HB 7225

1	A bill to be entitled
2	An act relating to Medicaid; amending s. 393.0661, F.S.,
3	relating to the home and community-based services delivery
4	system for persons with developmental disabilities;
5	requiring the Agency for Persons with Disabilities to
6	establish a transition plan for current Medicaid
7	recipients under certain circumstances; providing for
8	expiration of the section on a specified date; creating s.
9	400.0713, F.S.; requiring the Agency for Health Care
10	Administration to establish a nursing home licensure
11	workgroup; amending s. 408.040, F.S.; providing for
12	suspension of conditions precedent to the issuance of a
13	certificate of need for a nursing home, effective on a
14	specified date; amending s. 408.0435, F.S.; extending the
15	certificate-of-need moratorium for additional community
16	nursing home beds; designating ss. 409.016-409.803, F.S.,
17	as pt. I of ch. 409, F.S., and entitling the part "Social
18	and Economic Assistance"; designating ss. 409.810-409.821,
19	F.S., as pt. II of ch. 409, F.S., and entitling the part
20	"Kidcare"; designating ss. 409.901-409.9205, F.S., as part
21	III of ch. 409, F.S., and entitling the part "Medicaid";
22	amending s. 409.907, F.S.; authorizing the Agency for
23	Health Care Administration to enroll entities as Medicare
24	crossover-only providers for payment purposes only;
25	specifying requirements for Medicare crossover-only
26	agreements; amending s. 409.908, F.S.; providing penalties
27	for providers that fail to report suspension or
28	disenrollment from Medicare within a specified time;
29	amending s. 409.912, F.S.; authorizing provider service
30	networks to provide comprehensive behavioral health care
31	services to certain Medicaid recipients; providing payment
32	requirements for provider service networks; providing for
33	the expiration of various provisions of the section on
34	specified dates to conform to the reorganization of
35	Medicaid managed care; eliminating obsolete provisions and
36	updating provisions within the section; amending ss.
37	409.91195 and 409.91196, F.S.; conforming cross-
38	references; amending s. 409.91207, F.S.; providing
39	authority of the Agency for Health Care Administration
40	with respect to the development of a method for
41	designating qualified plans as a medical home network;
42	providing purposes and principles for creating medical
43	home networks; providing criteria for designation of a
44	qualified plan as a medical home network; providing agency
45	duties with respect thereto; amending s. 409.91211, F.S.;
46	providing authority of the Agency for Health Care
47	Administration to implement a managed care pilot program
48	based on specified waiver authority with respect to the
49	Medicaid reform program; continuing the existing pilot
50	program in specified counties; requiring the agency to
51	seek an extension of the waiver; providing for monthly
52	reports; requiring approval of the Legislative Budget
53	Commission for changes to specified terms and conditions ;
54	providing for expansion of the managed care pilot program
55	to Miami-Dade County; specifying managed care plans that
56	are qualified to participate in the Medicaid managed care
57	pilot program; providing requirements for qualified
58	managed care plans; requiring the agency to develop and
59	seek federal approval to implement methodologies to
60	preserve intergovernmental transfers of funds and
61	certified public expenditures from Miami-Dade County;
62	requiring the agency to submit a plan and specified
63	amendment to the Legislative Budget Commission; providing
64	for a report; requiring Medicaid recipients in counties in
65	which the managed care pilot program has been implemented
66	to be enrolled in a qualified plan; providing a time limit
67	for enrollment; requiring the agency to provide choice
68	counseling; providing requirements with respect to choice
69	counseling information provided to Medicaid recipients;
70	providing for automatic enrollment of certain Medicaid
71	recipients; establishing criteria for automatic
72	enrollment; providing procedures and requirements with
73	respect to voluntary disenrollment of a recipient in a
74	qualified plan; providing for an enrollment period;
75	requiring qualified plans to establish a process for
76	review of and response to grievances of enrollees;
77	requiring qualified plans to submit quarterly reports;
78	specifying services to be covered by qualified plans;
79	authorizing qualified plans to offer specified
80	customizations, variances, and coverage for additional
81	services; requiring agency evaluation of proposed benefit
82	packages; requiring qualified plans to reimburse the
83	agency for the cost of specified enrollment changes;
84	providing for access to encounter data; requiring
85	participating plans to establish an incentive program to
86	reward healthy behaviors; requiring the agency to continue
87	budget-neutral adjustment of capitation rates for all
88	prepaid plans in existing managed care pilot program
89	counties; providing for transition to payment
90	methodologies for Miami-Dade County plans; providing a
91	phased schedule for risk-adjusted capitation rates;
92	requiring the establishment of a technical advisory panel;
93	providing for distribution of funds from a low-income
94	pool; specifying purposes for such distribution; requiring
95	the agency to maintain and operate the Medicaid Encounter
96	Data System; requiring the agency to contract with the
97	University of Florida for evaluation of the pilot program;
98	amending s. 409.9122, F.S.; eliminating outdated
99	provisions; providing for the expiration of various
100	provisions of the section on specified dates to conform to
101	the reorganization of Medicaid managed care; requiring the
102	Agency for Health Care Administration to begin a budget-
103	neutral adjustment of capitation rates for all Medicaid
104	prepaid plans in the state on a specified date; providing
105	the basis for the adjustment; providing a phased schedule
106	for risk adjusted capitation rates; providing for the
107	establishment of a technical advisory panel; requiring the
108	agency to develop a process to enable any recipient with
109	access to employer sponsored insurance to opt out of
110	qualified plans in the Medicaid program; requiring the
111	agency, contingent on federal approval, to enable
112	recipients with access to other insurance or related
113	products providing access to specified health care
114	services to opt out of qualified plans in the Medicaid
115	program; providing a limitation on the amount of financial
116	assistance provided for each recipient; requiring each
117	qualified plan to establish an incentive program that
118	rewards specific healthy behaviors; requiring plans to
119	maintain a specified reserve account; requiring the agency
120	to maintain and operate the Medicaid Encounter Data
121	System; requiring the agency to establish a designated
122	payment for specified Medicare Advantage Special Needs
123	members; authorizing the agency to develop a designated
124	payment for Medicaid-only covered services for which the
125	state is responsible; requiring the agency to establish,
126	and managed care plans to use, a uniform method of
127	accounting for and reporting of medical and nonmedical
128	costs; requiring reimbursement by Medicaid of school
129	districts participating in a certified school match
130	program for a Medicaid-eligible child participating in the
131	services, effective on a specified date; requiring the
132	agency, the Department of Health, and the Department of
133	Education to develop procedures for ensuring that a
134	student's managed care plan receives information relating
135	to services provided; authorizing the Agency for Health
136	Care Administration to create exceptions to mandatory
137	enrollment in managed care under specified circumstances;
138	amending s. 430.04, F.S.; eliminating outdated provisions;
139	requiring the Department of Elderly Affairs to develop a
140	transition plan for specified elder and disabled adults
141	receiving long-term care Medicaid services when qualified
142	plans become available; providing for expiration thereof;
143	amending s. 430.2053, F.S.; eliminating outdated
144	provisions; providing additional duties of aging resource
145	centers; providing an additional exception to direct
146	services that may not be provided by an aging resource
147	center; providing for the cessation of specified  payments
148	by the department as qualified plans become available;
149	providing for a memorandum of understanding between the
150	Agency for Health Care Administration and aging resource
151	centers under certain circumstances; eliminating
152	provisions requiring reports; amending s. 641.386, F.S.;
153	conforming a cross-reference; repealing s. 430.701, F.S.,
154	relating to legislative findings and intent and approval
155	for action relating to provider enrollment levels;
156	repealing s. 430.702, F.S., relating to the Long-Term Care
157	Community Diversion Pilot Project Act; repealing s.
158	430.703, F.S., relating to definitions; repealing s.
159	430.7031, F.S., relating to nursing home transition
160	program; repealing s. 430.704, F.S., relating to
161	evaluation of long-term care through the pilot projects;
162	repealing s. 430.705, F.S., relating to implementation of
163	long-term care community diversion pilot projects;
164	repealing s. 430.706, F.S., relating to quality of care;
165	repealing s. 430.707, F.S., relating to contracts;
166	repealing s. 430.708, F.S., relating to certificate of
167	need; repealing s. 430.709, F.S., relating to reports and
168	evaluations; renumbering ss. 409.9301, 409.942, 409.944,
169	409.945, 409.946, 409.953, and 409.9531, F.S., as ss.
170	402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
171	402.87, F.S., respectively; amending s. 443.111, F.S.;
172	conforming a cross-reference; providing contingent
173	effective dates.
174
175	Be It Enacted by the Legislature of the State of Florida:
176
177	Section 1.  Section 393.0661, Florida Statutes, is amended
178	to read:
179	393.0661  Home and community-based services delivery
180	system; comprehensive redesign.-The Legislature finds that the
181	home and community-based services delivery system for persons
182	with developmental disabilities and the availability of
183	appropriated funds are two of the critical elements in making
184	services available. Therefore, it is the intent of the
185	Legislature that the Agency for Persons with Disabilities shall
186	develop and implement a comprehensive redesign of the system.
187	(1)  The redesign of the home and community-based services
188	system shall include, at a minimum, all actions necessary to
189	achieve an appropriate rate structure, client choice within a
190	specified service package, appropriate assessment strategies, an
191	efficient billing process that contains reconciliation and
192	monitoring components, a redefined role for support coordinators
193	that avoids potential conflicts of interest, and ensures that
194	family/client budgets are linked to levels of need.
195	(a)  The agency shall use an assessment instrument that is
196	reliable and valid. The agency may contract with an external
197	vendor or may use support coordinators to complete client
198	assessments if it develops sufficient safeguards and training to
199	ensure ongoing inter-rater reliability.
200	(b)  The agency, with the concurrence of the Agency for
201	Health Care Administration, may contract for the determination
202	of medical necessity and establishment of individual budgets.
203	(2)  A provider of services rendered to persons with
204	developmental disabilities pursuant to a federally approved
205	waiver shall be reimbursed according to a rate methodology based
206	upon an analysis of the expenditure history and prospective
207	costs of providers participating in the waiver program, or under
208	any other methodology developed by the Agency for Health Care
209	Administration, in consultation with the Agency for Persons with
210	Disabilities, and approved by the Federal Government in
211	accordance with the waiver.
212	(3)  The Agency for Health Care Administration, in
213	consultation with the agency, shall seek federal approval and
214	implement a four-tiered waiver system to serve eligible clients
215	through the developmental disabilities and family and supported
216	living waivers. The agency shall assign all clients receiving
217	services through the developmental disabilities waiver to a tier
218	based on a valid assessment instrument, client characteristics,
219	and other appropriate assessment methods.
220	(a)  Tier one is limited to clients who have service needs
221	that cannot be met in tier two, three, or four for intensive
222	medical or adaptive needs and that are essential for avoiding
223	institutionalization, or who possess behavioral problems that
224	are exceptional in intensity, duration, or frequency and present
225	a substantial risk of harm to themselves or others.
226	(b)  Tier two is limited to clients whose service needs
227	include a licensed residential facility and who are authorized
228	to receive a moderate level of support for standard residential
229	habilitation services or a minimal level of support for behavior
230	focus residential habilitation services, or clients in supported
231	living who receive more than 6 hours a day of in-home support
232	services. Total annual expenditures under tier two may not
233	exceed $55,000 per client each year.
234	(c)  Tier three includes, but is not limited to, clients
235	requiring residential placements, clients in independent or
236	supported living situations, and clients who live in their
237	family home. Total annual expenditures under tier three may not
238	exceed $35,000 per client each year.
239	(d)  Tier four is the family and supported living waiver
240	and includes, but is not limited to, clients in independent or
241	supported living situations and clients who live in their family
242	home. Total annual expenditures under tier four may not exceed
243	$14,792 per client each year.
244	(e)  The Agency for Health Care Administration shall also
245	seek federal approval to provide a consumer-directed option for
246	persons with developmental disabilities which corresponds to the
247	funding levels in each of the waiver tiers. The agency shall
248	implement the four-tiered waiver system beginning with tiers
249	one, three, and four and followed by tier two. The agency and
250	the Agency for Health Care Administration may adopt rules
251	necessary to administer this subsection.
252	(f)  The agency shall seek federal waivers and amend
253	contracts as necessary to make changes to services defined in
254	federal waiver programs administered by the agency as follows:
255	1.  Supported living coaching services may not exceed 20
256	hours per month for persons who also receive in-home support
257	services.
258	2.  Limited support coordination services is the only type
259	of support coordination service that may be provided to persons
260	under the age of 18 who live in the family home.
261	3.  Personal care assistance services are limited to 180
262	hours per calendar month and may not include rate modifiers.
263	Additional hours may be authorized for persons who have
264	intensive physical, medical, or adaptive needs if such hours are
265	essential for avoiding institutionalization.
266	4.  Residential habilitation services are limited to 8
267	hours per day. Additional hours may be authorized for persons
268	who have intensive medical or adaptive needs and if such hours
269	are essential for avoiding institutionalization, or for persons
270	who possess behavioral problems that are exceptional in
271	intensity, duration, or frequency and present a substantial risk
272	of harming themselves or others. This restriction shall be in
273	effect until the four-tiered waiver system is fully implemented.
274	5.  Chore services, nonresidential support services, and
275	homemaker services are eliminated. The agency shall expand the
276	definition of in-home support services to allow the service
277	provider to include activities previously provided in these
278	eliminated services.
279	6.  Massage therapy, medication review, and psychological
280	assessment services are eliminated.
281	7.  The agency shall conduct supplemental cost plan reviews
282	to verify the medical necessity of authorized services for plans
283	that have increased by more than 8 percent during either of the
284	2 preceding fiscal years.
285	8.  The agency shall implement a consolidated residential
286	habilitation rate structure to increase savings to the state
287	through a more cost-effective payment method and establish
288	uniform rates for intensive behavioral residential habilitation
289	services.
290	9.  Pending federal approval, the agency may extend current
291	support plans for clients receiving services under Medicaid
292	waivers for 1 year beginning July 1, 2007, or from the date
293	approved, whichever is later. Clients who have a substantial
294	change in circumstances which threatens their health and safety
295	may be reassessed during this year in order to determine the
296	necessity for a change in their support plan.
297	10.  The agency shall develop a plan to eliminate
298	redundancies and duplications between in-home support services,
299	companion services, personal care services, and supported living
300	coaching by limiting or consolidating such services.
301	11.  The agency shall develop a plan to reduce the
302	intensity and frequency of supported employment services to
303	clients in stable employment situations who have a documented
304	history of at least 3 years' employment with the same company or
305	in the same industry.
306	(4)  The geographic differential for Miami-Dade, Broward,
307	and Palm Beach Counties for residential habilitation services
308	shall be 7.5 percent.
309	(5)  The geographic differential for Monroe County for
310	residential habilitation services shall be 20 percent.
311	(6)  Effective January 1, 2010, and except as otherwise
312	provided in this section, a client served by the home and
313	community-based services waiver or the family and supported
314	living waiver funded through the agency shall have his or her
315	cost plan adjusted to reflect the amount of expenditures for the
316	previous state fiscal year plus 5 percent if such amount is less
317	than the client's existing cost plan. The agency shall use
318	actual paid claims for services provided during the previous
319	fiscal year that are submitted by October 31 to calculate the
320	revised cost plan amount. If the client was not served for the
321	entire previous state fiscal year or there was any single change
322	in the cost plan amount of more than 5 percent during the
323	previous state fiscal year, the agency shall set the cost plan
324	amount at an estimated annualized expenditure amount plus 5
325	percent. The agency shall estimate the annualized expenditure
326	amount by calculating the average of monthly expenditures,
327	beginning in the fourth month after the client enrolled,
328	interrupted services are resumed, or the cost plan was changed
329	by more than 5 percent and ending on August 31, 2009, and
330	multiplying the average by 12. In order to determine whether a
331	client was not served for the entire year, the agency shall
332	include any interruption of a waiver-funded service or services
333	lasting at least 18 days. If at least 3 months of actual
334	expenditure data are not available to estimate annualized
335	expenditures, the agency may not rebase a cost plan pursuant to
336	this subsection. The agency may not rebase the cost plan of any
337	client who experiences a significant change in recipient
338	condition or circumstance which results in a change of more than
339	5 percent to his or her cost plan between July 1 and the date
340	that a rebased cost plan would take effect pursuant to this
341	subsection.
342	(7)  Nothing in this section or in any administrative rule
343	shall be construed to prevent or limit the Agency for Health
344	Care Administration, in consultation with the Agency for Persons
345	with Disabilities, from adjusting fees, reimbursement rates,
346	lengths of stay, number of visits, or number of services, or
347	from limiting enrollment, or making any other adjustment
348	necessary to comply with the availability of moneys and any
349	limitations or directions provided for in the General
350	Appropriations Act.
351	(8)  The Agency for Persons with Disabilities shall submit
352	quarterly status reports to the Executive Office of the
353	Governor, the chair of the Senate Ways and Means Committee or
354	its successor, and the chair of the House Fiscal Council or its
355	successor regarding the financial status of home and community-
356	based services, including the number of enrolled individuals who
357	are receiving services through one or more programs; the number
358	of individuals who have requested services who are not enrolled
359	but who are receiving services through one or more programs,
360	with a description indicating the programs from which the
361	individual is receiving services; the number of individuals who
362	have refused an offer of services but who choose to remain on
363	the list of individuals waiting for services; the number of
364	individuals who have requested services but who are receiving no
365	services; a frequency distribution indicating the length of time
366	individuals have been waiting for services; and information
367	concerning the actual and projected costs compared to the amount
368	of the appropriation available to the program and any projected
369	surpluses or deficits. If at any time an analysis by the agency,
370	in consultation with the Agency for Health Care Administration,
371	indicates that the cost of services is expected to exceed the
372	amount appropriated, the agency shall submit a plan in
373	accordance with subsection (7) to the Executive Office of the
374	Governor, the chair of the Senate Ways and Means Committee or
375	its successor, and the chair of the House Fiscal Council or its
376	successor to remain within the amount appropriated. The agency
377	shall work with the Agency for Health Care Administration to
378	implement the plan so as to remain within the appropriation.
379	(9)  The agency shall develop a transition plan for
380	recipients who are receiving services in one of the four waiver
381	tiers at the time qualified plans are available in each
382	recipient's region pursuant to s. 409.989(3) to enroll those
383	recipients in qualified plans.
384	(10)  This section expires October 1, 2015.
385	Section 2.  Section 400.0713, Florida Statutes, is created
386	to read:
387	400.0713  Nursing home licensure workgroup.-The agency
388	shall establish a workgroup to develop a plan for licensure
389	flexibility to assist nursing homes in developing comprehensive
390	long-term care service capabilities.
391	Section 3.  Paragraphs (b) and (d) of subsection (1) of
392	section 408.040, Florida Statutes, are amended to read:
393	408.040  Conditions and monitoring.-
394	(1)
395	(b)  The agency may consider, in addition to the other
396	criteria specified in s. 408.035, a statement of intent by the
397	applicant that a specified percentage of the annual patient days
398	at the facility will be utilized by patients eligible for care
399	under Title XIX of the Social Security Act. Any certificate of
400	need issued to a nursing home in reliance upon an applicant's
401	statements that a specified percentage of annual patient days
402	will be utilized by residents eligible for care under Title XIX
403	of the Social Security Act must include a statement that such
404	certification is a condition of issuance of the certificate of
405	need. The certificate-of-need program shall notify the Medicaid
406	program office and the Department of Elderly Affairs when it
407	imposes conditions as authorized in this paragraph in an area in
408	which a community diversion pilot project is implemented.
409	Effective July 1, 2011, the agency shall not consider, or impose
410	conditions related to, patient day utilization by patients
411	eligible for care under Title XIX the Social Security Act in
412	making certificate-of-need determinations for nursing homes.
413	(d)  If a nursing home is located in a county in which a
414	long-term care community diversion pilot project has been
415	implemented under s. 430.705 or in a county in which an
416	integrated, fixed-payment delivery program for Medicaid
417	recipients who are 60 years of age or older or dually eligible
418	for Medicare and Medicaid has been implemented under s.
419	409.912(5), the nursing home may request a reduction in the
420	percentage of annual patient days used by residents who are
421	eligible for care under Title XIX of the Social Security Act,
422	which is a condition of the nursing home's certificate of need.
423	The agency shall automatically grant the nursing home's request
424	if the reduction is not more than 15 percent of the nursing
425	home's annual Medicaid-patient-days condition. A nursing home
426	may submit only one request every 2 years for an automatic
427	reduction. A requesting nursing home must notify the agency in
428	writing at least 60 days in advance of its intent to reduce its
429	annual Medicaid-patient-days condition by not more than 15
430	percent. The agency must acknowledge the request in writing and
431	must change its records to reflect the revised certificate-of-
432	need condition. This paragraph expires June 30, 2011.
433	Section 4.  Subsection (1) of section 408.0435, Florida
434	Statutes, is amended to read:
435	408.0435  Moratorium on nursing home certificates of need.-
436	(1)  Notwithstanding the establishment of need as provided
437	for in this chapter, a certificate of need for additional
438	community nursing home beds may not be approved by the agency
439	until after Medicaid managed care is implemented statewide
440	pursuant to ss. 409.961-409.992, or October 1, 2015, whichever
441	is earlier July 1, 2011.
442	Section 5.  Sections 409.016 through 409.803, Florida
443	Statutes, are designated as part I of chapter 409, Florida
444	Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
445	Section 6.  Sections 409.810 through 409.821, Florida
446	Statutes, are designated as part II of chapter 409, Florida
447	Statutes, and entitled "KIDCARE."
448	Section 7.  Sections 409.901 through 409.9205, Florida
449	Statutes, are designated as part III of chapter 409, Florida
450	Statutes, and entitled "MEDICAID."
451	Section 8.  Subsection (5) of section 409.907, Florida
452	Statutes, is amended to read:
453	409.907  Medicaid provider agreements.-The agency may make
454	payments for medical assistance and related services rendered to
455	Medicaid recipients only to an individual or entity who has a
456	provider agreement in effect with the agency, who is performing
457	services or supplying goods in accordance with federal, state,
458	and local law, and who agrees that no person shall, on the
459	grounds of handicap, race, color, or national origin, or for any
460	other reason, be subjected to discrimination under any program
461	or activity for which the provider receives payment from the
462	agency.
463	(5)  The agency:
464	(a)  Is required to make timely payment at the established
465	rate for services or goods furnished to a recipient by the
466	provider upon receipt of a properly completed claim form. The
467	claim form shall require certification that the services or
468	goods have been completely furnished to the recipient and that,
469	with the exception of those services or goods specified by the
470	agency, the amount billed does not exceed the provider's usual
471	and customary charge for the same services or goods.
472	(b)  Is prohibited from demanding repayment from the
473	provider in any instance in which the Medicaid overpayment is
474	attributable to error of the department in the determination of
475	eligibility of a recipient.
476	(c)  May adopt, and include in the provider agreement, such
477	other requirements and stipulations on either party as the
478	agency finds necessary to properly and efficiently administer
479	the Medicaid program.
480	(d)  May enroll entities as Medicare crossover-only
481	providers for payment purposes only. The provider agreement
482	shall:
483	1.  Require that the provider is an eligible Medicare
484	provider, has a current provider agreement in place with the
485	Centers for Medicare and Medicaid Services, and provides
486	verification that the provider is currently in good standing
487	with the agency.
488	2.  Require that the provider notify the agency
489	immediately, in writing, upon being suspended or disenrolled as
490	a Medicare provider. If a provider does not provide such
491	notification within 5 business days after suspension or
492	disenrollment, sanctions may be imposed pursuant to this chapter
493	and the provider may be required to return funds paid to the
494	provider during the period of time that the provider was
495	suspended or disenrolled as a Medicare provider.
496	3.  Require that all records pertaining to health care
497	services provided to each of the provider's recipients be kept
498	for a minimum of 5 years. The agreement shall also require that
499	records and information relating to payments claimed by the
500	provider for services under the agreement be delivered to the
501	agency or the Office of the Attorney General Medicaid Fraud
502	Control Unit when requested. If a provider does not provide such
503	records and information when requested, sanctions may be imposed
504	pursuant to this chapter.
505	4.  Disclose that the agreement is for the purposes of
506	paying Medicare crossover claims only.
507
508	This paragraph pertains solely to Medicare crossover-only
509	providers. In order to become a standard Medicaid provider, the
510	other requirements of this section and applicable rules must be
511	met.
512	Section 9.  Subsection (24) is added to section 409.908,
513	Florida Statutes, to read:
514	409.908  Reimbursement of Medicaid providers.-Subject to
515	specific appropriations, the agency shall reimburse Medicaid
516	providers, in accordance with state and federal law, according
517	to methodologies set forth in the rules of the agency and in
518	policy manuals and handbooks incorporated by reference therein.
519	These methodologies may include fee schedules, reimbursement
520	methods based on cost reporting, negotiated fees, competitive
521	bidding pursuant to s. 287.057, and other mechanisms the agency
522	considers efficient and effective for purchasing services or
523	goods on behalf of recipients. If a provider is reimbursed based
524	on cost reporting and submits a cost report late and that cost
525	report would have been used to set a lower reimbursement rate
526	for a rate semester, then the provider's rate for that semester
527	shall be retroactively calculated using the new cost report, and
528	full payment at the recalculated rate shall be effected
529	retroactively. Medicare-granted extensions for filing cost
530	reports, if applicable, shall also apply to Medicaid cost
531	reports. Payment for Medicaid compensable services made on
532	behalf of Medicaid eligible persons is subject to the
533	availability of moneys and any limitations or directions
534	provided for in the General Appropriations Act or chapter 216.
535	Further, nothing in this section shall be construed to prevent
536	or limit the agency from adjusting fees, reimbursement rates,
537	lengths of stay, number of visits, or number of services, or
538	making any other adjustments necessary to comply with the
539	availability of moneys and any limitations or directions
540	provided for in the General Appropriations Act, provided the
541	adjustment is consistent with legislative intent.
542	(24)  If a provider fails to notify the agency within 5
543	business days after suspension or disenrollment from Medicare,
544	sanctions may be imposed pursuant to this chapter and the
545	provider may be required to return funds paid to the provider
546	during the period of time that the provider was suspended or
547	disenrolled as a Medicare provider.
548	Section 10.  Section 409.912, Florida Statutes, is amended
549	to read:
550	409.912  Cost-effective purchasing of health care.-The
551	agency shall purchase goods and services for Medicaid recipients
552	in the most cost-effective manner consistent with the delivery
553	of quality medical care. To ensure that medical services are
554	effectively utilized, the agency may, in any case, require a
555	confirmation or second physician's opinion of the correct
556	diagnosis for purposes of authorizing future services under the
557	Medicaid program. This section does not restrict access to
558	emergency services or poststabilization care services as defined
559	in 42 C.F.R. part 438.114. Such confirmation or second opinion
560	shall be rendered in a manner approved by the agency. The agency
561	shall maximize the use of prepaid per capita and prepaid
562	aggregate fixed-sum basis services when appropriate and other
563	alternative service delivery and reimbursement methodologies,
564	including competitive bidding pursuant to s. 287.057, designed
565	to facilitate the cost-effective purchase of a case-managed
566	continuum of care. The agency shall also require providers to
567	minimize the exposure of recipients to the need for acute
568	inpatient, custodial, and other institutional care and the
569	inappropriate or unnecessary use of high-cost services. The
570	agency shall contract with a vendor to monitor and evaluate the
571	clinical practice patterns of providers in order to identify
572	trends that are outside the normal practice patterns of a
573	provider's professional peers or the national guidelines of a
574	provider's professional association. The vendor must be able to
575	provide information and counseling to a provider whose practice
576	patterns are outside the norms, in consultation with the agency,
577	to improve patient care and reduce inappropriate utilization.
578	The agency may mandate prior authorization, drug therapy
579	management, or disease management participation for certain
580	populations of Medicaid beneficiaries, certain drug classes, or
581	particular drugs to prevent fraud, abuse, overuse, and possible
582	dangerous drug interactions. The Pharmaceutical and Therapeutics
583	Committee shall make recommendations to the agency on drugs for
584	which prior authorization is required. The agency shall inform
585	the Pharmaceutical and Therapeutics Committee of its decisions
586	regarding drugs subject to prior authorization. The agency is
587	authorized to limit the entities it contracts with or enrolls as
588	Medicaid providers by developing a provider network through
589	provider credentialing. The agency may competitively bid single-
590	source-provider contracts if procurement of goods or services
591	results in demonstrated cost savings to the state without
592	limiting access to care. The agency may limit its network based
593	on the assessment of beneficiary access to care, provider
594	availability, provider quality standards, time and distance
595	standards for access to care, the cultural competence of the
596	provider network, demographic characteristics of Medicaid
597	beneficiaries, practice and provider-to-beneficiary standards,
598	appointment wait times, beneficiary use of services, provider
599	turnover, provider profiling, provider licensure history,
600	previous program integrity investigations and findings, peer
601	review, provider Medicaid policy and billing compliance records,
602	clinical and medical record audits, and other factors. Providers
603	shall not be entitled to enrollment in the Medicaid provider
604	network. The agency shall determine instances in which allowing
605	Medicaid beneficiaries to purchase durable medical equipment and
606	other goods is less expensive to the Medicaid program than long-
607	term rental of the equipment or goods. The agency may establish
608	rules to facilitate purchases in lieu of long-term rentals in
609	order to protect against fraud and abuse in the Medicaid program
610	as defined in s. 409.913. The agency may seek federal waivers
611	necessary to administer these policies.
612	(1)  The agency shall work with the Department of Children
613	and Family Services to ensure access of children and families in
614	the child protection system to needed and appropriate mental
615	health and substance abuse services. This subsection expires
616	October 1, 2013.
617	(2)  The agency may enter into agreements with appropriate
618	agents of other state agencies or of any agency of the Federal
619	Government and accept such duties in respect to social welfare
620	or public aid as may be necessary to implement the provisions of
621	Title XIX of the Social Security Act and ss. 409.901-409.920.
622	This subsection expires October 1, 2015.
623	(3)  The agency may contract with health maintenance
624	organizations certified pursuant to part I of chapter 641 for
625	the provision of services to recipients. This subsection expires
626	October 1, 2013.
627	(4)  The agency may contract with:
628	(a)  An entity that provides no prepaid health care
629	services other than Medicaid services under contract with the
630	agency and which is owned and operated by a county, county
631	health department, or county-owned and operated hospital to
632	provide health care services on a prepaid or fixed-sum basis to
633	recipients, which entity may provide such prepaid services
634	either directly or through arrangements with other providers.
635	Such prepaid health care services entities must be licensed
636	under parts I and III of chapter 641. An entity recognized under
637	this paragraph which demonstrates to the satisfaction of the
638	Office of Insurance Regulation of the Financial Services
639	Commission that it is backed by the full faith and credit of the
640	county in which it is located may be exempted from s. 641.225.
641	This paragraph expires October 1, 2013.
642	(b)  An entity that is providing comprehensive behavioral
643	health care services to certain Medicaid recipients through a
644	capitated, prepaid arrangement pursuant to the federal waiver
645	provided for by s. 409.905(5). Such entity must be licensed
646	under chapter 624, chapter 636, or chapter 641, or authorized
647	under paragraph (c) or paragraph (d), and must possess the
648	clinical systems and operational competence to manage risk and
649	provide comprehensive behavioral health care to Medicaid
650	recipients. As used in this paragraph, the term "comprehensive
651	behavioral health care services" means covered mental health and
652	substance abuse treatment services that are available to
653	Medicaid recipients. The secretary of the Department of Children
654	and Family Services shall approve provisions of procurements
655	related to children in the department's care or custody before
656	enrolling such children in a prepaid behavioral health plan. Any
657	contract awarded under this paragraph must be competitively
658	procured. In developing the behavioral health care prepaid plan
659	procurement document, the agency shall ensure that the
660	procurement document requires the contractor to develop and
661	implement a plan to ensure compliance with s. 394.4574 related
662	to services provided to residents of licensed assisted living
663	facilities that hold a limited mental health license. Except as
664	provided in subparagraph 5. 8., and except in counties where the
665	Medicaid managed care pilot program is authorized pursuant to s.
666	409.91211, the agency shall seek federal approval to contract
667	with a single entity meeting these requirements to provide
668	comprehensive behavioral health care services to all Medicaid
669	recipients not enrolled in a Medicaid managed care plan
670	authorized under s. 409.91211, a provider service network as
671	described in paragraph (d), or a Medicaid health maintenance
672	organization in an AHCA area. In an AHCA area where the Medicaid
673	managed care pilot program is authorized pursuant to s.
674	409.91211 in one or more counties, the agency may procure a
675	contract with a single entity to serve the remaining counties as
676	an AHCA area or the remaining counties may be included with an
677	adjacent AHCA area and are subject to this paragraph. Each
678	entity must offer a sufficient choice of providers in its
679	network to ensure recipient access to care and the opportunity
680	to select a provider with whom they are satisfied. The network
681	shall include all public mental health hospitals. To ensure
682	unimpaired access to behavioral health care services by Medicaid
683	recipients, all contracts issued pursuant to this paragraph must
684	require 80 percent of the capitation paid to the managed care
685	plan, including health maintenance organizations and capitated
686	provider service networks, to be expended for the provision of
687	behavioral health care services. If the managed care plan
688	expends less than 80 percent of the capitation paid for the
689	provision of behavioral health care services, the difference
690	shall be returned to the agency. The agency shall provide the
691	plan with a certification letter indicating the amount of
692	capitation paid during each calendar year for behavioral health
693	care services pursuant to this section. The agency may reimburse
694	for substance abuse treatment services on a fee-for-service
695	basis until the agency finds that adequate funds are available
696	for capitated, prepaid arrangements.
697	1.  By January 1, 2001, The agency shall modify the
698	contracts with the entities providing comprehensive inpatient
699	and outpatient mental health care services to Medicaid
700	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
701	Counties, to include substance abuse treatment services.
702	2.  By July 1, 2003, the agency and the Department of
703	Children and Family Services shall execute a written agreement
704	that requires collaboration and joint development of all policy,
705	budgets, procurement documents, contracts, and monitoring plans
706	that have an impact on the state and Medicaid community mental
707	health and targeted case management programs.
708	2.3.  Except as provided in subparagraph 5. 8., by July 1,
709	2006, the agency and the Department of Children and Family
710	Services shall contract with managed care entities in each AHCA
711	area except area 6 or arrange to provide comprehensive inpatient
712	and outpatient mental health and substance abuse services
713	through capitated prepaid arrangements to all Medicaid
714	recipients who are eligible to participate in such plans under
715	federal law and regulation. In AHCA areas where eligible
716	individuals number less than 150,000, the agency shall contract
717	with a single managed care plan to provide comprehensive
718	behavioral health services to all recipients who are not
719	enrolled in a Medicaid health maintenance organization, a
720	provider service network as described in paragraph (d), or a
721	Medicaid capitated managed care plan authorized under s.
722	409.91211. The agency may contract with more than one
723	comprehensive behavioral health provider to provide care to
724	recipients who are not enrolled in a Medicaid capitated managed
725	care plan authorized under s. 409.91211, a provider service
726	network as described in paragraph (d), or a Medicaid health
727	maintenance organization in AHCA areas where the eligible
728	population exceeds 150,000. In an AHCA area where the Medicaid
729	managed care pilot program is authorized pursuant to s.
730	409.91211 in one or more counties, the agency may procure a
731	contract with a single entity to serve the remaining counties as
732	an AHCA area or the remaining counties may be included with an
733	adjacent AHCA area and shall be subject to this paragraph.
734	Contracts for comprehensive behavioral health providers awarded
735	pursuant to this section shall be competitively procured. Both
736	for-profit and not-for-profit corporations are eligible to
737	compete. Managed care plans contracting with the agency under
738	subsection (3) or paragraph (d), shall provide and receive
739	payment for the same comprehensive behavioral health benefits as
740	provided in AHCA rules, including handbooks incorporated by
741	reference. In AHCA area 11, the agency shall contract with at
742	least two comprehensive behavioral health care providers to
743	provide behavioral health care to recipients in that area who
744	are enrolled in, or assigned to, the MediPass program. One of
745	the behavioral health care contracts must be with the existing
746	provider service network pilot project, as described in
747	paragraph (d), for the purpose of demonstrating the cost-
748	effectiveness of the provision of quality mental health services
749	through a public hospital-operated managed care model. Payment
750	shall be at an agreed-upon capitated rate to ensure cost
751	savings. Of the recipients in area 11 who are assigned to
752	MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
753	MediPass-enrolled recipients shall be assigned to the existing
754	provider service network in area 11 for their behavioral care.
755	4.  By October 1, 2003, the agency and the department shall
756	submit a plan to the Governor, the President of the Senate, and
757	the Speaker of the House of Representatives which provides for
758	the full implementation of capitated prepaid behavioral health
759	care in all areas of the state.
760	a.  Implementation shall begin in 2003 in those AHCA areas
761	of the state where the agency is able to establish sufficient
762	capitation rates.
763	b.  If the agency determines that the proposed capitation
764	rate in any area is insufficient to provide appropriate
765	services, the agency may adjust the capitation rate to ensure
766	that care will be available. The agency and the department may
767	use existing general revenue to address any additional required
768	match but may not over-obligate existing funds on an annualized
769	basis.
770	c.  Subject to any limitations provided in the General
771	Appropriations Act, the agency, in compliance with appropriate
772	federal authorization, shall develop policies and procedures
773	that allow for certification of local and state funds.
774	3.5.  Children residing in a statewide inpatient
775	psychiatric program, or in a Department of Juvenile Justice or a
776	Department of Children and Family Services residential program
777	approved as a Medicaid behavioral health overlay services
778	provider may not be included in a behavioral health care prepaid
779	health plan or any other Medicaid managed care plan pursuant to
780	this paragraph.
781	6.  In converting to a prepaid system of delivery, the
782	agency shall in its procurement document require an entity
783	providing only comprehensive behavioral health care services to
784	prevent the displacement of indigent care patients by enrollees
785	in the Medicaid prepaid health plan providing behavioral health
786	care services from facilities receiving state funding to provide
787	indigent behavioral health care, to facilities licensed under
788	chapter 395 which do not receive state funding for indigent
789	behavioral health care, or reimburse the unsubsidized facility
790	for the cost of behavioral health care provided to the displaced
791	indigent care patient.
792	4.7.  Traditional community mental health providers under
793	contract with the Department of Children and Family Services
794	pursuant to part IV of chapter 394, child welfare providers
795	under contract with the Department of Children and Family
796	Services in areas 1 and 6, and inpatient mental health providers
797	licensed pursuant to chapter 395 must be offered an opportunity
798	to accept or decline a contract to participate in any provider
799	network for prepaid behavioral health services.
800	5.8.  All Medicaid-eligible children, except children in
801	area 1 and children in Highlands County, Hardee County, Polk
802	County, or Manatee County of area 6, that are open for child
803	welfare services in the HomeSafeNet system, shall receive their
804	behavioral health care services through a specialty prepaid plan
805	operated by community-based lead agencies through a single
806	agency or formal agreements among several agencies. The
807	specialty prepaid plan must result in savings to the state
808	comparable to savings achieved in other Medicaid managed care
809	and prepaid programs. Such plan must provide mechanisms to
810	maximize state and local revenues. The specialty prepaid plan
811	shall be developed by the agency and the Department of Children
812	and Family Services. The agency may seek federal waivers to
813	implement this initiative. Medicaid-eligible children whose
814	cases are open for child welfare services in the HomeSafeNet
815	system and who reside in AHCA area 10 are exempt from the
816	specialty prepaid plan upon the development of a service
817	delivery mechanism for children who reside in area 10 as
818	specified in s. 409.91211(3)(dd).
819
820	This paragraph expires October 1, 2013.
821	(c)  A federally qualified health center or an entity owned
822	by one or more federally qualified health centers or an entity
823	owned by other migrant and community health centers receiving
824	non-Medicaid financial support from the Federal Government to
825	provide health care services on a prepaid or fixed-sum basis to
826	recipients. A federally qualified health center or an entity
827	that is owned by one or more federally qualified health centers
828	and is reimbursed by the agency on a prepaid basis is exempt
829	from parts I and III of chapter 641, but must comply with the
830	solvency requirements in s. 641.2261(2) and meet the appropriate
831	requirements governing financial reserve, quality assurance, and
832	patients' rights established by the agency. This paragraph
833	expires October 1, 2013.
834	(d)1.  A provider service network may be reimbursed on a
835	fee-for-service or prepaid basis. Prepaid provider service
836	networks receive per-member per-month payments. Provider service
837	networks that do not choose to be prepaid plans shall receive
838	fee-for-service rates with a shared savings settlement. The fee-
839	for-service option shall be available to a provider service
840	network only for the first 5 years of the plan's operation in a
841	given region or until the contract year beginning October 1,
842	2015, whichever is later. The agency shall annually conduct cost
843	reconciliations to determine the amount of cost savings achieved
844	by fee-for-service provider service networks for the dates of
845	service in the period being reconciled. Only payments for
846	covered services for dates of service within the reconciliation
847	period and paid within 6 months after the last date of service
848	in the reconciliation period shall be included. The agency shall
849	perform the necessary adjustments for the inclusion of claims
850	incurred but not reported within the reconciliation for claims
851	that could be received and paid by the agency after the 6-month
852	claims processing time lag. The agency shall provide the results
853	of the reconciliations to the fee-for-service provider service
854	networks within 45 days after the end of the reconciliation
855	period. The fee-for-service provider service networks shall
856	review and provide written comments or a letter of concurrence
857	to the agency within 45 days after receipt of the reconciliation
858	results. This reconciliation shall be considered final.
859	2.  A provider service network which is reimbursed by the
860	agency on a prepaid basis shall be exempt from parts I and III
861	of chapter 641, but must comply with the solvency requirements
862	in s. 641.2261(2) and meet appropriate financial reserve,
863	quality assurance, and patient rights requirements as
864	established by the agency.
865	3.  Medicaid recipients assigned to a provider service
866	network shall be chosen equally from those who would otherwise
867	have been assigned to prepaid plans and MediPass. The agency is
868	authorized to seek federal Medicaid waivers as necessary to
869	implement the provisions of this section. This subparagraph
870	expires October 1, 2013. Any contract previously awarded to a
871	provider service network operated by a hospital pursuant to this
872	subsection shall remain in effect for a period of 3 years
873	following the current contract expiration date, regardless of
874	any contractual provisions to the contrary.
875	4.  A provider service network is a network established or
876	organized and operated by a health care provider, or group of
877	affiliated health care providers, including minority physician
878	networks and emergency room diversion programs that meet the
879	requirements of s. 409.91211, which provides a substantial
880	proportion of the health care items and services under a
881	contract directly through the provider or affiliated group of
882	providers and may make arrangements with physicians or other
883	health care professionals, health care institutions, or any
884	combination of such individuals or institutions to assume all or
885	part of the financial risk on a prospective basis for the
886	provision of basic health services by the physicians, by other
887	health professionals, or through the institutions. The health
888	care providers must have a controlling interest in the governing
889	body of the provider service network organization.
890	(e)  An entity that provides only comprehensive behavioral
891	health care services to certain Medicaid recipients through an
892	administrative services organization agreement. Such an entity
893	must possess the clinical systems and operational competence to
894	provide comprehensive health care to Medicaid recipients. As
895	used in this paragraph, the term "comprehensive behavioral
896	health care services" means covered mental health and substance
897	abuse treatment services that are available to Medicaid
898	recipients. Any contract awarded under this paragraph must be
899	competitively procured. The agency must ensure that Medicaid
900	recipients have available the choice of at least two managed
901	care plans for their behavioral health care services. This
902	paragraph expires October 1, 2013.
903	(f)  An entity that provides in-home physician services to
904	test the cost-effectiveness of enhanced home-based medical care
905	to Medicaid recipients with degenerative neurological diseases
906	and other diseases or disabling conditions associated with high
907	costs to Medicaid. The program shall be designed to serve very
908	disabled persons and to reduce Medicaid reimbursed costs for
909	inpatient, outpatient, and emergency department services. The
910	agency shall contract with vendors on a risk-sharing basis.
911	(g)  Children's provider networks that provide care
912	coordination and care management for Medicaid-eligible pediatric
913	patients, primary care, authorization of specialty care, and
914	other urgent and emergency care through organized providers
915	designed to service Medicaid eligibles under age 18 and
916	pediatric emergency departments' diversion programs. The
917	networks shall provide after-hour operations, including evening
918	and weekend hours, to promote, when appropriate, the use of the
919	children's networks rather than hospital emergency departments.
920	(f)(h)  An entity authorized in s. 430.205 to contract with
921	the agency and the Department of Elderly Affairs to provide
922	health care and social services on a prepaid or fixed-sum basis
923	to elderly recipients. Such prepaid health care services
924	entities are exempt from the provisions of part I of chapter 641
925	for the first 3 years of operation. An entity recognized under
926	this paragraph that demonstrates to the satisfaction of the
927	Office of Insurance Regulation that it is backed by the full
928	faith and credit of one or more counties in which it operates
929	may be exempted from s. 641.225. This paragraph expires October
930	1, 2012.
931	(g)(i)  A Children's Medical Services Network, as defined
932	in s. 391.021. This paragraph expires October 1, 2013.
933	(5)  The Agency for Health Care Administration, in
934	partnership with the Department of Elderly Affairs, shall create
935	an integrated, fixed-payment delivery program for Medicaid
936	recipients who are 60 years of age or older or dually eligible
937	for Medicare and Medicaid. The Agency for Health Care
938	Administration shall implement the integrated program initially
939	on a pilot basis in two areas of the state. The pilot areas
940	shall be Area 7 and Area 11 of the Agency for Health Care
941	Administration. Enrollment in the pilot areas shall be on a
942	voluntary basis and in accordance with approved federal waivers
943	and this section. The agency and its program contractors and
944	providers shall not enroll any individual in the integrated
945	program because the individual or the person legally responsible
946	for the individual fails to choose to enroll in the integrated
947	program. Enrollment in the integrated program shall be
948	exclusively by affirmative choice of the eligible individual or
949	by the person legally responsible for the individual. The
950	integrated program must transfer all Medicaid services for
951	eligible elderly individuals who choose to participate into an
952	integrated-care management model designed to serve Medicaid
953	recipients in the community. The integrated program must combine
954	all funding for Medicaid services provided to individuals who
955	are 60 years of age or older or dually eligible for Medicare and
956	Medicaid into the integrated program, including funds for
957	Medicaid home and community-based waiver services; all Medicaid
958	services authorized in ss. 409.905 and 409.906, excluding funds
959	for Medicaid nursing home services unless the agency is able to
960	demonstrate how the integration of the funds will improve
961	coordinated care for these services in a less costly manner; and
962	Medicare coinsurance and deductibles for persons dually eligible
963	for Medicaid and Medicare as prescribed in s. 409.908(13).
964	(a)  Individuals who are 60 years of age or older or dually
965	eligible for Medicare and Medicaid and enrolled in the
966	developmental disabilities waiver program, the family and
967	supported-living waiver program, the project AIDS care waiver
968	program, the traumatic brain injury and spinal cord injury
969	waiver program, the consumer-directed care waiver program, and
970	the program of all-inclusive care for the elderly program, and
971	residents of institutional care facilities for the
972	developmentally disabled, must be excluded from the integrated
973	program.
974	(b)  Managed care entities who meet or exceed the agency's
975	minimum standards are eligible to operate the integrated
976	program. Entities eligible to participate include managed care
977	organizations licensed under chapter 641, including entities
978	eligible to participate in the nursing home diversion program,
979	other qualified providers as defined in s. 430.703(7), community
980	care for the elderly lead agencies, and other state-certified
981	community service networks that meet comparable standards as
982	defined by the agency, in consultation with the Department of
983	Elderly Affairs and the Office of Insurance Regulation, to be
984	financially solvent and able to take on financial risk for
985	managed care. Community service networks that are certified
986	pursuant to the comparable standards defined by the agency are
987	not required to be licensed under chapter 641. Managed care
988	entities who operate the integrated program shall be subject to
989	s. 408.7056. Eligible entities shall choose to serve enrollees
990	who are dually eligible for Medicare and Medicaid, enrollees who
991	are 60 years of age or older, or both.
992	(c)  The agency must ensure that the capitation-rate-
993	setting methodology for the integrated program is actuarially
994	sound and reflects the intent to provide quality care in the
995	least restrictive setting. The agency must also require
996	integrated-program providers to develop a credentialing system
997	for service providers and to contract with all Gold Seal nursing
998	homes, where feasible, and exclude, where feasible, chronically
999	poor-performing facilities and providers as defined by the
1000	agency. The integrated program must develop and maintain an
1001	informal provider grievance system that addresses provider
1002	payment and contract problems. The agency shall also establish a
1003	formal grievance system to address those issues that were not
1004	resolved through the informal grievance system. The integrated
1005	program must provide that if the recipient resides in a
1006	noncontracted residential facility licensed under chapter 400 or
1007	chapter 429 at the time of enrollment in the integrated program,
1008	the recipient must be permitted to continue to reside in the
1009	noncontracted facility as long as the recipient desires. The
1010	integrated program must also provide that, in the absence of a
1011	contract between the integrated-program provider and the
1012	residential facility licensed under chapter 400 or chapter 429,
1013	current Medicaid rates must prevail. The integrated-program
1014	provider must ensure that electronic nursing home claims that
1015	contain sufficient information for processing are paid within 10
1016	business days after receipt. Alternately, the integrated-program
1017	provider may establish a capitated payment mechanism to
1018	prospectively pay nursing homes at the beginning of each month.
1019	The agency and the Department of Elderly Affairs must jointly
1020	develop procedures to manage the services provided through the
1021	integrated program in order to ensure quality and recipient
1022	choice.
1023	(d)  The Office of Program Policy Analysis and Government
1024	Accountability, in consultation with the Auditor General, shall
1025	comprehensively evaluate the pilot project for the integrated,
1026	fixed-payment delivery program for Medicaid recipients created
1027	under this subsection. The evaluation shall begin as soon as
1028	Medicaid recipients are enrolled in the managed care pilot
1029	program plans and shall continue for 24 months thereafter. The
1030	evaluation must include assessments of each managed care plan in
1031	the integrated program with regard to cost savings; consumer
1032	education, choice, and access to services; coordination of care;
1033	and quality of care. The evaluation must describe administrative
1034	or legal barriers to the implementation and operation of the
1035	pilot program and include recommendations regarding statewide
1036	expansion of the pilot program. The office shall submit its
1037	evaluation report to the Governor, the President of the Senate,
1038	and the Speaker of the House of Representatives no later than
1039	December 31, 2009.
1040	(e)  The agency may seek federal waivers or Medicaid state
1041	plan amendments and adopt rules as necessary to administer the
1042	integrated program. The agency may implement the approved
1043	federal waivers and other provisions as specified in this
1044	subsection.
1045	(f)  No later than December 31, 2007, the agency shall
1046	provide a report to the Governor, the President of the Senate,
1047	and the Speaker of the House of Representatives containing an
1048	analysis of the merits and challenges of seeking a waiver to
1049	implement a voluntary program that integrates payments and
1050	services for dually enrolled Medicare and Medicaid recipients
1051	who are 65 years of age or older.
1052	(g)  The implementation of the integrated, fixed-payment
1053	delivery program created under this subsection is subject to an
1054	appropriation in the General Appropriations Act.
1055	(5)(6)  The agency may contract with any public or private
1056	entity otherwise authorized by this section on a prepaid or
1057	fixed-sum basis for the provision of health care services to
1058	recipients. An entity may provide prepaid services to
1059	recipients, either directly or through arrangements with other
1060	entities, if each entity involved in providing services:
1061	(a)  Is organized primarily for the purpose of providing
1062	health care or other services of the type regularly offered to
1063	Medicaid recipients;
1064	(b)  Ensures that services meet the standards set by the
1065	agency for quality, appropriateness, and timeliness;
1066	(c)  Makes provisions satisfactory to the agency for
1067	insolvency protection and ensures that neither enrolled Medicaid
1068	recipients nor the agency will be liable for the debts of the
1069	entity;
1070	(d)  Submits to the agency, if a private entity, a
1071	financial plan that the agency finds to be fiscally sound and
1072	that provides for working capital in the form of cash or
1073	equivalent liquid assets excluding revenues from Medicaid
1074	premium payments equal to at least the first 3 months of
1075	operating expenses or $200,000, whichever is greater;
1076	(e)  Furnishes evidence satisfactory to the agency of
1077	adequate liability insurance coverage or an adequate plan of
1078	self-insurance to respond to claims for injuries arising out of
1079	the furnishing of health care;
1080	(f)  Provides, through contract or otherwise, for periodic
1081	review of its medical facilities and services, as required by
1082	the agency; and
1083	(g)  Provides organizational, operational, financial, and
1084	other information required by the agency.
1085
1086	This subsection expires October 1, 2013.
1087	(6)(7)  The agency may contract on a prepaid or fixed-sum
1088	basis with any health insurer that:
1089	(a)  Pays for health care services provided to enrolled
1090	Medicaid recipients in exchange for a premium payment paid by
1091	the agency;
1092	(b)  Assumes the underwriting risk; and
1093	(c)  Is organized and licensed under applicable provisions
1094	of the Florida Insurance Code and is currently in good standing
1095	with the Office of Insurance Regulation.
1096
1097	This subsection expires October 1, 2013.
1098	(7)(8)(a)  The agency may contract on a prepaid or fixed-
1099	sum basis with an exclusive provider organization to provide
1100	health care services to Medicaid recipients provided that the
1101	exclusive provider organization meets applicable managed care
1102	plan requirements in this section, ss. 409.9122, 409.9123,
1103	409.9128, and 627.6472, and other applicable provisions of law.
1104	This subsection expires October 1, 2013.
1105	(b)  For a period of no longer than 24 months after the
1106	effective date of this paragraph, when a member of an exclusive
1107	provider organization that is contracted by the agency to
1108	provide health care services to Medicaid recipients in rural
1109	areas without a health maintenance organization obtains services
1110	from a provider that participates in the Medicaid program in
1111	this state, the provider shall be paid in accordance with the
1112	appropriate fee schedule for services provided to eligible
1113	Medicaid recipients. The agency may seek waiver authority to
1114	implement this paragraph.
1115	(8)(9)  The Agency for Health Care Administration may
1116	provide cost-effective purchasing of chiropractic services on a
1117	fee-for-service basis to Medicaid recipients through
1118	arrangements with a statewide chiropractic preferred provider
1119	organization incorporated in this state as a not-for-profit
1120	corporation. The agency shall ensure that the benefit limits and
1121	prior authorization requirements in the current Medicaid program
1122	shall apply to the services provided by the chiropractic
1123	preferred provider organization. This subsection expires October
1124	1, 2013.
1125	(9)(10)  The agency shall not contract on a prepaid or
1126	fixed-sum basis for Medicaid services with an entity which knows
1127	or reasonably should know that any officer, director, agent,
1128	managing employee, or owner of stock or beneficial interest in
1129	excess of 5 percent common or preferred stock, or the entity
1130	itself, has been found guilty of, regardless of adjudication, or
1131	entered a plea of nolo contendere, or guilty, to:
1132	(a)  Fraud;
1133	(b)  Violation of federal or state antitrust statutes,
1134	including those proscribing price fixing between competitors and
1135	the allocation of customers among competitors;
1136	(c)  Commission of a felony involving embezzlement, theft,
1137	forgery, income tax evasion, bribery, falsification or
1138	destruction of records, making false statements, receiving
1139	stolen property, making false claims, or obstruction of justice;
1140	or
1141	(d)  Any crime in any jurisdiction which directly relates
1142	to the provision of health services on a prepaid or fixed-sum
1143	basis.
1144
1145	This subsection expires October 1, 2013.
1146	(10)(11)  The agency, after notifying the Legislature, may
1147	apply for waivers of applicable federal laws and regulations as
1148	necessary to implement more appropriate systems of health care
1149	for Medicaid recipients and reduce the cost of the Medicaid
1150	program to the state and federal governments and shall implement
1151	such programs, after legislative approval, within a reasonable
1152	period of time after federal approval. These programs must be
1153	designed primarily to reduce the need for inpatient care,
1154	custodial care and other long-term or institutional care, and
1155	other high-cost services. Prior to seeking legislative approval
1156	of such a waiver as authorized by this subsection, the agency
1157	shall provide notice and an opportunity for public comment.
1158	Notice shall be provided to all persons who have made requests
1159	of the agency for advance notice and shall be published in the
1160	Florida Administrative Weekly not less than 28 days prior to the
1161	intended action. This subsection expires October 1, 2015.
1162	(11)(12)  The agency shall establish a postpayment
1163	utilization control program designed to identify recipients who
1164	may inappropriately overuse or underuse Medicaid services and
1165	shall provide methods to correct such misuse. This subsection
1166	expires October 1, 2013.
1167	(12)(13)  The agency shall develop and provide coordinated
1168	systems of care for Medicaid recipients and may contract with
1169	public or private entities to develop and administer such
1170	systems of care among public and private health care providers
1171	in a given geographic area. This subsection expires October 1,
1172	2013.
1173	(13)(14)(a)  The agency shall operate or contract for the
1174	operation of utilization management and incentive systems
1175	designed to encourage cost-effective use of services and to
1176	eliminate services that are medically unnecessary. The agency
1177	shall track Medicaid provider prescription and billing patterns
1178	and evaluate them against Medicaid medical necessity criteria
1179	and coverage and limitation guidelines adopted by rule. Medical
1180	necessity determination requires that service be consistent with
1181	symptoms or confirmed diagnosis of illness or injury under
1182	treatment and not in excess of the patient's needs. The agency
1183	shall conduct reviews of provider exceptions to peer group norms
1184	and shall, using statistical methodologies, provider profiling,
1185	and analysis of billing patterns, detect and investigate
1186	abnormal or unusual increases in billing or payment of claims
1187	for Medicaid services and medically unnecessary provision of
1188	services. Providers that demonstrate a pattern of submitting
1189	claims for medically unnecessary services shall be referred to
1190	the Medicaid program integrity unit for investigation. In its
1191	annual report, required in s. 409.913, the agency shall report
1192	on its efforts to control overutilization as described in this
1193	subsection paragraph. This subsection expires October 1, 2013.
1194	(b)  The agency shall develop a procedure for determining
1195	whether health care providers and service vendors can provide
1196	the Medicaid program using a business case that demonstrates
1197	whether a particular good or service can offset the cost of
1198	providing the good or service in an alternative setting or
1199	through other means and therefore should receive a higher
1200	reimbursement. The business case must include, but need not be
1201	limited to:
1202	1.  A detailed description of the good or service to be
1203	provided, a description and analysis of the agency's current
1204	performance of the service, and a rationale documenting how
1205	providing the service in an alternative setting would be in the
1206	best interest of the state, the agency, and its clients.
1207	2.  A cost-benefit analysis documenting the estimated
1208	specific direct and indirect costs, savings, performance
1209	improvements, risks, and qualitative and quantitative benefits
1210	involved in or resulting from providing the service. The cost-
1211	benefit analysis must include a detailed plan and timeline
1212	identifying all actions that must be implemented to realize
1213	expected benefits. The Secretary of Health Care Administration
1214	shall verify that all costs, savings, and benefits are valid and
1215	achievable.
1216	(c)  If the agency determines that the increased
1217	reimbursement is cost-effective, the agency shall recommend a
1218	change in the reimbursement schedule for that particular good or
1219	service. If, within 12 months after implementing any rate change
1220	under this procedure, the agency determines that costs were not
1221	offset by the increased reimbursement schedule, the agency may
1222	revert to the former reimbursement schedule for the particular
1223	good or service.
1224	(14)(15)(a)  The agency shall operate the Comprehensive
1225	Assessment and Review for Long-Term Care Services (CARES)
1226	nursing facility preadmission screening program to ensure that
1227	Medicaid payment for nursing facility care is made only for
1228	individuals whose conditions require such care and to ensure
1229	that long-term care services are provided in the setting most
1230	appropriate to the needs of the person and in the most
1231	economical manner possible. The CARES program shall also ensure
1232	that individuals participating in Medicaid home and community-
1233	based waiver programs meet criteria for those programs,
1234	consistent with approved federal waivers.
1235	(b)  The agency shall operate the CARES program through an
1236	interagency agreement with the Department of Elderly Affairs.
1237	The agency, in consultation with the Department of Elderly
1238	Affairs, may contract for any function or activity of the CARES
1239	program, including any function or activity required by 42
1240	C.F.R. part 483.20, relating to preadmission screening and
1241	resident review.
1242	(c)  Prior to making payment for nursing facility services
1243	for a Medicaid recipient, the agency must verify that the
1244	nursing facility preadmission screening program has determined
1245	that the individual requires nursing facility care and that the
1246	individual cannot be safely served in community-based programs.
1247	The nursing facility preadmission screening program shall refer
1248	a Medicaid recipient to a community-based program if the
1249	individual could be safely served at a lower cost and the
1250	recipient chooses to participate in such program. For
1251	individuals whose nursing home stay is initially funded by
1252	Medicare and Medicare coverage is being terminated for lack of
1253	progress towards rehabilitation, CARES staff shall consult with
1254	the person making the determination of progress toward
1255	rehabilitation to ensure that the recipient is not being
1256	inappropriately disqualified from Medicare coverage. If, in
1257	their professional judgment, CARES staff believes that a
1258	Medicare beneficiary is still making progress toward
1259	rehabilitation, they may assist the Medicare beneficiary with an
1260	appeal of the disqualification from Medicare coverage. The use
1261	of CARES teams to review Medicare denials for coverage under
1262	this section is authorized only if it is determined that such
1263	reviews qualify for federal matching funds through Medicaid. The
1264	agency shall seek or amend federal waivers as necessary to
1265	implement this section.
1266	(d)  For the purpose of initiating immediate prescreening
1267	and diversion assistance for individuals residing in nursing
1268	homes and in order to make families aware of alternative long-
1269	term care resources so that they may choose a more cost-
1270	effective setting for long-term placement, CARES staff shall
1271	conduct an assessment and review of a sample of individuals
1272	whose nursing home stay is expected to exceed 20 days,
1273	regardless of the initial funding source for the nursing home
1274	placement. CARES staff shall provide counseling and referral
1275	services to these individuals regarding choosing appropriate
1276	long-term care alternatives. This paragraph does not apply to
1277	continuing care facilities licensed under chapter 651 or to
1278	retirement communities that provide a combination of nursing
1279	home, independent living, and other long-term care services.
1280	(e)  By January 15 of each year, the agency shall submit a
1281	report to the Legislature describing the operations of the CARES
1282	program. The report must describe:
1283	1.  Rate of diversion to community alternative programs;
1284	2.  CARES program staffing needs to achieve additional
1285	diversions;
1286	3.  Reasons the program is unable to place individuals in
1287	less restrictive settings when such individuals desired such
1288	services and could have been served in such settings;
1289	4.  Barriers to appropriate placement, including barriers
1290	due to policies or operations of other agencies or state-funded
1291	programs; and
1292	5.  Statutory changes necessary to ensure that individuals
1293	in need of long-term care services receive care in the least
1294	restrictive environment.
1295	(f)  The Department of Elderly Affairs shall track
1296	individuals over time who are assessed under the CARES program
1297	and who are diverted from nursing home placement. By January 15
1298	of each year, the department shall submit to the Legislature a
1299	longitudinal study of the individuals who are diverted from
1300	nursing home placement. The study must include:
1301	1.  The demographic characteristics of the individuals
1302	assessed and diverted from nursing home placement, including,
1303	but not limited to, age, race, gender, frailty, caregiver
1304	status, living arrangements, and geographic location;
1305	2.  A summary of community services provided to individuals
1306	for 1 year after assessment and diversion;
1307	3.  A summary of inpatient hospital admissions for
1308	individuals who have been diverted; and
1309	4.  A summary of the length of time between diversion and
1310	subsequent entry into a nursing home or death.
1311	(g)  By July 1, 2005, the department and the Agency for
1312	Health Care Administration shall report to the President of the
1313	Senate and the Speaker of the House of Representatives regarding
1314	the impact to the state of modifying level-of-care criteria to
1315	eliminate the Intermediate II level of care.
1316
1317	This subsection expires October 1, 2012.
1318	(15)(16)(a)  The agency shall identify health care
1319	utilization and price patterns within the Medicaid program which
1320	are not cost-effective or medically appropriate and assess the
1321	effectiveness of new or alternate methods of providing and
1322	monitoring service, and may implement such methods as it
1323	considers appropriate. Such methods may include disease
1324	management initiatives, an integrated and systematic approach
1325	for managing the health care needs of recipients who are at risk
1326	of or diagnosed with a specific disease by using best practices,
1327	prevention strategies, clinical-practice improvement, clinical
1328	interventions and protocols, outcomes research, information
1329	technology, and other tools and resources to reduce overall
1330	costs and improve measurable outcomes.
1331	(b)  The responsibility of the agency under this subsection
1332	shall include the development of capabilities to identify actual
1333	and optimal practice patterns; patient and provider educational
1334	initiatives; methods for determining patient compliance with
1335	prescribed treatments; fraud, waste, and abuse prevention and
1336	detection programs; and beneficiary case management programs.
1337	1.  The practice pattern identification program shall
1338	evaluate practitioner prescribing patterns based on national and
1339	regional practice guidelines, comparing practitioners to their
1340	peer groups. The agency and its Drug Utilization Review Board
1341	shall consult with the Department of Health and a panel of
1342	practicing health care professionals consisting of the
1343	following: the Speaker of the House of Representatives and the
1344	President of the Senate shall each appoint three physicians
1345	licensed under chapter 458 or chapter 459; and the Governor
1346	shall appoint two pharmacists licensed under chapter 465 and one
1347	dentist licensed under chapter 466 who is an oral surgeon. Terms
1348	of the panel members shall expire at the discretion of the
1349	appointing official. The advisory panel shall be responsible for
1350	evaluating treatment guidelines and recommending ways to
1351	incorporate their use in the practice pattern identification
1352	program. Practitioners who are prescribing inappropriately or
1353	inefficiently, as determined by the agency, may have their
1354	prescribing of certain drugs subject to prior authorization or
1355	may be terminated from all participation in the Medicaid
1356	program.
1357	2.  The agency shall also develop educational interventions
1358	designed to promote the proper use of medications by providers
1359	and beneficiaries.
1360	3.  The agency shall implement a pharmacy fraud, waste, and
1361	abuse initiative that may include a surety bond or letter of
1362	credit requirement for participating pharmacies, enhanced
1363	provider auditing practices, the use of additional fraud and
1364	abuse software, recipient management programs for beneficiaries
1365	inappropriately using their benefits, and other steps that will
1366	eliminate provider and recipient fraud, waste, and abuse. The
1367	initiative shall address enforcement efforts to reduce the
1368	number and use of counterfeit prescriptions.
1369	4.  By September 30, 2002, the agency shall contract with
1370	an entity in the state to implement a wireless handheld clinical
1371	pharmacology drug information database for practitioners. The
1372	initiative shall be designed to enhance the agency's efforts to
1373	reduce fraud, abuse, and errors in the prescription drug benefit
1374	program and to otherwise further the intent of this paragraph.
1375	5.  By April 1, 2006, the agency shall contract with an
1376	entity to design a database of clinical utilization information
1377	or electronic medical records for Medicaid providers. This
1378	system must be web-based and allow providers to review on a
1379	real-time basis the utilization of Medicaid services, including,
1380	but not limited to, physician office visits, inpatient and
1381	outpatient hospitalizations, laboratory and pathology services,
1382	radiological and other imaging services, dental care, and
1383	patterns of dispensing prescription drugs in order to coordinate
1384	care and identify potential fraud and abuse.
1385	6.  The agency may apply for any federal waivers needed to
1386	administer this paragraph.
1387
1388	This subsection expires October 1, 2013.
1389	(16)(17)  An entity contracting on a prepaid or fixed-sum
1390	basis shall meet the surplus requirements of s. 641.225. If an
1391	entity's surplus falls below an amount equal to the surplus
1392	requirements of s. 641.225, the agency shall prohibit the entity
1393	from engaging in marketing and preenrollment activities, shall
1394	cease to process new enrollments, and may not renew the entity's
1395	contract until the required balance is achieved. The
1396	requirements of this subsection do not apply:
1397	(a)  Where a public entity agrees to fund any deficit
1398	incurred by the contracting entity; or
1399	(b)  Where the entity's performance and obligations are
1400	guaranteed in writing by a guaranteeing organization which:
1401	1.  Has been in operation for at least 5 years and has
1402	assets in excess of $50 million; or
1403	2.  Submits a written guarantee acceptable to the agency
1404	which is irrevocable during the term of the contracting entity's
1405	contract with the agency and, upon termination of the contract,
1406	until the agency receives proof of satisfaction of all
1407	outstanding obligations incurred under the contract.
1408
1409	This subsection expires October 1, 2013.
1410	(17)(18)(a)  The agency may require an entity contracting
1411	on a prepaid or fixed-sum basis to establish a restricted
1412	insolvency protection account with a federally guaranteed
1413	financial institution licensed to do business in this state. The
1414	entity shall deposit into that account 5 percent of the
1415	capitation payments made by the agency each month until a
1416	maximum total of 2 percent of the total current contract amount
1417	is reached. The restricted insolvency protection account may be
1418	drawn upon with the authorized signatures of two persons
1419	designated by the entity and two representatives of the agency.
1420	If the agency finds that the entity is insolvent, the agency may
1421	draw upon the account solely with the two authorized signatures
1422	of representatives of the agency, and the funds may be disbursed
1423	to meet financial obligations incurred by the entity under the
1424	prepaid contract. If the contract is terminated, expired, or not
1425	continued, the account balance must be released by the agency to
1426	the entity upon receipt of proof of satisfaction of all
1427	outstanding obligations incurred under this contract.
1428	(b)  The agency may waive the insolvency protection account
1429	requirement in writing when evidence is on file with the agency
1430	of adequate insolvency insurance and reinsurance that will
1431	protect enrollees if the entity becomes unable to meet its
1432	obligations.
1433
1434	This subsection expires October 1, 2013.
1435	(18)(19)  An entity that contracts with the agency on a
1436	prepaid or fixed-sum basis for the provision of Medicaid
1437	services shall reimburse any hospital or physician that is
1438	outside the entity's authorized geographic service area as
1439	specified in its contract with the agency, and that provides
1440	services authorized by the entity to its members, at a rate
1441	negotiated with the hospital or physician for the provision of
1442	services or according to the lesser of the following:
1443	(a)  The usual and customary charges made to the general
1444	public by the hospital or physician; or
1445	(b)  The Florida Medicaid reimbursement rate established
1446	for the hospital or physician.
1447
1448	This subsection expires October 1, 2013.
1449	(19)(20)  When a merger or acquisition of a Medicaid
1450	prepaid contractor has been approved by the Office of Insurance
1451	Regulation pursuant to s. 628.4615, the agency shall approve the
1452	assignment or transfer of the appropriate Medicaid prepaid
1453	contract upon request of the surviving entity of the merger or
1454	acquisition if the contractor and the other entity have been in
1455	good standing with the agency for the most recent 12-month
1456	period, unless the agency determines that the assignment or
1457	transfer would be detrimental to the Medicaid recipients or the
1458	Medicaid program. To be in good standing, an entity must not
1459	have failed accreditation or committed any material violation of
1460	the requirements of s. 641.52 and must meet the Medicaid
1461	contract requirements. For purposes of this section, a merger or
1462	acquisition means a change in controlling interest of an entity,
1463	including an asset or stock purchase. This subsection expires
1464	October 1, 2013.
1465	(20)(21)  Any entity contracting with the agency pursuant
1466	to this section to provide health care services to Medicaid
1467	recipients is prohibited from engaging in any of the following
1468	practices or activities:
1469	(a)  Practices that are discriminatory, including, but not
1470	limited to, attempts to discourage participation on the basis of
1471	actual or perceived health status.
1472	(b)  Activities that could mislead or confuse recipients,
1473	or misrepresent the organization, its marketing representatives,
1474	or the agency. Violations of this paragraph include, but are not
1475	limited to:
1476	1.  False or misleading claims that marketing
1477	representatives are employees or representatives of the state or
1478	county, or of anyone other than the entity or the organization
1479	by whom they are reimbursed.
1480	2.  False or misleading claims that the entity is
1481	recommended or endorsed by any state or county agency, or by any
1482	other organization which has not certified its endorsement in
1483	writing to the entity.
1484	3.  False or misleading claims that the state or county
1485	recommends that a Medicaid recipient enroll with an entity.
1486	4.  Claims that a Medicaid recipient will lose benefits
1487	under the Medicaid program, or any other health or welfare
1488	benefits to which the recipient is legally entitled, if the
1489	recipient does not enroll with the entity.
1490	(c)  Granting or offering of any monetary or other valuable
1491	consideration for enrollment, except as authorized by subsection
1492	(23) (24).
1493	(d)  Door-to-door solicitation of recipients who have not
1494	contacted the entity or who have not invited the entity to make
1495	a presentation.
1496	(e)  Solicitation of Medicaid recipients by marketing
1497	representatives stationed in state offices unless approved and
1498	supervised by the agency or its agent and approved by the
1499	affected state agency when solicitation occurs in an office of
1500	the state agency. The agency shall ensure that marketing
1501	representatives stationed in state offices shall market their
1502	managed care plans to Medicaid recipients only in designated
1503	areas and in such a way as to not interfere with the recipients'
1504	activities in the state office.
1505	(f)  Enrollment of Medicaid recipients.
1506
1507	This subsection expires October 1, 2013.
1508	(21)(22)  The agency may impose a fine for a violation of
1509	this section or the contract with the agency by a person or
1510	entity that is under contract with the agency. With respect to
1511	any nonwillful violation, such fine shall not exceed $2,500 per
1512	violation. In no event shall such fine exceed an aggregate
1513	amount of $10,000 for all nonwillful violations arising out of
1514	the same action. With respect to any knowing and willful
1515	violation of this section or the contract with the agency, the
1516	agency may impose a fine upon the entity in an amount not to
1517	exceed $20,000 for each such violation. In no event shall such
1518	fine exceed an aggregate amount of $100,000 for all knowing and
1519	willful violations arising out of the same action. This
1520	subsection expires October 1, 2013.
1521	(22)(23)  A health maintenance organization or a person or
1522	entity exempt from chapter 641 that is under contract with the
1523	agency for the provision of health care services to Medicaid
1524	recipients may not use or distribute marketing materials used to
1525	solicit Medicaid recipients, unless such materials have been
1526	approved by the agency. The provisions of this subsection do not
1527	apply to general advertising and marketing materials used by a
1528	health maintenance organization to solicit both non-Medicaid
1529	subscribers and Medicaid recipients. This subsection expires
1530	October 1, 2013.
1531	(23)(24)  Upon approval by the agency, health maintenance
1532	organizations and persons or entities exempt from chapter 641
1533	that are under contract with the agency for the provision of
1534	health care services to Medicaid recipients may be permitted
1535	within the capitation rate to provide additional health benefits
1536	that the agency has found are of high quality, are practicably
1537	available, provide reasonable value to the recipient, and are
1538	provided at no additional cost to the state. This subsection
1539	expires October 1, 2013.
1540	(24)(25)  The agency shall utilize the statewide health
1541	maintenance organization complaint hotline for the purpose of
1542	investigating and resolving Medicaid and prepaid health plan
1543	complaints, maintaining a record of complaints and confirmed
1544	problems, and receiving disenrollment requests made by
1545	recipients. This subsection expires October 1, 2013.
1546	(25)(26)  The agency shall require the publication of the
1547	health maintenance organization's and the prepaid health plan's
1548	consumer services telephone numbers and the "800" telephone
1549	number of the statewide health maintenance organization
1550	complaint hotline on each Medicaid identification card issued by
1551	a health maintenance organization or prepaid health plan
1552	contracting with the agency to serve Medicaid recipients and on
1553	each subscriber handbook issued to a Medicaid recipient. This
1554	subsection expires October 1, 2013.
1555	(26)(27)  The agency shall establish a health care quality
1556	improvement system for those entities contracting with the
1557	agency pursuant to this section, incorporating all the standards
1558	and guidelines developed by the Medicaid Bureau of the Health
1559	Care Financing Administration as a part of the quality assurance
1560	reform initiative. The system shall include, but need not be
1561	limited to, the following:
1562	(a)  Guidelines for internal quality assurance programs,
1563	including standards for:
1564	1.  Written quality assurance program descriptions.
1565	2.  Responsibilities of the governing body for monitoring,
1566	evaluating, and making improvements to care.
1567	3.  An active quality assurance committee.
1568	4.  Quality assurance program supervision.
1569	5.  Requiring the program to have adequate resources to
1570	effectively carry out its specified activities.
1571	6.  Provider participation in the quality assurance
1572	program.
1573	7.  Delegation of quality assurance program activities.
1574	8.  Credentialing and recredentialing.
1575	9.  Enrollee rights and responsibilities.
1576	10.  Availability and accessibility to services and care.
1577	11.  Ambulatory care facilities.
1578	12.  Accessibility and availability of medical records, as
1579	well as proper recordkeeping and process for record review.
1580	13.  Utilization review.
1581	14.  A continuity of care system.
1582	15.  Quality assurance program documentation.
1583	16.  Coordination of quality assurance activity with other
1584	management activity.
1585	17.  Delivering care to pregnant women and infants; to
1586	elderly and disabled recipients, especially those who are at
1587	risk of institutional placement; to persons with developmental
1588	disabilities; and to adults who have chronic, high-cost medical
1589	conditions.
1590	(b)  Guidelines which require the entities to conduct
1591	quality-of-care studies which:
1592	1.  Target specific conditions and specific health service
1593	delivery issues for focused monitoring and evaluation.
1594	2.  Use clinical care standards or practice guidelines to
1595	objectively evaluate the care the entity delivers or fails to
1596	deliver for the targeted clinical conditions and health services
1597	delivery issues.
1598	3.  Use quality indicators derived from the clinical care
1599	standards or practice guidelines to screen and monitor care and
1600	services delivered.
1601	(c)  Guidelines for external quality review of each
1602	contractor which require: focused studies of patterns of care;
1603	individual care review in specific situations; and followup
1604	activities on previous pattern-of-care study findings and
1605	individual-care-review findings. In designing the external
1606	quality review function and determining how it is to operate as
1607	part of the state's overall quality improvement system, the
1608	agency shall construct its external quality review organization
1609	and entity contracts to address each of the following:
1610	1.  Delineating the role of the external quality review
1611	organization.
1612	2.  Length of the external quality review organization
1613	contract with the state.
1614	3.  Participation of the contracting entities in designing
1615	external quality review organization review activities.
1616	4.  Potential variation in the type of clinical conditions
1617	and health services delivery issues to be studied at each plan.
1618	5.  Determining the number of focused pattern-of-care
1619	studies to be conducted for each plan.
1620	6.  Methods for implementing focused studies.
1621	7.  Individual care review.
1622	8.  Followup activities.
1623
1624	This subsection expires October 1, 2015.
1625	(27)(28)  In order to ensure that children receive health
1626	care services for which an entity has already been compensated,
1627	an entity contracting with the agency pursuant to this section
1628	shall achieve an annual Early and Periodic Screening, Diagnosis,
1629	and Treatment (EPSDT) Service screening rate of at least 60
1630	percent for those recipients continuously enrolled for at least
1631	8 months. The agency shall develop a method by which the EPSDT
1632	screening rate shall be calculated. For any entity which does
1633	not achieve the annual 60 percent rate, the entity must submit a
1634	corrective action plan for the agency's approval. If the entity
1635	does not meet the standard established in the corrective action
1636	plan during the specified timeframe, the agency is authorized to
1637	impose appropriate contract sanctions. At least annually, the
1638	agency shall publicly release the EPSDT Services screening rates
1639	of each entity it has contracted with on a prepaid basis to
1640	serve Medicaid recipients. This subsection expires October 1,
1641	2013.
1642	(28)(29)  The agency shall perform enrollments and
1643	disenrollments for Medicaid recipients who are eligible for
1644	MediPass or managed care plans. Notwithstanding the prohibition
1645	contained in paragraph (20)(21)(f), managed care plans may
1646	perform preenrollments of Medicaid recipients under the
1647	supervision of the agency or its agents. For the purposes of
1648	this section, "preenrollment" means the provision of marketing
1649	and educational materials to a Medicaid recipient and assistance
1650	in completing the application forms, but shall not include
1651	actual enrollment into a managed care plan. An application for
1652	enrollment shall not be deemed complete until the agency or its
1653	agent verifies that the recipient made an informed, voluntary
1654	choice. The agency, in cooperation with the Department of
1655	Children and Family Services, may test new marketing initiatives
1656	to inform Medicaid recipients about their managed care options
1657	at selected sites. The agency shall report to the Legislature on
1658	the effectiveness of such initiatives. The agency may contract
1659	with a third party to perform managed care plan and MediPass
1660	enrollment and disenrollment services for Medicaid recipients
1661	and is authorized to adopt rules to implement such services. The
1662	agency may adjust the capitation rate only to cover the costs of
1663	a third-party enrollment and disenrollment contract, and for
1664	agency supervision and management of the managed care plan
1665	enrollment and disenrollment contract. This subsection expires
1666	October 1, 2013.
1667	(29)(30)  Any lists of providers made available to Medicaid
1668	recipients, MediPass enrollees, or managed care plan enrollees
1669	shall be arranged alphabetically showing the provider's name and
1670	specialty and, separately, by specialty in alphabetical order.
1671	This subsection expires October 1, 2013.
1672	(30)(31)  The agency shall establish an enhanced managed
1673	care quality assurance oversight function, to include at least
1674	the following components:
1675	(a)  At least quarterly analysis and followup, including
1676	sanctions as appropriate, of managed care participant
1677	utilization of services.
1678	(b)  At least quarterly analysis and followup, including
1679	sanctions as appropriate, of quality findings of the Medicaid
1680	peer review organization and other external quality assurance
1681	programs.
1682	(c)  At least quarterly analysis and followup, including
1683	sanctions as appropriate, of the fiscal viability of managed
1684	care plans.
1685	(d)  At least quarterly analysis and followup, including
1686	sanctions as appropriate, of managed care participant
1687	satisfaction and disenrollment surveys.
1688	(e)  The agency shall conduct regular and ongoing Medicaid
1689	recipient satisfaction surveys.
1690
1691	The analyses and followup activities conducted by the agency
1692	under its enhanced managed care quality assurance oversight
1693	function shall not duplicate the activities of accreditation
1694	reviewers for entities regulated under part III of chapter 641,
1695	but may include a review of the finding of such reviewers. This
1696	subsection expires October 1, 2013.
1697	(31)(32)  Each managed care plan that is under contract
1698	with the agency to provide health care services to Medicaid
1699	recipients shall annually conduct a background check with the
1700	Florida Department of Law Enforcement of all persons with
1701	ownership interest of 5 percent or more or executive management
1702	responsibility for the managed care plan and shall submit to the
1703	agency information concerning any such person who has been found
1704	guilty of, regardless of adjudication, or has entered a plea of
1705	nolo contendere or guilty to, any of the offenses listed in s.
1706	435.03. This subsection expires October 1, 2013.
1707	(32)(33)  The agency shall, by rule, develop a process
1708	whereby a Medicaid managed care plan enrollee who wishes to
1709	enter hospice care may be disenrolled from the managed care plan
1710	within 24 hours after contacting the agency regarding such
1711	request. The agency rule shall include a methodology for the
1712	agency to recoup managed care plan payments on a pro rata basis
1713	if payment has been made for the enrollment month when
1714	disenrollment occurs. This subsection expires October 1, 2013.
1715	(33)(34)  The agency and entities that contract with the
1716	agency to provide health care services to Medicaid recipients
1717	under this section or ss. 409.91211 and 409.9122 must comply
1718	with the provisions of s. 641.513 in providing emergency
1719	services and care to Medicaid recipients and MediPass
1720	recipients. Where feasible, safe, and cost-effective, the agency
1721	shall encourage hospitals, emergency medical services providers,
1722	and other public and private health care providers to work
1723	together in their local communities to enter into agreements or
1724	arrangements to ensure access to alternatives to emergency
1725	services and care for those Medicaid recipients who need
1726	nonemergent care. The agency shall coordinate with hospitals,
1727	emergency medical services providers, private health plans,
1728	capitated managed care networks as established in s. 409.91211,
1729	and other public and private health care providers to implement
1730	the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1731	and 641.31097 to develop and implement emergency department
1732	diversion programs for Medicaid recipients. This subsection
1733	expires October 1, 2013.
1734	(34)(35)  All entities providing health care services to
1735	Medicaid recipients shall make available, and encourage all
1736	pregnant women and mothers with infants to receive, and provide
1737	documentation in the medical records to reflect, the following:
1738	(a)  Healthy Start prenatal or infant screening.
1739	(b)  Healthy Start care coordination, when screening or
1740	other factors indicate need.
1741	(c)  Healthy Start enhanced services in accordance with the
1742	prenatal or infant screening results.
1743	(d)  Immunizations in accordance with recommendations of
1744	the Advisory Committee on Immunization Practices of the United
1745	States Public Health Service and the American Academy of
1746	Pediatrics, as appropriate.
1747	(e)  Counseling and services for family planning to all
1748	women and their partners.
1749	(f)  A scheduled postpartum visit for the purpose of
1750	voluntary family planning, to include discussion of all methods
1751	of contraception, as appropriate.
1752	(g)  Referral to the Special Supplemental Nutrition Program
1753	for Women, Infants, and Children (WIC).
1754
1755	This subsection expires October 1, 2013.
1756	(35)(36)  Any entity that provides Medicaid prepaid health
1757	plan services shall ensure the appropriate coordination of
1758	health care services with an assisted living facility in cases
1759	where a Medicaid recipient is both a member of the entity's
1760	prepaid health plan and a resident of the assisted living
1761	facility. If the entity is at risk for Medicaid targeted case
1762	management and behavioral health services, the entity shall
1763	inform the assisted living facility of the procedures to follow
1764	should an emergent condition arise. This subsection expires
1765	October 1, 2013.
1766	(37)  The agency may seek and implement federal waivers
1767	necessary to provide for cost-effective purchasing of home
1768	health services, private duty nursing services, transportation,
1769	independent laboratory services, and durable medical equipment
1770	and supplies through competitive bidding pursuant to s. 287.057.
1771	The agency may request appropriate waivers from the federal
1772	Health Care Financing Administration in order to competitively
1773	bid such services. The agency may exclude providers not selected
1774	through the bidding process from the Medicaid provider network.
1775	(36)(38)  The agency shall enter into agreements with not-
1776	for-profit organizations based in this state for the purpose of
1777	providing vision screening. This subsection expires October 1,
1778	2013.
1779	(37)(39)(a)  The agency shall implement a Medicaid
1780	prescribed-drug spending-control program that includes the
1781	following components:
1782	1.  A Medicaid preferred drug list, which shall be a
1783	listing of cost-effective therapeutic options recommended by the
1784	Medicaid Pharmacy and Therapeutics Committee established
1785	pursuant to s. 409.91195 and adopted by the agency for each
1786	therapeutic class on the preferred drug list. At the discretion
1787	of the committee, and when feasible, the preferred drug list
1788	should include at least two products in a therapeutic class. The
1789	agency may post the preferred drug list and updates to the
1790	preferred drug list on an Internet website without following the
1791	rulemaking procedures of chapter 120. Antiretroviral agents are
1792	excluded from the preferred drug list. The agency shall also
1793	limit the amount of a prescribed drug dispensed to no more than
1794	a 34-day supply unless the drug products' smallest marketed
1795	package is greater than a 34-day supply, or the drug is
1796	determined by the agency to be a maintenance drug in which case
1797	a 100-day maximum supply may be authorized. The agency is
1798	authorized to seek any federal waivers necessary to implement
1799	these cost-control programs and to continue participation in the
1800	federal Medicaid rebate program, or alternatively to negotiate
1801	state-only manufacturer rebates. The agency may adopt rules to
1802	implement this subparagraph. The agency shall continue to
1803	provide unlimited contraceptive drugs and items. The agency must
1804	establish procedures to ensure that:
1805	a.  There is a response to a request for prior consultation
1806	by telephone or other telecommunication device within 24 hours
1807	after receipt of a request for prior consultation; and
1808	b.  A 72-hour supply of the drug prescribed is provided in
1809	an emergency or when the agency does not provide a response
1810	within 24 hours as required by sub-subparagraph a.
1811	2.  Reimbursement to pharmacies for Medicaid prescribed
1812	drugs shall be set at the lesser of: the average wholesale price
1813	(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
1814	plus 4.75 percent, the federal upper limit (FUL), the state
1815	maximum allowable cost (SMAC), or the usual and customary (UAC)
1816	charge billed by the provider.
1817	3.  The agency shall develop and implement a process for
1818	managing the drug therapies of Medicaid recipients who are using
1819	significant numbers of prescribed drugs each month. The
1820	management process may include, but is not limited to,
1821	comprehensive, physician-directed medical-record reviews, claims
1822	analyses, and case evaluations to determine the medical
1823	necessity and appropriateness of a patient's treatment plan and
1824	drug therapies. The agency may contract with a private
1825	organization to provide drug-program-management services. The
1826	Medicaid drug benefit management program shall include
1827	initiatives to manage drug therapies for HIV/AIDS patients,
1828	patients using 20 or more unique prescriptions in a 180-day
1829	period, and the top 1,000 patients in annual spending. The
1830	agency shall enroll any Medicaid recipient in the drug benefit
1831	management program if he or she meets the specifications of this
1832	provision and is not enrolled in a Medicaid health maintenance
1833	organization.
1834	4.  The agency may limit the size of its pharmacy network
1835	based on need, competitive bidding, price negotiations,
1836	credentialing, or similar criteria. The agency shall give
1837	special consideration to rural areas in determining the size and
1838	location of pharmacies included in the Medicaid pharmacy
1839	network. A pharmacy credentialing process may include criteria
1840	such as a pharmacy's full-service status, location, size,
1841	patient educational programs, patient consultation, disease
1842	management services, and other characteristics. The agency may
1843	impose a moratorium on Medicaid pharmacy enrollment when it is
1844	determined that it has a sufficient number of Medicaid-
1845	participating providers. The agency must allow dispensing
1846	practitioners to participate as a part of the Medicaid pharmacy
1847	network regardless of the practitioner's proximity to any other
1848	entity that is dispensing prescription drugs under the Medicaid
1849	program. A dispensing practitioner must meet all credentialing
1850	requirements applicable to his or her practice, as determined by
1851	the agency.
1852	5.  The agency shall develop and implement a program that
1853	requires Medicaid practitioners who prescribe drugs to use a
1854	counterfeit-proof prescription pad for Medicaid prescriptions.
1855	The agency shall require the use of standardized counterfeit-
1856	proof prescription pads by Medicaid-participating prescribers or
1857	prescribers who write prescriptions for Medicaid recipients. The
1858	agency may implement the program in targeted geographic areas or
1859	statewide.
1860	6.  The agency may enter into arrangements that require
1861	manufacturers of generic drugs prescribed to Medicaid recipients
1862	to provide rebates of at least 15.1 percent of the average
1863	manufacturer price for the manufacturer's generic products.
1864	These arrangements shall require that if a generic-drug
1865	manufacturer pays federal rebates for Medicaid-reimbursed drugs
1866	at a level below 15.1 percent, the manufacturer must provide a
1867	supplemental rebate to the state in an amount necessary to
1868	achieve a 15.1-percent rebate level.
1869	7.  The agency may establish a preferred drug list as
1870	described in this subsection, and, pursuant to the establishment
1871	of such preferred drug list, it is authorized to negotiate
1872	supplemental rebates from manufacturers that are in addition to
1873	those required by Title XIX of the Social Security Act and at no
1874	less than 14 percent of the average manufacturer price as
1875	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
1876	the federal or supplemental rebate, or both, equals or exceeds
1877	29 percent. There is no upper limit on the supplemental rebates
1878	the agency may negotiate. The agency may determine that specific
1879	products, brand-name or generic, are competitive at lower rebate
1880	percentages. Agreement to pay the minimum supplemental rebate
1881	percentage will guarantee a manufacturer that the Medicaid
1882	Pharmaceutical and Therapeutics Committee will consider a
1883	product for inclusion on the preferred drug list. However, a
1884	pharmaceutical manufacturer is not guaranteed placement on the
1885	preferred drug list by simply paying the minimum supplemental
1886	rebate. Agency decisions will be made on the clinical efficacy
1887	of a drug and recommendations of the Medicaid Pharmaceutical and
1888	Therapeutics Committee, as well as the price of competing
1889	products minus federal and state rebates. The agency is
1890	authorized to contract with an outside agency or contractor to
1891	conduct negotiations for supplemental rebates. For the purposes
1892	of this section, the term "supplemental rebates" means cash
1893	rebates. Effective July 1, 2004, value-added programs as a
1894	substitution for supplemental rebates are prohibited. The agency
1895	is authorized to seek any federal waivers to implement this
1896	initiative.
1897	8.  The Agency for Health Care Administration shall expand
1898	home delivery of pharmacy products. To assist Medicaid patients
1899	in securing their prescriptions and reduce program costs, the
1900	agency shall expand its current mail-order-pharmacy diabetes-
1901	supply program to include all generic and brand-name drugs used
1902	by Medicaid patients with diabetes. Medicaid recipients in the
1903	current program may obtain nondiabetes drugs on a voluntary
1904	basis. This initiative is limited to the geographic area covered
1905	by the current contract. The agency may seek and implement any
1906	federal waivers necessary to implement this subparagraph.
1907	9.  The agency shall limit to one dose per month any drug
1908	prescribed to treat erectile dysfunction.
1909	10.a.  The agency may implement a Medicaid behavioral drug
1910	management system. The agency may contract with a vendor that
1911	has experience in operating behavioral drug management systems
1912	to implement this program. The agency is authorized to seek
1913	federal waivers to implement this program.
1914	b.  The agency, in conjunction with the Department of
1915	Children and Family Services, may implement the Medicaid
1916	behavioral drug management system that is designed to improve
1917	the quality of care and behavioral health prescribing practices
1918	based on best practice guidelines, improve patient adherence to
1919	medication plans, reduce clinical risk, and lower prescribed
1920	drug costs and the rate of inappropriate spending on Medicaid
1921	behavioral drugs. The program may include the following
1922	elements:
1923	(I)  Provide for the development and adoption of best
1924	practice guidelines for behavioral health-related drugs such as
1925	antipsychotics, antidepressants, and medications for treating
1926	bipolar disorders and other behavioral conditions; translate
1927	them into practice; review behavioral health prescribers and
1928	compare their prescribing patterns to a number of indicators
1929	that are based on national standards; and determine deviations
1930	from best practice guidelines.
1931	(II)  Implement processes for providing feedback to and
1932	educating prescribers using best practice educational materials
1933	and peer-to-peer consultation.
1934	(III)  Assess Medicaid beneficiaries who are outliers in
1935	their use of behavioral health drugs with regard to the numbers
1936	and types of drugs taken, drug dosages, combination drug
1937	therapies, and other indicators of improper use of behavioral
1938	health drugs.
1939	(IV)  Alert prescribers to patients who fail to refill
1940	prescriptions in a timely fashion, are prescribed multiple same-
1941	class behavioral health drugs, and may have other potential
1942	medication problems.
1943	(V)  Track spending trends for behavioral health drugs and
1944	deviation from best practice guidelines.
1945	(VI)  Use educational and technological approaches to
1946	promote best practices, educate consumers, and train prescribers
1947	in the use of practice guidelines.
1948	(VII)  Disseminate electronic and published materials.
1949	(VIII)  Hold statewide and regional conferences.
1950	(IX)  Implement a disease management program with a model
1951	quality-based medication component for severely mentally ill
1952	individuals and emotionally disturbed children who are high
1953	users of care.
1954	11.a.  The agency shall implement a Medicaid prescription
1955	drug management system. The agency may contract with a vendor
1956	that has experience in operating prescription drug management
1957	systems in order to implement this system. Any management system
1958	that is implemented in accordance with this subparagraph must
1959	rely on cooperation between physicians and pharmacists to
1960	determine appropriate practice patterns and clinical guidelines
1961	to improve the prescribing, dispensing, and use of drugs in the
1962	Medicaid program. The agency may seek federal waivers to
1963	implement this program.
1964	b.  The drug management system must be designed to improve
1965	the quality of care and prescribing practices based on best
1966	practice guidelines, improve patient adherence to medication
1967	plans, reduce clinical risk, and lower prescribed drug costs and
1968	the rate of inappropriate spending on Medicaid prescription
1969	drugs. The program must:
1970	(I)  Provide for the development and adoption of best
1971	practice guidelines for the prescribing and use of drugs in the
1972	Medicaid program, including translating best practice guidelines
1973	into practice; reviewing prescriber patterns and comparing them
1974	to indicators that are based on national standards and practice
1975	patterns of clinical peers in their community, statewide, and
1976	nationally; and determine deviations from best practice
1977	guidelines.
1978	(II)  Implement processes for providing feedback to and
1979	educating prescribers using best practice educational materials
1980	and peer-to-peer consultation.
1981	(III)  Assess Medicaid recipients who are outliers in their
1982	use of a single or multiple prescription drugs with regard to
1983	the numbers and types of drugs taken, drug dosages, combination
1984	drug therapies, and other indicators of improper use of
1985	prescription drugs.
1986	(IV)  Alert prescribers to patients who fail to refill
1987	prescriptions in a timely fashion, are prescribed multiple drugs
1988	that may be redundant or contraindicated, or may have other
1989	potential medication problems.
1990	(V)  Track spending trends for prescription drugs and
1991	deviation from best practice guidelines.
1992	(VI)  Use educational and technological approaches to
1993	promote best practices, educate consumers, and train prescribers
1994	in the use of practice guidelines.
1995	(VII)  Disseminate electronic and published materials.
1996	(VIII)  Hold statewide and regional conferences.
1997	(IX)  Implement disease management programs in cooperation
1998	with physicians and pharmacists, along with a model quality-
1999	based medication component for individuals having chronic
2000	medical conditions.
2001	12.  The agency is authorized to contract for drug rebate
2002	administration, including, but not limited to, calculating
2003	rebate amounts, invoicing manufacturers, negotiating disputes
2004	with manufacturers, and maintaining a database of rebate
2005	collections.
2006	13.  The agency may specify the preferred daily dosing form
2007	or strength for the purpose of promoting best practices with
2008	regard to the prescribing of certain drugs as specified in the
2009	General Appropriations Act and ensuring cost-effective
2010	prescribing practices.
2011	14.  The agency may require prior authorization for
2012	Medicaid-covered prescribed drugs. The agency may, but is not
2013	required to, prior-authorize the use of a product:
2014	a.  For an indication not approved in labeling;
2015	b.  To comply with certain clinical guidelines; or
2016	c.  If the product has the potential for overuse, misuse,
2017	or abuse.
2018
2019	The agency may require the prescribing professional to provide
2020	information about the rationale and supporting medical evidence
2021	for the use of a drug. The agency may post prior authorization
2022	criteria and protocol and updates to the list of drugs that are
2023	subject to prior authorization on an Internet website without
2024	amending its rule or engaging in additional rulemaking.
2025	15.  The agency, in conjunction with the Pharmaceutical and
2026	Therapeutics Committee, may require age-related prior
2027	authorizations for certain prescribed drugs. The agency may
2028	preauthorize the use of a drug for a recipient who may not meet
2029	the age requirement or may exceed the length of therapy for use
2030	of this product as recommended by the manufacturer and approved
2031	by the Food and Drug Administration. Prior authorization may
2032	require the prescribing professional to provide information
2033	about the rationale and supporting medical evidence for the use
2034	of a drug.
2035	16.  The agency shall implement a step-therapy prior
2036	authorization approval process for medications excluded from the
2037	preferred drug list. Medications listed on the preferred drug
2038	list must be used within the previous 12 months prior to the
2039	alternative medications that are not listed. The step-therapy
2040	prior authorization may require the prescriber to use the
2041	medications of a similar drug class or for a similar medical
2042	indication unless contraindicated in the Food and Drug
2043	Administration labeling. The trial period between the specified
2044	steps may vary according to the medical indication. The step-
2045	therapy approval process shall be developed in accordance with
2046	the committee as stated in s. 409.91195(7) and (8). A drug
2047	product may be approved without meeting the step-therapy prior
2048	authorization criteria if the prescribing physician provides the
2049	agency with additional written medical or clinical documentation
2050	that the product is medically necessary because:
2051	a.  There is not a drug on the preferred drug list to treat
2052	the disease or medical condition which is an acceptable clinical
2053	alternative;
2054	b.  The alternatives have been ineffective in the treatment
2055	of the beneficiary's disease; or
2056	c.  Based on historic evidence and known characteristics of
2057	the patient and the drug, the drug is likely to be ineffective,
2058	or the number of doses have been ineffective.
2059
2060	The agency shall work with the physician to determine the best
2061	alternative for the patient. The agency may adopt rules waiving
2062	the requirements for written clinical documentation for specific
2063	drugs in limited clinical situations.
2064	17.  The agency shall implement a return and reuse program
2065	for drugs dispensed by pharmacies to institutional recipients,
2066	which includes payment of a $5 restocking fee for the
2067	implementation and operation of the program. The return and
2068	reuse program shall be implemented electronically and in a
2069	manner that promotes efficiency. The program must permit a
2070	pharmacy to exclude drugs from the program if it is not
2071	practical or cost-effective for the drug to be included and must
2072	provide for the return to inventory of drugs that cannot be
2073	credited or returned in a cost-effective manner. The agency
2074	shall determine if the program has reduced the amount of
2075	Medicaid prescription drugs which are destroyed on an annual
2076	basis and if there are additional ways to ensure more
2077	prescription drugs are not destroyed which could safely be
2078	reused. The agency's conclusion and recommendations shall be
2079	reported to the Legislature by December 1, 2005.
2080	(b)  The agency shall implement this subsection to the
2081	extent that funds are appropriated to administer the Medicaid
2082	prescribed-drug spending-control program. The agency may
2083	contract all or any part of this program to private
2084	organizations.
2085	(c)  The agency shall submit quarterly reports to the
2086	Governor, the President of the Senate, and the Speaker of the
2087	House of Representatives which must include, but need not be
2088	limited to, the progress made in implementing this subsection
2089	and its effect on Medicaid prescribed-drug expenditures.
2090	(38)(40)  Notwithstanding the provisions of chapter 287,
2091	the agency may, at its discretion, renew a contract or contracts
2092	for fiscal intermediary services one or more times for such
2093	periods as the agency may decide; however, all such renewals may
2094	not combine to exceed a total period longer than the term of the
2095	original contract.
2096	(39)(41)  The agency shall provide for the development of a
2097	demonstration project by establishment in Miami-Dade County of a
2098	long-term-care facility licensed pursuant to chapter 395 to
2099	improve access to health care for a predominantly minority,
2100	medically underserved, and medically complex population and to
2101	evaluate alternatives to nursing home care and general acute
2102	care for such population. Such project is to be located in a
2103	health care condominium and colocated with licensed facilities
2104	providing a continuum of care. The establishment of this project
2105	is not subject to the provisions of s. 408.036 or s. 408.039.
2106	This subsection expires October 1, 2012.
2107	(42)  The agency shall develop and implement a utilization
2108	management program for Medicaid-eligible recipients for the
2109	management of occupational, physical, respiratory, and speech
2110	therapies. The agency shall establish a utilization program that
2111	may require prior authorization in order to ensure medically
2112	necessary and cost-effective treatments. The program shall be
2113	operated in accordance with a federally approved waiver program
2114	or state plan amendment. The agency may seek a federal waiver or
2115	state plan amendment to implement this program. The agency may
2116	also competitively procure these services from an outside vendor
2117	on a regional or statewide basis.
2118	(40)(43)  The agency may contract on a prepaid or fixed-sum
2119	basis with appropriately licensed prepaid dental health plans to
2120	provide dental services. This subsection expires October 1,
2121	2013.
2122	(41)(44)  The Agency for Health Care Administration shall
2123	ensure that any Medicaid managed care plan as defined in s.
2124	409.9122(2)(f), whether paid on a capitated basis or a shared
2125	savings basis, is cost-effective. For purposes of this
2126	subsection, the term "cost-effective" means that a network's
2127	per-member, per-month costs to the state, including, but not
2128	limited to, fee-for-service costs, administrative costs, and
2129	case-management fees, if any, must be no greater than the
2130	state's costs associated with contracts for Medicaid services
2131	established under subsection (3), which may be adjusted for
2132	health status. The agency shall conduct actuarially sound
2133	adjustments for health status in order to ensure such cost-
2134	effectiveness and shall publish the results on its Internet
2135	website and submit the results annually to the Governor, the
2136	President of the Senate, and the Speaker of the House of
2137	Representatives no later than December 31 of each year.
2138	Contracts established pursuant to this subsection which are not
2139	cost-effective may not be renewed. This subsection expires
2140	October 1, 2013.
2141	(42)(45)  Subject to the availability of funds, the agency
2142	shall mandate a recipient's participation in a provider lock-in
2143	program, when appropriate, if a recipient is found by the agency
2144	to have used Medicaid goods or services at a frequency or amount
2145	not medically necessary, limiting the receipt of goods or
2146	services to medically necessary providers after the 21-day
2147	appeal process has ended, for a period of not less than 1 year.
2148	The lock-in programs shall include, but are not limited to,
2149	pharmacies, medical doctors, and infusion clinics. The
2150	limitation does not apply to emergency services and care
2151	provided to the recipient in a hospital emergency department.
2152	The agency shall seek any federal waivers necessary to implement
2153	this subsection. The agency shall adopt any rules necessary to
2154	comply with or administer this subsection. This subsection
2155	expires October 1, 2013.
2156	(43)(46)  The agency shall seek a federal waiver for
2157	permission to terminate the eligibility of a Medicaid recipient
2158	who has been found to have committed fraud, through judicial or
2159	administrative determination, two times in a period of 5 years.
2160	(47)  The agency shall conduct a study of available
2161	electronic systems for the purpose of verifying the identity and
2162	eligibility of a Medicaid recipient. The agency shall recommend
2163	to the Legislature a plan to implement an electronic
2164	verification system for Medicaid recipients by January 31, 2005.
2165	(44)(48)(a)  A provider is not entitled to enrollment in
2166	the Medicaid provider network. The agency may implement a
2167	Medicaid fee-for-service provider network controls, including,
2168	but not limited to, competitive procurement and provider
2169	credentialing. If a credentialing process is used, the agency
2170	may limit its provider network based upon the following
2171	considerations: beneficiary access to care, provider
2172	availability, provider quality standards and quality assurance
2173	processes, cultural competency, demographic characteristics of
2174	beneficiaries, practice standards, service wait times, provider
2175	turnover, provider licensure and accreditation history, program
2176	integrity history, peer review, Medicaid policy and billing
2177	compliance records, clinical and medical record audit findings,
2178	and such other areas that are considered necessary by the agency
2179	to ensure the integrity of the program.
2180	(b)  The agency shall limit its network of durable medical
2181	equipment and medical supply providers. For dates of service
2182	after January 1, 2009, the agency shall limit payment for
2183	durable medical equipment and supplies to providers that meet
2184	all the requirements of this paragraph.
2185	1.  Providers must be accredited by a Centers for Medicare
2186	and Medicaid Services deemed accreditation organization for
2187	suppliers of durable medical equipment, prosthetics, orthotics,
2188	and supplies. The provider must maintain accreditation and is
2189	subject to unannounced reviews by the accrediting organization.
2190	2.  Providers must provide the services or supplies
2191	directly to the Medicaid recipient or caregiver at the provider
2192	location or recipient's residence or send the supplies directly
2193	to the recipient's residence with receipt of mailed delivery.
2194	Subcontracting or consignment of the service or supply to a
2195	third party is prohibited.
2196	3.  Notwithstanding subparagraph 2., a durable medical
2197	equipment provider may store nebulizers at a physician's office
2198	for the purpose of having the physician's staff issue the
2199	equipment if it meets all of the following conditions:
2200	a.  The physician must document the medical necessity and
2201	need to prevent further deterioration of the patient's
2202	respiratory status by the timely delivery of the nebulizer in
2203	the physician's office.
2204	b.  The durable medical equipment provider must have
2205	written documentation of the competency and training by a
2206	Florida-licensed registered respiratory therapist of any durable
2207	medical equipment staff who participate in the training of
2208	physician office staff for the use of nebulizers, including
2209	cleaning, warranty, and special needs of patients.
2210	c.  The physician's office must have documented the
2211	training and competency of any staff member who initiates the
2212	delivery of nebulizers to patients. The durable medical
2213	equipment provider must maintain copies of all physician office
2214	training.
2215	d.  The physician's office must maintain inventory records
2216	of stored nebulizers, including documentation of the durable
2217	medical equipment provider source.
2218	e.  A physician contracted with a Medicaid durable medical
2219	equipment provider may not have a financial relationship with
2220	that provider or receive any financial gain from the delivery of
2221	nebulizers to patients.
2222	4.  Providers must have a physical business location and a
2223	functional landline business phone. The location must be within
2224	the state or not more than 50 miles from the Florida state line.
2225	The agency may make exceptions for providers of durable medical
2226	equipment or supplies not otherwise available from other
2227	enrolled providers located within the state.
2228	5.  Physical business locations must be clearly identified
2229	as a business that furnishes durable medical equipment or
2230	medical supplies by signage that can be read from 20 feet away.
2231	The location must be readily accessible to the public during
2232	normal, posted business hours and must operate no less than 5
2233	hours per day and no less than 5 days per week, with the
2234	exception of scheduled and posted holidays. The location may not
2235	be located within or at the same numbered street address as
2236	another enrolled Medicaid durable medical equipment or medical
2237	supply provider or as an enrolled Medicaid pharmacy that is also
2238	enrolled as a durable medical equipment provider. A licensed
2239	orthotist or prosthetist that provides only orthotic or
2240	prosthetic devices as a Medicaid durable medical equipment
2241	provider is exempt from the provisions in this paragraph.
2242	6.  Providers must maintain a stock of durable medical
2243	equipment and medical supplies on site that is readily available
2244	to meet the needs of the durable medical equipment business
2245	location's customers.
2246	7.  Providers must provide a surety bond of $50,000 for
2247	each provider location, up to a maximum of 5 bonds statewide or
2248	an aggregate bond of $250,000 statewide, as identified by
2249	Federal Employer Identification Number. Providers who post a
2250	statewide or an aggregate bond must identify all of their
2251	locations in any Medicaid durable medical equipment and medical
2252	supply provider enrollment application or bond renewal. Each
2253	provider location's surety bond must be renewed annually and the
2254	provider must submit proof of renewal even if the original bond
2255	is a continuous bond. A licensed orthotist or prosthetist that
2256	provides only orthotic or prosthetic devices as a Medicaid
2257	durable medical equipment provider is exempt from the provisions
2258	in this paragraph.
2259	8.  Providers must obtain a level 2 background screening,
2260	as provided under s. 435.04, for each provider employee in
2261	direct contact with or providing direct services to recipients
2262	of durable medical equipment and medical supplies in their
2263	homes. This requirement includes, but is not limited to, repair
2264	and service technicians, fitters, and delivery staff. The
2265	provider shall pay for the cost of the background screening.
2266	9.  The following providers are exempt from the
2267	requirements of subparagraphs 1. and 7.:
2268	a.  Durable medical equipment providers owned and operated
2269	by a government entity.
2270	b.  Durable medical equipment providers that are operating
2271	within a pharmacy that is currently enrolled as a Medicaid
2272	pharmacy provider.
2273	c.  Active, Medicaid-enrolled orthopedic physician groups,
2274	primarily owned by physicians, which provide only orthotic and
2275	prosthetic devices.
2276	(45)(49)  The agency shall contract with established
2277	minority physician networks that provide services to
2278	historically underserved minority patients. The networks must
2279	provide cost-effective Medicaid services, comply with the
2280	requirements to be a MediPass provider, and provide their
2281	primary care physicians with access to data and other management
2282	tools necessary to assist them in ensuring the appropriate use
2283	of services, including inpatient hospital services and
2284	pharmaceuticals.
2285	(a)  The agency shall provide for the development and
2286	expansion of minority physician networks in each service area to
2287	provide services to Medicaid recipients who are eligible to
2288	participate under federal law and rules.
2289	(b)  The agency shall reimburse each minority physician
2290	network as a fee-for-service provider, including the case
2291	management fee for primary care, if any, or as a capitated rate
2292	provider for Medicaid services. Any savings shall be shared with
2293	the minority physician networks pursuant to the contract.
2294	(c)  For purposes of this subsection, the term "cost-
2295	effective" means that a network's per-member, per-month costs to
2296	the state, including, but not limited to, fee-for-service costs,
2297	administrative costs, and case-management fees, if any, must be
2298	no greater than the state's costs associated with contracts for
2299	Medicaid services established under subsection (3), which shall
2300	be actuarially adjusted for case mix, model, and service area.
2301	The agency shall conduct actuarially sound audits adjusted for
2302	case mix and model in order to ensure such cost-effectiveness
2303	and shall publish the audit results on its Internet website and
2304	submit the audit results annually to the Governor, the President
2305	of the Senate, and the Speaker of the House of Representatives
2306	no later than December 31. Contracts established pursuant to
2307	this subsection which are not cost-effective may not be renewed.
2308	(d)  The agency may apply for any federal waivers needed to
2309	implement this subsection.
2310
2311	This subsection expires October 1, 2013.
2312	(46)(50)  To the extent permitted by federal law and as
2313	allowed under s. 409.906, the agency shall provide reimbursement
2314	for emergency mental health care services for Medicaid
2315	recipients in crisis stabilization facilities licensed under s.
2316	394.875 as long as those services are less expensive than the
2317	same services provided in a hospital setting.
2318	(47)(51)  The agency shall work with the Agency for Persons
2319	with Disabilities to develop a home and community-based waiver
2320	to serve children and adults who are diagnosed with familial
2321	dysautonomia or Riley-Day syndrome caused by a mutation of the
2322	IKBKAP gene on chromosome 9. The agency shall seek federal
2323	waiver approval and implement the approved waiver subject to the
2324	availability of funds and any limitations provided in the
2325	General Appropriations Act. The agency may adopt rules to
2326	implement this waiver program.
2327	(48)(52)  The agency shall implement a program of all-
2328	inclusive care for children. The program of all-inclusive care
2329	for children shall be established to provide in-home hospice-
2330	like support services to children diagnosed with a life-
2331	threatening illness and enrolled in the Children's Medical
2332	Services network to reduce hospitalizations as appropriate. The
2333	agency, in consultation with the Department of Health, may
2334	implement the program of all-inclusive care for children after
2335	obtaining approval from the Centers for Medicare and Medicaid
2336	Services.
2337	(49)(53)  Before seeking an amendment to the state plan for
2338	purposes of implementing programs authorized by the Deficit
2339	Reduction Act of 2005, the agency shall notify the Legislature.
2340	Section 11.  Subsection (4) of section 409.91195, Florida
2341	Statutes, is amended to read:
2342	409.91195  Medicaid Pharmaceutical and Therapeutics
2343	Committee.-There is created a Medicaid Pharmaceutical and
2344	Therapeutics Committee within the agency for the purpose of
2345	developing a Medicaid preferred drug list.
2346	(4)  Upon recommendation of the committee, the agency shall
2347	adopt a preferred drug list as described in s. 409.912(37)(39).
2348	To the extent feasible, the committee shall review all drug
2349	classes included on the preferred drug list every 12 months, and
2350	may recommend additions to and deletions from the preferred drug
2351	list, such that the preferred drug list provides for medically
2352	appropriate drug therapies for Medicaid patients which achieve
2353	cost savings contained in the General Appropriations Act.
2354	Section 12.  Subsection (1) of section 409.91196, Florida
2355	Statutes, is amended to read:
2356	409.91196  Supplemental rebate agreements; public records
2357	and public meetings exemption.-
2358	(1)  The rebate amount, percent of rebate, manufacturer's
2359	pricing, and supplemental rebate, and other trade secrets as
2360	defined in s. 688.002 that the agency has identified for use in
2361	negotiations, held by the Agency for Health Care Administration
2362	under s. 409.912(37)(39)(a)7. are confidential and exempt from
2363	s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
2364	Section 13.  Section 409.91207, Florida Statutes, is
2365	amended to read:
2366	(Substantial rewording of section. See s. 409.91207,
2367	F.S., for present text.)
2368	409.91207  Medical homes.-
2369	(1)  AUTHORITY.-The agency shall develop a method for
2370	designating qualified plans as a medical home network.
2371	(2)  PURPOSE AND PRINCIPLES.-Medical home networks foster
2372	and support coordinated and effective primary care through case
2373	management, support to primary care providers, supplemental
2374	services, and dissemination of best practices. Medical home
2375	networks target patients with chronic illnesses and frequent
2376	service utilization in order to coordinate services, provide
2377	disease management and patient education, and improve quality of
2378	care. In addition to primary care, medical home networks are
2379	able to provide or arrange for pharmacy, outpatient diagnostic,
2380	and specialty physician services and coordinate with inpatient
2381	facilities and rehabilitative service providers.
2382	(3)  DESIGNATION.-A qualified plan may request agency
2383	designation as a medical home network if the plan is accredited
2384	as a medical home network by the National Committee for Quality
2385	Assurance or:
2386	(a)  The plan establishes a method for its enrollees to
2387	choose to participate as medical home patients and select a
2388	primary care provider that is certified as a medical home.
2389	(b)  At least 85 percent of the primary care providers in a
2390	medical home network are certified by the qualified plan as
2391	having the following service capabilities:
2392	1.  Supply all medically necessary primary and preventive
2393	services and provide all scheduled immunizations.
2394	2.  Organize clinical data in electronic form using a
2395	patient-centered charting system.
2396	3.  Maintain and update a patient's medication list and
2397	review all medications during each office visit.
2398	4.  Maintain a system to track diagnostic tests and provide
2399	followup services regarding test results.
2400	5.  Maintain a system to track referrals, including self-
2401	referrals by members.
2402	6.  Supply care coordination and continuity of care through
2403	proactive contact with members and encourage family
2404	participation in care.
2405	7.  Supply education and support using various materials
2406	and processes appropriate for individual patient needs.
2407	8.  Communicate electronically.
2408	9.  Supply voice-to-voice telephone coverage to medical
2409	home patients 24 hours per day, 7 days per week, to enable
2410	medical home patients to speak to a licensed health care
2411	professional who triages and forwards calls, as appropriate.
2412	10.  Maintain an office schedule of at least 30 scheduled
2413	hours per week.
2414	11.  Use scheduling processes to promote continuity with
2415	clinicians, including providing care for walk-in, routine, and
2416	urgent care visits.
2417	12.  Implement and document behavioral health and substance
2418	abuse screening procedures and make referrals as needed.
2419	13.  Use data to identify and track patients' health and
2420	service use patterns.
2421	14.  Coordinate care and followup for patients receiving
2422	services in inpatient and outpatient facilities.
2423	15.  Implement processes to promote access to care and
2424	member communication.
2425	16.  Maintain electronic medical records.
2426	17.  Develop a health care team that provides ongoing
2427	support, oversight, and guidance for all medical care received
2428	by the patient and documents contact with specialists and other
2429	health care providers caring for the patient.
2430	18.  Supply postvisit followup care for patients.
2431	19.  Implement specific evidence-based clinical practice
2432	guidelines for preventive and chronic care.
2433	20.  Implement a medication reconciliation procedure to
2434	avoid interactions or duplications.
2435	21.  Use personalized screening, brief intervention, and
2436	referral to treatment procedures for appropriate patients
2437	requiring specialty treatment.
2438	22.  Offer at least 4 hours per week of after-hours care to
2439	patients.
2440	23.  Use health assessment tools to identify patient needs
2441	and risks.
2442	(c)  The qualified plan offers support services to its
2443	primary care providers, including:
2444	1.  Case management, outreach, care coordination, and other
2445	targeted support services for medical home patients.
2446	2.  Ongoing assessment of spending and service utilization
2447	by all medical home network patients.
2448	3.  Periodic evaluation of patient outcomes.
2449	4.  Coordination with inpatient facilities, behavioral
2450	health, and rehabilitative service providers.
2451	5.  Establishing specific methods to manage pharmacy and
2452	behavioral health services.
2453	6.  Paying primary care providers at rates equal to or
2454	greater than 80 percent of the Medicare rate.
2455	(4)  AGENCY DUTIES.-The agency shall:
2456	(a)  Maintain a record of qualified plans designated as
2457	medical home networks.
2458	(b)  Develop a standard form to be used by the qualified
2459	plans to certify to the agency that they meet the necessary
2460	service and primary care provider support capabilities to be
2461	designated a medical home.
2462	Section 14.  Section 409.91211, Florida Statutes, is
2463	amended to read:
2464	(Substantial rewording of section. See s. 409.91211,
2465	F.S., for present text.)
2466	409.91211.-Medicaid managed care pilot program.-
2467	(1)  AUTHORITY.-The agency is authorized to implement a
2468	managed care pilot program based on the Section 1115 waiver
2469	approved by the Centers for Medicare and Medicaid Services on
2470	October 19, 2005, including continued operation of the program
2471	in Baker, Broward, Clay, Duval, and Nassau Counties. The managed
2472	care pilot program shall be consistent with the provisions of
2473	this section, subject to federal approval.
2474	(2)  EXTENSION.-No later than July 1, 2010, the agency
2475	shall begin the process of requesting an extension of the
2476	Section 1115 waiver. The agency shall report at least monthly to
2477	the Legislature on progress in negotiating for the extension of
2478	the waiver. Changes to the terms and conditions relating to the
2479	low-income pool must be approved by the Legislative Budget
2480	Commission.
2481	(3)  EXPANSION.-The agency shall expand the managed care
2482	pilot program to Miami-Dade County in a manner that enrolls all
2483	eligible recipients in a qualified plan no later than June 30,
2484	2011.
2485	(4)  QUALIFIED PLANS.-Managed care plans qualified to
2486	participate in the Medicaid managed care pilot program include
2487	health insurers authorized under chapter 624, exclusive provider
2488	organizations authorized under chapter 627, health maintenance
2489	organizations authorized under chapter 641, the Children's
2490	Medical Services Network under chapter 391, and provider service
2491	networks authorized pursuant to s. 409.912(4)(d).
2492	(5)  PLAN REQUIREMENTS.-The agency shall apply the
2493	following requirements to all qualified plans:
2494	(a)  Prepaid rates shall be risk adjusted pursuant to
2495	subsection (17).
2496	(b)  All Medicaid recipients shall be offered the
2497	opportunity to use their Medicaid premium to pay for the
2498	recipient's share of cost pursuant to s. 409.9122(13).
2499	(6)  INTERGOVERNMENTAL TRANSFERS.-In order to preserve
2500	intergovernmental transfers of funds from Miami-Dade County, the
2501	agency shall develop methodologies, including, but not limited
2502	to, a supplemental capitation rate, risk pool, or incentive
2503	payments, which may be paid to prepaid plans or plans owned and
2504	operated by providers that contract with safety net providers,
2505	trauma hospitals, children's hospitals, and statutory teaching
2506	hospitals. In order to preserve certified public expenditures
2507	from Miami-Dade County, the agency shall seek federal approval
2508	to implement a methodology that allows supplemental payments to
2509	be made directly to physicians employed by or under contract
2510	with a medical school in Florida in recognition of the costs
2511	associated with graduate medical education or their teaching
2512	mission. Alternatively, the agency may develop additional
2513	methodologies including, but not limited to, methodologies
2514	mentioned above, as well as capitated rates that exclude
2515	payments made to these physicians so that they may be paid
2516	directly. Once methodologies and payment mechanisms are
2517	approved, the agency shall submit the plan for preserving
2518	intergovernmental transfers and certified public expenditures to
2519	the Legislative Budget Commission. After the assignment and
2520	enrollment of all mandatory eligible persons in Miami-Dade
2521	County into managed care plans, an amendment shall be submitted
2522	to the Legislative Budget Commission requesting authority for
2523	the transfer of sufficient funds from appropriate line items
2524	within the Grants and Donations Trust Fund and the Medical Care
2525	Trust Fund within the Agency for Health Care Administration in
2526	the General Appropriations Act to the line item for Prepaid
2527	Health Plans within the General Appropriations Act. The agency
2528	shall submit a report to the Legislature regarding how the
2529	developed and approved methodologies and payment mechanisms may
2530	be applied to other counties in the state pursuant to managed
2531	care payments under s. 409.968.
2532	(7)  ENROLLMENT.-All Medicaid recipients in the counties in
2533	which the managed care pilot program has been implemented shall
2534	be enrolled in a qualified plan. Each recipient shall have a
2535	choice of plans and may select any plan unless that plan is
2536	restricted by contract to a specific population that does not
2537	include the recipient. Medicaid recipients shall have 30 days in
2538	which to make a choice of plans. All recipients shall be offered
2539	choice counseling services in accordance with this section.
2540	(8)  CHOICE COUNSELING.-The agency shall provide choice
2541	counseling and may contract for the provision of choice
2542	counseling services. Choice counseling shall be provided in the
2543	native or preferred language of the recipient, consistent with
2544	federal requirements. The agency shall maintain a record of the
2545	recipients who receive such services, identifying the scope and
2546	method of the services provided. The agency shall make available
2547	clear and easily understandable choice information to Medicaid
2548	recipients that includes:
2549	(a)  An explanation that each recipient has the right to
2550	choose a qualified plan at the time of enrollment in Medicaid
2551	and again at regular intervals set by the agency and that, if a
2552	recipient does not choose a qualified plan, the agency will
2553	assign the recipient to a qualified plan according to the
2554	criteria specified in this section.
2555	(b)  A list and description of the benefits provided in
2556	each plan.
2557	(c)  Information about earning credits in the plan's
2558	enhanced benefit program.
2559	(d)  An explanation of benefit limits.
2560	(e)  Information about cost-sharing requirements of each
2561	plan.
2562	(f)  A current list of providers participating in the
2563	network, including location and contact information.
2564	(g)  Plan performance data.
2565	(9)  AUTOMATIC ENROLLMENT.-The agency shall automatically
2566	enroll Medicaid recipients who do not voluntarily choose a
2567	managed care plan. Enrollment shall be distributed among all
2568	qualified plans. When automatically enrolling recipients, the
2569	agency shall take into account the following criteria:
2570	(a)  The plan has sufficient network capacity to meet the
2571	needs of the recipients.
2572	(b)  The recipient has previously received services from
2573	one of the plan's primary care providers.
2574	(c)  Primary care providers in one plan are more
2575	geographically accessible to the recipient's residence.
2576
2577	The agency may not engage in practices that are designed to
2578	favor one qualified plan over another.
2579	(10)  DISENROLLMENT.-After a recipient has selected and
2580	enrolled in a qualified plan, the recipient shall have 90 days
2581	to voluntarily disenroll and select another qualified plan.
2582	After 90 days, further changes may be made only for good cause.
2583	"Good cause" includes, but is not limited to, poor quality of
2584	care, lack of access to necessary specialty services, an
2585	unreasonable delay or denial of service, or fraudulent
2586	enrollment. The agency must make a determination as to whether
2587	cause exists. However, the agency may require a recipient to use
2588	the qualified plan's grievance process prior to the agency's
2589	determination of cause, except in cases in which immediate risk
2590	of permanent damage to the recipient's health is alleged.  The
2591	agency must make a determination and take final action on a
2592	recipient's request so that disenrollment occurs no later than
2593	the first day of the second month after the month the request
2594	was made. If the agency fails to act within the specified
2595	timeframe, the recipient's request to disenroll is deemed to be
2596	approved as of the date agency action was required. Recipients
2597	who disagree with the agency's finding that cause does not exist
2598	for disenrollment shall be advised of their right to pursue a
2599	Medicaid fair hearing to dispute the agency's finding.
2600	(11)  ENROLLMENT PERIOD.-Medicaid recipients enrolled in a
2601	qualified plan after the 90-day period shall remain in the plan
2602	for 12 months. After 12 months, the recipient may select another
2603	plan. However, nothing shall prevent a Medicaid recipient from
2604	changing primary care providers within the qualified plan during
2605	the 12-month period.
2606	(12)  GRIEVANCES.-Each qualified plan shall establish an
2607	internal process for reviewing and responding to grievances from
2608	enrollees. The contract shall specify timeframes for submission,
2609	plan response, and resolution. Grievances not resolved by a
2610	plan's internal process shall be submitted to the Subscriber
2611	Assistance Panel pursuant to s. 408.7056. Each plan shall submit
2612	quarterly reports on the number, description, and outcome of
2613	grievances filed by enrollees. The agency shall establish a
2614	similar process for provider service networks.
2615	(13)  BENEFITS.-Qualified plans operating in the Medicaid
2616	managed care pilot program shall cover the services specified in
2617	ss. 409.905 and 409.906, emergency services provided under s.
2618	409.9128, and such other services as the plan may offer. Plans
2619	may customize benefit packages for nonpregnant adults, vary
2620	cost-sharing provisions, and provide coverage for additional
2621	services. The agency shall evaluate the proposed benefit
2622	packages to ensure services are sufficient to meet the needs of
2623	the plans' enrollees and to verify actuarial equivalence.
2624	(14)  PENALTIES.-Qualified plans that reduce enrollment
2625	levels or leave a county where the managed care pilot program
2626	has been implemented shall reimburse the agency for the cost of
2627	enrollment changes, including the cost of additional choice
2628	counseling services. When more than one qualified plan leaves a
2629	county at the same time, costs shall be shared by the plans
2630	proportionate to their enrollments.
2631	(15)  ACCESS TO DATA.-The agency shall make encounter data
2632	available to those plans accepting enrollees who are assigned to
2633	them from other plans leaving a county where the managed care
2634	pilot program has been implemented.
2635	(16)  ENHANCED BENEFITS.-Each plan operating in the managed
2636	care pilot program shall establish an incentive program that
2637	rewards specific healthy behaviors with credits in a flexible
2638	spending account pursuant to s. 409.9122(14).
2639	(17)  PAYMENTS TO MANAGED CARE PLANS.-
2640	(a)  The agency shall continue the budget-neutral
2641	adjustment of capitation rates for all prepaid plans in existing
2642	managed care pilot program counties.
2643	(b)  Beginning September 1, 2010, the agency shall begin a
2644	budget-neutral adjustment of capitation rates for all prepaid
2645	plans in Miami-Dade County. The adjustment to capitation rates
2646	shall be based on aggregate risk scores for each prepaid plan's
2647	enrollees. During the first 2 years of the adjustment, the
2648	agency shall ensure that no plan has an aggregate risk score
2649	that varies by more than 10 percent from the aggregate weighted
2650	average for all plans. The risk adjusted capitation rates shall
2651	be phased in as follows:
2652	1.  In the first fiscal year, 75 percent of the capitation
2653	rate shall be based on the current methodology and 25 percent
2654	shall be based on the risk-adjusted rate methodology.
2655	2.  In the second fiscal year, 50 percent of the capitation
2656	rate shall be based on the current methodology and 50 percent
2657	shall be based on the risk-adjusted methodology.
2658	3.  In the third fiscal year, the risk-adjusted capitation
2659	methodology shall be fully implemented.
2660	(c)  During this period, the agency shall establish a
2661	technical advisory panel to obtain input from the prepaid plans
2662	affected by the transition to risk adjusted rates.
2663	(18)  LOW-INCOME POOL.-Funds from a low-income pool shall
2664	be distributed in accordance with the terms and conditions of
2665	the 1115 waiver and in a manner authorized by the General
2666	Appropriations Act. The distribution of funds is intended for
2667	the following purposes:
2668	(a)  Assure a broad and fair distribution of available
2669	funds based on the access provided by Medicaid participating
2670	hospitals, regardless of their ownership status, through their
2671	delivery of inpatient or outpatient care for Medicaid
2672	beneficiaries and uninsured and underinsured individuals;
2673	(b)  Assure accessible emergency inpatient and outpatient
2674	care for Medicaid beneficiaries and uninsured and underinsured
2675	individuals;
2676	(c)  Enhance primary, preventive, and other ambulatory care
2677	coverages for uninsured individuals;
2678	(d)  Promote teaching and specialty hospital programs;
2679	(e)  Promote the stability and viability of statutorily
2680	defined rural hospitals and hospitals that serve as sole
2681	community hospitals;
2682	(f)  Recognize the extent of hospital uncompensated care
2683	costs;
2684	(g)  Maintain and enhance essential community hospital
2685	care;
2686	(h)  Maintain incentives for local governmental entities to
2687	contribute to the cost of uncompensated care;
2688	(i)  Promote measures to avoid preventable
2689	hospitalizations;
2690	(j)  Account for hospital efficiency; and
2691	(k)  Contribute to a community's overall health system.
2692	(19)  ENCOUNTER DATA.-The agency shall maintain and operate
2693	the Medicaid Encounter Data System pursuant to s. 409.9122(15).
2694	(20)  EVALUATION.-The agency shall contract with the
2695	University of Florida to complete a comprehensive evaluation of
2696	the managed care pilot program. The evaluation shall include an
2697	assessment of patient satisfaction, changes in benefits and
2698	coverage, implementation and impact of enhanced benefits, access
2699	to care and service utilization by enrolled recipients, and
2700	costs per enrollee.
2701	Section 15.  Section 409.9122, Florida Statutes, is amended
2702	to read:
2703	409.9122  Mandatory Medicaid managed care enrollment;
2704	programs and procedures.-
2705	(1)  It is the intent of the Legislature that the MediPass
2706	program be cost-effective, provide quality health care, and
2707	improve access to health services, and that the program be
2708	statewide. This subsection expires October 1, 2013.
2709	(2)(a)  The agency shall enroll in a managed care plan or
2710	MediPass all Medicaid recipients, except those Medicaid
2711	recipients who are: in an institution; enrolled in the Medicaid
2712	medically needy program; or eligible for both Medicaid and
2713	Medicare. Upon enrollment, individuals will be able to change
2714	their managed care option during the 90-day opt out period
2715	required by federal Medicaid regulations. The agency is
2716	authorized to seek the necessary Medicaid state plan amendment
2717	to implement this policy. However, to the extent permitted by
2718	federal law, the agency may enroll in a managed care plan or
2719	MediPass a Medicaid recipient who is exempt from mandatory
2720	managed care enrollment, provided that:
2721	1.  The recipient's decision to enroll in a managed care
2722	plan or MediPass is voluntary;
2723	2.  If the recipient chooses to enroll in a managed care
2724	plan, the agency has determined that the managed care plan
2725	provides specific programs and services which address the
2726	special health needs of the recipient; and
2727	3.  The agency receives any necessary waivers from the
2728	federal Centers for Medicare and Medicaid Services.
2729
2730	The agency shall develop rules to establish policies by which
2731	exceptions to the mandatory managed care enrollment requirement
2732	may be made on a case-by-case basis. The rules shall include the
2733	specific criteria to be applied when making a determination as
2734	to whether to exempt a recipient from mandatory enrollment in a
2735	managed care plan or MediPass. School districts participating in
2736	the certified school match program pursuant to ss. 409.908(21)
2737	and 1011.70 shall be reimbursed by Medicaid, subject to the
2738	limitations of s. 1011.70(1), for a Medicaid-eligible child
2739	participating in the services as authorized in s. 1011.70, as
2740	provided for in s. 409.9071, regardless of whether the child is
2741	enrolled in MediPass or a managed care plan. Managed care plans
2742	shall make a good faith effort to execute agreements with school
2743	districts regarding the coordinated provision of services
2744	authorized under s. 1011.70. County health departments
2745	delivering school-based services pursuant to ss. 381.0056 and
2746	381.0057 shall be reimbursed by Medicaid for the federal share
2747	for a Medicaid-eligible child who receives Medicaid-covered
2748	services in a school setting, regardless of whether the child is
2749	enrolled in MediPass or a managed care plan. Managed care plans
2750	shall make a good faith effort to execute agreements with county
2751	health departments regarding the coordinated provision of
2752	services to a Medicaid-eligible child. To ensure continuity of
2753	care for Medicaid patients, the agency, the Department of
2754	Health, and the Department of Education shall develop procedures
2755	for ensuring that a student's managed care plan or MediPass
2756	provider receives information relating to services provided in
2757	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2758	(b)  A Medicaid recipient shall not be enrolled in or
2759	assigned to a managed care plan or MediPass unless the managed
2760	care plan or MediPass has complied with the quality-of-care
2761	standards specified in paragraphs (3)(a) and (b), respectively.
2762	(c)  Medicaid recipients shall have a choice of managed
2763	care plans or MediPass. The Agency for Health Care
2764	Administration, the Department of Health, the Department of
2765	Children and Family Services, and the Department of Elderly
2766	Affairs shall cooperate to ensure that each Medicaid recipient
2767	receives clear and easily understandable information that meets
2768	the following requirements:
2769	1.  Explains the concept of managed care, including
2770	MediPass.
2771	2.  Provides information on the comparative performance of
2772	managed care plans and MediPass in the areas of quality,
2773	credentialing, preventive health programs, network size and
2774	availability, and patient satisfaction.
2775	3.  Explains where additional information on each managed
2776	care plan and MediPass in the recipient's area can be obtained.
2777	4.  Explains that recipients have the right to choose their
2778	managed care coverage at the time they first enroll in Medicaid
2779	and again at regular intervals set by the agency. However, if a
2780	recipient does not choose a managed care plan or MediPass, the
2781	agency will assign the recipient to a managed care plan or
2782	MediPass according to the criteria specified in this section.
2783	5.  Explains the recipient's right to complain, file a
2784	grievance, or change managed care plans or MediPass providers if
2785	the recipient is not satisfied with the managed care plan or
2786	MediPass.
2787	(d)  The agency shall develop a mechanism for providing
2788	information to Medicaid recipients for the purpose of making a
2789	managed care plan or MediPass selection. Examples of such
2790	mechanisms may include, but not be limited to, interactive
2791	information systems, mailings, and mass marketing materials.
2792	Managed care plans and MediPass providers are prohibited from
2793	providing inducements to Medicaid recipients to select their
2794	plans or from prejudicing Medicaid recipients against other
2795	managed care plans or MediPass providers.
2796	(e)  Medicaid recipients who are already enrolled in a
2797	managed care plan or MediPass shall be offered the opportunity
2798	to change managed care plans or MediPass providers on a
2799	staggered basis, as defined by the agency. All Medicaid
2800	recipients shall have 30 days in which to make a choice of
2801	managed care plans or MediPass providers. Those Medicaid
2802	recipients who do not make a choice shall be assigned in
2803	accordance with paragraph (f). To facilitate continuity of care,
2804	for a Medicaid recipient who is also a recipient of Supplemental
2805	Security Income (SSI), prior to assigning the SSI recipient to a
2806	managed care plan or MediPass, the agency shall determine
2807	whether the SSI recipient has an ongoing relationship with a
2808	MediPass provider or managed care plan, and if so, the agency
2809	shall assign the SSI recipient to that MediPass provider or
2810	managed care plan. Those SSI recipients who do not have such a
2811	provider relationship shall be assigned to a managed care plan
2812	or MediPass provider in accordance with paragraph (f).
2813	(f)  If a Medicaid recipient does not choose a managed care
2814	plan or MediPass provider, the agency shall assign the Medicaid
2815	recipient to a managed care plan or MediPass provider. Medicaid
2816	recipients eligible for managed care plan enrollment who are
2817	subject to mandatory assignment but who fail to make a choice
2818	shall be assigned to managed care plans until an enrollment of
2819	35 percent in MediPass and 65 percent in managed care plans, of
2820	all those eligible to choose managed care, is achieved. Once
2821	this enrollment is achieved, the assignments shall be divided in
2822	order to maintain an enrollment in MediPass and managed care
2823	plans which is in a 35 percent and 65 percent proportion,
2824	respectively. Thereafter, assignment of Medicaid recipients who
2825	fail to make a choice shall be based proportionally on the
2826	preferences of recipients who have made a choice in the previous
2827	period. Such proportions shall be revised at least quarterly to
2828	reflect an update of the preferences of Medicaid recipients. The
2829	agency shall disproportionately assign Medicaid-eligible
2830	recipients who are required to but have failed to make a choice
2831	of managed care plan or MediPass, including children, and who
2832	would be assigned to the MediPass program to children's networks
2833	as described in s. 409.912(4)(g), Children's Medical Services
2834	Network as defined in s. 391.021, exclusive provider
2835	organizations, provider service networks, minority physician
2836	networks, and pediatric emergency department diversion programs
2837	authorized by this chapter or the General Appropriations Act, in
2838	such manner as the agency deems appropriate, until the agency
2839	has determined that the networks and programs have sufficient
2840	numbers to be operated economically. For purposes of this
2841	paragraph, when referring to assignment, the term "managed care
2842	plans" includes health maintenance organizations, exclusive
2843	provider organizations, provider service networks, minority
2844	physician networks, Children's Medical Services Network, and
2845	pediatric emergency department diversion programs authorized by
2846	this chapter or the General Appropriations Act. When making
2847	assignments, the agency shall take into account the following
2848	criteria:
2849	1.  A managed care plan has sufficient network capacity to
2850	meet the need of members.
2851	2.  The managed care plan or MediPass has previously
2852	enrolled the recipient as a member, or one of the managed care
2853	plan's primary care providers or MediPass providers has
2854	previously provided health care to the recipient.
2855	3.  The agency has knowledge that the member has previously
2856	expressed a preference for a particular managed care plan or
2857	MediPass provider as indicated by Medicaid fee-for-service
2858	claims data, but has failed to make a choice.
2859	4.  The managed care plan's or MediPass primary care
2860	providers are geographically accessible to the recipient's
2861	residence.
2862	(g)  When more than one managed care plan or MediPass
2863	provider meets the criteria specified in paragraph (f), the
2864	agency shall make recipient assignments consecutively by family
2865	unit.
2866	(h)  The agency may not engage in practices that are
2867	designed to favor one managed care plan over another or that are
2868	designed to influence Medicaid recipients to enroll in MediPass
2869	rather than in a managed care plan or to enroll in a managed
2870	care plan rather than in MediPass. This subsection does not
2871	prohibit the agency from reporting on the performance of
2872	MediPass or any managed care plan, as measured by performance
2873	criteria developed by the agency.
2874	(i)  After a recipient has made his or her selection or has
2875	been enrolled in a managed care plan or MediPass, the recipient
2876	shall have 90 days to exercise the opportunity to voluntarily
2877	disenroll and select another managed care plan or MediPass.
2878	After 90 days, no further changes may be made except for good
2879	cause. Good cause includes, but is not limited to, poor quality
2880	of care, lack of access to necessary specialty services, an
2881	unreasonable delay or denial of service, or fraudulent
2882	enrollment. The agency shall develop criteria for good cause
2883	disenrollment for chronically ill and disabled populations who
2884	are assigned to managed care plans if more appropriate care is
2885	available through the MediPass program. The agency must make a
2886	determination as to whether cause exists. However, the agency
2887	may require a recipient to use the managed care plan's or
2888	MediPass grievance process prior to the agency's determination
2889	of cause, except in cases in which immediate risk of permanent
2890	damage to the recipient's health is alleged. The grievance
2891	process, when utilized, must be completed in time to permit the
2892	recipient to disenroll by the first day of the second month
2893	after the month the disenrollment request was made. If the
2894	managed care plan or MediPass, as a result of the grievance
2895	process, approves an enrollee's request to disenroll, the agency
2896	is not required to make a determination in the case. The agency
2897	must make a determination and take final action on a recipient's
2898	request so that disenrollment occurs no later than the first day
2899	of the second month after the month the request was made. If the
2900	agency fails to act within the specified timeframe, the
2901	recipient's request to disenroll is deemed to be approved as of
2902	the date agency action was required. Recipients who disagree
2903	with the agency's finding that cause does not exist for
2904	disenrollment shall be advised of their right to pursue a
2905	Medicaid fair hearing to dispute the agency's finding.
2906	(j)  The agency shall apply for a federal waiver from the
2907	Centers for Medicare and Medicaid Services to lock eligible
2908	Medicaid recipients into a managed care plan or MediPass for 12
2909	months after an open enrollment period. After 12 months'
2910	enrollment, a recipient may select another managed care plan or
2911	MediPass provider. However, nothing shall prevent a Medicaid
2912	recipient from changing primary care providers within the
2913	managed care plan or MediPass program during the 12-month
2914	period.
2915	(k)  When a Medicaid recipient does not choose a managed
2916	care plan or MediPass provider, the agency shall assign the
2917	Medicaid recipient to a managed care plan, except in those
2918	counties in which there are fewer than two managed care plans
2919	accepting Medicaid enrollees, in which case assignment shall be
2920	to a managed care plan or a MediPass provider. Medicaid
2921	recipients in counties with fewer than two managed care plans
2922	accepting Medicaid enrollees who are subject to mandatory
2923	assignment but who fail to make a choice shall be assigned to
2924	managed care plans until an enrollment of 35 percent in MediPass
2925	and 65 percent in managed care plans, of all those eligible to
2926	choose managed care, is achieved. Once that enrollment is
2927	achieved, the assignments shall be divided in order to maintain
2928	an enrollment in MediPass and managed care plans which is in a
2929	35 percent and 65 percent proportion, respectively. For purposes
2930	of this paragraph, when referring to assignment, the term
2931	"managed care plans" includes exclusive provider organizations,
2932	provider service networks, Children's Medical Services Network,
2933	minority physician networks, and pediatric emergency department
2934	diversion programs authorized by this chapter or the General
2935	Appropriations Act. When making assignments, the agency shall
2936	take into account the following criteria:
2937	1.  A managed care plan has sufficient network capacity to
2938	meet the need of members.
2939	2.  The managed care plan or MediPass has previously
2940	enrolled the recipient as a member, or one of the managed care
2941	plan's primary care providers or MediPass providers has
2942	previously provided health care to the recipient.
2943	3.  The agency has knowledge that the member has previously
2944	expressed a preference for a particular managed care plan or
2945	MediPass provider as indicated by Medicaid fee-for-service
2946	claims data, but has failed to make a choice.
2947	4.  The managed care plan's or MediPass primary care
2948	providers are geographically accessible to the recipient's
2949	residence.
2950	5.  The agency has authority to make mandatory assignments
2951	based on quality of service and performance of managed care
2952	plans.
2953	(l)  Notwithstanding the provisions of chapter 287, the
2954	agency may, at its discretion, renew cost-effective contracts
2955	for choice counseling services once or more for such periods as
2956	the agency may decide. However, all such renewals may not
2957	combine to exceed a total period longer than the term of the
2958	original contract.
2959
2960	This subsection expires October 1, 2013.
2961	(3)(a)  The agency shall establish quality-of-care
2962	standards for managed care plans. These standards shall be based
2963	upon, but are not limited to:
2964	1.  Compliance with the accreditation requirements as
2965	provided in s. 641.512.
2966	2.  Compliance with Early and Periodic Screening,
2967	Diagnosis, and Treatment screening requirements.
2968	3.  The percentage of voluntary disenrollments.
2969	4.  Immunization rates.
2970	5.  Standards of the National Committee for Quality
2971	Assurance and other approved accrediting bodies.
2972	6.  Recommendations of other authoritative bodies.
2973	7.  Specific requirements of the Medicaid program, or
2974	standards designed to specifically assist the unique needs of
2975	Medicaid recipients.
2976	8.  Compliance with the health quality improvement system
2977	as established by the agency, which incorporates standards and
2978	guidelines developed by the Medicaid Bureau of the Health Care
2979	Financing Administration as part of the quality assurance reform
2980	initiative.
2981	(b)  For the MediPass program, the agency shall establish
2982	standards which are based upon, but are not limited to:
2983	1.  Quality-of-care standards which are comparable to those
2984	required of managed care plans.
2985	2.  Credentialing standards for MediPass providers.
2986	3.  Compliance with Early and Periodic Screening,
2987	Diagnosis, and Treatment screening requirements.
2988	4.  Immunization rates.
2989	5.  Specific requirements of the Medicaid program, or
2990	standards designed to specifically assist the unique needs of
2991	Medicaid recipients.
2992
2993	This subsection expires October 1, 2013.
2994	(4)(a)  Each female recipient may select as her primary
2995	care provider an obstetrician/gynecologist who has agreed to
2996	participate as a MediPass primary care case manager.
2997	(b)  The agency shall establish a complaints and grievance
2998	process to assist Medicaid recipients enrolled in the MediPass
2999	program to resolve complaints and grievances. The agency shall
3000	investigate reports of quality-of-care grievances which remain
3001	unresolved to the satisfaction of the enrollee.
3002
3003	This subsection expires October 1, 2013.
3004	(5)(a)  The agency shall work cooperatively with the Social
3005	Security Administration to identify beneficiaries who are
3006	jointly eligible for Medicare and Medicaid and shall develop
3007	cooperative programs to encourage these beneficiaries to enroll
3008	in a Medicare participating health maintenance organization or
3009	prepaid health plans.
3010	(b)  The agency shall work cooperatively with the
3011	Department of Elderly Affairs to assess the potential cost-
3012	effectiveness of providing MediPass to beneficiaries who are
3013	jointly eligible for Medicare and Medicaid on a voluntary choice
3014	basis. If the agency determines that enrollment of these
3015	beneficiaries in MediPass has the potential for being cost-
3016	effective for the state, the agency shall offer MediPass to
3017	these beneficiaries on a voluntary choice basis in the counties
3018	where MediPass operates.
3019
3020	This subsection expires October 1, 2013.
3021	(6)  MediPass enrolled recipients may receive up to 10
3022	visits of reimbursable services by participating Medicaid
3023	physicians licensed under chapter 460 and up to four visits of
3024	reimbursable services by participating Medicaid physicians
3025	licensed under chapter 461. Any further visits must be by prior
3026	authorization by the MediPass primary care provider. However,
3027	nothing in this subsection may be construed to increase the
3028	total number of visits or the total amount of dollars per year
3029	per person under current Medicaid rules, unless otherwise
3030	provided for in the General Appropriations Act. This subsection
3031	expires October 1, 2013.
3032	(7)  The agency shall investigate the feasibility of
3033	developing managed care plan and MediPass options for the
3034	following groups of Medicaid recipients:
3035	(a)  Pregnant women and infants.
3036	(b)  Elderly and disabled recipients, especially those who
3037	are at risk of nursing home placement.
3038	(c)  Persons with developmental disabilities.
3039	(d)  Qualified Medicare beneficiaries.
3040	(e)  Adults who have chronic, high-cost medical conditions.
3041	(f)  Adults and children who have mental health problems.
3042	(g)  Other recipients for whom managed care plans and
3043	MediPass offer the opportunity of more cost-effective care and
3044	greater access to qualified providers.
3045	(8)(a)  The agency shall encourage the development of
3046	public and private partnerships to foster the growth of health
3047	maintenance organizations and prepaid health plans that will
3048	provide high-quality health care to Medicaid recipients.
3049	(b)  Subject to the availability of moneys and any
3050	limitations established by the General Appropriations Act or
3051	chapter 216, the agency is authorized to enter into contracts
3052	with traditional providers of health care to low-income persons
3053	to assist such providers with the technical aspects of
3054	cooperatively developing Medicaid prepaid health plans.
3055	1.  The agency may contract with disproportionate share
3056	hospitals, county health departments, federally initiated or
3057	federally funded community health centers, and counties that
3058	operate either a hospital or a community clinic.
3059	2.  A contract may not be for more than $100,000 per year,
3060	and no contract may be extended with any particular provider for
3061	more than 2 years. The contract is intended only as seed or
3062	development funding and requires a commitment from the
3063	interested party.
3064	3.  A contract must require participation by at least one
3065	community health clinic and one disproportionate share hospital.
3066	(7)(9)(a)  The agency shall develop and implement a
3067	comprehensive plan to ensure that recipients are adequately
3068	informed of their choices and rights under all Medicaid managed
3069	care programs and that Medicaid managed care programs meet
3070	acceptable standards of quality in patient care, patient
3071	satisfaction, and financial solvency.
3072	(b)  The agency shall provide adequate means for informing
3073	patients of their choice and rights under a managed care plan at
3074	the time of eligibility determination.
3075	(c)  The agency shall require managed care plans and
3076	MediPass providers to demonstrate and document plans and
3077	activities, as defined by rule, including outreach and followup,
3078	undertaken to ensure that Medicaid recipients receive the health
3079	care service to which they are entitled.
3080
3081	This subsection expires October 1, 2013.
3082	(8)(10)  The agency shall consult with Medicaid consumers
3083	and their representatives on an ongoing basis regarding
3084	measurements of patient satisfaction, procedures for resolving
3085	patient grievances, standards for ensuring quality of care,
3086	mechanisms for providing patient access to services, and
3087	policies affecting patient care. This subsection expires October
3088	1, 2013.
3089	(9)(11)  The agency may extend eligibility for Medicaid
3090	recipients enrolled in licensed and accredited health
3091	maintenance organizations for the duration of the enrollment
3092	period or for 6 months, whichever is earlier, provided the
3093	agency certifies that such an offer will not increase state
3094	expenditures. This subsection expires October 1, 2013.
3095	(10)(12)  A managed care plan that has a Medicaid contract
3096	shall at least annually review each primary care physician's
3097	active patient load and shall ensure that additional Medicaid
3098	recipients are not assigned to physicians who have a total
3099	active patient load of more than 3,000 patients. As used in this
3100	subsection, the term "active patient" means a patient who is
3101	seen by the same primary care physician, or by a physician
3102	assistant or advanced registered nurse practitioner under the
3103	supervision of the primary care physician, at least three times
3104	within a calendar year. Each primary care physician shall
3105	annually certify to the managed care plan whether or not his or
3106	her patient load exceeds the limits established under this
3107	subsection and the managed care plan shall accept such
3108	certification on face value as compliance with this subsection.
3109	The agency shall accept the managed care plan's representations
3110	that it is in compliance with this subsection based on the
3111	certification of its primary care physicians, unless the agency
3112	has an objective indication that access to primary care is being
3113	compromised, such as receiving complaints or grievances relating
3114	to access to care. If the agency determines that an objective
3115	indication exists that access to primary care is being
3116	compromised, it may verify the patient load certifications
3117	submitted by the managed care plan's primary care physicians and
3118	that the managed care plan is not assigning Medicaid recipients
3119	to primary care physicians who have an active patient load of
3120	more than 3,000 patients. This subsection expires October 1,
3121	2013.
3122	(13)  Effective July 1, 2003, the agency shall adjust the
3123	enrollee assignment process of Medicaid managed prepaid health
3124	plans for those Medicaid managed prepaid plans operating in
3125	Miami-Dade County which have executed a contract with the agency
3126	for a minimum of 8 consecutive years in order for the Medicaid
3127	managed prepaid plan to maintain a minimum enrollment level of
3128	15,000 members per month. When assigning enrollees pursuant to
3129	this subsection, the agency shall give priority to providers
3130	that initially qualified under this subsection until such
3131	providers reach and maintain an enrollment level of 15,000
3132	members per month. A prepaid health plan that has a statewide
3133	Medicaid enrollment of 25,000 or more members is not eligible
3134	for enrollee assignments under this subsection.
3135	(11)(14)  The agency shall include in its calculation of
3136	the hospital inpatient component of a Medicaid health
3137	maintenance organization's capitation rate any special payments,
3138	including, but not limited to, upper payment limit or
3139	disproportionate share hospital payments, made to qualifying
3140	hospitals through the fee-for-service program. The agency may
3141	seek federal waiver approval or state plan amendment as needed
3142	to implement this adjustment.
3143	(12)(a)  Beginning September 1, 2010, the agency shall
3144	begin a budget-neutral adjustment of capitation rates for all
3145	Medicaid prepaid plans in the state. The adjustment to
3146	capitation rates shall be based on aggregate risk scores for
3147	each prepaid plan's enrollees. During the first 2 years of the
3148	adjustment, the agency shall ensure that no plan has an
3149	aggregate risk score that varies more than 10 percent from the
3150	aggregate weighted average for all plans. The risk adjusted
3151	capitation rates shall be phased in as follows:
3152	1.  In the first fiscal year, 75 percent of the capitation
3153	rate shall be based on the current methodology and 25 percent
3154	shall be based on the risk-adjusted rate methodology.
3155	2.  In the second fiscal year, 50 percent of the capitation
3156	rate shall be based on the current methodology and 50 percent
3157	shall be based on the risk-adjusted methodology.
3158	3.  In the third fiscal year, the risk-adjusted capitation
3159	methodology shall be fully implemented.
3160	(b)  During this period, the agency shall establish a
3161	technical advisory panel to obtain input from the prepaid plans
3162	affected by the transition to risk adjusted rates.
3163	(13)  The agency shall develop a process to enable any
3164	recipient with access to employer sponsored insurance to opt out
3165	of all qualified plans in the Medicaid program and to use
3166	Medicaid financial assistance to pay for the recipient's share
3167	of cost in any such plan. Contingent on federal approval, the
3168	agency shall also enable recipients with access to other
3169	insurance or related products providing access to health care
3170	services created pursuant to state law, including any plan or
3171	product available pursuant to Cover Florida, the Florida Health
3172	Choices Program, or any health exchange, to opt out. The amount
3173	of financial assistance provided for each recipient shall not
3174	exceed the amount of the Medicaid premium that would have been
3175	paid to a plan for that recipient.
3176	(14)  Each qualified plan shall establish an incentive
3177	program that rewards specific healthy behaviors with credits in
3178	a flexible spending account pursuant to s. 409.9122(14).
3179	(a)  At the discretion of the recipient, credits shall be
3180	used to purchase otherwise uncovered health and related services
3181	during the entire period of and for a maximum of 3 years after
3182	the recipient's Medicaid eligibility, whether or not the
3183	recipient remains continuously enrolled in the plan in which the
3184	credits were earned.
3185	(b)  Enhanced benefits offered by a qualified plan shall be
3186	structured to provide greater incentives for those diseases
3187	linked with lifestyle and conditions or behaviors associated
3188	with avoidable utilization of high-cost services.
3189	(c)  To fund these credits, each plan must maintain a
3190	reserve account in an amount up to 2 percent of the plan's
3191	Medicaid premium revenue or benchmark premium revenue in the
3192	case of provider service networks based on an actuarial
3193	assessment of the value of the enhanced benefit program.
3194	(15)  The agency shall maintain and operate the Medicaid
3195	Encounter Data System to collect, process, store, and report on
3196	covered services provided to all Florida Medicaid recipients
3197	enrolled in prepaid managed care plans. Prepaid managed care
3198	plans shall submit encounter data electronically in a format
3199	that complies with the Health Insurance Portability and
3200	Accountability Act provisions for electronic claims and in
3201	accordance with deadlines established by the agency. Prepaid
3202	managed care plans must certify that the data reported is
3203	accurate and complete. The agency is responsible for validating
3204	the data submitted by the plans.
3205	(16)  The agency may establish a per-member per-month
3206	payment for Medicare Advantage Special Needs members that are
3207	also eligible for Medicaid as a mechanism for meeting the
3208	state's cost sharing obligation.  The agency may also develop a
3209	per-member per-month payment for Medicaid only covered services
3210	for which the state is responsible. The agency shall develop a
3211	mechanism to ensure that such per-member per-month payment
3212	enhances the value to the state and enrolled members by limiting
3213	cost sharing, enhancing the scope of Medicare supplemental
3214	benefits that are equal to or greater than Medicaid coverage for
3215	select services, and improving care coordination.
3216	(17)  The agency shall establish, and managed care plans
3217	shall use, a uniform method of accounting for and reporting
3218	medical and nonmedical costs. The agency shall make such
3219	information available to the public.
3220	(18)  Effective October 1, 2013, school districts
3221	participating in the certified school match program pursuant to
3222	ss. 409.908(21) and 1011.70 shall be reimbursed by Medicaid,
3223	subject to the limitations of s. 1011.70(1), for a Medicaid-
3224	eligible child participating in the services as authorized in s.
3225	1011.70, as provided for in s. 409.9071. Managed care plans
3226	shall make a good faith effort to execute agreements with school
3227	districts regarding the coordinated provision of services
3228	authorized under s. 1011.70 and county health departments
3229	delivering school-based services pursuant to ss. 381.0056 and
3230	381.0057. To ensure continuity of care for Medicaid patients,
3231	the agency, the Department of Health, and the Department of
3232	Education shall develop procedures for ensuring that a student's
3233	managed care plan receives information relating to services
3234	provided in accordance with ss. 381.0056, 381.0057, 409.9071,
3235	and 1011.70.
3236	(19)  The agency may, on a case-by-case basis, exempt a
3237	recipient from mandatory enrollment in a managed care plan when
3238	the recipient has a unique, time-limited disease or condition-
3239	related circumstance and managed care enrollment will interfere
3240	with ongoing care because the recipient's provider does not
3241	participate in the managed care plans available in the
3242	recipient's area.
3243	Section 16.  Subsection (18) of section 430.04, Florida
3244	Statutes, is amended to read:
3245	430.04  Duties and responsibilities of the Department of
3246	Elderly Affairs.-The Department of Elderly Affairs shall:
3247	(18)  Administer all Medicaid waivers and programs relating
3248	to elders and their appropriations. The waivers include, but are
3249	not limited to:
3250	(a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3251	established in s. 430.502(7), (8), and (9).
3252	(a)(b)  The Assisted Living for the Frail Elderly Waiver.
3253	(b)(c)  The Aged and Disabled Adult Waiver.
3254	(c)(d)  The Adult Day Health Care Waiver.
3255	(d)(e)  The Consumer-Directed Care Plus Program as defined
3256	in s. 409.221.
3257	(e)(f)  The Program of All-inclusive Care for the Elderly.
3258	(f)(g)  The Long-Term Care Community-Based Diversion Pilot
3259	Project as described in s. 430.705.
3260	(g)(h)  The Channeling Services Waiver for Frail Elders.
3261
3262	The department shall develop a transition plan for recipients
3263	receiving services in long-term care Medicaid waivers for elders
3264	or disabled adults on the date qualified plans become available
3265	in each recipient's region pursuant to s. 409.981(2) to enroll
3266	those recipients in qualified plans. This subsection expires
3267	October 1, 2012.
3268	Section 17.  Section 430.2053, Florida Statutes, is amended
3269	to read:
3270	430.2053  Aging resource centers.-
3271	(1)  The department, in consultation with the Agency for
3272	Health Care Administration and the Department of Children and
3273	Family Services, shall develop pilot projects for aging resource
3274	centers. By October 31, 2004, the department, in consultation
3275	with the agency and the Department of Children and Family
3276	Services, shall develop an implementation plan for aging
3277	resource centers and submit the plan to the Governor, the
3278	President of the Senate, and the Speaker of the House of
3279	Representatives. The plan must include qualifications for
3280	designation as a center, the functions to be performed by each
3281	center, and a process for determining that a current area agency
3282	on aging is ready to assume the functions of an aging resource
3283	center.
3284	(2)  Each area agency on aging shall develop, in
3285	consultation with the existing community care for the elderly
3286	lead agencies within their planning and service areas, a
3287	proposal that describes the process the area agency on aging
3288	intends to undertake to transition to an aging resource center
3289	prior to July 1, 2005, and that describes the area agency's
3290	compliance with the requirements of this section. The proposals
3291	must be submitted to the department prior to December 31, 2004.
3292	The department shall evaluate all proposals for readiness and,
3293	prior to March 1, 2005, shall select three area agencies on
3294	aging which meet the requirements of this section to begin the
3295	transition to aging resource centers. Those area agencies on
3296	aging which are not selected to begin the transition to aging
3297	resource centers shall, in consultation with the department and
3298	the existing community care for the elderly lead agencies within
3299	their planning and service areas, amend their proposals as
3300	necessary and resubmit them to the department prior to July 1,
3301	2005. The department may transition additional area agencies to
3302	aging resource centers as it determines that area agencies are
3303	in compliance with the requirements of this section.
3304	(3)  The Auditor General and the Office of Program Policy
3305	Analysis and Government Accountability (OPPAGA) shall jointly
3306	review and assess the department's process for determining an
3307	area agency's readiness to transition to an aging resource
3308	center.
3309	(a)  The review must, at a minimum, address the
3310	appropriateness of the department's criteria for selection of an
3311	area agency to transition to an aging resource center, the
3312	instruments applied, the degree to which the department
3313	accurately determined each area agency's compliance with the
3314	readiness criteria, the quality of the technical assistance
3315	provided by the department to an area agency in correcting any
3316	weaknesses identified in the readiness assessment, and the
3317	degree to which each area agency overcame any identified
3318	weaknesses.
3319	(b)  Reports of these reviews must be submitted to the
3320	appropriate substantive and appropriations committees in the
3321	Senate and the House of Representatives on March 1 and September
3322	1 of each year until full transition to aging resource centers
3323	has been accomplished statewide, except that the first report
3324	must be submitted by February 1, 2005, and must address all
3325	readiness activities undertaken through December 31, 2004. The
3326	perspectives of all participants in this review process must be
3327	included in each report.
3328	(2)(4)  The purposes of an aging resource center shall be:
3329	(a)  To provide Florida's elders and their families with a
3330	locally focused, coordinated approach to integrating information
3331	and referral for all available services for elders with the
3332	eligibility determination entities for state and federally
3333	funded long-term-care services.
3334	(b)  To provide for easier access to long-term-care
3335	services by Florida's elders and their families by creating
3336	multiple access points to the long-term-care network that flow
3337	through one established entity with wide community recognition.
3338	(3)(5)  The duties of an aging resource center are to:
3339	(a)  Develop referral agreements with local community
3340	service organizations, such as senior centers, existing elder
3341	service providers, volunteer associations, and other similar
3342	organizations, to better assist clients who do not need or do
3343	not wish to enroll in programs funded by the department or the
3344	agency. The referral agreements must also include a protocol,
3345	developed and approved by the department, which provides
3346	specific actions that an aging resource center and local
3347	community service organizations must take when an elder or an
3348	elder's representative seeking information on long-term-care
3349	services contacts a local community service organization prior
3350	to contacting the aging resource center. The protocol shall be
3351	designed to ensure that elders and their families are able to
3352	access information and services in the most efficient and least
3353	cumbersome manner possible.
3354	(b)  Provide an initial screening of all clients who
3355	request long-term-care services to determine whether the person
3356	would be most appropriately served through any combination of
3357	federally funded programs, state-funded programs, locally funded
3358	or community volunteer programs, or private funding for
3359	services.
3360	(c)  Determine eligibility for the programs and services
3361	listed in subsection (9) (11) for persons residing within the
3362	geographic area served by the aging resource center and
3363	determine a priority ranking for services which is based upon
3364	the potential recipient's frailty level and likelihood of
3365	institutional placement without such services.
3366	(d)  Manage the availability of financial resources for the
3367	programs and services listed in subsection (9) (11) for persons
3368	residing within the geographic area served by the aging resource
3369	center.
3370	(e)  When financial resources become available, refer a
3371	client to the most appropriate entity to begin receiving
3372	services. The aging resource center shall make referrals to lead
3373	agencies for service provision that ensure that individuals who
3374	are vulnerable adults in need of services pursuant to s.
3375	415.104(3)(b), or who are victims of abuse, neglect, or
3376	exploitation in need of immediate services to prevent further
3377	harm and are referred by the adult protective services program,
3378	are given primary consideration for receiving community-care-
3379	for-the-elderly services in compliance with the requirements of
3380	s. 430.205(5)(a) and that other referrals for services are in
3381	compliance with s. 430.205(5)(b).
3382	(f)  Convene a work group to advise in the planning,
3383	implementation, and evaluation of the aging resource center. The
3384	work group shall be comprised of representatives of local
3385	service providers, Alzheimer's Association chapters, housing
3386	authorities, social service organizations, advocacy groups,
3387	representatives of clients receiving services through the aging
3388	resource center, and any other persons or groups as determined
3389	by the department. The aging resource center, in consultation
3390	with the work group, must develop annual program improvement
3391	plans that shall be submitted to the department for
3392	consideration. The department shall review each annual
3393	improvement plan and make recommendations on how to implement
3394	the components of the plan.
3395	(g)  Enhance the existing area agency on aging in each
3396	planning and service area by integrating, either physically or
3397	virtually, the staff and services of the area agency on aging
3398	with the staff of the department's local CARES Medicaid nursing
3399	home preadmission screening unit and a sufficient number of
3400	staff from the Department of Children and Family Services'
3401	Economic Self-Sufficiency Unit necessary to determine the
3402	financial eligibility for all persons age 60 and older residing
3403	within the area served by the aging resource center that are
3404	seeking Medicaid services, Supplemental Security Income, and
3405	food stamps.
3406	(h)  Assist clients who request long-term care services in
3407	being evaluated for eligibility for enrollment in the Medicaid
3408	long-term care managed care program as qualified plans become
3409	available in each of the regions pursuant to s. 409.981(2).
3410	(i)  Provide choice counseling for the Medicaid long-term
3411	care managed care program by integrating, either physically or
3412	virtually, choice counseling staff and services as qualified
3413	plans become available in each of the regions pursuant to s.
3414	409.981(2). Pursuant to s. 409.984(1), the agency may contract
3415	directly with the aging resource center to provide choice
3416	counseling services or may contract with another vendor if the
3417	aging resource center does not choose to provide such services.
3418	(j)  Assist Medicaid recipients enrolled in the Medicaid
3419	long-term care managed care program with informally resolving
3420	grievances with a managed care network and assist Medicaid
3421	recipients in accessing the managed care network's formal
3422	grievance process as qualified plans become available in each of
3423	the regions pursuant to s. 409.981(2).
3424	(4)(6)  The department shall select the entities to become
3425	aging resource centers based on each entity's readiness and
3426	ability to perform the duties listed in subsection (3) (5) and
3427	the entity's:
3428	(a)  Expertise in the needs of each target population the
3429	center proposes to serve and a thorough knowledge of the
3430	providers that serve these populations.
3431	(b)  Strong connections to service providers, volunteer
3432	agencies, and community institutions.
3433	(c)  Expertise in information and referral activities.
3434	(d)  Knowledge of long-term-care resources, including
3435	resources designed to provide services in the least restrictive
3436	setting.
3437	(e)  Financial solvency and stability.
3438	(f)  Ability to collect, monitor, and analyze data in a
3439	timely and accurate manner, along with systems that meet the
3440	department's standards.
3441	(g)  Commitment to adequate staffing by qualified personnel
3442	to effectively perform all functions.
3443	(h)  Ability to meet all performance standards established
3444	by the department.
3445	(5)(7)  The aging resource center shall have a governing
3446	body which shall be the same entity described in s. 20.41(7),
3447	and an executive director who may be the same person as
3448	described in s. 20.41(7). The governing body shall annually
3449	evaluate the performance of the executive director.
3450	(6)(8)  The aging resource center may not be a provider of
3451	direct services other than choice counseling as qualified plans
3452	become available in each of the regions pursuant to s.
3453	409.981(2), information and referral services, and screening.
3454	(7)(9)  The aging resource center must agree to allow the
3455	department to review any financial information the department
3456	determines is necessary for monitoring or reporting purposes,
3457	including financial relationships.
3458	(8)(10)  The duties and responsibilities of the community
3459	care for the elderly lead agencies within each area served by an
3460	aging resource center shall be to:
3461	(a)  Develop strong community partnerships to maximize the
3462	use of community resources for the purpose of assisting elders
3463	to remain in their community settings for as long as it is
3464	safely possible.
3465	(b)  Conduct comprehensive assessments of clients that have
3466	been determined eligible and develop a care plan consistent with
3467	established protocols that ensures that the unique needs of each
3468	client are met.
3469	(9)(11)  The services to be administered through the aging
3470	resource center shall include those funded by the following
3471	programs:
3472	(a)  Community care for the elderly.
3473	(b)  Home care for the elderly.
3474	(c)  Contracted services.
3475	(d)  Alzheimer's disease initiative.
3476	(e)  Aged and disabled adult Medicaid waiver. This
3477	paragraph expires October 1, 2012.
3478	(f)  Assisted living for the frail elderly Medicaid waiver.
3479	This paragraph expires October 1, 2012.
3480	(g)  Older Americans Act.
3481	(10)(12)  The department shall, prior to designation of an
3482	aging resource center, develop by rule operational and quality
3483	assurance standards and outcome measures to ensure that clients
3484	receiving services through all long-term-care programs
3485	administered through an aging resource center are receiving the
3486	appropriate care they require and that contractors and
3487	subcontractors are adhering to the terms of their contracts and
3488	are acting in the best interests of the clients they are
3489	serving, consistent with the intent of the Legislature to reduce
3490	the use of and cost of nursing home care. The department shall
3491	by rule provide operating procedures for aging resource centers,
3492	which shall include:
3493	(a)  Minimum standards for financial operation, including
3494	audit procedures.
3495	(b)  Procedures for monitoring and sanctioning of service
3496	providers.
3497	(c)  Minimum standards for technology utilized by the aging
3498	resource center.
3499	(d)  Minimum staff requirements which shall ensure that the
3500	aging resource center employs sufficient quality and quantity of
3501	staff to adequately meet the needs of the elders residing within
3502	the area served by the aging resource center.
3503	(e)  Minimum accessibility standards, including hours of
3504	operation.
3505	(f)  Minimum oversight standards for the governing body of
3506	the aging resource center to ensure its continuous involvement
3507	in, and accountability for, all matters related to the
3508	development, implementation, staffing, administration, and
3509	operations of the aging resource center.
3510	(g)  Minimum education and experience requirements for
3511	executive directors and other executive staff positions of aging
3512	resource centers.
3513	(h)  Minimum requirements regarding any executive staff
3514	positions that the aging resource center must employ and minimum
3515	requirements that a candidate must meet in order to be eligible
3516	for appointment to such positions.
3517	(11)(13)  In an area in which the department has designated
3518	an area agency on aging as an aging resource center, the
3519	department and the agency shall not make payments for the
3520	services listed in subsection (9) (11) and the Long-Term Care
3521	Community Diversion Project for such persons who were not
3522	screened and enrolled through the aging resource center. The
3523	department shall cease making payments for recipients in
3524	qualified plans as qualified plans become available in each of
3525	the regions pursuant to s. 409.981(2).
3526	(12)(14)  Each aging resource center shall enter into a
3527	memorandum of understanding with the department for
3528	collaboration with the CARES unit staff. The memorandum of
3529	understanding shall outline the staff person responsible for
3530	each function and shall provide the staffing levels necessary to
3531	carry out the functions of the aging resource center.
3532	(13)(15)  Each aging resource center shall enter into a
3533	memorandum of understanding with the Department of Children and
3534	Family Services for collaboration with the Economic Self-
3535	Sufficiency Unit staff. The memorandum of understanding shall
3536	outline which staff persons are responsible for which functions
3537	and shall provide the staffing levels necessary to carry out the
3538	functions of the aging resource center.
3539	(14)  As qualified plans become available in each of the
3540	regions pursuant to s. 409.981(2), if an aging resource center
3541	does not contract with the agency to provide Medicaid long-term
3542	care managed care choice counseling pursuant to s. 409.984(1),
3543	the aging resource center shall enter into a memorandum of
3544	understanding with the agency to coordinate staffing and
3545	collaborate with the choice counseling vendor. The memorandum of
3546	understanding shall identify the staff responsible for each
3547	function and shall provide the staffing levels necessary to
3548	carry out the functions of the aging resource center.
3549	(15)(16)  If any of the state activities described in this
3550	section are outsourced, either in part or in whole, the contract
3551	executing the outsourcing shall mandate that the contractor or
3552	its subcontractors shall, either physically or virtually,
3553	execute the provisions of the memorandum of understanding
3554	instead of the state entity whose function the contractor or
3555	subcontractor now performs.
3556	(16)(17)  In order to be eligible to begin transitioning to
3557	an aging resource center, an area agency on aging board must
3558	ensure that the area agency on aging which it oversees meets all
3559	of the minimum requirements set by law and in rule.
3560	(18)  The department shall monitor the three initial
3561	projects for aging resource centers and report on the progress
3562	of those projects to the Governor, the President of the Senate,
3563	and the Speaker of the House of Representatives by June 30,
3564	2005. The report must include an evaluation of the
3565	implementation process.
3566	(17)(19)(a)  Once an aging resource center is operational,
3567	the department, in consultation with the agency, may develop
3568	capitation rates for any of the programs administered through
3569	the aging resource center. Capitation rates for programs shall
3570	be based on the historical cost experience of the state in
3571	providing those same services to the population age 60 or older
3572	residing within each area served by an aging resource center.
3573	Each capitated rate may vary by geographic area as determined by
3574	the department.
3575	(b)  The department and the agency may determine for each
3576	area served by an aging resource center whether it is
3577	appropriate, consistent with federal and state laws and
3578	regulations, to develop and pay separate capitated rates for
3579	each program administered through the aging resource center or
3580	to develop and pay capitated rates for service packages which
3581	include more than one program or service administered through
3582	the aging resource center.
3583	(c)  Once capitation rates have been developed and
3584	certified as actuarially sound, the department and the agency
3585	may pay service providers the capitated rates for services when
3586	appropriate.
3587	(d)  The department, in consultation with the agency, shall
3588	annually reevaluate and recertify the capitation rates,
3589	adjusting forward to account for inflation, programmatic
3590	changes.
3591	(20)  The department, in consultation with the agency,
3592	shall submit to the Governor, the President of the Senate, and
3593	the Speaker of the House of Representatives, by December 1,
3594	2006, a report addressing the feasibility of administering the
3595	following services through aging resource centers beginning July
3596	1, 2007:
3597	(a)  Medicaid nursing home services.
3598	(b)  Medicaid transportation services.
3599	(c)  Medicaid hospice care services.
3600	(d)  Medicaid intermediate care services.
3601	(e)  Medicaid prescribed drug services.
3602	(f)  Medicaid assistive care services.
3603	(g)  Any other long-term-care program or Medicaid service.
3604	(18)(21)  This section shall not be construed to allow an
3605	aging resource center to restrict, manage, or impede the local
3606	fundraising activities of service providers.
3607	Section 18.  Subsection (4) of section 641.386, Florida
3608	Statutes, is amended to read:
3609	641.386  Agent licensing and appointment required;
3610	exceptions.-
3611	(4)  All agents and health maintenance organizations shall
3612	comply with and be subject to the applicable provisions of ss.
3613	641.309 and 409.912(20)(21), and all companies and entities
3614	appointing agents shall comply with s. 626.451, when marketing
3615	for any health maintenance organization licensed pursuant to
3616	this part, including those organizations under contract with the
3617	Agency for Health Care Administration to provide health care
3618	services to Medicaid recipients or any private entity providing
3619	health care services to Medicaid recipients pursuant to a
3620	prepaid health plan contract with the Agency for Health Care
3621	Administration.
3622	Section 19.  Effective October 1, 2012, sections 430.701,
3623	430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3624	430.708, and 430.709 Florida Statutes, are repealed.
3625	Section 20.  Sections 409.9301, 409.942, 409.944, 409.945,
3626	409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3627	as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3628	402.87, Florida Statutes, respectively.
3629	Section 21.  Paragraph (a) of subsection (1) of section
3630	443.111, Florida Statutes, is amended to read:
3631	443.111  Payment of benefits.-
3632	(1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3633	in accordance with rules adopted by the Agency for Workforce
3634	Innovation, subject to the following requirements:
3635	(a)  Benefits are payable by mail or electronically.
3636	Notwithstanding s. 402.82(4) 409.942(4), The agency may develop
3637	a system for the payment of benefits by electronic funds
3638	transfer, including, but not limited to, debit cards, electronic
3639	payment cards, or any other means of electronic payment that the
3640	agency deems to be commercially viable or cost-effective.
3641	Commodities or services related to the development of such a
3642	system shall be procured by competitive solicitation, unless
3643	they are purchased from a state term contract pursuant to s.
3644	287.056. The agency shall adopt rules necessary to administer
3645	the system.
3646	Section 22.  Except as otherwise expressly provided in this
3647	act, this act shall take effect July 1, 2010, if HB 7223 or
3648	similar legislation is adopted in the same legislative session
3649	or an extension thereof and becomes law.

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