CS/HB 7109

1	A bill to be entitled
2	An act relating to Medicaid; amending s. 393.0661, F.S.;
3	requiring the Agency for Persons with Disabilities to
4	establish a transition plan for current Medicaid
5	recipients of home and community-based services under
6	certain circumstances; providing for expiration of the
7	section on a specified date; amending s. 393.0662, F.S.;
8	requiring the Agency for Persons with Disabilities to
9	complete the transition for current Medicaid recipients of
10	home and community-based services to the iBudget system by
11	a specified date; requiring the Agency for Persons with
12	Disabilities to develop a transition plan for current
13	Medicaid recipients of home and community-based services
14	to managed care plans; providing for expiration of the
15	section on a specified date; amending s. 408.040, F.S.;
16	providing for suspension of certain conditions precedent
17	to the issuance of a certificate of need for a nursing
18	home, effective on a specified date; amending s. 408.0435,
19	F.S.; extending the certificate-of-need moratorium for
20	additional community nursing home beds; designating ss.
21	409.016-409.803, F.S., as pt. I of ch. 409, F.S., and
22	entitling the part "Social and Economic Assistance";
23	designating ss. 409.810-409.821, F.S., as pt. II of ch.
24	409, F.S., and entitling the part "Kidcare"; designating
25	ss. 409.901-409.9205, F.S., as part III of ch. 409, F.S.,
26	and entitling the part "Medicaid"; amending s. 409.905,
27	F.S.; requiring the Agency for Health Care Administration
28	to set reimbursements rates for hospitals that provide
29	Medicaid services based on allowable-cost reporting from
30	the hospitals; providing the methodology for the rate
31	calculation and adjustments; requiring the rates to be
32	subject to certain limits or ceilings; providing that
33	exemptions to the limits or ceilings may be provided in
34	the General Appropriations Act; deleting provisions
35	relating to agency adjustments to a hospital's inpatient
36	per diem rate; directing the agency to develop a plan to
37	convert inpatient hospital rates to a prospective payment
38	system that categorizes each case into diagnosis-related
39	groups; requiring a report to the Governor and
40	Legislature; amending s. 409.907, F.S.; providing
41	additional requirements for provider agreements for
42	Medicare crossover providers; providing that the agency is
43	not obligated to enroll certain providers as Medicare
44	crossover providers; specifying additional requirements
45	for certain providers; providing the agency may establish
46	additional criteria for providers to promote program
47	integrity; amending s. 409.911, F.S.; providing for
48	expiration of the Medicaid Low-Income Pool Council;
49	amending s. 409.912, F.S.; providing payment requirements
50	for provider service networks; providing for the
51	expiration of various provisions relating to agency
52	contracts and agreements with certain entities on
53	specified dates to conform to the reorganization of
54	Medicaid managed care; requiring the agency to contract on
55	a prepaid or fixed-sum basis with certain prepaid dental
56	health plans; eliminating obsolete provisions and updating
57	provisions, to conform; amending ss. 409.91195 and
58	409.91196, F.S.; conforming cross-references; repealing s.
59	409.91207, F.S., relating to the medical home pilot
60	project; amending s. 409.91211, F.S.; conforming cross-
61	references; providing for future repeal of s. 409.91211,
62	F.S., relating to the Medicaid managed care pilot program;
63	amending s. 409.9122, F.S.; providing for the expiration
64	of provisions relating to mandatory enrollment in a
65	Medicaid managed care plan or MediPass on specified dates
66	to conform to the reorganization of Medicaid managed care;
67	eliminating obsolete provisions; requiring the agency to
68	develop a process to enable any recipient with access to
69	employer-sponsored coverage to opt out of eligible plans
70	in the Medicaid program; requiring the agency, contingent
71	on federal approval, to enable recipients with access to
72	other coverage or related products that provide access to
73	specified health care services to opt out of eligible
74	plans in the Medicaid program; requiring the agency to
75	maintain and operate the Medicaid Encounter Data System;
76	requiring the agency to conduct a review of encounter data
77	and publish the results of the review before adjusting
78	rates for prepaid plans; authorizing the agency to
79	establish a designated payment for specified Medicare
80	Advantage Special Needs members; authorizing the agency to
81	develop a designated payment for Medicaid-only covered
82	services for which the state is responsible; requiring the
83	agency to establish, and managed care plans to use, a
84	uniform method of accounting for and reporting medical and
85	nonmedical costs; authorizing the agency to create
86	exceptions to mandatory enrollment in managed care under
87	specified circumstances; requiring the agency to contract
88	with a provider service network to function as a third-
89	party administrator and managing entity for the MediPass
90	program; providing contract provisions; providing for the
91	expiration of such contract requirements on a specified
92	date; requiring the agency to contract with a single
93	provider service network to function as a third-party
94	administrator and managing entity for the Medically Needy
95	program; providing contract provisions; providing for the
96	expiration of such contract requirements on a specified
97	date; amending s. 430.04, F.S.; eliminating obsolete
98	provisions; requiring the Department of Elderly Affairs to
99	develop a transition plan for specified elders and
100	disabled adults receiving long-term care Medicaid services
101	when eligible plans become available; providing for
102	expiration of the plan; amending s. 430.2053, F.S.;
103	eliminating obsolete provisions; providing additional
104	duties of aging resource centers; providing an additional
105	exception to direct services that may not be provided by
106	an aging resource center; providing an expiration date for
107	certain services administered through aging resource
108	centers; providing for the cessation of specified payments
109	by the department as eligible plans become available;
110	providing for a memorandum of understanding between the
111	agency and aging resource centers under certain
112	circumstances; eliminating provisions requiring reports;
113	repealing s. 430.701, F.S., relating to legislative
114	findings and intent and approval for action relating to
115	provider enrollment levels; repealing s. 430.702, F.S.,
116	relating to the Long-Term Care Community Diversion Pilot
117	Project Act; repealing s. 430.703, F.S., relating to
118	definitions; repealing s. 430.7031, F.S., relating to the
119	nursing home transition program; repealing s. 430.704,
120	F.S., relating to evaluation of long-term care through the
121	pilot projects; repealing s. 430.705, F.S., relating to
122	implementation of long-term care community diversion pilot
123	projects; repealing s. 430.706, F.S., relating to quality
124	of care; repealing s. 430.707, F.S., relating to
125	contracts; repealing s. 430.708, F.S., relating to
126	certificate of need; repealing s. 430.709, F.S., relating
127	to reports and evaluations; renumbering ss. 409.9301,
128	409.942, 409.944, 409.945, 409.946, 409.953, and 409.9531,
129	F.S., as ss. 402.81, 402.82, 402.83, 402.84, 402.85,
130	402.86, and 402.87, F.S., respectively; amending ss.
131	443.111 and 641.386, F.S.; conforming cross-references;
132	directing the agency to develop a plan to implement the
133	enrollment of the medically needy into managed care;
134	amending s. 766.118, F.S.; providing a limitation on
135	noneconomic damages for negligence of practitioners
136	providing services and care to Medicaid recipients;
137	providing effective dates and a contingent effective date.
138
139	Be It Enacted by the Legislature of the State of Florida:
140
141	Section 1.  Section 393.0661, Florida Statutes, is amended
142	to read:
143	393.0661  Home and community-based services delivery
144	system; comprehensive redesign.-The Legislature finds that the
145	home and community-based services delivery system for persons
146	with developmental disabilities and the availability of
147	appropriated funds are two of the critical elements in making
148	services available. Therefore, it is the intent of the
149	Legislature that the Agency for Persons with Disabilities shall
150	develop and implement a comprehensive redesign of the system.
151	(1)  The redesign of the home and community-based services
152	system shall include, at a minimum, all actions necessary to
153	achieve an appropriate rate structure, client choice within a
154	specified service package, appropriate assessment strategies, an
155	efficient billing process that contains reconciliation and
156	monitoring components, and a redefined role for support
157	coordinators that avoids potential conflicts of interest and
158	ensures that family/client budgets are linked to levels of need.
159	(a)  The agency shall use an assessment instrument that the
160	agency deems to be reliable and valid, including, but not
161	limited to, the Department of Children and Family Services'
162	Individual Cost Guidelines or the agency's Questionnaire for
163	Situational Information. The agency may contract with an
164	external vendor or may use support coordinators to complete
165	client assessments if it develops sufficient safeguards and
166	training to ensure ongoing inter-rater reliability.
167	(b)  The agency, with the concurrence of the Agency for
168	Health Care Administration, may contract for the determination
169	of medical necessity and establishment of individual budgets.
170	(2)  A provider of services rendered to persons with
171	developmental disabilities pursuant to a federally approved
172	waiver shall be reimbursed according to a rate methodology based
173	upon an analysis of the expenditure history and prospective
174	costs of providers participating in the waiver program, or under
175	any other methodology developed by the Agency for Health Care
176	Administration, in consultation with the Agency for Persons with
177	Disabilities, and approved by the Federal Government in
178	accordance with the waiver.
179	(3)  The Agency for Health Care Administration, in
180	consultation with the agency, shall seek federal approval and
181	implement a four-tiered waiver system to serve eligible clients
182	through the developmental disabilities and family and supported
183	living waivers. The agency shall assign all clients receiving
184	services through the developmental disabilities waiver to a tier
185	based on the Department of Children and Family Services'
186	Individual Cost Guidelines, the agency's Questionnaire for
187	Situational Information, or another such assessment instrument
188	deemed to be valid and reliable by the agency; client
189	characteristics, including, but not limited to, age; and other
190	appropriate assessment methods.
191	(a)  Tier one is limited to clients who have service needs
192	that cannot be met in tier two, three, or four for intensive
193	medical or adaptive needs and that are essential for avoiding
194	institutionalization, or who possess behavioral problems that
195	are exceptional in intensity, duration, or frequency and present
196	a substantial risk of harm to themselves or others. Total annual
197	expenditures under tier one may not exceed $150,000 per client
198	each year, provided that expenditures for clients in tier one
199	with a documented medical necessity requiring intensive
200	behavioral residential habilitation services, intensive
201	behavioral residential habilitation services with medical needs,
202	or special medical home care, as provided in the Developmental
203	Disabilities Waiver Services Coverage and Limitations Handbook,
204	are not subject to the $150,000 limit on annual expenditures.
205	(b)  Tier two is limited to clients whose service needs
206	include a licensed residential facility and who are authorized
207	to receive a moderate level of support for standard residential
208	habilitation services or a minimal level of support for behavior
209	focus residential habilitation services, or clients in supported
210	living who receive more than 6 hours a day of in-home support
211	services. Total annual expenditures under tier two may not
212	exceed $53,625 per client each year.
213	(c)  Tier three includes, but is not limited to, clients
214	requiring residential placements, clients in independent or
215	supported living situations, and clients who live in their
216	family home. Total annual expenditures under tier three may not
217	exceed $34,125 per client each year.
218	(d)  Tier four includes individuals who were enrolled in
219	the family and supported living waiver on July 1, 2007, who
220	shall be assigned to this tier without the assessments required
221	by this section. Tier four also includes, but is not limited to,
222	clients in independent or supported living situations and
223	clients who live in their family home. Total annual expenditures
224	under tier four may not exceed $14,422 per client each year.
225	(e)  The Agency for Health Care Administration shall also
226	seek federal approval to provide a consumer-directed option for
227	persons with developmental disabilities which corresponds to the
228	funding levels in each of the waiver tiers. The agency shall
229	implement the four-tiered waiver system beginning with tiers
230	one, three, and four and followed by tier two. The agency and
231	the Agency for Health Care Administration may adopt rules
232	necessary to administer this subsection.
233	(f)  The agency shall seek federal waivers and amend
234	contracts as necessary to make changes to services defined in
235	federal waiver programs administered by the agency as follows:
236	1.  Supported living coaching services may not exceed 20
237	hours per month for persons who also receive in-home support
238	services.
239	2.  Limited support coordination services is the only type
240	of support coordination service that may be provided to persons
241	under the age of 18 who live in the family home.
242	3.  Personal care assistance services are limited to 180
243	hours per calendar month and may not include rate modifiers.
244	Additional hours may be authorized for persons who have
245	intensive physical, medical, or adaptive needs if such hours are
246	essential for avoiding institutionalization.
247	4.  Residential habilitation services are limited to 8
248	hours per day. Additional hours may be authorized for persons
249	who have intensive medical or adaptive needs and if such hours
250	are essential for avoiding institutionalization, or for persons
251	who possess behavioral problems that are exceptional in
252	intensity, duration, or frequency and present a substantial risk
253	of harming themselves or others. This restriction shall be in
254	effect until the four-tiered waiver system is fully implemented.
255	5.  Chore services, nonresidential support services, and
256	homemaker services are eliminated. The agency shall expand the
257	definition of in-home support services to allow the service
258	provider to include activities previously provided in these
259	eliminated services.
260	6.  Massage therapy, medication review, and psychological
261	assessment services are eliminated.
262	7.  The agency shall conduct supplemental cost plan reviews
263	to verify the medical necessity of authorized services for plans
264	that have increased by more than 8 percent during either of the
265	2 preceding fiscal years.
266	8.  The agency shall implement a consolidated residential
267	habilitation rate structure to increase savings to the state
268	through a more cost-effective payment method and establish
269	uniform rates for intensive behavioral residential habilitation
270	services.
271	9.  Pending federal approval, the agency may extend current
272	support plans for clients receiving services under Medicaid
273	waivers for 1 year beginning July 1, 2007, or from the date
274	approved, whichever is later. Clients who have a substantial
275	change in circumstances which threatens their health and safety
276	may be reassessed during this year in order to determine the
277	necessity for a change in their support plan.
278	10.  The agency shall develop a plan to eliminate
279	redundancies and duplications between in-home support services,
280	companion services, personal care services, and supported living
281	coaching by limiting or consolidating such services.
282	11.  The agency shall develop a plan to reduce the
283	intensity and frequency of supported employment services to
284	clients in stable employment situations who have a documented
285	history of at least 3 years' employment with the same company or
286	in the same industry.
287	(4)  The geographic differential for Miami-Dade, Broward,
288	and Palm Beach Counties for residential habilitation services
289	shall be 7.5 percent.
290	(5)  The geographic differential for Monroe County for
291	residential habilitation services shall be 20 percent.
292	(6)  Effective January 1, 2010, and except as otherwise
293	provided in this section, a client served by the home and
294	community-based services waiver or the family and supported
295	living waiver funded through the agency shall have his or her
296	cost plan adjusted to reflect the amount of expenditures for the
297	previous state fiscal year plus 5 percent if such amount is less
298	than the client's existing cost plan. The agency shall use
299	actual paid claims for services provided during the previous
300	fiscal year that are submitted by October 31 to calculate the
301	revised cost plan amount. If the client was not served for the
302	entire previous state fiscal year or there was any single change
303	in the cost plan amount of more than 5 percent during the
304	previous state fiscal year, the agency shall set the cost plan
305	amount at an estimated annualized expenditure amount plus 5
306	percent. The agency shall estimate the annualized expenditure
307	amount by calculating the average of monthly expenditures,
308	beginning in the fourth month after the client enrolled,
309	interrupted services are resumed, or the cost plan was changed
310	by more than 5 percent and ending on August 31, 2009, and
311	multiplying the average by 12. In order to determine whether a
312	client was not served for the entire year, the agency shall
313	include any interruption of a waiver-funded service or services
314	lasting at least 18 days. If at least 3 months of actual
315	expenditure data are not available to estimate annualized
316	expenditures, the agency may not rebase a cost plan pursuant to
317	this subsection. The agency may not rebase the cost plan of any
318	client who experiences a significant change in recipient
319	condition or circumstance which results in a change of more than
320	5 percent to his or her cost plan between July 1 and the date
321	that a rebased cost plan would take effect pursuant to this
322	subsection.
323	(7)  Nothing in this section or in any administrative rule
324	shall be construed to prevent or limit the Agency for Health
325	Care Administration, in consultation with the Agency for Persons
326	with Disabilities, from adjusting fees, reimbursement rates,
327	lengths of stay, number of visits, or number of services, or
328	from limiting enrollment, or making any other adjustment
329	necessary to comply with the availability of moneys and any
330	limitations or directions provided for in the General
331	Appropriations Act.
332	(8)  The Agency for Persons with Disabilities shall submit
333	quarterly status reports to the Executive Office of the
334	Governor, the chair of the Senate Ways and Means Committee or
335	its successor, and the chair of the House Fiscal Council or its
336	successor regarding the financial status of home and community-
337	based services, including the number of enrolled individuals who
338	are receiving services through one or more programs; the number
339	of individuals who have requested services who are not enrolled
340	but who are receiving services through one or more programs,
341	with a description indicating the programs from which the
342	individual is receiving services; the number of individuals who
343	have refused an offer of services but who choose to remain on
344	the list of individuals waiting for services; the number of
345	individuals who have requested services but who are receiving no
346	services; a frequency distribution indicating the length of time
347	individuals have been waiting for services; and information
348	concerning the actual and projected costs compared to the amount
349	of the appropriation available to the program and any projected
350	surpluses or deficits. If at any time an analysis by the agency,
351	in consultation with the Agency for Health Care Administration,
352	indicates that the cost of services is expected to exceed the
353	amount appropriated, the agency shall submit a plan in
354	accordance with subsection (7) to the Executive Office of the
355	Governor, the chair of the Senate Ways and Means Committee or
356	its successor, and the chair of the House Fiscal Council or its
357	successor to remain within the amount appropriated. The agency
358	shall work with the Agency for Health Care Administration to
359	implement the plan so as to remain within the appropriation.
360	(9)  The agency shall develop a transition plan for
361	recipients who are receiving services in one of the four waiver
362	tiers at the time eligible managed care plans are available in
363	each recipient's region as defined in s. 409.989 to enroll those
364	recipients in eligible plans.
365	(10)  This section expires October 1, 2016.
366	Section 2.  Section 393.0662, Florida Statutes, is amended
367	to read:
368	393.0662  Individual budgets for delivery of home and
369	community-based services; iBudget system established.-The
370	Legislature finds that improved financial management of the
371	existing home and community-based Medicaid waiver program is
372	necessary to avoid deficits that impede the provision of
373	services to individuals who are on the waiting list for
374	enrollment in the program. The Legislature further finds that
375	clients and their families should have greater flexibility to
376	choose the services that best allow them to live in their
377	community within the limits of an established budget. Therefore,
378	the Legislature intends that the agency, in consultation with
379	the Agency for Health Care Administration, develop and implement
380	a comprehensive redesign of the service delivery system using
381	individual budgets as the basis for allocating the funds
382	appropriated for the home and community-based services Medicaid
383	waiver program among eligible enrolled clients. The service
384	delivery system that uses individual budgets shall be called the
385	iBudget system.
386	(1)  The agency shall establish an individual budget,
387	referred to as an iBudget, for each individual served by the
388	home and community-based services Medicaid waiver program. The
389	funds appropriated to the agency shall be allocated through the
390	iBudget system to eligible, Medicaid-enrolled clients. The
391	iBudget system shall be designed to provide for: enhanced client
392	choice within a specified service package; appropriate
393	assessment strategies; an efficient consumer budgeting and
394	billing process that includes reconciliation and monitoring
395	components; a redefined role for support coordinators that
396	avoids potential conflicts of interest; a flexible and
397	streamlined service review process; and a methodology and
398	process that ensures the equitable allocation of available funds
399	to each client based on the client's level of need, as
400	determined by the variables in the allocation algorithm.
401	(a)  In developing each client's iBudget, the agency shall
402	use an allocation algorithm and methodology. The algorithm shall
403	use variables that have been determined by the agency to have a
404	statistically validated relationship to the client's level of
405	need for services provided through the home and community-based
406	services Medicaid waiver program. The algorithm and methodology
407	may consider individual characteristics, including, but not
408	limited to, a client's age and living situation, information
409	from a formal assessment instrument that the agency determines
410	is valid and reliable, and information from other assessment
411	processes.
412	(b)  The allocation methodology shall provide the algorithm
413	that determines the amount of funds allocated to a client's
414	iBudget. The agency may approve an increase in the amount of
415	funds allocated, as determined by the algorithm, based on the
416	client having one or more of the following needs that cannot be
417	accommodated within the funding as determined by the algorithm
418	and having no other resources, supports, or services available
419	to meet the need:
420	1.  An extraordinary need that would place the health and
421	safety of the client, the client's caregiver, or the public in
422	immediate, serious jeopardy unless the increase is approved. An
423	extraordinary need may include, but is not limited to:
424	a.  A documented history of significant, potentially life-
425	threatening behaviors, such as recent attempts at suicide,
426	arson, nonconsensual sexual behavior, or self-injurious behavior
427	requiring medical attention;
428	b.  A complex medical condition that requires active
429	intervention by a licensed nurse on an ongoing basis that cannot
430	be taught or delegated to a nonlicensed person;
431	c.  A chronic comorbid condition. As used in this
432	subparagraph, the term "comorbid condition" means a medical
433	condition existing simultaneously but independently with another
434	medical condition in a patient; or
435	d.  A need for total physical assistance with activities
436	such as eating, bathing, toileting, grooming, and personal
437	hygiene.
438
439	However, the presence of an extraordinary need alone does not
440	warrant an increase in the amount of funds allocated to a
441	client's iBudget as determined by the algorithm.
442	2.  A significant need for one-time or temporary support or
443	services that, if not provided, would place the health and
444	safety of the client, the client's caregiver, or the public in
445	serious jeopardy, unless the increase is approved. A significant
446	need may include, but is not limited to, the provision of
447	environmental modifications, durable medical equipment, services
448	to address the temporary loss of support from a caregiver, or
449	special services or treatment for a serious temporary condition
450	when the service or treatment is expected to ameliorate the
451	underlying condition. As used in this subparagraph, the term
452	"temporary" means a period of fewer than 12 continuous months.
453	However, the presence of such significant need for one-time or
454	temporary supports or services alone does not warrant an
455	increase in the amount of funds allocated to a client's iBudget
456	as determined by the algorithm.
457	3.  A significant increase in the need for services after
458	the beginning of the service plan year that would place the
459	health and safety of the client, the client's caregiver, or the
460	public in serious jeopardy because of substantial changes in the
461	client's circumstances, including, but not limited to, permanent
462	or long-term loss or incapacity of a caregiver, loss of services
463	authorized under the state Medicaid plan due to a change in age,
464	or a significant change in medical or functional status which
465	requires the provision of additional services on a permanent or
466	long-term basis that cannot be accommodated within the client's
467	current iBudget. As used in this subparagraph, the term "long-
468	term" means a period of 12 or more continuous months. However,
469	such significant increase in need for services of a permanent or
470	long-term nature alone does not warrant an increase in the
471	amount of funds allocated to a client's iBudget as determined by
472	the algorithm.
473
474	The agency shall reserve portions of the appropriation for the
475	home and community-based services Medicaid waiver program for
476	adjustments required pursuant to this paragraph and may use the
477	services of an independent actuary in determining the amount of
478	the portions to be reserved.
479	(c)  A client's iBudget shall be the total of the amount
480	determined by the algorithm and any additional funding provided
481	pursuant to paragraph (b). A client's annual expenditures for
482	home and community-based services Medicaid waiver services may
483	not exceed the limits of his or her iBudget. The total of all
484	clients' projected annual iBudget expenditures may not exceed
485	the agency's appropriation for waiver services.
486	(2)  The Agency for Health Care Administration, in
487	consultation with the agency, shall seek federal approval to
488	amend current waivers, request a new waiver, and amend contracts
489	as necessary to implement the iBudget system to serve eligible,
490	enrolled clients through the home and community-based services
491	Medicaid waiver program and the Consumer-Directed Care Plus
492	Program.
493	(3)  The agency shall transition all eligible, enrolled
494	clients to the iBudget system. The agency may gradually phase in
495	the iBudget system and must complete the phase in by January 1,
496	2015.
497	(a)  While the agency phases in the iBudget system, the
498	agency may continue to serve eligible, enrolled clients under
499	the four-tiered waiver system established under s. 393.065 while
500	those clients await transitioning to the iBudget system.
501	(b)  The agency shall design the phase-in process to ensure
502	that a client does not experience more than one-half of any
503	expected overall increase or decrease to his or her existing
504	annualized cost plan during the first year that the client is
505	provided an iBudget due solely to the transition to the iBudget
506	system.
507	(4)  A client must use all available services authorized
508	under the state Medicaid plan, school-based services, private
509	insurance and other benefits, and any other resources that may
510	be available to the client before using funds from his or her
511	iBudget to pay for support and services.
512	(5)  The service limitations in s. 393.0661(3)(f)1., 2.,
513	and 3. do not apply to the iBudget system.
514	(6)  Rates for any or all services established under rules
515	of the Agency for Health Care Administration shall be designated
516	as the maximum rather than a fixed amount for individuals who
517	receive an iBudget, except for services specifically identified
518	in those rules that the agency determines are not appropriate
519	for negotiation, which may include, but are not limited to,
520	residential habilitation services.
521	(7)  The agency shall ensure that clients and caregivers
522	have access to training and education to inform them about the
523	iBudget system and enhance their ability for self-direction.
524	Such training shall be offered in a variety of formats and at a
525	minimum shall address the policies and processes of the iBudget
526	system; the roles and responsibilities of consumers, caregivers,
527	waiver support coordinators, providers, and the agency;
528	information available to help the client make decisions
529	regarding the iBudget system; and examples of support and
530	resources available in the community.
531	(8)  The agency shall collect data to evaluate the
532	implementation and outcomes of the iBudget system.
533	(9)  The agency and the Agency for Health Care
534	Administration may adopt rules specifying the allocation
535	algorithm and methodology; criteria and processes for clients to
536	access reserved funds for extraordinary needs, temporarily or
537	permanently changed needs, and one-time needs; and processes and
538	requirements for selection and review of services, development
539	of support and cost plans, and management of the iBudget system
540	as needed to administer this section.
541	(10)  The agency shall develop a transition plan for
542	recipients who are receiving services through the iBudget system
543	at the time eligible managed care plans are available in each
544	recipient's region defined in s. 409.989 to enroll those
545	recipients in eligible plans.
546	(11)  This section expires October 1, 2016.
547	Section 3.  Paragraph (e) of subsection (1) of section
548	408.040, Florida Statutes, is redesignated as paragraph (d), and
549	paragraph (b) and present paragraph (d) of that subsection are
550	amended to read:
551	408.040  Conditions and monitoring.-
552	(1)
553	(b)  The agency may consider, in addition to the other
554	criteria specified in s. 408.035, a statement of intent by the
555	applicant that a specified percentage of the annual patient days
556	at the facility will be utilized by patients eligible for care
557	under Title XIX of the Social Security Act. Any certificate of
558	need issued to a nursing home in reliance upon an applicant's
559	statements that a specified percentage of annual patient days
560	will be utilized by residents eligible for care under Title XIX
561	of the Social Security Act must include a statement that such
562	certification is a condition of issuance of the certificate of
563	need. The certificate-of-need program shall notify the Medicaid
564	program office and the Department of Elderly Affairs when it
565	imposes conditions as authorized in this paragraph in an area in
566	which a community diversion pilot project is implemented.
567	Effective July 1, 2012, the agency may not consider, or impose
568	conditions or sanctions related to, patient day utilization by
569	patients eligible for care under Title XIX the Social Security
570	Act in making certificate-of-need determinations for nursing
571	homes.
572	(d)  If a nursing home is located in a county in which a
573	long-term care community diversion pilot project has been
574	implemented under s. 430.705 or in a county in which an
575	integrated, fixed-payment delivery program for Medicaid
576	recipients who are 60 years of age or older or dually eligible
577	for Medicare and Medicaid has been implemented under s.
578	409.912(5), the nursing home may request a reduction in the
579	percentage of annual patient days used by residents who are
580	eligible for care under Title XIX of the Social Security Act,
581	which is a condition of the nursing home's certificate of need.
582	The agency shall automatically grant the nursing home's request
583	if the reduction is not more than 15 percent of the nursing
584	home's annual Medicaid-patient-days condition. A nursing home
585	may submit only one request every 2 years for an automatic
586	reduction. A requesting nursing home must notify the agency in
587	writing at least 60 days in advance of its intent to reduce its
588	annual Medicaid-patient-days condition by not more than 15
589	percent. The agency must acknowledge the request in writing and
590	must change its records to reflect the revised certificate-of-
591	need condition. This paragraph expires June 30, 2011.
592	Section 4.  Subsection (1) of section 408.0435, Florida
593	Statutes, is amended to read:
594	408.0435  Moratorium on nursing home certificates of need.-
595	(1)  Notwithstanding the establishment of need as provided
596	for in this chapter, a certificate of need for additional
597	community nursing home beds may not be approved by the agency
598	until Medicaid managed care is implemented statewide pursuant to
599	ss. 409.961-409.992 or October 1, 2016, whichever is earlier
600	July 1, 2011.
601	Section 5.  Sections 409.016 through 409.803, Florida
602	Statutes, are designated as part I of chapter 409, Florida
603	Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
604	Section 6.  Sections 409.810 through 409.821, Florida
605	Statutes, are designated as part II of chapter 409, Florida
606	Statutes, and entitled "KIDCARE."
607	Section 7.  Sections 409.901 through 409.9205, Florida
608	Statutes, are designated as part III of chapter 409, Florida
609	Statutes, and entitled "MEDICAID."
610	Section 8.  Paragraph (c) of subsection (5) of section
611	409.905, Florida Statutes, is amended, and paragraph (g) is
612	added that subsection, to read:
613	409.905  Mandatory Medicaid services.-The agency may make
614	payments for the following services, which are required of the
615	state by Title XIX of the Social Security Act, furnished by
616	Medicaid providers to recipients who are determined to be
617	eligible on the dates on which the services were provided. Any
618	service under this section shall be provided only when medically
619	necessary and in accordance with state and federal law.
620	Mandatory services rendered by providers in mobile units to
621	Medicaid recipients may be restricted by the agency. Nothing in
622	this section shall be construed to prevent or limit the agency
623	from adjusting fees, reimbursement rates, lengths of stay,
624	number of visits, number of services, or any other adjustments
625	necessary to comply with the availability of moneys and any
626	limitations or directions provided for in the General
627	Appropriations Act or chapter 216.
628	(5)  HOSPITAL INPATIENT SERVICES.-The agency shall pay for
629	all covered services provided for the medical care and treatment
630	of a recipient who is admitted as an inpatient by a licensed
631	physician or dentist to a hospital licensed under part I of
632	chapter 395. However, the agency shall limit the payment for
633	inpatient hospital services for a Medicaid recipient 21 years of
634	age or older to 45 days or the number of days necessary to
635	comply with the General Appropriations Act.
636	(c)  The agency shall implement a methodology for
637	establishing base reimbursement rates for each hospital based on
638	allowable costs, as defined by the agency. Rates shall be
639	calculated annually and take effect July 1 of each year based on
640	the most recent complete and accurate cost report submitted by
641	each hospital. Adjustments may not be made to the rates after
642	September 30 of the state fiscal year in which the rate takes
643	effect. Errors in cost reporting or calculation of rates
644	discovered after September 30 must be reconciled in a subsequent
645	rate period. Cost reports must be reconciled within 5 years
646	after the end of the applicable fiscal year. Hospital rates
647	shall be subject to such limits or ceilings as may be
648	established in law or described in the agency's hospital
649	reimbursement plan. Specific exemptions to the limits or
650	ceilings may be provided in the General Appropriations Act. The
651	agency shall adjust a hospital's current inpatient per diem rate
652	to reflect the cost of serving the Medicaid population at that
653	institution if:
654	1.  The hospital experiences an increase in Medicaid
655	caseload by more than 25 percent in any year, primarily
656	resulting from the closure of a hospital in the same service
657	area occurring after July 1, 1995;
658	2.  The hospital's Medicaid per diem rate is at least 25
659	percent below the Medicaid per patient cost for that year; or
660	3.  The hospital is located in a county that has six or
661	fewer general acute care hospitals, began offering obstetrical
662	services on or after September 1999, and has submitted a request
663	in writing to the agency for a rate adjustment after July 1,
664	2000, but before September 30, 2000, in which case such
665	hospital's Medicaid inpatient per diem rate shall be adjusted to
666	cost, effective July 1, 2002.
667
668	By October 1 of each year, the agency must provide estimated
669	costs for any adjustment in a hospital inpatient per diem rate
670	to the Executive Office of the Governor, the House of
671	Representatives General Appropriations Committee, and the Senate
672	Appropriations Committee. Before the agency implements a change
673	in a hospital's inpatient per diem rate pursuant to this
674	paragraph, the Legislature must have specifically appropriated
675	sufficient funds in the General Appropriations Act to support
676	the increase in cost as estimated by the agency.
677	(g)  The agency shall develop a plan to convert inpatient
678	hospital rates to a prospective payment system that categorizes
679	each case into diagnosis-related groups (DRG) and assigns a
680	payment weight based on the average resources used to treat
681	Medicaid patients in that DRG. To the extent possible, the
682	agency shall propose an adaptation of an existing prospective
683	payment system, such as the one used by Medicare, and shall
684	propose such adjustments as are necessary for the Medicaid
685	population and to maintain budget neutrality for inpatient
686	hospital expenditures. The agency shall submit the Medicaid DRG
687	plan, identifying all steps necessary for the transition and any
688	costs associated with plan implementation, to the Governor, the
689	President of the Senate, and the Speaker of the House of
690	Representatives no later than January 1, 2013.
691	Section 9.  Paragraphs (d) and (e) of subsection (5) of
692	section 409.907, Florida Statutes, are amended to read:
693	409.907  Medicaid provider agreements.-The agency may make
694	payments for medical assistance and related services rendered to
695	Medicaid recipients only to an individual or entity who has a
696	provider agreement in effect with the agency, who is performing
697	services or supplying goods in accordance with federal, state,
698	and local law, and who agrees that no person shall, on the
699	grounds of handicap, race, color, or national origin, or for any
700	other reason, be subjected to discrimination under any program
701	or activity for which the provider receives payment from the
702	agency.
703	(5)  The agency:
704	(d)  May enroll entities as Medicare crossover-only
705	providers for payment and claims processing purposes only. The
706	provider agreement shall:
707	1.  Require that the provider be able to demonstrate to the
708	satisfaction of the agency that the provider is an eligible
709	Medicare provider and has a current provider agreement in place
710	with the Centers for Medicare and Medicaid Services.
711	2.  Require the provider to notify the agency immediately
712	in writing upon being suspended or disenrolled as a Medicare
713	provider. If the provider does not provide such notification
714	within 5 business days after suspension or disenrollment,
715	sanctions may be imposed pursuant to this chapter and the
716	provider may be required to return funds paid to the provider
717	during the period of time that the provider was suspended or
718	disenrolled as a Medicare provider.
719	3.  Require the applicant to submit an attestation, as
720	approved by the agency, that the provider meets the requirements
721	of Florida Medicaid provider enrollment criteria.
722	4.  Require the applicant to submit fingerprints as
723	required by the agency.
724	5.3.  Require that all records pertaining to health care
725	services provided to each of the provider's recipients be kept
726	for a minimum of 6 years. The agreement shall also require that
727	records and any information relating to payments claimed by the
728	provider for services under the agreement be delivered to the
729	agency or the Office of the Attorney General Medicaid Fraud
730	Control Unit when requested. If a provider does not provide such
731	records and information when requested, sanctions may be imposed
732	pursuant to this chapter.
733	6.4.  Disclose that the agreement is for the purposes of
734	paying and processing Medicare crossover claims only.
735
736	This paragraph pertains solely to Medicare crossover-only
737	providers. In order to become a standard Medicaid provider, the
738	requirements of this section and applicable rules must be met.
739	This paragraph does not create an entitlement or obligation of
740	the agency to enroll all Medicare providers that may be
741	considered a Medicare crossover-only provider in the Medicaid
742	program.
743	(e)  Providers that are required to post a surety bond as
744	part of the Medicaid enrollment process are excluded for
745	enrollment under paragraph (d) and must complete a full Medicaid
746	application. The agency may establish additional criteria to
747	promote program integrity.
748	Section 10.  Subsection (10) of section 409.911, Florida
749	Statutes, is amended to read:
750	409.911  Disproportionate share program.-Subject to
751	specific allocations established within the General
752	Appropriations Act and any limitations established pursuant to
753	chapter 216, the agency shall distribute, pursuant to this
754	section, moneys to hospitals providing a disproportionate share
755	of Medicaid or charity care services by making quarterly
756	Medicaid payments as required. Notwithstanding the provisions of
757	s. 409.915, counties are exempt from contributing toward the
758	cost of this special reimbursement for hospitals serving a
759	disproportionate share of low-income patients.
760	(10)  The Agency for Health Care Administration shall
761	create a Medicaid Low-Income Pool Council by July 1, 2006. The
762	Low-Income Pool Council shall consist of 24 members, including 2
763	members appointed by the President of the Senate, 2 members
764	appointed by the Speaker of the House of Representatives, 3
765	representatives of statutory teaching hospitals, 3
766	representatives of public hospitals, 3 representatives of
767	nonprofit hospitals, 3 representatives of for-profit hospitals,
768	2 representatives of rural hospitals, 2 representatives of units
769	of local government which contribute funding, 1 representative
770	of family practice teaching hospitals, 1 representative of
771	federally qualified health centers, 1 representative from the
772	Department of Health, and 1 nonvoting representative of the
773	Agency for Health Care Administration who shall serve as chair
774	of the council. Except for a full-time employee of a public
775	entity, an individual who qualifies as a lobbyist under s.
776	11.045 or s. 112.3215 may not serve as a member of the council.
777	Of the members appointed by the Senate President, only one shall
778	be a physician. Of the members appointed by the Speaker of the
779	House of Representatives, only one shall be a physician. The
780	physician member appointed by the Senate President and the
781	physician member appointed by the Speaker of the House of
782	Representatives must be physicians who routinely take calls in a
783	trauma center, as defined in s. 395.4001, or a hospital
784	emergency department. The council shall:
785	(a)  Make recommendations on the financing of the low-
786	income pool and the disproportionate share hospital program and
787	the distribution of their funds.
788	(b)  Advise the Agency for Health Care Administration on
789	the development of the low-income pool plan required by the
790	federal Centers for Medicare and Medicaid Services pursuant to
791	the Medicaid reform waiver.
792	(c)  Advise the Agency for Health Care Administration on
793	the distribution of hospital funds used to adjust inpatient
794	hospital rates, rebase rates, or otherwise exempt hospitals from
795	reimbursement limits as financed by intergovernmental transfers.
796	(d)  Submit its findings and recommendations to the
797	Governor and the Legislature no later than February 1 of each
798	year.
799
800	This subsection expires October 1, 2014.
801	Section 11.  Subsection (4) of section 409.91195, Florida
802	Statutes, is amended to read:
803	409.91195  Medicaid Pharmaceutical and Therapeutics
804	Committee.-There is created a Medicaid Pharmaceutical and
805	Therapeutics Committee within the agency for the purpose of
806	developing a Medicaid preferred drug list.
807	(4)  Upon recommendation of the committee, the agency shall
808	adopt a preferred drug list as described in s. 409.912(37)(39).
809	To the extent feasible, the committee shall review all drug
810	classes included on the preferred drug list every 12 months, and
811	may recommend additions to and deletions from the preferred drug
812	list, such that the preferred drug list provides for medically
813	appropriate drug therapies for Medicaid patients which achieve
814	cost savings contained in the General Appropriations Act.
815	Section 12.  Subsection (1) of section 409.91196, Florida
816	Statutes, is amended to read:
817	409.91196  Supplemental rebate agreements; public records
818	and public meetings exemption.-
819	(1)  The rebate amount, percent of rebate, manufacturer's
820	pricing, and supplemental rebate, and other trade secrets as
821	defined in s. 688.002 that the agency has identified for use in
822	negotiations, held by the Agency for Health Care Administration
823	under s. 409.912(37)(39)(a)7. are confidential and exempt from
824	s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
825	Section 13.  Section 409.912, Florida Statutes, is amended
826	to read:
827	409.912  Cost-effective purchasing of health care.-The
828	agency shall purchase goods and services for Medicaid recipients
829	in the most cost-effective manner consistent with the delivery
830	of quality medical care. To ensure that medical services are
831	effectively utilized, the agency may, in any case, require a
832	confirmation or second physician's opinion of the correct
833	diagnosis for purposes of authorizing future services under the
834	Medicaid program. This section does not restrict access to
835	emergency services or poststabilization care services as defined
836	in 42 C.F.R. part 438.114. Such confirmation or second opinion
837	shall be rendered in a manner approved by the agency. The agency
838	shall maximize the use of prepaid per capita and prepaid
839	aggregate fixed-sum basis services when appropriate and other
840	alternative service delivery and reimbursement methodologies,
841	including competitive bidding pursuant to s. 287.057, designed
842	to facilitate the cost-effective purchase of a case-managed
843	continuum of care. The agency shall also require providers to
844	minimize the exposure of recipients to the need for acute
845	inpatient, custodial, and other institutional care and the
846	inappropriate or unnecessary use of high-cost services. The
847	agency shall contract with a vendor to monitor and evaluate the
848	clinical practice patterns of providers in order to identify
849	trends that are outside the normal practice patterns of a
850	provider's professional peers or the national guidelines of a
851	provider's professional association. The vendor must be able to
852	provide information and counseling to a provider whose practice
853	patterns are outside the norms, in consultation with the agency,
854	to improve patient care and reduce inappropriate utilization.
855	The agency may mandate prior authorization, drug therapy
856	management, or disease management participation for certain
857	populations of Medicaid beneficiaries, certain drug classes, or
858	particular drugs to prevent fraud, abuse, overuse, and possible
859	dangerous drug interactions. The Pharmaceutical and Therapeutics
860	Committee shall make recommendations to the agency on drugs for
861	which prior authorization is required. The agency shall inform
862	the Pharmaceutical and Therapeutics Committee of its decisions
863	regarding drugs subject to prior authorization. The agency is
864	authorized to limit the entities it contracts with or enrolls as
865	Medicaid providers by developing a provider network through
866	provider credentialing. The agency may competitively bid single-
867	source-provider contracts if procurement of goods or services
868	results in demonstrated cost savings to the state without
869	limiting access to care. The agency may limit its network based
870	on the assessment of beneficiary access to care, provider
871	availability, provider quality standards, time and distance
872	standards for access to care, the cultural competence of the
873	provider network, demographic characteristics of Medicaid
874	beneficiaries, practice and provider-to-beneficiary standards,
875	appointment wait times, beneficiary use of services, provider
876	turnover, provider profiling, provider licensure history,
877	previous program integrity investigations and findings, peer
878	review, provider Medicaid policy and billing compliance records,
879	clinical and medical record audits, and other factors. Providers
880	are shall not be entitled to enrollment in the Medicaid provider
881	network. The agency shall determine instances in which allowing
882	Medicaid beneficiaries to purchase durable medical equipment and
883	other goods is less expensive to the Medicaid program than long-
884	term rental of the equipment or goods. The agency may establish
885	rules to facilitate purchases in lieu of long-term rentals in
886	order to protect against fraud and abuse in the Medicaid program
887	as defined in s. 409.913. The agency may seek federal waivers
888	necessary to administer these policies.
889	(1)  The agency shall work with the Department of Children
890	and Family Services to ensure access of children and families in
891	the child protection system to needed and appropriate mental
892	health and substance abuse services. This subsection expires
893	October 1, 2014.
894	(2)  The agency may enter into agreements with appropriate
895	agents of other state agencies or of any agency of the Federal
896	Government and accept such duties in respect to social welfare
897	or public aid as may be necessary to implement the provisions of
898	Title XIX of the Social Security Act and ss. 409.901-409.920.
899	This subsection expires October 1, 2016.
900	(3)  The agency may contract with health maintenance
901	organizations certified pursuant to part I of chapter 641 for
902	the provision of services to recipients. This subsection expires
903	October 1, 2014.
904	(4)  The agency may contract with:
905	(a)  An entity that provides no prepaid health care
906	services other than Medicaid services under contract with the
907	agency and which is owned and operated by a county, county
908	health department, or county-owned and operated hospital to
909	provide health care services on a prepaid or fixed-sum basis to
910	recipients, which entity may provide such prepaid services
911	either directly or through arrangements with other providers.
912	Such prepaid health care services entities must be licensed
913	under parts I and III of chapter 641. An entity recognized under
914	this paragraph which demonstrates to the satisfaction of the
915	Office of Insurance Regulation of the Financial Services
916	Commission that it is backed by the full faith and credit of the
917	county in which it is located may be exempted from s. 641.225.
918	This paragraph expires October 1, 2014.
919	(b)  An entity that is providing comprehensive behavioral
920	health care services to certain Medicaid recipients through a
921	capitated, prepaid arrangement pursuant to the federal waiver
922	provided for by s. 409.905(5). Such entity must be licensed
923	under chapter 624, chapter 636, or chapter 641, or authorized
924	under paragraph (c) or paragraph (d), and must possess the
925	clinical systems and operational competence to manage risk and
926	provide comprehensive behavioral health care to Medicaid
927	recipients. As used in this paragraph, the term "comprehensive
928	behavioral health care services" means covered mental health and
929	substance abuse treatment services that are available to
930	Medicaid recipients. The secretary of the Department of Children
931	and Family Services shall approve provisions of procurements
932	related to children in the department's care or custody before
933	enrolling such children in a prepaid behavioral health plan. Any
934	contract awarded under this paragraph must be competitively
935	procured. In developing the behavioral health care prepaid plan
936	procurement document, the agency shall ensure that the
937	procurement document requires the contractor to develop and
938	implement a plan to ensure compliance with s. 394.4574 related
939	to services provided to residents of licensed assisted living
940	facilities that hold a limited mental health license. Except as
941	provided in subparagraph 5. 8., and except in counties where the
942	Medicaid managed care pilot program is authorized pursuant to s.
943	409.91211, the agency shall seek federal approval to contract
944	with a single entity meeting these requirements to provide
945	comprehensive behavioral health care services to all Medicaid
946	recipients not enrolled in a Medicaid managed care plan
947	authorized under s. 409.91211, a provider service network
948	authorized under paragraph (d), or a Medicaid health maintenance
949	organization in an AHCA area. In an AHCA area where the Medicaid
950	managed care pilot program is authorized pursuant to s.
951	409.91211 in one or more counties, the agency may procure a
952	contract with a single entity to serve the remaining counties as
953	an AHCA area or the remaining counties may be included with an
954	adjacent AHCA area and are subject to this paragraph. Each
955	entity must offer a sufficient choice of providers in its
956	network to ensure recipient access to care and the opportunity
957	to select a provider with whom they are satisfied. The network
958	shall include all public mental health hospitals. To ensure
959	unimpaired access to behavioral health care services by Medicaid
960	recipients, all contracts issued pursuant to this paragraph must
961	require 80 percent of the capitation paid to the managed care
962	plan, including health maintenance organizations and capitated
963	provider service networks, to be expended for the provision of
964	behavioral health care services. If the managed care plan
965	expends less than 80 percent of the capitation paid for the
966	provision of behavioral health care services, the difference
967	shall be returned to the agency. The agency shall provide the
968	plan with a certification letter indicating the amount of
969	capitation paid during each calendar year for behavioral health
970	care services pursuant to this section. The agency may reimburse
971	for substance abuse treatment services on a fee-for-service
972	basis until the agency finds that adequate funds are available
973	for capitated, prepaid arrangements.
974	1.  By January 1, 2001, The agency shall modify the
975	contracts with the entities providing comprehensive inpatient
976	and outpatient mental health care services to Medicaid
977	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
978	Counties, to include substance abuse treatment services.
979	2.  By July 1, 2003, the agency and the Department of
980	Children and Family Services shall execute a written agreement
981	that requires collaboration and joint development of all policy,
982	budgets, procurement documents, contracts, and monitoring plans
983	that have an impact on the state and Medicaid community mental
984	health and targeted case management programs.
985	2.3.  Except as provided in subparagraph 5. 8., by July 1,
986	2006, the agency and the Department of Children and Family
987	Services shall contract with managed care entities in each AHCA
988	area except area 6 or arrange to provide comprehensive inpatient
989	and outpatient mental health and substance abuse services
990	through capitated prepaid arrangements to all Medicaid
991	recipients who are eligible to participate in such plans under
992	federal law and regulation. In AHCA areas where eligible
993	individuals number less than 150,000, the agency shall contract
994	with a single managed care plan to provide comprehensive
995	behavioral health services to all recipients who are not
996	enrolled in a Medicaid health maintenance organization, a
997	provider service network authorized under paragraph (d), or a
998	Medicaid capitated managed care plan authorized under s.
999	409.91211. The agency may contract with more than one
1000	comprehensive behavioral health provider to provide care to
1001	recipients who are not enrolled in a Medicaid capitated managed
1002	care plan authorized under s. 409.91211, a provider service
1003	network authorized under paragraph (d), or a Medicaid health
1004	maintenance organization in AHCA areas where the eligible
1005	population exceeds 150,000. In an AHCA area where the Medicaid
1006	managed care pilot program is authorized pursuant to s.
1007	409.91211 in one or more counties, the agency may procure a
1008	contract with a single entity to serve the remaining counties as
1009	an AHCA area or the remaining counties may be included with an
1010	adjacent AHCA area and shall be subject to this paragraph.
1011	Contracts for comprehensive behavioral health providers awarded
1012	pursuant to this section shall be competitively procured. Both
1013	for-profit and not-for-profit corporations are eligible to
1014	compete. Managed care plans contracting with the agency under
1015	subsection (3) or paragraph (d), shall provide and receive
1016	payment for the same comprehensive behavioral health benefits as
1017	provided in AHCA rules, including handbooks incorporated by
1018	reference. In AHCA area 11, the agency shall contract with at
1019	least two comprehensive behavioral health care providers to
1020	provide behavioral health care to recipients in that area who
1021	are enrolled in, or assigned to, the MediPass program. One of
1022	the behavioral health care contracts must be with the existing
1023	provider service network pilot project, as described in
1024	paragraph (d), for the purpose of demonstrating the cost-
1025	effectiveness of the provision of quality mental health services
1026	through a public hospital-operated managed care model. Payment
1027	shall be at an agreed-upon capitated rate to ensure cost
1028	savings. Of the recipients in area 11 who are assigned to
1029	MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1030	MediPass-enrolled recipients shall be assigned to the existing
1031	provider service network in area 11 for their behavioral care.
1032	4.  By October 1, 2003, the agency and the department shall
1033	submit a plan to the Governor, the President of the Senate, and
1034	the Speaker of the House of Representatives which provides for
1035	the full implementation of capitated prepaid behavioral health
1036	care in all areas of the state.
1037	a.  Implementation shall begin in 2003 in those AHCA areas
1038	of the state where the agency is able to establish sufficient
1039	capitation rates.
1040	b.  If the agency determines that the proposed capitation
1041	rate in any area is insufficient to provide appropriate
1042	services, the agency may adjust the capitation rate to ensure
1043	that care will be available. The agency and the department may
1044	use existing general revenue to address any additional required
1045	match but may not over-obligate existing funds on an annualized
1046	basis.
1047	c.  Subject to any limitations provided in the General
1048	Appropriations Act, the agency, in compliance with appropriate
1049	federal authorization, shall develop policies and procedures
1050	that allow for certification of local and state funds.
1051	3.5.  Children residing in a statewide inpatient
1052	psychiatric program, or in a Department of Juvenile Justice or a
1053	Department of Children and Family Services residential program
1054	approved as a Medicaid behavioral health overlay services
1055	provider may not be included in a behavioral health care prepaid
1056	health plan or any other Medicaid managed care plan pursuant to
1057	this paragraph.
1058	6.  In converting to a prepaid system of delivery, the
1059	agency shall in its procurement document require an entity
1060	providing only comprehensive behavioral health care services to
1061	prevent the displacement of indigent care patients by enrollees
1062	in the Medicaid prepaid health plan providing behavioral health
1063	care services from facilities receiving state funding to provide
1064	indigent behavioral health care, to facilities licensed under
1065	chapter 395 which do not receive state funding for indigent
1066	behavioral health care, or reimburse the unsubsidized facility
1067	for the cost of behavioral health care provided to the displaced
1068	indigent care patient.
1069	4.7.  Traditional community mental health providers under
1070	contract with the Department of Children and Family Services
1071	pursuant to part IV of chapter 394, child welfare providers
1072	under contract with the Department of Children and Family
1073	Services in areas 1 and 6, and inpatient mental health providers
1074	licensed pursuant to chapter 395 must be offered an opportunity
1075	to accept or decline a contract to participate in any provider
1076	network for prepaid behavioral health services.
1077	5.8.  All Medicaid-eligible children, except children in
1078	area 1 and children in Highlands County, Hardee County, Polk
1079	County, or Manatee County of area 6, that are open for child
1080	welfare services in the HomeSafeNet system, shall receive their
1081	behavioral health care services through a specialty prepaid plan
1082	operated by community-based lead agencies through a single
1083	agency or formal agreements among several agencies. The
1084	specialty prepaid plan must result in savings to the state
1085	comparable to savings achieved in other Medicaid managed care
1086	and prepaid programs. Such plan must provide mechanisms to
1087	maximize state and local revenues. The specialty prepaid plan
1088	shall be developed by the agency and the Department of Children
1089	and Family Services. The agency may seek federal waivers to
1090	implement this initiative. Medicaid-eligible children whose
1091	cases are open for child welfare services in the HomeSafeNet
1092	system and who reside in AHCA area 10 are exempt from the
1093	specialty prepaid plan upon the development of a service
1094	delivery mechanism for children who reside in area 10 as
1095	specified in s. 409.91211(3)(dd).
1096
1097	This paragraph expires October 1, 2014.
1098	(c)  A federally qualified health center or an entity owned
1099	by one or more federally qualified health centers or an entity
1100	owned by other migrant and community health centers receiving
1101	non-Medicaid financial support from the Federal Government to
1102	provide health care services on a prepaid or fixed-sum basis to
1103	recipients. A federally qualified health center or an entity
1104	that is owned by one or more federally qualified health centers
1105	and is reimbursed by the agency on a prepaid basis is exempt
1106	from parts I and III of chapter 641, but must comply with the
1107	solvency requirements in s. 641.2261(2) and meet the appropriate
1108	requirements governing financial reserve, quality assurance, and
1109	patients' rights established by the agency. This paragraph
1110	expires October 1, 2014.
1111	(d)1.  A provider service network may be reimbursed on a
1112	fee-for-service or prepaid basis. Prepaid provider service
1113	networks shall receive per-member, per-month payments. A
1114	provider service network that does not choose to be a prepaid
1115	plan shall receive fee-for-service rates with a shared savings
1116	settlement. The fee-for-service option shall be available to a
1117	provider service network only for the first 5 years of the
1118	plan's operation or until the contract year beginning October 1,
1119	2014, whichever is later. The agency shall annually conduct cost
1120	reconciliations to determine the amount of cost savings achieved
1121	by fee-for-service provider service networks for the dates of
1122	service in the period being reconciled. Only payments for
1123	covered services for dates of service within the reconciliation
1124	period and paid within 6 months after the last date of service
1125	in the reconciliation period shall be included. The agency shall
1126	perform the necessary adjustments for the inclusion of claims
1127	incurred but not reported within the reconciliation for claims
1128	that could be received and paid by the agency after the 6-month
1129	claims processing time lag. The agency shall provide the results
1130	of the reconciliations to the fee-for-service provider service
1131	networks within 45 days after the end of the reconciliation
1132	period. The fee-for-service provider service networks shall
1133	review and provide written comments or a letter of concurrence
1134	to the agency within 45 days after receipt of the reconciliation
1135	results. This reconciliation shall be considered final.
1136	2.  A provider service network which is reimbursed by the
1137	agency on a prepaid basis shall be exempt from parts I and III
1138	of chapter 641, but must comply with the solvency requirements
1139	in s. 641.2261(2) and meet appropriate financial reserve,
1140	quality assurance, and patient rights requirements as
1141	established by the agency.
1142	3.  Medicaid recipients assigned to a provider service
1143	network shall be chosen equally from those who would otherwise
1144	have been assigned to prepaid plans and MediPass. The agency is
1145	authorized to seek federal Medicaid waivers as necessary to
1146	implement the provisions of this section. This subparagraph
1147	expires October 1, 2014. Any contract previously awarded to a
1148	provider service network operated by a hospital pursuant to this
1149	subsection shall remain in effect for a period of 3 years
1150	following the current contract expiration date, regardless of
1151	any contractual provisions to the contrary.
1152	4.  A provider service network is a network established or
1153	organized and operated by a health care provider, or group of
1154	affiliated health care providers, including minority physician
1155	networks and emergency room diversion programs that meet the
1156	requirements of s. 409.91211, which provides a substantial
1157	proportion of the health care items and services under a
1158	contract directly through the provider or affiliated group of
1159	providers and may make arrangements with physicians or other
1160	health care professionals, health care institutions, or any
1161	combination of such individuals or institutions to assume all or
1162	part of the financial risk on a prospective basis for the
1163	provision of basic health services by the physicians, by other
1164	health professionals, or through the institutions. The health
1165	care providers must have a controlling interest in the governing
1166	body of the provider service network organization.
1167	(e)  An entity that provides only comprehensive behavioral
1168	health care services to certain Medicaid recipients through an
1169	administrative services organization agreement. Such an entity
1170	must possess the clinical systems and operational competence to
1171	provide comprehensive health care to Medicaid recipients. As
1172	used in this paragraph, the term "comprehensive behavioral
1173	health care services" means covered mental health and substance
1174	abuse treatment services that are available to Medicaid
1175	recipients. Any contract awarded under this paragraph must be
1176	competitively procured. The agency must ensure that Medicaid
1177	recipients have available the choice of at least two managed
1178	care plans for their behavioral health care services. This
1179	paragraph expires October 1, 2014.
1180	(f)  An entity that provides in-home physician services to
1181	test the cost-effectiveness of enhanced home-based medical care
1182	to Medicaid recipients with degenerative neurological diseases
1183	and other diseases or disabling conditions associated with high
1184	costs to Medicaid. The program shall be designed to serve very
1185	disabled persons and to reduce Medicaid reimbursed costs for
1186	inpatient, outpatient, and emergency department services. The
1187	agency shall contract with vendors on a risk-sharing basis.
1188	(g)  Children's provider networks that provide care
1189	coordination and care management for Medicaid-eligible pediatric
1190	patients, primary care, authorization of specialty care, and
1191	other urgent and emergency care through organized providers
1192	designed to service Medicaid eligibles under age 18 and
1193	pediatric emergency departments' diversion programs. The
1194	networks shall provide after-hour operations, including evening
1195	and weekend hours, to promote, when appropriate, the use of the
1196	children's networks rather than hospital emergency departments.
1197	(f)(h)  An entity authorized in s. 430.205 to contract with
1198	the agency and the Department of Elderly Affairs to provide
1199	health care and social services on a prepaid or fixed-sum basis
1200	to elderly recipients. Such prepaid health care services
1201	entities are exempt from the provisions of part I of chapter 641
1202	for the first 3 years of operation. An entity recognized under
1203	this paragraph that demonstrates to the satisfaction of the
1204	Office of Insurance Regulation that it is backed by the full
1205	faith and credit of one or more counties in which it operates
1206	may be exempted from s. 641.225. This paragraph expires October
1207	1, 2013.
1208	(g)(i)  A Children's Medical Services Network, as defined
1209	in s. 391.021. This paragraph expires October 1, 2014.
1210	(5)  The Agency for Health Care Administration, in
1211	partnership with the Department of Elderly Affairs, shall create
1212	an integrated, fixed-payment delivery program for Medicaid
1213	recipients who are 60 years of age or older or dually eligible
1214	for Medicare and Medicaid. The Agency for Health Care
1215	Administration shall implement the integrated program initially
1216	on a pilot basis in two areas of the state. The pilot areas
1217	shall be Area 7 and Area 11 of the Agency for Health Care
1218	Administration. Enrollment in the pilot areas shall be on a
1219	voluntary basis and in accordance with approved federal waivers
1220	and this section. The agency and its program contractors and
1221	providers shall not enroll any individual in the integrated
1222	program because the individual or the person legally responsible
1223	for the individual fails to choose to enroll in the integrated
1224	program. Enrollment in the integrated program shall be
1225	exclusively by affirmative choice of the eligible individual or
1226	by the person legally responsible for the individual. The
1227	integrated program must transfer all Medicaid services for
1228	eligible elderly individuals who choose to participate into an
1229	integrated-care management model designed to serve Medicaid
1230	recipients in the community. The integrated program must combine
1231	all funding for Medicaid services provided to individuals who
1232	are 60 years of age or older or dually eligible for Medicare and
1233	Medicaid into the integrated program, including funds for
1234	Medicaid home and community-based waiver services; all Medicaid
1235	services authorized in ss. 409.905 and 409.906, excluding funds
1236	for Medicaid nursing home services unless the agency is able to
1237	demonstrate how the integration of the funds will improve
1238	coordinated care for these services in a less costly manner; and
1239	Medicare coinsurance and deductibles for persons dually eligible
1240	for Medicaid and Medicare as prescribed in s. 409.908(13).
1241	(a)  Individuals who are 60 years of age or older or dually
1242	eligible for Medicare and Medicaid and enrolled in the
1243	developmental disabilities waiver program, the family and
1244	supported-living waiver program, the project AIDS care waiver
1245	program, the traumatic brain injury and spinal cord injury
1246	waiver program, the consumer-directed care waiver program, and
1247	the program of all-inclusive care for the elderly program, and
1248	residents of institutional care facilities for the
1249	developmentally disabled, must be excluded from the integrated
1250	program.
1251	(b)  Managed care entities who meet or exceed the agency's
1252	minimum standards are eligible to operate the integrated
1253	program. Entities eligible to participate include managed care
1254	organizations licensed under chapter 641, including entities
1255	eligible to participate in the nursing home diversion program,
1256	other qualified providers as defined in s. 430.703(7), community
1257	care for the elderly lead agencies, and other state-certified
1258	community service networks that meet comparable standards as
1259	defined by the agency, in consultation with the Department of
1260	Elderly Affairs and the Office of Insurance Regulation, to be
1261	financially solvent and able to take on financial risk for
1262	managed care. Community service networks that are certified
1263	pursuant to the comparable standards defined by the agency are
1264	not required to be licensed under chapter 641. Managed care
1265	entities who operate the integrated program shall be subject to
1266	s. 408.7056. Eligible entities shall choose to serve enrollees
1267	who are dually eligible for Medicare and Medicaid, enrollees who
1268	are 60 years of age or older, or both.
1269	(c)  The agency must ensure that the capitation-rate-
1270	setting methodology for the integrated program is actuarially
1271	sound and reflects the intent to provide quality care in the
1272	least restrictive setting. The agency must also require
1273	integrated-program providers to develop a credentialing system
1274	for service providers and to contract with all Gold Seal nursing
1275	homes, where feasible, and exclude, where feasible, chronically
1276	poor-performing facilities and providers as defined by the
1277	agency. The integrated program must develop and maintain an
1278	informal provider grievance system that addresses provider
1279	payment and contract problems. The agency shall also establish a
1280	formal grievance system to address those issues that were not
1281	resolved through the informal grievance system. The integrated
1282	program must provide that if the recipient resides in a
1283	noncontracted residential facility licensed under chapter 400 or
1284	chapter 429 at the time of enrollment in the integrated program,
1285	the recipient must be permitted to continue to reside in the
1286	noncontracted facility as long as the recipient desires. The
1287	integrated program must also provide that, in the absence of a
1288	contract between the integrated-program provider and the
1289	residential facility licensed under chapter 400 or chapter 429,
1290	current Medicaid rates must prevail. The integrated-program
1291	provider must ensure that electronic nursing home claims that
1292	contain sufficient information for processing are paid within 10
1293	business days after receipt. Alternately, the integrated-program
1294	provider may establish a capitated payment mechanism to
1295	prospectively pay nursing homes at the beginning of each month.
1296	The agency and the Department of Elderly Affairs must jointly
1297	develop procedures to manage the services provided through the
1298	integrated program in order to ensure quality and recipient
1299	choice.
1300	(d)  The Office of Program Policy Analysis and Government
1301	Accountability, in consultation with the Auditor General, shall
1302	comprehensively evaluate the pilot project for the integrated,
1303	fixed-payment delivery program for Medicaid recipients created
1304	under this subsection. The evaluation shall begin as soon as
1305	Medicaid recipients are enrolled in the managed care pilot
1306	program plans and shall continue for 24 months thereafter. The
1307	evaluation must include assessments of each managed care plan in
1308	the integrated program with regard to cost savings; consumer
1309	education, choice, and access to services; coordination of care;
1310	and quality of care. The evaluation must describe administrative
1311	or legal barriers to the implementation and operation of the
1312	pilot program and include recommendations regarding statewide
1313	expansion of the pilot program. The office shall submit its
1314	evaluation report to the Governor, the President of the Senate,
1315	and the Speaker of the House of Representatives no later than
1316	December 31, 2009.
1317	(e)  The agency may seek federal waivers or Medicaid state
1318	plan amendments and adopt rules as necessary to administer the
1319	integrated program. The agency may implement the approved
1320	federal waivers and other provisions as specified in this
1321	subsection.
1322	(f)  The implementation of the integrated, fixed-payment
1323	delivery program created under this subsection is subject to an
1324	appropriation in the General Appropriations Act.
1325	(5)(6)  The agency may contract with any public or private
1326	entity otherwise authorized by this section on a prepaid or
1327	fixed-sum basis for the provision of health care services to
1328	recipients. An entity may provide prepaid services to
1329	recipients, either directly or through arrangements with other
1330	entities, if each entity involved in providing services:
1331	(a)  Is organized primarily for the purpose of providing
1332	health care or other services of the type regularly offered to
1333	Medicaid recipients;
1334	(b)  Ensures that services meet the standards set by the
1335	agency for quality, appropriateness, and timeliness;
1336	(c)  Makes provisions satisfactory to the agency for
1337	insolvency protection and ensures that neither enrolled Medicaid
1338	recipients nor the agency will be liable for the debts of the
1339	entity;
1340	(d)  Submits to the agency, if a private entity, a
1341	financial plan that the agency finds to be fiscally sound and
1342	that provides for working capital in the form of cash or
1343	equivalent liquid assets excluding revenues from Medicaid
1344	premium payments equal to at least the first 3 months of
1345	operating expenses or $200,000, whichever is greater;
1346	(e)  Furnishes evidence satisfactory to the agency of
1347	adequate liability insurance coverage or an adequate plan of
1348	self-insurance to respond to claims for injuries arising out of
1349	the furnishing of health care;
1350	(f)  Provides, through contract or otherwise, for periodic
1351	review of its medical facilities and services, as required by
1352	the agency; and
1353	(g)  Provides organizational, operational, financial, and
1354	other information required by the agency.
1355
1356	This subsection expires October 1, 2014.
1357	(6)(7)  The agency may contract on a prepaid or fixed-sum
1358	basis with any health insurer that:
1359	(a)  Pays for health care services provided to enrolled
1360	Medicaid recipients in exchange for a premium payment paid by
1361	the agency;
1362	(b)  Assumes the underwriting risk; and
1363	(c)  Is organized and licensed under applicable provisions
1364	of the Florida Insurance Code and is currently in good standing
1365	with the Office of Insurance Regulation.
1366
1367	This subsection expires October 1, 2014.
1368	(7)(8)(a)  The agency may contract on a prepaid or fixed-
1369	sum basis with an exclusive provider organization to provide
1370	health care services to Medicaid recipients provided that the
1371	exclusive provider organization meets applicable managed care
1372	plan requirements in this section, ss. 409.9122, 409.9123,
1373	409.9128, and 627.6472, and other applicable provisions of law.
1374	This subsection expires October 1, 2014.
1375	(b)  For a period of no longer than 24 months after the
1376	effective date of this paragraph, when a member of an exclusive
1377	provider organization that is contracted by the agency to
1378	provide health care services to Medicaid recipients in rural
1379	areas without a health maintenance organization obtains services
1380	from a provider that participates in the Medicaid program in
1381	this state, the provider shall be paid in accordance with the
1382	appropriate fee schedule for services provided to eligible
1383	Medicaid recipients. The agency may seek waiver authority to
1384	implement this paragraph.
1385	(8)(9)  The Agency for Health Care Administration may
1386	provide cost-effective purchasing of chiropractic services on a
1387	fee-for-service basis to Medicaid recipients through
1388	arrangements with a statewide chiropractic preferred provider
1389	organization incorporated in this state as a not-for-profit
1390	corporation. The agency shall ensure that the benefit limits and
1391	prior authorization requirements in the current Medicaid program
1392	shall apply to the services provided by the chiropractic
1393	preferred provider organization. This subsection expires October
1394	1, 2014.
1395	(9)(10)  The agency shall not contract on a prepaid or
1396	fixed-sum basis for Medicaid services with an entity which knows
1397	or reasonably should know that any officer, director, agent,
1398	managing employee, or owner of stock or beneficial interest in
1399	excess of 5 percent common or preferred stock, or the entity
1400	itself, has been found guilty of, regardless of adjudication, or
1401	entered a plea of nolo contendere, or guilty, to:
1402	(a)  Fraud;
1403	(b)  Violation of federal or state antitrust statutes,
1404	including those proscribing price fixing between competitors and
1405	the allocation of customers among competitors;
1406	(c)  Commission of a felony involving embezzlement, theft,
1407	forgery, income tax evasion, bribery, falsification or
1408	destruction of records, making false statements, receiving
1409	stolen property, making false claims, or obstruction of justice;
1410	or
1411	(d)  Any crime in any jurisdiction which directly relates
1412	to the provision of health services on a prepaid or fixed-sum
1413	basis.
1414
1415	This subsection expires October 1, 2014.
1416	(10)(11)  The agency, after notifying the Legislature, may
1417	apply for waivers of applicable federal laws and regulations as
1418	necessary to implement more appropriate systems of health care
1419	for Medicaid recipients and reduce the cost of the Medicaid
1420	program to the state and federal governments and shall implement
1421	such programs, after legislative approval, within a reasonable
1422	period of time after federal approval. These programs must be
1423	designed primarily to reduce the need for inpatient care,
1424	custodial care and other long-term or institutional care, and
1425	other high-cost services. Prior to seeking legislative approval
1426	of such a waiver as authorized by this subsection, the agency
1427	shall provide notice and an opportunity for public comment.
1428	Notice shall be provided to all persons who have made requests
1429	of the agency for advance notice and shall be published in the
1430	Florida Administrative Weekly not less than 28 days prior to the
1431	intended action. This subsection expires October 1, 2016.
1432	(11)(12)  The agency shall establish a postpayment
1433	utilization control program designed to identify recipients who
1434	may inappropriately overuse or underuse Medicaid services and
1435	shall provide methods to correct such misuse. This subsection
1436	expires October 1, 2014.
1437	(12)(13)  The agency shall develop and provide coordinated
1438	systems of care for Medicaid recipients and may contract with
1439	public or private entities to develop and administer such
1440	systems of care among public and private health care providers
1441	in a given geographic area. This subsection expires October 1,
1442	2014.
1443	(13)(14)(a)  The agency shall operate or contract for the
1444	operation of utilization management and incentive systems
1445	designed to encourage cost-effective use of services and to
1446	eliminate services that are medically unnecessary. The agency
1447	shall track Medicaid provider prescription and billing patterns
1448	and evaluate them against Medicaid medical necessity criteria
1449	and coverage and limitation guidelines adopted by rule. Medical
1450	necessity determination requires that service be consistent with
1451	symptoms or confirmed diagnosis of illness or injury under
1452	treatment and not in excess of the patient's needs. The agency
1453	shall conduct reviews of provider exceptions to peer group norms
1454	and shall, using statistical methodologies, provider profiling,
1455	and analysis of billing patterns, detect and investigate
1456	abnormal or unusual increases in billing or payment of claims
1457	for Medicaid services and medically unnecessary provision of
1458	services. Providers that demonstrate a pattern of submitting
1459	claims for medically unnecessary services shall be referred to
1460	the Medicaid program integrity unit for investigation. In its
1461	annual report, required in s. 409.913, the agency shall report
1462	on its efforts to control overutilization as described in this
1463	subsection paragraph. This subsection expires October 1, 2014.
1464	(b)  The agency shall develop a procedure for determining
1465	whether health care providers and service vendors can provide
1466	the Medicaid program using a business case that demonstrates
1467	whether a particular good or service can offset the cost of
1468	providing the good or service in an alternative setting or
1469	through other means and therefore should receive a higher
1470	reimbursement. The business case must include, but need not be
1471	limited to:
1472	1.  A detailed description of the good or service to be
1473	provided, a description and analysis of the agency's current
1474	performance of the service, and a rationale documenting how
1475	providing the service in an alternative setting would be in the
1476	best interest of the state, the agency, and its clients.
1477	2.  A cost-benefit analysis documenting the estimated
1478	specific direct and indirect costs, savings, performance
1479	improvements, risks, and qualitative and quantitative benefits
1480	involved in or resulting from providing the service. The cost-
1481	benefit analysis must include a detailed plan and timeline
1482	identifying all actions that must be implemented to realize
1483	expected benefits. The Secretary of Health Care Administration
1484	shall verify that all costs, savings, and benefits are valid and
1485	achievable.
1486	(c)  If the agency determines that the increased
1487	reimbursement is cost-effective, the agency shall recommend a
1488	change in the reimbursement schedule for that particular good or
1489	service. If, within 12 months after implementing any rate change
1490	under this procedure, the agency determines that costs were not
1491	offset by the increased reimbursement schedule, the agency may
1492	revert to the former reimbursement schedule for the particular
1493	good or service.
1494	(14)(15)(a)  The agency shall operate the Comprehensive
1495	Assessment and Review for Long-Term Care Services (CARES)
1496	nursing facility preadmission screening program to ensure that
1497	Medicaid payment for nursing facility care is made only for
1498	individuals whose conditions require such care and to ensure
1499	that long-term care services are provided in the setting most
1500	appropriate to the needs of the person and in the most
1501	economical manner possible. The CARES program shall also ensure
1502	that individuals participating in Medicaid home and community-
1503	based waiver programs meet criteria for those programs,
1504	consistent with approved federal waivers.
1505	(b)  The agency shall operate the CARES program through an
1506	interagency agreement with the Department of Elderly Affairs.
1507	The agency, in consultation with the Department of Elderly
1508	Affairs, may contract for any function or activity of the CARES
1509	program, including any function or activity required by 42
1510	C.F.R. part 483.20, relating to preadmission screening and
1511	resident review.
1512	(c)  Prior to making payment for nursing facility services
1513	for a Medicaid recipient, the agency must verify that the
1514	nursing facility preadmission screening program has determined
1515	that the individual requires nursing facility care and that the
1516	individual cannot be safely served in community-based programs.
1517	The nursing facility preadmission screening program shall refer
1518	a Medicaid recipient to a community-based program if the
1519	individual could be safely served at a lower cost and the
1520	recipient chooses to participate in such program. For
1521	individuals whose nursing home stay is initially funded by
1522	Medicare and Medicare coverage is being terminated for lack of
1523	progress towards rehabilitation, CARES staff shall consult with
1524	the person making the determination of progress toward
1525	rehabilitation to ensure that the recipient is not being
1526	inappropriately disqualified from Medicare coverage. If, in
1527	their professional judgment, CARES staff believes that a
1528	Medicare beneficiary is still making progress toward
1529	rehabilitation, they may assist the Medicare beneficiary with an
1530	appeal of the disqualification from Medicare coverage. The use
1531	of CARES teams to review Medicare denials for coverage under
1532	this section is authorized only if it is determined that such
1533	reviews qualify for federal matching funds through Medicaid. The
1534	agency shall seek or amend federal waivers as necessary to
1535	implement this section.
1536	(d)  For the purpose of initiating immediate prescreening
1537	and diversion assistance for individuals residing in nursing
1538	homes and in order to make families aware of alternative long-
1539	term care resources so that they may choose a more cost-
1540	effective setting for long-term placement, CARES staff shall
1541	conduct an assessment and review of a sample of individuals
1542	whose nursing home stay is expected to exceed 20 days,
1543	regardless of the initial funding source for the nursing home
1544	placement. CARES staff shall provide counseling and referral
1545	services to these individuals regarding choosing appropriate
1546	long-term care alternatives. This paragraph does not apply to
1547	continuing care facilities licensed under chapter 651 or to
1548	retirement communities that provide a combination of nursing
1549	home, independent living, and other long-term care services.
1550	(e)  By January 15 of each year, the agency shall submit a
1551	report to the Legislature describing the operations of the CARES
1552	program. The report must describe:
1553	1.  Rate of diversion to community alternative programs;
1554	2.  CARES program staffing needs to achieve additional
1555	diversions;
1556	3.  Reasons the program is unable to place individuals in
1557	less restrictive settings when such individuals desired such
1558	services and could have been served in such settings;
1559	4.  Barriers to appropriate placement, including barriers
1560	due to policies or operations of other agencies or state-funded
1561	programs; and
1562	5.  Statutory changes necessary to ensure that individuals
1563	in need of long-term care services receive care in the least
1564	restrictive environment.
1565	(f)  The Department of Elderly Affairs shall track
1566	individuals over time who are assessed under the CARES program
1567	and who are diverted from nursing home placement. By January 15
1568	of each year, the department shall submit to the Legislature a
1569	longitudinal study of the individuals who are diverted from
1570	nursing home placement. The study must include:
1571	1.  The demographic characteristics of the individuals
1572	assessed and diverted from nursing home placement, including,
1573	but not limited to, age, race, gender, frailty, caregiver
1574	status, living arrangements, and geographic location;
1575	2.  A summary of community services provided to individuals
1576	for 1 year after assessment and diversion;
1577	3.  A summary of inpatient hospital admissions for
1578	individuals who have been diverted; and
1579	4.  A summary of the length of time between diversion and
1580	subsequent entry into a nursing home or death.
1581
1582	This subsection expires October 1, 2013.
1583	(15)(16)(a)  The agency shall identify health care
1584	utilization and price patterns within the Medicaid program which
1585	are not cost-effective or medically appropriate and assess the
1586	effectiveness of new or alternate methods of providing and
1587	monitoring service, and may implement such methods as it
1588	considers appropriate. Such methods may include disease
1589	management initiatives, an integrated and systematic approach
1590	for managing the health care needs of recipients who are at risk
1591	of or diagnosed with a specific disease by using best practices,
1592	prevention strategies, clinical-practice improvement, clinical
1593	interventions and protocols, outcomes research, information
1594	technology, and other tools and resources to reduce overall
1595	costs and improve measurable outcomes.
1596	(b)  The responsibility of the agency under this subsection
1597	shall include the development of capabilities to identify actual
1598	and optimal practice patterns; patient and provider educational
1599	initiatives; methods for determining patient compliance with
1600	prescribed treatments; fraud, waste, and abuse prevention and
1601	detection programs; and beneficiary case management programs.
1602	1.  The practice pattern identification program shall
1603	evaluate practitioner prescribing patterns based on national and
1604	regional practice guidelines, comparing practitioners to their
1605	peer groups. The agency and its Drug Utilization Review Board
1606	shall consult with the Department of Health and a panel of
1607	practicing health care professionals consisting of the
1608	following: the Speaker of the House of Representatives and the
1609	President of the Senate shall each appoint three physicians
1610	licensed under chapter 458 or chapter 459; and the Governor
1611	shall appoint two pharmacists licensed under chapter 465 and one
1612	dentist licensed under chapter 466 who is an oral surgeon. Terms
1613	of the panel members shall expire at the discretion of the
1614	appointing official. The advisory panel shall be responsible for
1615	evaluating treatment guidelines and recommending ways to
1616	incorporate their use in the practice pattern identification
1617	program. Practitioners who are prescribing inappropriately or
1618	inefficiently, as determined by the agency, may have their
1619	prescribing of certain drugs subject to prior authorization or
1620	may be terminated from all participation in the Medicaid
1621	program.
1622	2.  The agency shall also develop educational interventions
1623	designed to promote the proper use of medications by providers
1624	and beneficiaries.
1625	3.  The agency shall implement a pharmacy fraud, waste, and
1626	abuse initiative that may include a surety bond or letter of
1627	credit requirement for participating pharmacies, enhanced
1628	provider auditing practices, the use of additional fraud and
1629	abuse software, recipient management programs for beneficiaries
1630	inappropriately using their benefits, and other steps that will
1631	eliminate provider and recipient fraud, waste, and abuse. The
1632	initiative shall address enforcement efforts to reduce the
1633	number and use of counterfeit prescriptions.
1634	4.  By September 30, 2002, the agency shall contract with
1635	an entity in the state to implement a wireless handheld clinical
1636	pharmacology drug information database for practitioners. The
1637	initiative shall be designed to enhance the agency's efforts to
1638	reduce fraud, abuse, and errors in the prescription drug benefit
1639	program and to otherwise further the intent of this paragraph.
1640	5.  By April 1, 2006, the agency shall contract with an
1641	entity to design a database of clinical utilization information
1642	or electronic medical records for Medicaid providers. This
1643	system must be web-based and allow providers to review on a
1644	real-time basis the utilization of Medicaid services, including,
1645	but not limited to, physician office visits, inpatient and
1646	outpatient hospitalizations, laboratory and pathology services,
1647	radiological and other imaging services, dental care, and
1648	patterns of dispensing prescription drugs in order to coordinate
1649	care and identify potential fraud and abuse.
1650	6.  The agency may apply for any federal waivers needed to
1651	administer this paragraph.
1652
1653	This subsection expires October 1, 2014.
1654	(16)(17)  An entity contracting on a prepaid or fixed-sum
1655	basis shall meet the surplus requirements of s. 641.225. If an
1656	entity's surplus falls below an amount equal to the surplus
1657	requirements of s. 641.225, the agency shall prohibit the entity
1658	from engaging in marketing and preenrollment activities, shall
1659	cease to process new enrollments, and may not renew the entity's
1660	contract until the required balance is achieved. The
1661	requirements of this subsection do not apply:
1662	(a)  Where a public entity agrees to fund any deficit
1663	incurred by the contracting entity; or
1664	(b)  Where the entity's performance and obligations are
1665	guaranteed in writing by a guaranteeing organization which:
1666	1.  Has been in operation for at least 5 years and has
1667	assets in excess of $50 million; or
1668	2.  Submits a written guarantee acceptable to the agency
1669	which is irrevocable during the term of the contracting entity's
1670	contract with the agency and, upon termination of the contract,
1671	until the agency receives proof of satisfaction of all
1672	outstanding obligations incurred under the contract.
1673
1674	This subsection expires October 1, 2014.
1675	(17)(18)(a)  The agency may require an entity contracting
1676	on a prepaid or fixed-sum basis to establish a restricted
1677	insolvency protection account with a federally guaranteed
1678	financial institution licensed to do business in this state. The
1679	entity shall deposit into that account 5 percent of the
1680	capitation payments made by the agency each month until a
1681	maximum total of 2 percent of the total current contract amount
1682	is reached. The restricted insolvency protection account may be
1683	drawn upon with the authorized signatures of two persons
1684	designated by the entity and two representatives of the agency.
1685	If the agency finds that the entity is insolvent, the agency may
1686	draw upon the account solely with the two authorized signatures
1687	of representatives of the agency, and the funds may be disbursed
1688	to meet financial obligations incurred by the entity under the
1689	prepaid contract. If the contract is terminated, expired, or not
1690	continued, the account balance must be released by the agency to
1691	the entity upon receipt of proof of satisfaction of all
1692	outstanding obligations incurred under this contract.
1693	(b)  The agency may waive the insolvency protection account
1694	requirement in writing when evidence is on file with the agency
1695	of adequate insolvency insurance and reinsurance that will
1696	protect enrollees if the entity becomes unable to meet its
1697	obligations.
1698
1699	This subsection expires October 1, 2014.
1700	(18)(19)  An entity that contracts with the agency on a
1701	prepaid or fixed-sum basis for the provision of Medicaid
1702	services shall reimburse any hospital or physician that is
1703	outside the entity's authorized geographic service area as
1704	specified in its contract with the agency, and that provides
1705	services authorized by the entity to its members, at a rate
1706	negotiated with the hospital or physician for the provision of
1707	services or according to the lesser of the following:
1708	(a)  The usual and customary charges made to the general
1709	public by the hospital or physician; or
1710	(b)  The Florida Medicaid reimbursement rate established
1711	for the hospital or physician.
1712
1713	This subsection expires October 1, 2014.
1714	(19)(20)  When a merger or acquisition of a Medicaid
1715	prepaid contractor has been approved by the Office of Insurance
1716	Regulation pursuant to s. 628.4615, the agency shall approve the
1717	assignment or transfer of the appropriate Medicaid prepaid
1718	contract upon request of the surviving entity of the merger or
1719	acquisition if the contractor and the other entity have been in
1720	good standing with the agency for the most recent 12-month
1721	period, unless the agency determines that the assignment or
1722	transfer would be detrimental to the Medicaid recipients or the
1723	Medicaid program. To be in good standing, an entity must not
1724	have failed accreditation or committed any material violation of
1725	the requirements of s. 641.52 and must meet the Medicaid
1726	contract requirements. For purposes of this section, a merger or
1727	acquisition means a change in controlling interest of an entity,
1728	including an asset or stock purchase. This subsection expires
1729	October 1, 2014.
1730	(20)(21)  Any entity contracting with the agency pursuant
1731	to this section to provide health care services to Medicaid
1732	recipients is prohibited from engaging in any of the following
1733	practices or activities:
1734	(a)  Practices that are discriminatory, including, but not
1735	limited to, attempts to discourage participation on the basis of
1736	actual or perceived health status.
1737	(b)  Activities that could mislead or confuse recipients,
1738	or misrepresent the organization, its marketing representatives,
1739	or the agency. Violations of this paragraph include, but are not
1740	limited to:
1741	1.  False or misleading claims that marketing
1742	representatives are employees or representatives of the state or
1743	county, or of anyone other than the entity or the organization
1744	by whom they are reimbursed.
1745	2.  False or misleading claims that the entity is
1746	recommended or endorsed by any state or county agency, or by any
1747	other organization which has not certified its endorsement in
1748	writing to the entity.
1749	3.  False or misleading claims that the state or county
1750	recommends that a Medicaid recipient enroll with an entity.
1751	4.  Claims that a Medicaid recipient will lose benefits
1752	under the Medicaid program, or any other health or welfare
1753	benefits to which the recipient is legally entitled, if the
1754	recipient does not enroll with the entity.
1755	(c)  Granting or offering of any monetary or other valuable
1756	consideration for enrollment, except as authorized by subsection
1757	(23) (24).
1758	(d)  Door-to-door solicitation of recipients who have not
1759	contacted the entity or who have not invited the entity to make
1760	a presentation.
1761	(e)  Solicitation of Medicaid recipients by marketing
1762	representatives stationed in state offices unless approved and
1763	supervised by the agency or its agent and approved by the
1764	affected state agency when solicitation occurs in an office of
1765	the state agency. The agency shall ensure that marketing
1766	representatives stationed in state offices shall market their
1767	managed care plans to Medicaid recipients only in designated
1768	areas and in such a way as to not interfere with the recipients'
1769	activities in the state office.
1770	(f)  Enrollment of Medicaid recipients.
1771
1772	This subsection expires October 1, 2014.
1773	(21)(22)  The agency may impose a fine for a violation of
1774	this section or the contract with the agency by a person or
1775	entity that is under contract with the agency. With respect to
1776	any nonwillful violation, such fine shall not exceed $2,500 per
1777	violation. In no event shall such fine exceed an aggregate
1778	amount of $10,000 for all nonwillful violations arising out of
1779	the same action. With respect to any knowing and willful
1780	violation of this section or the contract with the agency, the
1781	agency may impose a fine upon the entity in an amount not to
1782	exceed $20,000 for each such violation. In no event shall such
1783	fine exceed an aggregate amount of $100,000 for all knowing and
1784	willful violations arising out of the same action. This
1785	subsection expires October 1, 2014.
1786	(22)(23)  A health maintenance organization or a person or
1787	entity exempt from chapter 641 that is under contract with the
1788	agency for the provision of health care services to Medicaid
1789	recipients may not use or distribute marketing materials used to
1790	solicit Medicaid recipients, unless such materials have been
1791	approved by the agency. The provisions of this subsection do not
1792	apply to general advertising and marketing materials used by a
1793	health maintenance organization to solicit both non-Medicaid
1794	subscribers and Medicaid recipients. This subsection expires
1795	October 1, 2014.
1796	(23)(24)  Upon approval by the agency, health maintenance
1797	organizations and persons or entities exempt from chapter 641
1798	that are under contract with the agency for the provision of
1799	health care services to Medicaid recipients may be permitted
1800	within the capitation rate to provide additional health benefits
1801	that the agency has found are of high quality, are practicably
1802	available, provide reasonable value to the recipient, and are
1803	provided at no additional cost to the state. This subsection
1804	expires October 1, 2014.
1805	(24)(25)  The agency shall utilize the statewide health
1806	maintenance organization complaint hotline for the purpose of
1807	investigating and resolving Medicaid and prepaid health plan
1808	complaints, maintaining a record of complaints and confirmed
1809	problems, and receiving disenrollment requests made by
1810	recipients. This subsection expires October 1, 2014.
1811	(25)(26)  The agency shall require the publication of the
1812	health maintenance organization's and the prepaid health plan's
1813	consumer services telephone numbers and the "800" telephone
1814	number of the statewide health maintenance organization
1815	complaint hotline on each Medicaid identification card issued by
1816	a health maintenance organization or prepaid health plan
1817	contracting with the agency to serve Medicaid recipients and on
1818	each subscriber handbook issued to a Medicaid recipient. This
1819	subsection expires October 1, 2014.
1820	(26)(27)  The agency shall establish a health care quality
1821	improvement system for those entities contracting with the
1822	agency pursuant to this section, incorporating all the standards
1823	and guidelines developed by the Medicaid Bureau of the Health
1824	Care Financing Administration as a part of the quality assurance
1825	reform initiative. The system shall include, but need not be
1826	limited to, the following:
1827	(a)  Guidelines for internal quality assurance programs,
1828	including standards for:
1829	1.  Written quality assurance program descriptions.
1830	2.  Responsibilities of the governing body for monitoring,
1831	evaluating, and making improvements to care.
1832	3.  An active quality assurance committee.
1833	4.  Quality assurance program supervision.
1834	5.  Requiring the program to have adequate resources to
1835	effectively carry out its specified activities.
1836	6.  Provider participation in the quality assurance
1837	program.
1838	7.  Delegation of quality assurance program activities.
1839	8.  Credentialing and recredentialing.
1840	9.  Enrollee rights and responsibilities.
1841	10.  Availability and accessibility to services and care.
1842	11.  Ambulatory care facilities.
1843	12.  Accessibility and availability of medical records, as
1844	well as proper recordkeeping and process for record review.
1845	13.  Utilization review.
1846	14.  A continuity of care system.
1847	15.  Quality assurance program documentation.
1848	16.  Coordination of quality assurance activity with other
1849	management activity.
1850	17.  Delivering care to pregnant women and infants; to
1851	elderly and disabled recipients, especially those who are at
1852	risk of institutional placement; to persons with developmental
1853	disabilities; and to adults who have chronic, high-cost medical
1854	conditions.
1855	(b)  Guidelines which require the entities to conduct
1856	quality-of-care studies which:
1857	1.  Target specific conditions and specific health service
1858	delivery issues for focused monitoring and evaluation.
1859	2.  Use clinical care standards or practice guidelines to
1860	objectively evaluate the care the entity delivers or fails to
1861	deliver for the targeted clinical conditions and health services
1862	delivery issues.
1863	3.  Use quality indicators derived from the clinical care
1864	standards or practice guidelines to screen and monitor care and
1865	services delivered.
1866	(c)  Guidelines for external quality review of each
1867	contractor which require: focused studies of patterns of care;
1868	individual care review in specific situations; and followup
1869	activities on previous pattern-of-care study findings and
1870	individual-care-review findings. In designing the external
1871	quality review function and determining how it is to operate as
1872	part of the state's overall quality improvement system, the
1873	agency shall construct its external quality review organization
1874	and entity contracts to address each of the following:
1875	1.  Delineating the role of the external quality review
1876	organization.
1877	2.  Length of the external quality review organization
1878	contract with the state.
1879	3.  Participation of the contracting entities in designing
1880	external quality review organization review activities.
1881	4.  Potential variation in the type of clinical conditions
1882	and health services delivery issues to be studied at each plan.
1883	5.  Determining the number of focused pattern-of-care
1884	studies to be conducted for each plan.
1885	6.  Methods for implementing focused studies.
1886	7.  Individual care review.
1887	8.  Followup activities.
1888
1889	This subsection expires October 1, 2016.
1890	(27)(28)  In order to ensure that children receive health
1891	care services for which an entity has already been compensated,
1892	an entity contracting with the agency pursuant to this section
1893	shall achieve an annual Early and Periodic Screening, Diagnosis,
1894	and Treatment (EPSDT) Service screening rate of at least 60
1895	percent for those recipients continuously enrolled for at least
1896	8 months. The agency shall develop a method by which the EPSDT
1897	screening rate shall be calculated. For any entity which does
1898	not achieve the annual 60 percent rate, the entity must submit a
1899	corrective action plan for the agency's approval. If the entity
1900	does not meet the standard established in the corrective action
1901	plan during the specified timeframe, the agency is authorized to
1902	impose appropriate contract sanctions. At least annually, the
1903	agency shall publicly release the EPSDT Services screening rates
1904	of each entity it has contracted with on a prepaid basis to
1905	serve Medicaid recipients. This subsection expires October 1,
1906	2014.
1907	(28)(29)  The agency shall perform enrollments and
1908	disenrollments for Medicaid recipients who are eligible for
1909	MediPass or managed care plans. Notwithstanding the prohibition
1910	contained in paragraph (20)(21)(f), managed care plans may
1911	perform preenrollments of Medicaid recipients under the
1912	supervision of the agency or its agents. For the purposes of
1913	this section, the term "preenrollment" means the provision of
1914	marketing and educational materials to a Medicaid recipient and
1915	assistance in completing the application forms, but does not
1916	include actual enrollment into a managed care plan. An
1917	application for enrollment may not be deemed complete until the
1918	agency or its agent verifies that the recipient made an
1919	informed, voluntary choice. The agency, in cooperation with the
1920	Department of Children and Family Services, may test new
1921	marketing initiatives to inform Medicaid recipients about their
1922	managed care options at selected sites. The agency may contract
1923	with a third party to perform managed care plan and MediPass
1924	enrollment and disenrollment services for Medicaid recipients
1925	and may adopt rules to administer such services. The agency may
1926	adjust the capitation rate only to cover the costs of a third-
1927	party enrollment and disenrollment contract, and for agency
1928	supervision and management of the managed care plan enrollment
1929	and disenrollment contract. This subsection expires October 1,
1930	2014.
1931	(29)(30)  Any lists of providers made available to Medicaid
1932	recipients, MediPass enrollees, or managed care plan enrollees
1933	shall be arranged alphabetically showing the provider's name and
1934	specialty and, separately, by specialty in alphabetical order.
1935	This subsection expires October 1, 2014.
1936	(30)(31)  The agency shall establish an enhanced managed
1937	care quality assurance oversight function, to include at least
1938	the following components:
1939	(a)  At least quarterly analysis and followup, including
1940	sanctions as appropriate, of managed care participant
1941	utilization of services.
1942	(b)  At least quarterly analysis and followup, including
1943	sanctions as appropriate, of quality findings of the Medicaid
1944	peer review organization and other external quality assurance
1945	programs.
1946	(c)  At least quarterly analysis and followup, including
1947	sanctions as appropriate, of the fiscal viability of managed
1948	care plans.
1949	(d)  At least quarterly analysis and followup, including
1950	sanctions as appropriate, of managed care participant
1951	satisfaction and disenrollment surveys.
1952	(e)  The agency shall conduct regular and ongoing Medicaid
1953	recipient satisfaction surveys.
1954
1955	The analyses and followup activities conducted by the agency
1956	under its enhanced managed care quality assurance oversight
1957	function shall not duplicate the activities of accreditation
1958	reviewers for entities regulated under part III of chapter 641,
1959	but may include a review of the finding of such reviewers. This
1960	subsection expires October 1, 2014.
1961	(31)(32)  Each managed care plan that is under contract
1962	with the agency to provide health care services to Medicaid
1963	recipients shall annually conduct a background check with the
1964	Department of Law Enforcement of all persons with ownership
1965	interest of 5 percent or more or executive management
1966	responsibility for the managed care plan and shall submit to the
1967	agency information concerning any such person who has been found
1968	guilty of, regardless of adjudication, or has entered a plea of
1969	nolo contendere or guilty to, any of the offenses listed in s.
1970	435.04. This subsection expires October 1, 2014.
1971	(32)(33)  The agency shall, by rule, develop a process
1972	whereby a Medicaid managed care plan enrollee who wishes to
1973	enter hospice care may be disenrolled from the managed care plan
1974	within 24 hours after contacting the agency regarding such
1975	request. The agency rule shall include a methodology for the
1976	agency to recoup managed care plan payments on a pro rata basis
1977	if payment has been made for the enrollment month when
1978	disenrollment occurs. This subsection expires October 1, 2014.
1979	(33)(34)  The agency and entities that contract with the
1980	agency to provide health care services to Medicaid recipients
1981	under this section or ss. 409.91211 and 409.9122 must comply
1982	with the provisions of s. 641.513 in providing emergency
1983	services and care to Medicaid recipients and MediPass
1984	recipients. Where feasible, safe, and cost-effective, the agency
1985	shall encourage hospitals, emergency medical services providers,
1986	and other public and private health care providers to work
1987	together in their local communities to enter into agreements or
1988	arrangements to ensure access to alternatives to emergency
1989	services and care for those Medicaid recipients who need
1990	nonemergent care. The agency shall coordinate with hospitals,
1991	emergency medical services providers, private health plans,
1992	capitated managed care networks as established in s. 409.91211,
1993	and other public and private health care providers to implement
1994	the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1995	and 641.31097 to develop and implement emergency department
1996	diversion programs for Medicaid recipients. This subsection
1997	expires October 1, 2014.
1998	(34)(35)  All entities providing health care services to
1999	Medicaid recipients shall make available, and encourage all
2000	pregnant women and mothers with infants to receive, and provide
2001	documentation in the medical records to reflect, the following:
2002	(a)  Healthy Start prenatal or infant screening.
2003	(b)  Healthy Start care coordination, when screening or
2004	other factors indicate need.
2005	(c)  Healthy Start enhanced services in accordance with the
2006	prenatal or infant screening results.
2007	(d)  Immunizations in accordance with recommendations of
2008	the Advisory Committee on Immunization Practices of the United
2009	States Public Health Service and the American Academy of
2010	Pediatrics, as appropriate.
2011	(e)  Counseling and services for family planning to all
2012	women and their partners.
2013	(f)  A scheduled postpartum visit for the purpose of
2014	voluntary family planning, to include discussion of all methods
2015	of contraception, as appropriate.
2016	(g)  Referral to the Special Supplemental Nutrition Program
2017	for Women, Infants, and Children (WIC).
2018
2019	This subsection expires October 1, 2014.
2020	(35)(36)  Any entity that provides Medicaid prepaid health
2021	plan services shall ensure the appropriate coordination of
2022	health care services with an assisted living facility in cases
2023	where a Medicaid recipient is both a member of the entity's
2024	prepaid health plan and a resident of the assisted living
2025	facility. If the entity is at risk for Medicaid targeted case
2026	management and behavioral health services, the entity shall
2027	inform the assisted living facility of the procedures to follow
2028	should an emergent condition arise. This subsection expires
2029	October 1, 2014.
2030	(37)  The agency may seek and implement federal waivers
2031	necessary to provide for cost-effective purchasing of home
2032	health services, private duty nursing services, transportation,
2033	independent laboratory services, and durable medical equipment
2034	and supplies through competitive bidding pursuant to s. 287.057.
2035	The agency may request appropriate waivers from the federal
2036	Health Care Financing Administration in order to competitively
2037	bid such services. The agency may exclude providers not selected
2038	through the bidding process from the Medicaid provider network.
2039	(36)(38)  The agency shall enter into agreements with not-
2040	for-profit organizations based in this state for the purpose of
2041	providing vision screening. This subsection expires October 1,
2042	2014.
2043	(37)(39)(a)  The agency shall implement a Medicaid
2044	prescribed-drug spending-control program that includes the
2045	following components:
2046	1.  A Medicaid preferred drug list, which shall be a
2047	listing of cost-effective therapeutic options recommended by the
2048	Medicaid Pharmacy and Therapeutics Committee established
2049	pursuant to s. 409.91195 and adopted by the agency for each
2050	therapeutic class on the preferred drug list. At the discretion
2051	of the committee, and when feasible, the preferred drug list
2052	should include at least two products in a therapeutic class. The
2053	agency may post the preferred drug list and updates to the
2054	preferred drug list on an Internet website without following the
2055	rulemaking procedures of chapter 120. Antiretroviral agents are
2056	excluded from the preferred drug list. The agency shall also
2057	limit the amount of a prescribed drug dispensed to no more than
2058	a 34-day supply unless the drug products' smallest marketed
2059	package is greater than a 34-day supply, or the drug is
2060	determined by the agency to be a maintenance drug in which case
2061	a 100-day maximum supply may be authorized. The agency is
2062	authorized to seek any federal waivers necessary to implement
2063	these cost-control programs and to continue participation in the
2064	federal Medicaid rebate program, or alternatively to negotiate
2065	state-only manufacturer rebates. The agency may adopt rules to
2066	implement this subparagraph. The agency shall continue to
2067	provide unlimited contraceptive drugs and items. The agency must
2068	establish procedures to ensure that:
2069	a.  There is a response to a request for prior consultation
2070	by telephone or other telecommunication device within 24 hours
2071	after receipt of a request for prior consultation; and
2072	b.  A 72-hour supply of the drug prescribed is provided in
2073	an emergency or when the agency does not provide a response
2074	within 24 hours as required by sub-subparagraph a.
2075	2.  Reimbursement to pharmacies for Medicaid prescribed
2076	drugs shall be set at the lesser of: the average wholesale price
2077	(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2078	plus 4.75 percent, the federal upper limit (FUL), the state
2079	maximum allowable cost (SMAC), or the usual and customary (UAC)
2080	charge billed by the provider.
2081	3.  The agency shall develop and implement a process for
2082	managing the drug therapies of Medicaid recipients who are using
2083	significant numbers of prescribed drugs each month. The
2084	management process may include, but is not limited to,
2085	comprehensive, physician-directed medical-record reviews, claims
2086	analyses, and case evaluations to determine the medical
2087	necessity and appropriateness of a patient's treatment plan and
2088	drug therapies. The agency may contract with a private
2089	organization to provide drug-program-management services. The
2090	Medicaid drug benefit management program shall include
2091	initiatives to manage drug therapies for HIV/AIDS patients,
2092	patients using 20 or more unique prescriptions in a 180-day
2093	period, and the top 1,000 patients in annual spending. The
2094	agency shall enroll any Medicaid recipient in the drug benefit
2095	management program if he or she meets the specifications of this
2096	provision and is not enrolled in a Medicaid health maintenance
2097	organization.
2098	4.  The agency may limit the size of its pharmacy network
2099	based on need, competitive bidding, price negotiations,
2100	credentialing, or similar criteria. The agency shall give
2101	special consideration to rural areas in determining the size and
2102	location of pharmacies included in the Medicaid pharmacy
2103	network. A pharmacy credentialing process may include criteria
2104	such as a pharmacy's full-service status, location, size,
2105	patient educational programs, patient consultation, disease
2106	management services, and other characteristics. The agency may
2107	impose a moratorium on Medicaid pharmacy enrollment when it is
2108	determined that it has a sufficient number of Medicaid-
2109	participating providers. The agency must allow dispensing
2110	practitioners to participate as a part of the Medicaid pharmacy
2111	network regardless of the practitioner's proximity to any other
2112	entity that is dispensing prescription drugs under the Medicaid
2113	program. A dispensing practitioner must meet all credentialing
2114	requirements applicable to his or her practice, as determined by
2115	the agency.
2116	5.  The agency shall develop and implement a program that
2117	requires Medicaid practitioners who prescribe drugs to use a
2118	counterfeit-proof prescription pad for Medicaid prescriptions.
2119	The agency shall require the use of standardized counterfeit-
2120	proof prescription pads by Medicaid-participating prescribers or
2121	prescribers who write prescriptions for Medicaid recipients. The
2122	agency may implement the program in targeted geographic areas or
2123	statewide.
2124	6.  The agency may enter into arrangements that require
2125	manufacturers of generic drugs prescribed to Medicaid recipients
2126	to provide rebates of at least 15.1 percent of the average
2127	manufacturer price for the manufacturer's generic products.
2128	These arrangements shall require that if a generic-drug
2129	manufacturer pays federal rebates for Medicaid-reimbursed drugs
2130	at a level below 15.1 percent, the manufacturer must provide a
2131	supplemental rebate to the state in an amount necessary to
2132	achieve a 15.1-percent rebate level.
2133	7.  The agency may establish a preferred drug list as
2134	described in this subsection, and, pursuant to the establishment
2135	of such preferred drug list, it is authorized to negotiate
2136	supplemental rebates from manufacturers that are in addition to
2137	those required by Title XIX of the Social Security Act and at no
2138	less than 14 percent of the average manufacturer price as
2139	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2140	the federal or supplemental rebate, or both, equals or exceeds
2141	29 percent. There is no upper limit on the supplemental rebates
2142	the agency may negotiate. The agency may determine that specific
2143	products, brand-name or generic, are competitive at lower rebate
2144	percentages. Agreement to pay the minimum supplemental rebate
2145	percentage will guarantee a manufacturer that the Medicaid
2146	Pharmaceutical and Therapeutics Committee will consider a
2147	product for inclusion on the preferred drug list. However, a
2148	pharmaceutical manufacturer is not guaranteed placement on the
2149	preferred drug list by simply paying the minimum supplemental
2150	rebate. Agency decisions will be made on the clinical efficacy
2151	of a drug and recommendations of the Medicaid Pharmaceutical and
2152	Therapeutics Committee, as well as the price of competing
2153	products minus federal and state rebates. The agency is
2154	authorized to contract with an outside agency or contractor to
2155	conduct negotiations for supplemental rebates. For the purposes
2156	of this section, the term "supplemental rebates" means cash
2157	rebates. Effective July 1, 2004, value-added programs as a
2158	substitution for supplemental rebates are prohibited. The agency
2159	is authorized to seek any federal waivers to implement this
2160	initiative.
2161	8.  The Agency for Health Care Administration shall expand
2162	home delivery of pharmacy products. To assist Medicaid patients
2163	in securing their prescriptions and reduce program costs, the
2164	agency shall expand its current mail-order-pharmacy diabetes-
2165	supply program to include all generic and brand-name drugs used
2166	by Medicaid patients with diabetes. Medicaid recipients in the
2167	current program may obtain nondiabetes drugs on a voluntary
2168	basis. This initiative is limited to the geographic area covered
2169	by the current contract. The agency may seek and implement any
2170	federal waivers necessary to implement this subparagraph.
2171	9.  The agency shall limit to one dose per month any drug
2172	prescribed to treat erectile dysfunction.
2173	10.a.  The agency may implement a Medicaid behavioral drug
2174	management system. The agency may contract with a vendor that
2175	has experience in operating behavioral drug management systems
2176	to implement this program. The agency is authorized to seek
2177	federal waivers to implement this program.
2178	b.  The agency, in conjunction with the Department of
2179	Children and Family Services, may implement the Medicaid
2180	behavioral drug management system that is designed to improve
2181	the quality of care and behavioral health prescribing practices
2182	based on best practice guidelines, improve patient adherence to
2183	medication plans, reduce clinical risk, and lower prescribed
2184	drug costs and the rate of inappropriate spending on Medicaid
2185	behavioral drugs. The program may include the following
2186	elements:
2187	(I)  Provide for the development and adoption of best
2188	practice guidelines for behavioral health-related drugs such as
2189	antipsychotics, antidepressants, and medications for treating
2190	bipolar disorders and other behavioral conditions; translate
2191	them into practice; review behavioral health prescribers and
2192	compare their prescribing patterns to a number of indicators
2193	that are based on national standards; and determine deviations
2194	from best practice guidelines.
2195	(II)  Implement processes for providing feedback to and
2196	educating prescribers using best practice educational materials
2197	and peer-to-peer consultation.
2198	(III)  Assess Medicaid beneficiaries who are outliers in
2199	their use of behavioral health drugs with regard to the numbers
2200	and types of drugs taken, drug dosages, combination drug
2201	therapies, and other indicators of improper use of behavioral
2202	health drugs.
2203	(IV)  Alert prescribers to patients who fail to refill
2204	prescriptions in a timely fashion, are prescribed multiple same-
2205	class behavioral health drugs, and may have other potential
2206	medication problems.
2207	(V)  Track spending trends for behavioral health drugs and
2208	deviation from best practice guidelines.
2209	(VI)  Use educational and technological approaches to
2210	promote best practices, educate consumers, and train prescribers
2211	in the use of practice guidelines.
2212	(VII)  Disseminate electronic and published materials.
2213	(VIII)  Hold statewide and regional conferences.
2214	(IX)  Implement a disease management program with a model
2215	quality-based medication component for severely mentally ill
2216	individuals and emotionally disturbed children who are high
2217	users of care.
2218	11.a.  The agency shall implement a Medicaid prescription
2219	drug management system. The agency may contract with a vendor
2220	that has experience in operating prescription drug management
2221	systems in order to implement this system. Any management system
2222	that is implemented in accordance with this subparagraph must
2223	rely on cooperation between physicians and pharmacists to
2224	determine appropriate practice patterns and clinical guidelines
2225	to improve the prescribing, dispensing, and use of drugs in the
2226	Medicaid program. The agency may seek federal waivers to
2227	implement this program.
2228	b.  The drug management system must be designed to improve
2229	the quality of care and prescribing practices based on best
2230	practice guidelines, improve patient adherence to medication
2231	plans, reduce clinical risk, and lower prescribed drug costs and
2232	the rate of inappropriate spending on Medicaid prescription
2233	drugs. The program must:
2234	(I)  Provide for the development and adoption of best
2235	practice guidelines for the prescribing and use of drugs in the
2236	Medicaid program, including translating best practice guidelines
2237	into practice; reviewing prescriber patterns and comparing them
2238	to indicators that are based on national standards and practice
2239	patterns of clinical peers in their community, statewide, and
2240	nationally; and determine deviations from best practice
2241	guidelines.
2242	(II)  Implement processes for providing feedback to and
2243	educating prescribers using best practice educational materials
2244	and peer-to-peer consultation.
2245	(III)  Assess Medicaid recipients who are outliers in their
2246	use of a single or multiple prescription drugs with regard to
2247	the numbers and types of drugs taken, drug dosages, combination
2248	drug therapies, and other indicators of improper use of
2249	prescription drugs.
2250	(IV)  Alert prescribers to patients who fail to refill
2251	prescriptions in a timely fashion, are prescribed multiple drugs
2252	that may be redundant or contraindicated, or may have other
2253	potential medication problems.
2254	(V)  Track spending trends for prescription drugs and
2255	deviation from best practice guidelines.
2256	(VI)  Use educational and technological approaches to
2257	promote best practices, educate consumers, and train prescribers
2258	in the use of practice guidelines.
2259	(VII)  Disseminate electronic and published materials.
2260	(VIII)  Hold statewide and regional conferences.
2261	(IX)  Implement disease management programs in cooperation
2262	with physicians and pharmacists, along with a model quality-
2263	based medication component for individuals having chronic
2264	medical conditions.
2265	12.  The agency is authorized to contract for drug rebate
2266	administration, including, but not limited to, calculating
2267	rebate amounts, invoicing manufacturers, negotiating disputes
2268	with manufacturers, and maintaining a database of rebate
2269	collections.
2270	13.  The agency may specify the preferred daily dosing form
2271	or strength for the purpose of promoting best practices with
2272	regard to the prescribing of certain drugs as specified in the
2273	General Appropriations Act and ensuring cost-effective
2274	prescribing practices.
2275	14.  The agency may require prior authorization for
2276	Medicaid-covered prescribed drugs. The agency may, but is not
2277	required to, prior-authorize the use of a product:
2278	a.  For an indication not approved in labeling;
2279	b.  To comply with certain clinical guidelines; or
2280	c.  If the product has the potential for overuse, misuse,
2281	or abuse.
2282
2283	The agency may require the prescribing professional to provide
2284	information about the rationale and supporting medical evidence
2285	for the use of a drug. The agency may post prior authorization
2286	criteria and protocol and updates to the list of drugs that are
2287	subject to prior authorization on an Internet website without
2288	amending its rule or engaging in additional rulemaking.
2289	15.  The agency, in conjunction with the Pharmaceutical and
2290	Therapeutics Committee, may require age-related prior
2291	authorizations for certain prescribed drugs. The agency may
2292	preauthorize the use of a drug for a recipient who may not meet
2293	the age requirement or may exceed the length of therapy for use
2294	of this product as recommended by the manufacturer and approved
2295	by the Food and Drug Administration. Prior authorization may
2296	require the prescribing professional to provide information
2297	about the rationale and supporting medical evidence for the use
2298	of a drug.
2299	16.  The agency shall implement a step-therapy prior
2300	authorization approval process for medications excluded from the
2301	preferred drug list. Medications listed on the preferred drug
2302	list must be used within the previous 12 months prior to the
2303	alternative medications that are not listed. The step-therapy
2304	prior authorization may require the prescriber to use the
2305	medications of a similar drug class or for a similar medical
2306	indication unless contraindicated in the Food and Drug
2307	Administration labeling. The trial period between the specified
2308	steps may vary according to the medical indication. The step-
2309	therapy approval process shall be developed in accordance with
2310	the committee as stated in s. 409.91195(7) and (8). A drug
2311	product may be approved without meeting the step-therapy prior
2312	authorization criteria if the prescribing physician provides the
2313	agency with additional written medical or clinical documentation
2314	that the product is medically necessary because:
2315	a.  There is not a drug on the preferred drug list to treat
2316	the disease or medical condition which is an acceptable clinical
2317	alternative;
2318	b.  The alternatives have been ineffective in the treatment
2319	of the beneficiary's disease; or
2320	c.  Based on historic evidence and known characteristics of
2321	the patient and the drug, the drug is likely to be ineffective,
2322	or the number of doses have been ineffective.
2323
2324	The agency shall work with the physician to determine the best
2325	alternative for the patient. The agency may adopt rules waiving
2326	the requirements for written clinical documentation for specific
2327	drugs in limited clinical situations.
2328	17.  The agency shall implement a return and reuse program
2329	for drugs dispensed by pharmacies to institutional recipients,
2330	which includes payment of a $5 restocking fee for the
2331	implementation and operation of the program. The return and
2332	reuse program shall be implemented electronically and in a
2333	manner that promotes efficiency. The program must permit a
2334	pharmacy to exclude drugs from the program if it is not
2335	practical or cost-effective for the drug to be included and must
2336	provide for the return to inventory of drugs that cannot be
2337	credited or returned in a cost-effective manner. The agency
2338	shall determine if the program has reduced the amount of
2339	Medicaid prescription drugs which are destroyed on an annual
2340	basis and if there are additional ways to ensure more
2341	prescription drugs are not destroyed which could safely be
2342	reused. The agency's conclusion and recommendations shall be
2343	reported to the Legislature by December 1, 2005.
2344	(b)  The agency shall implement this subsection to the
2345	extent that funds are appropriated to administer the Medicaid
2346	prescribed-drug spending-control program. The agency may
2347	contract all or any part of this program to private
2348	organizations.
2349	(c)  The agency shall submit quarterly reports to the
2350	Governor, the President of the Senate, and the Speaker of the
2351	House of Representatives which must include, but need not be
2352	limited to, the progress made in implementing this subsection
2353	and its effect on Medicaid prescribed-drug expenditures.
2354	(38)(40)  Notwithstanding the provisions of chapter 287,
2355	the agency may, at its discretion, renew a contract or contracts
2356	for fiscal intermediary services one or more times for such
2357	periods as the agency may decide; however, all such renewals may
2358	not combine to exceed a total period longer than the term of the
2359	original contract.
2360	(39)(41)  The agency shall provide for the development of a
2361	demonstration project by establishment in Miami-Dade County of a
2362	long-term-care facility licensed pursuant to chapter 395 to
2363	improve access to health care for a predominantly minority,
2364	medically underserved, and medically complex population and to
2365	evaluate alternatives to nursing home care and general acute
2366	care for such population. Such project is to be located in a
2367	health care condominium and colocated with licensed facilities
2368	providing a continuum of care. The establishment of this project
2369	is not subject to the provisions of s. 408.036 or s. 408.039.
2370	This subsection expires October 1, 2013.
2371	(40)(42)  The agency shall develop and implement a
2372	utilization management program for Medicaid-eligible recipients
2373	for the management of occupational, physical, respiratory, and
2374	speech therapies. The agency shall establish a utilization
2375	program that may require prior authorization in order to ensure
2376	medically necessary and cost-effective treatments. The program
2377	shall be operated in accordance with a federally approved waiver
2378	program or state plan amendment. The agency may seek a federal
2379	waiver or state plan amendment to implement this program. The
2380	agency may also competitively procure these services from an
2381	outside vendor on a regional or statewide basis. This subsection
2382	expires October 1, 2014.
2383	(41)(43)  The agency shall may contract on a prepaid or
2384	fixed-sum basis with appropriately licensed prepaid dental
2385	health plans to provide dental services. This subsection expires
2386	October 1, 2014.
2387	(42)(44)  The Agency for Health Care Administration shall
2388	ensure that any Medicaid managed care plan as defined in s.
2389	409.9122(2)(f), whether paid on a capitated basis or a shared
2390	savings basis, is cost-effective. For purposes of this
2391	subsection, the term "cost-effective" means that a network's
2392	per-member, per-month costs to the state, including, but not
2393	limited to, fee-for-service costs, administrative costs, and
2394	case-management fees, if any, must be no greater than the
2395	state's costs associated with contracts for Medicaid services
2396	established under subsection (3), which may be adjusted for
2397	health status. The agency shall conduct actuarially sound
2398	adjustments for health status in order to ensure such cost-
2399	effectiveness and shall annually publish the results on its
2400	Internet website. Contracts established pursuant to this
2401	subsection which are not cost-effective may not be renewed. This
2402	subsection expires October 1, 2014.
2403	(43)(45)  Subject to the availability of funds, the agency
2404	shall mandate a recipient's participation in a provider lock-in
2405	program, when appropriate, if a recipient is found by the agency
2406	to have used Medicaid goods or services at a frequency or amount
2407	not medically necessary, limiting the receipt of goods or
2408	services to medically necessary providers after the 21-day
2409	appeal process has ended, for a period of not less than 1 year.
2410	The lock-in programs shall include, but are not limited to,
2411	pharmacies, medical doctors, and infusion clinics. The
2412	limitation does not apply to emergency services and care
2413	provided to the recipient in a hospital emergency department.
2414	The agency shall seek any federal waivers necessary to implement
2415	this subsection. The agency shall adopt any rules necessary to
2416	comply with or administer this subsection. This subsection
2417	expires October 1, 2014.
2418	(44)(46)  The agency shall seek a federal waiver for
2419	permission to terminate the eligibility of a Medicaid recipient
2420	who has been found to have committed fraud, through judicial or
2421	administrative determination, two times in a period of 5 years.
2422	(47)  The agency shall conduct a study of available
2423	electronic systems for the purpose of verifying the identity and
2424	eligibility of a Medicaid recipient. The agency shall recommend
2425	to the Legislature a plan to implement an electronic
2426	verification system for Medicaid recipients by January 31, 2005.
2427	(45)(48)(a)  A provider is not entitled to enrollment in
2428	the Medicaid provider network. The agency may implement a
2429	Medicaid fee-for-service provider network controls, including,
2430	but not limited to, competitive procurement and provider
2431	credentialing. If a credentialing process is used, the agency
2432	may limit its provider network based upon the following
2433	considerations: beneficiary access to care, provider
2434	availability, provider quality standards and quality assurance
2435	processes, cultural competency, demographic characteristics of
2436	beneficiaries, practice standards, service wait times, provider
2437	turnover, provider licensure and accreditation history, program
2438	integrity history, peer review, Medicaid policy and billing
2439	compliance records, clinical and medical record audit findings,
2440	and such other areas that are considered necessary by the agency
2441	to ensure the integrity of the program.
2442	(b)  The agency shall limit its network of durable medical
2443	equipment and medical supply providers. For dates of service
2444	after January 1, 2009, the agency shall limit payment for
2445	durable medical equipment and supplies to providers that meet
2446	all the requirements of this paragraph.
2447	1.  Providers must be accredited by a Centers for Medicare
2448	and Medicaid Services deemed accreditation organization for
2449	suppliers of durable medical equipment, prosthetics, orthotics,
2450	and supplies. The provider must maintain accreditation and is
2451	subject to unannounced reviews by the accrediting organization.
2452	2.  Providers must provide the services or supplies
2453	directly to the Medicaid recipient or caregiver at the provider
2454	location or recipient's residence or send the supplies directly
2455	to the recipient's residence with receipt of mailed delivery.
2456	Subcontracting or consignment of the service or supply to a
2457	third party is prohibited.
2458	3.  Notwithstanding subparagraph 2., a durable medical
2459	equipment provider may store nebulizers at a physician's office
2460	for the purpose of having the physician's staff issue the
2461	equipment if it meets all of the following conditions:
2462	a.  The physician must document the medical necessity and
2463	need to prevent further deterioration of the patient's
2464	respiratory status by the timely delivery of the nebulizer in
2465	the physician's office.
2466	b.  The durable medical equipment provider must have
2467	written documentation of the competency and training by a
2468	Florida-licensed registered respiratory therapist of any durable
2469	medical equipment staff who participate in the training of
2470	physician office staff for the use of nebulizers, including
2471	cleaning, warranty, and special needs of patients.
2472	c.  The physician's office must have documented the
2473	training and competency of any staff member who initiates the
2474	delivery of nebulizers to patients. The durable medical
2475	equipment provider must maintain copies of all physician office
2476	training.
2477	d.  The physician's office must maintain inventory records
2478	of stored nebulizers, including documentation of the durable
2479	medical equipment provider source.
2480	e.  A physician contracted with a Medicaid durable medical
2481	equipment provider may not have a financial relationship with
2482	that provider or receive any financial gain from the delivery of
2483	nebulizers to patients.
2484	4.  Providers must have a physical business location and a
2485	functional landline business phone. The location must be within
2486	the state or not more than 50 miles from the Florida state line.
2487	The agency may make exceptions for providers of durable medical
2488	equipment or supplies not otherwise available from other
2489	enrolled providers located within the state.
2490	5.  Physical business locations must be clearly identified
2491	as a business that furnishes durable medical equipment or
2492	medical supplies by signage that can be read from 20 feet away.
2493	The location must be readily accessible to the public during
2494	normal, posted business hours and must operate at least 5 hours
2495	per day and at least 5 days per week, with the exception of
2496	scheduled and posted holidays. The location may not be located
2497	within or at the same numbered street address as another
2498	enrolled Medicaid durable medical equipment or medical supply
2499	provider or as an enrolled Medicaid pharmacy that is also
2500	enrolled as a durable medical equipment provider. A licensed
2501	orthotist or prosthetist that provides only orthotic or
2502	prosthetic devices as a Medicaid durable medical equipment
2503	provider is exempt from this paragraph.
2504	6.  Providers must maintain a stock of durable medical
2505	equipment and medical supplies on site that is readily available
2506	to meet the needs of the durable medical equipment business
2507	location's customers.
2508	7.  Providers must provide a surety bond of $50,000 for
2509	each provider location, up to a maximum of 5 bonds statewide or
2510	an aggregate bond of $250,000 statewide, as identified by
2511	Federal Employer Identification Number. Providers who post a
2512	statewide or an aggregate bond must identify all of their
2513	locations in any Medicaid durable medical equipment and medical
2514	supply provider enrollment application or bond renewal. Each
2515	provider location's surety bond must be renewed annually and the
2516	provider must submit proof of renewal even if the original bond
2517	is a continuous bond. A licensed orthotist or prosthetist that
2518	provides only orthotic or prosthetic devices as a Medicaid
2519	durable medical equipment provider is exempt from the provisions
2520	in this paragraph.
2521	8.  Providers must obtain a level 2 background screening,
2522	in accordance with chapter 435 and s. 408.809, for each provider
2523	employee in direct contact with or providing direct services to
2524	recipients of durable medical equipment and medical supplies in
2525	their homes. This requirement includes, but is not limited to,
2526	repair and service technicians, fitters, and delivery staff. The
2527	provider shall pay for the cost of the background screening.
2528	9.  The following providers are exempt from subparagraphs
2529	1. and 7.:
2530	a.  Durable medical equipment providers owned and operated
2531	by a government entity.
2532	b.  Durable medical equipment providers that are operating
2533	within a pharmacy that is currently enrolled as a Medicaid
2534	pharmacy provider.
2535	c.  Active, Medicaid-enrolled orthopedic physician groups,
2536	primarily owned by physicians, which provide only orthotic and
2537	prosthetic devices.
2538	(46)(49)  The agency shall contract with established
2539	minority physician networks that provide services to
2540	historically underserved minority patients. The networks must
2541	provide cost-effective Medicaid services, comply with the
2542	requirements to be a MediPass provider, and provide their
2543	primary care physicians with access to data and other management
2544	tools necessary to assist them in ensuring the appropriate use
2545	of services, including inpatient hospital services and
2546	pharmaceuticals.
2547	(a)  The agency shall provide for the development and
2548	expansion of minority physician networks in each service area to
2549	provide services to Medicaid recipients who are eligible to
2550	participate under federal law and rules.
2551	(b)  The agency shall reimburse each minority physician
2552	network as a fee-for-service provider, including the case
2553	management fee for primary care, if any, or as a capitated rate
2554	provider for Medicaid services. Any savings shall be shared with
2555	the minority physician networks pursuant to the contract.
2556	(c)  For purposes of this subsection, the term "cost-
2557	effective" means that a network's per-member, per-month costs to
2558	the state, including, but not limited to, fee-for-service costs,
2559	administrative costs, and case-management fees, if any, must be
2560	no greater than the state's costs associated with contracts for
2561	Medicaid services established under subsection (3), which shall
2562	be actuarially adjusted for case mix, model, and service area.
2563	The agency shall conduct actuarially sound audits adjusted for
2564	case mix and model in order to ensure such cost-effectiveness
2565	and shall annually publish the audit results on its Internet
2566	website. Contracts established pursuant to this subsection which
2567	are not cost-effective may not be renewed.
2568	(d)  The agency may apply for any federal waivers needed to
2569	implement this subsection.
2570
2571	This subsection expires October 1, 2014.
2572	(47)(50)  To the extent permitted by federal law and as
2573	allowed under s. 409.906, the agency shall provide reimbursement
2574	for emergency mental health care services for Medicaid
2575	recipients in crisis stabilization facilities licensed under s.
2576	394.875 as long as those services are less expensive than the
2577	same services provided in a hospital setting.
2578	(48)(51)  The agency shall work with the Agency for Persons
2579	with Disabilities to develop a home and community-based waiver
2580	to serve children and adults who are diagnosed with familial
2581	dysautonomia or Riley-Day syndrome caused by a mutation of the
2582	IKBKAP gene on chromosome 9. The agency shall seek federal
2583	waiver approval and implement the approved waiver subject to the
2584	availability of funds and any limitations provided in the
2585	General Appropriations Act. The agency may adopt rules to
2586	implement this waiver program.
2587	(49)(52)  The agency shall implement a program of all-
2588	inclusive care for children. The program of all-inclusive care
2589	for children shall be established to provide in-home hospice-
2590	like support services to children diagnosed with a life-
2591	threatening illness and enrolled in the Children's Medical
2592	Services network to reduce hospitalizations as appropriate. The
2593	agency, in consultation with the Department of Health, may
2594	implement the program of all-inclusive care for children after
2595	obtaining approval from the Centers for Medicare and Medicaid
2596	Services.
2597	(50)(53)  Before seeking an amendment to the state plan for
2598	purposes of implementing programs authorized by the Deficit
2599	Reduction Act of 2005, the agency shall notify the Legislature.
2600	Section 14.  Section 409.91207, Florida Statutes, is
2601	repealed.
2602	Section 15.  Paragraphs (e), (l), (p), (w), and (dd) of
2603	subsection (3) of section 409.91211, Florida Statutes, are
2604	amended to read:
2605	409.91211  Medicaid managed care pilot program.-
2606	(3)  The agency shall have the following powers, duties,
2607	and responsibilities with respect to the pilot program:
2608	(e)  To implement policies and guidelines for phasing in
2609	financial risk for approved provider service networks that, for
2610	purposes of this paragraph, include the Children's Medical
2611	Services Network, over the period of the waiver and the
2612	extension thereof. These policies and guidelines must include an
2613	option for a provider service network to be paid fee-for-service
2614	rates. For any provider service network established in a managed
2615	care pilot area, the option to be paid fee-for-service rates
2616	must include a savings-settlement mechanism that is consistent
2617	with s. 409.912(42)(44). This model must be converted to a risk-
2618	adjusted capitated rate by the beginning of the final year of
2619	operation under the waiver extension, and may be converted
2620	earlier at the option of the provider service network. Federally
2621	qualified health centers may be offered an opportunity to accept
2622	or decline a contract to participate in any provider network for
2623	prepaid primary care services.
2624	(l)  To implement a system that prohibits capitated managed
2625	care plans, their representatives, and providers employed by or
2626	contracted with the capitated managed care plans from recruiting
2627	persons eligible for or enrolled in Medicaid, from providing
2628	inducements to Medicaid recipients to select a particular
2629	capitated managed care plan, and from prejudicing Medicaid
2630	recipients against other capitated managed care plans. The
2631	system shall require the entity performing choice counseling to
2632	determine if the recipient has made a choice of a plan or has
2633	opted out because of duress, threats, payment to the recipient,
2634	or incentives promised to the recipient by a third party. If the
2635	choice counseling entity determines that the decision to choose
2636	a plan was unlawfully influenced or a plan violated any of the
2637	provisions of s. 409.912(20)(21), the choice counseling entity
2638	shall immediately report the violation to the agency's program
2639	integrity section for investigation. Verification of choice
2640	counseling by the recipient shall include a stipulation that the
2641	recipient acknowledges the provisions of this subsection.
2642	(p)  To implement standards for plan compliance, including,
2643	but not limited to, standards for quality assurance and
2644	performance improvement, standards for peer or professional
2645	reviews, grievance policies, and policies for maintaining
2646	program integrity. The agency shall develop a data-reporting
2647	system, seek input from managed care plans in order to establish
2648	requirements for patient-encounter reporting, and ensure that
2649	the data reported is accurate and complete.
2650	1.  In performing the duties required under this section,
2651	the agency shall work with managed care plans to establish a
2652	uniform system to measure and monitor outcomes for a recipient
2653	of Medicaid services.
2654	2.  The system shall use financial, clinical, and other
2655	criteria based on pharmacy, medical services, and other data
2656	that is related to the provision of Medicaid services,
2657	including, but not limited to:
2658	a.  The Health Plan Employer Data and Information Set
2659	(HEDIS) or measures that are similar to HEDIS.
2660	b.  Member satisfaction.
2661	c.  Provider satisfaction.
2662	d.  Report cards on plan performance and best practices.
2663	e.  Compliance with the requirements for prompt payment of
2664	claims under ss. 627.613, 641.3155, and 641.513.
2665	f.  Utilization and quality data for the purpose of
2666	ensuring access to medically necessary services, including
2667	underutilization or inappropriate denial of services.
2668	3.  The agency shall require the managed care plans that
2669	have contracted with the agency to establish a quality assurance
2670	system that incorporates the provisions of s. 409.912(26)(27)
2671	and any standards, rules, and guidelines developed by the
2672	agency.
2673	4.  The agency shall establish an encounter database in
2674	order to compile data on health services rendered by health care
2675	practitioners who provide services to patients enrolled in
2676	managed care plans in the demonstration sites. The encounter
2677	database shall:
2678	a.  Collect the following for each type of patient
2679	encounter with a health care practitioner or facility,
2680	including:
2681	(I)  The demographic characteristics of the patient.
2682	(II)  The principal, secondary, and tertiary diagnosis.
2683	(III)  The procedure performed.
2684	(IV)  The date and location where the procedure was
2685	performed.
2686	(V)  The payment for the procedure, if any.
2687	(VI)  If applicable, the health care practitioner's
2688	universal identification number.
2689	(VII)  If the health care practitioner rendering the
2690	service is a dependent practitioner, the modifiers appropriate
2691	to indicate that the service was delivered by the dependent
2692	practitioner.
2693	b.  Collect appropriate information relating to
2694	prescription drugs for each type of patient encounter.
2695	c.  Collect appropriate information related to health care
2696	costs and utilization from managed care plans participating in
2697	the demonstration sites.
2698	5.  To the extent practicable, when collecting the data the
2699	agency shall use a standardized claim form or electronic
2700	transfer system that is used by health care practitioners,
2701	facilities, and payors.
2702	6.  Health care practitioners and facilities in the
2703	demonstration sites shall electronically submit, and managed
2704	care plans participating in the demonstration sites shall
2705	electronically receive, information concerning claims payments
2706	and any other information reasonably related to the encounter
2707	database using a standard format as required by the agency.
2708	7.  The agency shall establish reasonable deadlines for
2709	phasing in the electronic transmittal of full encounter data.
2710	8.  The system must ensure that the data reported is
2711	accurate and complete.
2712	(w)  To implement procedures to minimize the risk of
2713	Medicaid fraud and abuse in all plans operating in the Medicaid
2714	managed care pilot program authorized in this section.
2715	1.  The agency shall ensure that applicable provisions of
2716	this chapter and chapters 414, 626, 641, and 932 which relate to
2717	Medicaid fraud and abuse are applied and enforced at the
2718	demonstration project sites.
2719	2.  Providers must have the certification, license, and
2720	credentials that are required by law and waiver requirements.
2721	3.  The agency shall ensure that the plan is in compliance
2722	with s. 409.912(20) and (21) and (22).
2723	4.  The agency shall require that each plan establish
2724	functions and activities governing program integrity in order to
2725	reduce the incidence of fraud and abuse. Plans must report
2726	instances of fraud and abuse pursuant to chapter 641.
2727	5.  The plan shall have written administrative and
2728	management arrangements or procedures, including a mandatory
2729	compliance plan, which are designed to guard against fraud and
2730	abuse. The plan shall designate a compliance officer who has
2731	sufficient experience in health care.
2732	6.a.  The agency shall require all managed care plan
2733	contractors in the pilot program to report all instances of
2734	suspected fraud and abuse. A failure to report instances of
2735	suspected fraud and abuse is a violation of law and subject to
2736	the penalties provided by law.
2737	b.  An instance of fraud and abuse in the managed care
2738	plan, including, but not limited to, defrauding the state health
2739	care benefit program by misrepresentation of fact in reports,
2740	claims, certifications, enrollment claims, demographic
2741	statistics, or patient-encounter data; misrepresentation of the
2742	qualifications of persons rendering health care and ancillary
2743	services; bribery and false statements relating to the delivery
2744	of health care; unfair and deceptive marketing practices; and
2745	false claims actions in the provision of managed care, is a
2746	violation of law and subject to the penalties provided by law.
2747	c.  The agency shall require that all contractors make all
2748	files and relevant billing and claims data accessible to state
2749	regulators and investigators and that all such data is linked
2750	into a unified system to ensure consistent reviews and
2751	investigations.
2752	(dd)  To implement service delivery mechanisms within a
2753	specialty plan in area 10 to provide behavioral health care
2754	services to Medicaid-eligible children whose cases are open for
2755	child welfare services in the HomeSafeNet system. These services
2756	must be coordinated with community-based care providers as
2757	specified in s. 409.1671, where available, and be sufficient to
2758	meet the developmental, behavioral, and emotional needs of these
2759	children. Children in area 10 who have an open case in the
2760	HomeSafeNet system shall be enrolled into the specialty plan.
2761	These service delivery mechanisms must be implemented no later
2762	than July 1, 2011, in AHCA area 10 in order for the children in
2763	AHCA area 10 to remain exempt from the statewide plan under s.
2764	409.912(4)(b)5.8. An administrative fee may be paid to the
2765	specialty plan for the coordination of services based on the
2766	receipt of the state share of that fee being provided through
2767	intergovernmental transfers.
2768	Section 16.  Effective October 1, 2014, section 409.91211,
2769	Florida Statutes, is repealed.
2770	Section 17.  Section 409.9122, Florida Statutes, is amended
2771	to read:
2772	409.9122  Mandatory Medicaid managed care enrollment;
2773	programs and procedures.-
2774	(1)  It is the intent of the Legislature that the MediPass
2775	program be cost-effective, provide quality health care, and
2776	improve access to health services, and that the program be
2777	statewide. This subsection expires October 1, 2014.
2778	(2)(a)  The agency shall enroll in a managed care plan or
2779	MediPass all Medicaid recipients, except those Medicaid
2780	recipients who are: in an institution; enrolled in the Medicaid
2781	medically needy program; or eligible for both Medicaid and
2782	Medicare. Upon enrollment, individuals will be able to change
2783	their managed care option during the 90-day opt out period
2784	required by federal Medicaid regulations. The agency is
2785	authorized to seek the necessary Medicaid state plan amendment
2786	to implement this policy. However, to the extent permitted by
2787	federal law, the agency may enroll in a managed care plan or
2788	MediPass a Medicaid recipient who is exempt from mandatory
2789	managed care enrollment, provided that:
2790	1.  The recipient's decision to enroll in a managed care
2791	plan or MediPass is voluntary;
2792	2.  If the recipient chooses to enroll in a managed care
2793	plan, the agency has determined that the managed care plan
2794	provides specific programs and services which address the
2795	special health needs of the recipient; and
2796	3.  The agency receives any necessary waivers from the
2797	federal Centers for Medicare and Medicaid Services.
2798
2799	The agency shall develop rules to establish policies by which
2800	exceptions to the mandatory managed care enrollment requirement
2801	may be made on a case-by-case basis. The rules shall include the
2802	specific criteria to be applied when making a determination as
2803	to whether to exempt a recipient from mandatory enrollment in a
2804	managed care plan or MediPass. School districts participating in
2805	the certified school match program pursuant to ss. 409.908(21)
2806	and 1011.70 shall be reimbursed by Medicaid, subject to the
2807	limitations of s. 1011.70(1), for a Medicaid-eligible child
2808	participating in the services as authorized in s. 1011.70, as
2809	provided for in s. 409.9071, regardless of whether the child is
2810	enrolled in MediPass or a managed care plan. Managed care plans
2811	shall make a good faith effort to execute agreements with school
2812	districts regarding the coordinated provision of services
2813	authorized under s. 1011.70. County health departments
2814	delivering school-based services pursuant to ss. 381.0056 and
2815	381.0057 shall be reimbursed by Medicaid for the federal share
2816	for a Medicaid-eligible child who receives Medicaid-covered
2817	services in a school setting, regardless of whether the child is
2818	enrolled in MediPass or a managed care plan. Managed care plans
2819	shall make a good faith effort to execute agreements with county
2820	health departments regarding the coordinated provision of
2821	services to a Medicaid-eligible child. To ensure continuity of
2822	care for Medicaid patients, the agency, the Department of
2823	Health, and the Department of Education shall develop procedures
2824	for ensuring that a student's managed care plan or MediPass
2825	provider receives information relating to services provided in
2826	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2827	(b)  A Medicaid recipient shall not be enrolled in or
2828	assigned to a managed care plan or MediPass unless the managed
2829	care plan or MediPass has complied with the quality-of-care
2830	standards specified in paragraphs (3)(a) and (b), respectively.
2831	(c)  Medicaid recipients shall have a choice of managed
2832	care plans or MediPass. The Agency for Health Care
2833	Administration, the Department of Health, the Department of
2834	Children and Family Services, and the Department of Elderly
2835	Affairs shall cooperate to ensure that each Medicaid recipient
2836	receives clear and easily understandable information that meets
2837	the following requirements:
2838	1.  Explains the concept of managed care, including
2839	MediPass.
2840	2.  Provides information on the comparative performance of
2841	managed care plans and MediPass in the areas of quality,
2842	credentialing, preventive health programs, network size and
2843	availability, and patient satisfaction.
2844	3.  Explains where additional information on each managed
2845	care plan and MediPass in the recipient's area can be obtained.
2846	4.  Explains that recipients have the right to choose their
2847	managed care coverage at the time they first enroll in Medicaid
2848	and again at regular intervals set by the agency. However, if a
2849	recipient does not choose a managed care plan or MediPass, the
2850	agency will assign the recipient to a managed care plan or
2851	MediPass according to the criteria specified in this section.
2852	5.  Explains the recipient's right to complain, file a
2853	grievance, or change managed care plans or MediPass providers if
2854	the recipient is not satisfied with the managed care plan or
2855	MediPass.
2856	(d)  The agency shall develop a mechanism for providing
2857	information to Medicaid recipients for the purpose of making a
2858	managed care plan or MediPass selection. Examples of such
2859	mechanisms may include, but not be limited to, interactive
2860	information systems, mailings, and mass marketing materials.
2861	Managed care plans and MediPass providers are prohibited from
2862	providing inducements to Medicaid recipients to select their
2863	plans or from prejudicing Medicaid recipients against other
2864	managed care plans or MediPass providers.
2865	(e)  Medicaid recipients who are already enrolled in a
2866	managed care plan or MediPass shall be offered the opportunity
2867	to change managed care plans or MediPass providers on a
2868	staggered basis, as defined by the agency. All Medicaid
2869	recipients shall have 30 days in which to make a choice of
2870	managed care plans or MediPass providers. Those Medicaid
2871	recipients who do not make a choice shall be assigned in
2872	accordance with paragraph (f). To facilitate continuity of care,
2873	for a Medicaid recipient who is also a recipient of Supplemental
2874	Security Income (SSI), prior to assigning the SSI recipient to a
2875	managed care plan or MediPass, the agency shall determine
2876	whether the SSI recipient has an ongoing relationship with a
2877	MediPass provider or managed care plan, and if so, the agency
2878	shall assign the SSI recipient to that MediPass provider or
2879	managed care plan. Those SSI recipients who do not have such a
2880	provider relationship shall be assigned to a managed care plan
2881	or MediPass provider in accordance with paragraph (f).
2882	(f)  If a Medicaid recipient does not choose a managed care
2883	plan or MediPass provider, the agency shall assign the Medicaid
2884	recipient to a managed care plan or MediPass provider. Medicaid
2885	recipients eligible for managed care plan enrollment who are
2886	subject to mandatory assignment but who fail to make a choice
2887	shall be assigned to managed care plans until an enrollment of
2888	35 percent in MediPass and 65 percent in managed care plans, of
2889	all those eligible to choose managed care, is achieved. Once
2890	this enrollment is achieved, the assignments shall be divided in
2891	order to maintain an enrollment in MediPass and managed care
2892	plans which is in a 35 percent and 65 percent proportion,
2893	respectively. Thereafter, assignment of Medicaid recipients who
2894	fail to make a choice shall be based proportionally on the
2895	preferences of recipients who have made a choice in the previous
2896	period. Such proportions shall be revised at least quarterly to
2897	reflect an update of the preferences of Medicaid recipients. The
2898	agency shall disproportionately assign Medicaid-eligible
2899	recipients who are required to but have failed to make a choice
2900	of managed care plan or MediPass, including children, and who
2901	would be assigned to the MediPass program to the children's
2902	networks as described in s. 409.912(4)(g), Children's Medical
2903	Services Network as defined in s. 391.021, exclusive provider
2904	organizations, provider service networks, minority physician
2905	networks, and pediatric emergency department diversion programs
2906	authorized by this chapter or the General Appropriations Act, in
2907	such manner as the agency deems appropriate, until the agency
2908	has determined that the networks and programs have sufficient
2909	numbers to be operated economically. For purposes of this
2910	paragraph, when referring to assignment, the term "managed care
2911	plans" includes health maintenance organizations, exclusive
2912	provider organizations, provider service networks, minority
2913	physician networks, Children's Medical Services Network, and
2914	pediatric emergency department diversion programs authorized by
2915	this chapter or the General Appropriations Act. When making
2916	assignments, the agency shall take into account the following
2917	criteria:
2918	1.  A managed care plan has sufficient network capacity to
2919	meet the need of members.
2920	2.  The managed care plan or MediPass has previously
2921	enrolled the recipient as a member, or one of the managed care
2922	plan's primary care providers or MediPass providers has
2923	previously provided health care to the recipient.
2924	3.  The agency has knowledge that the member has previously
2925	expressed a preference for a particular managed care plan or
2926	MediPass provider as indicated by Medicaid fee-for-service
2927	claims data, but has failed to make a choice.
2928	4.  The managed care plan's or MediPass primary care
2929	providers are geographically accessible to the recipient's
2930	residence.
2931	(g)  When more than one managed care plan or MediPass
2932	provider meets the criteria specified in paragraph (f), the
2933	agency shall make recipient assignments consecutively by family
2934	unit.
2935	(h)  The agency may not engage in practices that are
2936	designed to favor one managed care plan over another or that are
2937	designed to influence Medicaid recipients to enroll in MediPass
2938	rather than in a managed care plan or to enroll in a managed
2939	care plan rather than in MediPass. This subsection does not
2940	prohibit the agency from reporting on the performance of
2941	MediPass or any managed care plan, as measured by performance
2942	criteria developed by the agency.
2943	(i)  After a recipient has made his or her selection or has
2944	been enrolled in a managed care plan or MediPass, the recipient
2945	shall have 90 days to exercise the opportunity to voluntarily
2946	disenroll and select another managed care plan or MediPass.
2947	After 90 days, no further changes may be made except for good
2948	cause. Good cause includes, but is not limited to, poor quality
2949	of care, lack of access to necessary specialty services, an
2950	unreasonable delay or denial of service, or fraudulent
2951	enrollment. The agency shall develop criteria for good cause
2952	disenrollment for chronically ill and disabled populations who
2953	are assigned to managed care plans if more appropriate care is
2954	available through the MediPass program. The agency must make a
2955	determination as to whether cause exists. However, the agency
2956	may require a recipient to use the managed care plan's or
2957	MediPass grievance process prior to the agency's determination
2958	of cause, except in cases in which immediate risk of permanent
2959	damage to the recipient's health is alleged. The grievance
2960	process, when utilized, must be completed in time to permit the
2961	recipient to disenroll by the first day of the second month
2962	after the month the disenrollment request was made. If the
2963	managed care plan or MediPass, as a result of the grievance
2964	process, approves an enrollee's request to disenroll, the agency
2965	is not required to make a determination in the case. The agency
2966	must make a determination and take final action on a recipient's
2967	request so that disenrollment occurs no later than the first day
2968	of the second month after the month the request was made. If the
2969	agency fails to act within the specified timeframe, the
2970	recipient's request to disenroll is deemed to be approved as of
2971	the date agency action was required. Recipients who disagree
2972	with the agency's finding that cause does not exist for
2973	disenrollment shall be advised of their right to pursue a
2974	Medicaid fair hearing to dispute the agency's finding.
2975	(j)  The agency shall apply for a federal waiver from the
2976	Centers for Medicare and Medicaid Services to lock eligible
2977	Medicaid recipients into a managed care plan or MediPass for 12
2978	months after an open enrollment period. After 12 months'
2979	enrollment, a recipient may select another managed care plan or
2980	MediPass provider. However, nothing shall prevent a Medicaid
2981	recipient from changing primary care providers within the
2982	managed care plan or MediPass program during the 12-month
2983	period.
2984	(k)  When a Medicaid recipient does not choose a managed
2985	care plan or MediPass provider, the agency shall assign the
2986	Medicaid recipient to a managed care plan, except in those
2987	counties in which there are fewer than two managed care plans
2988	accepting Medicaid enrollees, in which case assignment shall be
2989	to a managed care plan or a MediPass provider. Medicaid
2990	recipients in counties with fewer than two managed care plans
2991	accepting Medicaid enrollees who are subject to mandatory
2992	assignment but who fail to make a choice shall be assigned to
2993	managed care plans until an enrollment of 35 percent in MediPass
2994	and 65 percent in managed care plans, of all those eligible to
2995	choose managed care, is achieved. Once that enrollment is
2996	achieved, the assignments shall be divided in order to maintain
2997	an enrollment in MediPass and managed care plans which is in a
2998	35 percent and 65 percent proportion, respectively. For purposes
2999	of this paragraph, when referring to assignment, the term
3000	"managed care plans" includes exclusive provider organizations,
3001	provider service networks, Children's Medical Services Network,
3002	minority physician networks, and pediatric emergency department
3003	diversion programs authorized by this chapter or the General
3004	Appropriations Act. When making assignments, the agency shall
3005	take into account the following criteria:
3006	1.  A managed care plan has sufficient network capacity to
3007	meet the need of members.
3008	2.  The managed care plan or MediPass has previously
3009	enrolled the recipient as a member, or one of the managed care
3010	plan's primary care providers or MediPass providers has
3011	previously provided health care to the recipient.
3012	3.  The agency has knowledge that the member has previously
3013	expressed a preference for a particular managed care plan or
3014	MediPass provider as indicated by Medicaid fee-for-service
3015	claims data, but has failed to make a choice.
3016	4.  The managed care plan's or MediPass primary care
3017	providers are geographically accessible to the recipient's
3018	residence.
3019	5.  The agency has authority to make mandatory assignments
3020	based on quality of service and performance of managed care
3021	plans.
3022	(l)  Notwithstanding the provisions of chapter 287, the
3023	agency may, at its discretion, renew cost-effective contracts
3024	for choice counseling services once or more for such periods as
3025	the agency may decide. However, all such renewals may not
3026	combine to exceed a total period longer than the term of the
3027	original contract.
3028
3029	This subsection expires October 1, 2014.
3030	(3)(a)  The agency shall establish quality-of-care
3031	standards for managed care plans. These standards shall be based
3032	upon, but are not limited to:
3033	1.  Compliance with the accreditation requirements as
3034	provided in s. 641.512.
3035	2.  Compliance with Early and Periodic Screening,
3036	Diagnosis, and Treatment screening requirements.
3037	3.  The percentage of voluntary disenrollments.
3038	4.  Immunization rates.
3039	5.  Standards of the National Committee for Quality
3040	Assurance and other approved accrediting bodies.
3041	6.  Recommendations of other authoritative bodies.
3042	7.  Specific requirements of the Medicaid program, or
3043	standards designed to specifically assist the unique needs of
3044	Medicaid recipients.
3045	8.  Compliance with the health quality improvement system
3046	as established by the agency, which incorporates standards and
3047	guidelines developed by the Medicaid Bureau of the Health Care
3048	Financing Administration as part of the quality assurance reform
3049	initiative.
3050	(b)  For the MediPass program, the agency shall establish
3051	standards which are based upon, but are not limited to:
3052	1.  Quality-of-care standards which are comparable to those
3053	required of managed care plans.
3054	2.  Credentialing standards for MediPass providers.
3055	3.  Compliance with Early and Periodic Screening,
3056	Diagnosis, and Treatment screening requirements.
3057	4.  Immunization rates.
3058	5.  Specific requirements of the Medicaid program, or
3059	standards designed to specifically assist the unique needs of
3060	Medicaid recipients.
3061
3062	This subsection expires October 1, 2014.
3063	(4)(a)  Each female recipient may select as her primary
3064	care provider an obstetrician/gynecologist who has agreed to
3065	participate as a MediPass primary care case manager.
3066	(b)  The agency shall establish a complaints and grievance
3067	process to assist Medicaid recipients enrolled in the MediPass
3068	program to resolve complaints and grievances. The agency shall
3069	investigate reports of quality-of-care grievances which remain
3070	unresolved to the satisfaction of the enrollee.
3071
3072	This subsection expires October 1, 2014.
3073	(5)(a)  The agency shall work cooperatively with the Social
3074	Security Administration to identify beneficiaries who are
3075	jointly eligible for Medicare and Medicaid and shall develop
3076	cooperative programs to encourage these beneficiaries to enroll
3077	in a Medicare participating health maintenance organization or
3078	prepaid health plans.
3079	(b)  The agency shall work cooperatively with the
3080	Department of Elderly Affairs to assess the potential cost-
3081	effectiveness of providing MediPass to beneficiaries who are
3082	jointly eligible for Medicare and Medicaid on a voluntary choice
3083	basis. If the agency determines that enrollment of these
3084	beneficiaries in MediPass has the potential for being cost-
3085	effective for the state, the agency shall offer MediPass to
3086	these beneficiaries on a voluntary choice basis in the counties
3087	where MediPass operates.
3088
3089	This subsection expires October 1, 2014.
3090	(6)  MediPass enrolled recipients may receive up to 10
3091	visits of reimbursable services by participating Medicaid
3092	physicians licensed under chapter 460 and up to four visits of
3093	reimbursable services by participating Medicaid physicians
3094	licensed under chapter 461. Any further visits must be by prior
3095	authorization by the MediPass primary care provider. However,
3096	nothing in this subsection may be construed to increase the
3097	total number of visits or the total amount of dollars per year
3098	per person under current Medicaid rules, unless otherwise
3099	provided for in the General Appropriations Act. This subsection
3100	expires October 1, 2014.
3101	(7)  The agency shall investigate the feasibility of
3102	developing managed care plan and MediPass options for the
3103	following groups of Medicaid recipients:
3104	(a)  Pregnant women and infants.
3105	(b)  Elderly and disabled recipients, especially those who
3106	are at risk of nursing home placement.
3107	(c)  Persons with developmental disabilities.
3108	(d)  Qualified Medicare beneficiaries.
3109	(e)  Adults who have chronic, high-cost medical conditions.
3110	(f)  Adults and children who have mental health problems.
3111	(g)  Other recipients for whom managed care plans and
3112	MediPass offer the opportunity of more cost-effective care and
3113	greater access to qualified providers.
3114	(8)(a)  The agency shall encourage the development of
3115	public and private partnerships to foster the growth of health
3116	maintenance organizations and prepaid health plans that will
3117	provide high-quality health care to Medicaid recipients.
3118	(b)  Subject to the availability of moneys and any
3119	limitations established by the General Appropriations Act or
3120	chapter 216, the agency is authorized to enter into contracts
3121	with traditional providers of health care to low-income persons
3122	to assist such providers with the technical aspects of
3123	cooperatively developing Medicaid prepaid health plans.
3124	1.  The agency may contract with disproportionate share
3125	hospitals, county health departments, federally initiated or
3126	federally funded community health centers, and counties that
3127	operate either a hospital or a community clinic.
3128	2.  A contract may not be for more than $100,000 per year,
3129	and no contract may be extended with any particular provider for
3130	more than 2 years. The contract is intended only as seed or
3131	development funding and requires a commitment from the
3132	interested party.
3133	3.  A contract must require participation by at least one
3134	community health clinic and one disproportionate share hospital.
3135	(7)(9)(a)  The agency shall develop and implement a
3136	comprehensive plan to ensure that recipients are adequately
3137	informed of their choices and rights under all Medicaid managed
3138	care programs and that Medicaid managed care programs meet
3139	acceptable standards of quality in patient care, patient
3140	satisfaction, and financial solvency.
3141	(b)  The agency shall provide adequate means for informing
3142	patients of their choice and rights under a managed care plan at
3143	the time of eligibility determination.
3144	(c)  The agency shall require managed care plans and
3145	MediPass providers to demonstrate and document plans and
3146	activities, as defined by rule, including outreach and followup,
3147	undertaken to ensure that Medicaid recipients receive the health
3148	care service to which they are entitled.
3149
3150	This subsection expires October 1, 2014.
3151	(8)(10)  The agency shall consult with Medicaid consumers
3152	and their representatives on an ongoing basis regarding
3153	measurements of patient satisfaction, procedures for resolving
3154	patient grievances, standards for ensuring quality of care,
3155	mechanisms for providing patient access to services, and
3156	policies affecting patient care. This subsection expires October
3157	1, 2014.
3158	(9)(11)  The agency may extend eligibility for Medicaid
3159	recipients enrolled in licensed and accredited health
3160	maintenance organizations for the duration of the enrollment
3161	period or for 6 months, whichever is earlier, provided the
3162	agency certifies that such an offer will not increase state
3163	expenditures. This subsection expires October 1, 2013.
3164	(10)(12)  A managed care plan that has a Medicaid contract
3165	shall at least annually review each primary care physician's
3166	active patient load and shall ensure that additional Medicaid
3167	recipients are not assigned to physicians who have a total
3168	active patient load of more than 3,000 patients. As used in this
3169	subsection, the term "active patient" means a patient who is
3170	seen by the same primary care physician, or by a physician
3171	assistant or advanced registered nurse practitioner under the
3172	supervision of the primary care physician, at least three times
3173	within a calendar year. Each primary care physician shall
3174	annually certify to the managed care plan whether or not his or
3175	her patient load exceeds the limits established under this
3176	subsection and the managed care plan shall accept such
3177	certification on face value as compliance with this subsection.
3178	The agency shall accept the managed care plan's representations
3179	that it is in compliance with this subsection based on the
3180	certification of its primary care physicians, unless the agency
3181	has an objective indication that access to primary care is being
3182	compromised, such as receiving complaints or grievances relating
3183	to access to care. If the agency determines that an objective
3184	indication exists that access to primary care is being
3185	compromised, it may verify the patient load certifications
3186	submitted by the managed care plan's primary care physicians and
3187	that the managed care plan is not assigning Medicaid recipients
3188	to primary care physicians who have an active patient load of
3189	more than 3,000 patients. This subsection expires October 1,
3190	2014.
3191	(11)(13)  Effective July 1, 2003, the agency shall adjust
3192	the enrollee assignment process of Medicaid managed prepaid
3193	health plans for those Medicaid managed prepaid plans operating
3194	in Miami-Dade County which have executed a contract with the
3195	agency for a minimum of 8 consecutive years in order for the
3196	Medicaid managed prepaid plan to maintain a minimum enrollment
3197	level of 15,000 members per month. When assigning enrollees
3198	pursuant to this subsection, the agency shall give priority to
3199	providers that initially qualified under this subsection until
3200	such providers reach and maintain an enrollment level of 15,000
3201	members per month. A prepaid health plan that has a statewide
3202	Medicaid enrollment of 25,000 or more members is not eligible
3203	for enrollee assignments under this subsection. This subsection
3204	expires October 1, 2014.
3205	(12)(14)  The agency shall include in its calculation of
3206	the hospital inpatient component of a Medicaid health
3207	maintenance organization's capitation rate any special payments,
3208	including, but not limited to, upper payment limit or
3209	disproportionate share hospital payments, made to qualifying
3210	hospitals through the fee-for-service program. The agency may
3211	seek federal waiver approval or state plan amendment as needed
3212	to implement this adjustment.
3213	(13)  The agency shall develop a process to enable any
3214	recipient with access to employer-sponsored health care coverage
3215	to opt out of all eligible plans in the Medicaid program and to
3216	use Medicaid financial assistance to pay for the recipient's
3217	share of cost in any such employer-sponsored coverage.
3218	Contingent on federal approval, the agency shall also enable
3219	recipients with access to other insurance or related products
3220	that provide access to health care services created pursuant to
3221	state law, including any plan or product available pursuant to
3222	the Florida Health Choices Program or any health exchange, to
3223	opt out. The amount of financial assistance provided for each
3224	recipient may not exceed the amount of the Medicaid premium that
3225	would have been paid to a plan for that recipient.
3226	(14)  The agency shall maintain and operate the Medicaid
3227	Encounter Data System to collect, process, store, and report on
3228	covered services provided to all Florida Medicaid recipients
3229	enrolled in prepaid managed care plans.
3230	(a)  Prepaid managed care plans shall submit encounter data
3231	electronically in a format that complies with the Health
3232	Insurance Portability and Accountability Act provisions for
3233	electronic claims and in accordance with deadlines established
3234	by the agency. Prepaid managed care plans must certify that the
3235	data reported is accurate and complete.
3236	(b)  The agency is responsible for validating the data
3237	submitted by the plans. The agency shall develop methods and
3238	protocols for ongoing analysis of the encounter data that
3239	adjusts for differences in characteristics of prepaid plan
3240	enrollees to allow comparison of service utilization among plans
3241	and against expected levels of use. The analysis shall be used
3242	to identify possible cases of systemic underutilization or
3243	denials of claims and inappropriate service utilization such as
3244	higher-than-expected emergency department encounters. The
3245	analysis shall provide periodic feedback to the plans and enable
3246	the agency to establish corrective action plans when necessary.
3247	One of the focus areas for the analysis shall be the use of
3248	prescription drugs.
3249	(15)  The agency may establish a per-member, per-month
3250	payment for Medicare Advantage Special Needs members that are
3251	also eligible for Medicaid as a mechanism for meeting the
3252	state's cost-sharing obligation. The agency may also develop a
3253	per-member, per-month payment only for Medicaid-covered services
3254	for which the state is responsible. The agency shall develop a
3255	mechanism to ensure that such per-member, per-month payment
3256	enhances the value to the state and enrolled members by limiting
3257	cost sharing, enhances the scope of Medicare supplemental
3258	benefits that are equal to or greater than Medicaid coverage for
3259	select services, and improves care coordination.
3260	(16)  The agency shall establish, and managed care plans
3261	shall use, a uniform method of accounting for and reporting
3262	medical and nonmedical costs. The agency shall make such
3263	information available to the public.
3264	(17)  The agency may, on a case-by-case basis, exempt a
3265	recipient from mandatory enrollment in a managed care plan when
3266	the recipient has a unique, time-limited disease or condition-
3267	related circumstance and managed care enrollment will interfere
3268	with ongoing care because the recipient's provider does not
3269	participate in the managed care plans available in the
3270	recipient's area.
3271	(18)  The agency shall contract with a single provider
3272	service network to function as a third-party administrator and
3273	managing entity for the MediPass program in all counties with
3274	fewer than two prepaid plans. The contractor may earn an
3275	administrative fee, if the fee is less than any savings
3276	determined by the reconciliation process pursuant to s.
3277	409.912(4)(d)1. This subsection expires October 1, 2014, or upon
3278	full implementation of the managed medical assistance program,
3279	whichever is sooner.
3280	(19)  Subject to federal approval, the agency shall
3281	contract with a single provider service network to function as a
3282	third-party administrator and managing entity for the Medically
3283	Needy program in all counties. The contractor shall provide care
3284	coordination and utilization management in order to achieve more
3285	cost-effective services for Medically Needy enrollees. To
3286	facilitate the care management functions of the provider service
3287	network, enrollment in the network shall be for a continuous 6-
3288	month period or until the end of the contract between the
3289	provider service network and the agency, whichever is sooner.
3290	Beginning the second month after the determination of
3291	eligibility, the contractor may collect a monthly premium from
3292	each Medically Needy recipient provided the premium does not
3293	exceed the enrollee's share of cost as determined by the
3294	Department of Children and Family Services. The contractor must
3295	provide a 90-day grace period before disenrolling a Medically
3296	Needy recipient for failure to pay premiums. The contractor may
3297	earn an administrative fee, if the fee is less than any savings
3298	determined by the reconciliation process pursuant to s.
3299	409.912(4)(d)1. Premium revenue collected from the recipients
3300	shall be deducted from the contractor's earned savings. This
3301	subsection expires October 1, 2014, or upon full implementation
3302	of the managed medical assistance program, whichever is sooner.
3303	Section 18.  Subsection (15) of section 430.04, Florida
3304	Statutes, is amended to read:
3305	430.04  Duties and responsibilities of the Department of
3306	Elderly Affairs.-The Department of Elderly Affairs shall:
3307	(15)  Administer all Medicaid waivers and programs relating
3308	to elders and their appropriations. The waivers include, but are
3309	not limited to:
3310	(a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3311	established in s. 430.502(7), (8), and (9).
3312	(a)(b)  The Assisted Living for the Frail Elderly Waiver.
3313	(b)(c)  The Aged and Disabled Adult Waiver.
3314	(c)(d)  The Adult Day Health Care Waiver.
3315	(d)(e)  The Consumer-Directed Care Plus Program as defined
3316	in s. 409.221.
3317	(e)(f)  The Program of All-inclusive Care for the Elderly.
3318	(f)(g)  The Long-Term Care Community-Based Diversion Pilot
3319	Project as described in s. 430.705.
3320	(g)(h)  The Channeling Services Waiver for Frail Elders.
3321
3322	The department shall develop a transition plan for recipients
3323	receiving services in long-term care Medicaid waivers for elders
3324	or disabled adults on the date eligible plans become available
3325	in each recipient's region defined in s. 409.981(2) to enroll
3326	those recipients in eligible plans. This subsection expires
3327	October 1, 2014.
3328	Section 19.  Section 430.2053, Florida Statutes, is amended
3329	to read:
3330	430.2053  Aging resource centers.-
3331	(1)  The department, in consultation with the Agency for
3332	Health Care Administration and the Department of Children and
3333	Family Services, shall develop pilot projects for aging resource
3334	centers. By October 31, 2004, the department, in consultation
3335	with the agency and the Department of Children and Family
3336	Services, shall develop an implementation plan for aging
3337	resource centers and submit the plan to the Governor, the
3338	President of the Senate, and the Speaker of the House of
3339	Representatives. The plan must include qualifications for
3340	designation as a center, the functions to be performed by each
3341	center, and a process for determining that a current area agency
3342	on aging is ready to assume the functions of an aging resource
3343	center.
3344	(2)  Each area agency on aging shall develop, in
3345	consultation with the existing community care for the elderly
3346	lead agencies within their planning and service areas, a
3347	proposal that describes the process the area agency on aging
3348	intends to undertake to transition to an aging resource center
3349	prior to July 1, 2005, and that describes the area agency's
3350	compliance with the requirements of this section. The proposals
3351	must be submitted to the department prior to December 31, 2004.
3352	The department shall evaluate all proposals for readiness and,
3353	prior to March 1, 2005, shall select three area agencies on
3354	aging which meet the requirements of this section to begin the
3355	transition to aging resource centers. Those area agencies on
3356	aging which are not selected to begin the transition to aging
3357	resource centers shall, in consultation with the department and
3358	the existing community care for the elderly lead agencies within
3359	their planning and service areas, amend their proposals as
3360	necessary and resubmit them to the department prior to July 1,
3361	2005. The department may transition additional area agencies to
3362	aging resource centers as it determines that area agencies are
3363	in compliance with the requirements of this section.
3364	(3)  The Auditor General and the Office of Program Policy
3365	Analysis and Government Accountability (OPPAGA) shall jointly
3366	review and assess the department's process for determining an
3367	area agency's readiness to transition to an aging resource
3368	center.
3369	(a)  The review must, at a minimum, address the
3370	appropriateness of the department's criteria for selection of an
3371	area agency to transition to an aging resource center, the
3372	instruments applied, the degree to which the department
3373	accurately determined each area agency's compliance with the
3374	readiness criteria, the quality of the technical assistance
3375	provided by the department to an area agency in correcting any
3376	weaknesses identified in the readiness assessment, and the
3377	degree to which each area agency overcame any identified
3378	weaknesses.
3379	(b)  Reports of these reviews must be submitted to the
3380	appropriate substantive and appropriations committees in the
3381	Senate and the House of Representatives on March 1 and September
3382	1 of each year until full transition to aging resource centers
3383	has been accomplished statewide, except that the first report
3384	must be submitted by February 1, 2005, and must address all
3385	readiness activities undertaken through December 31, 2004. The
3386	perspectives of all participants in this review process must be
3387	included in each report.
3388	(2)(4)  The purposes of an aging resource center shall be:
3389	(a)  To provide Florida's elders and their families with a
3390	locally focused, coordinated approach to integrating information
3391	and referral for all available services for elders with the
3392	eligibility determination entities for state and federally
3393	funded long-term-care services.
3394	(b)  To provide for easier access to long-term-care
3395	services by Florida's elders and their families by creating
3396	multiple access points to the long-term-care network that flow
3397	through one established entity with wide community recognition.
3398	(3)(5)  The duties of an aging resource center are to:
3399	(a)  Develop referral agreements with local community
3400	service organizations, such as senior centers, existing elder
3401	service providers, volunteer associations, and other similar
3402	organizations, to better assist clients who do not need or do
3403	not wish to enroll in programs funded by the department or the
3404	agency. The referral agreements must also include a protocol,
3405	developed and approved by the department, which provides
3406	specific actions that an aging resource center and local
3407	community service organizations must take when an elder or an
3408	elder's representative seeking information on long-term-care
3409	services contacts a local community service organization prior
3410	to contacting the aging resource center. The protocol shall be
3411	designed to ensure that elders and their families are able to
3412	access information and services in the most efficient and least
3413	cumbersome manner possible.
3414	(b)  Provide an initial screening of all clients who
3415	request long-term-care services to determine whether the person
3416	would be most appropriately served through any combination of
3417	federally funded programs, state-funded programs, locally funded
3418	or community volunteer programs, or private funding for
3419	services.
3420	(c)  Determine eligibility for the programs and services
3421	listed in subsection (9) (11) for persons residing within the
3422	geographic area served by the aging resource center and
3423	determine a priority ranking for services which is based upon
3424	the potential recipient's frailty level and likelihood of
3425	institutional placement without such services.
3426	(d)  Manage the availability of financial resources for the
3427	programs and services listed in subsection (9) (11) for persons
3428	residing within the geographic area served by the aging resource
3429	center.
3430	(e)  When financial resources become available, refer a
3431	client to the most appropriate entity to begin receiving
3432	services. The aging resource center shall make referrals to lead
3433	agencies for service provision that ensure that individuals who
3434	are vulnerable adults in need of services pursuant to s.
3435	415.104(3)(b), or who are victims of abuse, neglect, or
3436	exploitation in need of immediate services to prevent further
3437	harm and are referred by the adult protective services program,
3438	are given primary consideration for receiving community-care-
3439	for-the-elderly services in compliance with the requirements of
3440	s. 430.205(5)(a) and that other referrals for services are in
3441	compliance with s. 430.205(5)(b).
3442	(f)  Convene a work group to advise in the planning,
3443	implementation, and evaluation of the aging resource center. The
3444	work group shall be comprised of representatives of local
3445	service providers, Alzheimer's Association chapters, housing
3446	authorities, social service organizations, advocacy groups,
3447	representatives of clients receiving services through the aging
3448	resource center, and any other persons or groups as determined
3449	by the department. The aging resource center, in consultation
3450	with the work group, must develop annual program improvement
3451	plans that shall be submitted to the department for
3452	consideration. The department shall review each annual
3453	improvement plan and make recommendations on how to implement
3454	the components of the plan.
3455	(g)  Enhance the existing area agency on aging in each
3456	planning and service area by integrating, either physically or
3457	virtually, the staff and services of the area agency on aging
3458	with the staff of the department's local CARES Medicaid nursing
3459	home preadmission screening unit and a sufficient number of
3460	staff from the Department of Children and Family Services'
3461	Economic Self-Sufficiency Unit necessary to determine the
3462	financial eligibility for all persons age 60 and older residing
3463	within the area served by the aging resource center that are
3464	seeking Medicaid services, Supplemental Security Income, and
3465	food assistance.
3466	(h)  Assist clients who request long-term care services in
3467	being evaluated for eligibility for enrollment in the Medicaid
3468	long-term care managed care program as eligible plans become
3469	available in each of the regions pursuant to s. 409.981(2).
3470	(i)  Provide choice counseling for the Medicaid long-term
3471	care managed care program by integrating, either physically or
3472	virtually, choice counseling staff and services as eligible
3473	plans become available in each of the regions pursuant to s.
3474	409.981(2). Pursuant to s. 409.984(1), the agency may contract
3475	directly with the aging resource center to provide choice
3476	counseling services or may contract with another vendor if the
3477	aging resource center does not choose to provide such services.
3478	(j)  Assist Medicaid recipients enrolled in the Medicaid
3479	long-term care managed care program with informally resolving
3480	grievances with a managed care network and assist Medicaid
3481	recipients in accessing the managed care network's formal
3482	grievance process as eligible plans become available in each of
3483	the regions defined in s. 409.981(2).
3484	(4)(6)  The department shall select the entities to become
3485	aging resource centers based on each entity's readiness and
3486	ability to perform the duties listed in subsection (3) (5) and
3487	the entity's:
3488	(a)  Expertise in the needs of each target population the
3489	center proposes to serve and a thorough knowledge of the
3490	providers that serve these populations.
3491	(b)  Strong connections to service providers, volunteer
3492	agencies, and community institutions.
3493	(c)  Expertise in information and referral activities.
3494	(d)  Knowledge of long-term-care resources, including
3495	resources designed to provide services in the least restrictive
3496	setting.
3497	(e)  Financial solvency and stability.
3498	(f)  Ability to collect, monitor, and analyze data in a
3499	timely and accurate manner, along with systems that meet the
3500	department's standards.
3501	(g)  Commitment to adequate staffing by qualified personnel
3502	to effectively perform all functions.
3503	(h)  Ability to meet all performance standards established
3504	by the department.
3505	(5)(7)  The aging resource center shall have a governing
3506	body which shall be the same entity described in s. 20.41(7),
3507	and an executive director who may be the same person as
3508	described in s. 20.41(7). The governing body shall annually
3509	evaluate the performance of the executive director.
3510	(6)(8)  The aging resource center may not be a provider of
3511	direct services other than choice counseling as eligible plans
3512	become available in each of the regions defined in s.
3513	409.981(2), information and referral services, and screening.
3514	(7)(9)  The aging resource center must agree to allow the
3515	department to review any financial information the department
3516	determines is necessary for monitoring or reporting purposes,
3517	including financial relationships.
3518	(8)(10)  The duties and responsibilities of the community
3519	care for the elderly lead agencies within each area served by an
3520	aging resource center shall be to:
3521	(a)  Develop strong community partnerships to maximize the
3522	use of community resources for the purpose of assisting elders
3523	to remain in their community settings for as long as it is
3524	safely possible.
3525	(b)  Conduct comprehensive assessments of clients that have
3526	been determined eligible and develop a care plan consistent with
3527	established protocols that ensures that the unique needs of each
3528	client are met.
3529	(9)(11)  The services to be administered through the aging
3530	resource center shall include those funded by the following
3531	programs:
3532	(a)  Community care for the elderly.
3533	(b)  Home care for the elderly.
3534	(c)  Contracted services.
3535	(d)  Alzheimer's disease initiative.
3536	(e)  Aged and disabled adult Medicaid waiver. This
3537	paragraph expires October 1, 2013.
3538	(f)  Assisted living for the frail elderly Medicaid waiver.
3539	This paragraph expires October 1, 2013.
3540	(g)  Older Americans Act.
3541	(10)(12)  The department shall, prior to designation of an
3542	aging resource center, develop by rule operational and quality
3543	assurance standards and outcome measures to ensure that clients
3544	receiving services through all long-term-care programs
3545	administered through an aging resource center are receiving the
3546	appropriate care they require and that contractors and
3547	subcontractors are adhering to the terms of their contracts and
3548	are acting in the best interests of the clients they are
3549	serving, consistent with the intent of the Legislature to reduce
3550	the use of and cost of nursing home care. The department shall
3551	by rule provide operating procedures for aging resource centers,
3552	which shall include:
3553	(a)  Minimum standards for financial operation, including
3554	audit procedures.
3555	(b)  Procedures for monitoring and sanctioning of service
3556	providers.
3557	(c)  Minimum standards for technology utilized by the aging
3558	resource center.
3559	(d)  Minimum staff requirements which shall ensure that the
3560	aging resource center employs sufficient quality and quantity of
3561	staff to adequately meet the needs of the elders residing within
3562	the area served by the aging resource center.
3563	(e)  Minimum accessibility standards, including hours of
3564	operation.
3565	(f)  Minimum oversight standards for the governing body of
3566	the aging resource center to ensure its continuous involvement
3567	in, and accountability for, all matters related to the
3568	development, implementation, staffing, administration, and
3569	operations of the aging resource center.
3570	(g)  Minimum education and experience requirements for
3571	executive directors and other executive staff positions of aging
3572	resource centers.
3573	(h)  Minimum requirements regarding any executive staff
3574	positions that the aging resource center must employ and minimum
3575	requirements that a candidate must meet in order to be eligible
3576	for appointment to such positions.
3577	(11)(13)  In an area in which the department has designated
3578	an area agency on aging as an aging resource center, the
3579	department and the agency shall not make payments for the
3580	services listed in subsection (9) (11) and the Long-Term Care
3581	Community Diversion Project for such persons who were not
3582	screened and enrolled through the aging resource center. The
3583	department shall cease making payments for recipients in
3584	eligible plans as eligible plans become available in each of the
3585	regions defined in s. 409.981(2).
3586	(12)(14)  Each aging resource center shall enter into a
3587	memorandum of understanding with the department for
3588	collaboration with the CARES unit staff. The memorandum of
3589	understanding shall outline the staff person responsible for
3590	each function and shall provide the staffing levels necessary to
3591	carry out the functions of the aging resource center.
3592	(13)(15)  Each aging resource center shall enter into a
3593	memorandum of understanding with the Department of Children and
3594	Family Services for collaboration with the Economic Self-
3595	Sufficiency Unit staff. The memorandum of understanding shall
3596	outline which staff persons are responsible for which functions
3597	and shall provide the staffing levels necessary to carry out the
3598	functions of the aging resource center.
3599	(14)  As eligible plans become available in each of the
3600	regions defined in s. 409.981(2), if an aging resource center
3601	does not contract with the agency to provide Medicaid long-term
3602	care managed care choice counseling pursuant to s. 409.984(1),
3603	the aging resource center shall enter into a memorandum of
3604	understanding with the agency to coordinate staffing and
3605	collaborate with the choice counseling vendor. The memorandum of
3606	understanding shall identify the staff responsible for each
3607	function and shall provide the staffing levels necessary to
3608	carry out the functions of the aging resource center.
3609	(15)(16)  If any of the state activities described in this
3610	section are outsourced, either in part or in whole, the contract
3611	executing the outsourcing shall mandate that the contractor or
3612	its subcontractors shall, either physically or virtually,
3613	execute the provisions of the memorandum of understanding
3614	instead of the state entity whose function the contractor or
3615	subcontractor now performs.
3616	(16)(17)  In order to be eligible to begin transitioning to
3617	an aging resource center, an area agency on aging board must
3618	ensure that the area agency on aging which it oversees meets all
3619	of the minimum requirements set by law and in rule.
3620	(18)  The department shall monitor the three initial
3621	projects for aging resource centers and report on the progress
3622	of those projects to the Governor, the President of the Senate,
3623	and the Speaker of the House of Representatives by June 30,
3624	2005. The report must include an evaluation of the
3625	implementation process.
3626	(17)(19)(a)  Once an aging resource center is operational,
3627	the department, in consultation with the agency, may develop
3628	capitation rates for any of the programs administered through
3629	the aging resource center. Capitation rates for programs shall
3630	be based on the historical cost experience of the state in
3631	providing those same services to the population age 60 or older
3632	residing within each area served by an aging resource center.
3633	Each capitated rate may vary by geographic area as determined by
3634	the department.
3635	(b)  The department and the agency may determine for each
3636	area served by an aging resource center whether it is
3637	appropriate, consistent with federal and state laws and
3638	regulations, to develop and pay separate capitated rates for
3639	each program administered through the aging resource center or
3640	to develop and pay capitated rates for service packages which
3641	include more than one program or service administered through
3642	the aging resource center.
3643	(c)  Once capitation rates have been developed and
3644	certified as actuarially sound, the department and the agency
3645	may pay service providers the capitated rates for services when
3646	appropriate.
3647	(d)  The department, in consultation with the agency, shall
3648	annually reevaluate and recertify the capitation rates,
3649	adjusting forward to account for inflation, programmatic
3650	changes.
3651	(20)  The department, in consultation with the agency,
3652	shall submit to the Governor, the President of the Senate, and
3653	the Speaker of the House of Representatives, by December 1,
3654	2006, a report addressing the feasibility of administering the
3655	following services through aging resource centers beginning July
3656	1, 2007:
3657	(a)  Medicaid nursing home services.
3658	(b)  Medicaid transportation services.
3659	(c)  Medicaid hospice care services.
3660	(d)  Medicaid intermediate care services.
3661	(e)  Medicaid prescribed drug services.
3662	(f)  Medicaid assistive care services.
3663	(g)  Any other long-term-care program or Medicaid service.
3664	(18)(21)  This section shall not be construed to allow an
3665	aging resource center to restrict, manage, or impede the local
3666	fundraising activities of service providers.
3667	Section 20.  Effective October 1, 2013, sections 430.701,
3668	430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3669	430.708, and 430.709, Florida Statutes, are repealed.
3670	Section 21.  Sections 409.9301, 409.942, 409.944, 409.945,
3671	409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3672	as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3673	402.87, Florida Statutes, respectively.
3674	Section 22.  Paragraph (a) of subsection (1) of section
3675	443.111, Florida Statutes, is amended to read:
3676	443.111  Payment of benefits.-
3677	(1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3678	in accordance with rules adopted by the Agency for Workforce
3679	Innovation, subject to the following requirements:
3680	(a)  Benefits are payable by mail or electronically.
3681	Notwithstanding s. 402.84(4) s. 409.942(4), the agency may
3682	develop a system for the payment of benefits by electronic funds
3683	transfer, including, but not limited to, debit cards, electronic
3684	payment cards, or any other means of electronic payment that the
3685	agency deems to be commercially viable or cost-effective.
3686	Commodities or services related to the development of such a
3687	system shall be procured by competitive solicitation, unless
3688	they are purchased from a state term contract pursuant to s.
3689	287.056. The agency shall adopt rules necessary to administer
3690	the system.
3691	Section 23.  Subsection (4) of section 641.386, Florida
3692	Statutes, is amended to read:
3693	641.386  Agent licensing and appointment required;
3694	exceptions.-
3695	(4)  All agents and health maintenance organizations shall
3696	comply with and be subject to the applicable provisions of ss.
3697	641.309 and 409.912(20)(21), and all companies and entities
3698	appointing agents shall comply with s. 626.451, when marketing
3699	for any health maintenance organization licensed pursuant to
3700	this part, including those organizations under contract with the
3701	Agency for Health Care Administration to provide health care
3702	services to Medicaid recipients or any private entity providing
3703	health care services to Medicaid recipients pursuant to a
3704	prepaid health plan contract with the Agency for Health Care
3705	Administration.
3706	Section 24.  Subsections (6) and (7) of section 766.118,
3707	Florida Statutes, are renumbered as subsections (7) and (8),
3708	respectively, and a new subsection (6) is added to that section,
3709	to read:
3710	766.118  Determination of noneconomic damages.-
3711	(6)  LIMITATION ON NONECONOMIC DAMAGES FOR NEGLIGENCE OF
3712	PRACTITIONERS PROVIDING SERVICES AND CARE TO MEDICAID
3713	RECIPIENTS.-Notwithstanding subsections (2), (3), (4), and (5),
3714	with respect to a cause of action for personal injury or
3715	wrongful death arising from medical negligence of practitioners
3716	providing services and care to Medicaid recipients as defined in
3717	s. 409.901, regardless of the number of such practitioner
3718	defendants providing services and care to Medicaid recipients as
3719	defined in s. 409.901, noneconomic damages may not exceed
3720	$300,000 per claimant. A practitioner providing services and
3721	care to Medicaid recipients as defined in s. 409.901 is not
3722	liable for more than $200,000 in noneconomic damages, regardless
3723	of the number of claimants.
3724	Section 25.  The Agency for Health Care Administration
3725	shall develop a plan for implementing s. 409.975(8), Florida
3726	Statutes, and shall immediately seek federal approval to
3727	implement that subsection. The plan shall include a preliminary
3728	calculation of actuarially sound rates and estimated fiscal
3729	impact.
3730	Section 26.  Except as otherwise expressly provided in this
3731	act, this act shall take effect July 1, 2011, if HB 7107 or
3732	similar legislation is adopted in the same legislative session
3733	or an extension thereof and becomes law.

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