Florida Senate - 2009 PROPOSED COMMITTEE SUBSTITUTE
Bill No. SB 8-A
Barcode 220142
603-00060A-09A
Proposed Committee Substitute by the Committee on Health and
Human Services Appropriations
1 A bill to be entitled
2 An act relating to the Medicaid program; amending ss.
3 409.908 and 409.912, F.S.; revising the amount
4 reimbursed to providers and pharmacies for drugs
5 prescribed under the program; creating s. 409.9082,
6 F.S.; providing definitions; requiring the Agency for
7 Health Care Administration to calculate and assess a
8 quality assessment on health care items or services
9 provided by nursing facilities; requiring the agency
10 to seek a waiver of broad-based and uniform provider
11 assessment requirements of federal law; providing for
12 the return of collected assessments under certain
13 circumstances; requiring the agency to adopt rules;
14 providing for the use of moneys in the Grants and
15 Donations Trust Fund and specifying an order of
16 priority; providing for nullification of the quality
17 assessment under certain circumstances; authorizing
18 the agency to impose certain penalties and fines;
19 prohibiting the reversion of moneys in the fund
20 relating to the quality assessment; providing an
21 effective date.
22
23 Be It Enacted by the Legislature of the State of Florida:
24
25 Section 1. Subsection (14) of section 409.908, Florida
26 Statutes, is amended to read:
27 409.908 Reimbursement of Medicaid providers.—Subject to
28 specific appropriations, the agency shall reimburse Medicaid
29 providers, in accordance with state and federal law, according
30 to methodologies set forth in the rules of the agency and in
31 policy manuals and handbooks incorporated by reference therein.
32 These methodologies may include fee schedules, reimbursement
33 methods based on cost reporting, negotiated fees, competitive
34 bidding pursuant to s. 287.057, and other mechanisms the agency
35 considers efficient and effective for purchasing services or
36 goods on behalf of recipients. If a provider is reimbursed based
37 on cost reporting and submits a cost report late and that cost
38 report would have been used to set a lower reimbursement rate
39 for a rate semester, then the provider's rate for that semester
40 shall be retroactively calculated using the new cost report, and
41 full payment at the recalculated rate shall be effected
42 retroactively. Medicare-granted extensions for filing cost
43 reports, if applicable, shall also apply to Medicaid cost
44 reports. Payment for Medicaid compensable services made on
45 behalf of Medicaid eligible persons is subject to the
46 availability of moneys and any limitations or directions
47 provided for in the General Appropriations Act or chapter 216.
48 Further, nothing in this section shall be construed to prevent
49 or limit the agency from adjusting fees, reimbursement rates,
50 lengths of stay, number of visits, or number of services, or
51 making any other adjustments necessary to comply with the
52 availability of moneys and any limitations or directions
53 provided for in the General Appropriations Act, provided the
54 adjustment is consistent with legislative intent.
55 (14) A provider of prescribed drugs shall be reimbursed the
56 least of the amount billed by the provider, the provider's usual
57 and customary charge, or the Medicaid maximum allowable fee
58 established by the agency, plus a dispensing fee. The Medicaid
59 maximum allowable fee for ingredient cost will be based on the
60 lower of: average wholesale price (AWP) minus 18.4 16.4 percent,
61 wholesaler acquisition cost (WAC) plus 2.75 4.75 percent, the
62 federal upper limit (FUL), the state maximum allowable cost
63 (SMAC), or the usual and customary (UAC) charge billed by the
64 provider. Medicaid providers are required to dispense generic
65 drugs if available at lower cost and the agency has not
66 determined that the branded product is more cost-effective,
67 unless the prescriber has requested and received approval to
68 require the branded product. The agency is directed to implement
69 a variable dispensing fee for payments for prescribed medicines
70 while ensuring continued access for Medicaid recipients. The
71 variable dispensing fee may be based upon, but not limited to,
72 either or both the volume of prescriptions dispensed by a
73 specific pharmacy provider, the volume of prescriptions
74 dispensed to an individual recipient, and dispensing of
75 preferred-drug-list products. The agency may increase the
76 pharmacy dispensing fee authorized by statute and in the annual
77 General Appropriations Act by $0.50 for the dispensing of a
78 Medicaid preferred-drug-list product and reduce the pharmacy
79 dispensing fee by $0.50 for the dispensing of a Medicaid product
80 that is not included on the preferred drug list. The agency may
81 establish a supplemental pharmaceutical dispensing fee to be
82 paid to providers returning unused unit-dose packaged
83 medications to stock and crediting the Medicaid program for the
84 ingredient cost of those medications if the ingredient costs to
85 be credited exceed the value of the supplemental dispensing fee.
86 The agency is authorized to limit reimbursement for prescribed
87 medicine in order to comply with any limitations or directions
88 provided for in the General Appropriations Act, which may
89 include implementing a prospective or concurrent utilization
90 review program.
91 Section 2. Subsection (39) of section 409.912, Florida
92 Statutes, is amended to read:
93 409.912 Cost-effective purchasing of health care.—The
94 agency shall purchase goods and services for Medicaid recipients
95 in the most cost-effective manner consistent with the delivery
96 of quality medical care. To ensure that medical services are
97 effectively utilized, the agency may, in any case, require a
98 confirmation or second physician's opinion of the correct
99 diagnosis for purposes of authorizing future services under the
100 Medicaid program. This section does not restrict access to
101 emergency services or poststabilization care services as defined
102 in 42 C.F.R. part 438.114. Such confirmation or second opinion
103 shall be rendered in a manner approved by the agency. The agency
104 shall maximize the use of prepaid per capita and prepaid
105 aggregate fixed-sum basis services when appropriate and other
106 alternative service delivery and reimbursement methodologies,
107 including competitive bidding pursuant to s. 287.057, designed
108 to facilitate the cost-effective purchase of a case-managed
109 continuum of care. The agency shall also require providers to
110 minimize the exposure of recipients to the need for acute
111 inpatient, custodial, and other institutional care and the
112 inappropriate or unnecessary use of high-cost services. The
113 agency shall contract with a vendor to monitor and evaluate the
114 clinical practice patterns of providers in order to identify
115 trends that are outside the normal practice patterns of a
116 provider's professional peers or the national guidelines of a
117 provider's professional association. The vendor must be able to
118 provide information and counseling to a provider whose practice
119 patterns are outside the norms, in consultation with the agency,
120 to improve patient care and reduce inappropriate utilization.
121 The agency may mandate prior authorization, drug therapy
122 management, or disease management participation for certain
123 populations of Medicaid beneficiaries, certain drug classes, or
124 particular drugs to prevent fraud, abuse, overuse, and possible
125 dangerous drug interactions. The Pharmaceutical and Therapeutics
126 Committee shall make recommendations to the agency on drugs for
127 which prior authorization is required. The agency shall inform
128 the Pharmaceutical and Therapeutics Committee of its decisions
129 regarding drugs subject to prior authorization. The agency is
130 authorized to limit the entities it contracts with or enrolls as
131 Medicaid providers by developing a provider network through
132 provider credentialing. The agency may competitively bid single
133 source-provider contracts if procurement of goods or services
134 results in demonstrated cost savings to the state without
135 limiting access to care. The agency may limit its network based
136 on the assessment of beneficiary access to care, provider
137 availability, provider quality standards, time and distance
138 standards for access to care, the cultural competence of the
139 provider network, demographic characteristics of Medicaid
140 beneficiaries, practice and provider-to-beneficiary standards,
141 appointment wait times, beneficiary use of services, provider
142 turnover, provider profiling, provider licensure history,
143 previous program integrity investigations and findings, peer
144 review, provider Medicaid policy and billing compliance records,
145 clinical and medical record audits, and other factors. Providers
146 shall not be entitled to enrollment in the Medicaid provider
147 network. The agency shall determine instances in which allowing
148 Medicaid beneficiaries to purchase durable medical equipment and
149 other goods is less expensive to the Medicaid program than long
150 term rental of the equipment or goods. The agency may establish
151 rules to facilitate purchases in lieu of long-term rentals in
152 order to protect against fraud and abuse in the Medicaid program
153 as defined in s. 409.913. The agency may seek federal waivers
154 necessary to administer these policies.
155 (39)(a) The agency shall implement a Medicaid prescribed
156 drug spending-control program that includes the following
157 components:
158 1. A Medicaid preferred drug list, which shall be a listing
159 of cost-effective therapeutic options recommended by the
160 Medicaid Pharmacy and Therapeutics Committee established
161 pursuant to s. 409.91195 and adopted by the agency for each
162 therapeutic class on the preferred drug list. At the discretion
163 of the committee, and when feasible, the preferred drug list
164 should include at least two products in a therapeutic class. The
165 agency may post the preferred drug list and updates to the
166 preferred drug list on an Internet website without following the
167 rulemaking procedures of chapter 120. Antiretroviral agents are
168 excluded from the preferred drug list. The agency shall also
169 limit the amount of a prescribed drug dispensed to no more than
170 a 34-day supply unless the drug products' smallest marketed
171 package is greater than a 34-day supply, or the drug is
172 determined by the agency to be a maintenance drug in which case
173 a 100-day maximum supply may be authorized. The agency is
174 authorized to seek any federal waivers necessary to implement
175 these cost-control programs and to continue participation in the
176 federal Medicaid rebate program, or alternatively to negotiate
177 state-only manufacturer rebates. The agency may adopt rules to
178 implement this subparagraph. The agency shall continue to
179 provide unlimited contraceptive drugs and items. The agency must
180 establish procedures to ensure that:
181 a. There is a response to a request for prior consultation
182 by telephone or other telecommunication device within 24 hours
183 after receipt of a request for prior consultation; and
184 b. A 72-hour supply of the drug prescribed is provided in
185 an emergency or when the agency does not provide a response
186 within 24 hours as required by sub-subparagraph a.
187 2. Reimbursement to pharmacies for Medicaid prescribed
188 drugs shall be set at the lesser of: the average wholesale price
189 (AWP) minus 18.4 16.4 percent, the wholesaler acquisition cost
190 (WAC) plus 2.75 4.75 percent, the federal upper limit (FUL), the
191 state maximum allowable cost (SMAC), or the usual and customary
192 (UAC) charge billed by the provider.
193 3. The agency shall develop and implement a process for
194 managing the drug therapies of Medicaid recipients who are using
195 significant numbers of prescribed drugs each month. The
196 management process may include, but is not limited to,
197 comprehensive, physician-directed medical-record reviews, claims
198 analyses, and case evaluations to determine the medical
199 necessity and appropriateness of a patient's treatment plan and
200 drug therapies. The agency may contract with a private
201 organization to provide drug-program-management services. The
202 Medicaid drug benefit management program shall include
203 initiatives to manage drug therapies for HIV/AIDS patients,
204 patients using 20 or more unique prescriptions in a 180-day
205 period, and the top 1,000 patients in annual spending. The
206 agency shall enroll any Medicaid recipient in the drug benefit
207 management program if he or she meets the specifications of this
208 provision and is not enrolled in a Medicaid health maintenance
209 organization.
210 4. The agency may limit the size of its pharmacy network
211 based on need, competitive bidding, price negotiations,
212 credentialing, or similar criteria. The agency shall give
213 special consideration to rural areas in determining the size and
214 location of pharmacies included in the Medicaid pharmacy
215 network. A pharmacy credentialing process may include criteria
216 such as a pharmacy's full-service status, location, size,
217 patient educational programs, patient consultation, disease
218 management services, and other characteristics. The agency may
219 impose a moratorium on Medicaid pharmacy enrollment when it is
220 determined that it has a sufficient number of Medicaid
221 participating providers. The agency must allow dispensing
222 practitioners to participate as a part of the Medicaid pharmacy
223 network regardless of the practitioner's proximity to any other
224 entity that is dispensing prescription drugs under the Medicaid
225 program. A dispensing practitioner must meet all credentialing
226 requirements applicable to his or her practice, as determined by
227 the agency.
228 5. The agency shall develop and implement a program that
229 requires Medicaid practitioners who prescribe drugs to use a
230 counterfeit-proof prescription pad for Medicaid prescriptions.
231 The agency shall require the use of standardized counterfeit
232 proof prescription pads by Medicaid-participating prescribers or
233 prescribers who write prescriptions for Medicaid recipients. The
234 agency may implement the program in targeted geographic areas or
235 statewide.
236 6. The agency may enter into arrangements that require
237 manufacturers of generic drugs prescribed to Medicaid recipients
238 to provide rebates of at least 15.1 percent of the average
239 manufacturer price for the manufacturer's generic products.
240 These arrangements shall require that if a generic-drug
241 manufacturer pays federal rebates for Medicaid-reimbursed drugs
242 at a level below 15.1 percent, the manufacturer must provide a
243 supplemental rebate to the state in an amount necessary to
244 achieve a 15.1-percent rebate level.
245 7. The agency may establish a preferred drug list as
246 described in this subsection, and, pursuant to the establishment
247 of such preferred drug list, it is authorized to negotiate
248 supplemental rebates from manufacturers that are in addition to
249 those required by Title XIX of the Social Security Act and at no
250 less than 14 percent of the average manufacturer price as
251 defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
252 the federal or supplemental rebate, or both, equals or exceeds
253 29 percent. There is no upper limit on the supplemental rebates
254 the agency may negotiate. The agency may determine that specific
255 products, brand-name or generic, are competitive at lower rebate
256 percentages. Agreement to pay the minimum supplemental rebate
257 percentage will guarantee a manufacturer that the Medicaid
258 Pharmaceutical and Therapeutics Committee will consider a
259 product for inclusion on the preferred drug list. However, a
260 pharmaceutical manufacturer is not guaranteed placement on the
261 preferred drug list by simply paying the minimum supplemental
262 rebate. Agency decisions will be made on the clinical efficacy
263 of a drug and recommendations of the Medicaid Pharmaceutical and
264 Therapeutics Committee, as well as the price of competing
265 products minus federal and state rebates. The agency is
266 authorized to contract with an outside agency or contractor to
267 conduct negotiations for supplemental rebates. For the purposes
268 of this section, the term “supplemental rebates” means cash
269 rebates. Effective July 1, 2004, value-added programs as a
270 substitution for supplemental rebates are prohibited. The agency
271 is authorized to seek any federal waivers to implement this
272 initiative.
273 8. The Agency for Health Care Administration shall expand
274 home delivery of pharmacy products. To assist Medicaid patients
275 in securing their prescriptions and reduce program costs, the
276 agency shall expand its current mail-order-pharmacy diabetes
277 supply program to include all generic and brand-name drugs used
278 by Medicaid patients with diabetes. Medicaid recipients in the
279 current program may obtain nondiabetes drugs on a voluntary
280 basis. This initiative is limited to the geographic area covered
281 by the current contract. The agency may seek and implement any
282 federal waivers necessary to implement this subparagraph.
283 9. The agency shall limit to one dose per month any drug
284 prescribed to treat erectile dysfunction.
285 10.a. The agency may implement a Medicaid behavioral drug
286 management system. The agency may contract with a vendor that
287 has experience in operating behavioral drug management systems
288 to implement this program. The agency is authorized to seek
289 federal waivers to implement this program.
290 b. The agency, in conjunction with the Department of
291 Children and Family Services, may implement the Medicaid
292 behavioral drug management system that is designed to improve
293 the quality of care and behavioral health prescribing practices
294 based on best practice guidelines, improve patient adherence to
295 medication plans, reduce clinical risk, and lower prescribed
296 drug costs and the rate of inappropriate spending on Medicaid
297 behavioral drugs. The program may include the following
298 elements:
299 (I) Provide for the development and adoption of best
300 practice guidelines for behavioral health-related drugs such as
301 antipsychotics, antidepressants, and medications for treating
302 bipolar disorders and other behavioral conditions; translate
303 them into practice; review behavioral health prescribers and
304 compare their prescribing patterns to a number of indicators
305 that are based on national standards; and determine deviations
306 from best practice guidelines.
307 (II) Implement processes for providing feedback to and
308 educating prescribers using best practice educational materials
309 and peer-to-peer consultation.
310 (III) Assess Medicaid beneficiaries who are outliers in
311 their use of behavioral health drugs with regard to the numbers
312 and types of drugs taken, drug dosages, combination drug
313 therapies, and other indicators of improper use of behavioral
314 health drugs.
315 (IV) Alert prescribers to patients who fail to refill
316 prescriptions in a timely fashion, are prescribed multiple same
317 class behavioral health drugs, and may have other potential
318 medication problems.
319 (V) Track spending trends for behavioral health drugs and
320 deviation from best practice guidelines.
321 (VI) Use educational and technological approaches to
322 promote best practices, educate consumers, and train prescribers
323 in the use of practice guidelines.
324 (VII) Disseminate electronic and published materials.
325 (VIII) Hold statewide and regional conferences.
326 (IX) Implement a disease management program with a model
327 quality-based medication component for severely mentally ill
328 individuals and emotionally disturbed children who are high
329 users of care.
330 11.a. The agency shall implement a Medicaid prescription
331 drug management system. The agency may contract with a vendor
332 that has experience in operating prescription drug management
333 systems in order to implement this system. Any management system
334 that is implemented in accordance with this subparagraph must
335 rely on cooperation between physicians and pharmacists to
336 determine appropriate practice patterns and clinical guidelines
337 to improve the prescribing, dispensing, and use of drugs in the
338 Medicaid program. The agency may seek federal waivers to
339 implement this program.
340 b. The drug management system must be designed to improve
341 the quality of care and prescribing practices based on best
342 practice guidelines, improve patient adherence to medication
343 plans, reduce clinical risk, and lower prescribed drug costs and
344 the rate of inappropriate spending on Medicaid prescription
345 drugs. The program must:
346 (I) Provide for the development and adoption of best
347 practice guidelines for the prescribing and use of drugs in the
348 Medicaid program, including translating best practice guidelines
349 into practice; reviewing prescriber patterns and comparing them
350 to indicators that are based on national standards and practice
351 patterns of clinical peers in their community, statewide, and
352 nationally; and determine deviations from best practice
353 guidelines.
354 (II) Implement processes for providing feedback to and
355 educating prescribers using best practice educational materials
356 and peer-to-peer consultation.
357 (III) Assess Medicaid recipients who are outliers in their
358 use of a single or multiple prescription drugs with regard to
359 the numbers and types of drugs taken, drug dosages, combination
360 drug therapies, and other indicators of improper use of
361 prescription drugs.
362 (IV) Alert prescribers to patients who fail to refill
363 prescriptions in a timely fashion, are prescribed multiple drugs
364 that may be redundant or contraindicated, or may have other
365 potential medication problems.
366 (V) Track spending trends for prescription drugs and
367 deviation from best practice guidelines.
368 (VI) Use educational and technological approaches to
369 promote best practices, educate consumers, and train prescribers
370 in the use of practice guidelines.
371 (VII) Disseminate electronic and published materials.
372 (VIII) Hold statewide and regional conferences.
373 (IX) Implement disease management programs in cooperation
374 with physicians and pharmacists, along with a model quality
375 based medication component for individuals having chronic
376 medical conditions.
377 12. The agency is authorized to contract for drug rebate
378 administration, including, but not limited to, calculating
379 rebate amounts, invoicing manufacturers, negotiating disputes
380 with manufacturers, and maintaining a database of rebate
381 collections.
382 13. The agency may specify the preferred daily dosing form
383 or strength for the purpose of promoting best practices with
384 regard to the prescribing of certain drugs as specified in the
385 General Appropriations Act and ensuring cost-effective
386 prescribing practices.
387 14. The agency may require prior authorization for
388 Medicaid-covered prescribed drugs. The agency may, but is not
389 required to, prior-authorize the use of a product:
390 a. For an indication not approved in labeling;
391 b. To comply with certain clinical guidelines; or
392 c. If the product has the potential for overuse, misuse, or
393 abuse.
394 The agency may require the prescribing professional to provide
395 information about the rationale and supporting medical evidence
396 for the use of a drug. The agency may post prior authorization
397 criteria and protocol and updates to the list of drugs that are
398 subject to prior authorization on an Internet website without
399 amending its rule or engaging in additional rulemaking.
400 15. The agency, in conjunction with the Pharmaceutical and
401 Therapeutics Committee, may require age-related prior
402 authorizations for certain prescribed drugs. The agency may
403 preauthorize the use of a drug for a recipient who may not meet
404 the age requirement or may exceed the length of therapy for use
405 of this product as recommended by the manufacturer and approved
406 by the Food and Drug Administration. Prior authorization may
407 require the prescribing professional to provide information
408 about the rationale and supporting medical evidence for the use
409 of a drug.
410 16. The agency shall implement a step-therapy prior
411 authorization approval process for medications excluded from the
412 preferred drug list. Medications listed on the preferred drug
413 list must be used within the previous 12 months prior to the
414 alternative medications that are not listed. The step-therapy
415 prior authorization may require the prescriber to use the
416 medications of a similar drug class or for a similar medical
417 indication unless contraindicated in the Food and Drug
418 Administration labeling. The trial period between the specified
419 steps may vary according to the medical indication. The step
420 therapy approval process shall be developed in accordance with
421 the committee as stated in s. 409.91195(7) and (8). A drug
422 product may be approved without meeting the step-therapy prior
423 authorization criteria if the prescribing physician provides the
424 agency with additional written medical or clinical documentation
425 that the product is medically necessary because:
426 a. There is not a drug on the preferred drug list to treat
427 the disease or medical condition which is an acceptable clinical
428 alternative;
429 b. The alternatives have been ineffective in the treatment
430 of the beneficiary's disease; or
431 c. Based on historic evidence and known characteristics of
432 the patient and the drug, the drug is likely to be ineffective,
433 or the number of doses have been ineffective.
434 The agency shall work with the physician to determine the best
435 alternative for the patient. The agency may adopt rules waiving
436 the requirements for written clinical documentation for specific
437 drugs in limited clinical situations.
438 17. The agency shall implement a return and reuse program
439 for drugs dispensed by pharmacies to institutional recipients,
440 which includes payment of a $5 restocking fee for the
441 implementation and operation of the program. The return and
442 reuse program shall be implemented electronically and in a
443 manner that promotes efficiency. The program must permit a
444 pharmacy to exclude drugs from the program if it is not
445 practical or cost-effective for the drug to be included and must
446 provide for the return to inventory of drugs that cannot be
447 credited or returned in a cost-effective manner. The agency
448 shall determine if the program has reduced the amount of
449 Medicaid prescription drugs which are destroyed on an annual
450 basis and if there are additional ways to ensure more
451 prescription drugs are not destroyed which could safely be
452 reused. The agency's conclusion and recommendations shall be
453 reported to the Legislature by December 1, 2005.
454 (b) The agency shall implement this subsection to the
455 extent that funds are appropriated to administer the Medicaid
456 prescribed-drug spending-control program. The agency may
457 contract all or any part of this program to private
458 organizations.
459 (c) The agency shall submit quarterly reports to the
460 Governor, the President of the Senate, and the Speaker of the
461 House of Representatives which must include, but need not be
462 limited to, the progress made in implementing this subsection
463 and its effect on Medicaid prescribed-drug expenditures.
464 Section 3. Section 409.9082, Florida Statutes, is created
465 to read:
466 409.9082 Nursing facility quality assessment; uses of
467 revenues and matching federal funds.—
468 (1) As used in this section, the term:
469 (a) “Certain high-volume Medicaid nursing facilities” means
470 the fewest number of facilities necessary and having the highest
471 number of Medicaid days or total patient days annually to meet
472 the statistical redistribution test under 42 C.F.R. s.
473 433.68(e)(2).
474 (b) “Medicare Part A resident days” means those patient
475 days funded by the Medicare program or by a Medicare Advantage
476 or special needs plan.
477 (c) “Net patient service revenue” means gross revenues from
478 services to nursing facility patients, less deductions from
479 revenue.
480 (d) “Deductions from revenue” means reductions from gross
481 revenue resulting from an inability to collect payment of
482 charges. Such reductions include bad debts; contractual
483 adjustments; uncompensated care; administrative, courtesy, and
484 policy discounts and adjustments; and other such revenue
485 deductions.
486 (e) “Nursing facility” or “nursing home” has the same
487 meaning as the term “nursing home facility” in s. 400.021.
488 (f) “Resident day” means a calendar day of care provided to
489 a nursing facility resident and includes the day of admission
490 and excludes the day of discharge, except that, when admission
491 and discharge occur on the same day, one day of care is deemed
492 to exist.
493 (g) “Skilled nursing facility units of acute care
494 hospitals” means the Medicare or Medicare-certified skilled
495 nursing beds located in hospitals licensed by the agency under
496 chapter 395 and defined as such by s. 395.002(10) and (12).
497 (h) “Fund” means the Grants and Donations Trust Fund of the
498 Agency for Health Care Administration.
499 (2) Effective May 1, 2009, the agency shall calculate
500 annually the quality assessment rates that nonexempt providers
501 will report and pay on a monthly basis for each non-Medicare
502 patient day. The quality assessment may not exceed 5 percent of
503 the total aggregate net patient service revenue of assessed
504 facilities. The agency shall notify providers of the quality
505 assessment and provide a standardized form to complete and
506 submit with payments. The agency shall collect the quality
507 assessment on health care items or services provided by nursing
508 facilities for the purpose of obtaining federal financial
509 participation under the state’s Medicaid program, and shall use
510 these funds to provide reimbursement up to the Medicaid rates of
511 nursing facilities as they existed in accordance with the
512 approved state Medicaid plan in effect on December 31, 2007, so
513 as to ensure continued quality of care in those facilities. The
514 quality assessment and federal matching funds shall be used
515 exclusively for the purposes described in subsection (9).
516 (3) The quality assessment shall be calculated and paid on
517 the basis of a per-resident day, exclusive of Medicare Part A
518 resident days. The per-resident-day assessment rate shall be the
519 same amount for each affected facility except as prescribed in
520 subsection (4).
521 (4) In accordance with the redistribution method set forth
522 in 42 C.F.R. s. 433.68(e)(1) and (2), the agency shall seek a
523 waiver of the broad-based and uniform provider assessment
524 requirements of federal law to exclude certain nursing
525 facilities from the quality assessment and to permit certain
526 high-volume Medicaid nursing facilities or nursing facilities
527 that have a high number of total annual patient days to pay the
528 quality assessment at a lesser amount per non-Medicare resident
529 day.
530 (a) The agency shall exempt the following nursing facility
531 providers from the quality assessment subject to federal
532 approval under 42 C.F.R. s. 433.68(e)(2):
533 1. Nursing facilities on the campus of continuing care
534 retirement communities licensed by the agency under chapter 651;
535 2. Nursing facilities that have 45 or fewer beds; and
536 3. The skilled nursing facility units of acute care
537 hospitals licensed by the agency under chapter 395.
538 (b) The agency shall lower the quality assessment for
539 certain high-volume Medicaid nursing facilities or certain
540 facilities that have high patient volumes to meet the
541 redistributive tests of 42 C.F.R. s. 433.68(e)(2).
542 (5) The collection of the nursing facility quality
543 assessment shall commence no sooner than 10 days after the
544 agency’s initial payment of the Medicaid rates containing the
545 elements prescribed in subsection (9).
546 (6) If the nursing facility quality assessment and the
547 broad-based and uniformity waiver are not approved by the
548 Federal Government, notwithstanding any other provision of this
549 section, the agency shall return all collected assessment
550 amounts to the nursing facilities that paid them, less any
551 amounts expended by the agency as authorized in the General
552 Appropriations Act for purposes of implementing the assessment,
553 and shall discontinue the imposition, assessment, and collection
554 of the nursing facility quality assessment.
555 (7) The agency shall collect the nursing facility quality
556 assessment each month and shall collect the assessment from
557 nursing facility providers by no later than the 15th of the next
558 succeeding calendar month. The agency shall require nursing
559 facility providers to report monthly their total number of days
560 of care provided to non-Medicare Part A residents.
561 (8) The agency shall adopt any rules necessary for the
562 administration and implementation of this section.
563 (9) The fund and all matching federal funds received for
564 expenditures of the nursing facility quality assessment shall be
565 used only for the following purposes and in the following order
566 of priority:
567 (a) A pass through to reimburse the Medicaid share of the
568 quality assessment as a Medicaid-allowable cost;
569 (b) Such increase to each nursing facility’s Medicaid rate
570 as needed to bring that rate to the same amount or level as the
571 Medicaid rate for that nursing facility would have been on
572 January 1, 2008, if the approved Medicaid state plan in effect
573 on December 31, 2007, had remained in effect;
574 (c) Such increase to each nursing facility’s Medicaid rates
575 needed to increase rates for the 2008-2009 fiscal year in
576 accordance with the approved state plan in effect on December
577 31, 2007; and
578 (d) Such increase to each nursing facility’s Medicaid rate
579 accounting for the portion of the total assessment not included
580 in paragraphs (a)-(c) which begins a phase-in to a pricing model
581 for the operating cost component.
582 (10) The provisions of this section shall become null and
583 void, having no force and effect, if any of the following occur:
584 (a) The nursing facility quality assessment and the broad
585 based and uniformity waiver are not approved by the Federal
586 Government;
587 (b) The Medicaid plan amendment reflecting the payment
588 rates in subsection (9) is not approved by the Federal
589 Government; or
590 (c) The weighted average Medicaid rate paid to nursing
591 facilities is reduced below the weighted average Medicaid rate
592 to nursing facilities in effect on June 30, 2008, plus any
593 future annual amount of the quality assessment and the
594 applicable matching federal funds.
595 (11) If this section does not become operative or becomes
596 null and void, all moneys in the fund relating to the assessment
597 shall be returned on a pro rata basis to the nursing facilities
598 that paid the quality assessment.
599 (12) If the nursing facility fails to make its payments
600 timely, the agency may seek any remedy provided by law,
601 including, but not limited to:
602 (a) Withholding any medical assistance reimbursement
603 payments until such time as the assessment amount is recovered;
604 (b) Suspension or revocation of the nursing facility
605 license; or
606 (c) Imposition of a fine of up to $1,000 per day for each
607 delinquent payment, not to exceed the amount of the assessment.
608 (13) Nursing facilities may not create a separate line-item
609 charge for the purpose of passing through the assessment to
610 residents.
611 (14) Moneys in the fund relating to this assessment will
612 not revert to the General Revenue Fund or to any other state
613 fund at any time.
614 Section 4. This act shall take effect March 1, 2009.