum
635 of these three components, divided by three.
636 (2) By October 1 of each year, the agency shall use the
637 following formula to calculate the maximum additional
638 disproportionate share payment for statutorily defined teaching
639 hospitals:
640 TAP = THAF x A
641
642 Where:
643 TAP = total additional payment.
644 THAF = teaching hospital allocation factor.
645 A = amount appropriated for a teaching hospital
646 disproportionate share program.
647 Section 12. Section 409.9117, Florida Statutes, is amended
648 to read:
649 409.9117 Primary care disproportionate share program.—For
650 the 2009-2010 state fiscal year 2008-2009, the agency shall not
651 distribute moneys under the primary care disproportionate share
652 program.
653 (1) If federal funds are available for disproportionate
654 share programs in addition to those otherwise provided by law,
655 there shall be created a primary care disproportionate share
656 program.
657 (2) The following formula shall be used by the agency to
658 calculate the total amount earned for hospitals that participate
659 in the primary care disproportionate share program:
660 TAE = HDSP/THDSP
661
662 Where:
663 TAE = total amount earned by a hospital participating in
664 the primary care disproportionate share program.
665 HDSP = the prior state fiscal year primary care
666 disproportionate share payment to the individual hospital.
667 THDSP = the prior state fiscal year total primary care
668 disproportionate share payments to all hospitals.
669 (3) The total additional payment for hospitals that
670 participate in the primary care disproportionate share program
671 shall be calculated by the agency as follows:
672 TAP = TAE x TA
673
674 Where:
675 TAP = total additional payment for a primary care hospital.
676 TAE = total amount earned by a primary care hospital.
677 TA = total appropriation for the primary care
678 disproportionate share program.
679 (4) In the establishment and funding of this program, the
680 agency shall use the following criteria in addition to those
681 specified in s. 409.911, and payments may not be made to a
682 hospital unless the hospital agrees to:
683 (a) Cooperate with a Medicaid prepaid health plan, if one
684 exists in the community.
685 (b) Ensure the availability of primary and specialty care
686 physicians to Medicaid recipients who are not enrolled in a
687 prepaid capitated arrangement and who are in need of access to
688 such physicians.
689 (c) Coordinate and provide primary care services free of
690 charge, except copayments, to all persons with incomes up to 100
691 percent of the federal poverty level who are not otherwise
692 covered by Medicaid or another program administered by a
693 governmental entity, and to provide such services based on a
694 sliding fee scale to all persons with incomes up to 200 percent
695 of the federal poverty level who are not otherwise covered by
696 Medicaid or another program administered by a governmental
697 entity, except that eligibility may be limited to persons who
698 reside within a more limited area, as agreed to by the agency
699 and the hospital.
700 (d) Contract with any federally qualified health center, if
701 one exists within the agreed geopolitical boundaries, concerning
702 the provision of primary care services, in order to guarantee
703 delivery of services in a nonduplicative fashion, and to provide
704 for referral arrangements, privileges, and admissions, as
705 appropriate. The hospital shall agree to provide at an onsite or
706 offsite facility primary care services within 24 hours to which
707 all Medicaid recipients and persons eligible under this
708 paragraph who do not require emergency room services are
709 referred during normal daylight hours.
710 (e) Cooperate with the agency, the county, and other
711 entities to ensure the provision of certain public health
712 services, case management, referral and acceptance of patients,
713 and sharing of epidemiological data, as the agency and the
714 hospital find mutually necessary and desirable to promote and
715 protect the public health within the agreed geopolitical
716 boundaries.
717 (f) In cooperation with the county in which the hospital
718 resides, develop a low-cost, outpatient, prepaid health care
719 program to persons who are not eligible for the Medicaid
720 program, and who reside within the area.
721 (g) Provide inpatient services to residents within the area
722 who are not eligible for Medicaid or Medicare, and who do not
723 have private health insurance, regardless of ability to pay, on
724 the basis of available space, except that hospitals may not be
725 prevented nothing shall prevent the hospital from establishing
726 bill collection programs based on ability to pay.
727 (h) Work with the Florida Healthy Kids Corporation, the
728 Florida Health Care Purchasing Cooperative, and business health
729 coalitions, as appropriate, to develop a feasibility study and
730 plan to provide a low-cost comprehensive health insurance plan
731 to persons who reside within the area and who do not have access
732 to such a plan.
733 (i) Work with public health officials and other experts to
734 provide community health education and prevention activities
735 designed to promote healthy lifestyles and appropriate use of
736 health services.
737 (j) Work with the local health council to develop a plan
738 for promoting access to affordable health care services for all
739 persons who reside within the area, including, but not limited
740 to, public health services, primary care services, inpatient
741 services, and affordable health insurance generally.
742
743 Any hospital that fails to comply with any of the provisions of
744 this subsection, or any other contractual condition, may not
745 receive payments under this section until full compliance is
746 achieved.
747 Section 13. Subsection (4) of section 409.91195, Florida
748 Statutes, is amended to read:
749 409.91195 Medicaid Pharmaceutical and Therapeutics
750 Committee.—There is created a Medicaid Pharmaceutical and
751 Therapeutics Committee within the agency for the purpose of
752 developing a Medicaid preferred drug list.
753 (4) Upon recommendation of the committee, the agency shall
754 adopt a preferred drug list as described in s. 409.912(38) s.
755 409.912(39). If To the extent feasible, the committee shall
756 review all drug classes included on the preferred drug list
757 every 12 months, and may recommend additions to and deletions
758 from the preferred drug list, such that the preferred drug list
759 provides for medically appropriate drug therapies for Medicaid
760 patients which achieve cost savings contained in the General
761 Appropriations Act.
762 Section 14. Subsection (1) of section 409.91196, Florida
763 Statutes, is amended to read:
764 409.91196 Supplemental rebate agreements; public records
765 and public meetings exemption.—
766 (1) The rebate amount, percent of rebate, manufacturer’s
767 pricing, and supplemental rebate, and other trade secrets as
768 defined in s. 688.002 that the agency has identified for use in
769 negotiations, held by the agency for Health Care Administration
770 under s. 409.912(38)(a)7. s. 409.912(39)(a)7. are confidential
771 and exempt from s. 119.07(1) and s. 24(a), Art. I of the State
772 Constitution.
773 Section 15. Present subsections (6) through (53) of section
774 409.912, Florida Statutes, are redesignated as subsections (5)
775 through (52), respectively, and present subsections (5), (21),
776 and (29) of that section, are amended to read:
777 409.912 Cost-effective purchasing of health care.—The
778 agency shall purchase goods and services for Medicaid recipients
779 in the most cost-effective manner consistent with the delivery
780 of quality medical care. To ensure that medical services are
781 effectively utilized, the agency may, in any case, require a
782 confirmation or second physician’s opinion of the correct
783 diagnosis for purposes of authorizing future services under the
784 Medicaid program. This section does not restrict access to
785 emergency services or poststabilization care services as defined
786 in 42 C.F.R. part 438.114. Such confirmation or second opinion
787 shall be rendered in a manner approved by the agency. The agency
788 shall maximize the use of prepaid per capita and prepaid
789 aggregate fixed-sum basis services when appropriate and other
790 alternative service delivery and reimbursement methodologies,
791 including competitive bidding pursuant to s. 287.057, designed
792 to facilitate the cost-effective purchase of a case-managed
793 continuum of care. The agency shall also require providers to
794 minimize the exposure of recipients to the need for acute
795 inpatient, custodial, and other institutional care and the
796 inappropriate or unnecessary use of high-cost services. The
797 agency shall contract with a vendor to monitor and evaluate the
798 clinical practice patterns of providers in order to identify
799 trends that are outside the normal practice patterns of a
800 provider’s professional peers or the national guidelines of a
801 provider’s professional association. The vendor must be able to
802 provide information and counseling to a provider whose practice
803 patterns are outside the norms, in consultation with the agency,
804 to improve patient care and reduce inappropriate utilization.
805 The agency may mandate prior authorization, drug therapy
806 management, or disease management participation for certain
807 populations of Medicaid beneficiaries, certain drug classes, or
808 particular drugs to prevent fraud, abuse, overuse, and possible
809 dangerous drug interactions. The Pharmaceutical and Therapeutics
810 Committee shall make recommendations to the agency on drugs for
811 which prior authorization is required. The agency shall inform
812 the Pharmaceutical and Therapeutics Committee of its decisions
813 regarding drugs subject to prior authorization. The agency is
814 authorized to limit the entities it contracts with or enrolls as
815 Medicaid providers by developing a provider network through
816 provider credentialing. The agency may competitively bid single
817 source-provider contracts if procurement of goods or services
818 results in demonstrated cost savings to the state without
819 limiting access to care. The agency may limit its network based
820 on the assessment of beneficiary access to care, provider
821 availability, provider quality standards, time and distance
822 standards for access to care, the cultural competence of the
823 provider network, demographic characteristics of Medicaid
824 beneficiaries, practice and provider-to-beneficiary standards,
825 appointment wait times, beneficiary use of services, provider
826 turnover, provider profiling, provider licensure history,
827 previous program integrity investigations and findings, peer
828 review, provider Medicaid policy and billing compliance records,
829 clinical and medical record audits, and other factors. Providers
830 shall not be entitled to enrollment in the Medicaid provider
831 network. The agency shall determine instances in which allowing
832 Medicaid beneficiaries to purchase durable medical equipment and
833 other goods is less expensive to the Medicaid program than long
834 term rental of the equipment or goods. The agency may establish
835 rules to facilitate purchases in lieu of long-term rentals in
836 order to protect against fraud and abuse in the Medicaid program
837 as defined in s. 409.913. The agency may seek federal waivers
838 necessary to administer these policies.
839 (5) The Agency for Health Care Administration, in
840 partnership with the Department of Elderly Affairs, shall create
841 an integrated, fixed-payment delivery program for Medicaid
842 recipients who are 60 years of age or older or dually eligible
843 for Medicare and Medicaid. The Agency for Health Care
844 Administration shall implement the integrated program initially
845 on a pilot basis in two areas of the state. The pilot areas
846 shall be Area 7 and Area 11 of the Agency for Health Care
847 Administration. Enrollment in the pilot areas shall be on a
848 voluntary basis and in accordance with approved federal waivers
849 and this section. The agency and its program contractors and
850 providers shall not enroll any individual in the integrated
851 program because the individual or the person legally responsible
852 for the individual fails to choose to enroll in the integrated
853 program. Enrollment in the integrated program shall be
854 exclusively by affirmative choice of the eligible individual or
855 by the person legally responsible for the individual. The
856 integrated program must transfer all Medicaid services for
857 eligible elderly individuals who choose to participate into an
858 integrated-care management model designed to serve Medicaid
859 recipients in the community. The integrated program must combine
860 all funding for Medicaid services provided to individuals who
861 are 60 years of age or older or dually eligible for Medicare and
862 Medicaid into the integrated program, including funds for
863 Medicaid home and community-based waiver services; all Medicaid
864 services authorized in ss. 409.905 and 409.906, excluding funds
865 for Medicaid nursing home services unless the agency is able to
866 demonstrate how the integration of the funds will improve
867 coordinated care for these services in a less costly manner; and
868 Medicare coinsurance and deductibles for persons dually eligible
869 for Medicaid and Medicare as prescribed in s. 409.908(13).
870 (a) Individuals who are 60 years of age or older or dually
871 eligible for Medicare and Medicaid and enrolled in the
872 developmental disabilities waiver program, the family and
873 supported-living waiver program, the project AIDS care waiver
874 program, the traumatic brain injury and spinal cord injury
875 waiver program, the consumer-directed care waiver program, and
876 the program of all-inclusive care for the elderly program, and
877 residents of institutional care facilities for the
878 developmentally disabled, must be excluded from the integrated
879 program.
880 (b) Managed care entities who meet or exceed the agency’s
881 minimum standards are eligible to operate the integrated
882 program. Entities eligible to participate include managed care
883 organizations licensed under chapter 641, including entities
884 eligible to participate in the nursing home diversion program,
885 other qualified providers as defined in s. 430.703(7), community
886 care for the elderly lead agencies, and other state-certified
887 community service networks that meet comparable standards as
888 defined by the agency, in consultation with the Department of
889 Elderly Affairs and the Office of Insurance Regulation, to be
890 financially solvent and able to take on financial risk for
891 managed care. Community service networks that are certified
892 pursuant to the comparable standards defined by the agency are
893 not required to be licensed under chapter 641. Managed care
894 entities who operate the integrated program shall be subject to
895 s. 408.7056. Eligible entities shall choose to serve enrollees
896 who are dually eligible for Medicare and Medicaid, enrollees who
897 are 60 years of age or older, or both.
898 (c) The agency must ensure that the capitation-rate-setting
899 methodology for the integrated program is actuarially sound and
900 reflects the intent to provide quality care in the least
901 restrictive setting. The agency must also require integrated
902 program providers to develop a credentialing system for service
903 providers and to contract with all Gold Seal nursing homes,
904 where feasible, and exclude, where feasible, chronically poor
905 performing facilities and providers as defined by the agency.
906 The integrated program must develop and maintain an informal
907 provider grievance system that addresses provider payment and
908 contract problems. The agency shall also establish a formal
909 grievance system to address those issues that were not resolved
910 through the informal grievance system. The integrated program
911 must provide that if the recipient resides in a noncontracted
912 residential facility licensed under chapter 400 or chapter 429
913 at the time of enrollment in the integrated program, the
914 recipient must be permitted to continue to reside in the
915 noncontracted facility as long as the recipient desires. The
916 integrated program must also provide that, in the absence of a
917 contract between the integrated-program provider and the
918 residential facility licensed under chapter 400 or chapter 429,
919 current Medicaid rates must prevail. The integrated-program
920 provider must ensure that electronic nursing home claims that
921 contain sufficient information for processing are paid within 10
922 business days after receipt. Alternately, the integrated-program
923 provider may establish a capitated payment mechanism to
924 prospectively pay nursing homes at the beginning of each month.
925 The agency and the Department of Elderly Affairs must jointly
926 develop procedures to manage the services provided through the
927 integrated program in order to ensure quality and recipient
928 choice.
929 (d) The Office of Program Policy Analysis and Government
930 Accountability, in consultation with the Auditor General, shall
931 comprehensively evaluate the pilot project for the integrated,
932 fixed-payment delivery program for Medicaid recipients created
933 under this subsection. The evaluation shall begin as soon as
934 Medicaid recipients are enrolled in the managed care pilot
935 program plans and shall continue for 24 months thereafter. The
936 evaluation must include assessments of each managed care plan in
937 the integrated program with regard to cost savings; consumer
938 education, choice, and access to services; coordination of care;
939 and quality of care. The evaluation must describe administrative
940 or legal barriers to the implementation and operation of the
941 pilot program and include recommendations regarding statewide
942 expansion of the pilot program. The office shall submit its
943 evaluation report to the Governor, the President of the Senate,
944 and the Speaker of the House of Representatives no later than
945 December 31, 2009.
946 (e) The agency may seek federal waivers or Medicaid state
947 plan amendments and adopt rules as necessary to administer the
948 integrated program. The agency may implement the approved
949 federal waivers and other provisions as specified in this
950 subsection.
951 (f) No later than December 31, 2007, the agency shall
952 provide a report to the Governor, the President of the Senate,
953 and the Speaker of the House of Representatives containing an
954 analysis of the merits and challenges of seeking a waiver to
955 implement a voluntary program that integrates payments and
956 services for dually enrolled Medicare and Medicaid recipients
957 who are 65 years of age or older.
958 (20)(21) Any entity contracting with the agency pursuant to
959 this section to provide health care services to Medicaid
960 recipients is prohibited from engaging in any of the following
961 practices or activities:
962 (c) Granting or offering of any monetary or other valuable
963 consideration for enrollment, except as authorized by subsection
964 (23) (24).
965 (28)(29) The agency shall perform enrollments and
966 disenrollments for Medicaid recipients who are eligible for
967 MediPass or managed care plans. Notwithstanding the prohibition
968 contained in paragraph (20)(f) (21)(f), managed care plans may
969 perform preenrollments of Medicaid recipients under the
970 supervision of the agency or its agents. For the purposes of
971 this section, “preenrollment” means the provision of marketing
972 and educational materials to a Medicaid recipient and assistance
973 in completing the application forms, but does shall not include
974 actual enrollment into a managed care plan. An application for
975 enrollment is shall not be deemed complete until the agency or
976 its agent verifies that the recipient made an informed,
977 voluntary choice. The agency, in cooperation with the Department
978 of Children and Family Services, may test new marketing
979 initiatives to inform Medicaid recipients about their managed
980 care options at selected sites. The agency shall report to the
981 Legislature on the effectiveness of such initiatives. The agency
982 may contract with a third party to perform managed care plan and
983 MediPass enrollment and disenrollment services for Medicaid
984 recipients and may is authorized to adopt rules to implement
985 such services. The agency may adjust the capitation rate only to
986 cover the costs of a third-party enrollment and disenrollment
987 contract, and for agency supervision and management of the
988 managed care plan enrollment and disenrollment contract.
989 Section 16. Paragraphs (e), (l), (p), and (w) of subsection
990 (3) and subsection (12) of section 409.91211, Florida Statutes,
991 are amended to read:
992 409.91211 Medicaid managed care pilot program.—
993 (3) The agency shall have the following powers, duties, and
994 responsibilities with respect to the pilot program:
995 (e) To implement policies and guidelines for phasing in
996 financial risk for approved provider service networks over a 5-
997 year 3-year period. These policies and guidelines must include
998 an option for a provider service network to be paid fee-for
999 service rates. For any provider service network established in a
1000 managed care pilot area, the option to be paid fee-for-service
1001 rates must shall include a savings-settlement mechanism that is
1002 consistent with s. 409.912(44). This model must shall be
1003 converted to a risk-adjusted capitated rate by no later than the
1004 beginning of the sixth fourth year of operation, and may be
1005 converted earlier at the option of the provider service network.
1006 Federally qualified health centers may be offered an opportunity
1007 to accept or decline a contract to participate in any provider
1008 network for prepaid primary care services.
1009 (l) To implement a system that prohibits capitated managed
1010 care plans, their representatives, and providers employed by or
1011 contracted with the capitated managed care plans from recruiting
1012 persons eligible for or enrolled in Medicaid, from providing
1013 inducements to Medicaid recipients to select a particular
1014 capitated managed care plan, and from prejudicing Medicaid
1015 recipients against other capitated managed care plans. The
1016 system must shall require the entity performing choice
1017 counseling to determine if the recipient has made a choice of a
1018 plan or has opted out because of duress, threats, payment to the
1019 recipient, or incentives promised to the recipient by a third
1020 party. If the choice counseling entity determines that the
1021 decision to choose a plan was unlawfully influenced or a plan
1022 violated any of the provisions of s. 409.912(20) s. 409.912(21),
1023 the choice counseling entity shall immediately report the
1024 violation to the agency’s program integrity section for
1025 investigation. Verification of choice counseling by the
1026 recipient must shall include a stipulation that the recipient
1027 acknowledges the provisions of this subsection.
1028 (p) To implement standards for plan compliance, including,
1029 but not limited to, standards for quality assurance and
1030 performance improvement, standards for peer or professional
1031 reviews, grievance policies, and policies for maintaining
1032 program integrity. The agency shall develop a data-reporting
1033 system, seek input from managed care plans in order to establish
1034 requirements for patient-encounter reporting, and ensure that
1035 the data reported is accurate and complete.
1036 1. In performing the duties required under this section,
1037 the agency shall work with managed care plans to establish a
1038 uniform system to measure and monitor outcomes for a recipient
1039 of Medicaid services.
1040 2. The system must shall use financial, clinical, and other
1041 criteria based on pharmacy, medical services, and other data
1042 that is related to the provision of Medicaid services,
1043 including, but not limited to:
1044 a. The Health Plan Employer Data and Information Set
1045 (HEDIS) or measures that are similar to HEDIS.
1046 b. Member satisfaction.
1047 c. Provider satisfaction.
1048 d. Report cards on plan performance and best practices.
1049 e. Compliance with the requirements for prompt payment of
1050 claims under ss. 627.613, 641.3155, and 641.513.
1051 f. Utilization and quality data for the purpose of ensuring
1052 access to medically necessary services, including
1053 underutilization or inappropriate denial of services.
1054 3. The agency shall require the managed care plans that
1055 have contracted with the agency to establish a quality assurance
1056 system that incorporates the provisions of s. 409.912(26) s.
1057 409.912(27) and any standards, rules, and guidelines developed
1058 by the agency.
1059 4. The agency shall establish an encounter database in
1060 order to compile data on health services rendered by health care
1061 practitioners who provide services to patients enrolled in
1062 managed care plans in the demonstration sites. The encounter
1063 database shall:
1064 a. Collect the following for each type of patient encounter
1065 with a health care practitioner or facility, including:
1066 (I) The demographic characteristics of the patient.
1067 (II) The principal, secondary, and tertiary diagnosis.
1068 (III) The procedure performed.
1069 (IV) The date and location where the procedure was
1070 performed.
1071 (V) The payment for the procedure, if any.
1072 (VI) If applicable, the health care practitioner’s
1073 universal identification number.
1074 (VII) If the health care practitioner rendering the service
1075 is a dependent practitioner, the modifiers appropriate to
1076 indicate that the service was delivered by the dependent
1077 practitioner.
1078 b. Collect appropriate information relating to prescription
1079 drugs for each type of patient encounter.
1080 c. Collect appropriate information related to health care
1081 costs and utilization from managed care plans participating in
1082 the demonstration sites.
1083 5. If To the extent practicable, when collecting the data
1084 the agency shall use a standardized claim form or electronic
1085 transfer system that is used by health care practitioners,
1086 facilities, and payors.
1087 6. Health care practitioners and facilities in the
1088 demonstration sites shall electronically submit, and managed
1089 care plans participating in the demonstration sites shall
1090 electronically receive, information concerning claims payments
1091 and any other information reasonably related to the encounter
1092 database using a standard format as required by the agency.
1093 7. The agency shall establish reasonable deadlines for
1094 phasing in the electronic transmittal of full encounter data.
1095 8. The system must ensure that the data reported is
1096 accurate and complete.
1097 (w) To implement procedures to minimize the risk of
1098 Medicaid fraud and abuse in all plans operating in the Medicaid
1099 managed care pilot program authorized in this section.
1100 1. The agency shall ensure that applicable provisions of
1101 this chapter and chapters 414, 626, 641, and 932 which relate to
1102 Medicaid fraud and abuse are applied and enforced at the
1103 demonstration project sites.
1104 2. Providers must have the certification, license, and
1105 credentials that are required by law and waiver requirements.
1106 3. The agency shall ensure that the plan is in compliance
1107 with s. 409.912(20) and (21) s. 409.912(21) and (22).
1108 4. The agency shall require that each plan establish
1109 functions and activities governing program integrity in order to
1110 reduce the incidence of fraud and abuse. Plans must report
1111 instances of fraud and abuse pursuant to chapter 641.
1112 5. The plan must shall have written administrative and
1113 management arrangements or procedures, including a mandatory
1114 compliance plan, which are designed to guard against fraud and
1115 abuse. The plan shall designate a compliance officer who has
1116 sufficient experience in health care.
1117 6.a. The agency shall require all managed care plan
1118 contractors in the pilot program to report all instances of
1119 suspected fraud and abuse. A failure to report instances of
1120 suspected fraud and abuse is a violation of law and subject to
1121 the penalties provided by law.
1122 b. An instance of fraud and abuse in the managed care plan,
1123 including, but not limited to, defrauding the state health care
1124 benefit program by misrepresentation of fact in reports, claims,
1125 certifications, enrollment claims, demographic statistics, or
1126 patient-encounter data; misrepresentation of the qualifications
1127 of persons rendering health care and ancillary services; bribery
1128 and false statements relating to the delivery of health care;
1129 unfair and deceptive marketing practices; and false claims
1130 actions in the provision of managed care, is a violation of law
1131 and subject to the penalties provided by law.
1132 c. The agency shall require that all contractors make all
1133 files and relevant billing and claims data accessible to state
1134 regulators and investigators and that all such data is linked
1135 into a unified system to ensure consistent reviews and
1136 investigations.
1137 (12) For purposes of this section, the term “capitated
1138 managed care plan” includes health insurers authorized under
1139 chapter 624, exclusive provider organizations authorized under
1140 chapter 627, health maintenance organizations authorized under
1141 chapter 641, the Children’s Medical Services Network under
1142 chapter 391, and provider service networks that elect to be paid
1143 fee-for-service for up to 5 3 years as authorized under this
1144 section.
1145 Section 17. Subsection (18) is added to section 430.04,
1146 Florida Statutes, to read:
1147 430.04 Duties and responsibilities of the Department of
1148 Elderly Affairs.—The Department of Elderly Affairs shall:
1149 (18) Administer all Medicaid waivers and programs relating
1150 to elders and their appropriations. The waivers include, but are
1151 not limited to:
1152 (a) The Alzheimer’s Dementia-Specific Medicaid Waiver as
1153 established in s. 430.502(7), (8), and (9).
1154 (b) The Assisted Living for the Frail Elderly Waiver.
1155 (c) The Aged and Disabled Adult Waiver.
1156 (d) The Adult Day Health Care Waiver.
1157 (e) The Consumer Directed Care Plus Program as defined in
1158 s. 409.221.
1159 (f) The Program for All-inclusive Care for the Elderly.
1160 (g) The Long-Term Care Community-Based Diversion Pilot
1161 Project as described in s. 430.705.
1162 (h) The Channeling Services Waiver for Frail Elders.
1163 Section 18. Subsection (4) of section 641.386, Florida
1164 Statutes, is amended to read:
1165 641.386 Agent licensing and appointment required;
1166 exceptions.—
1167 (4) All agents and health maintenance organizations must
1168 shall comply with and be subject to the applicable provisions of
1169 ss. 641.309 and 409.912(20) 409.912(21), and all companies and
1170 entities appointing agents must shall comply with s. 626.451,
1171 when marketing for any health maintenance organization licensed
1172 pursuant to this part, including those organizations under
1173 contract with the Agency for Health Care Administration to
1174 provide health care services to Medicaid recipients or any
1175 private entity providing health care services to Medicaid
1176 recipients pursuant to a prepaid health plan contract with the
1177 Agency for Health Care Administration.
1178 Section 19. The Agency for Health Care Administration shall
1179 develop and implement a home health agency monitoring pilot
1180 project in Miami-Dade County by January 1, 2010. The agency
1181 shall contract with a vendor to verify the utilization and the
1182 delivery of home health services and provide an electronic
1183 billing interface for such services. The contract must require
1184 the creation of a program to submit claims for the home health
1185 services electronically. The program must verify visits for the
1186 delivery of home health services telephonically using voice
1187 biometrics. The agency may seek amendments to the Medicaid state
1188 plan and waivers of federal laws, as necessary, to implement the
1189 pilot project. Notwithstanding s. 287.057(5)(f), Florida
1190 Statutes, the agency must award the contract through the
1191 competitive solicitation process. The agency shall submit a
1192 report to the Governor, the President of the Senate, and the
1193 Speaker of the House of Representatives evaluating the pilot
1194 project by February 1, 2011.
1195 Section 20. The Agency for Health Care Administration shall
1196 implement a comprehensive care management pilot project in
1197 Miami-Dade County for home health services by January 1, 2010,
1198 which includes face-to-face assessments by a state-licensed
1199 nurse, consultation with physicians ordering services to
1200 substantiate the medical necessity for services, and on-site or
1201 desk reviews of recipients’ medical records. The agency may
1202 enter into a contract with a qualified organization to implement
1203 the pilot project. The agency may seek amendments to the
1204 Medicaid state plan and waivers of federal laws, as necessary,
1205 to implement the pilot project.
1206 Section 21. This act shall take effect upon becoming a law.