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	collect premiums or cost sharing for a home and community-
5	based delivery system; providing that implementation of
6	Medicaid waiver programs and services authorized under ch.
7	393, F.S., are subject to certain funding limitations;
8	requiring that certain provisions relating to agency cost
9	containment initiatives be included in contracts with
10	independent support coordinators and service providers;
11	providing for establishment of agency corrective action
12	plans and redesign of the waiver program under certain
13	circumstances; requiring the plan to be submitted to the
14	Legislature; amending s. 393.063, F.S.; defining the term
15	"Down syndrome"; amending s. 408.040, F.S.; prohibiting
16	the agency from imposing sanctions related to patient day
17	utilization by patients eligible for care under Title XIX
18	of the Social Security Act for a nursing home, effective
19	on a specified date; amending s. 408.0435, F.S.; extending
20	the certificate-of-need moratorium for additional
21	community nursing home beds; designating ss. 409.016-
22	409.803, F.S., as pt. I of ch. 409, F.S., and entitling
23	the part "Social and Economic Assistance"; designating ss.
24	409.810-409.821, F.S., as pt. II of ch. 409, F.S., and
25	entitling the part "Kidcare"; designating ss. 409.901-
26	409.9205, F.S., as part III of ch. 409, F.S., and
27	entitling the part "Medicaid"; amending s. 409.9021, F.S.;
28	revising the time period during which a Medicaid applicant
29	must agree to forfeiture of all entitlements upon a
30	judicial or administrative finding of fraud; amending s.
31	409.905, F.S.; requiring the Agency for Health Care
32	Administration to set reimbursements rates for hospitals
33	that provide Medicaid services based on allowable-cost
34	reporting from the hospitals; removing requirements for
35	prior authorization for the provision of certain services;
36	providing the methodology for the rate calculation and
37	adjustments; requiring the rates to be subject to certain
38	limits or ceilings; authorizing the agency to require
39	prior authorization of home health services under certain
40	conditions; providing that exemptions to the limits or
41	ceilings may be provided in the General Appropriations
42	Act; deleting provisions relating to agency adjustments to
43	a hospital's inpatient per diem rate; directing the agency
44	to develop a plan to convert inpatient hospital rates to a
45	prospective payment system that categorizes each case into
46	diagnosis-related groups; requiring a report to the
47	Governor and Legislature; amending s. 409.906, F.S.;
48	providing conditions under which the agency shall seek
49	federal approval to develop a system to require payment of
50	premiums or other cost sharing by the parents of certain
51	children receiving Medicaid home and community-based
52	waiver services; authorizing the Department of Children
53	and Family Services to collect certain income information;
54	requiring a report to the Legislature; amending s.
55	409.907, F.S.; providing additional requirements for
56	provider agreements for Medicare crossover providers;
57	providing that the agency is not obligated to enroll
58	certain providers as Medicare crossover providers;
59	specifying additional requirements for certain providers;
60	providing the agency may establish additional criteria for
61	providers to promote program integrity; amending s.
62	409.908, F.S.; revising provisions relating to
63	reimbursement of Medicaid direct care providers to include
64	additional, specified medically necessary care; amending
65	s. 409.9081, F.S.; providing conditions for copayments by
66	Medicaid recipients for nonemergency care and services
67	provided in a hospital emergency; amending s. 409.911,
68	F.S.; providing for expiration of the Medicaid Low-Income
69	Pool Council; amending s. 409.912, F.S.; providing payment
70	requirements for provider service networks; providing for
71	the expiration of various provisions relating to agency
72	contracts and agreements with certain entities on
73	specified dates to conform to the reorganization of
74	Medicaid managed care; requiring the agency to contract on
75	a prepaid or fixed-sum basis with certain prepaid dental
76	health plans; eliminating obsolete provisions and updating
77	provisions, to conform; amending ss. 409.91195 and
78	409.91196, F.S.; conforming cross-references; repealing s.
79	409.91207, F.S., relating to the medical home pilot
80	project; amending s. 409.91211, F.S.; conforming cross-
81	references; providing for future repeal of s. 409.91211,
82	F.S., relating to the Medicaid managed care pilot program;
83	amending s. 409.9122, F.S.; providing for the expiration
84	of provisions relating to mandatory enrollment in a
85	Medicaid managed care plan or MediPass on specified dates
86	to conform to the reorganization of Medicaid managed care;
87	eliminating obsolete provisions; providing for the agency
88	to assign Medicaid recipients with HIV/AIDS in specified
89	counties to a managed care plan that is a health
90	maintenance organization under certain conditions;
91	requiring the agency to develop a process to enable any
92	recipient with access to employer-sponsored coverage to
93	opt out of eligible plans in the Medicaid program;
94	requiring the agency, contingent on federal approval, to
95	enable recipients with access to other coverage or related
96	products that provide access to specified health care
97	services to opt out of eligible plans in the Medicaid
98	program; requiring the agency to maintain and operate the
99	Medicaid Encounter Data System; requiring the agency to
100	conduct a review of encounter data and publish the results
101	of the review before adjusting rates for prepaid plans;
102	authorizing the agency to establish a designated payment
103	for specified Medicare Advantage Special Needs members;
104	authorizing the agency to develop a designated payment for
105	Medicaid-only covered services for which the state is
106	responsible; requiring the agency to establish, and
107	managed care plans to use, a uniform method of accounting
108	for and reporting medical and nonmedical costs;
109	authorizing the agency to create exceptions to mandatory
110	enrollment in managed care under specified circumstances;
111	requiring the agency to contract with a provider service
112	network to function as a third-party administrator and
113	managing entity for the MediPass program; providing
114	contract provisions; providing for the expiration of such
115	contract requirements on a specified date; requiring the
116	agency to contract with a single provider service network
117	to function as a third-party administrator and managing
118	entity for the Medically Needy program; providing contract
119	provisions; providing for the expiration of such contract
120	requirements on a specified date; amending s. 430.04,
121	F.S.; eliminating obsolete provisions; requiring the
122	Department of Elderly Affairs to develop a transition plan
123	for specified elders and disabled adults receiving long-
124	term care Medicaid services when eligible plans become
125	available; providing for expiration of the plan; amending
126	s. 430.2053, F.S.; eliminating obsolete provisions;
127	providing additional duties of aging resource centers;
128	providing an additional exception to direct services that
129	may not be provided by an aging resource center; providing
130	an expiration date for certain services administered
131	through aging resource centers; providing for the
132	cessation of specified payments by the department as
133	eligible plans become available; providing for a
134	memorandum of understanding between the agency and aging
135	resource centers under certain circumstances; eliminating
136	provisions requiring reports; repealing s. 430.701, F.S.,
137	relating to legislative findings and intent and approval
138	for action relating to provider enrollment levels;
139	repealing s. 430.702, F.S., relating to the Long-Term Care
140	Community Diversion Pilot Project Act; repealing s.
141	430.703, F.S., relating to definitions; repealing s.
142	430.7031, F.S., relating to the nursing home transition
143	program; repealing s. 430.704, F.S., relating to
144	evaluation of long-term care through the pilot projects;
145	repealing s. 430.705, F.S., relating to implementation of
146	long-term care community diversion pilot projects;
147	repealing s. 430.706, F.S., relating to quality of care;
148	repealing s. 430.707, F.S., relating to contracts;
149	repealing s. 430.708, F.S., relating to certificate of
150	need; repealing s. 430.709, F.S., relating to reports and
151	evaluations; renumbering ss. 409.9301, 409.942, 409.944,
152	409.945, 409.946, 409.953, and 409.9531, F.S., as ss.
153	402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
154	402.87, F.S., respectively; amending ss. 443.111 and
155	641.386, F.S.; conforming cross-references; amending s.
156	766.118, F.S.; providing a limitation on noneconomic
157	damages for negligence of practitioners providing medical
158	services and medical care to Medicaid recipients; defining
159	terms for purposes of the limitation; requiring the agency
160	to develop a plan to implement and seek federal approval
161	for the medically needy program for Medicaid enrollees;
162	requiring the agency to develop a reorganization plan for
163	realignment of administrative resources of the Medicaid
164	program; requiring the plan to be submitted to the
165	Governor and Legislature; amending s. 393.0662, F.S.;
166	including certain individuals with Down syndrome or a
167	developmental disability as eligible to participate in the
168	iBudget system; amending s. 409.902, F.S.; restricting
169	Medicaid eligibility to citizens of the United States who
170	meet certain criteria; amending s. 641.19, F.S.; defining
171	the term "provider service network" for purposes of pt. I
172	of ch. 641, F.S.; creating s. 641.2019, F.S.; providing
173	conditions under which a prepaid provider service network
174	may obtain a certificate of authority under s. 641.21,
175	F.S.; amending s. 641.2261, F.S.; providing an exception
176	for provider service networks from certain federal
177	solvency requirements; providing for severability;
178	providing effective dates and a contingent effective date.
179
180	Be It Enacted by the Legislature of the State of Florida:
181
182	Section 1.  Section 393.0661, Florida Statutes, is amended
183	to read:
184	393.0661  Home and community-based services delivery
185	system; comprehensive redesign.-The Legislature finds that the
186	home and community-based services delivery system for persons
187	with developmental disabilities and the availability of
188	appropriated funds are two of the critical elements in making
189	services available. Therefore, it is the intent of the
190	Legislature that the Agency for Persons with Disabilities shall
191	develop and implement a comprehensive redesign of the system.
192	(1)  The redesign of the home and community-based services
193	system shall include, at a minimum, all actions necessary to
194	achieve an appropriate rate structure, client choice within a
195	specified service package, appropriate assessment strategies, an
196	efficient billing process that contains reconciliation and
197	monitoring components, and a redefined role for support
198	coordinators that avoids potential conflicts of interest and
199	ensures that family/client budgets are linked to levels of need.
200	(a)  The agency shall use an assessment instrument that the
201	agency deems to be reliable and valid, including, but not
202	limited to, the Department of Children and Family Services'
203	Individual Cost Guidelines or the agency's Questionnaire for
204	Situational Information. The agency may contract with an
205	external vendor or may use support coordinators to complete
206	client assessments if it develops sufficient safeguards and
207	training to ensure ongoing inter-rater reliability.
208	(b)  The agency, with the concurrence of the Agency for
209	Health Care Administration, may contract for the determination
210	of medical necessity and establishment of individual budgets.
211	(2)  A provider of services rendered to persons with
212	developmental disabilities pursuant to a federally approved
213	waiver shall be reimbursed according to a rate methodology based
214	upon an analysis of the expenditure history and prospective
215	costs of providers participating in the waiver program, or under
216	any other methodology developed by the Agency for Health Care
217	Administration, in consultation with the Agency for Persons with
218	Disabilities, and approved by the Federal Government in
219	accordance with the waiver.
220	(3)  The Agency for Health Care Administration, in
221	consultation with the agency, shall seek federal approval and
222	implement a four-tiered waiver system to serve eligible clients
223	through the developmental disabilities and family and supported
224	living waivers. For the purpose of this waiver program, eligible
225	clients shall include individuals with a diagnosis of Down
226	syndrome or a developmental disability as defined in s. 393.063.
227	The agency shall assign all clients receiving services through
228	the developmental disabilities waiver to a tier based on the
229	Department of Children and Family Services' Individual Cost
230	Guidelines, the agency's Questionnaire for Situational
231	Information, or another such assessment instrument deemed to be
232	valid and reliable by the agency; client characteristics,
233	including, but not limited to, age; and other appropriate
234	assessment methods.
235	(a)  Tier one is limited to clients who have service needs
236	that cannot be met in tier two, three, or four for intensive
237	medical or adaptive needs and that are essential for avoiding
238	institutionalization, or who possess behavioral problems that
239	are exceptional in intensity, duration, or frequency and present
240	a substantial risk of harm to themselves or others. Total annual
241	expenditures under tier one may not exceed $150,000 per client
242	each year, provided that expenditures for clients in tier one
243	with a documented medical necessity requiring intensive
244	behavioral residential habilitation services, intensive
245	behavioral residential habilitation services with medical needs,
246	or special medical home care, as provided in the Developmental
247	Disabilities Waiver Services Coverage and Limitations Handbook,
248	are not subject to the $150,000 limit on annual expenditures.
249	(b)  Tier two is limited to clients whose service needs
250	include a licensed residential facility and who are authorized
251	to receive a moderate level of support for standard residential
252	habilitation services or a minimal level of support for behavior
253	focus residential habilitation services, or clients in supported
254	living who receive more than 6 hours a day of in-home support
255	services. Total annual expenditures under tier two may not
256	exceed $53,625 per client each year.
257	(c)  Tier three includes, but is not limited to, clients
258	requiring residential placements, clients in independent or
259	supported living situations, and clients who live in their
260	family home. Total annual expenditures under tier three may not
261	exceed $34,125 per client each year.
262	(d)  Tier four includes individuals who were enrolled in
263	the family and supported living waiver on July 1, 2007, who
264	shall be assigned to this tier without the assessments required
265	by this section. Tier four also includes, but is not limited to,
266	clients in independent or supported living situations and
267	clients who live in their family home. Total annual expenditures
268	under tier four may not exceed $14,422 per client each year.
269	(e)  The Agency for Health Care Administration shall also
270	seek federal approval to provide a consumer-directed option for
271	persons with developmental disabilities which corresponds to the
272	funding levels in each of the waiver tiers. The agency shall
273	implement the four-tiered waiver system beginning with tiers
274	one, three, and four and followed by tier two. The agency and
275	the Agency for Health Care Administration may adopt rules
276	necessary to administer this subsection.
277	(f)  The agency shall seek federal waivers and amend
278	contracts as necessary to make changes to services defined in
279	federal waiver programs administered by the agency as follows:
280	1.  Supported living coaching services may not exceed 20
281	hours per month for persons who also receive in-home support
282	services.
283	2.  Limited support coordination services is the only type
284	of support coordination service that may be provided to persons
285	under the age of 18 who live in the family home.
286	3.  Personal care assistance services are limited to 180
287	hours per calendar month and may not include rate modifiers.
288	Additional hours may be authorized for persons who have
289	intensive physical, medical, or adaptive needs if such hours are
290	essential for avoiding institutionalization.
291	4.  Residential habilitation services are limited to 8
292	hours per day. Additional hours may be authorized for persons
293	who have intensive medical or adaptive needs and if such hours
294	are essential for avoiding institutionalization, or for persons
295	who possess behavioral problems that are exceptional in
296	intensity, duration, or frequency and present a substantial risk
297	of harming themselves or others. This restriction shall be in
298	effect until the four-tiered waiver system is fully implemented.
299	5.  Chore services, nonresidential support services, and
300	homemaker services are eliminated. The agency shall expand the
301	definition of in-home support services to allow the service
302	provider to include activities previously provided in these
303	eliminated services.
304	6.  Massage therapy, medication review, and psychological
305	assessment services are eliminated.
306	7.  The agency shall conduct supplemental cost plan reviews
307	to verify the medical necessity of authorized services for plans
308	that have increased by more than 8 percent during either of the
309	2 preceding fiscal years.
310	8.  The agency shall implement a consolidated residential
311	habilitation rate structure to increase savings to the state
312	through a more cost-effective payment method and establish
313	uniform rates for intensive behavioral residential habilitation
314	services.
315	9.  Pending federal approval, the agency may extend current
316	support plans for clients receiving services under Medicaid
317	waivers for 1 year beginning July 1, 2007, or from the date
318	approved, whichever is later. Clients who have a substantial
319	change in circumstances which threatens their health and safety
320	may be reassessed during this year in order to determine the
321	necessity for a change in their support plan.
322	10.  The agency shall develop a plan to eliminate
323	redundancies and duplications between in-home support services,
324	companion services, personal care services, and supported living
325	coaching by limiting or consolidating such services.
326	11.  The agency shall develop a plan to reduce the
327	intensity and frequency of supported employment services to
328	clients in stable employment situations who have a documented
329	history of at least 3 years' employment with the same company or
330	in the same industry.
331	(4)  The geographic differential for Miami-Dade, Broward,
332	and Palm Beach Counties for residential habilitation services
333	shall be 7.5 percent.
334	(5)  The geographic differential for Monroe County for
335	residential habilitation services shall be 20 percent.
336	(6)  Effective January 1, 2010, and except as otherwise
337	provided in this section, a client served by the home and
338	community-based services waiver or the family and supported
339	living waiver funded through the agency shall have his or her
340	cost plan adjusted to reflect the amount of expenditures for the
341	previous state fiscal year plus 5 percent if such amount is less
342	than the client's existing cost plan. The agency shall use
343	actual paid claims for services provided during the previous
344	fiscal year that are submitted by October 31 to calculate the
345	revised cost plan amount. If the client was not served for the
346	entire previous state fiscal year or there was any single change
347	in the cost plan amount of more than 5 percent during the
348	previous state fiscal year, the agency shall set the cost plan
349	amount at an estimated annualized expenditure amount plus 5
350	percent. The agency shall estimate the annualized expenditure
351	amount by calculating the average of monthly expenditures,
352	beginning in the fourth month after the client enrolled,
353	interrupted services are resumed, or the cost plan was changed
354	by more than 5 percent and ending on August 31, 2009, and
355	multiplying the average by 12. In order to determine whether a
356	client was not served for the entire year, the agency shall
357	include any interruption of a waiver-funded service or services
358	lasting at least 18 days. If at least 3 months of actual
359	expenditure data are not available to estimate annualized
360	expenditures, the agency may not rebase a cost plan pursuant to
361	this subsection. The agency may not rebase the cost plan of any
362	client who experiences a significant change in recipient
363	condition or circumstance which results in a change of more than
364	5 percent to his or her cost plan between July 1 and the date
365	that a rebased cost plan would take effect pursuant to this
366	subsection.
367	(7)  The agency shall collect premiums or cost sharing
368	pursuant to s. 409.906(13)(d).
369	(8)(7)  Nothing in This section or related in any
370	administrative rule does not shall be construed to prevent or
371	limit the Agency for Health Care Administration, in consultation
372	with the Agency for Persons with Disabilities, from adjusting
373	fees, reimbursement rates, lengths of stay, number of visits, or
374	number of services, or from limiting enrollment, or making any
375	other adjustment necessary to comply with the availability of
376	moneys and any limitations or directions provided for in the
377	General Appropriations Act.
378	(9)(8)  The Agency for Persons with Disabilities shall
379	submit quarterly status reports to the Executive Office of the
380	Governor, the chair of the Senate Ways and Means Committee or
381	its successor, and the chair of the House Fiscal Council or its
382	successor regarding the financial status of home and community-
383	based services, including the number of enrolled individuals who
384	are receiving services through one or more programs; the number
385	of individuals who have requested services who are not enrolled
386	but who are receiving services through one or more programs,
387	with a description indicating the programs from which the
388	individual is receiving services; the number of individuals who
389	have refused an offer of services but who choose to remain on
390	the list of individuals waiting for services; the number of
391	individuals who have requested services but who are receiving no
392	services; a frequency distribution indicating the length of time
393	individuals have been waiting for services; and information
394	concerning the actual and projected costs compared to the amount
395	of the appropriation available to the program and any projected
396	surpluses or deficits. If at any time an analysis by the agency,
397	in consultation with the Agency for Health Care Administration,
398	indicates that the cost of services is expected to exceed the
399	amount appropriated, the agency shall submit a plan in
400	accordance with subsection (8) (7) to the Executive Office of
401	the Governor, the chair of the Senate Ways and Means Committee
402	or its successor, and the chair of the House Fiscal Council or
403	its successor to remain within the amount appropriated. The
404	agency shall work with the Agency for Health Care Administration
405	to implement the plan so as to remain within the appropriation.
406	(10)  Implementation of Medicaid waiver programs and
407	services authorized under this chapter is limited by the funds
408	appropriated for the individual budgets pursuant to s. 393.0662
409	and the four-tiered waiver system pursuant to subsection (3).
410	Contracts with independent support coordinators and service
411	providers must include provisions requiring compliance with
412	agency cost containment initiatives. The agency shall implement
413	monitoring and accounting procedures necessary to track actual
414	expenditures and project future spending compared to available
415	appropriations for Medicaid waiver programs. When necessary
416	based on projected deficits, the agency must establish specific
417	corrective action plans that incorporate corrective actions of
418	contracted providers that are sufficient to align program
419	expenditures with annual appropriations. If deficits continue
420	during the 2012-2013 fiscal year, the agency in conjunction with
421	the Agency for Health Care Administration shall develop a plan
422	to redesign the waiver program and submit the plan to the
423	President of the Senate and the Speaker of the House of
424	Representatives by September 30, 2013. At a minimum, the plan
425	must include the following elements:
426	(a)  Budget predictability.-Agency budget recommendations
427	must include specific steps to restrict spending to budgeted
428	amounts based on alternatives to the iBudget and four-tiered
429	Medicaid waiver models.
430	(b)  Services.-The agency shall identify core services that
431	are essential to provide for client health and safety and
432	recommend elimination of coverage for other services that are
433	not affordable based on available resources.
434	(c)  Flexibility.-The redesign shall be responsive to
435	individual needs and to the extent possible encourage client
436	control over allocated resources for their needs.
437	(d)  Support coordination services.-The plan shall modify
438	the manner of providing support coordination services to improve
439	management of service utilization and increase accountability
440	and responsiveness to agency priorities.
441	(e)  Reporting.-The agency shall provide monthly reports to
442	the President of the Senate and the Speaker of the House of
443	Representatives on plan progress and development on July 31,
444	2013, and August 31, 2013.
445	(f)  Implementation.-The implementation of a redesigned
446	program is subject to legislative approval and shall occur no
447	later than July 1, 2014. The Agency for Health Care
448	Administration shall seek federal waivers as needed to implement
449	the redesigned plan approved by the Legislature.
450	Section 2.  Subsections (13) through (40) of section
451	393.063, Florida Statutes, are renumbered as subsections (14)
452	through (41), respectively, and a new subsection (13) is added
453	to that section to read:
454	393.063  Definitions.-For the purposes of this chapter, the
455	term:
456	(13)  "Down syndrome" means a disorder caused by the
457	presence of an extra chromosome 21.
458	Section 3.  Paragraph (e) of subsection (1) of section
459	408.040, Florida Statutes, is redesignated as paragraph (d), and
460	paragraph (b) and present paragraph (d) of that subsection are
461	amended to read:
462	408.040  Conditions and monitoring.-
463	(1)
464	(b)  The agency may consider, in addition to the other
465	criteria specified in s. 408.035, a statement of intent by the
466	applicant that a specified percentage of the annual patient days
467	at the facility will be utilized by patients eligible for care
468	under Title XIX of the Social Security Act. Any certificate of
469	need issued to a nursing home in reliance upon an applicant's
470	statements that a specified percentage of annual patient days
471	will be utilized by residents eligible for care under Title XIX
472	of the Social Security Act must include a statement that such
473	certification is a condition of issuance of the certificate of
474	need. The certificate-of-need program shall notify the Medicaid
475	program office and the Department of Elderly Affairs when it
476	imposes conditions as authorized in this paragraph in an area in
477	which a community diversion pilot project is implemented.
478	Effective July 1, 2012, the agency may not impose sanctions
479	related to patient day utilization by patients eligible for care
480	under Title XIX of the Social Security Act for nursing homes.
481	(d)  If a nursing home is located in a county in which a
482	long-term care community diversion pilot project has been
483	implemented under s. 430.705 or in a county in which an
484	integrated, fixed-payment delivery program for Medicaid
485	recipients who are 60 years of age or older or dually eligible
486	for Medicare and Medicaid has been implemented under s.
487	409.912(5), the nursing home may request a reduction in the
488	percentage of annual patient days used by residents who are
489	eligible for care under Title XIX of the Social Security Act,
490	which is a condition of the nursing home's certificate of need.
491	The agency shall automatically grant the nursing home's request
492	if the reduction is not more than 15 percent of the nursing
493	home's annual Medicaid-patient-days condition. A nursing home
494	may submit only one request every 2 years for an automatic
495	reduction. A requesting nursing home must notify the agency in
496	writing at least 60 days in advance of its intent to reduce its
497	annual Medicaid-patient-days condition by not more than 15
498	percent. The agency must acknowledge the request in writing and
499	must change its records to reflect the revised certificate-of-
500	need condition. This paragraph expires June 30, 2011.
501	Section 4.  Subsection (1) of section 408.0435, Florida
502	Statutes, is amended to read:
503	408.0435  Moratorium on nursing home certificates of need.-
504	(1)  Notwithstanding the establishment of need as provided
505	for in this chapter, a certificate of need for additional
506	community nursing home beds may not be approved by the agency
507	until Medicaid managed care is implemented statewide pursuant to
508	ss. 409.961-409.985 or October 1, 2016, whichever is earlier
509	July 1, 2011.
510	Section 5.  Sections 409.016 through 409.803, Florida
511	Statutes, are designated as part I of chapter 409, Florida
512	Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
513	Section 6.  Sections 409.810 through 409.821, Florida
514	Statutes, are designated as part II of chapter 409, Florida
515	Statutes, and entitled "KIDCARE."
516	Section 7.  Sections 409.901 through 409.9205, Florida
517	Statutes, are designated as part III of chapter 409, Florida
518	Statutes, and entitled "MEDICAID."
519	Section 8.  Section 409.9021, Florida Statutes, is amended
520	to read:
521	409.9021  Forfeiture of eligibility agreement.-As a
522	condition of Medicaid eligibility, subject to federal approval,
523	a Medicaid applicant shall agree in writing to forfeit all
524	entitlements to any goods or services provided through the
525	Medicaid program for the next 10 years if he or she has been
526	found to have committed Medicaid fraud, through judicial or
527	administrative determination, two times in a period of 5 years.
528	This provision applies only to the Medicaid recipient found to
529	have committed or participated in Medicaid the fraud and does
530	not apply to any family member of the recipient who was not
531	involved in the fraud.
532	Section 9.  Subsections (2) and (4) and paragraph (c) of
533	subsection (5) of section 409.905, Florida Statutes, are
534	amended, and paragraph (g) is added to subsection (5), to read:
535	409.905  Mandatory Medicaid services.-The agency may make
536	payments for the following services, which are required of the
537	state by Title XIX of the Social Security Act, furnished by
538	Medicaid providers to recipients who are determined to be
539	eligible on the dates on which the services were provided. Any
540	service under this section shall be provided only when medically
541	necessary and in accordance with state and federal law.
542	Mandatory services rendered by providers in mobile units to
543	Medicaid recipients may be restricted by the agency. Nothing in
544	this section shall be construed to prevent or limit the agency
545	from adjusting fees, reimbursement rates, lengths of stay,
546	number of visits, number of services, or any other adjustments
547	necessary to comply with the availability of moneys and any
548	limitations or directions provided for in the General
549	Appropriations Act or chapter 216.
550	(2)  EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT
551	SERVICES.-The agency shall pay for early and periodic screening
552	and diagnosis of a recipient under age 21 to ascertain physical
553	and mental problems and conditions and provide treatment to
554	correct or ameliorate these problems and conditions. These
555	services include all services determined by the agency to be
556	medically necessary for the treatment, correction, or
557	amelioration of these problems and conditions, including
558	personal care, private duty nursing, durable medical equipment,
559	physical therapy, occupational therapy, speech therapy,
560	respiratory therapy, and immunizations.
561	(4)  HOME HEALTH CARE SERVICES.-The agency shall pay for
562	nursing and home health aide services, supplies, appliances, and
563	durable medical equipment, necessary to assist a recipient
564	living at home. An entity that provides such services must
565	pursuant to this subsection shall be licensed under part III of
566	chapter 400. These services, equipment, and supplies, or
567	reimbursement therefor, may be limited as provided in the
568	General Appropriations Act and do not include services,
569	equipment, or supplies provided to a person residing in a
570	hospital or nursing facility.
571	(a)  In providing home health care services, The agency
572	shall may require prior authorization of home health services
573	care based on diagnosis, utilization rates, and or billing
574	rates. The agency shall require prior authorization for visits
575	for home health services that are not associated with a skilled
576	nursing visit when the home health agency billing rates exceed
577	the state average by 50 percent or more. The home health agency
578	must submit the recipient's plan of care and documentation that
579	supports the recipient's diagnosis to the agency when requesting
580	prior authorization.
581	(b)  The agency shall implement a comprehensive utilization
582	management program that requires prior authorization of all
583	private duty nursing services, an individualized treatment plan
584	that includes information about medication and treatment orders,
585	treatment goals, methods of care to be used, and plans for care
586	coordination by nurses and other health professionals. The
587	utilization management program must shall also include a process
588	for periodically reviewing the ongoing use of private duty
589	nursing services. The assessment of need shall be based on a
590	child's condition;, family support and care supplements;, a
591	family's ability to provide care;, and a family's and child's
592	schedule regarding work, school, sleep, and care for other
593	family dependents; and a determination of the medical necessity
594	for private duty nursing instead of other more cost-effective
595	in-home services. When implemented, the private duty nursing
596	utilization management program shall replace the current
597	authorization program used by the agency for Health Care
598	Administration and the Children's Medical Services program of
599	the Department of Health. The agency may competitively bid on a
600	contract to select a qualified organization to provide
601	utilization management of private duty nursing services. The
602	agency may is authorized to seek federal waivers to implement
603	this initiative.
604	(c)  The agency may not pay for home health services unless
605	the services are medically necessary and:
606	1.  The services are ordered by a physician.
607	2.  The written prescription for the services is signed and
608	dated by the recipient's physician before the development of a
609	plan of care and before any request requiring prior
610	authorization.
611	3.  The physician ordering the services is not employed,
612	under contract with, or otherwise affiliated with the home
613	health agency rendering the services. However, this subparagraph
614	does not apply to a home health agency affiliated with a
615	retirement community, of which the parent corporation or a
616	related legal entity owns a rural health clinic certified under
617	42 C.F.R. part 491, subpart A, ss. 1-11, a nursing home licensed
618	under part II of chapter 400, or an apartment or single-family
619	home for independent living. For purposes of this subparagraph,
620	the agency may, on a case-by-case basis, provide an exception
621	for medically fragile children who are younger than 21 years of
622	age.
623	4.  The physician ordering the services has examined the
624	recipient within the 30 days preceding the initial request for
625	the services and biannually thereafter.
626	5.  The written prescription for the services includes the
627	recipient's acute or chronic medical condition or diagnosis, the
628	home health service required, and, for skilled nursing services,
629	the frequency and duration of the services.
630	6.  The national provider identifier, Medicaid
631	identification number, or medical practitioner license number of
632	the physician ordering the services is listed on the written
633	prescription for the services, the claim for home health
634	reimbursement, and the prior authorization request.
635	(5)  HOSPITAL INPATIENT SERVICES.-The agency shall pay for
636	all covered services provided for the medical care and treatment
637	of a recipient who is admitted as an inpatient by a licensed
638	physician or dentist to a hospital licensed under part I of
639	chapter 395. However, the agency shall limit the payment for
640	inpatient hospital services for a Medicaid recipient 21 years of
641	age or older to 45 days or the number of days necessary to
642	comply with the General Appropriations Act.
643	(c)  The agency shall implement a methodology for
644	establishing base reimbursement rates for each hospital based on
645	allowable costs, as defined by the agency. Rates shall be
646	calculated annually and take effect July 1 of each year based on
647	the most recent complete and accurate cost report submitted by
648	each hospital. Adjustments may not be made to the rates after
649	September 30 of the state fiscal year in which the rate takes
650	effect. Errors in cost reporting or calculation of rates
651	discovered after September 30 must be reconciled in a subsequent
652	rate period. The agency may not make any adjustment to a
653	hospital's reimbursement rate more than 5 years after a hospital
654	is notified of an audited rate established by the agency. The
655	requirement that the agency may not make any adjustment to a
656	hospital's reimbursement rate more than 5 years after a hospital
657	is notified of an audited rate established by the agency is
658	remedial and shall apply to actions by providers involving
659	Medicaid claims for hospital services. Hospital rates shall be
660	subject to such limits or ceilings as may be established in law
661	or described in the agency's hospital reimbursement plan.
662	Specific exemptions to the limits or ceilings may be provided in
663	the General Appropriations Act. The agency shall adjust a
664	hospital's current inpatient per diem rate to reflect the cost
665	of serving the Medicaid population at that institution if:
666	1.  The hospital experiences an increase in Medicaid
667	caseload by more than 25 percent in any year, primarily
668	resulting from the closure of a hospital in the same service
669	area occurring after July 1, 1995;
670	2.  The hospital's Medicaid per diem rate is at least 25
671	percent below the Medicaid per patient cost for that year; or
672	3.  The hospital is located in a county that has six or
673	fewer general acute care hospitals, began offering obstetrical
674	services on or after September 1999, and has submitted a request
675	in writing to the agency for a rate adjustment after July 1,
676	2000, but before September 30, 2000, in which case such
677	hospital's Medicaid inpatient per diem rate shall be adjusted to
678	cost, effective July 1, 2002.
679
680	By October 1 of each year, the agency must provide estimated
681	costs for any adjustment in a hospital inpatient per diem rate
682	to the Executive Office of the Governor, the House of
683	Representatives General Appropriations Committee, and the Senate
684	Appropriations Committee. Before the agency implements a change
685	in a hospital's inpatient per diem rate pursuant to this
686	paragraph, the Legislature must have specifically appropriated
687	sufficient funds in the General Appropriations Act to support
688	the increase in cost as estimated by the agency.
689	(g)  The agency shall develop a plan to convert inpatient
690	hospital rates to a prospective payment system that categorizes
691	each case into diagnosis-related groups (DRG) and assigns a
692	payment weight based on the average resources used to treat
693	Medicaid patients in that DRG. To the extent possible, the
694	agency shall propose an adaptation of an existing prospective
695	payment system, such as the one used by Medicare, and shall
696	propose such adjustments as are necessary for the Medicaid
697	population and to maintain budget neutrality for inpatient
698	hospital expenditures. The agency shall submit the Medicaid DRG
699	plan, identifying all steps necessary for the transition and any
700	costs associated with plan implementation, to the Governor, the
701	President of the Senate, and the Speaker of the House of
702	Representatives no later than January 1, 2013.
703	Section 10.  Paragraph (d) is added to subsection (13) of
704	section 409.906, Florida Statutes, to read:
705	409.906  Optional Medicaid services.-Subject to specific
706	appropriations, the agency may make payments for services which
707	are optional to the state under Title XIX of the Social Security
708	Act and are furnished by Medicaid providers to recipients who
709	are determined to be eligible on the dates on which the services
710	were provided. Any optional service that is provided shall be
711	provided only when medically necessary and in accordance with
712	state and federal law. Optional services rendered by providers
713	in mobile units to Medicaid recipients may be restricted or
714	prohibited by the agency. Nothing in this section shall be
715	construed to prevent or limit the agency from adjusting fees,
716	reimbursement rates, lengths of stay, number of visits, or
717	number of services, or making any other adjustments necessary to
718	comply with the availability of moneys and any limitations or
719	directions provided for in the General Appropriations Act or
720	chapter 216. If necessary to safeguard the state's systems of
721	providing services to elderly and disabled persons and subject
722	to the notice and review provisions of s. 216.177, the Governor
723	may direct the Agency for Health Care Administration to amend
724	the Medicaid state plan to delete the optional Medicaid service
725	known as "Intermediate Care Facilities for the Developmentally
726	Disabled." Optional services may include:
727	(13)  HOME AND COMMUNITY-BASED SERVICES.-
728	(d)  The agency shall request federal approval to develop a
729	system to require payment of premiums or other cost sharing by
730	the parents of a child who is being served by a waiver under
731	this subsection if the adjusted household income is greater than
732	100 percent of the federal poverty level. The amount of the
733	premium or cost sharing shall be calculated using a sliding
734	scale based on the size of the family, the amount of the
735	parent's adjusted gross income, and the federal poverty
736	guidelines. The premium and cost sharing system developed by the
737	agency shall not adversely affect federal funding to the state.
738	After the agency receives federal approval, the Department of
739	Children and Family Services may collect income information from
740	parents of children who will be affected by this paragraph. The
741	agency shall prepare a report to include the estimated
742	operational cost of implementing the premium and cost sharing
743	system and the estimated revenues to be collected from parents
744	of children in the waiver program. The report shall be delivered
745	to the President of the Senate and the Speaker of the House of
746	Representatives by June 30, 2012.
747	Section 11.  Paragraphs (d) and (e) of subsection (5) of
748	section 409.907, Florida Statutes, are amended to read:
749	409.907  Medicaid provider agreements.-The agency may make
750	payments for medical assistance and related services rendered to
751	Medicaid recipients only to an individual or entity who has a
752	provider agreement in effect with the agency, who is performing
753	services or supplying goods in accordance with federal, state,
754	and local law, and who agrees that no person shall, on the
755	grounds of handicap, race, color, or national origin, or for any
756	other reason, be subjected to discrimination under any program
757	or activity for which the provider receives payment from the
758	agency.
759	(5)  The agency:
760	(d)  May enroll entities as Medicare crossover-only
761	providers for payment and claims processing purposes only. The
762	provider agreement shall:
763	1.  Require that the provider be able to demonstrate to the
764	satisfaction of the agency that the provider is an eligible
765	Medicare provider and has a current provider agreement in place
766	with the Centers for Medicare and Medicaid Services.
767	2.  Require the provider to notify the agency immediately
768	in writing upon being suspended or disenrolled as a Medicare
769	provider. If the provider does not provide such notification
770	within 5 business days after suspension or disenrollment,
771	sanctions may be imposed pursuant to this chapter and the
772	provider may be required to return funds paid to the provider
773	during the period of time that the provider was suspended or
774	disenrolled as a Medicare provider.
775	3.  Require the applicant to submit an attestation, as
776	approved by the agency, that the provider meets the requirements
777	of Florida Medicaid provider enrollment criteria.
778	4.  Require the applicant to submit fingerprints as
779	required by the agency.
780	5.3.  Require that all records pertaining to health care
781	services provided to each of the provider's recipients be kept
782	for a minimum of 6 years. The agreement shall also require that
783	records and any information relating to payments claimed by the
784	provider for services under the agreement be delivered to the
785	agency or the Office of the Attorney General Medicaid Fraud
786	Control Unit when requested. If a provider does not provide such
787	records and information when requested, sanctions may be imposed
788	pursuant to this chapter.
789	6.4.  Disclose that the agreement is for the purposes of
790	paying and processing Medicare crossover claims only.
791
792	This paragraph pertains solely to Medicare crossover-only
793	providers. In order to become a standard Medicaid provider, the
794	requirements of this section and applicable rules must be met.
795	This paragraph does not create an entitlement or obligation of
796	the agency to enroll all Medicare providers that may be
797	considered a Medicare crossover-only provider in the Medicaid
798	program.
799	(e)  Providers that are required to post a surety bond as
800	part of the Medicaid enrollment process are excluded for
801	enrollment under paragraph (d) and must complete a full Medicaid
802	application. The agency may establish additional criteria to
803	promote program integrity.
804	Section 12.  Paragraph (b) of subsection (2) of section
805	409.908, Florida Statutes, is amended to read:
806	409.908  Reimbursement of Medicaid providers.-Subject to
807	specific appropriations, the agency shall reimburse Medicaid
808	providers, in accordance with state and federal law, according
809	to methodologies set forth in the rules of the agency and in
810	policy manuals and handbooks incorporated by reference therein.
811	These methodologies may include fee schedules, reimbursement
812	methods based on cost reporting, negotiated fees, competitive
813	bidding pursuant to s. 287.057, and other mechanisms the agency
814	considers efficient and effective for purchasing services or
815	goods on behalf of recipients. If a provider is reimbursed based
816	on cost reporting and submits a cost report late and that cost
817	report would have been used to set a lower reimbursement rate
818	for a rate semester, then the provider's rate for that semester
819	shall be retroactively calculated using the new cost report, and
820	full payment at the recalculated rate shall be effected
821	retroactively. Medicare-granted extensions for filing cost
822	reports, if applicable, shall also apply to Medicaid cost
823	reports. Payment for Medicaid compensable services made on
824	behalf of Medicaid eligible persons is subject to the
825	availability of moneys and any limitations or directions
826	provided for in the General Appropriations Act or chapter 216.
827	Further, nothing in this section shall be construed to prevent
828	or limit the agency from adjusting fees, reimbursement rates,
829	lengths of stay, number of visits, or number of services, or
830	making any other adjustments necessary to comply with the
831	availability of moneys and any limitations or directions
832	provided for in the General Appropriations Act, provided the
833	adjustment is consistent with legislative intent.
834	(2)
835	(b)  Subject to any limitations or directions provided for
836	in the General Appropriations Act, the agency shall establish
837	and implement a Florida Title XIX Long-Term Care Reimbursement
838	Plan (Medicaid) for nursing home care in order to provide care
839	and services in conformance with the applicable state and
840	federal laws, rules, regulations, and quality and safety
841	standards and to ensure that individuals eligible for medical
842	assistance have reasonable geographic access to such care.
843	1.  The agency shall amend the long-term care reimbursement
844	plan and cost reporting system to create direct care and
845	indirect care subcomponents of the patient care component of the
846	per diem rate. These two subcomponents together shall equal the
847	patient care component of the per diem rate. Separate cost-based
848	ceilings shall be calculated for each patient care subcomponent.
849	The direct care subcomponent of the per diem rate shall be
850	limited by the cost-based class ceiling, and the indirect care
851	subcomponent may be limited by the lower of the cost-based class
852	ceiling, the target rate class ceiling, or the individual
853	provider target.
854	2.  The direct care subcomponent shall include salaries and
855	benefits of direct care staff providing nursing services
856	including registered nurses, licensed practical nurses, and
857	certified nursing assistants who deliver care directly to
858	residents in the nursing home facility. This excludes nursing
859	administration, minimum data set, and care plan coordinators,
860	staff development, and the staffing coordinator. The direct care
861	subcomponent also includes medically necessary dental care,
862	vision care, hearing care, and podiatric care.
863	3.  All other patient care costs shall be included in the
864	indirect care cost subcomponent of the patient care per diem
865	rate. There shall be no costs directly or indirectly allocated
866	to the direct care subcomponent from a home office or management
867	company.
868	4.  On July 1 of each year, the agency shall report to the
869	Legislature direct and indirect care costs, including average
870	direct and indirect care costs per resident per facility and
871	direct care and indirect care salaries and benefits per category
872	of staff member per facility.
873	5.  In order to offset the cost of general and professional
874	liability insurance, the agency shall amend the plan to allow
875	for interim rate adjustments to reflect increases in the cost of
876	general or professional liability insurance for nursing homes.
877	This provision shall be implemented to the extent existing
878	appropriations are available.
879
880	It is the intent of the Legislature that the reimbursement plan
881	achieve the goal of providing access to health care for nursing
882	home residents who require large amounts of care while
883	encouraging diversion services as an alternative to nursing home
884	care for residents who can be served within the community. The
885	agency shall base the establishment of any maximum rate of
886	payment, whether overall or component, on the available moneys
887	as provided for in the General Appropriations Act. The agency
888	may base the maximum rate of payment on the results of
889	scientifically valid analysis and conclusions derived from
890	objective statistical data pertinent to the particular maximum
891	rate of payment.
892	Section 13.  Paragraph (c) of subsection (1) of section
893	409.9081, Florida Statutes, is amended to read:
894	409.9081  Copayments.-
895	(1)  The agency shall require, subject to federal
896	regulations and limitations, each Medicaid recipient to pay at
897	the time of service a nominal copayment for the following
898	Medicaid services:
899	(c)  Hospital emergency department visits for nonemergency
900	care: 5 percent of up to the first $300 of the Medicaid payment
901	for emergency room services, not to exceed $15. The agency shall
902	seek federal approval to require Medicaid recipients to pay $100
903	copayment for nonemergency services and care furnished in a
904	hospital emergency department. Upon waiver approval, a Medicaid
905	recipient who requests such services and care must pay a $100
906	copayment to the hospital for the nonemergency services and care
907	provided in the hospital emergency department.
908	Section 14.  Subsection (10) of section 409.911, Florida
909	Statutes, is amended to read:
910	409.911  Disproportionate share program.-Subject to
911	specific allocations established within the General
912	Appropriations Act and any limitations established pursuant to
913	chapter 216, the agency shall distribute, pursuant to this
914	section, moneys to hospitals providing a disproportionate share
915	of Medicaid or charity care services by making quarterly
916	Medicaid payments as required. Notwithstanding the provisions of
917	s. 409.915, counties are exempt from contributing toward the
918	cost of this special reimbursement for hospitals serving a
919	disproportionate share of low-income patients.
920	(10)  The Agency for Health Care Administration shall
921	create a Medicaid Low-Income Pool Council by July 1, 2006. The
922	Low-Income Pool Council shall consist of 24 members, including 2
923	members appointed by the President of the Senate, 2 members
924	appointed by the Speaker of the House of Representatives, 3
925	representatives of statutory teaching hospitals, 3
926	representatives of public hospitals, 3 representatives of
927	nonprofit hospitals, 3 representatives of for-profit hospitals,
928	2 representatives of rural hospitals, 2 representatives of units
929	of local government which contribute funding, 1 representative
930	of family practice teaching hospitals, 1 representative of
931	federally qualified health centers, 1 representative from the
932	Department of Health, and 1 nonvoting representative of the
933	Agency for Health Care Administration who shall serve as chair
934	of the council. Except for a full-time employee of a public
935	entity, an individual who qualifies as a lobbyist under s.
936	11.045 or s. 112.3215 may not serve as a member of the council.
937	Of the members appointed by the Senate President, only one shall
938	be a physician. Of the members appointed by the Speaker of the
939	House of Representatives, only one shall be a physician. The
940	physician member appointed by the Senate President and the
941	physician member appointed by the Speaker of the House of
942	Representatives must be physicians who routinely take calls in a
943	trauma center, as defined in s. 395.4001, or a hospital
944	emergency department. The council shall:
945	(a)  Make recommendations on the financing of the low-
946	income pool and the disproportionate share hospital program and
947	the distribution of their funds.
948	(b)  Advise the Agency for Health Care Administration on
949	the development of the low-income pool plan required by the
950	federal Centers for Medicare and Medicaid Services pursuant to
951	the Medicaid reform waiver.
952	(c)  Advise the Agency for Health Care Administration on
953	the distribution of hospital funds used to adjust inpatient
954	hospital rates, rebase rates, or otherwise exempt hospitals from
955	reimbursement limits as financed by intergovernmental transfers.
956	(d)  Submit its findings and recommendations to the
957	Governor and the Legislature no later than February 1 of each
958	year.
959
960	This subsection expires October 1, 2014.
961	Section 15.  Subsection (4) of section 409.91195, Florida
962	Statutes, is amended to read:
963	409.91195  Medicaid Pharmaceutical and Therapeutics
964	Committee.-There is created a Medicaid Pharmaceutical and
965	Therapeutics Committee within the agency for the purpose of
966	developing a Medicaid preferred drug list.
967	(4)  Upon recommendation of the committee, the agency shall
968	adopt a preferred drug list as described in s. 409.912(37)(39).
969	To the extent feasible, the committee shall review all drug
970	classes included on the preferred drug list every 12 months, and
971	may recommend additions to and deletions from the preferred drug
972	list, such that the preferred drug list provides for medically
973	appropriate drug therapies for Medicaid patients which achieve
974	cost savings contained in the General Appropriations Act.
975	Section 16.  Subsection (1) of section 409.91196, Florida
976	Statutes, is amended to read:
977	409.91196  Supplemental rebate agreements; public records
978	and public meetings exemption.-
979	(1)  The rebate amount, percent of rebate, manufacturer's
980	pricing, and supplemental rebate, and other trade secrets as
981	defined in s. 688.002 that the agency has identified for use in
982	negotiations, held by the Agency for Health Care Administration
983	under s. 409.912(37)(39)(a)7. are confidential and exempt from
984	s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
985	Section 17.  Section 409.912, Florida Statutes, is amended
986	to read:
987	409.912  Cost-effective purchasing of health care.-The
988	agency shall purchase goods and services for Medicaid recipients
989	in the most cost-effective manner consistent with the delivery
990	of quality medical care. To ensure that medical services are
991	effectively utilized, the agency may, in any case, require a
992	confirmation or second physician's opinion of the correct
993	diagnosis for purposes of authorizing future services under the
994	Medicaid program. This section does not restrict access to
995	emergency services or poststabilization care services as defined
996	in 42 C.F.R. part 438.114. Such confirmation or second opinion
997	shall be rendered in a manner approved by the agency. The agency
998	shall maximize the use of prepaid per capita and prepaid
999	aggregate fixed-sum basis services when appropriate and other
1000	alternative service delivery and reimbursement methodologies,
1001	including competitive bidding pursuant to s. 287.057, designed
1002	to facilitate the cost-effective purchase of a case-managed
1003	continuum of care. The agency shall also require providers to
1004	minimize the exposure of recipients to the need for acute
1005	inpatient, custodial, and other institutional care and the
1006	inappropriate or unnecessary use of high-cost services. The
1007	agency shall contract with a vendor to monitor and evaluate the
1008	clinical practice patterns of providers in order to identify
1009	trends that are outside the normal practice patterns of a
1010	provider's professional peers or the national guidelines of a
1011	provider's professional association. The vendor must be able to
1012	provide information and counseling to a provider whose practice
1013	patterns are outside the norms, in consultation with the agency,
1014	to improve patient care and reduce inappropriate utilization.
1015	The agency may mandate prior authorization, drug therapy
1016	management, or disease management participation for certain
1017	populations of Medicaid beneficiaries, certain drug classes, or
1018	particular drugs to prevent fraud, abuse, overuse, and possible
1019	dangerous drug interactions. The Pharmaceutical and Therapeutics
1020	Committee shall make recommendations to the agency on drugs for
1021	which prior authorization is required. The agency shall inform
1022	the Pharmaceutical and Therapeutics Committee of its decisions
1023	regarding drugs subject to prior authorization. The agency is
1024	authorized to limit the entities it contracts with or enrolls as
1025	Medicaid providers by developing a provider network through
1026	provider credentialing. The agency may competitively bid single-
1027	source-provider contracts if procurement of goods or services
1028	results in demonstrated cost savings to the state without
1029	limiting access to care. The agency may limit its network based
1030	on the assessment of beneficiary access to care, provider
1031	availability, provider quality standards, time and distance
1032	standards for access to care, the cultural competence of the
1033	provider network, demographic characteristics of Medicaid
1034	beneficiaries, practice and provider-to-beneficiary standards,
1035	appointment wait times, beneficiary use of services, provider
1036	turnover, provider profiling, provider licensure history,
1037	previous program integrity investigations and findings, peer
1038	review, provider Medicaid policy and billing compliance records,
1039	clinical and medical record audits, and other factors. Providers
1040	are shall not be entitled to enrollment in the Medicaid provider
1041	network. The agency shall determine instances in which allowing
1042	Medicaid beneficiaries to purchase durable medical equipment and
1043	other goods is less expensive to the Medicaid program than long-
1044	term rental of the equipment or goods. The agency may establish
1045	rules to facilitate purchases in lieu of long-term rentals in
1046	order to protect against fraud and abuse in the Medicaid program
1047	as defined in s. 409.913. The agency may seek federal waivers
1048	necessary to administer these policies.
1049	(1)  The agency shall work with the Department of Children
1050	and Family Services to ensure access of children and families in
1051	the child protection system to needed and appropriate mental
1052	health and substance abuse services. This subsection expires
1053	October 1, 2014.
1054	(2)  The agency may enter into agreements with appropriate
1055	agents of other state agencies or of any agency of the Federal
1056	Government and accept such duties in respect to social welfare
1057	or public aid as may be necessary to implement the provisions of
1058	Title XIX of the Social Security Act and ss. 409.901-409.920.
1059	This subsection expires October 1, 2016.
1060	(3)  The agency may contract with health maintenance
1061	organizations certified pursuant to part I of chapter 641 for
1062	the provision of services to recipients. This subsection expires
1063	October 1, 2014.
1064	(4)  The agency may contract with:
1065	(a)  An entity that provides no prepaid health care
1066	services other than Medicaid services under contract with the
1067	agency and which is owned and operated by a county, county
1068	health department, or county-owned and operated hospital to
1069	provide health care services on a prepaid or fixed-sum basis to
1070	recipients, which entity may provide such prepaid services
1071	either directly or through arrangements with other providers.
1072	Such prepaid health care services entities must be licensed
1073	under parts I and III of chapter 641. An entity recognized under
1074	this paragraph which demonstrates to the satisfaction of the
1075	Office of Insurance Regulation of the Financial Services
1076	Commission that it is backed by the full faith and credit of the
1077	county in which it is located may be exempted from s. 641.225.
1078	This paragraph expires October 1, 2014.
1079	(b)  An entity that is providing comprehensive behavioral
1080	health care services to certain Medicaid recipients through a
1081	capitated, prepaid arrangement pursuant to the federal waiver
1082	provided for by s. 409.905(5). Such entity must be licensed
1083	under chapter 624, chapter 636, or chapter 641, or authorized
1084	under paragraph (c) or paragraph (d), and must possess the
1085	clinical systems and operational competence to manage risk and
1086	provide comprehensive behavioral health care to Medicaid
1087	recipients. As used in this paragraph, the term "comprehensive
1088	behavioral health care services" means covered mental health and
1089	substance abuse treatment services that are available to
1090	Medicaid recipients. The secretary of the Department of Children
1091	and Family Services shall approve provisions of procurements
1092	related to children in the department's care or custody before
1093	enrolling such children in a prepaid behavioral health plan. Any
1094	contract awarded under this paragraph must be competitively
1095	procured. In developing the behavioral health care prepaid plan
1096	procurement document, the agency shall ensure that the
1097	procurement document requires the contractor to develop and
1098	implement a plan to ensure compliance with s. 394.4574 related
1099	to services provided to residents of licensed assisted living
1100	facilities that hold a limited mental health license. Except as
1101	provided in subparagraph 5. 8., and except in counties where the
1102	Medicaid managed care pilot program is authorized pursuant to s.
1103	409.91211, the agency shall seek federal approval to contract
1104	with a single entity meeting these requirements to provide
1105	comprehensive behavioral health care services to all Medicaid
1106	recipients not enrolled in a Medicaid managed care plan
1107	authorized under s. 409.91211, a provider service network
1108	authorized under paragraph (d), or a Medicaid health maintenance
1109	organization in an AHCA area. In an AHCA area where the Medicaid
1110	managed care pilot program is authorized pursuant to s.
1111	409.91211 in one or more counties, the agency may procure a
1112	contract with a single entity to serve the remaining counties as
1113	an AHCA area or the remaining counties may be included with an
1114	adjacent AHCA area and are subject to this paragraph. Each
1115	entity must offer a sufficient choice of providers in its
1116	network to ensure recipient access to care and the opportunity
1117	to select a provider with whom they are satisfied. The network
1118	shall include all public mental health hospitals. To ensure
1119	unimpaired access to behavioral health care services by Medicaid
1120	recipients, all contracts issued pursuant to this paragraph must
1121	require 80 percent of the capitation paid to the managed care
1122	plan, including health maintenance organizations and capitated
1123	provider service networks, to be expended for the provision of
1124	behavioral health care services. If the managed care plan
1125	expends less than 80 percent of the capitation paid for the
1126	provision of behavioral health care services, the difference
1127	shall be returned to the agency. The agency shall provide the
1128	plan with a certification letter indicating the amount of
1129	capitation paid during each calendar year for behavioral health
1130	care services pursuant to this section. The agency may reimburse
1131	for substance abuse treatment services on a fee-for-service
1132	basis until the agency finds that adequate funds are available
1133	for capitated, prepaid arrangements.
1134	1.  By January 1, 2001, The agency shall modify the
1135	contracts with the entities providing comprehensive inpatient
1136	and outpatient mental health care services to Medicaid
1137	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
1138	Counties, to include substance abuse treatment services.
1139	2.  By July 1, 2003, the agency and the Department of
1140	Children and Family Services shall execute a written agreement
1141	that requires collaboration and joint development of all policy,
1142	budgets, procurement documents, contracts, and monitoring plans
1143	that have an impact on the state and Medicaid community mental
1144	health and targeted case management programs.
1145	2.3.  Except as provided in subparagraph 5. 8., by July 1,
1146	2006, the agency and the Department of Children and Family
1147	Services shall contract with managed care entities in each AHCA
1148	area except area 6 or arrange to provide comprehensive inpatient
1149	and outpatient mental health and substance abuse services
1150	through capitated prepaid arrangements to all Medicaid
1151	recipients who are eligible to participate in such plans under
1152	federal law and regulation. In AHCA areas where eligible
1153	individuals number less than 150,000, the agency shall contract
1154	with a single managed care plan to provide comprehensive
1155	behavioral health services to all recipients who are not
1156	enrolled in a Medicaid health maintenance organization, a
1157	provider service network authorized under paragraph (d), or a
1158	Medicaid capitated managed care plan authorized under s.
1159	409.91211. The agency may contract with more than one
1160	comprehensive behavioral health provider to provide care to
1161	recipients who are not enrolled in a Medicaid capitated managed
1162	care plan authorized under s. 409.91211, a provider service
1163	network authorized under paragraph (d), or a Medicaid health
1164	maintenance organization in AHCA areas where the eligible
1165	population exceeds 150,000. In an AHCA area where the Medicaid
1166	managed care pilot program is authorized pursuant to s.
1167	409.91211 in one or more counties, the agency may procure a
1168	contract with a single entity to serve the remaining counties as
1169	an AHCA area or the remaining counties may be included with an
1170	adjacent AHCA area and shall be subject to this paragraph.
1171	Contracts for comprehensive behavioral health providers awarded
1172	pursuant to this section shall be competitively procured. Both
1173	for-profit and not-for-profit corporations are eligible to
1174	compete. Managed care plans contracting with the agency under
1175	subsection (3) or paragraph (d), shall provide and receive
1176	payment for the same comprehensive behavioral health benefits as
1177	provided in AHCA rules, including handbooks incorporated by
1178	reference. In AHCA area 11, the agency shall contract with at
1179	least two comprehensive behavioral health care providers to
1180	provide behavioral health care to recipients in that area who
1181	are enrolled in, or assigned to, the MediPass program. One of
1182	the behavioral health care contracts must be with the existing
1183	provider service network pilot project, as described in
1184	paragraph (d), for the purpose of demonstrating the cost-
1185	effectiveness of the provision of quality mental health services
1186	through a public hospital-operated managed care model. Payment
1187	shall be at an agreed-upon capitated rate to ensure cost
1188	savings. Of the recipients in area 11 who are assigned to
1189	MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1190	MediPass-enrolled recipients shall be assigned to the existing
1191	provider service network in area 11 for their behavioral care.
1192	4.  By October 1, 2003, the agency and the department shall
1193	submit a plan to the Governor, the President of the Senate, and
1194	the Speaker of the House of Representatives which provides for
1195	the full implementation of capitated prepaid behavioral health
1196	care in all areas of the state.
1197	a.  Implementation shall begin in 2003 in those AHCA areas
1198	of the state where the agency is able to establish sufficient
1199	capitation rates.
1200	b.  If the agency determines that the proposed capitation
1201	rate in any area is insufficient to provide appropriate
1202	services, the agency may adjust the capitation rate to ensure
1203	that care will be available. The agency and the department may
1204	use existing general revenue to address any additional required
1205	match but may not over-obligate existing funds on an annualized
1206	basis.
1207	c.  Subject to any limitations provided in the General
1208	Appropriations Act, the agency, in compliance with appropriate
1209	federal authorization, shall develop policies and procedures
1210	that allow for certification of local and state funds.
1211	3.5.  Children residing in a statewide inpatient
1212	psychiatric program, or in a Department of Juvenile Justice or a
1213	Department of Children and Family Services residential program
1214	approved as a Medicaid behavioral health overlay services
1215	provider may not be included in a behavioral health care prepaid
1216	health plan or any other Medicaid managed care plan pursuant to
1217	this paragraph.
1218	6.  In converting to a prepaid system of delivery, the
1219	agency shall in its procurement document require an entity
1220	providing only comprehensive behavioral health care services to
1221	prevent the displacement of indigent care patients by enrollees
1222	in the Medicaid prepaid health plan providing behavioral health
1223	care services from facilities receiving state funding to provide
1224	indigent behavioral health care, to facilities licensed under
1225	chapter 395 which do not receive state funding for indigent
1226	behavioral health care, or reimburse the unsubsidized facility
1227	for the cost of behavioral health care provided to the displaced
1228	indigent care patient.
1229	4.7.  Traditional community mental health providers under
1230	contract with the Department of Children and Family Services
1231	pursuant to part IV of chapter 394, child welfare providers
1232	under contract with the Department of Children and Family
1233	Services in areas 1 and 6, and inpatient mental health providers
1234	licensed pursuant to chapter 395 must be offered an opportunity
1235	to accept or decline a contract to participate in any provider
1236	network for prepaid behavioral health services.
1237	5.8.  All Medicaid-eligible children, except children in
1238	area 1 and children in Highlands County, Hardee County, Polk
1239	County, or Manatee County of area 6, that are open for child
1240	welfare services in the statewide automated child welfare
1241	information HomeSafeNet system, shall receive their behavioral
1242	health care services through a specialty prepaid plan operated
1243	by community-based lead agencies through a single agency or
1244	formal agreements among several agencies. The specialty prepaid
1245	plan must result in savings to the state comparable to savings
1246	achieved in other Medicaid managed care and prepaid programs.
1247	Such plan must provide mechanisms to maximize state and local
1248	revenues. The specialty prepaid plan shall be developed by the
1249	agency and the Department of Children and Family Services. The
1250	agency may seek federal waivers to implement this initiative.
1251	Medicaid-eligible children whose cases are open for child
1252	welfare services in the statewide automated child welfare
1253	information HomeSafeNet system and who reside in AHCA area 10
1254	shall be enrolled in a capitated provider service network or
1255	other capitated managed care plan, which, in coordination with
1256	available community-based care providers specified in s.
1257	409.1671, shall provide sufficient medical, developmental, and
1258	behavioral health services to meet the needs of these children
1259	are exempt from the specialty prepaid plan upon the development
1260	of a service delivery mechanism for children who reside in area
1261	10 as specified in s. 409.91211(3)(dd).
1262
1263	This paragraph expires October 1, 2014.
1264	(c)  A federally qualified health center or an entity owned
1265	by one or more federally qualified health centers or an entity
1266	owned by other migrant and community health centers receiving
1267	non-Medicaid financial support from the Federal Government to
1268	provide health care services on a prepaid or fixed-sum basis to
1269	recipients. A federally qualified health center or an entity
1270	that is owned by one or more federally qualified health centers
1271	and is reimbursed by the agency on a prepaid basis is exempt
1272	from parts I and III of chapter 641, but must comply with the
1273	solvency requirements in s. 641.2261(2) and meet the appropriate
1274	requirements governing financial reserve, quality assurance, and
1275	patients' rights established by the agency. This paragraph
1276	expires October 1, 2014.
1277	(d)1.  A provider service network, which may be reimbursed
1278	on a fee-for-service or prepaid basis. Prepaid provider service
1279	networks shall receive per-member, per-month payments. A
1280	provider service network that does not choose to be a prepaid
1281	plan shall receive fee-for-service rates with a shared savings
1282	settlement. The fee-for-service option shall be available to a
1283	provider service network only for the first 2 years of the
1284	plan's operation or until the contract year beginning September
1285	1, 2014, whichever is later. The agency shall annually conduct
1286	cost reconciliations to determine the amount of cost savings
1287	achieved by fee-for-service provider service networks for the
1288	dates of service in the period being reconciled. Only payments
1289	for covered services for dates of service within the
1290	reconciliation period and paid within 6 months after the last
1291	date of service in the reconciliation period shall be included.
1292	The agency shall perform the necessary adjustments for the
1293	inclusion of claims incurred but not reported within the
1294	reconciliation for claims that could be received and paid by the
1295	agency after the 6-month claims processing time lag. The agency
1296	shall provide the results of the reconciliations to the fee-for-
1297	service provider service networks within 45 days after the end
1298	of the reconciliation period. The fee-for-service provider
1299	service networks shall review and provide written comments or a
1300	letter of concurrence to the agency within 45 days after receipt
1301	of the reconciliation results. This reconciliation shall be
1302	considered final.
1303	2.  A provider service network which is reimbursed by the
1304	agency on a prepaid basis shall be exempt from parts I and III
1305	of chapter 641, but must comply with the solvency requirements
1306	in s. 641.2261(2) and meet appropriate financial reserve,
1307	quality assurance, and patient rights requirements as
1308	established by the agency.
1309	3.  Medicaid recipients assigned to a provider service
1310	network shall be chosen equally from those who would otherwise
1311	have been assigned to prepaid plans and MediPass. The agency is
1312	authorized to seek federal Medicaid waivers as necessary to
1313	implement the provisions of this section. This subparagraph
1314	expires October 1, 2014. Any contract previously awarded to a
1315	provider service network operated by a hospital pursuant to this
1316	subsection shall remain in effect for a period of 3 years
1317	following the current contract expiration date, regardless of
1318	any contractual provisions to the contrary.
1319	4.  A provider service network is a network established or
1320	organized and operated by a health care provider, or group of
1321	affiliated health care providers, including minority physician
1322	networks and emergency room diversion programs that meet the
1323	requirements of s. 409.91211, which provides a substantial
1324	proportion of the health care items and services under a
1325	contract directly through the provider or affiliated group of
1326	providers and may make arrangements with physicians or other
1327	health care professionals, health care institutions, or any
1328	combination of such individuals or institutions to assume all or
1329	part of the financial risk on a prospective basis for the
1330	provision of basic health services by the physicians, by other
1331	health professionals, or through the institutions. The health
1332	care providers must have a controlling interest in the governing
1333	body of the provider service network organization.
1334	(e)  An entity that provides only comprehensive behavioral
1335	health care services to certain Medicaid recipients through an
1336	administrative services organization agreement. Such an entity
1337	must possess the clinical systems and operational competence to
1338	provide comprehensive health care to Medicaid recipients. As
1339	used in this paragraph, the term "comprehensive behavioral
1340	health care services" means covered mental health and substance
1341	abuse treatment services that are available to Medicaid
1342	recipients. Any contract awarded under this paragraph must be
1343	competitively procured. The agency must ensure that Medicaid
1344	recipients have available the choice of at least two managed
1345	care plans for their behavioral health care services. This
1346	paragraph expires October 1, 2014.
1347	(f)  An entity that provides in-home physician services to
1348	test the cost-effectiveness of enhanced home-based medical care
1349	to Medicaid recipients with degenerative neurological diseases
1350	and other diseases or disabling conditions associated with high
1351	costs to Medicaid. The program shall be designed to serve very
1352	disabled persons and to reduce Medicaid reimbursed costs for
1353	inpatient, outpatient, and emergency department services. The
1354	agency shall contract with vendors on a risk-sharing basis.
1355	(g)  Children's provider networks that provide care
1356	coordination and care management for Medicaid-eligible pediatric
1357	patients, primary care, authorization of specialty care, and
1358	other urgent and emergency care through organized providers
1359	designed to service Medicaid eligibles under age 18 and
1360	pediatric emergency departments' diversion programs. The
1361	networks shall provide after-hour operations, including evening
1362	and weekend hours, to promote, when appropriate, the use of the
1363	children's networks rather than hospital emergency departments.
1364	(f)(h)  An entity authorized in s. 430.205 to contract with
1365	the agency and the Department of Elderly Affairs to provide
1366	health care and social services on a prepaid or fixed-sum basis
1367	to elderly recipients. Such prepaid health care services
1368	entities are exempt from the provisions of part I of chapter 641
1369	for the first 3 years of operation. An entity recognized under
1370	this paragraph that demonstrates to the satisfaction of the
1371	Office of Insurance Regulation that it is backed by the full
1372	faith and credit of one or more counties in which it operates
1373	may be exempted from s. 641.225. This paragraph expires October
1374	1, 2013.
1375	(g)(i)  A Children's Medical Services Network, as defined
1376	in s. 391.021. This paragraph expires October 1, 2014.
1377	(5)  The Agency for Health Care Administration, in
1378	partnership with the Department of Elderly Affairs, shall create
1379	an integrated, fixed-payment delivery program for Medicaid
1380	recipients who are 60 years of age or older or dually eligible
1381	for Medicare and Medicaid. The Agency for Health Care
1382	Administration shall implement the integrated program initially
1383	on a pilot basis in two areas of the state. The pilot areas
1384	shall be Area 7 and Area 11 of the Agency for Health Care
1385	Administration. Enrollment in the pilot areas shall be on a
1386	voluntary basis and in accordance with approved federal waivers
1387	and this section. The agency and its program contractors and
1388	providers shall not enroll any individual in the integrated
1389	program because the individual or the person legally responsible
1390	for the individual fails to choose to enroll in the integrated
1391	program. Enrollment in the integrated program shall be
1392	exclusively by affirmative choice of the eligible individual or
1393	by the person legally responsible for the individual. The
1394	integrated program must transfer all Medicaid services for
1395	eligible elderly individuals who choose to participate into an
1396	integrated-care management model designed to serve Medicaid
1397	recipients in the community. The integrated program must combine
1398	all funding for Medicaid services provided to individuals who
1399	are 60 years of age or older or dually eligible for Medicare and
1400	Medicaid into the integrated program, including funds for
1401	Medicaid home and community-based waiver services; all Medicaid
1402	services authorized in ss. 409.905 and 409.906, excluding funds
1403	for Medicaid nursing home services unless the agency is able to
1404	demonstrate how the integration of the funds will improve
1405	coordinated care for these services in a less costly manner; and
1406	Medicare coinsurance and deductibles for persons dually eligible
1407	for Medicaid and Medicare as prescribed in s. 409.908(13).
1408	(a)  Individuals who are 60 years of age or older or dually
1409	eligible for Medicare and Medicaid and enrolled in the
1410	developmental disabilities waiver program, the family and
1411	supported-living waiver program, the project AIDS care waiver
1412	program, the traumatic brain injury and spinal cord injury
1413	waiver program, the consumer-directed care waiver program, and
1414	the program of all-inclusive care for the elderly program, and
1415	residents of institutional care facilities for the
1416	developmentally disabled, must be excluded from the integrated
1417	program.
1418	(b)  Managed care entities who meet or exceed the agency's
1419	minimum standards are eligible to operate the integrated
1420	program. Entities eligible to participate include managed care
1421	organizations licensed under chapter 641, including entities
1422	eligible to participate in the nursing home diversion program,
1423	other qualified providers as defined in s. 430.703(7), community
1424	care for the elderly lead agencies, and other state-certified
1425	community service networks that meet comparable standards as
1426	defined by the agency, in consultation with the Department of
1427	Elderly Affairs and the Office of Insurance Regulation, to be
1428	financially solvent and able to take on financial risk for
1429	managed care. Community service networks that are certified
1430	pursuant to the comparable standards defined by the agency are
1431	not required to be licensed under chapter 641. Managed care
1432	entities who operate the integrated program shall be subject to
1433	s. 408.7056. Eligible entities shall choose to serve enrollees
1434	who are dually eligible for Medicare and Medicaid, enrollees who
1435	are 60 years of age or older, or both.
1436	(c)  The agency must ensure that the capitation-rate-
1437	setting methodology for the integrated program is actuarially
1438	sound and reflects the intent to provide quality care in the
1439	least restrictive setting. The agency must also require
1440	integrated-program providers to develop a credentialing system
1441	for service providers and to contract with all Gold Seal nursing
1442	homes, where feasible, and exclude, where feasible, chronically
1443	poor-performing facilities and providers as defined by the
1444	agency. The integrated program must develop and maintain an
1445	informal provider grievance system that addresses provider
1446	payment and contract problems. The agency shall also establish a
1447	formal grievance system to address those issues that were not
1448	resolved through the informal grievance system. The integrated
1449	program must provide that if the recipient resides in a
1450	noncontracted residential facility licensed under chapter 400 or
1451	chapter 429 at the time of enrollment in the integrated program,
1452	the recipient must be permitted to continue to reside in the
1453	noncontracted facility as long as the recipient desires. The
1454	integrated program must also provide that, in the absence of a
1455	contract between the integrated-program provider and the
1456	residential facility licensed under chapter 400 or chapter 429,
1457	current Medicaid rates must prevail. The integrated-program
1458	provider must ensure that electronic nursing home claims that
1459	contain sufficient information for processing are paid within 10
1460	business days after receipt. Alternately, the integrated-program
1461	provider may establish a capitated payment mechanism to
1462	prospectively pay nursing homes at the beginning of each month.
1463	The agency and the Department of Elderly Affairs must jointly
1464	develop procedures to manage the services provided through the
1465	integrated program in order to ensure quality and recipient
1466	choice.
1467	(d)  The Office of Program Policy Analysis and Government
1468	Accountability, in consultation with the Auditor General, shall
1469	comprehensively evaluate the pilot project for the integrated,
1470	fixed-payment delivery program for Medicaid recipients created
1471	under this subsection. The evaluation shall begin as soon as
1472	Medicaid recipients are enrolled in the managed care pilot
1473	program plans and shall continue for 24 months thereafter. The
1474	evaluation must include assessments of each managed care plan in
1475	the integrated program with regard to cost savings; consumer
1476	education, choice, and access to services; coordination of care;
1477	and quality of care. The evaluation must describe administrative
1478	or legal barriers to the implementation and operation of the
1479	pilot program and include recommendations regarding statewide
1480	expansion of the pilot program. The office shall submit its
1481	evaluation report to the Governor, the President of the Senate,
1482	and the Speaker of the House of Representatives no later than
1483	December 31, 2009.
1484	(e)  The agency may seek federal waivers or Medicaid state
1485	plan amendments and adopt rules as necessary to administer the
1486	integrated program. The agency may implement the approved
1487	federal waivers and other provisions as specified in this
1488	subsection.
1489	(f)  The implementation of the integrated, fixed-payment
1490	delivery program created under this subsection is subject to an
1491	appropriation in the General Appropriations Act.
1492	(5)(6)  The agency may contract with any public or private
1493	entity otherwise authorized by this section on a prepaid or
1494	fixed-sum basis for the provision of health care services to
1495	recipients. An entity may provide prepaid services to
1496	recipients, either directly or through arrangements with other
1497	entities, if each entity involved in providing services:
1498	(a)  Is organized primarily for the purpose of providing
1499	health care or other services of the type regularly offered to
1500	Medicaid recipients;
1501	(b)  Ensures that services meet the standards set by the
1502	agency for quality, appropriateness, and timeliness;
1503	(c)  Makes provisions satisfactory to the agency for
1504	insolvency protection and ensures that neither enrolled Medicaid
1505	recipients nor the agency will be liable for the debts of the
1506	entity;
1507	(d)  Submits to the agency, if a private entity, a
1508	financial plan that the agency finds to be fiscally sound and
1509	that provides for working capital in the form of cash or
1510	equivalent liquid assets excluding revenues from Medicaid
1511	premium payments equal to at least the first 3 months of
1512	operating expenses or $200,000, whichever is greater;
1513	(e)  Furnishes evidence satisfactory to the agency of
1514	adequate liability insurance coverage or an adequate plan of
1515	self-insurance to respond to claims for injuries arising out of
1516	the furnishing of health care;
1517	(f)  Provides, through contract or otherwise, for periodic
1518	review of its medical facilities and services, as required by
1519	the agency; and
1520	(g)  Provides organizational, operational, financial, and
1521	other information required by the agency.
1522
1523	This subsection expires October 1, 2014.
1524	(6)(7)  The agency may contract on a prepaid or fixed-sum
1525	basis with any health insurer that:
1526	(a)  Pays for health care services provided to enrolled
1527	Medicaid recipients in exchange for a premium payment paid by
1528	the agency;
1529	(b)  Assumes the underwriting risk; and
1530	(c)  Is organized and licensed under applicable provisions
1531	of the Florida Insurance Code and is currently in good standing
1532	with the Office of Insurance Regulation.
1533
1534	This subsection expires October 1, 2014.
1535	(7)(8)(a)  The agency may contract on a prepaid or fixed-
1536	sum basis with an exclusive provider organization to provide
1537	health care services to Medicaid recipients provided that the
1538	exclusive provider organization meets applicable managed care
1539	plan requirements in this section, ss. 409.9122, 409.9123,
1540	409.9128, and 627.6472, and other applicable provisions of law.
1541	This subsection expires October 1, 2014.
1542	(b)  For a period of no longer than 24 months after the
1543	effective date of this paragraph, when a member of an exclusive
1544	provider organization that is contracted by the agency to
1545	provide health care services to Medicaid recipients in rural
1546	areas without a health maintenance organization obtains services
1547	from a provider that participates in the Medicaid program in
1548	this state, the provider shall be paid in accordance with the
1549	appropriate fee schedule for services provided to eligible
1550	Medicaid recipients. The agency may seek waiver authority to
1551	implement this paragraph.
1552	(8)(9)  The Agency for Health Care Administration may
1553	provide cost-effective purchasing of chiropractic services on a
1554	fee-for-service basis to Medicaid recipients through
1555	arrangements with a statewide chiropractic preferred provider
1556	organization incorporated in this state as a not-for-profit
1557	corporation. The agency shall ensure that the benefit limits and
1558	prior authorization requirements in the current Medicaid program
1559	shall apply to the services provided by the chiropractic
1560	preferred provider organization. This subsection expires October
1561	1, 2014.
1562	(9)(10)  The agency shall not contract on a prepaid or
1563	fixed-sum basis for Medicaid services with an entity which knows
1564	or reasonably should know that any officer, director, agent,
1565	managing employee, or owner of stock or beneficial interest in
1566	excess of 5 percent common or preferred stock, or the entity
1567	itself, has been found guilty of, regardless of adjudication, or
1568	entered a plea of nolo contendere, or guilty, to:
1569	(a)  Fraud;
1570	(b)  Violation of federal or state antitrust statutes,
1571	including those proscribing price fixing between competitors and
1572	the allocation of customers among competitors;
1573	(c)  Commission of a felony involving embezzlement, theft,
1574	forgery, income tax evasion, bribery, falsification or
1575	destruction of records, making false statements, receiving
1576	stolen property, making false claims, or obstruction of justice;
1577	or
1578	(d)  Any crime in any jurisdiction which directly relates
1579	to the provision of health services on a prepaid or fixed-sum
1580	basis.
1581
1582	This subsection expires October 1, 2014.
1583	(10)(11)  The agency, after notifying the Legislature, may
1584	apply for waivers of applicable federal laws and regulations as
1585	necessary to implement more appropriate systems of health care
1586	for Medicaid recipients and reduce the cost of the Medicaid
1587	program to the state and federal governments and shall implement
1588	such programs, after legislative approval, within a reasonable
1589	period of time after federal approval. These programs must be
1590	designed primarily to reduce the need for inpatient care,
1591	custodial care and other long-term or institutional care, and
1592	other high-cost services. Prior to seeking legislative approval
1593	of such a waiver as authorized by this subsection, the agency
1594	shall provide notice and an opportunity for public comment.
1595	Notice shall be provided to all persons who have made requests
1596	of the agency for advance notice and shall be published in the
1597	Florida Administrative Weekly not less than 28 days prior to the
1598	intended action. This subsection expires October 1, 2016.
1599	(11)(12)  The agency shall establish a postpayment
1600	utilization control program designed to identify recipients who
1601	may inappropriately overuse or underuse Medicaid services and
1602	shall provide methods to correct such misuse. This subsection
1603	expires October 1, 2014.
1604	(12)(13)  The agency shall develop and provide coordinated
1605	systems of care for Medicaid recipients and may contract with
1606	public or private entities to develop and administer such
1607	systems of care among public and private health care providers
1608	in a given geographic area. This subsection expires October 1,
1609	2014.
1610	(13)(14)(a)  The agency shall operate or contract for the
1611	operation of utilization management and incentive systems
1612	designed to encourage cost-effective use of services and to
1613	eliminate services that are medically unnecessary. The agency
1614	shall track Medicaid provider prescription and billing patterns
1615	and evaluate them against Medicaid medical necessity criteria
1616	and coverage and limitation guidelines adopted by rule. Medical
1617	necessity determination requires that service be consistent with
1618	symptoms or confirmed diagnosis of illness or injury under
1619	treatment and not in excess of the patient's needs. The agency
1620	shall conduct reviews of provider exceptions to peer group norms
1621	and shall, using statistical methodologies, provider profiling,
1622	and analysis of billing patterns, detect and investigate
1623	abnormal or unusual increases in billing or payment of claims
1624	for Medicaid services and medically unnecessary provision of
1625	services. Providers that demonstrate a pattern of submitting
1626	claims for medically unnecessary services shall be referred to
1627	the Medicaid program integrity unit for investigation. In its
1628	annual report, required in s. 409.913, the agency shall report
1629	on its efforts to control overutilization as described in this
1630	subsection paragraph. This subsection expires October 1, 2014.
1631	(b)  The agency shall develop a procedure for determining
1632	whether health care providers and service vendors can provide
1633	the Medicaid program using a business case that demonstrates
1634	whether a particular good or service can offset the cost of
1635	providing the good or service in an alternative setting or
1636	through other means and therefore should receive a higher
1637	reimbursement. The business case must include, but need not be
1638	limited to:
1639	1.  A detailed description of the good or service to be
1640	provided, a description and analysis of the agency's current
1641	performance of the service, and a rationale documenting how
1642	providing the service in an alternative setting would be in the
1643	best interest of the state, the agency, and its clients.
1644	2.  A cost-benefit analysis documenting the estimated
1645	specific direct and indirect costs, savings, performance
1646	improvements, risks, and qualitative and quantitative benefits
1647	involved in or resulting from providing the service. The cost-
1648	benefit analysis must include a detailed plan and timeline
1649	identifying all actions that must be implemented to realize
1650	expected benefits. The Secretary of Health Care Administration
1651	shall verify that all costs, savings, and benefits are valid and
1652	achievable.
1653	(c)  If the agency determines that the increased
1654	reimbursement is cost-effective, the agency shall recommend a
1655	change in the reimbursement schedule for that particular good or
1656	service. If, within 12 months after implementing any rate change
1657	under this procedure, the agency determines that costs were not
1658	offset by the increased reimbursement schedule, the agency may
1659	revert to the former reimbursement schedule for the particular
1660	good or service.
1661	(14)(15)(a)  The agency shall operate the Comprehensive
1662	Assessment and Review for Long-Term Care Services (CARES)
1663	nursing facility preadmission screening program to ensure that
1664	Medicaid payment for nursing facility care is made only for
1665	individuals whose conditions require such care and to ensure
1666	that long-term care services are provided in the setting most
1667	appropriate to the needs of the person and in the most
1668	economical manner possible. The CARES program shall also ensure
1669	that individuals participating in Medicaid home and community-
1670	based waiver programs meet criteria for those programs,
1671	consistent with approved federal waivers.
1672	(b)  The agency shall operate the CARES program through an
1673	interagency agreement with the Department of Elderly Affairs.
1674	The agency, in consultation with the Department of Elderly
1675	Affairs, may contract for any function or activity of the CARES
1676	program, including any function or activity required by 42
1677	C.F.R. part 483.20, relating to preadmission screening and
1678	resident review.
1679	(c)  Prior to making payment for nursing facility services
1680	for a Medicaid recipient, the agency must verify that the
1681	nursing facility preadmission screening program has determined
1682	that the individual requires nursing facility care and that the
1683	individual cannot be safely served in community-based programs.
1684	The nursing facility preadmission screening program shall refer
1685	a Medicaid recipient to a community-based program if the
1686	individual could be safely served at a lower cost and the
1687	recipient chooses to participate in such program. For
1688	individuals whose nursing home stay is initially funded by
1689	Medicare and Medicare coverage is being terminated for lack of
1690	progress towards rehabilitation, CARES staff shall consult with
1691	the person making the determination of progress toward
1692	rehabilitation to ensure that the recipient is not being
1693	inappropriately disqualified from Medicare coverage. If, in
1694	their professional judgment, CARES staff believes that a
1695	Medicare beneficiary is still making progress toward
1696	rehabilitation, they may assist the Medicare beneficiary with an
1697	appeal of the disqualification from Medicare coverage. The use
1698	of CARES teams to review Medicare denials for coverage under
1699	this section is authorized only if it is determined that such
1700	reviews qualify for federal matching funds through Medicaid. The
1701	agency shall seek or amend federal waivers as necessary to
1702	implement this section.
1703	(d)  For the purpose of initiating immediate prescreening
1704	and diversion assistance for individuals residing in nursing
1705	homes and in order to make families aware of alternative long-
1706	term care resources so that they may choose a more cost-
1707	effective setting for long-term placement, CARES staff shall
1708	conduct an assessment and review of a sample of individuals
1709	whose nursing home stay is expected to exceed 20 days,
1710	regardless of the initial funding source for the nursing home
1711	placement. CARES staff shall provide counseling and referral
1712	services to these individuals regarding choosing appropriate
1713	long-term care alternatives. This paragraph does not apply to
1714	continuing care facilities licensed under chapter 651 or to
1715	retirement communities that provide a combination of nursing
1716	home, independent living, and other long-term care services.
1717	(e)  By January 15 of each year, the agency shall submit a
1718	report to the Legislature describing the operations of the CARES
1719	program. The report must describe:
1720	1.  Rate of diversion to community alternative programs;
1721	2.  CARES program staffing needs to achieve additional
1722	diversions;
1723	3.  Reasons the program is unable to place individuals in
1724	less restrictive settings when such individuals desired such
1725	services and could have been served in such settings;
1726	4.  Barriers to appropriate placement, including barriers
1727	due to policies or operations of other agencies or state-funded
1728	programs; and
1729	5.  Statutory changes necessary to ensure that individuals
1730	in need of long-term care services receive care in the least
1731	restrictive environment.
1732	(f)  The Department of Elderly Affairs shall track
1733	individuals over time who are assessed under the CARES program
1734	and who are diverted from nursing home placement. By January 15
1735	of each year, the department shall submit to the Legislature a
1736	longitudinal study of the individuals who are diverted from
1737	nursing home placement. The study must include:
1738	1.  The demographic characteristics of the individuals
1739	assessed and diverted from nursing home placement, including,
1740	but not limited to, age, race, gender, frailty, caregiver
1741	status, living arrangements, and geographic location;
1742	2.  A summary of community services provided to individuals
1743	for 1 year after assessment and diversion;
1744	3.  A summary of inpatient hospital admissions for
1745	individuals who have been diverted; and
1746	4.  A summary of the length of time between diversion and
1747	subsequent entry into a nursing home or death.
1748
1749	This subsection expires October 1, 2013.
1750	(15)(16)(a)  The agency shall identify health care
1751	utilization and price patterns within the Medicaid program which
1752	are not cost-effective or medically appropriate and assess the
1753	effectiveness of new or alternate methods of providing and
1754	monitoring service, and may implement such methods as it
1755	considers appropriate. Such methods may include disease
1756	management initiatives, an integrated and systematic approach
1757	for managing the health care needs of recipients who are at risk
1758	of or diagnosed with a specific disease by using best practices,
1759	prevention strategies, clinical-practice improvement, clinical
1760	interventions and protocols, outcomes research, information
1761	technology, and other tools and resources to reduce overall
1762	costs and improve measurable outcomes.
1763	(b)  The responsibility of the agency under this subsection
1764	shall include the development of capabilities to identify actual
1765	and optimal practice patterns; patient and provider educational
1766	initiatives; methods for determining patient compliance with
1767	prescribed treatments; fraud, waste, and abuse prevention and
1768	detection programs; and beneficiary case management programs.
1769	1.  The practice pattern identification program shall
1770	evaluate practitioner prescribing patterns based on national and
1771	regional practice guidelines, comparing practitioners to their
1772	peer groups. The agency and its Drug Utilization Review Board
1773	shall consult with the Department of Health and a panel of
1774	practicing health care professionals consisting of the
1775	following: the Speaker of the House of Representatives and the
1776	President of the Senate shall each appoint three physicians
1777	licensed under chapter 458 or chapter 459; and the Governor
1778	shall appoint two pharmacists licensed under chapter 465 and one
1779	dentist licensed under chapter 466 who is an oral surgeon. Terms
1780	of the panel members shall expire at the discretion of the
1781	appointing official. The advisory panel shall be responsible for
1782	evaluating treatment guidelines and recommending ways to
1783	incorporate their use in the practice pattern identification
1784	program. Practitioners who are prescribing inappropriately or
1785	inefficiently, as determined by the agency, may have their
1786	prescribing of certain drugs subject to prior authorization or
1787	may be terminated from all participation in the Medicaid
1788	program.
1789	2.  The agency shall also develop educational interventions
1790	designed to promote the proper use of medications by providers
1791	and beneficiaries.
1792	3.  The agency shall implement a pharmacy fraud, waste, and
1793	abuse initiative that may include a surety bond or letter of
1794	credit requirement for participating pharmacies, enhanced
1795	provider auditing practices, the use of additional fraud and
1796	abuse software, recipient management programs for beneficiaries
1797	inappropriately using their benefits, and other steps that will
1798	eliminate provider and recipient fraud, waste, and abuse. The
1799	initiative shall address enforcement efforts to reduce the
1800	number and use of counterfeit prescriptions.
1801	4.  By September 30, 2002, the agency shall contract with
1802	an entity in the state to implement a wireless handheld clinical
1803	pharmacology drug information database for practitioners. The
1804	initiative shall be designed to enhance the agency's efforts to
1805	reduce fraud, abuse, and errors in the prescription drug benefit
1806	program and to otherwise further the intent of this paragraph.
1807	5.  By April 1, 2006, the agency shall contract with an
1808	entity to design a database of clinical utilization information
1809	or electronic medical records for Medicaid providers. This
1810	system must be web-based and allow providers to review on a
1811	real-time basis the utilization of Medicaid services, including,
1812	but not limited to, physician office visits, inpatient and
1813	outpatient hospitalizations, laboratory and pathology services,
1814	radiological and other imaging services, dental care, and
1815	patterns of dispensing prescription drugs in order to coordinate
1816	care and identify potential fraud and abuse.
1817	6.  The agency may apply for any federal waivers needed to
1818	administer this paragraph.
1819
1820	This subsection expires October 1, 2014.
1821	(16)(17)  An entity contracting on a prepaid or fixed-sum
1822	basis shall meet the surplus requirements of s. 641.225. If an
1823	entity's surplus falls below an amount equal to the surplus
1824	requirements of s. 641.225, the agency shall prohibit the entity
1825	from engaging in marketing and preenrollment activities, shall
1826	cease to process new enrollments, and may not renew the entity's
1827	contract until the required balance is achieved. The
1828	requirements of this subsection do not apply:
1829	(a)  Where a public entity agrees to fund any deficit
1830	incurred by the contracting entity; or
1831	(b)  Where the entity's performance and obligations are
1832	guaranteed in writing by a guaranteeing organization which:
1833	1.  Has been in operation for at least 5 years and has
1834	assets in excess of $50 million; or
1835	2.  Submits a written guarantee acceptable to the agency
1836	which is irrevocable during the term of the contracting entity's
1837	contract with the agency and, upon termination of the contract,
1838	until the agency receives proof of satisfaction of all
1839	outstanding obligations incurred under the contract.
1840
1841	This subsection expires October 1, 2014.
1842	(17)(18)(a)  The agency may require an entity contracting
1843	on a prepaid or fixed-sum basis to establish a restricted
1844	insolvency protection account with a federally guaranteed
1845	financial institution licensed to do business in this state. The
1846	entity shall deposit into that account 5 percent of the
1847	capitation payments made by the agency each month until a
1848	maximum total of 2 percent of the total current contract amount
1849	is reached. The restricted insolvency protection account may be
1850	drawn upon with the authorized signatures of two persons
1851	designated by the entity and two representatives of the agency.
1852	If the agency finds that the entity is insolvent, the agency may
1853	draw upon the account solely with the two authorized signatures
1854	of representatives of the agency, and the funds may be disbursed
1855	to meet financial obligations incurred by the entity under the
1856	prepaid contract. If the contract is terminated, expired, or not
1857	continued, the account balance must be released by the agency to
1858	the entity upon receipt of proof of satisfaction of all
1859	outstanding obligations incurred under this contract.
1860	(b)  The agency may waive the insolvency protection account
1861	requirement in writing when evidence is on file with the agency
1862	of adequate insolvency insurance and reinsurance that will
1863	protect enrollees if the entity becomes unable to meet its
1864	obligations.
1865	(18)(19)  An entity that contracts with the agency on a
1866	prepaid or fixed-sum basis for the provision of Medicaid
1867	services shall reimburse any hospital or physician that is
1868	outside the entity's authorized geographic service area as
1869	specified in its contract with the agency, and that provides
1870	services authorized by the entity to its members, at a rate
1871	negotiated with the hospital or physician for the provision of
1872	services or according to the lesser of the following:
1873	(a)  The usual and customary charges made to the general
1874	public by the hospital or physician; or
1875	(b)  The Florida Medicaid reimbursement rate established
1876	for the hospital or physician.
1877
1878	This subsection expires October 1, 2014.
1879	(19)(20)  When a merger or acquisition of a Medicaid
1880	prepaid contractor has been approved by the Office of Insurance
1881	Regulation pursuant to s. 628.4615, the agency shall approve the
1882	assignment or transfer of the appropriate Medicaid prepaid
1883	contract upon request of the surviving entity of the merger or
1884	acquisition if the contractor and the other entity have been in
1885	good standing with the agency for the most recent 12-month
1886	period, unless the agency determines that the assignment or
1887	transfer would be detrimental to the Medicaid recipients or the
1888	Medicaid program. To be in good standing, an entity must not
1889	have failed accreditation or committed any material violation of
1890	the requirements of s. 641.52 and must meet the Medicaid
1891	contract requirements. For purposes of this section, a merger or
1892	acquisition means a change in controlling interest of an entity,
1893	including an asset or stock purchase. This subsection expires
1894	October 1, 2014.
1895	(20)(21)  Any entity contracting with the agency pursuant
1896	to this section to provide health care services to Medicaid
1897	recipients is prohibited from engaging in any of the following
1898	practices or activities:
1899	(a)  Practices that are discriminatory, including, but not
1900	limited to, attempts to discourage participation on the basis of
1901	actual or perceived health status.
1902	(b)  Activities that could mislead or confuse recipients,
1903	or misrepresent the organization, its marketing representatives,
1904	or the agency. Violations of this paragraph include, but are not
1905	limited to:
1906	1.  False or misleading claims that marketing
1907	representatives are employees or representatives of the state or
1908	county, or of anyone other than the entity or the organization
1909	by whom they are reimbursed.
1910	2.  False or misleading claims that the entity is
1911	recommended or endorsed by any state or county agency, or by any
1912	other organization which has not certified its endorsement in
1913	writing to the entity.
1914	3.  False or misleading claims that the state or county
1915	recommends that a Medicaid recipient enroll with an entity.
1916	4.  Claims that a Medicaid recipient will lose benefits
1917	under the Medicaid program, or any other health or welfare
1918	benefits to which the recipient is legally entitled, if the
1919	recipient does not enroll with the entity.
1920	(c)  Granting or offering of any monetary or other valuable
1921	consideration for enrollment, except as authorized by subsection
1922	(23) (24).
1923	(d)  Door-to-door solicitation of recipients who have not
1924	contacted the entity or who have not invited the entity to make
1925	a presentation.
1926	(e)  Solicitation of Medicaid recipients by marketing
1927	representatives stationed in state offices unless approved and
1928	supervised by the agency or its agent and approved by the
1929	affected state agency when solicitation occurs in an office of
1930	the state agency. The agency shall ensure that marketing
1931	representatives stationed in state offices shall market their
1932	managed care plans to Medicaid recipients only in designated
1933	areas and in such a way as to not interfere with the recipients'
1934	activities in the state office.
1935	(f)  Enrollment of Medicaid recipients.
1936	(21)(22)  The agency may impose a fine for a violation of
1937	this section or the contract with the agency by a person or
1938	entity that is under contract with the agency. With respect to
1939	any nonwillful violation, such fine shall not exceed $2,500 per
1940	violation. In no event shall such fine exceed an aggregate
1941	amount of $10,000 for all nonwillful violations arising out of
1942	the same action. With respect to any knowing and willful
1943	violation of this section or the contract with the agency, the
1944	agency may impose a fine upon the entity in an amount not to
1945	exceed $20,000 for each such violation. In no event shall such
1946	fine exceed an aggregate amount of $100,000 for all knowing and
1947	willful violations arising out of the same action. This
1948	subsection expires October 1, 2014.
1949	(22)(23)  A health maintenance organization or a person or
1950	entity exempt from chapter 641 that is under contract with the
1951	agency for the provision of health care services to Medicaid
1952	recipients may not use or distribute marketing materials used to
1953	solicit Medicaid recipients, unless such materials have been
1954	approved by the agency. The provisions of this subsection do not
1955	apply to general advertising and marketing materials used by a
1956	health maintenance organization to solicit both non-Medicaid
1957	subscribers and Medicaid recipients. This subsection expires
1958	October 1, 2014.
1959	(23)(24)  Upon approval by the agency, health maintenance
1960	organizations and persons or entities exempt from chapter 641
1961	that are under contract with the agency for the provision of
1962	health care services to Medicaid recipients may be permitted
1963	within the capitation rate to provide additional health benefits
1964	that the agency has found are of high quality, are practicably
1965	available, provide reasonable value to the recipient, and are
1966	provided at no additional cost to the state. This subsection
1967	expires October 1, 2014.
1968	(24)(25)  The agency shall utilize the statewide health
1969	maintenance organization complaint hotline for the purpose of
1970	investigating and resolving Medicaid and prepaid health plan
1971	complaints, maintaining a record of complaints and confirmed
1972	problems, and receiving disenrollment requests made by
1973	recipients. This subsection expires October 1, 2014.
1974	(25)(26)  The agency shall require the publication of the
1975	health maintenance organization's and the prepaid health plan's
1976	consumer services telephone numbers and the "800" telephone
1977	number of the statewide health maintenance organization
1978	complaint hotline on each Medicaid identification card issued by
1979	a health maintenance organization or prepaid health plan
1980	contracting with the agency to serve Medicaid recipients and on
1981	each subscriber handbook issued to a Medicaid recipient. This
1982	subsection expires October 1, 2014.
1983	(26)(27)  The agency shall establish a health care quality
1984	improvement system for those entities contracting with the
1985	agency pursuant to this section, incorporating all the standards
1986	and guidelines developed by the Medicaid Bureau of the Health
1987	Care Financing Administration as a part of the quality assurance
1988	reform initiative. The system shall include, but need not be
1989	limited to, the following:
1990	(a)  Guidelines for internal quality assurance programs,
1991	including standards for:
1992	1.  Written quality assurance program descriptions.
1993	2.  Responsibilities of the governing body for monitoring,
1994	evaluating, and making improvements to care.
1995	3.  An active quality assurance committee.
1996	4.  Quality assurance program supervision.
1997	5.  Requiring the program to have adequate resources to
1998	effectively carry out its specified activities.
1999	6.  Provider participation in the quality assurance
2000	program.
2001	7.  Delegation of quality assurance program activities.
2002	8.  Credentialing and recredentialing.
2003	9.  Enrollee rights and responsibilities.
2004	10.  Availability and accessibility to services and care.
2005	11.  Ambulatory care facilities.
2006	12.  Accessibility and availability of medical records, as
2007	well as proper recordkeeping and process for record review.
2008	13.  Utilization review.
2009	14.  A continuity of care system.
2010	15.  Quality assurance program documentation.
2011	16.  Coordination of quality assurance activity with other
2012	management activity.
2013	17.  Delivering care to pregnant women and infants; to
2014	elderly and disabled recipients, especially those who are at
2015	risk of institutional placement; to persons with developmental
2016	disabilities; and to adults who have chronic, high-cost medical
2017	conditions.
2018	(b)  Guidelines which require the entities to conduct
2019	quality-of-care studies which:
2020	1.  Target specific conditions and specific health service
2021	delivery issues for focused monitoring and evaluation.
2022	2.  Use clinical care standards or practice guidelines to
2023	objectively evaluate the care the entity delivers or fails to
2024	deliver for the targeted clinical conditions and health services
2025	delivery issues.
2026	3.  Use quality indicators derived from the clinical care
2027	standards or practice guidelines to screen and monitor care and
2028	services delivered.
2029	(c)  Guidelines for external quality review of each
2030	contractor which require: focused studies of patterns of care;
2031	individual care review in specific situations; and followup
2032	activities on previous pattern-of-care study findings and
2033	individual-care-review findings. In designing the external
2034	quality review function and determining how it is to operate as
2035	part of the state's overall quality improvement system, the
2036	agency shall construct its external quality review organization
2037	and entity contracts to address each of the following:
2038	1.  Delineating the role of the external quality review
2039	organization.
2040	2.  Length of the external quality review organization
2041	contract with the state.
2042	3.  Participation of the contracting entities in designing
2043	external quality review organization review activities.
2044	4.  Potential variation in the type of clinical conditions
2045	and health services delivery issues to be studied at each plan.
2046	5.  Determining the number of focused pattern-of-care
2047	studies to be conducted for each plan.
2048	6.  Methods for implementing focused studies.
2049	7.  Individual care review.
2050	8.  Followup activities.
2051
2052	This subsection expires October 1, 2016.
2053	(27)(28)  In order to ensure that children receive health
2054	care services for which an entity has already been compensated,
2055	an entity contracting with the agency pursuant to this section
2056	shall achieve an annual Early and Periodic Screening, Diagnosis,
2057	and Treatment (EPSDT) Service screening rate of at least 60
2058	percent for those recipients continuously enrolled for at least
2059	8 months. The agency shall develop a method by which the EPSDT
2060	screening rate shall be calculated. For any entity which does
2061	not achieve the annual 60 percent rate, the entity must submit a
2062	corrective action plan for the agency's approval. If the entity
2063	does not meet the standard established in the corrective action
2064	plan during the specified timeframe, the agency is authorized to
2065	impose appropriate contract sanctions. At least annually, the
2066	agency shall publicly release the EPSDT Services screening rates
2067	of each entity it has contracted with on a prepaid basis to
2068	serve Medicaid recipients. This subsection expires October 1,
2069	2014.
2070	(28)(29)  The agency shall perform enrollments and
2071	disenrollments for Medicaid recipients who are eligible for
2072	MediPass or managed care plans. Notwithstanding the prohibition
2073	contained in paragraph (20)(21)(f), managed care plans may
2074	perform preenrollments of Medicaid recipients under the
2075	supervision of the agency or its agents. For the purposes of
2076	this section, the term "preenrollment" means the provision of
2077	marketing and educational materials to a Medicaid recipient and
2078	assistance in completing the application forms, but does not
2079	include actual enrollment into a managed care plan. An
2080	application for enrollment may not be deemed complete until the
2081	agency or its agent verifies that the recipient made an
2082	informed, voluntary choice. The agency, in cooperation with the
2083	Department of Children and Family Services, may test new
2084	marketing initiatives to inform Medicaid recipients about their
2085	managed care options at selected sites. The agency may contract
2086	with a third party to perform managed care plan and MediPass
2087	enrollment and disenrollment services for Medicaid recipients
2088	and may adopt rules to administer such services. The agency may
2089	adjust the capitation rate only to cover the costs of a third-
2090	party enrollment and disenrollment contract, and for agency
2091	supervision and management of the managed care plan enrollment
2092	and disenrollment contract. This subsection expires October 1,
2093	2014.
2094	(29)(30)  Any lists of providers made available to Medicaid
2095	recipients, MediPass enrollees, or managed care plan enrollees
2096	shall be arranged alphabetically showing the provider's name and
2097	specialty and, separately, by specialty in alphabetical order.
2098	This subsection expires October 1, 2014.
2099	(30)(31)  The agency shall establish an enhanced managed
2100	care quality assurance oversight function, to include at least
2101	the following components:
2102	(a)  At least quarterly analysis and followup, including
2103	sanctions as appropriate, of managed care participant
2104	utilization of services.
2105	(b)  At least quarterly analysis and followup, including
2106	sanctions as appropriate, of quality findings of the Medicaid
2107	peer review organization and other external quality assurance
2108	programs.
2109	(c)  At least quarterly analysis and followup, including
2110	sanctions as appropriate, of the fiscal viability of managed
2111	care plans.
2112	(d)  At least quarterly analysis and followup, including
2113	sanctions as appropriate, of managed care participant
2114	satisfaction and disenrollment surveys.
2115	(e)  The agency shall conduct regular and ongoing Medicaid
2116	recipient satisfaction surveys.
2117
2118	The analyses and followup activities conducted by the agency
2119	under its enhanced managed care quality assurance oversight
2120	function shall not duplicate the activities of accreditation
2121	reviewers for entities regulated under part III of chapter 641,
2122	but may include a review of the finding of such reviewers. This
2123	subsection expires October 1, 2014.
2124	(31)(32)  Each managed care plan that is under contract
2125	with the agency to provide health care services to Medicaid
2126	recipients shall annually conduct a background check with the
2127	Department of Law Enforcement of all persons with ownership
2128	interest of 5 percent or more or executive management
2129	responsibility for the managed care plan and shall submit to the
2130	agency information concerning any such person who has been found
2131	guilty of, regardless of adjudication, or has entered a plea of
2132	nolo contendere or guilty to, any of the offenses listed in s.
2133	435.04. This subsection expires October 1, 2014.
2134	(32)(33)  The agency shall, by rule, develop a process
2135	whereby a Medicaid managed care plan enrollee who wishes to
2136	enter hospice care may be disenrolled from the managed care plan
2137	within 24 hours after contacting the agency regarding such
2138	request. The agency rule shall include a methodology for the
2139	agency to recoup managed care plan payments on a pro rata basis
2140	if payment has been made for the enrollment month when
2141	disenrollment occurs. This subsection expires October 1, 2014.
2142	(33)(34)  The agency and entities that contract with the
2143	agency to provide health care services to Medicaid recipients
2144	under this section or ss. 409.91211 and 409.9122 must comply
2145	with the provisions of s. 641.513 in providing emergency
2146	services and care to Medicaid recipients and MediPass
2147	recipients. Where feasible, safe, and cost-effective, the agency
2148	shall encourage hospitals, emergency medical services providers,
2149	and other public and private health care providers to work
2150	together in their local communities to enter into agreements or
2151	arrangements to ensure access to alternatives to emergency
2152	services and care for those Medicaid recipients who need
2153	nonemergent care. The agency shall coordinate with hospitals,
2154	emergency medical services providers, private health plans,
2155	capitated managed care networks as established in s. 409.91211,
2156	and other public and private health care providers to implement
2157	the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
2158	and 641.31097 to develop and implement emergency department
2159	diversion programs for Medicaid recipients. This subsection
2160	expires October 1, 2014.
2161	(34)(35)  All entities providing health care services to
2162	Medicaid recipients shall make available, and encourage all
2163	pregnant women and mothers with infants to receive, and provide
2164	documentation in the medical records to reflect, the following:
2165	(a)  Healthy Start prenatal or infant screening.
2166	(b)  Healthy Start care coordination, when screening or
2167	other factors indicate need.
2168	(c)  Healthy Start enhanced services in accordance with the
2169	prenatal or infant screening results.
2170	(d)  Immunizations in accordance with recommendations of
2171	the Advisory Committee on Immunization Practices of the United
2172	States Public Health Service and the American Academy of
2173	Pediatrics, as appropriate.
2174	(e)  Counseling and services for family planning to all
2175	women and their partners.
2176	(f)  A scheduled postpartum visit for the purpose of
2177	voluntary family planning, to include discussion of all methods
2178	of contraception, as appropriate.
2179	(g)  Referral to the Special Supplemental Nutrition Program
2180	for Women, Infants, and Children (WIC).
2181
2182	This subsection expires October 1, 2014.
2183	(35)(36)  Any entity that provides Medicaid prepaid health
2184	plan services shall ensure the appropriate coordination of
2185	health care services with an assisted living facility in cases
2186	where a Medicaid recipient is both a member of the entity's
2187	prepaid health plan and a resident of the assisted living
2188	facility. If the entity is at risk for Medicaid targeted case
2189	management and behavioral health services, the entity shall
2190	inform the assisted living facility of the procedures to follow
2191	should an emergent condition arise. This subsection expires
2192	October 1, 2014.
2193	(37)  The agency may seek and implement federal waivers
2194	necessary to provide for cost-effective purchasing of home
2195	health services, private duty nursing services, transportation,
2196	independent laboratory services, and durable medical equipment
2197	and supplies through competitive bidding pursuant to s. 287.057.
2198	The agency may request appropriate waivers from the federal
2199	Health Care Financing Administration in order to competitively
2200	bid such services. The agency may exclude providers not selected
2201	through the bidding process from the Medicaid provider network.
2202	(36)(38)  The agency shall enter into agreements with not-
2203	for-profit organizations based in this state for the purpose of
2204	providing vision screening. This subsection expires October 1,
2205	2014.
2206	(37)(39)(a)  The agency shall implement a Medicaid
2207	prescribed-drug spending-control program that includes the
2208	following components:
2209	1.  A Medicaid preferred drug list, which shall be a
2210	listing of cost-effective therapeutic options recommended by the
2211	Medicaid Pharmacy and Therapeutics Committee established
2212	pursuant to s. 409.91195 and adopted by the agency for each
2213	therapeutic class on the preferred drug list. At the discretion
2214	of the committee, and when feasible, the preferred drug list
2215	should include at least two products in a therapeutic class. The
2216	agency may post the preferred drug list and updates to the
2217	preferred drug list on an Internet website without following the
2218	rulemaking procedures of chapter 120. Antiretroviral agents are
2219	excluded from the preferred drug list. The agency shall also
2220	limit the amount of a prescribed drug dispensed to no more than
2221	a 34-day supply unless the drug products' smallest marketed
2222	package is greater than a 34-day supply, or the drug is
2223	determined by the agency to be a maintenance drug in which case
2224	a 100-day maximum supply may be authorized. The agency is
2225	authorized to seek any federal waivers necessary to implement
2226	these cost-control programs and to continue participation in the
2227	federal Medicaid rebate program, or alternatively to negotiate
2228	state-only manufacturer rebates. The agency may adopt rules to
2229	implement this subparagraph. The agency shall continue to
2230	provide unlimited contraceptive drugs and items. The agency must
2231	establish procedures to ensure that:
2232	a.  There is a response to a request for prior consultation
2233	by telephone or other telecommunication device within 24 hours
2234	after receipt of a request for prior consultation; and
2235	b.  A 72-hour supply of the drug prescribed is provided in
2236	an emergency or when the agency does not provide a response
2237	within 24 hours as required by sub-subparagraph a.
2238	2.  Reimbursement to pharmacies for Medicaid prescribed
2239	drugs shall be set at the lesser of: the average wholesale price
2240	(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2241	plus 4.75 percent, the federal upper limit (FUL), the state
2242	maximum allowable cost (SMAC), or the usual and customary (UAC)
2243	charge billed by the provider.
2244	3.  The agency shall develop and implement a process for
2245	managing the drug therapies of Medicaid recipients who are using
2246	significant numbers of prescribed drugs each month. The
2247	management process may include, but is not limited to,
2248	comprehensive, physician-directed medical-record reviews, claims
2249	analyses, and case evaluations to determine the medical
2250	necessity and appropriateness of a patient's treatment plan and
2251	drug therapies. The agency may contract with a private
2252	organization to provide drug-program-management services. The
2253	Medicaid drug benefit management program shall include
2254	initiatives to manage drug therapies for HIV/AIDS patients,
2255	patients using 20 or more unique prescriptions in a 180-day
2256	period, and the top 1,000 patients in annual spending. The
2257	agency shall enroll any Medicaid recipient in the drug benefit
2258	management program if he or she meets the specifications of this
2259	provision and is not enrolled in a Medicaid health maintenance
2260	organization.
2261	4.  The agency may limit the size of its pharmacy network
2262	based on need, competitive bidding, price negotiations,
2263	credentialing, or similar criteria. The agency shall give
2264	special consideration to rural areas in determining the size and
2265	location of pharmacies included in the Medicaid pharmacy
2266	network. A pharmacy credentialing process may include criteria
2267	such as a pharmacy's full-service status, location, size,
2268	patient educational programs, patient consultation, disease
2269	management services, and other characteristics. The agency may
2270	impose a moratorium on Medicaid pharmacy enrollment when it is
2271	determined that it has a sufficient number of Medicaid-
2272	participating providers. The agency must allow dispensing
2273	practitioners to participate as a part of the Medicaid pharmacy
2274	network regardless of the practitioner's proximity to any other
2275	entity that is dispensing prescription drugs under the Medicaid
2276	program. A dispensing practitioner must meet all credentialing
2277	requirements applicable to his or her practice, as determined by
2278	the agency.
2279	5.  The agency shall develop and implement a program that
2280	requires Medicaid practitioners who prescribe drugs to use a
2281	counterfeit-proof prescription pad for Medicaid prescriptions.
2282	The agency shall require the use of standardized counterfeit-
2283	proof prescription pads by Medicaid-participating prescribers or
2284	prescribers who write prescriptions for Medicaid recipients. The
2285	agency may implement the program in targeted geographic areas or
2286	statewide.
2287	6.  The agency may enter into arrangements that require
2288	manufacturers of generic drugs prescribed to Medicaid recipients
2289	to provide rebates of at least 15.1 percent of the average
2290	manufacturer price for the manufacturer's generic products.
2291	These arrangements shall require that if a generic-drug
2292	manufacturer pays federal rebates for Medicaid-reimbursed drugs
2293	at a level below 15.1 percent, the manufacturer must provide a
2294	supplemental rebate to the state in an amount necessary to
2295	achieve a 15.1-percent rebate level.
2296	7.  The agency may establish a preferred drug list as
2297	described in this subsection, and, pursuant to the establishment
2298	of such preferred drug list, it is authorized to negotiate
2299	supplemental rebates from manufacturers that are in addition to
2300	those required by Title XIX of the Social Security Act and at no
2301	less than 14 percent of the average manufacturer price as
2302	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2303	the federal or supplemental rebate, or both, equals or exceeds
2304	29 percent. There is no upper limit on the supplemental rebates
2305	the agency may negotiate. The agency may determine that specific
2306	products, brand-name or generic, are competitive at lower rebate
2307	percentages. Agreement to pay the minimum supplemental rebate
2308	percentage will guarantee a manufacturer that the Medicaid
2309	Pharmaceutical and Therapeutics Committee will consider a
2310	product for inclusion on the preferred drug list. However, a
2311	pharmaceutical manufacturer is not guaranteed placement on the
2312	preferred drug list by simply paying the minimum supplemental
2313	rebate. Agency decisions will be made on the clinical efficacy
2314	of a drug and recommendations of the Medicaid Pharmaceutical and
2315	Therapeutics Committee, as well as the price of competing
2316	products minus federal and state rebates. The agency is
2317	authorized to contract with an outside agency or contractor to
2318	conduct negotiations for supplemental rebates. For the purposes
2319	of this section, the term "supplemental rebates" means cash
2320	rebates. Effective July 1, 2004, value-added programs as a
2321	substitution for supplemental rebates are prohibited. The agency
2322	is authorized to seek any federal waivers to implement this
2323	initiative.
2324	8.  The Agency for Health Care Administration shall expand
2325	home delivery of pharmacy products. To assist Medicaid patients
2326	in securing their prescriptions and reduce program costs, the
2327	agency shall expand its current mail-order-pharmacy diabetes-
2328	supply program to include all generic and brand-name drugs used
2329	by Medicaid patients with diabetes. Medicaid recipients in the
2330	current program may obtain nondiabetes drugs on a voluntary
2331	basis. This initiative is limited to the geographic area covered
2332	by the current contract. The agency may seek and implement any
2333	federal waivers necessary to implement this subparagraph.
2334	9.  The agency shall limit to one dose per month any drug
2335	prescribed to treat erectile dysfunction.
2336	10.a.  The agency may implement a Medicaid behavioral drug
2337	management system. The agency may contract with a vendor that
2338	has experience in operating behavioral drug management systems
2339	to implement this program. The agency is authorized to seek
2340	federal waivers to implement this program.
2341	b.  The agency, in conjunction with the Department of
2342	Children and Family Services, may implement the Medicaid
2343	behavioral drug management system that is designed to improve
2344	the quality of care and behavioral health prescribing practices
2345	based on best practice guidelines, improve patient adherence to
2346	medication plans, reduce clinical risk, and lower prescribed
2347	drug costs and the rate of inappropriate spending on Medicaid
2348	behavioral drugs. The program may include the following
2349	elements:
2350	(I)  Provide for the development and adoption of best
2351	practice guidelines for behavioral health-related drugs such as
2352	antipsychotics, antidepressants, and medications for treating
2353	bipolar disorders and other behavioral conditions; translate
2354	them into practice; review behavioral health prescribers and
2355	compare their prescribing patterns to a number of indicators
2356	that are based on national standards; and determine deviations
2357	from best practice guidelines.
2358	(II)  Implement processes for providing feedback to and
2359	educating prescribers using best practice educational materials
2360	and peer-to-peer consultation.
2361	(III)  Assess Medicaid beneficiaries who are outliers in
2362	their use of behavioral health drugs with regard to the numbers
2363	and types of drugs taken, drug dosages, combination drug
2364	therapies, and other indicators of improper use of behavioral
2365	health drugs.
2366	(IV)  Alert prescribers to patients who fail to refill
2367	prescriptions in a timely fashion, are prescribed multiple same-
2368	class behavioral health drugs, and may have other potential
2369	medication problems.
2370	(V)  Track spending trends for behavioral health drugs and
2371	deviation from best practice guidelines.
2372	(VI)  Use educational and technological approaches to
2373	promote best practices, educate consumers, and train prescribers
2374	in the use of practice guidelines.
2375	(VII)  Disseminate electronic and published materials.
2376	(VIII)  Hold statewide and regional conferences.
2377	(IX)  Implement a disease management program with a model
2378	quality-based medication component for severely mentally ill
2379	individuals and emotionally disturbed children who are high
2380	users of care.
2381	11.a.  The agency shall implement a Medicaid prescription
2382	drug management system. The agency may contract with a vendor
2383	that has experience in operating prescription drug management
2384	systems in order to implement this system. Any management system
2385	that is implemented in accordance with this subparagraph must
2386	rely on cooperation between physicians and pharmacists to
2387	determine appropriate practice patterns and clinical guidelines
2388	to improve the prescribing, dispensing, and use of drugs in the
2389	Medicaid program. The agency may seek federal waivers to
2390	implement this program.
2391	b.  The drug management system must be designed to improve
2392	the quality of care and prescribing practices based on best
2393	practice guidelines, improve patient adherence to medication
2394	plans, reduce clinical risk, and lower prescribed drug costs and
2395	the rate of inappropriate spending on Medicaid prescription
2396	drugs. The program must:
2397	(I)  Provide for the development and adoption of best
2398	practice guidelines for the prescribing and use of drugs in the
2399	Medicaid program, including translating best practice guidelines
2400	into practice; reviewing prescriber patterns and comparing them
2401	to indicators that are based on national standards and practice
2402	patterns of clinical peers in their community, statewide, and
2403	nationally; and determine deviations from best practice
2404	guidelines.
2405	(II)  Implement processes for providing feedback to and
2406	educating prescribers using best practice educational materials
2407	and peer-to-peer consultation.
2408	(III)  Assess Medicaid recipients who are outliers in their
2409	use of a single or multiple prescription drugs with regard to
2410	the numbers and types of drugs taken, drug dosages, combination
2411	drug therapies, and other indicators of improper use of
2412	prescription drugs.
2413	(IV)  Alert prescribers to patients who fail to refill
2414	prescriptions in a timely fashion, are prescribed multiple drugs
2415	that may be redundant or contraindicated, or may have other
2416	potential medication problems.
2417	(V)  Track spending trends for prescription drugs and
2418	deviation from best practice guidelines.
2419	(VI)  Use educational and technological approaches to
2420	promote best practices, educate consumers, and train prescribers
2421	in the use of practice guidelines.
2422	(VII)  Disseminate electronic and published materials.
2423	(VIII)  Hold statewide and regional conferences.
2424	(IX)  Implement disease management programs in cooperation
2425	with physicians and pharmacists, along with a model quality-
2426	based medication component for individuals having chronic
2427	medical conditions.
2428	12.  The agency is authorized to contract for drug rebate
2429	administration, including, but not limited to, calculating
2430	rebate amounts, invoicing manufacturers, negotiating disputes
2431	with manufacturers, and maintaining a database of rebate
2432	collections.
2433	13.  The agency may specify the preferred daily dosing form
2434	or strength for the purpose of promoting best practices with
2435	regard to the prescribing of certain drugs as specified in the
2436	General Appropriations Act and ensuring cost-effective
2437	prescribing practices.
2438	14.  The agency may require prior authorization for
2439	Medicaid-covered prescribed drugs. The agency may, but is not
2440	required to, prior-authorize the use of a product:
2441	a.  For an indication not approved in labeling;
2442	b.  To comply with certain clinical guidelines; or
2443	c.  If the product has the potential for overuse, misuse,
2444	or abuse.
2445
2446	The agency may require the prescribing professional to provide
2447	information about the rationale and supporting medical evidence
2448	for the use of a drug. The agency may post prior authorization
2449	criteria and protocol and updates to the list of drugs that are
2450	subject to prior authorization on an Internet website without
2451	amending its rule or engaging in additional rulemaking.
2452	15.  The agency, in conjunction with the Pharmaceutical and
2453	Therapeutics Committee, may require age-related prior
2454	authorizations for certain prescribed drugs. The agency may
2455	preauthorize the use of a drug for a recipient who may not meet
2456	the age requirement or may exceed the length of therapy for use
2457	of this product as recommended by the manufacturer and approved
2458	by the Food and Drug Administration. Prior authorization may
2459	require the prescribing professional to provide information
2460	about the rationale and supporting medical evidence for the use
2461	of a drug.
2462	16.  The agency shall implement a step-therapy prior
2463	authorization approval process for medications excluded from the
2464	preferred drug list. Medications listed on the preferred drug
2465	list must be used within the previous 12 months prior to the
2466	alternative medications that are not listed. The step-therapy
2467	prior authorization may require the prescriber to use the
2468	medications of a similar drug class or for a similar medical
2469	indication unless contraindicated in the Food and Drug
2470	Administration labeling. The trial period between the specified
2471	steps may vary according to the medical indication. The step-
2472	therapy approval process shall be developed in accordance with
2473	the committee as stated in s. 409.91195(7) and (8). A drug
2474	product may be approved without meeting the step-therapy prior
2475	authorization criteria if the prescribing physician provides the
2476	agency with additional written medical or clinical documentation
2477	that the product is medically necessary because:
2478	a.  There is not a drug on the preferred drug list to treat
2479	the disease or medical condition which is an acceptable clinical
2480	alternative;
2481	b.  The alternatives have been ineffective in the treatment
2482	of the beneficiary's disease; or
2483	c.  Based on historic evidence and known characteristics of
2484	the patient and the drug, the drug is likely to be ineffective,
2485	or the number of doses have been ineffective.
2486
2487	The agency shall work with the physician to determine the best
2488	alternative for the patient. The agency may adopt rules waiving
2489	the requirements for written clinical documentation for specific
2490	drugs in limited clinical situations.
2491	17.  The agency shall implement a return and reuse program
2492	for drugs dispensed by pharmacies to institutional recipients,
2493	which includes payment of a $5 restocking fee for the
2494	implementation and operation of the program. The return and
2495	reuse program shall be implemented electronically and in a
2496	manner that promotes efficiency. The program must permit a
2497	pharmacy to exclude drugs from the program if it is not
2498	practical or cost-effective for the drug to be included and must
2499	provide for the return to inventory of drugs that cannot be
2500	credited or returned in a cost-effective manner. The agency
2501	shall determine if the program has reduced the amount of
2502	Medicaid prescription drugs which are destroyed on an annual
2503	basis and if there are additional ways to ensure more
2504	prescription drugs are not destroyed which could safely be
2505	reused. The agency's conclusion and recommendations shall be
2506	reported to the Legislature by December 1, 2005.
2507	(b)  The agency shall implement this subsection to the
2508	extent that funds are appropriated to administer the Medicaid
2509	prescribed-drug spending-control program. The agency may
2510	contract all or any part of this program to private
2511	organizations.
2512	(c)  The agency shall submit quarterly reports to the
2513	Governor, the President of the Senate, and the Speaker of the
2514	House of Representatives which must include, but need not be
2515	limited to, the progress made in implementing this subsection
2516	and its effect on Medicaid prescribed-drug expenditures.
2517	(38)(40)  Notwithstanding the provisions of chapter 287,
2518	the agency may, at its discretion, renew a contract or contracts
2519	for fiscal intermediary services one or more times for such
2520	periods as the agency may decide; however, all such renewals may
2521	not combine to exceed a total period longer than the term of the
2522	original contract.
2523	(39)(41)  The agency shall provide for the development of a
2524	demonstration project by establishment in Miami-Dade County of a
2525	long-term-care facility licensed pursuant to chapter 395 to
2526	improve access to health care for a predominantly minority,
2527	medically underserved, and medically complex population and to
2528	evaluate alternatives to nursing home care and general acute
2529	care for such population. Such project is to be located in a
2530	health care condominium and colocated with licensed facilities
2531	providing a continuum of care. The establishment of this project
2532	is not subject to the provisions of s. 408.036 or s. 408.039.
2533	This subsection expires October 1, 2013.
2534	(40)(42)  The agency shall develop and implement a
2535	utilization management program for Medicaid-eligible recipients
2536	for the management of occupational, physical, respiratory, and
2537	speech therapies. The agency shall establish a utilization
2538	program that may require prior authorization in order to ensure
2539	medically necessary and cost-effective treatments. The program
2540	shall be operated in accordance with a federally approved waiver
2541	program or state plan amendment. The agency may seek a federal
2542	waiver or state plan amendment to implement this program. The
2543	agency may also competitively procure these services from an
2544	outside vendor on a regional or statewide basis. This subsection
2545	expires October 1, 2014.
2546	(41)(43)  The agency shall may contract on a prepaid or
2547	fixed-sum basis with appropriately licensed prepaid dental
2548	health plans to provide dental services. This subsection expires
2549	October 1, 2014.
2550	(42)(44)  The Agency for Health Care Administration shall
2551	ensure that any Medicaid managed care plan as defined in s.
2552	409.9122(2)(f), whether paid on a capitated basis or a shared
2553	savings basis, is cost-effective. For purposes of this
2554	subsection, the term "cost-effective" means that a network's
2555	per-member, per-month costs to the state, including, but not
2556	limited to, fee-for-service costs, administrative costs, and
2557	case-management fees, if any, must be no greater than the
2558	state's costs associated with contracts for Medicaid services
2559	established under subsection (3), which may be adjusted for
2560	health status. The agency shall conduct actuarially sound
2561	adjustments for health status in order to ensure such cost-
2562	effectiveness and shall annually publish the results on its
2563	Internet website. Contracts established pursuant to this
2564	subsection which are not cost-effective may not be renewed. This
2565	subsection expires October 1, 2014.
2566	(43)(45)  Subject to the availability of funds, the agency
2567	shall mandate a recipient's participation in a provider lock-in
2568	program, when appropriate, if a recipient is found by the agency
2569	to have used Medicaid goods or services at a frequency or amount
2570	not medically necessary, limiting the receipt of goods or
2571	services to medically necessary providers after the 21-day
2572	appeal process has ended, for a period of not less than 1 year.
2573	The lock-in programs shall include, but are not limited to,
2574	pharmacies, medical doctors, and infusion clinics. The
2575	limitation does not apply to emergency services and care
2576	provided to the recipient in a hospital emergency department.
2577	The agency shall seek any federal waivers necessary to implement
2578	this subsection. The agency shall adopt any rules necessary to
2579	comply with or administer this subsection. This subsection
2580	expires October 1, 2014.
2581	(44)(46)  The agency shall seek a federal waiver for
2582	permission to terminate the eligibility of a Medicaid recipient
2583	who has been found to have committed fraud, through judicial or
2584	administrative determination, two times in a period of 5 years.
2585	(47)  The agency shall conduct a study of available
2586	electronic systems for the purpose of verifying the identity and
2587	eligibility of a Medicaid recipient. The agency shall recommend
2588	to the Legislature a plan to implement an electronic
2589	verification system for Medicaid recipients by January 31, 2005.
2590	(45)(48)(a)  A provider is not entitled to enrollment in
2591	the Medicaid provider network. The agency may implement a
2592	Medicaid fee-for-service provider network controls, including,
2593	but not limited to, competitive procurement and provider
2594	credentialing. If a credentialing process is used, the agency
2595	may limit its provider network based upon the following
2596	considerations: beneficiary access to care, provider
2597	availability, provider quality standards and quality assurance
2598	processes, cultural competency, demographic characteristics of
2599	beneficiaries, practice standards, service wait times, provider
2600	turnover, provider licensure and accreditation history, program
2601	integrity history, peer review, Medicaid policy and billing
2602	compliance records, clinical and medical record audit findings,
2603	and such other areas that are considered necessary by the agency
2604	to ensure the integrity of the program.
2605	(b)  The agency shall limit its network of durable medical
2606	equipment and medical supply providers. For dates of service
2607	after January 1, 2009, the agency shall limit payment for
2608	durable medical equipment and supplies to providers that meet
2609	all the requirements of this paragraph.
2610	1.  Providers must be accredited by a Centers for Medicare
2611	and Medicaid Services deemed accreditation organization for
2612	suppliers of durable medical equipment, prosthetics, orthotics,
2613	and supplies. The provider must maintain accreditation and is
2614	subject to unannounced reviews by the accrediting organization.
2615	2.  Providers must provide the services or supplies
2616	directly to the Medicaid recipient or caregiver at the provider
2617	location or recipient's residence or send the supplies directly
2618	to the recipient's residence with receipt of mailed delivery.
2619	Subcontracting or consignment of the service or supply to a
2620	third party is prohibited.
2621	3.  Notwithstanding subparagraph 2., a durable medical
2622	equipment provider may store nebulizers at a physician's office
2623	for the purpose of having the physician's staff issue the
2624	equipment if it meets all of the following conditions:
2625	a.  The physician must document the medical necessity and
2626	need to prevent further deterioration of the patient's
2627	respiratory status by the timely delivery of the nebulizer in
2628	the physician's office.
2629	b.  The durable medical equipment provider must have
2630	written documentation of the competency and training by a
2631	Florida-licensed registered respiratory therapist of any durable
2632	medical equipment staff who participate in the training of
2633	physician office staff for the use of nebulizers, including
2634	cleaning, warranty, and special needs of patients.
2635	c.  The physician's office must have documented the
2636	training and competency of any staff member who initiates the
2637	delivery of nebulizers to patients. The durable medical
2638	equipment provider must maintain copies of all physician office
2639	training.
2640	d.  The physician's office must maintain inventory records
2641	of stored nebulizers, including documentation of the durable
2642	medical equipment provider source.
2643	e.  A physician contracted with a Medicaid durable medical
2644	equipment provider may not have a financial relationship with
2645	that provider or receive any financial gain from the delivery of
2646	nebulizers to patients.
2647	4.  Providers must have a physical business location and a
2648	functional landline business phone. The location must be within
2649	the state or not more than 50 miles from the Florida state line.
2650	The agency may make exceptions for providers of durable medical
2651	equipment or supplies not otherwise available from other
2652	enrolled providers located within the state.
2653	5.  Physical business locations must be clearly identified
2654	as a business that furnishes durable medical equipment or
2655	medical supplies by signage that can be read from 20 feet away.
2656	The location must be readily accessible to the public during
2657	normal, posted business hours and must operate at least 5 hours
2658	per day and at least 5 days per week, with the exception of
2659	scheduled and posted holidays. The location may not be located
2660	within or at the same numbered street address as another
2661	enrolled Medicaid durable medical equipment or medical supply
2662	provider or as an enrolled Medicaid pharmacy that is also
2663	enrolled as a durable medical equipment provider. A licensed
2664	orthotist or prosthetist that provides only orthotic or
2665	prosthetic devices as a Medicaid durable medical equipment
2666	provider is exempt from this paragraph.
2667	6.  Providers must maintain a stock of durable medical
2668	equipment and medical supplies on site that is readily available
2669	to meet the needs of the durable medical equipment business
2670	location's customers.
2671	7.  Providers must provide a surety bond of $50,000 for
2672	each provider location, up to a maximum of 5 bonds statewide or
2673	an aggregate bond of $250,000 statewide, as identified by
2674	Federal Employer Identification Number. Providers who post a
2675	statewide or an aggregate bond must identify all of their
2676	locations in any Medicaid durable medical equipment and medical
2677	supply provider enrollment application or bond renewal. Each
2678	provider location's surety bond must be renewed annually and the
2679	provider must submit proof of renewal even if the original bond
2680	is a continuous bond. A licensed orthotist or prosthetist that
2681	provides only orthotic or prosthetic devices as a Medicaid
2682	durable medical equipment provider is exempt from the provisions
2683	in this paragraph.
2684	8.  Providers must obtain a level 2 background screening,
2685	in accordance with chapter 435 and s. 408.809, for each provider
2686	employee in direct contact with or providing direct services to
2687	recipients of durable medical equipment and medical supplies in
2688	their homes. This requirement includes, but is not limited to,
2689	repair and service technicians, fitters, and delivery staff. The
2690	provider shall pay for the cost of the background screening.
2691	9.  The following providers are exempt from subparagraphs
2692	1. and 7.:
2693	a.  Durable medical equipment providers owned and operated
2694	by a government entity.
2695	b.  Durable medical equipment providers that are operating
2696	within a pharmacy that is currently enrolled as a Medicaid
2697	pharmacy provider.
2698	c.  Active, Medicaid-enrolled orthopedic physician groups,
2699	primarily owned by physicians, which provide only orthotic and
2700	prosthetic devices.
2701	(46)(49)  The agency shall contract with established
2702	minority physician networks that provide services to
2703	historically underserved minority patients. The networks must
2704	provide cost-effective Medicaid services, comply with the
2705	requirements to be a MediPass provider, and provide their
2706	primary care physicians with access to data and other management
2707	tools necessary to assist them in ensuring the appropriate use
2708	of services, including inpatient hospital services and
2709	pharmaceuticals.
2710	(a)  The agency shall provide for the development and
2711	expansion of minority physician networks in each service area to
2712	provide services to Medicaid recipients who are eligible to
2713	participate under federal law and rules.
2714	(b)  The agency shall reimburse each minority physician
2715	network as a fee-for-service provider, including the case
2716	management fee for primary care, if any, or as a capitated rate
2717	provider for Medicaid services. Any savings shall be shared with
2718	the minority physician networks pursuant to the contract.
2719	(c)  For purposes of this subsection, the term "cost-
2720	effective" means that a network's per-member, per-month costs to
2721	the state, including, but not limited to, fee-for-service costs,
2722	administrative costs, and case-management fees, if any, must be
2723	no greater than the state's costs associated with contracts for
2724	Medicaid services established under subsection (3), which shall
2725	be actuarially adjusted for case mix, model, and service area.
2726	The agency shall conduct actuarially sound audits adjusted for
2727	case mix and model in order to ensure such cost-effectiveness
2728	and shall annually publish the audit results on its Internet
2729	website. Contracts established pursuant to this subsection which
2730	are not cost-effective may not be renewed.
2731	(d)  The agency may apply for any federal waivers needed to
2732	implement this subsection.
2733
2734	This subsection expires October 1, 2014.
2735	(47)(50)  To the extent permitted by federal law and as
2736	allowed under s. 409.906, the agency shall provide reimbursement
2737	for emergency mental health care services for Medicaid
2738	recipients in crisis stabilization facilities licensed under s.
2739	394.875 as long as those services are less expensive than the
2740	same services provided in a hospital setting.
2741	(48)(51)  The agency shall work with the Agency for Persons
2742	with Disabilities to develop a home and community-based waiver
2743	to serve children and adults who are diagnosed with familial
2744	dysautonomia or Riley-Day syndrome caused by a mutation of the
2745	IKBKAP gene on chromosome 9. The agency shall seek federal
2746	waiver approval and implement the approved waiver subject to the
2747	availability of funds and any limitations provided in the
2748	General Appropriations Act. The agency may adopt rules to
2749	implement this waiver program.
2750	(49)(52)  The agency shall implement a program of all-
2751	inclusive care for children. The program of all-inclusive care
2752	for children shall be established to provide in-home hospice-
2753	like support services to children diagnosed with a life-
2754	threatening illness and enrolled in the Children's Medical
2755	Services network to reduce hospitalizations as appropriate. The
2756	agency, in consultation with the Department of Health, may
2757	implement the program of all-inclusive care for children after
2758	obtaining approval from the Centers for Medicare and Medicaid
2759	Services.
2760	(50)(53)  Before seeking an amendment to the state plan for
2761	purposes of implementing programs authorized by the Deficit
2762	Reduction Act of 2005, the agency shall notify the Legislature.
2763	(51)  The agency may not pay for psychotropic medication
2764	prescribed for a child in the Medicaid program without the
2765	express and informed consent of the child's parent or legal
2766	guardian. The physician shall document the consent in the
2767	child's medical record and provide the pharmacy with a signed
2768	attestation of this documentation with the prescription. The
2769	express and informed consent or court authorization for a
2770	prescription of psychotropic medication for a child in the
2771	custody of the Department of Children and Family Services shall
2772	be obtained pursuant to s. 39.407.
2773	Section 18.  Section 409.91207, Florida Statutes, is
2774	repealed.
2775	Section 19.  Paragraphs (e), (l), (p), (w), and (dd) of
2776	subsection (3) of section 409.91211, Florida Statutes, are
2777	amended to read:
2778	409.91211  Medicaid managed care pilot program.-
2779	(3)  The agency shall have the following powers, duties,
2780	and responsibilities with respect to the pilot program:
2781	(e)  To implement policies and guidelines for phasing in
2782	financial risk for approved provider service networks that, for
2783	purposes of this paragraph, include the Children's Medical
2784	Services Network, over the period of the waiver and the
2785	extension thereof. These policies and guidelines must include an
2786	option for a provider service network to be paid fee-for-service
2787	rates. For any provider service network established in a managed
2788	care pilot area, the option to be paid fee-for-service rates
2789	must include a savings-settlement mechanism that is consistent
2790	with s. 409.912(42)(44). This model must be converted to a risk-
2791	adjusted capitated rate by the beginning of the final year of
2792	operation under the waiver extension, and may be converted
2793	earlier at the option of the provider service network. Federally
2794	qualified health centers may be offered an opportunity to accept
2795	or decline a contract to participate in any provider network for
2796	prepaid primary care services.
2797	(l)  To implement a system that prohibits capitated managed
2798	care plans, their representatives, and providers employed by or
2799	contracted with the capitated managed care plans from recruiting
2800	persons eligible for or enrolled in Medicaid, from providing
2801	inducements to Medicaid recipients to select a particular
2802	capitated managed care plan, and from prejudicing Medicaid
2803	recipients against other capitated managed care plans. The
2804	system shall require the entity performing choice counseling to
2805	determine if the recipient has made a choice of a plan or has
2806	opted out because of duress, threats, payment to the recipient,
2807	or incentives promised to the recipient by a third party. If the
2808	choice counseling entity determines that the decision to choose
2809	a plan was unlawfully influenced or a plan violated any of the
2810	provisions of s. 409.912(20)(21), the choice counseling entity
2811	shall immediately report the violation to the agency's program
2812	integrity section for investigation. Verification of choice
2813	counseling by the recipient shall include a stipulation that the
2814	recipient acknowledges the provisions of this subsection.
2815	(p)  To implement standards for plan compliance, including,
2816	but not limited to, standards for quality assurance and
2817	performance improvement, standards for peer or professional
2818	reviews, grievance policies, and policies for maintaining
2819	program integrity. The agency shall develop a data-reporting
2820	system, seek input from managed care plans in order to establish
2821	requirements for patient-encounter reporting, and ensure that
2822	the data reported is accurate and complete.
2823	1.  In performing the duties required under this section,
2824	the agency shall work with managed care plans to establish a
2825	uniform system to measure and monitor outcomes for a recipient
2826	of Medicaid services.
2827	2.  The system shall use financial, clinical, and other
2828	criteria based on pharmacy, medical services, and other data
2829	that is related to the provision of Medicaid services,
2830	including, but not limited to:
2831	a.  The Health Plan Employer Data and Information Set
2832	(HEDIS) or measures that are similar to HEDIS.
2833	b.  Member satisfaction.
2834	c.  Provider satisfaction.
2835	d.  Report cards on plan performance and best practices.
2836	e.  Compliance with the requirements for prompt payment of
2837	claims under ss. 627.613, 641.3155, and 641.513.
2838	f.  Utilization and quality data for the purpose of
2839	ensuring access to medically necessary services, including
2840	underutilization or inappropriate denial of services.
2841	3.  The agency shall require the managed care plans that
2842	have contracted with the agency to establish a quality assurance
2843	system that incorporates the provisions of s. 409.912(26)(27)
2844	and any standards, rules, and guidelines developed by the
2845	agency.
2846	4.  The agency shall establish an encounter database in
2847	order to compile data on health services rendered by health care
2848	practitioners who provide services to patients enrolled in
2849	managed care plans in the demonstration sites. The encounter
2850	database shall:
2851	a.  Collect the following for each type of patient
2852	encounter with a health care practitioner or facility,
2853	including:
2854	(I)  The demographic characteristics of the patient.
2855	(II)  The principal, secondary, and tertiary diagnosis.
2856	(III)  The procedure performed.
2857	(IV)  The date and location where the procedure was
2858	performed.
2859	(V)  The payment for the procedure, if any.
2860	(VI)  If applicable, the health care practitioner's
2861	universal identification number.
2862	(VII)  If the health care practitioner rendering the
2863	service is a dependent practitioner, the modifiers appropriate
2864	to indicate that the service was delivered by the dependent
2865	practitioner.
2866	b.  Collect appropriate information relating to
2867	prescription drugs for each type of patient encounter.
2868	c.  Collect appropriate information related to health care
2869	costs and utilization from managed care plans participating in
2870	the demonstration sites.
2871	5.  To the extent practicable, when collecting the data the
2872	agency shall use a standardized claim form or electronic
2873	transfer system that is used by health care practitioners,
2874	facilities, and payors.
2875	6.  Health care practitioners and facilities in the
2876	demonstration sites shall electronically submit, and managed
2877	care plans participating in the demonstration sites shall
2878	electronically receive, information concerning claims payments
2879	and any other information reasonably related to the encounter
2880	database using a standard format as required by the agency.
2881	7.  The agency shall establish reasonable deadlines for
2882	phasing in the electronic transmittal of full encounter data.
2883	8.  The system must ensure that the data reported is
2884	accurate and complete.
2885	(w)  To implement procedures to minimize the risk of
2886	Medicaid fraud and abuse in all plans operating in the Medicaid
2887	managed care pilot program authorized in this section.
2888	1.  The agency shall ensure that applicable provisions of
2889	this chapter and chapters 414, 626, 641, and 932 which relate to
2890	Medicaid fraud and abuse are applied and enforced at the
2891	demonstration project sites.
2892	2.  Providers must have the certification, license, and
2893	credentials that are required by law and waiver requirements.
2894	3.  The agency shall ensure that the plan is in compliance
2895	with s. 409.912(20) and (21) and (22).
2896	4.  The agency shall require that each plan establish
2897	functions and activities governing program integrity in order to
2898	reduce the incidence of fraud and abuse. Plans must report
2899	instances of fraud and abuse pursuant to chapter 641.
2900	5.  The plan shall have written administrative and
2901	management arrangements or procedures, including a mandatory
2902	compliance plan, which are designed to guard against fraud and
2903	abuse. The plan shall designate a compliance officer who has
2904	sufficient experience in health care.
2905	6.a.  The agency shall require all managed care plan
2906	contractors in the pilot program to report all instances of
2907	suspected fraud and abuse. A failure to report instances of
2908	suspected fraud and abuse is a violation of law and subject to
2909	the penalties provided by law.
2910	b.  An instance of fraud and abuse in the managed care
2911	plan, including, but not limited to, defrauding the state health
2912	care benefit program by misrepresentation of fact in reports,
2913	claims, certifications, enrollment claims, demographic
2914	statistics, or patient-encounter data; misrepresentation of the
2915	qualifications of persons rendering health care and ancillary
2916	services; bribery and false statements relating to the delivery
2917	of health care; unfair and deceptive marketing practices; and
2918	false claims actions in the provision of managed care, is a
2919	violation of law and subject to the penalties provided by law.
2920	c.  The agency shall require that all contractors make all
2921	files and relevant billing and claims data accessible to state
2922	regulators and investigators and that all such data is linked
2923	into a unified system to ensure consistent reviews and
2924	investigations.
2925	(dd)  To implement service delivery mechanisms within a
2926	specialty plan in area 10 to provide behavioral health care
2927	services to Medicaid-eligible children whose cases are open for
2928	child welfare services in the HomeSafeNet system. These services
2929	must be coordinated with community-based care providers as
2930	specified in s. 409.1671, where available, and be sufficient to
2931	meet the developmental, behavioral, and emotional needs of these
2932	children. Children in area 10 who have an open case in the
2933	HomeSafeNet system shall be enrolled into the specialty plan.
2934	These service delivery mechanisms must be implemented no later
2935	than July 1, 2011, in AHCA area 10 in order for the children in
2936	AHCA area 10 to remain exempt from the statewide plan under s.
2937	409.912(4)(b)5.8. An administrative fee may be paid to the
2938	specialty plan for the coordination of services based on the
2939	receipt of the state share of that fee being provided through
2940	intergovernmental transfers.
2941	Section 20.  Effective October 1, 2014, section 409.91211,
2942	Florida Statutes, is repealed.
2943	Section 21.  Section 409.9122, Florida Statutes, is amended
2944	to read:
2945	409.9122  Mandatory Medicaid managed care enrollment;
2946	programs and procedures.-
2947	(1)  It is the intent of the Legislature that the MediPass
2948	program be cost-effective, provide quality health care, and
2949	improve access to health services, and that the program be
2950	statewide. This subsection expires October 1, 2014.
2951	(2)(a)  The agency shall enroll in a managed care plan or
2952	MediPass all Medicaid recipients, except those Medicaid
2953	recipients who are: in an institution; enrolled in the Medicaid
2954	medically needy program; or eligible for both Medicaid and
2955	Medicare. Upon enrollment, individuals will be able to change
2956	their managed care option during the 90-day opt out period
2957	required by federal Medicaid regulations. The agency is
2958	authorized to seek the necessary Medicaid state plan amendment
2959	to implement this policy. However, to the extent permitted by
2960	federal law, the agency may enroll in a managed care plan or
2961	MediPass a Medicaid recipient who is exempt from mandatory
2962	managed care enrollment, provided that:
2963	1.  The recipient's decision to enroll in a managed care
2964	plan or MediPass is voluntary;
2965	2.  If the recipient chooses to enroll in a managed care
2966	plan, the agency has determined that the managed care plan
2967	provides specific programs and services which address the
2968	special health needs of the recipient; and
2969	3.  The agency receives any necessary waivers from the
2970	federal Centers for Medicare and Medicaid Services.
2971
2972	The agency shall develop rules to establish policies by which
2973	exceptions to the mandatory managed care enrollment requirement
2974	may be made on a case-by-case basis. The rules shall include the
2975	specific criteria to be applied when making a determination as
2976	to whether to exempt a recipient from mandatory enrollment in a
2977	managed care plan or MediPass. School districts participating in
2978	the certified school match program pursuant to ss. 409.908(21)
2979	and 1011.70 shall be reimbursed by Medicaid, subject to the
2980	limitations of s. 1011.70(1), for a Medicaid-eligible child
2981	participating in the services as authorized in s. 1011.70, as
2982	provided for in s. 409.9071, regardless of whether the child is
2983	enrolled in MediPass or a managed care plan. Managed care plans
2984	shall make a good faith effort to execute agreements with school
2985	districts regarding the coordinated provision of services
2986	authorized under s. 1011.70. County health departments
2987	delivering school-based services pursuant to ss. 381.0056 and
2988	381.0057 shall be reimbursed by Medicaid for the federal share
2989	for a Medicaid-eligible child who receives Medicaid-covered
2990	services in a school setting, regardless of whether the child is
2991	enrolled in MediPass or a managed care plan. Managed care plans
2992	shall make a good faith effort to execute agreements with county
2993	health departments regarding the coordinated provision of
2994	services to a Medicaid-eligible child. To ensure continuity of
2995	care for Medicaid patients, the agency, the Department of
2996	Health, and the Department of Education shall develop procedures
2997	for ensuring that a student's managed care plan or MediPass
2998	provider receives information relating to services provided in
2999	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
3000	(b)  A Medicaid recipient shall not be enrolled in or
3001	assigned to a managed care plan or MediPass unless the managed
3002	care plan or MediPass has complied with the quality-of-care
3003	standards specified in paragraphs (3)(a) and (b), respectively.
3004	(c)  Medicaid recipients shall have a choice of managed
3005	care plans or MediPass. The Agency for Health Care
3006	Administration, the Department of Health, the Department of
3007	Children and Family Services, and the Department of Elderly
3008	Affairs shall cooperate to ensure that each Medicaid recipient
3009	receives clear and easily understandable information that meets
3010	the following requirements:
3011	1.  Explains the concept of managed care, including
3012	MediPass.
3013	2.  Provides information on the comparative performance of
3014	managed care plans and MediPass in the areas of quality,
3015	credentialing, preventive health programs, network size and
3016	availability, and patient satisfaction.
3017	3.  Explains where additional information on each managed
3018	care plan and MediPass in the recipient's area can be obtained.
3019	4.  Explains that recipients have the right to choose their
3020	managed care coverage at the time they first enroll in Medicaid
3021	and again at regular intervals set by the agency. However, if a
3022	recipient does not choose a managed care plan or MediPass, the
3023	agency will assign the recipient to a managed care plan or
3024	MediPass according to the criteria specified in this section.
3025	5.  Explains the recipient's right to complain, file a
3026	grievance, or change managed care plans or MediPass providers if
3027	the recipient is not satisfied with the managed care plan or
3028	MediPass.
3029	(d)  The agency shall develop a mechanism for providing
3030	information to Medicaid recipients for the purpose of making a
3031	managed care plan or MediPass selection. Examples of such
3032	mechanisms may include, but not be limited to, interactive
3033	information systems, mailings, and mass marketing materials.
3034	Managed care plans and MediPass providers are prohibited from
3035	providing inducements to Medicaid recipients to select their
3036	plans or from prejudicing Medicaid recipients against other
3037	managed care plans or MediPass providers.
3038	(e)  Medicaid recipients who are already enrolled in a
3039	managed care plan or MediPass shall be offered the opportunity
3040	to change managed care plans or MediPass providers on a
3041	staggered basis, as defined by the agency. All Medicaid
3042	recipients shall have 30 days in which to make a choice of
3043	managed care plans or MediPass providers. Those Medicaid
3044	recipients who do not make a choice shall be assigned in
3045	accordance with paragraph (f). To facilitate continuity of care,
3046	for a Medicaid recipient who is also a recipient of Supplemental
3047	Security Income (SSI), prior to assigning the SSI recipient to a
3048	managed care plan or MediPass, the agency shall determine
3049	whether the SSI recipient has an ongoing relationship with a
3050	MediPass provider or managed care plan, and if so, the agency
3051	shall assign the SSI recipient to that MediPass provider or
3052	managed care plan. Those SSI recipients who do not have such a
3053	provider relationship shall be assigned to a managed care plan
3054	or MediPass provider in accordance with paragraph (f).
3055	(f)  If a Medicaid recipient does not choose a managed care
3056	plan or MediPass provider, the agency shall assign the Medicaid
3057	recipient to a managed care plan or MediPass provider. Medicaid
3058	recipients eligible for managed care plan enrollment who are
3059	subject to mandatory assignment but who fail to make a choice
3060	shall be assigned to managed care plans until an enrollment of
3061	35 percent in MediPass and 65 percent in managed care plans, of
3062	all those eligible to choose managed care, is achieved. Once
3063	this enrollment is achieved, the assignments shall be divided in
3064	order to maintain an enrollment in MediPass and managed care
3065	plans which is in a 35 percent and 65 percent proportion,
3066	respectively. Thereafter, assignment of Medicaid recipients who
3067	fail to make a choice shall be based proportionally on the
3068	preferences of recipients who have made a choice in the previous
3069	period. Such proportions shall be revised at least quarterly to
3070	reflect an update of the preferences of Medicaid recipients. The
3071	agency shall disproportionately assign Medicaid-eligible
3072	recipients who are required to but have failed to make a choice
3073	of managed care plan or MediPass, including children, and who
3074	would be assigned to the MediPass program to the children's
3075	networks as described in s. 409.912(4)(g), Children's Medical
3076	Services Network as defined in s. 391.021, exclusive provider
3077	organizations, provider service networks, minority physician
3078	networks, and pediatric emergency department diversion programs
3079	authorized by this chapter or the General Appropriations Act, in
3080	such manner as the agency deems appropriate, until the agency
3081	has determined that the networks and programs have sufficient
3082	numbers to be operated economically. For purposes of this
3083	paragraph, when referring to assignment, the term "managed care
3084	plans" includes health maintenance organizations, exclusive
3085	provider organizations, provider service networks, minority
3086	physician networks, Children's Medical Services Network, and
3087	pediatric emergency department diversion programs authorized by
3088	this chapter or the General Appropriations Act. When making
3089	assignments, the agency shall take into account the following
3090	criteria:
3091	1.  A managed care plan has sufficient network capacity to
3092	meet the need of members.
3093	2.  The managed care plan or MediPass has previously
3094	enrolled the recipient as a member, or one of the managed care
3095	plan's primary care providers or MediPass providers has
3096	previously provided health care to the recipient.
3097	3.  The agency has knowledge that the member has previously
3098	expressed a preference for a particular managed care plan or
3099	MediPass provider as indicated by Medicaid fee-for-service
3100	claims data, but has failed to make a choice.
3101	4.  The managed care plan's or MediPass primary care
3102	providers are geographically accessible to the recipient's
3103	residence.
3104	(g)  When more than one managed care plan or MediPass
3105	provider meets the criteria specified in paragraph (f), the
3106	agency shall make recipient assignments consecutively by family
3107	unit.
3108	(h)  The agency may not engage in practices that are
3109	designed to favor one managed care plan over another or that are
3110	designed to influence Medicaid recipients to enroll in MediPass
3111	rather than in a managed care plan or to enroll in a managed
3112	care plan rather than in MediPass. This subsection does not
3113	prohibit the agency from reporting on the performance of
3114	MediPass or any managed care plan, as measured by performance
3115	criteria developed by the agency.
3116	(i)  After a recipient has made his or her selection or has
3117	been enrolled in a managed care plan or MediPass, the recipient
3118	shall have 90 days to exercise the opportunity to voluntarily
3119	disenroll and select another managed care plan or MediPass.
3120	After 90 days, no further changes may be made except for good
3121	cause. Good cause includes, but is not limited to, poor quality
3122	of care, lack of access to necessary specialty services, an
3123	unreasonable delay or denial of service, or fraudulent
3124	enrollment. The agency shall develop criteria for good cause
3125	disenrollment for chronically ill and disabled populations who
3126	are assigned to managed care plans if more appropriate care is
3127	available through the MediPass program. The agency must make a
3128	determination as to whether cause exists. However, the agency
3129	may require a recipient to use the managed care plan's or
3130	MediPass grievance process prior to the agency's determination
3131	of cause, except in cases in which immediate risk of permanent
3132	damage to the recipient's health is alleged. The grievance
3133	process, when utilized, must be completed in time to permit the
3134	recipient to disenroll by the first day of the second month
3135	after the month the disenrollment request was made. If the
3136	managed care plan or MediPass, as a result of the grievance
3137	process, approves an enrollee's request to disenroll, the agency
3138	is not required to make a determination in the case. The agency
3139	must make a determination and take final action on a recipient's
3140	request so that disenrollment occurs no later than the first day
3141	of the second month after the month the request was made. If the
3142	agency fails to act within the specified timeframe, the
3143	recipient's request to disenroll is deemed to be approved as of
3144	the date agency action was required. Recipients who disagree
3145	with the agency's finding that cause does not exist for
3146	disenrollment shall be advised of their right to pursue a
3147	Medicaid fair hearing to dispute the agency's finding.
3148	(j)  The agency shall apply for a federal waiver from the
3149	Centers for Medicare and Medicaid Services to lock eligible
3150	Medicaid recipients into a managed care plan or MediPass for 12
3151	months after an open enrollment period. After 12 months'
3152	enrollment, a recipient may select another managed care plan or
3153	MediPass provider. However, nothing shall prevent a Medicaid
3154	recipient from changing primary care providers within the
3155	managed care plan or MediPass program during the 12-month
3156	period.
3157	(k)  When a Medicaid recipient does not choose a managed
3158	care plan or MediPass provider, the agency shall assign the
3159	Medicaid recipient to a managed care plan, except in those
3160	counties in which there are fewer than two managed care plans
3161	accepting Medicaid enrollees, in which case assignment shall be
3162	to a managed care plan or a MediPass provider. Medicaid
3163	recipients in counties with fewer than two managed care plans
3164	accepting Medicaid enrollees who are subject to mandatory
3165	assignment but who fail to make a choice shall be assigned to
3166	managed care plans until an enrollment of 35 percent in MediPass
3167	and 65 percent in managed care plans, of all those eligible to
3168	choose managed care, is achieved. Once that enrollment is
3169	achieved, the assignments shall be divided in order to maintain
3170	an enrollment in MediPass and managed care plans which is in a
3171	35 percent and 65 percent proportion, respectively. For purposes
3172	of this paragraph, when referring to assignment, the term
3173	"managed care plans" includes exclusive provider organizations,
3174	provider service networks, Children's Medical Services Network,
3175	minority physician networks, and pediatric emergency department
3176	diversion programs authorized by this chapter or the General
3177	Appropriations Act. When making assignments, the agency shall
3178	take into account the following criteria:
3179	1.  A managed care plan has sufficient network capacity to
3180	meet the need of members.
3181	2.  The managed care plan or MediPass has previously
3182	enrolled the recipient as a member, or one of the managed care
3183	plan's primary care providers or MediPass providers has
3184	previously provided health care to the recipient.
3185	3.  The agency has knowledge that the member has previously
3186	expressed a preference for a particular managed care plan or
3187	MediPass provider as indicated by Medicaid fee-for-service
3188	claims data, but has failed to make a choice.
3189	4.  The managed care plan's or MediPass primary care
3190	providers are geographically accessible to the recipient's
3191	residence.
3192	5.  The agency has authority to make mandatory assignments
3193	based on quality of service and performance of managed care
3194	plans.
3195	(l)  If the Medicaid recipient is diagnosed with HIV/AIDS
3196	and resides in Broward, Miami-Dade, or Palm Beach Counties, the
3197	agency shall assign the Medicaid recipient to a managed care
3198	plan that is a health maintenance organization authorized under
3199	chapter 641, is under contract with the agency on July 1, 2011,
3200	and offers a delivery system through a university-based teaching
3201	and research-oriented organization that specializes in providing
3202	health care services and treatment for individuals diagnosed
3203	with HIV/AIDS.
3204	(m)(l)  Notwithstanding the provisions of chapter 287, the
3205	agency may, at its discretion, renew cost-effective contracts
3206	for choice counseling services once or more for such periods as
3207	the agency may decide. However, all such renewals may not
3208	combine to exceed a total period longer than the term of the
3209	original contract.
3210
3211	This subsection expires October 1, 2014.
3212	(3)(a)  The agency shall establish quality-of-care
3213	standards for managed care plans. These standards shall be based
3214	upon, but are not limited to:
3215	1.  Compliance with the accreditation requirements as
3216	provided in s. 641.512.
3217	2.  Compliance with Early and Periodic Screening,
3218	Diagnosis, and Treatment screening requirements.
3219	3.  The percentage of voluntary disenrollments.
3220	4.  Immunization rates.
3221	5.  Standards of the National Committee for Quality
3222	Assurance and other approved accrediting bodies.
3223	6.  Recommendations of other authoritative bodies.
3224	7.  Specific requirements of the Medicaid program, or
3225	standards designed to specifically assist the unique needs of
3226	Medicaid recipients.
3227	8.  Compliance with the health quality improvement system
3228	as established by the agency, which incorporates standards and
3229	guidelines developed by the Medicaid Bureau of the Health Care
3230	Financing Administration as part of the quality assurance reform
3231	initiative.
3232	(b)  For the MediPass program, the agency shall establish
3233	standards which are based upon, but are not limited to:
3234	1.  Quality-of-care standards which are comparable to those
3235	required of managed care plans.
3236	2.  Credentialing standards for MediPass providers.
3237	3.  Compliance with Early and Periodic Screening,
3238	Diagnosis, and Treatment screening requirements.
3239	4.  Immunization rates.
3240	5.  Specific requirements of the Medicaid program, or
3241	standards designed to specifically assist the unique needs of
3242	Medicaid recipients.
3243
3244	This subsection expires October 1, 2014.
3245	(4)(a)  Each female recipient may select as her primary
3246	care provider an obstetrician/gynecologist who has agreed to
3247	participate as a MediPass primary care case manager.
3248	(b)  The agency shall establish a complaints and grievance
3249	process to assist Medicaid recipients enrolled in the MediPass
3250	program to resolve complaints and grievances. The agency shall
3251	investigate reports of quality-of-care grievances which remain
3252	unresolved to the satisfaction of the enrollee.
3253
3254	This subsection expires October 1, 2014.
3255	(5)(a)  The agency shall work cooperatively with the Social
3256	Security Administration to identify beneficiaries who are
3257	jointly eligible for Medicare and Medicaid and shall develop
3258	cooperative programs to encourage these beneficiaries to enroll
3259	in a Medicare participating health maintenance organization or
3260	prepaid health plans.
3261	(b)  The agency shall work cooperatively with the
3262	Department of Elderly Affairs to assess the potential cost-
3263	effectiveness of providing MediPass to beneficiaries who are
3264	jointly eligible for Medicare and Medicaid on a voluntary choice
3265	basis. If the agency determines that enrollment of these
3266	beneficiaries in MediPass has the potential for being cost-
3267	effective for the state, the agency shall offer MediPass to
3268	these beneficiaries on a voluntary choice basis in the counties
3269	where MediPass operates.
3270
3271	This subsection expires October 1, 2014.
3272	(6)  MediPass enrolled recipients may receive up to 10
3273	visits of reimbursable services by participating Medicaid
3274	physicians licensed under chapter 460 and up to four visits of
3275	reimbursable services by participating Medicaid physicians
3276	licensed under chapter 461. Any further visits must be by prior
3277	authorization by the MediPass primary care provider. However,
3278	nothing in this subsection may be construed to increase the
3279	total number of visits or the total amount of dollars per year
3280	per person under current Medicaid rules, unless otherwise
3281	provided for in the General Appropriations Act. This subsection
3282	expires October 1, 2014.
3283	(7)  The agency shall investigate the feasibility of
3284	developing managed care plan and MediPass options for the
3285	following groups of Medicaid recipients:
3286	(a)  Pregnant women and infants.
3287	(b)  Elderly and disabled recipients, especially those who
3288	are at risk of nursing home placement.
3289	(c)  Persons with developmental disabilities.
3290	(d)  Qualified Medicare beneficiaries.
3291	(e)  Adults who have chronic, high-cost medical conditions.
3292	(f)  Adults and children who have mental health problems.
3293	(g)  Other recipients for whom managed care plans and
3294	MediPass offer the opportunity of more cost-effective care and
3295	greater access to qualified providers.
3296	(8)(a)  The agency shall encourage the development of
3297	public and private partnerships to foster the growth of health
3298	maintenance organizations and prepaid health plans that will
3299	provide high-quality health care to Medicaid recipients.
3300	(b)  Subject to the availability of moneys and any
3301	limitations established by the General Appropriations Act or
3302	chapter 216, the agency is authorized to enter into contracts
3303	with traditional providers of health care to low-income persons
3304	to assist such providers with the technical aspects of
3305	cooperatively developing Medicaid prepaid health plans.
3306	1.  The agency may contract with disproportionate share
3307	hospitals, county health departments, federally initiated or
3308	federally funded community health centers, and counties that
3309	operate either a hospital or a community clinic.
3310	2.  A contract may not be for more than $100,000 per year,
3311	and no contract may be extended with any particular provider for
3312	more than 2 years. The contract is intended only as seed or
3313	development funding and requires a commitment from the
3314	interested party.
3315	3.  A contract must require participation by at least one
3316	community health clinic and one disproportionate share hospital.
3317	(7)(9)(a)  The agency shall develop and implement a
3318	comprehensive plan to ensure that recipients are adequately
3319	informed of their choices and rights under all Medicaid managed
3320	care programs and that Medicaid managed care programs meet
3321	acceptable standards of quality in patient care, patient
3322	satisfaction, and financial solvency.
3323	(b)  The agency shall provide adequate means for informing
3324	patients of their choice and rights under a managed care plan at
3325	the time of eligibility determination.
3326	(c)  The agency shall require managed care plans and
3327	MediPass providers to demonstrate and document plans and
3328	activities, as defined by rule, including outreach and followup,
3329	undertaken to ensure that Medicaid recipients receive the health
3330	care service to which they are entitled.
3331
3332	This subsection expires October 1, 2014.
3333	(8)(10)  The agency shall consult with Medicaid consumers
3334	and their representatives on an ongoing basis regarding
3335	measurements of patient satisfaction, procedures for resolving
3336	patient grievances, standards for ensuring quality of care,
3337	mechanisms for providing patient access to services, and
3338	policies affecting patient care. This subsection expires October
3339	1, 2014.
3340	(9)(11)  The agency may extend eligibility for Medicaid
3341	recipients enrolled in licensed and accredited health
3342	maintenance organizations for the duration of the enrollment
3343	period or for 6 months, whichever is earlier, provided the
3344	agency certifies that such an offer will not increase state
3345	expenditures. This subsection expires October 1, 2013.
3346	(10)(12)  A managed care plan that has a Medicaid contract
3347	shall at least annually review each primary care physician's
3348	active patient load and shall ensure that additional Medicaid
3349	recipients are not assigned to physicians who have a total
3350	active patient load of more than 3,000 patients. As used in this
3351	subsection, the term "active patient" means a patient who is
3352	seen by the same primary care physician, or by a physician
3353	assistant or advanced registered nurse practitioner under the
3354	supervision of the primary care physician, at least three times
3355	within a calendar year. Each primary care physician shall
3356	annually certify to the managed care plan whether or not his or
3357	her patient load exceeds the limits established under this
3358	subsection and the managed care plan shall accept such
3359	certification on face value as compliance with this subsection.
3360	The agency shall accept the managed care plan's representations
3361	that it is in compliance with this subsection based on the
3362	certification of its primary care physicians, unless the agency
3363	has an objective indication that access to primary care is being
3364	compromised, such as receiving complaints or grievances relating
3365	to access to care. If the agency determines that an objective
3366	indication exists that access to primary care is being
3367	compromised, it may verify the patient load certifications
3368	submitted by the managed care plan's primary care physicians and
3369	that the managed care plan is not assigning Medicaid recipients
3370	to primary care physicians who have an active patient load of
3371	more than 3,000 patients. This subsection expires October 1,
3372	2014.
3373	(11)(13)  Effective July 1, 2003, the agency shall adjust
3374	the enrollee assignment process of Medicaid managed prepaid
3375	health plans for those Medicaid managed prepaid plans operating
3376	in Miami-Dade County which have executed a contract with the
3377	agency for a minimum of 8 consecutive years in order for the
3378	Medicaid managed prepaid plan to maintain a minimum enrollment
3379	level of 15,000 members per month. When assigning enrollees
3380	pursuant to this subsection, the agency shall give priority to
3381	providers that initially qualified under this subsection until
3382	such providers reach and maintain an enrollment level of 15,000
3383	members per month. A prepaid health plan that has a statewide
3384	Medicaid enrollment of 25,000 or more members is not eligible
3385	for enrollee assignments under this subsection. This subsection
3386	expires October 1, 2014.
3387	(12)(14)  The agency shall include in its calculation of
3388	the hospital inpatient component of a Medicaid health
3389	maintenance organization's capitation rate any special payments,
3390	including, but not limited to, upper payment limit or
3391	disproportionate share hospital payments, made to qualifying
3392	hospitals through the fee-for-service program. The agency may
3393	seek federal waiver approval or state plan amendment as needed
3394	to implement this adjustment.
3395	(13)  The agency shall develop a process to enable any
3396	recipient with access to employer-sponsored health care coverage
3397	to opt out of all eligible plans in the Medicaid program and to
3398	use Medicaid financial assistance to pay for the recipient's
3399	share of cost in any such employer-sponsored coverage.
3400	Contingent on federal approval, the agency shall also enable
3401	recipients with access to other insurance or related products
3402	that provide access to health care services created pursuant to
3403	state law, including any plan or product available pursuant to
3404	the Florida Health Choices Program or any health exchange, to
3405	opt out. The amount of financial assistance provided for each
3406	recipient may not exceed the amount of the Medicaid premium that
3407	would have been paid to a plan for that recipient.
3408	(14)  The agency shall maintain and operate the Medicaid
3409	Encounter Data System to collect, process, store, and report on
3410	covered services provided to all Florida Medicaid recipients
3411	enrolled in prepaid managed care plans.
3412	(a)  Prepaid managed care plans shall submit encounter data
3413	electronically in a format that complies with the Health
3414	Insurance Portability and Accountability Act provisions for
3415	electronic claims and in accordance with deadlines established
3416	by the agency. Prepaid managed care plans must certify that the
3417	data reported is accurate and complete.
3418	(b)  The agency is responsible for validating the data
3419	submitted by the plans. The agency shall develop methods and
3420	protocols for ongoing analysis of the encounter data that
3421	adjusts for differences in characteristics of prepaid plan
3422	enrollees to allow comparison of service utilization among plans
3423	and against expected levels of use. The analysis shall be used
3424	to identify possible cases of systemic underutilization or
3425	denials of claims and inappropriate service utilization such as
3426	higher-than-expected emergency department encounters. The
3427	analysis shall provide periodic feedback to the plans and enable
3428	the agency to establish corrective action plans when necessary.
3429	One of the focus areas for the analysis shall be the use of
3430	prescription drugs.
3431	(15)  The agency may establish a per-member, per-month
3432	payment for Medicare Advantage Special Needs members that are
3433	also eligible for Medicaid as a mechanism for meeting the
3434	state's cost-sharing obligation. The agency may also develop a
3435	per-member, per-month payment only for Medicaid-covered services
3436	for which the state is responsible. The agency shall develop a
3437	mechanism to ensure that such per-member, per-month payment
3438	enhances the value to the state and enrolled members by limiting
3439	cost sharing, enhances the scope of Medicare supplemental
3440	benefits that are equal to or greater than Medicaid coverage for
3441	select services, and improves care coordination.
3442	(16)  The agency shall establish, and managed care plans
3443	shall use, a uniform method of accounting for and reporting
3444	medical and nonmedical costs.
3445	(a)  Managed care plans shall submit financial data
3446	electronically in a format that complies with the uniform
3447	accounting procedures established by the agency. Managed care
3448	plans must certify that the data reported is accurate and
3449	complete.
3450	(b)  The agency is responsible for validating the financial
3451	data submitted by the plans. The agency shall develop methods
3452	and protocols for ongoing analysis of data that adjusts for
3453	differences in characteristics of plan enrollees to allow
3454	comparison among plans and against expected levels of
3455	expenditures. The analysis shall be used to identify possible
3456	cases of overspending on administrative costs or under spending
3457	on medical services.
3458	(17)  The agency shall establish and maintain an
3459	information system to make encounter data, financial data, and
3460	other measures of plan performance to the public and any
3461	interested party.
3462	(a)  Information submitted by the managed care plans shall
3463	be available online as well as in other formats.
3464	(b)  Periodic agency reports shall be published that
3465	include provide summary as well as plan specific measures of
3466	financial performance and service utilization.
3467	(c)  Any release of the financial and encounter data
3468	submitted by managed care plans shall ensure the confidentiality
3469	of personal health information.
3470	(18)  The agency may, on a case-by-case basis, exempt a
3471	recipient from mandatory enrollment in a managed care plan when
3472	the recipient has a unique, time-limited disease or condition-
3473	related circumstance and managed care enrollment will interfere
3474	with ongoing care because the recipient's provider does not
3475	participate in the managed care plans available in the
3476	recipient's area.
3477	(19)  The agency shall contract with a single provider
3478	service network to function as a managing entity for the
3479	MediPass program in all counties with fewer than two prepaid
3480	plans. The contractor shall be responsible for implementing
3481	preauthorization procedures, case management programs, and
3482	utilization management initiatives in order to improve care
3483	coordination and patient outcomes while reducing costs. The
3484	contractor may earn an administrative fee, if the fee is less
3485	than any savings determined by the reconciliation process
3486	pursuant to s. 409.912(4)(d)1. This subsection expires October
3487	1, 2014, or upon full implementation of the managed medical
3488	assistance program, whichever is sooner.
3489	(20)  Subject to federal approval, the agency shall
3490	contract with a single provider service network to function as a
3491	third-party administrator and managing entity for the Medically
3492	Needy program in all counties. The contractor shall provide care
3493	coordination and utilization management in order to achieve more
3494	cost-effective services for Medically Needy enrollees. To
3495	facilitate the care management functions of the provider service
3496	network, enrollment in the network shall be for a continuous 6-
3497	month period or until the end of the contract between the
3498	provider service network and the agency, whichever is sooner.
3499	Beginning the second month after the determination of
3500	eligibility, the contractor may collect a monthly premium from
3501	each Medically Needy recipient provided the premium does not
3502	exceed the enrollee's share of cost as determined by the
3503	Department of Children and Family Services. The contractor must
3504	provide a 90-day grace period before disenrolling a Medically
3505	Needy recipient for failure to pay premiums. The contractor may
3506	earn an administrative fee, if the fee is less than any savings
3507	determined by the reconciliation process pursuant to s.
3508	409.912(4)(d)1. Premium revenue collected from the recipients
3509	shall be deducted from the contractor's earned savings. This
3510	subsection expires October 1, 2014, or upon full implementation
3511	of the managed medical assistance program, whichever is sooner.
3512	Section 22.  Subsection (15) of section 430.04, Florida
3513	Statutes, is amended to read:
3514	430.04  Duties and responsibilities of the Department of
3515	Elderly Affairs.-The Department of Elderly Affairs shall:
3516	(15)  Administer all Medicaid waivers and programs relating
3517	to elders and their appropriations. The waivers include, but are
3518	not limited to:
3519	(a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3520	established in s. 430.502(7), (8), and (9).
3521	(a)(b)  The Assisted Living for the Frail Elderly Waiver.
3522	(b)(c)  The Aged and Disabled Adult Waiver.
3523	(c)(d)  The Adult Day Health Care Waiver.
3524	(d)(e)  The Consumer-Directed Care Plus Program as defined
3525	in s. 409.221.
3526	(e)(f)  The Program of All-inclusive Care for the Elderly.
3527	(f)(g)  The Long-Term Care Community-Based Diversion Pilot
3528	Project as described in s. 430.705.
3529	(g)(h)  The Channeling Services Waiver for Frail Elders.
3530
3531	The department shall develop a transition plan for recipients
3532	receiving services in long-term care Medicaid waivers for elders
3533	or disabled adults on the date eligible plans become available
3534	in each recipient's region defined in s. 409.981(2) to enroll
3535	those recipients in eligible plans. This subsection expires
3536	October 1, 2014.
3537	Section 23.  Section 430.2053, Florida Statutes, is amended
3538	to read:
3539	430.2053  Aging resource centers.-
3540	(1)  The department, in consultation with the Agency for
3541	Health Care Administration and the Department of Children and
3542	Family Services, shall develop pilot projects for aging resource
3543	centers. By October 31, 2004, the department, in consultation
3544	with the agency and the Department of Children and Family
3545	Services, shall develop an implementation plan for aging
3546	resource centers and submit the plan to the Governor, the
3547	President of the Senate, and the Speaker of the House of
3548	Representatives. The plan must include qualifications for
3549	designation as a center, the functions to be performed by each
3550	center, and a process for determining that a current area agency
3551	on aging is ready to assume the functions of an aging resource
3552	center.
3553	(2)  Each area agency on aging shall develop, in
3554	consultation with the existing community care for the elderly
3555	lead agencies within their planning and service areas, a
3556	proposal that describes the process the area agency on aging
3557	intends to undertake to transition to an aging resource center
3558	prior to July 1, 2005, and that describes the area agency's
3559	compliance with the requirements of this section. The proposals
3560	must be submitted to the department prior to December 31, 2004.
3561	The department shall evaluate all proposals for readiness and,
3562	prior to March 1, 2005, shall select three area agencies on
3563	aging which meet the requirements of this section to begin the
3564	transition to aging resource centers. Those area agencies on
3565	aging which are not selected to begin the transition to aging
3566	resource centers shall, in consultation with the department and
3567	the existing community care for the elderly lead agencies within
3568	their planning and service areas, amend their proposals as
3569	necessary and resubmit them to the department prior to July 1,
3570	2005. The department may transition additional area agencies to
3571	aging resource centers as it determines that area agencies are
3572	in compliance with the requirements of this section.
3573	(3)  The Auditor General and the Office of Program Policy
3574	Analysis and Government Accountability (OPPAGA) shall jointly
3575	review and assess the department's process for determining an
3576	area agency's readiness to transition to an aging resource
3577	center.
3578	(a)  The review must, at a minimum, address the
3579	appropriateness of the department's criteria for selection of an
3580	area agency to transition to an aging resource center, the
3581	instruments applied, the degree to which the department
3582	accurately determined each area agency's compliance with the
3583	readiness criteria, the quality of the technical assistance
3584	provided by the department to an area agency in correcting any
3585	weaknesses identified in the readiness assessment, and the
3586	degree to which each area agency overcame any identified
3587	weaknesses.
3588	(b)  Reports of these reviews must be submitted to the
3589	appropriate substantive and appropriations committees in the
3590	Senate and the House of Representatives on March 1 and September
3591	1 of each year until full transition to aging resource centers
3592	has been accomplished statewide, except that the first report
3593	must be submitted by February 1, 2005, and must address all
3594	readiness activities undertaken through December 31, 2004. The
3595	perspectives of all participants in this review process must be
3596	included in each report.
3597	(2)(4)  The purposes of an aging resource center shall be:
3598	(a)  To provide Florida's elders and their families with a
3599	locally focused, coordinated approach to integrating information
3600	and referral for all available services for elders with the
3601	eligibility determination entities for state and federally
3602	funded long-term-care services.
3603	(b)  To provide for easier access to long-term-care
3604	services by Florida's elders and their families by creating
3605	multiple access points to the long-term-care network that flow
3606	through one established entity with wide community recognition.
3607	(3)(5)  The duties of an aging resource center are to:
3608	(a)  Develop referral agreements with local community
3609	service organizations, such as senior centers, existing elder
3610	service providers, volunteer associations, and other similar
3611	organizations, to better assist clients who do not need or do
3612	not wish to enroll in programs funded by the department or the
3613	agency. The referral agreements must also include a protocol,
3614	developed and approved by the department, which provides
3615	specific actions that an aging resource center and local
3616	community service organizations must take when an elder or an
3617	elder's representative seeking information on long-term-care
3618	services contacts a local community service organization prior
3619	to contacting the aging resource center. The protocol shall be
3620	designed to ensure that elders and their families are able to
3621	access information and services in the most efficient and least
3622	cumbersome manner possible.
3623	(b)  Provide an initial screening of all clients who
3624	request long-term-care services to determine whether the person
3625	would be most appropriately served through any combination of
3626	federally funded programs, state-funded programs, locally funded
3627	or community volunteer programs, or private funding for
3628	services.
3629	(c)  Determine eligibility for the programs and services
3630	listed in subsection (9) (11) for persons residing within the
3631	geographic area served by the aging resource center and
3632	determine a priority ranking for services which is based upon
3633	the potential recipient's frailty level and likelihood of
3634	institutional placement without such services.
3635	(d)  Manage the availability of financial resources for the
3636	programs and services listed in subsection (9) (11) for persons
3637	residing within the geographic area served by the aging resource
3638	center.
3639	(e)  When financial resources become available, refer a
3640	client to the most appropriate entity to begin receiving
3641	services. The aging resource center shall make referrals to lead
3642	agencies for service provision that ensure that individuals who
3643	are vulnerable adults in need of services pursuant to s.
3644	415.104(3)(b), or who are victims of abuse, neglect, or
3645	exploitation in need of immediate services to prevent further
3646	harm and are referred by the adult protective services program,
3647	are given primary consideration for receiving community-care-
3648	for-the-elderly services in compliance with the requirements of
3649	s. 430.205(5)(a) and that other referrals for services are in
3650	compliance with s. 430.205(5)(b).
3651	(f)  Convene a work group to advise in the planning,
3652	implementation, and evaluation of the aging resource center. The
3653	work group shall be comprised of representatives of local
3654	service providers, Alzheimer's Association chapters, housing
3655	authorities, social service organizations, advocacy groups,
3656	representatives of clients receiving services through the aging
3657	resource center, and any other persons or groups as determined
3658	by the department. The aging resource center, in consultation
3659	with the work group, must develop annual program improvement
3660	plans that shall be submitted to the department for
3661	consideration. The department shall review each annual
3662	improvement plan and make recommendations on how to implement
3663	the components of the plan.
3664	(g)  Enhance the existing area agency on aging in each
3665	planning and service area by integrating, either physically or
3666	virtually, the staff and services of the area agency on aging
3667	with the staff of the department's local CARES Medicaid nursing
3668	home preadmission screening unit and a sufficient number of
3669	staff from the Department of Children and Family Services'
3670	Economic Self-Sufficiency Unit necessary to determine the
3671	financial eligibility for all persons age 60 and older residing
3672	within the area served by the aging resource center that are
3673	seeking Medicaid services, Supplemental Security Income, and
3674	food assistance.
3675	(h)  Assist clients who request long-term care services in
3676	being evaluated for eligibility for enrollment in the Medicaid
3677	long-term care managed care program as eligible plans become
3678	available in each of the regions pursuant to s. 409.981(2).
3679	(i)  Provide enrollment and coverage information to
3680	Medicaid managed long-term care enrollees as qualified plans
3681	become available in each of the regions pursuant to s.
3682	409.981(2).
3683	(j)  Assist Medicaid recipients enrolled in the Medicaid
3684	long-term care managed care program with informally resolving
3685	grievances with a managed care network and assist Medicaid
3686	recipients in accessing the managed care network's formal
3687	grievance process as eligible plans become available in each of
3688	the regions defined in s. 409.981(2).
3689	(4)(6)  The department shall select the entities to become
3690	aging resource centers based on each entity's readiness and
3691	ability to perform the duties listed in subsection (3) (5) and
3692	the entity's:
3693	(a)  Expertise in the needs of each target population the
3694	center proposes to serve and a thorough knowledge of the
3695	providers that serve these populations.
3696	(b)  Strong connections to service providers, volunteer
3697	agencies, and community institutions.
3698	(c)  Expertise in information and referral activities.
3699	(d)  Knowledge of long-term-care resources, including
3700	resources designed to provide services in the least restrictive
3701	setting.
3702	(e)  Financial solvency and stability.
3703	(f)  Ability to collect, monitor, and analyze data in a
3704	timely and accurate manner, along with systems that meet the
3705	department's standards.
3706	(g)  Commitment to adequate staffing by qualified personnel
3707	to effectively perform all functions.
3708	(h)  Ability to meet all performance standards established
3709	by the department.
3710	(5)(7)  The aging resource center shall have a governing
3711	body which shall be the same entity described in s. 20.41(7),
3712	and an executive director who may be the same person as
3713	described in s. 20.41(7). The governing body shall annually
3714	evaluate the performance of the executive director.
3715	(6)(8)  The aging resource center may not be a provider of
3716	direct services other than information and referral services,
3717	and screening.
3718	(7)(9)  The aging resource center must agree to allow the
3719	department to review any financial information the department
3720	determines is necessary for monitoring or reporting purposes,
3721	including financial relationships.
3722	(8)(10)  The duties and responsibilities of the community
3723	care for the elderly lead agencies within each area served by an
3724	aging resource center shall be to:
3725	(a)  Develop strong community partnerships to maximize the
3726	use of community resources for the purpose of assisting elders
3727	to remain in their community settings for as long as it is
3728	safely possible.
3729	(b)  Conduct comprehensive assessments of clients that have
3730	been determined eligible and develop a care plan consistent with
3731	established protocols that ensures that the unique needs of each
3732	client are met.
3733	(9)(11)  The services to be administered through the aging
3734	resource center shall include those funded by the following
3735	programs:
3736	(a)  Community care for the elderly.
3737	(b)  Home care for the elderly.
3738	(c)  Contracted services.
3739	(d)  Alzheimer's disease initiative.
3740	(e)  Aged and disabled adult Medicaid waiver. This
3741	paragraph expires October 1, 2013.
3742	(f)  Assisted living for the frail elderly Medicaid waiver.
3743	This paragraph expires October 1, 2013.
3744	(g)  Older Americans Act.
3745	(10)(12)  The department shall, prior to designation of an
3746	aging resource center, develop by rule operational and quality
3747	assurance standards and outcome measures to ensure that clients
3748	receiving services through all long-term-care programs
3749	administered through an aging resource center are receiving the
3750	appropriate care they require and that contractors and
3751	subcontractors are adhering to the terms of their contracts and
3752	are acting in the best interests of the clients they are
3753	serving, consistent with the intent of the Legislature to reduce
3754	the use of and cost of nursing home care. The department shall
3755	by rule provide operating procedures for aging resource centers,
3756	which shall include:
3757	(a)  Minimum standards for financial operation, including
3758	audit procedures.
3759	(b)  Procedures for monitoring and sanctioning of service
3760	providers.
3761	(c)  Minimum standards for technology utilized by the aging
3762	resource center.
3763	(d)  Minimum staff requirements which shall ensure that the
3764	aging resource center employs sufficient quality and quantity of
3765	staff to adequately meet the needs of the elders residing within
3766	the area served by the aging resource center.
3767	(e)  Minimum accessibility standards, including hours of
3768	operation.
3769	(f)  Minimum oversight standards for the governing body of
3770	the aging resource center to ensure its continuous involvement
3771	in, and accountability for, all matters related to the
3772	development, implementation, staffing, administration, and
3773	operations of the aging resource center.
3774	(g)  Minimum education and experience requirements for
3775	executive directors and other executive staff positions of aging
3776	resource centers.
3777	(h)  Minimum requirements regarding any executive staff
3778	positions that the aging resource center must employ and minimum
3779	requirements that a candidate must meet in order to be eligible
3780	for appointment to such positions.
3781	(11)(13)  In an area in which the department has designated
3782	an area agency on aging as an aging resource center, the
3783	department and the agency shall not make payments for the
3784	services listed in subsection (9)      (11) and the Long-Term Care
3785	Community Diversion Project for such persons who were not
3786	screened and enrolled through the aging resource center. The
3787	department shall cease making payments for recipients in
3788	eligible plans as eligible plans become available in each of the
3789	regions defined in s. 409.981(2).
3790	(12)(14)  Each aging resource center shall enter into a
3791	memorandum of understanding with the department for
3792	collaboration with the CARES unit staff. The memorandum of
3793	understanding shall outline the staff person responsible for
3794	each function and shall provide the staffing levels necessary to
3795	carry out the functions of the aging resource center.
3796	(13)(15)  Each aging resource center shall enter into a
3797	memorandum of understanding with the Department of Children and
3798	Family Services for collaboration with the Economic Self-
3799	Sufficiency Unit staff. The memorandum of understanding shall
3800	outline which staff persons are responsible for which functions
3801	and shall provide the staffing levels necessary to carry out the
3802	functions of the aging resource center.
3803	(14)(16)  If any of the state activities described in this
3804	section are outsourced, either in part or in whole, the contract
3805	executing the outsourcing shall mandate that the contractor or
3806	its subcontractors shall, either physically or virtually,
3807	execute the provisions of the memorandum of understanding
3808	instead of the state entity whose function the contractor or
3809	subcontractor now performs.
3810	(15)(17)  In order to be eligible to begin transitioning to
3811	an aging resource center, an area agency on aging board must
3812	ensure that the area agency on aging which it oversees meets all
3813	of the minimum requirements set by law and in rule.
3814	(18)  The department shall monitor the three initial
3815	projects for aging resource centers and report on the progress
3816	of those projects to the Governor, the President of the Senate,
3817	and the Speaker of the House of Representatives by June 30,
3818	2005. The report must include an evaluation of the
3819	implementation process.
3820	(16)(19)(a)  Once an aging resource center is operational,
3821	the department, in consultation with the agency, may develop
3822	capitation rates for any of the programs administered through
3823	the aging resource center. Capitation rates for programs shall
3824	be based on the historical cost experience of the state in
3825	providing those same services to the population age 60 or older
3826	residing within each area served by an aging resource center.
3827	Each capitated rate may vary by geographic area as determined by
3828	the department.
3829	(b)  The department and the agency may determine for each
3830	area served by an aging resource center whether it is
3831	appropriate, consistent with federal and state laws and
3832	regulations, to develop and pay separate capitated rates for
3833	each program administered through the aging resource center or
3834	to develop and pay capitated rates for service packages which
3835	include more than one program or service administered through
3836	the aging resource center.
3837	(c)  Once capitation rates have been developed and
3838	certified as actuarially sound, the department and the agency
3839	may pay service providers the capitated rates for services when
3840	appropriate.
3841	(d)  The department, in consultation with the agency, shall
3842	annually reevaluate and recertify the capitation rates,
3843	adjusting forward to account for inflation, programmatic
3844	changes.
3845	(20)  The department, in consultation with the agency,
3846	shall submit to the Governor, the President of the Senate, and
3847	the Speaker of the House of Representatives, by December 1,
3848	2006, a report addressing the feasibility of administering the
3849	following services through aging resource centers beginning July
3850	1, 2007:
3851	(a)  Medicaid nursing home services.
3852	(b)  Medicaid transportation services.
3853	(c)  Medicaid hospice care services.
3854	(d)  Medicaid intermediate care services.
3855	(e)  Medicaid prescribed drug services.
3856	(f)  Medicaid assistive care services.
3857	(g)  Any other long-term-care program or Medicaid service.
3858	(17)(21)  This section shall not be construed to allow an
3859	aging resource center to restrict, manage, or impede the local
3860	fundraising activities of service providers.
3861	Section 24.  Effective October 1, 2013, sections 430.701,
3862	430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3863	430.708, and 430.709, Florida Statutes, are repealed.
3864	Section 25.  Sections 409.9301, 409.942, 409.944, 409.945,
3865	409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3866	as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3867	402.87, Florida Statutes, respectively.
3868	Section 26.  Paragraph (a) of subsection (1) of section
3869	443.111, Florida Statutes, is amended to read:
3870	443.111  Payment of benefits.-
3871	(1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3872	in accordance with rules adopted by the Agency for Workforce
3873	Innovation, subject to the following requirements:
3874	(a)  Benefits are payable by mail or electronically.
3875	Notwithstanding s. 402.82(4) s. 409.942(4), the agency may
3876	develop a system for the payment of benefits by electronic funds
3877	transfer, including, but not limited to, debit cards, electronic
3878	payment cards, or any other means of electronic payment that the
3879	agency deems to be commercially viable or cost-effective.
3880	Commodities or services related to the development of such a
3881	system shall be procured by competitive solicitation, unless
3882	they are purchased from a state term contract pursuant to s.
3883	287.056. The agency shall adopt rules necessary to administer
3884	the system.
3885	Section 27.  Subsection (4) of section 641.386, Florida
3886	Statutes, is amended to read:
3887	641.386  Agent licensing and appointment required;
3888	exceptions.-
3889	(4)  All agents and health maintenance organizations shall
3890	comply with and be subject to the applicable provisions of ss.
3891	641.309 and 409.912(20)(21), and all companies and entities
3892	appointing agents shall comply with s. 626.451, when marketing
3893	for any health maintenance organization licensed pursuant to
3894	this part, including those organizations under contract with the
3895	Agency for Health Care Administration to provide health care
3896	services to Medicaid recipients or any private entity providing
3897	health care services to Medicaid recipients pursuant to a
3898	prepaid health plan contract with the Agency for Health Care
3899	Administration.
3900	Section 28.  Subsections (6) and (7) of section 766.118,
3901	Florida Statutes, are renumbered as subsections (7) and (8),
3902	respectively, and a new subsection (6) is added to that section,
3903	to read:
3904	766.118  Determination of noneconomic damages.-
3905	(6)  LIMITATION ON NONECONOMIC DAMAGES FOR NEGLIGENCE OF A
3906	PRACTITIONER PROVIDING SERVICES AND CARE TO A MEDICAID
3907	RECIPIENT.-Notwithstanding subsections (2), (3), and (5), with
3908	respect to a cause of action for personal injury or wrongful
3909	death arising from medical negligence of a practitioner
3910	committed in the course of providing medical services and
3911	medical care to a Medicaid recipient, regardless of the number
3912	of such practitioner defendants providing the services and care,
3913	noneconomic damages may not exceed $300,000 per claimant, unless
3914	the claimant pleads and proves, by clear and convincing
3915	evidence, that the practitioner acted in a wrongful manner. A
3916	practitioner providing medical services and medical care to a
3917	Medicaid recipient is not liable for more than $200,000 in
3918	noneconomic damages, regardless of the number of claimants,
3919	unless the claimant pleads and proves, by clear and convincing
3920	evidence, that the practitioner acted in a wrongful manner. The
3921	fact that a claimant proves that a practitioner acted in a
3922	wrongful manner does not preclude the application of the
3923	limitation on noneconomic damages prescribed elsewhere in this
3924	section. For purposes of this subsection:
3925	(a)  The terms "medical services," "medical care," and
3926	"Medicaid recipient" have the same meaning as provided in s.
3927	409.901.
3928	(b)  The term "practitioner," in addition to the meaning
3929	prescribed in subsection (1), includes any hospital, ambulatory
3930	surgical center, or mobile surgical facility as defined and
3931	licensed under chapter 395.
3932	(c)  The term "wrongful manner" means in bad faith or with
3933	malicious purpose or in a manner exhibiting wanton and willful
3934	disregard of human rights, safety, or property, and shall be
3935	construed in conformity with the standard set forth in s.
3936	768.28(9)(a).
3937	Section 29.  The Agency for Health Care Administration
3938	shall develop a plan for implementing a plan for medically needy
3939	Medicaid enrollees pursuant to s. 409.975(8), Florida Statutes,
3940	as created in HB 7107 or similar legislation that is adopted in
3941	the same legislative session or an extension thereof and becomes
3942	law, and shall immediately seek federal approval to implement
3943	that subsection. The plan shall include a preliminary
3944	calculation of actuarially sound rates and estimated fiscal
3945	impact.
3946	Section 30.  The Agency for Health Care Administration
3947	shall develop a reorganization plan for realignment of
3948	administrative resources of the Medicaid program to respond to
3949	changes in functional responsibilities and priorities necessary
3950	for implementation of HB 7107 or similar legislation that is
3951	adopted in the same legislative session or an extension thereof
3952	and becomes law. The plan shall assess the agency's current
3953	capabilities, identify shifts in staffing and other resources
3954	necessary to strengthen procurement and contract monitoring
3955	functions, and establish an implementation timeline. The plan
3956	shall be submitted to the Governor, the Speaker of the House of
3957	Representatives, and the President of the Senate by August 1,
3958	2011.
3959	Section 31.  Subsection (1) of section 393.0662, Florida
3960	Statutes, is amended to read:
3961	393.0662  Individual budgets for delivery of home and
3962	community-based services; iBudget system established.-The
3963	Legislature finds that improved financial management of the
3964	existing home and community-based Medicaid waiver program is
3965	necessary to avoid deficits that impede the provision of
3966	services to individuals who are on the waiting list for
3967	enrollment in the program. The Legislature further finds that
3968	clients and their families should have greater flexibility to
3969	choose the services that best allow them to live in their
3970	community within the limits of an established budget. Therefore,
3971	the Legislature intends that the agency, in consultation with
3972	the Agency for Health Care Administration, develop and implement
3973	a comprehensive redesign of the service delivery system using
3974	individual budgets as the basis for allocating the funds
3975	appropriated for the home and community-based services Medicaid
3976	waiver program among eligible enrolled clients. The service
3977	delivery system that uses individual budgets shall be called the
3978	iBudget system.
3979	(1)  The agency shall establish an individual budget,
3980	referred to as an iBudget, for each individual served by the
3981	home and community-based services Medicaid waiver program. The
3982	funds appropriated to the agency shall be allocated through the
3983	iBudget system to eligible, Medicaid-enrolled clients. For the
3984	iBudget system, eligible clients shall include individuals with
3985	a diagnosis of Down syndrome or a developmental disability as
3986	defined in s. 393.063. The iBudget system shall be designed to
3987	provide for: enhanced client choice within a specified service
3988	package; appropriate assessment strategies; an efficient
3989	consumer budgeting and billing process that includes
3990	reconciliation and monitoring components; a redefined role for
3991	support coordinators that avoids potential conflicts of
3992	interest; a flexible and streamlined service review process; and
3993	a methodology and process that ensures the equitable allocation
3994	of available funds to each client based on the client's level of
3995	need, as determined by the variables in the allocation
3996	algorithm.
3997	(a)  In developing each client's iBudget, the agency shall
3998	use an allocation algorithm and methodology. The algorithm shall
3999	use variables that have been determined by the agency to have a
4000	statistically validated relationship to the client's level of
4001	need for services provided through the home and community-based
4002	services Medicaid waiver program. The algorithm and methodology
4003	may consider individual characteristics, including, but not
4004	limited to, a client's age and living situation, information
4005	from a formal assessment instrument that the agency determines
4006	is valid and reliable, and information from other assessment
4007	processes.
4008	(b)  The allocation methodology shall provide the algorithm
4009	that determines the amount of funds allocated to a client's
4010	iBudget. The agency may approve an increase in the amount of
4011	funds allocated, as determined by the algorithm, based on the
4012	client having one or more of the following needs that cannot be
4013	accommodated within the funding as determined by the algorithm
4014	and having no other resources, supports, or services available
4015	to meet the need:
4016	1.  An extraordinary need that would place the health and
4017	safety of the client, the client's caregiver, or the public in
4018	immediate, serious jeopardy unless the increase is approved. An
4019	extraordinary need may include, but is not limited to:
4020	a.  A documented history of significant, potentially life-
4021	threatening behaviors, such as recent attempts at suicide,
4022	arson, nonconsensual sexual behavior, or self-injurious behavior
4023	requiring medical attention;
4024	b.  A complex medical condition that requires active
4025	intervention by a licensed nurse on an ongoing basis that cannot
4026	be taught or delegated to a nonlicensed person;
4027	c.  A chronic comorbid condition. As used in this
4028	subparagraph, the term "comorbid condition" means a medical
4029	condition existing simultaneously but independently with another
4030	medical condition in a patient; or
4031	d.  A need for total physical assistance with activities
4032	such as eating, bathing, toileting, grooming, and personal
4033	hygiene.
4034
4035	However, the presence of an extraordinary need alone does not
4036	warrant an increase in the amount of funds allocated to a
4037	client's iBudget as determined by the algorithm.
4038	2.  A significant need for one-time or temporary support or
4039	services that, if not provided, would place the health and
4040	safety of the client, the client's caregiver, or the public in
4041	serious jeopardy, unless the increase is approved. A significant
4042	need may include, but is not limited to, the provision of
4043	environmental modifications, durable medical equipment, services
4044	to address the temporary loss of support from a caregiver, or
4045	special services or treatment for a serious temporary condition
4046	when the service or treatment is expected to ameliorate the
4047	underlying condition. As used in this subparagraph, the term
4048	"temporary" means a period of fewer than 12 continuous months.
4049	However, the presence of such significant need for one-time or
4050	temporary supports or services alone does not warrant an
4051	increase in the amount of funds allocated to a client's iBudget
4052	as determined by the algorithm.
4053	3.  A significant increase in the need for services after
4054	the beginning of the service plan year that would place the
4055	health and safety of the client, the client's caregiver, or the
4056	public in serious jeopardy because of substantial changes in the
4057	client's circumstances, including, but not limited to, permanent
4058	or long-term loss or incapacity of a caregiver, loss of services
4059	authorized under the state Medicaid plan due to a change in age,
4060	or a significant change in medical or functional status which
4061	requires the provision of additional services on a permanent or
4062	long-term basis that cannot be accommodated within the client's
4063	current iBudget. As used in this subparagraph, the term "long-
4064	term" means a period of 12 or more continuous months. However,
4065	such significant increase in need for services of a permanent or
4066	long-term nature alone does not warrant an increase in the
4067	amount of funds allocated to a client's iBudget as determined by
4068	the algorithm.
4069
4070	The agency shall reserve portions of the appropriation for the
4071	home and community-based services Medicaid waiver program for
4072	adjustments required pursuant to this paragraph and may use the
4073	services of an independent actuary in determining the amount of
4074	the portions to be reserved.
4075	(c)  A client's iBudget shall be the total of the amount
4076	determined by the algorithm and any additional funding provided
4077	pursuant to paragraph (b). A client's annual expenditures for
4078	home and community-based services Medicaid waiver services may
4079	not exceed the limits of his or her iBudget. The total of all
4080	clients' projected annual iBudget expenditures may not exceed
4081	the agency's appropriation for waiver services.
4082	Section 32.  Section 409.902, Florida Statutes, is amended
4083	to read:
4084	409.902  Designated single state agency; payment
4085	requirements; program title; release of medical records.-
4086	(1)  The Agency for Health Care Administration is
4087	designated as the single state agency authorized to make
4088	payments for medical assistance and related services under Title
4089	XIX of the Social Security Act. These payments shall be made,
4090	subject to any limitations or directions provided for in the
4091	General Appropriations Act, only for services included in the
4092	program, shall be made only on behalf of eligible individuals,
4093	and shall be made only to qualified providers in accordance with
4094	federal requirements for Title XIX of the Social Security Act
4095	and the provisions of state law. This program of medical
4096	assistance is designated the "Medicaid program." The Department
4097	of Children and Family Services is responsible for Medicaid
4098	eligibility determinations, including, but not limited to,
4099	policy, rules, and the agreement with the Social Security
4100	Administration for Medicaid eligibility determinations for
4101	Supplemental Security Income recipients, as well as the actual
4102	determination of eligibility. As a condition of Medicaid
4103	eligibility, subject to federal approval, the Agency for Health
4104	Care Administration and the Department of Children and Family
4105	Services shall ensure that each recipient of Medicaid consents
4106	to the release of her or his medical records to the Agency for
4107	Health Care Administration and the Medicaid Fraud Control Unit
4108	of the Department of Legal Affairs.
4109	(2)  Eligibility is restricted to United States citizens
4110	and to lawfully admitted noncitizens who meet the criteria
4111	provided in s. 414.095(3).
4112	(a)  Citizenship or immigration status must be verified.
4113	For noncitizens, this includes verification of the validity of
4114	documents with the United States Citizenship and Immigration
4115	Services using the federal SAVE verification process.
4116	(b)  State funds may not be used to provide medical
4117	services to individuals who do not meet the requirements of this
4118	subsection unless the services are necessary to treat an
4119	emergency medical condition or are for pregnant women. Such
4120	services are authorized only to the extent provided under
4121	federal law and in accordance with federal regulations as
4122	provided in 42 C.F.R. s. 440.255.
4123	Section 33.  Subsection (22) is added to section 641.19,
4124	Florida Statutes, to read:
4125	641.19  Definitions.-As used in this part, the term:
4126	(22)  "Provider service network" means a network authorized
4127	under s. 409.912(4)(d), reimbursed on a prepaid basis, operated
4128	by a health care provider or group of affiliated health care
4129	providers, and which directly provides health care services
4130	under a Medicare, Medicaid, or Healthy Kids contract.
4131	Section 34.  Section 641.2019, Florida Statutes, is created
4132	to read:
4133	641.2019  Provider service network certificate of
4134	authority.-A prepaid provider service network that applies for
4135	and obtains a health care provider certificate pursuant to part
4136	III of this chapter, meets the surplus requirements of s.
4137	641.225, and meets all other applicable requirements of this
4138	part may obtain a certificate of authority under s. 641.21. A
4139	certified provider service network has the same rights and
4140	responsibilities as a health maintenance organization certified
4141	under this part.
4142	Section 35.  Subsection (2) of section 641.2261, Florida
4143	Statutes, is amended to read:
4144	641.2261  Application of solvency requirements to provider-
4145	sponsored organizations and Medicaid provider service networks.-
4146	(2)  Except for a provider service network seeking to
4147	obtain a certificate of authority under s. 641.2019, the
4148	solvency requirements in 42 C.F.R. s. 422.350, subpart H, and
4149	the solvency requirements established in approved federal
4150	waivers pursuant to chapter 409 apply to a Medicaid provider
4151	service network rather than the solvency requirements of this
4152	part.
4153	Section 36.  If any provision of this act or its
4154	application to any person or circumstance is held invalid, the
4155	invalidity does not affect other provisions or applications of
4156	the act which can be given effect without the invalid provision
4157	or application, and to this end the provisions of this act are
4158	severable.
4159	Section 37.  Except as otherwise expressly provided in this
4160	act, this act shall take effect July 1, 2011, if HB 7107 or
4161	similar legislation is adopted in the same legislative session
4162	or an extension thereof and becomes law.

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