HB 5301

1	A bill to be entitled
2	An act relating to Medicaid services; amending s. 400.141,
3	F.S.; conforming a cross-reference to changes made by the
4	act; amending s. 400.23, F.S.; providing for flexibility
5	in how to meet the minimum staffing requirements for
6	nursing home facilities; amending s. 409.903, F.S.;
7	eliminating eligibility and coverage for women during
8	pregnancy and the postpartum period who live in a family
9	that has an income at or below a specified percentage of
10	the federal poverty level; amending s. 409.904, F.S.;
11	revising the expiration date of provisions authorizing the
12	federal waiver for certain persons age 65 and over or who
13	have a disability; revising the expiration date of
14	provisions authorizing a specified medically needy
15	program; amending s. 409.906, F.S.; eliminating optional
16	adult Medicaid coverage for chiropractic services for
17	adult recipients; amending s. 409.908, F.S.; updating the
18	formula used for calculating reimbursements to providers
19	of prescribed drugs; amending s. 409.9082, F.S.; revising
20	the purpose of the use of the nursing home facility
21	quality assessment and federal matching funds; amending s.
22	409.9083, F.S.; revising the purpose of the use of the
23	privately operated intermediate care facilities for the
24	developmentally disabled quality assessment and federal
25	matching funds; amending s. 409.911, F.S.; updating the
26	data to be used in calculating disproportionate share;
27	revising the formula used to pay disproportionate share
28	dollars to provider service network hospitals; amending s.
29	409.9112, F.S.; continuing the prohibition against
30	distributing moneys under the perinatal intensive care
31	centers disproportionate share program; amending s.
32	409.9113, F.S.; continuing authorization for the
33	distribution of moneys to teaching hospitals under the
34	disproportionate share program; amending s. 409.9117,
35	F.S.; continuing the prohibition against distributing
36	moneys under the primary care disproportionate share
37	program; amending s. 409.912, F.S.; updating the formula
38	used for calculating reimbursements to providers of
39	prescribed drugs; amending s. 430.707, F.S.; permitting
40	the Agency for Health Care Administration, in consultation
41	with the Department of Elderly Affairs, to accept and
42	forward an application for expansion of service capacity
43	to the Centers for Medicare and Medicaid Services for a
44	specified entity that provides benefits under the Program
45	of All-inclusive Care for the Elderly; providing an
46	effective date.
47
48	Be It Enacted by the Legislature of the State of Florida:
49
50	Section 1.  Paragraph (o) of subsection (1) of section
51	400.141, Florida Statutes, is amended to read:
52	400.141  Administration and management of nursing home
53	facilities.-
54	(1)  Every licensed facility shall comply with all
55	applicable standards and rules of the agency and shall:
56	(o)1.  Submit semiannually to the agency, or more
57	frequently if requested by the agency, information regarding
58	facility staff-to-resident ratios, staff turnover, and staff
59	stability, including information regarding certified nursing
60	assistants, licensed nurses, the director of nursing, and the
61	facility administrator. For purposes of this reporting:
62	a.  Staff-to-resident ratios must be reported in the
63	categories specified in s. 400.23(3)(a) and applicable rules.
64	The ratio must be reported as an average for the most recent
65	calendar quarter.
66	b.  Staff turnover must be reported for the most recent 12-
67	month period ending on the last workday of the most recent
68	calendar quarter prior to the date the information is submitted.
69	The turnover rate must be computed quarterly, with the annual
70	rate being the cumulative sum of the quarterly rates. The
71	turnover rate is the total number of terminations or separations
72	experienced during the quarter, excluding any employee
73	terminated during a probationary period of 3 months or less,
74	divided by the total number of staff employed at the end of the
75	period for which the rate is computed, and expressed as a
76	percentage.
77	c.  The formula for determining staff stability is the
78	total number of employees that have been employed for more than
79	12 months, divided by the total number of employees employed at
80	the end of the most recent calendar quarter, and expressed as a
81	percentage.
82	d.  A nursing facility that has failed to comply with state
83	minimum-staffing requirements for 2 consecutive days is
84	prohibited from accepting new admissions until the facility has
85	achieved the minimum-staffing requirements for a period of 6
86	consecutive days. For the purposes of this sub-subparagraph, any
87	person who was a resident of the facility and was absent from
88	the facility for the purpose of receiving medical care at a
89	separate location or was on a leave of absence is not considered
90	a new admission. Failure to impose such an admissions moratorium
91	constitutes a class II deficiency.
92	e.  A nursing facility which does not have a conditional
93	license may be cited for failure to comply with the standards in
94	s. 400.23(3)(a)1.b. and c. s. 400.23(3)(a)1.a. only if it has
95	failed to meet those standards on 2 consecutive days or if it
96	has failed to meet at least 97 percent of those standards on any
97	one day.
98	f.  A facility which has a conditional license must be in
99	compliance with the standards in s. 400.23(3)(a) at all times.
100	2.  This paragraph does not limit the agency's ability to
101	impose a deficiency or take other actions if a facility does not
102	have enough staff to meet the residents' needs.
103	Section 2.  Paragraph (a) of subsection (3) of section
104	400.23, Florida Statutes, is amended to read:
105	400.23  Rules; evaluation and deficiencies; licensure
106	status.-
107	(3)(a)1.  The agency shall adopt rules providing minimum
108	staffing requirements for nursing homes. These requirements
109	shall include, for each nursing home facility:
110	a.  A minimum weekly average of certified nursing assistant
111	and licensed nursing staffing combined of 3.9 hours of direct
112	care per resident per day. As used in this sub-subparagraph, a
113	week is defined as Sunday through Saturday.
114	b.  A minimum certified nursing assistant staffing of 2.7
115	hours of direct care per resident per day. A facility may not
116	staff below one certified nursing assistant per 20 residents.
117	c.  A minimum licensed nursing staffing of 1.0 hour of
118	direct care per resident per day. A facility may not staff below
119	one licensed nurse per 40 residents.
120	a.  A minimum certified nursing assistant staffing of 2.6
121	hours of direct care per resident per day beginning January 1,
122	2003, and increasing to 2.7 hours of direct care per resident
123	per day beginning January 1, 2007. Beginning January 1, 2002, no
124	facility shall staff below one certified nursing assistant per
125	20 residents, and a minimum licensed nursing staffing of 1.0
126	hour of direct care per resident per day but never below one
127	licensed nurse per 40 residents.
128	b.  Beginning January 1, 2007, a minimum weekly average
129	certified nursing assistant staffing of 2.9 hours of direct care
130	per resident per day. For the purpose of this sub-subparagraph,
131	a week is defined as Sunday through Saturday.
132	2.  Nursing assistants employed under s. 400.211(2) may be
133	included in computing the staffing ratio for certified nursing
134	assistants only if their job responsibilities include only
135	nursing-assistant-related duties.
136	3.  Each nursing home must document compliance with
137	staffing standards as required under this paragraph and post
138	daily the names of staff on duty for the benefit of facility
139	residents and the public.
140	4.  The agency shall recognize the use of licensed nurses
141	for compliance with minimum staffing requirements for certified
142	nursing assistants, provided that the facility otherwise meets
143	the minimum staffing requirements for licensed nurses and that
144	the licensed nurses are performing the duties of a certified
145	nursing assistant. Unless otherwise approved by the agency,
146	licensed nurses counted toward the minimum staffing requirements
147	for certified nursing assistants must exclusively perform the
148	duties of a certified nursing assistant for the entire shift and
149	not also be counted toward the minimum staffing requirements for
150	licensed nurses. If the agency approved a facility's request to
151	use a licensed nurse to perform both licensed nursing and
152	certified nursing assistant duties, the facility must allocate
153	the amount of staff time specifically spent on certified nursing
154	assistant duties for the purpose of documenting compliance with
155	minimum staffing requirements for certified and licensed nursing
156	staff. In no event may the hours of a licensed nurse with dual
157	job responsibilities be counted twice.
158	Section 3. Subsection (5) of section 409.903, Florida
159	Statutes, is amended to read:
160	409.903  Mandatory payments for eligible persons.-The
161	agency shall make payments for medical assistance and related
162	services on behalf of the following persons who the department,
163	or the Social Security Administration by contract with the
164	Department of Children and Family Services, determines to be
165	eligible, subject to the income, assets, and categorical
166	eligibility tests set forth in federal and state law. Payment on
167	behalf of these Medicaid eligible persons is subject to the
168	availability of moneys and any limitations established by the
169	General Appropriations Act or chapter 216.
170	(5)  A pregnant woman for the duration of her pregnancy and
171	for the postpartum period as defined in federal law and rule, or
172	a child under age 1, if either is living in a family that has an
173	income which is at or below 150 percent of the most current
174	federal poverty level, or, effective January 1, 2011 1992, a
175	child under age 1 who is living in a family that has an income
176	which is at or below 185 percent of the most current federal
177	poverty level. Such a person is not subject to an assets test.
178	Further, a pregnant woman who applies for eligibility for the
179	Medicaid program through a qualified Medicaid provider must be
180	offered the opportunity, subject to federal rules, to be made
181	presumptively eligible for the Medicaid program.
182	Section 4.  Subsections (1) and (2) of section 409.904,
183	Florida Statutes, are amended to read:
184	409.904  Optional payments for eligible persons.-The agency
185	may make payments for medical assistance and related services on
186	behalf of the following persons who are determined to be
187	eligible subject to the income, assets, and categorical
188	eligibility tests set forth in federal and state law. Payment on
189	behalf of these Medicaid eligible persons is subject to the
190	availability of moneys and any limitations established by the
191	General Appropriations Act or chapter 216.
192	(1)  Effective January 1, 2006, and subject to federal
193	waiver approval, a person who is age 65 or older or is
194	determined to be disabled, whose income is at or below 88
195	percent of the federal poverty level, whose assets do not exceed
196	established limitations, and who is not eligible for Medicare
197	or, if eligible for Medicare, is also eligible for and receiving
198	Medicaid-covered institutional care services, hospice services,
199	or home and community-based services. The agency shall seek
200	federal authorization through a waiver to provide this coverage.
201	This subsection expires June 30, 2011 December 31, 2010.
202	(2)(a)  A family, a pregnant woman, a child under age 21, a
203	person age 65 or over, or a blind or disabled person, who would
204	be eligible under any group listed in s. 409.903(1), (2), or
205	(3), except that the income or assets of such family or person
206	exceed established limitations. For a family or person in one of
207	these coverage groups, medical expenses are deductible from
208	income in accordance with federal requirements in order to make
209	a determination of eligibility. A family or person eligible
210	under the coverage known as the "medically needy," is eligible
211	to receive the same services as other Medicaid recipients, with
212	the exception of services in skilled nursing facilities and
213	intermediate care facilities for the developmentally disabled.
214	This paragraph expires June 30, 2011 December 31, 2010.
215	(b)  Effective July 1, 2011 January 1, 2011, a pregnant
216	woman or a child younger than 21 years of age who would be
217	eligible under any group listed in s. 409.903, except that the
218	income or assets of such group exceed established limitations.
219	For a person in one of these coverage groups, medical expenses
220	are deductible from income in accordance with federal
221	requirements in order to make a determination of eligibility. A
222	person eligible under the coverage known as the "medically
223	needy" is eligible to receive the same services as other
224	Medicaid recipients, with the exception of services in skilled
225	nursing facilities and intermediate care facilities for the
226	developmentally disabled.
227	Section 5.  Subsection (7) of section 409.906, Florida
228	Statutes, is amended to read:
229	409.906  Optional Medicaid services.-Subject to specific
230	appropriations, the agency may make payments for services which
231	are optional to the state under Title XIX of the Social Security
232	Act and are furnished by Medicaid providers to recipients who
233	are determined to be eligible on the dates on which the services
234	were provided. Any optional service that is provided shall be
235	provided only when medically necessary and in accordance with
236	state and federal law. Optional services rendered by providers
237	in mobile units to Medicaid recipients may be restricted or
238	prohibited by the agency. Nothing in this section shall be
239	construed to prevent or limit the agency from adjusting fees,
240	reimbursement rates, lengths of stay, number of visits, or
241	number of services, or making any other adjustments necessary to
242	comply with the availability of moneys and any limitations or
243	directions provided for in the General Appropriations Act or
244	chapter 216. If necessary to safeguard the state's systems of
245	providing services to elderly and disabled persons and subject
246	to the notice and review provisions of s. 216.177, the Governor
247	may direct the Agency for Health Care Administration to amend
248	the Medicaid state plan to delete the optional Medicaid service
249	known as "Intermediate Care Facilities for the Developmentally
250	Disabled." Optional services may include:
251	(7)  CHIROPRACTIC SERVICES.-The agency may pay for manual
252	manipulation of the spine and initial services, screening, and X
253	rays provided to a recipient under the age of 21 by a licensed
254	chiropractic physician.
255	Section 6.  Subsection (14) of section 409.908, Florida
256	Statutes, is amended to read:
257	409.908  Reimbursement of Medicaid providers.-Subject to
258	specific appropriations, the agency shall reimburse Medicaid
259	providers, in accordance with state and federal law, according
260	to methodologies set forth in the rules of the agency and in
261	policy manuals and handbooks incorporated by reference therein.
262	These methodologies may include fee schedules, reimbursement
263	methods based on cost reporting, negotiated fees, competitive
264	bidding pursuant to s. 287.057, and other mechanisms the agency
265	considers efficient and effective for purchasing services or
266	goods on behalf of recipients. If a provider is reimbursed based
267	on cost reporting and submits a cost report late and that cost
268	report would have been used to set a lower reimbursement rate
269	for a rate semester, then the provider's rate for that semester
270	shall be retroactively calculated using the new cost report, and
271	full payment at the recalculated rate shall be effected
272	retroactively. Medicare-granted extensions for filing cost
273	reports, if applicable, shall also apply to Medicaid cost
274	reports. Payment for Medicaid compensable services made on
275	behalf of Medicaid eligible persons is subject to the
276	availability of moneys and any limitations or directions
277	provided for in the General Appropriations Act or chapter 216.
278	Further, nothing in this section shall be construed to prevent
279	or limit the agency from adjusting fees, reimbursement rates,
280	lengths of stay, number of visits, or number of services, or
281	making any other adjustments necessary to comply with the
282	availability of moneys and any limitations or directions
283	provided for in the General Appropriations Act, provided the
284	adjustment is consistent with legislative intent.
285	(14)  A provider of prescribed drugs shall be reimbursed
286	the least of the amount billed by the provider, the provider's
287	usual and customary charge, or the Medicaid maximum allowable
288	fee established by the agency, plus a dispensing fee. The
289	Medicaid maximum allowable fee for ingredient cost shall will be
290	based on the lowest lower of: the average wholesale price (AWP)
291	minus 16.4 percent, the wholesaler acquisition cost (WAC) plus
292	4.75 percent, the federal upper limit (FUL), the state maximum
293	allowable cost (SMAC), or the usual and customary (UAC) charge
294	billed by the provider. Effective March 1, 2011, the Medicaid
295	maximum allowable fee for ingredient cost shall be based on the
296	lowest of: the wholesaler acquisition cost (WAC), the federal
297	upper limit (FUL), the state maximum allowable cost (SMAC), or
298	the usual and customary (UAC) charge billed by the provider.
299	Medicaid providers are required to dispense generic drugs if
300	available at lower cost and the agency has not determined that
301	the branded product is more cost-effective, unless the
302	prescriber has requested and received approval to require the
303	branded product. The agency is directed to implement a variable
304	dispensing fee for payments for prescribed medicines while
305	ensuring continued access for Medicaid recipients. The variable
306	dispensing fee may be based upon, but not limited to, either or
307	both the volume of prescriptions dispensed by a specific
308	pharmacy provider, the volume of prescriptions dispensed to an
309	individual recipient, and dispensing of preferred-drug-list
310	products. The agency may increase the pharmacy dispensing fee
311	authorized by statute and in the annual General Appropriations
312	Act by $0.50 for the dispensing of a Medicaid preferred-drug-
313	list product and reduce the pharmacy dispensing fee by $0.50 for
314	the dispensing of a Medicaid product that is not included on the
315	preferred drug list. The agency may establish a supplemental
316	pharmaceutical dispensing fee to be paid to providers returning
317	unused unit-dose packaged medications to stock and crediting the
318	Medicaid program for the ingredient cost of those medications if
319	the ingredient costs to be credited exceed the value of the
320	supplemental dispensing fee. The agency is authorized to limit
321	reimbursement for prescribed medicine in order to comply with
322	any limitations or directions provided for in the General
323	Appropriations Act, which may include implementing a prospective
324	or concurrent utilization review program.
325	Section 7.  Subsection (4) of section 409.9082, Florida
326	Statutes, is amended to read:
327	409.9082  Quality assessment on nursing home facility
328	providers; exemptions; purpose; federal approval required;
329	remedies.-
330	(4)  The purpose of the nursing home facility quality
331	assessment is to ensure continued quality of care. Collected
332	assessment funds shall be used to obtain federal financial
333	participation through the Medicaid program to make Medicaid
334	payments for nursing home facility services up to the amount of
335	nursing home facility Medicaid rates as calculated in accordance
336	with the approved state Medicaid plan in effect on December 31,
337	2007. The quality assessment and federal matching funds shall be
338	used exclusively for the following purposes and in the following
339	order of priority:
340	(a)  To reimburse the Medicaid share of the quality
341	assessment as a pass-through, Medicaid-allowable cost;
342	(b)  To increase to each nursing home facility's Medicaid
343	rate, as needed, an amount that restores the rate reductions
344	effective on or after implemented January 1, 2008, as provided
345	in the General Appropriations Act; January 1, 2009; and March 1,
346	2009; and
347	(c)  To increase to each nursing home facility's Medicaid
348	rate, as needed, an amount that restores any rate reductions for
349	the 2009-2010 fiscal year; and
350	(c)(d)  To increase each nursing home facility's Medicaid
351	rate that accounts for the portion of the total assessment not
352	included in paragraphs (a) and (b) (a)-(c) which begins a phase-
353	in to a pricing model for the operating cost component.
354	Section 8.  Subsection (3) of section 409.9083, Florida
355	Statutes, is amended to read:
356	409.9083  Quality assessment on privately operated
357	intermediate care facilities for the developmentally disabled;
358	exemptions; purpose; federal approval required; remedies.-
359	(3)  The purpose of the facility quality assessment is to
360	ensure continued quality of care. Collected assessment funds
361	shall be used to obtain federal financial participation through
362	the Medicaid program to make Medicaid payments for ICF/DD
363	services up to the amount of the Medicaid rates for such
364	facilities as calculated in accordance with the approved state
365	Medicaid plan in effect on April 1, 2008. The quality assessment
366	and federal matching funds shall be used exclusively for the
367	following purposes and in the following order of priority to:
368	(a)  Reimburse the Medicaid share of the quality assessment
369	as a pass-through, Medicaid-allowable cost.
370	(b)  Increase each privately operated ICF/DD Medicaid rate,
371	as needed, by an amount that restores the rate reductions
372	effective on or after implemented on October 1, 2008, as
373	provided in the General Appropriations Act.
374	(c)  Increase each ICF/DD Medicaid rate, as needed, by an
375	amount that restores any rate reductions for the 2008-2009
376	fiscal year and the 2009-2010 fiscal year.
377	(c)(d)  Increase payments to such facilities to fund
378	covered services to Medicaid beneficiaries.
379	Section 9.  Paragraph (a) of subsection (2) and subsection
380	(5) of section 409.911, Florida Statutes, are amended to read:
381	409.911  Disproportionate share program.-Subject to
382	specific allocations established within the General
383	Appropriations Act and any limitations established pursuant to
384	chapter 216, the agency shall distribute, pursuant to this
385	section, moneys to hospitals providing a disproportionate share
386	of Medicaid or charity care services by making quarterly
387	Medicaid payments as required. Notwithstanding the provisions of
388	s. 409.915, counties are exempt from contributing toward the
389	cost of this special reimbursement for hospitals serving a
390	disproportionate share of low-income patients.
391	(2)  The Agency for Health Care Administration shall use
392	the following actual audited data to determine the Medicaid days
393	and charity care to be used in calculating the disproportionate
394	share payment:
395	(a)  The average of the 2003, 2004, and 2005, and 2006
396	audited disproportionate share data to determine each hospital's
397	Medicaid days and charity care for the 2010-2011 2009-2010 state
398	fiscal year.
399	(5)  The following formula shall be used to pay
400	disproportionate share dollars to provider service network (PSN)
401	hospitals:
402	DSHP = TAAPSNH x (IHPSND/THPSND IHPSND x THPSND)
403	Where:
404	DSHP = Disproportionate share hospital payments.
405	TAAPSNH = Total amount available for PSN hospitals.
406	IHPSND = Individual hospital PSN days.
407	THPSND = Total of all hospital PSN days.
408	For purposes of this subsection, the PSN inpatient days shall be
409	provided in the General Appropriations Act.
410	Section 10.  Section 409.9112, Florida Statutes, is amended
411	to read:
412	409.9112  Disproportionate share program for regional
413	perinatal intensive care centers.-In addition to the payments
414	made under s. 409.911, the agency shall design and implement a
415	system for making disproportionate share payments to those
416	hospitals that participate in the regional perinatal intensive
417	care center program established pursuant to chapter 383. The
418	system of payments must conform to federal requirements and
419	distribute funds in each fiscal year for which an appropriation
420	is made by making quarterly Medicaid payments. Notwithstanding
421	s. 409.915, counties are exempt from contributing toward the
422	cost of this special reimbursement for hospitals serving a
423	disproportionate share of low-income patients. For the 2010-2011
424	2009-2010 state fiscal year, the agency may not distribute
425	moneys under the regional perinatal intensive care centers
426	disproportionate share program.
427	(1)  The following formula shall be used by the agency to
428	calculate the total amount earned for hospitals that participate
429	in the regional perinatal intensive care center program:
430	TAE = HDSP/THDSP
431	Where:
432	TAE = total amount earned by a regional perinatal intensive
433	care center.
434	HDSP = the prior state fiscal year regional perinatal
435	intensive care center disproportionate share payment to the
436	individual hospital.
437	THDSP = the prior state fiscal year total regional
438	perinatal intensive care center disproportionate share payments
439	to all hospitals.
440	(2)  The total additional payment for hospitals that
441	participate in the regional perinatal intensive care center
442	program shall be calculated by the agency as follows:
443	TAP = TAE x TA
444	Where:
445	TAP = total additional payment for a regional perinatal
446	intensive care center.
447	TAE = total amount earned by a regional perinatal intensive
448	care center.
449	TA = total appropriation for the regional perinatal
450	intensive care center disproportionate share program.
451	(3)  In order to receive payments under this section, a
452	hospital must be participating in the regional perinatal
453	intensive care center program pursuant to chapter 383 and must
454	meet the following additional requirements:
455	(a)  Agree to conform to all departmental and agency
456	requirements to ensure high quality in the provision of
457	services, including criteria adopted by departmental and agency
458	rule concerning staffing ratios, medical records, standards of
459	care, equipment, space, and such other standards and criteria as
460	the department and agency deem appropriate as specified by rule.
461	(b)  Agree to provide information to the department and
462	agency, in a form and manner to be prescribed by rule of the
463	department and agency, concerning the care provided to all
464	patients in neonatal intensive care centers and high-risk
465	maternity care.
466	(c)  Agree to accept all patients for neonatal intensive
467	care and high-risk maternity care, regardless of ability to pay,
468	on a functional space-available basis.
469	(d)  Agree to develop arrangements with other maternity and
470	neonatal care providers in the hospital's region for the
471	appropriate receipt and transfer of patients in need of
472	specialized maternity and neonatal intensive care services.
473	(e)  Agree to establish and provide a developmental
474	evaluation and services program for certain high-risk neonates,
475	as prescribed and defined by rule of the department.
476	(f)  Agree to sponsor a program of continuing education in
477	perinatal care for health care professionals within the region
478	of the hospital, as specified by rule.
479	(g)  Agree to provide backup and referral services to the
480	county health departments and other low-income perinatal
481	providers within the hospital's region, including the
482	development of written agreements between these organizations
483	and the hospital.
484	(h)  Agree to arrange for transportation for high-risk
485	obstetrical patients and neonates in need of transfer from the
486	community to the hospital or from the hospital to another more
487	appropriate facility.
488	(4)  Hospitals which fail to comply with any of the
489	conditions in subsection (3) or the applicable rules of the
490	department and agency may not receive any payments under this
491	section until full compliance is achieved. A hospital which is
492	not in compliance in two or more consecutive quarters may not
493	receive its share of the funds. Any forfeited funds shall be
494	distributed by the remaining participating regional perinatal
495	intensive care center program hospitals.
496	Section 11.  Section 409.9113, Florida Statutes, is amended
497	to read:
498	409.9113  Disproportionate share program for teaching
499	hospitals.-In addition to the payments made under ss. 409.911
500	and 409.9112, the agency shall make disproportionate share
501	payments to statutorily defined teaching hospitals for their
502	increased costs associated with medical education programs and
503	for tertiary health care services provided to the indigent. This
504	system of payments must conform to federal requirements and
505	distribute funds in each fiscal year for which an appropriation
506	is made by making quarterly Medicaid payments. Notwithstanding
507	s. 409.915, counties are exempt from contributing toward the
508	cost of this special reimbursement for hospitals serving a
509	disproportionate share of low-income patients. For the 2010-2011
510	2009-2010 state fiscal year, the agency shall distribute the
511	moneys provided in the General Appropriations Act to statutorily
512	defined teaching hospitals and family practice teaching
513	hospitals under the teaching hospital disproportionate share
514	program. The funds provided for statutorily defined teaching
515	hospitals shall be distributed in the same proportion as the
516	state fiscal year 2003-2004 teaching hospital disproportionate
517	share funds were distributed or as otherwise provided in the
518	General Appropriations Act. The funds provided for family
519	practice teaching hospitals shall be distributed equally among
520	family practice teaching hospitals.
521	(1)  On or before September 15 of each year, the agency
522	shall calculate an allocation fraction to be used for
523	distributing funds to state statutory teaching hospitals.
524	Subsequent to the end of each quarter of the state fiscal year,
525	the agency shall distribute to each statutory teaching hospital,
526	as defined in s. 408.07, an amount determined by multiplying
527	one-fourth of the funds appropriated for this purpose by the
528	Legislature times such hospital's allocation fraction. The
529	allocation fraction for each such hospital shall be determined
530	by the sum of the following three primary factors, divided by
531	three:
532	(a)  The number of nationally accredited graduate medical
533	education programs offered by the hospital, including programs
534	accredited by the Accreditation Council for Graduate Medical
535	Education and the combined Internal Medicine and Pediatrics
536	programs acceptable to both the American Board of Internal
537	Medicine and the American Board of Pediatrics at the beginning
538	of the state fiscal year preceding the date on which the
539	allocation fraction is calculated. The numerical value of this
540	factor is the fraction that the hospital represents of the total
541	number of programs, where the total is computed for all state
542	statutory teaching hospitals.
543	(b)  The number of full-time equivalent trainees in the
544	hospital, which comprises two components:
545	1.  The number of trainees enrolled in nationally
546	accredited graduate medical education programs, as defined in
547	paragraph (a). Full-time equivalents are computed using the
548	fraction of the year during which each trainee is primarily
549	assigned to the given institution, over the state fiscal year
550	preceding the date on which the allocation fraction is
551	calculated. The numerical value of this factor is the fraction
552	that the hospital represents of the total number of full-time
553	equivalent trainees enrolled in accredited graduate programs,
554	where the total is computed for all state statutory teaching
555	hospitals.
556	2.  The number of medical students enrolled in accredited
557	colleges of medicine and engaged in clinical activities,
558	including required clinical clerkships and clinical electives.
559	Full-time equivalents are computed using the fraction of the
560	year during which each trainee is primarily assigned to the
561	given institution, over the course of the state fiscal year
562	preceding the date on which the allocation fraction is
563	calculated. The numerical value of this factor is the fraction
564	that the given hospital represents of the total number of full-
565	time equivalent students enrolled in accredited colleges of
566	medicine, where the total is computed for all state statutory
567	teaching hospitals.
568
569	The primary factor for full-time equivalent trainees is computed
570	as the sum of these two components, divided by two.
571	(c)  A service index that comprises three components:
572	1.  The Agency for Health Care Administration Service
573	Index, computed by applying the standard Service Inventory
574	Scores established by the agency to services offered by the
575	given hospital, as reported on Worksheet A-2 for the last fiscal
576	year reported to the agency before the date on which the
577	allocation fraction is calculated. The numerical value of this
578	factor is the fraction that the given hospital represents of the
579	total Agency for Health Care Administration Service Index
580	values, where the total is computed for all state statutory
581	teaching hospitals.
582	2.  A volume-weighted service index, computed by applying
583	the standard Service Inventory Scores established by the Agency
584	for Health Care Administration to the volume of each service,
585	expressed in terms of the standard units of measure reported on
586	Worksheet A-2 for the last fiscal year reported to the agency
587	before the date on which the allocation factor is calculated.
588	The numerical value of this factor is the fraction that the
589	given hospital represents of the total volume-weighted service
590	index values, where the total is computed for all state
591	statutory teaching hospitals.
592	3.  Total Medicaid payments to each hospital for direct
593	inpatient and outpatient services during the fiscal year
594	preceding the date on which the allocation factor is calculated.
595	This includes payments made to each hospital for such services
596	by Medicaid prepaid health plans, whether the plan was
597	administered by the hospital or not. The numerical value of this
598	factor is the fraction that each hospital represents of the
599	total of such Medicaid payments, where the total is computed for
600	all state statutory teaching hospitals.
601
602	The primary factor for the service index is computed as the sum
603	of these three components, divided by three.
604	(2)  By October 1 of each year, the agency shall use the
605	following formula to calculate the maximum additional
606	disproportionate share payment for statutorily defined teaching
607	hospitals:
608	TAP = THAF x A
609	Where:
610	TAP = total additional payment.
611	THAF = teaching hospital allocation factor.
612	A = amount appropriated for a teaching hospital
613	disproportionate share program.
614	Section 12.  Section 409.9117, Florida Statutes, is amended
615	to read:
616	409.9117  Primary care disproportionate share program.-For
617	the 2010-2011 2009-2010 state fiscal year, the agency shall not
618	distribute moneys under the primary care disproportionate share
619	program.
620	(1)  If federal funds are available for disproportionate
621	share programs in addition to those otherwise provided by law,
622	there shall be created a primary care disproportionate share
623	program.
624	(2)  The following formula shall be used by the agency to
625	calculate the total amount earned for hospitals that participate
626	in the primary care disproportionate share program:
627	TAE = HDSP/THDSP
628	Where:
629	TAE = total amount earned by a hospital participating in
630	the primary care disproportionate share program.
631	HDSP = the prior state fiscal year primary care
632	disproportionate share payment to the individual hospital.
633	THDSP = the prior state fiscal year total primary care
634	disproportionate share payments to all hospitals.
635	(3)  The total additional payment for hospitals that
636	participate in the primary care disproportionate share program
637	shall be calculated by the agency as follows:
638	TAP = TAE x TA
639	Where:
640	TAP = total additional payment for a primary care hospital.
641	TAE = total amount earned by a primary care hospital.
642	TA = total appropriation for the primary care
643	disproportionate share program.
644	(4)  In the establishment and funding of this program, the
645	agency shall use the following criteria in addition to those
646	specified in s. 409.911, and payments may not be made to a
647	hospital unless the hospital agrees to:
648	(a)  Cooperate with a Medicaid prepaid health plan, if one
649	exists in the community.
650	(b)  Ensure the availability of primary and specialty care
651	physicians to Medicaid recipients who are not enrolled in a
652	prepaid capitated arrangement and who are in need of access to
653	such physicians.
654	(c)  Coordinate and provide primary care services free of
655	charge, except copayments, to all persons with incomes up to 100
656	percent of the federal poverty level who are not otherwise
657	covered by Medicaid or another program administered by a
658	governmental entity, and to provide such services based on a
659	sliding fee scale to all persons with incomes up to 200 percent
660	of the federal poverty level who are not otherwise covered by
661	Medicaid or another program administered by a governmental
662	entity, except that eligibility may be limited to persons who
663	reside within a more limited area, as agreed to by the agency
664	and the hospital.
665	(d)  Contract with any federally qualified health center,
666	if one exists within the agreed geopolitical boundaries,
667	concerning the provision of primary care services, in order to
668	guarantee delivery of services in a nonduplicative fashion, and
669	to provide for referral arrangements, privileges, and
670	admissions, as appropriate. The hospital shall agree to provide
671	at an onsite or offsite facility primary care services within 24
672	hours to which all Medicaid recipients and persons eligible
673	under this paragraph who do not require emergency room services
674	are referred during normal daylight hours.
675	(e)  Cooperate with the agency, the county, and other
676	entities to ensure the provision of certain public health
677	services, case management, referral and acceptance of patients,
678	and sharing of epidemiological data, as the agency and the
679	hospital find mutually necessary and desirable to promote and
680	protect the public health within the agreed geopolitical
681	boundaries.
682	(f)  In cooperation with the county in which the hospital
683	resides, develop a low-cost, outpatient, prepaid health care
684	program to persons who are not eligible for the Medicaid
685	program, and who reside within the area.
686	(g)  Provide inpatient services to residents within the
687	area who are not eligible for Medicaid or Medicare, and who do
688	not have private health insurance, regardless of ability to pay,
689	on the basis of available space, except that hospitals may not
690	be prevented from establishing bill collection programs based on
691	ability to pay.
692	(h)  Work with the Florida Healthy Kids Corporation, the
693	Florida Health Care Purchasing Cooperative, and business health
694	coalitions, as appropriate, to develop a feasibility study and
695	plan to provide a low-cost comprehensive health insurance plan
696	to persons who reside within the area and who do not have access
697	to such a plan.
698	(i)  Work with public health officials and other experts to
699	provide community health education and prevention activities
700	designed to promote healthy lifestyles and appropriate use of
701	health services.
702	(j)  Work with the local health council to develop a plan
703	for promoting access to affordable health care services for all
704	persons who reside within the area, including, but not limited
705	to, public health services, primary care services, inpatient
706	services, and affordable health insurance generally.
707
708	Any hospital that fails to comply with any of the provisions of
709	this subsection, or any other contractual condition, may not
710	receive payments under this section until full compliance is
711	achieved.
712	Section 13.  Paragraph (a) of subsection (39) of section
713	409.912, Florida Statutes, is amended to read:
714	409.912  Cost-effective purchasing of health care.-The
715	agency shall purchase goods and services for Medicaid recipients
716	in the most cost-effective manner consistent with the delivery
717	of quality medical care. To ensure that medical services are
718	effectively utilized, the agency may, in any case, require a
719	confirmation or second physician's opinion of the correct
720	diagnosis for purposes of authorizing future services under the
721	Medicaid program. This section does not restrict access to
722	emergency services or poststabilization care services as defined
723	in 42 C.F.R. part 438.114. Such confirmation or second opinion
724	shall be rendered in a manner approved by the agency. The agency
725	shall maximize the use of prepaid per capita and prepaid
726	aggregate fixed-sum basis services when appropriate and other
727	alternative service delivery and reimbursement methodologies,
728	including competitive bidding pursuant to s. 287.057, designed
729	to facilitate the cost-effective purchase of a case-managed
730	continuum of care. The agency shall also require providers to
731	minimize the exposure of recipients to the need for acute
732	inpatient, custodial, and other institutional care and the
733	inappropriate or unnecessary use of high-cost services. The
734	agency shall contract with a vendor to monitor and evaluate the
735	clinical practice patterns of providers in order to identify
736	trends that are outside the normal practice patterns of a
737	provider's professional peers or the national guidelines of a
738	provider's professional association. The vendor must be able to
739	provide information and counseling to a provider whose practice
740	patterns are outside the norms, in consultation with the agency,
741	to improve patient care and reduce inappropriate utilization.
742	The agency may mandate prior authorization, drug therapy
743	management, or disease management participation for certain
744	populations of Medicaid beneficiaries, certain drug classes, or
745	particular drugs to prevent fraud, abuse, overuse, and possible
746	dangerous drug interactions. The Pharmaceutical and Therapeutics
747	Committee shall make recommendations to the agency on drugs for
748	which prior authorization is required. The agency shall inform
749	the Pharmaceutical and Therapeutics Committee of its decisions
750	regarding drugs subject to prior authorization. The agency is
751	authorized to limit the entities it contracts with or enrolls as
752	Medicaid providers by developing a provider network through
753	provider credentialing. The agency may competitively bid single-
754	source-provider contracts if procurement of goods or services
755	results in demonstrated cost savings to the state without
756	limiting access to care. The agency may limit its network based
757	on the assessment of beneficiary access to care, provider
758	availability, provider quality standards, time and distance
759	standards for access to care, the cultural competence of the
760	provider network, demographic characteristics of Medicaid
761	beneficiaries, practice and provider-to-beneficiary standards,
762	appointment wait times, beneficiary use of services, provider
763	turnover, provider profiling, provider licensure history,
764	previous program integrity investigations and findings, peer
765	review, provider Medicaid policy and billing compliance records,
766	clinical and medical record audits, and other factors. Providers
767	shall not be entitled to enrollment in the Medicaid provider
768	network. The agency shall determine instances in which allowing
769	Medicaid beneficiaries to purchase durable medical equipment and
770	other goods is less expensive to the Medicaid program than long-
771	term rental of the equipment or goods. The agency may establish
772	rules to facilitate purchases in lieu of long-term rentals in
773	order to protect against fraud and abuse in the Medicaid program
774	as defined in s. 409.913. The agency may seek federal waivers
775	necessary to administer these policies.
776	(39)(a)  The agency shall implement a Medicaid prescribed-
777	drug spending-control program that includes the following
778	components:
779	1.  A Medicaid preferred drug list, which shall be a
780	listing of cost-effective therapeutic options recommended by the
781	Medicaid Pharmacy and Therapeutics Committee established
782	pursuant to s. 409.91195 and adopted by the agency for each
783	therapeutic class on the preferred drug list. At the discretion
784	of the committee, and when feasible, the preferred drug list
785	should include at least two products in a therapeutic class. The
786	agency may post the preferred drug list and updates to the
787	preferred drug list on an Internet website without following the
788	rulemaking procedures of chapter 120. Antiretroviral agents are
789	excluded from the preferred drug list. The agency shall also
790	limit the amount of a prescribed drug dispensed to no more than
791	a 34-day supply unless the drug products' smallest marketed
792	package is greater than a 34-day supply, or the drug is
793	determined by the agency to be a maintenance drug in which case
794	a 100-day maximum supply may be authorized. The agency is
795	authorized to seek any federal waivers necessary to implement
796	these cost-control programs and to continue participation in the
797	federal Medicaid rebate program, or alternatively to negotiate
798	state-only manufacturer rebates. The agency may adopt rules to
799	implement this subparagraph. The agency shall continue to
800	provide unlimited contraceptive drugs and items. The agency must
801	establish procedures to ensure that:
802	a.  There is a response to a request for prior consultation
803	by telephone or other telecommunication device within 24 hours
804	after receipt of a request for prior consultation; and
805	b.  A 72-hour supply of the drug prescribed is provided in
806	an emergency or when the agency does not provide a response
807	within 24 hours as required by sub-subparagraph a.
808	2.  Reimbursement to pharmacies for Medicaid prescribed
809	drugs shall be set at the lowest lesser of: the average
810	wholesale price (AWP) minus 16.4 percent, the wholesaler
811	acquisition cost (WAC) plus 4.75 percent, the federal upper
812	limit (FUL), the state maximum allowable cost (SMAC), or the
813	usual and customary (UAC) charge billed by the provider.
814	Effective March 1, 2011, the Medicaid maximum allowable fee for
815	ingredient cost shall be based on the lowest of: the wholesaler
816	acquisition costs (WAC), the federal upper limit (FUL), the
817	state maximum allowable cost (SMAC), or the usual and customary
818	(UAC) charge billed by the provider.
819	3.  The agency shall develop and implement a process for
820	managing the drug therapies of Medicaid recipients who are using
821	significant numbers of prescribed drugs each month. The
822	management process may include, but is not limited to,
823	comprehensive, physician-directed medical-record reviews, claims
824	analyses, and case evaluations to determine the medical
825	necessity and appropriateness of a patient's treatment plan and
826	drug therapies. The agency may contract with a private
827	organization to provide drug-program-management services. The
828	Medicaid drug benefit management program shall include
829	initiatives to manage drug therapies for HIV/AIDS patients,
830	patients using 20 or more unique prescriptions in a 180-day
831	period, and the top 1,000 patients in annual spending. The
832	agency shall enroll any Medicaid recipient in the drug benefit
833	management program if he or she meets the specifications of this
834	provision and is not enrolled in a Medicaid health maintenance
835	organization.
836	4.  The agency may limit the size of its pharmacy network
837	based on need, competitive bidding, price negotiations,
838	credentialing, or similar criteria. The agency shall give
839	special consideration to rural areas in determining the size and
840	location of pharmacies included in the Medicaid pharmacy
841	network. A pharmacy credentialing process may include criteria
842	such as a pharmacy's full-service status, location, size,
843	patient educational programs, patient consultation, disease
844	management services, and other characteristics. The agency may
845	impose a moratorium on Medicaid pharmacy enrollment when it is
846	determined that it has a sufficient number of Medicaid-
847	participating providers. The agency must allow dispensing
848	practitioners to participate as a part of the Medicaid pharmacy
849	network regardless of the practitioner's proximity to any other
850	entity that is dispensing prescription drugs under the Medicaid
851	program. A dispensing practitioner must meet all credentialing
852	requirements applicable to his or her practice, as determined by
853	the agency.
854	5.  The agency shall develop and implement a program that
855	requires Medicaid practitioners who prescribe drugs to use a
856	counterfeit-proof prescription pad for Medicaid prescriptions.
857	The agency shall require the use of standardized counterfeit-
858	proof prescription pads by Medicaid-participating prescribers or
859	prescribers who write prescriptions for Medicaid recipients. The
860	agency may implement the program in targeted geographic areas or
861	statewide.
862	6.  The agency may enter into arrangements that require
863	manufacturers of generic drugs prescribed to Medicaid recipients
864	to provide rebates of at least 15.1 percent of the average
865	manufacturer price for the manufacturer's generic products.
866	These arrangements shall require that if a generic-drug
867	manufacturer pays federal rebates for Medicaid-reimbursed drugs
868	at a level below 15.1 percent, the manufacturer must provide a
869	supplemental rebate to the state in an amount necessary to
870	achieve a 15.1-percent rebate level.
871	7.  The agency may establish a preferred drug list as
872	described in this subsection, and, pursuant to the establishment
873	of such preferred drug list, it is authorized to negotiate
874	supplemental rebates from manufacturers that are in addition to
875	those required by Title XIX of the Social Security Act and at no
876	less than 14 percent of the average manufacturer price as
877	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
878	the federal or supplemental rebate, or both, equals or exceeds
879	29 percent. There is no upper limit on the supplemental rebates
880	the agency may negotiate. The agency may determine that specific
881	products, brand-name or generic, are competitive at lower rebate
882	percentages. Agreement to pay the minimum supplemental rebate
883	percentage will guarantee a manufacturer that the Medicaid
884	Pharmaceutical and Therapeutics Committee will consider a
885	product for inclusion on the preferred drug list. However, a
886	pharmaceutical manufacturer is not guaranteed placement on the
887	preferred drug list by simply paying the minimum supplemental
888	rebate. Agency decisions shall will be made on the clinical
889	efficacy of a drug and recommendations of the Medicaid
890	Pharmaceutical and Therapeutics Committee, as well as the price
891	of competing products minus federal and state rebates. The
892	agency is authorized to contract with an outside agency or
893	contractor to conduct negotiations for supplemental rebates. For
894	the purposes of this section, the term "supplemental rebates"
895	means cash rebates. Effective July 1, 2004, value-added programs
896	as a substitution for supplemental rebates are prohibited. The
897	agency is authorized to seek any federal waivers to implement
898	this initiative.
899	8.  The Agency for Health Care Administration shall expand
900	home delivery of pharmacy products. To assist Medicaid patients
901	in securing their prescriptions and reduce program costs, the
902	agency shall expand its current mail-order-pharmacy diabetes-
903	supply program to include all generic and brand-name drugs used
904	by Medicaid patients with diabetes. Medicaid recipients in the
905	current program may obtain nondiabetes drugs on a voluntary
906	basis. This initiative is limited to the geographic area covered
907	by the current contract. The agency may seek and implement any
908	federal waivers necessary to implement this subparagraph.
909	9.  The agency shall limit to one dose per month any drug
910	prescribed to treat erectile dysfunction.
911	10.a.  The agency may implement a Medicaid behavioral drug
912	management system. The agency may contract with a vendor that
913	has experience in operating behavioral drug management systems
914	to implement this program. The agency is authorized to seek
915	federal waivers to implement this program.
916	b.  The agency, in conjunction with the Department of
917	Children and Family Services, may implement the Medicaid
918	behavioral drug management system that is designed to improve
919	the quality of care and behavioral health prescribing practices
920	based on best practice guidelines, improve patient adherence to
921	medication plans, reduce clinical risk, and lower prescribed
922	drug costs and the rate of inappropriate spending on Medicaid
923	behavioral drugs. The program may include the following
924	elements:
925	(I)  Provide for the development and adoption of best
926	practice guidelines for behavioral health-related drugs such as
927	antipsychotics, antidepressants, and medications for treating
928	bipolar disorders and other behavioral conditions; translate
929	them into practice; review behavioral health prescribers and
930	compare their prescribing patterns to a number of indicators
931	that are based on national standards; and determine deviations
932	from best practice guidelines.
933	(II)  Implement processes for providing feedback to and
934	educating prescribers using best practice educational materials
935	and peer-to-peer consultation.
936	(III)  Assess Medicaid beneficiaries who are outliers in
937	their use of behavioral health drugs with regard to the numbers
938	and types of drugs taken, drug dosages, combination drug
939	therapies, and other indicators of improper use of behavioral
940	health drugs.
941	(IV)  Alert prescribers to patients who fail to refill
942	prescriptions in a timely fashion, are prescribed multiple same-
943	class behavioral health drugs, and may have other potential
944	medication problems.
945	(V)  Track spending trends for behavioral health drugs and
946	deviation from best practice guidelines.
947	(VI)  Use educational and technological approaches to
948	promote best practices, educate consumers, and train prescribers
949	in the use of practice guidelines.
950	(VII)  Disseminate electronic and published materials.
951	(VIII)  Hold statewide and regional conferences.
952	(IX)  Implement a disease management program with a model
953	quality-based medication component for severely mentally ill
954	individuals and emotionally disturbed children who are high
955	users of care.
956	11.a.  The agency shall implement a Medicaid prescription
957	drug management system. The agency may contract with a vendor
958	that has experience in operating prescription drug management
959	systems in order to implement this system. Any management system
960	that is implemented in accordance with this subparagraph must
961	rely on cooperation between physicians and pharmacists to
962	determine appropriate practice patterns and clinical guidelines
963	to improve the prescribing, dispensing, and use of drugs in the
964	Medicaid program. The agency may seek federal waivers to
965	implement this program.
966	b.  The drug management system must be designed to improve
967	the quality of care and prescribing practices based on best
968	practice guidelines, improve patient adherence to medication
969	plans, reduce clinical risk, and lower prescribed drug costs and
970	the rate of inappropriate spending on Medicaid prescription
971	drugs. The program must:
972	(I)  Provide for the development and adoption of best
973	practice guidelines for the prescribing and use of drugs in the
974	Medicaid program, including translating best practice guidelines
975	into practice; reviewing prescriber patterns and comparing them
976	to indicators that are based on national standards and practice
977	patterns of clinical peers in their community, statewide, and
978	nationally; and determine deviations from best practice
979	guidelines.
980	(II)  Implement processes for providing feedback to and
981	educating prescribers using best practice educational materials
982	and peer-to-peer consultation.
983	(III)  Assess Medicaid recipients who are outliers in their
984	use of a single or multiple prescription drugs with regard to
985	the numbers and types of drugs taken, drug dosages, combination
986	drug therapies, and other indicators of improper use of
987	prescription drugs.
988	(IV)  Alert prescribers to patients who fail to refill
989	prescriptions in a timely fashion, are prescribed multiple drugs
990	that may be redundant or contraindicated, or may have other
991	potential medication problems.
992	(V)  Track spending trends for prescription drugs and
993	deviation from best practice guidelines.
994	(VI)  Use educational and technological approaches to
995	promote best practices, educate consumers, and train prescribers
996	in the use of practice guidelines.
997	(VII)  Disseminate electronic and published materials.
998	(VIII)  Hold statewide and regional conferences.
999	(IX)  Implement disease management programs in cooperation
1000	with physicians and pharmacists, along with a model quality-
1001	based medication component for individuals having chronic
1002	medical conditions.
1003	12.  The agency is authorized to contract for drug rebate
1004	administration, including, but not limited to, calculating
1005	rebate amounts, invoicing manufacturers, negotiating disputes
1006	with manufacturers, and maintaining a database of rebate
1007	collections.
1008	13.  The agency may specify the preferred daily dosing form
1009	or strength for the purpose of promoting best practices with
1010	regard to the prescribing of certain drugs as specified in the
1011	General Appropriations Act and ensuring cost-effective
1012	prescribing practices.
1013	14.  The agency may require prior authorization for
1014	Medicaid-covered prescribed drugs. The agency may, but is not
1015	required to, prior-authorize the use of a product:
1016	a.  For an indication not approved in labeling;
1017	b.  To comply with certain clinical guidelines; or
1018	c.  If the product has the potential for overuse, misuse,
1019	or abuse.
1020
1021	The agency may require the prescribing professional to provide
1022	information about the rationale and supporting medical evidence
1023	for the use of a drug. The agency may post prior authorization
1024	criteria and protocol and updates to the list of drugs that are
1025	subject to prior authorization on an Internet website without
1026	amending its rule or engaging in additional rulemaking.
1027	15.  The agency, in conjunction with the Pharmaceutical and
1028	Therapeutics Committee, may require age-related prior
1029	authorizations for certain prescribed drugs. The agency may
1030	preauthorize the use of a drug for a recipient who may not meet
1031	the age requirement or may exceed the length of therapy for use
1032	of this product as recommended by the manufacturer and approved
1033	by the Food and Drug Administration. Prior authorization may
1034	require the prescribing professional to provide information
1035	about the rationale and supporting medical evidence for the use
1036	of a drug.
1037	16.  The agency shall implement a step-therapy prior
1038	authorization approval process for medications excluded from the
1039	preferred drug list. Medications listed on the preferred drug
1040	list must be used within the previous 12 months prior to the
1041	alternative medications that are not listed. The step-therapy
1042	prior authorization may require the prescriber to use the
1043	medications of a similar drug class or for a similar medical
1044	indication unless contraindicated in the Food and Drug
1045	Administration labeling. The trial period between the specified
1046	steps may vary according to the medical indication. The step-
1047	therapy approval process shall be developed in accordance with
1048	the committee as stated in s. 409.91195(7) and (8). A drug
1049	product may be approved without meeting the step-therapy prior
1050	authorization criteria if the prescribing physician provides the
1051	agency with additional written medical or clinical documentation
1052	that the product is medically necessary because:
1053	a.  There is not a drug on the preferred drug list to treat
1054	the disease or medical condition which is an acceptable clinical
1055	alternative;
1056	b.  The alternatives have been ineffective in the treatment
1057	of the beneficiary's disease; or
1058	c.  Based on historic evidence and known characteristics of
1059	the patient and the drug, the drug is likely to be ineffective,
1060	or the number of doses have been ineffective.
1061
1062	The agency shall work with the physician to determine the best
1063	alternative for the patient. The agency may adopt rules waiving
1064	the requirements for written clinical documentation for specific
1065	drugs in limited clinical situations.
1066	17.  The agency shall implement a return and reuse program
1067	for drugs dispensed by pharmacies to institutional recipients,
1068	which includes payment of a $5 restocking fee for the
1069	implementation and operation of the program. The return and
1070	reuse program shall be implemented electronically and in a
1071	manner that promotes efficiency. The program must permit a
1072	pharmacy to exclude drugs from the program if it is not
1073	practical or cost-effective for the drug to be included and must
1074	provide for the return to inventory of drugs that cannot be
1075	credited or returned in a cost-effective manner. The agency
1076	shall determine if the program has reduced the amount of
1077	Medicaid prescription drugs which are destroyed on an annual
1078	basis and if there are additional ways to ensure more
1079	prescription drugs are not destroyed which could safely be
1080	reused. The agency's conclusion and recommendations shall be
1081	reported to the Legislature by December 1, 2005.
1082	Section 14.  Subsection (3) is added to section 430.707,
1083	Florida Statutes, to read:
1084	430.707  Contracts.-
1085	(3)  Any entity that provides or is authorized by state law
1086	to provide benefits pursuant to the Program of All-inclusive
1087	Care for the Elderly on or before July 1, 2010, may submit an
1088	application for an expansion of service capacity sufficient to
1089	meet the needs of potentially eligible program enrollees within
1090	the service area designated by state law. The agency, in
1091	consultation with the department, shall accept and forward to
1092	the Centers for Medicare and Medicaid Services the application
1093	for an expansion of service capacity for additional enrollees
1094	from an entity that provides benefits pursuant to the Program of
1095	All-inclusive Care for the Elderly and that is in good standing
1096	with the agency, the department, and the Centers for Medicare
1097	and Medicaid Services.
1098	Section 15.  This act shall take effect July 1, 2010.

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