Florida Senate - 2009                              CS for SB 8-A
       
       
       
       By the Committee on Health and Human Services Appropriations and
       Senator Peaden
       
       
       
       603-00102-09A                                           20098Ac1
    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         409.9082Nursing 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 provided to nursing facility patients, less deductions
  479  from 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” provided in s.
  488  400.021.
  489         (f)“Resident day” means a calendar day of care provided to
  490  a nursing facility resident and includes the day of admission
  491  and excludes the day of discharge, except that, when admission
  492  and discharge occur on the same day, one day of care is deemed
  493  to exist.
  494         (g)“Skilled nursing facility units of acute care
  495  hospitals” means the Medicare or Medicare-certified skilled
  496  nursing beds located in hospitals licensed by the agency under
  497  chapter 395 and defined as such by s. 395.002(10) and (12).
  498         (h)“Fund” means the Grants and Donations Trust Fund of the
  499  Agency for Health Care Administration.
  500         (2)Effective May 1, 2009, the agency shall calculate
  501  annually the quality assessment rates that nonexempt providers
  502  will report and pay on a monthly basis for each non-Medicare
  503  patient day. The quality assessment may not exceed 5 percent of
  504  the total aggregate net patient service revenue of assessed
  505  facilities. The agency shall notify providers of the quality
  506  assessment and provide a standardized form to complete and
  507  submit with payments. The agency shall collect the quality
  508  assessment on health care items or services provided by nursing
  509  facilities for the purpose of obtaining federal financial
  510  participation under the state’s Medicaid program, and shall use
  511  these funds to provide reimbursement up to the Medicaid rates of
  512  nursing facilities as they existed in accordance with the
  513  approved state Medicaid plan in effect on December 31, 2007, so
  514  as to ensure continued quality of care in those facilities. The
  515  quality assessment and federal matching funds shall be used
  516  exclusively for the purposes described in subsection (9).
  517         (3)The quality assessment shall be calculated and paid on
  518  the basis of a per-resident day, exclusive of Medicare Part A
  519  resident days. The per-resident-day assessment rate shall be the
  520  same amount for each affected facility except as prescribed in
  521  subsection (4).
  522         (4)In accordance with the redistribution method set forth
  523  in 42 C.F.R. s. 433.68(e)(1) and (2), the agency shall seek a
  524  waiver of the broad-based and uniform provider assessment
  525  requirements of federal law to exclude certain nursing
  526  facilities from the quality assessment and to permit certain
  527  high-volume Medicaid nursing facilities or nursing facilities
  528  that have a high number of total annual patient days to pay the
  529  quality assessment at a lesser amount per non-Medicare resident
  530  day.
  531         (a)The agency shall exempt the following nursing facility
  532  providers from the quality assessment subject to federal
  533  approval under 42 C.F.R. s. 433.68(e)(2):
  534         1.Nursing facilities on the campus of continuing care
  535  retirement communities licensed by the agency under chapter 651;
  536         2.Nursing facilities that have 45 or fewer beds; and
  537         3.The skilled nursing facility units of acute care
  538  hospitals licensed by the agency under chapter 395.
  539         (b)The agency shall lower the quality assessment for
  540  certain high-volume Medicaid nursing facilities or certain
  541  facilities that have high patient volumes to meet the
  542  redistributive tests of 42 C.F.R. s. 433.68(e)(2).
  543         (5)The collection of the nursing facility quality
  544  assessment shall commence no sooner than 10 days after the
  545  agency’s initial payment of the Medicaid rates containing the
  546  elements prescribed in subsection (9).
  547         (6)If the nursing facility quality assessment and the
  548  broad-based and uniformity waiver are not approved by the
  549  Federal Government, notwithstanding any other provision of this
  550  section, the agency shall return all collected assessment
  551  amounts to the nursing facilities that paid them, less any
  552  amounts expended by the agency as authorized in the General
  553  Appropriations Act for purposes of implementing the assessment,
  554  and shall discontinue the imposition, assessment, and collection
  555  of the nursing facility quality assessment.
  556         (7)The agency shall collect the nursing facility quality
  557  assessment each month and shall collect the assessment from
  558  nursing facility providers by no later than the 15th of the next
  559  succeeding calendar month. The agency shall require nursing
  560  facility providers to report monthly their total number of days
  561  of care provided to non-Medicare Part A residents.
  562         (8)The agency shall adopt any rules necessary for the
  563  administration and implementation of this section.
  564         (9)The fund and all matching federal funds received for
  565  expenditures of the nursing facility quality assessment shall be
  566  used only for the following purposes and in the following order
  567  of priority:
  568         (a)A pass through to reimburse the Medicaid share of the
  569  quality assessment as a Medicaid-allowable cost;
  570         (b)Such increase to each nursing facility’s Medicaid rate
  571  as needed to bring that rate to the same amount or level as the
  572  Medicaid rate for that nursing facility would have been on
  573  January 1, 2008, if the approved Medicaid state plan in effect
  574  on December 31, 2007, had remained in effect;
  575         (c)Such increase to each nursing facility’s Medicaid rates
  576  needed to increase rates for the 2008-2009 fiscal year in
  577  accordance with the approved state plan in effect on December
  578  31, 2007; and
  579         (d)Such increase to each nursing facility’s Medicaid rate
  580  accounting for the portion of the total assessment not included
  581  in paragraphs (a)-(c) which begins a phase-in to a pricing model
  582  for the operating cost component.
  583         (10)The provisions of this section shall become null and
  584  void, having no force and effect, if any of the following occur:
  585         (a)The nursing facility quality assessment and the broad
  586  based and uniformity waiver are not approved by the Federal
  587  Government;
  588         (b)The Medicaid plan amendment reflecting the payment
  589  rates in subsection (9) is not approved by the Federal
  590  Government; or
  591         (c)The weighted average Medicaid rate paid to nursing
  592  facilities is reduced below the weighted average Medicaid rate
  593  to nursing facilities in effect on June 30, 2008, plus any
  594  future annual amount of the quality assessment and the
  595  applicable matching federal funds.
  596         (11)If this section does not become operative or becomes
  597  null and void, all moneys in the fund relating to the assessment
  598  shall be returned on a pro rata basis to the nursing facilities
  599  that paid the quality assessment.
  600         (12)If the nursing facility fails to make its payments
  601  timely, the agency may seek any remedy provided by law,
  602  including, but not limited to:
  603         (a)Withholding any medical assistance reimbursement
  604  payments until such time as the assessment amount is recovered;
  605         (b)Suspension or revocation of the nursing facility
  606  license; or
  607         (c)Imposition of a fine of up to $1,000 per day for each
  608  delinquent payment, not to exceed the amount of the assessment.
  609         (13)Nursing facilities may not create a separate line-item
  610  charge for the purpose of passing through the assessment to
  611  residents.
  612         (14)Moneys in the fund relating to this assessment will
  613  not revert to the General Revenue Fund or to any other state
  614  fund at any time.
  615         Section 4. This act shall take effect March 1, 2009.