Florida Senate - 2012                                    SB 1316
       
       
       
       By Senator Gaetz
       
       
       
       
       4-00891C-12                                           20121316__
    1                        A bill to be entitled                      
    2         An act relating to health care; amending s. 400.474,
    3         F.S.; revising the fine that may be imposed against a
    4         home health agency for failing to timely submit
    5         certain information to the Agency for Health Care
    6         Administration; amending s. 409.221, F.S.; revising
    7         the background screening requirements for persons
    8         rendering care in the consumer-directed care program
    9         administered by the Agency for Health Care
   10         Administration; amending s. 409.907, F.S.; extending
   11         the records-retention period for certain Medicaid
   12         provider records; revising the provider agreement to
   13         require Medicaid providers to report changes in any
   14         principal of the provider to the agency; defining the
   15         term “administrative fines” for purposes of revoking a
   16         Medicaid provider agreement due to changes of
   17         ownership; authorizing, rather than requiring, an
   18         onsite inspection of a Medicaid provider’s service
   19         location before entering into a provider agreement;
   20         specifying the principals of a hospital or nursing
   21         home provider for the purposes of submitting
   22         fingerprints for background screening; removing
   23         certain providers from being subject to agency
   24         background checks; amending s. 409.913, F.S.; defining
   25         the term “Medicaid provider” or “provider” for
   26         purposes of oversight of the integrity of the Medicaid
   27         program; authorizing the agency to review and analyze
   28         information from sources other than Medicaid-enrolled
   29         providers for purposes of determining fraud, abuse,
   30         overpayment, or neglect; extending the records
   31         retention period for certain Medicaid provider
   32         records; revising the grounds for terminating a
   33         provider from the Medicaid program; requiring the
   34         agency to base its overpayment audit reports on
   35         certain information; deleting a requirement that the
   36         agency pay interest on certain withheld Medicaid
   37         payments; requiring payment arrangements for
   38         overpayments and fines to be made within a certain
   39         time; specifying that the venue for all Medicaid
   40         program integrity cases lies in Leon County;
   41         authorizing the agency and the Medicaid Fraud Control
   42         Unit to review certain records; amending s. 409.920,
   43         F.S.; clarifying the applicability of immunity from
   44         civil liability extended to persons who provide
   45         information about fraud or suspected fraudulent acts
   46         by a Medicaid provider; amending s. 409.967, F.S.;
   47         specifying required components of a Medicaid managed
   48         care plan relating to the provisions of medications;
   49         amending s. 429.23, F.S.; requiring the agency to
   50         submit a report to the Legislature on adverse incident
   51         reports from assisted living facilities; amending s.
   52         429.26, F.S.; authorizing the agency to require a
   53         resident of an assisted living facility to undergo a
   54         physical examination if the agency questions the
   55         appropriateness of the resident’s placement in that
   56         facility; authorizing release of the results of the
   57         examination to a medical review team to be used along
   58         with additional information to determine whether the
   59         resident’s placement in the assisted living facility
   60         is appropriate; providing for resident notification
   61         and relocation if the resident’s continued placement
   62         in the facility is not appropriate; authorizing the
   63         agency to require the evaluation of a mental health
   64         resident by a mental health professional; authorizing
   65         an assisted living facility to discharge a resident
   66         who requires more services or care than the facility
   67         is able to provide; amending s. 456.0635, F.S.;
   68         revising the grounds under which the Department of
   69         Health or corresponding board is required to refuse to
   70         admit a candidate to an examination and refuse to
   71         issue or renew a license, certificate, or registration
   72         of a health care practitioner; providing an exception;
   73         amending s. 456.036, F.S.; providing that all persons
   74         who were denied renewal of licensure, certification,
   75         or registration under s. 456.0635(3), F.S., may regain
   76         licensure, certification, or registration only by
   77         completing the application process for initial
   78         licensure; providing an exception; amending s.
   79         456.074, F.S.; revising the federal offenses for which
   80         the Department of Health must issue an emergency order
   81         suspending the license of certain health care
   82         professionals; requiring the agency to prepare a
   83         report for public comment and submission to the
   84         Legislature following the expansion of services to new
   85         populations or of new services; providing effective
   86         dates.
   87  
   88  Be It Enacted by the Legislature of the State of Florida:
   89  
   90         Section 1. Subsection (6) of section 400.474, Florida
   91  Statutes, is amended, present subsection (7) of that section is
   92  renumbered as subsection (8), and a new subsection (7) is added
   93  to that section, to read:
   94         400.474 Administrative penalties.—
   95         (6) The agency may deny, revoke, or suspend the license of
   96  a home health agency and shall impose a fine of $5,000 against a
   97  home health agency that:
   98         (a) Gives remuneration for staffing services to:
   99         1. Another home health agency with which it has formal or
  100  informal patient-referral transactions or arrangements; or
  101         2. A health services pool with which it has formal or
  102  informal patient-referral transactions or arrangements,
  103  
  104  unless the home health agency has activated its comprehensive
  105  emergency management plan in accordance with s. 400.492. This
  106  paragraph does not apply to a Medicare-certified home health
  107  agency that provides fair market value remuneration for staffing
  108  services to a non-Medicare-certified home health agency that is
  109  part of a continuing care facility licensed under chapter 651
  110  for providing services to its own residents if each resident
  111  receiving home health services pursuant to this arrangement
  112  attests in writing that he or she made a decision without
  113  influence from staff of the facility to select, from a list of
  114  Medicare-certified home health agencies provided by the
  115  facility, that Medicare-certified home health agency to provide
  116  the services.
  117         (b) Provides services to residents in an assisted living
  118  facility for which the home health agency does not receive fair
  119  market value remuneration.
  120         (c) Provides staffing to an assisted living facility for
  121  which the home health agency does not receive fair market value
  122  remuneration.
  123         (d) Fails to provide the agency, upon request, with copies
  124  of all contracts with assisted living facilities which were
  125  executed within 5 years before the request.
  126         (e) Gives remuneration to a case manager, discharge
  127  planner, facility-based staff member, or third-party vendor who
  128  is involved in the discharge planning process of a facility
  129  licensed under chapter 395, chapter 429, or this chapter from
  130  whom the home health agency receives referrals.
  131         (f) Fails to submit to the agency, within 15 days after the
  132  end of each calendar quarter, a written report that includes the
  133  following data based on data as it existed on the last day of
  134  the quarter:
  135         1. The number of insulin-dependent diabetic patients
  136  receiving insulin-injection services from the home health
  137  agency;
  138         2. The number of patients receiving both home health
  139  services from the home health agency and hospice services;
  140         3. The number of patients receiving home health services
  141  from that home health agency; and
  142         4. The names and license numbers of nurses whose primary
  143  job responsibility is to provide home health services to
  144  patients and who received remuneration from the home health
  145  agency in excess of $25,000 during the calendar quarter.
  146         (f)(g) Gives cash, or its equivalent, to a Medicare or
  147  Medicaid beneficiary.
  148         (g)(h) Has more than one medical director contract in
  149  effect at one time or more than one medical director contract
  150  and one contract with a physician-specialist whose services are
  151  mandated for the home health agency in order to qualify to
  152  participate in a federal or state health care program at one
  153  time.
  154         (h)(i) Gives remuneration to a physician without a medical
  155  director contract being in effect. The contract must:
  156         1. Be in writing and signed by both parties;
  157         2. Provide for remuneration that is at fair market value
  158  for an hourly rate, which must be supported by invoices
  159  submitted by the medical director describing the work performed,
  160  the dates on which that work was performed, and the duration of
  161  that work; and
  162         3. Be for a term of at least 1 year.
  163  
  164  The hourly rate specified in the contract may not be increased
  165  during the term of the contract. The home health agency may not
  166  execute a subsequent contract with that physician which has an
  167  increased hourly rate and covers any portion of the term that
  168  was in the original contract.
  169         (i)(j) Gives remuneration to:
  170         1. A physician, and the home health agency is in violation
  171  of paragraph (g) (h) or paragraph (h) (i);
  172         2. A member of the physician’s office staff; or
  173         3. An immediate family member of the physician,
  174  
  175  if the home health agency has received a patient referral in the
  176  preceding 12 months from that physician or physician’s office
  177  staff.
  178         (j)(k) Fails to provide to the agency, upon request, copies
  179  of all contracts with a medical director which were executed
  180  within 5 years before the request.
  181         (k)(l) Demonstrates a pattern of billing the Medicaid
  182  program for services to Medicaid recipients which are medically
  183  unnecessary as determined by a final order. A pattern may be
  184  demonstrated by a showing of at least two such medically
  185  unnecessary services within one Medicaid program integrity audit
  186  period.
  187  
  188  Paragraphs (e) and (i) do not apply to or preclude Nothing in
  189  paragraph (e) or paragraph (j) shall be interpreted as applying
  190  to or precluding any discount, compensation, waiver of payment,
  191  or payment practice permitted by 42 U.S.C. s. 1320a-7(b) or
  192  regulations adopted thereunder, including 42 C.F.R. s. 1001.952
  193  or s. 1395nn or regulations adopted thereunder.
  194         (7) The agency shall impose a fine of $50 per day against a
  195  home health agency that fails to submit to the agency, within 15
  196  days after the end of each calendar quarter, a written report
  197  that includes the following data based on data as it existed on
  198  the last day of the quarter:
  199         (a) The number of patients receiving both home health
  200  services from the home health agency and hospice services;
  201         (b) The number of patients receiving home health services
  202  from the home health agency;
  203         (c) The number of insulin-dependent diabetic patients
  204  receiving insulin-injection services from the home health
  205  agency; and
  206         (d) The names and license numbers of nurses whose primary
  207  job responsibility is to provide home health services to
  208  patients and who received remuneration from the home health
  209  agency in excess of $25,000 during the calendar quarter.
  210         Section 2. Paragraph (i) of subsection (4) of section
  211  409.221, Florida Statutes, is amended to read:
  212         409.221 Consumer-directed care program.—
  213         (4) CONSUMER-DIRECTED CARE.—
  214         (i) Background screening requirements.—All persons who
  215  render care under this section must undergo level 2 background
  216  screening pursuant to chapter 435 and s. 408.809. The agency
  217  shall, as allowable, reimburse consumer-employed caregivers for
  218  the cost of conducting such background screening as required by
  219  this section. For purposes of this section, a person who has
  220  undergone screening, who is qualified for employment under this
  221  section and applicable rule, and who has not been unemployed for
  222  more than 90 days following such screening is not required to be
  223  rescreened. Such person must attest under penalty of perjury to
  224  not having been convicted of a disqualifying offense since
  225  completing such screening.
  226         Section 3. Paragraph (c) of subsection (3) of section
  227  409.907, Florida Statutes, is amended, paragraph (k) is added to
  228  that subsection, and subsections (6), (7), and (8) of that
  229  section are amended, to read:
  230         409.907 Medicaid provider agreements.—The agency may make
  231  payments for medical assistance and related services rendered to
  232  Medicaid recipients only to an individual or entity who has a
  233  provider agreement in effect with the agency, who is performing
  234  services or supplying goods in accordance with federal, state,
  235  and local law, and who agrees that no person shall, on the
  236  grounds of handicap, race, color, or national origin, or for any
  237  other reason, be subjected to discrimination under any program
  238  or activity for which the provider receives payment from the
  239  agency.
  240         (3) The provider agreement developed by the agency, in
  241  addition to the requirements specified in subsections (1) and
  242  (2), shall require the provider to:
  243         (c) Retain all medical and Medicaid-related records for 6 a
  244  period of 5 years to satisfy all necessary inquiries by the
  245  agency.
  246         (k) Report a change in any principal of the provider,
  247  including any officer, director, agent, managing employee, or
  248  affiliated person, or any partner or shareholder who has an
  249  ownership interest equal to 5 percent or more in the provider,
  250  to the agency in writing no later than 30 days after the change
  251  occurs.
  252         (6) A Medicaid provider agreement may be revoked, at the
  253  option of the agency, due to as the result of a change of
  254  ownership of any facility, association, partnership, or other
  255  entity named as the provider in the provider agreement.
  256         (a) In the event of a change of ownership, the transferor
  257  remains liable for all outstanding overpayments, administrative
  258  fines, and any other moneys owed to the agency before the
  259  effective date of the change of ownership. In addition to the
  260  continuing liability of the transferor, The transferee is also
  261  liable to the agency for all outstanding overpayments identified
  262  by the agency on or before the effective date of the change of
  263  ownership. For purposes of this subsection, the term
  264  “outstanding overpayment” includes any amount identified in a
  265  preliminary audit report issued to the transferor by the agency
  266  on or before the effective date of the change of ownership. In
  267  the event of a change of ownership for a skilled nursing
  268  facility or intermediate care facility, the Medicaid provider
  269  agreement shall be assigned to the transferee if the transferee
  270  meets all other Medicaid provider qualifications. In the event
  271  of a change of ownership involving a skilled nursing facility
  272  licensed under part II of chapter 400, liability for all
  273  outstanding overpayments, administrative fines, and any moneys
  274  owed to the agency before the effective date of the change of
  275  ownership shall be determined in accordance with s. 400.179.
  276         (b) At least 60 days before the anticipated date of the
  277  change of ownership, the transferor must shall notify the agency
  278  of the intended change of ownership and the transferee must
  279  shall submit to the agency a Medicaid provider enrollment
  280  application. If a change of ownership occurs without compliance
  281  with the notice requirements of this subsection, the transferor
  282  and transferee are shall be jointly and severally liable for all
  283  overpayments, administrative fines, and other moneys due to the
  284  agency, regardless of whether the agency identified the
  285  overpayments, administrative fines, or other moneys before or
  286  after the effective date of the change of ownership. The agency
  287  may not approve a transferee’s Medicaid provider enrollment
  288  application if the transferee or transferor has not paid or
  289  agreed in writing to a payment plan for all outstanding
  290  overpayments, administrative fines, and other moneys due to the
  291  agency. This subsection does not preclude the agency from
  292  seeking any other legal or equitable remedies available to the
  293  agency for the recovery of moneys owed to the Medicaid program.
  294  In the event of a change of ownership involving a skilled
  295  nursing facility licensed under part II of chapter 400,
  296  liability for all outstanding overpayments, administrative
  297  fines, and any moneys owed to the agency before the effective
  298  date of the change of ownership shall be determined in
  299  accordance with s. 400.179 if the Medicaid provider enrollment
  300  application for change of ownership is submitted before the
  301  change of ownership.
  302         (c) As used in this subsection, the term:
  303         1. “Administrative fines” includes any amount identified in
  304  a notice of a monetary penalty or fine which has been issued by
  305  the agency or other regulatory or licensing agency that governs
  306  the provider.
  307         2. “Outstanding overpayment” includes any amount identified
  308  in a preliminary audit report issued to the transferor by the
  309  agency on or before the effective date of a change of ownership.
  310         (7) The agency may require, As a condition of participating
  311  in the Medicaid program and before entering into the provider
  312  agreement, the agency may require that the provider to submit
  313  information, in an initial and any required renewal
  314  applications, concerning the professional, business, and
  315  personal background of the provider and permit an onsite
  316  inspection of the provider’s service location by agency staff or
  317  other personnel designated by the agency to perform this
  318  function. Before entering into a provider agreement, the agency
  319  may shall perform an a random onsite inspection, within 60 days
  320  after receipt of a fully complete new provider’s application, of
  321  the provider’s service location prior to making its first
  322  payment to the provider for Medicaid services to determine the
  323  applicant’s ability to provide the services in compliance with
  324  the Medicaid program and professional regulations that the
  325  applicant is proposing to provide for Medicaid reimbursement.
  326  The agency is not required to perform an onsite inspection of a
  327  provider or program that is licensed by the agency, that
  328  provides services under waiver programs for home and community
  329  based services, or that is licensed as a medical foster home by
  330  the Department of Children and Family Services. As a continuing
  331  condition of participation in the Medicaid program, a provider
  332  must shall immediately notify the agency of any current or
  333  pending bankruptcy filing. Before entering into the provider
  334  agreement, or as a condition of continuing participation in the
  335  Medicaid program, the agency may also require that Medicaid
  336  providers reimbursed on a fee-for-services basis or fee schedule
  337  basis that which is not cost-based, post a surety bond not to
  338  exceed $50,000 or the total amount billed by the provider to the
  339  program during the current or most recent calendar year,
  340  whichever is greater. For new providers, the amount of the
  341  surety bond shall be determined by the agency based on the
  342  provider’s estimate of its first year’s billing. If the
  343  provider’s billing during the first year exceeds the bond
  344  amount, the agency may require the provider to acquire an
  345  additional bond equal to the actual billing level of the
  346  provider. A provider’s bond may shall not exceed $50,000 if a
  347  physician or group of physicians licensed under chapter 458,
  348  chapter 459, or chapter 460 has a 50 percent or greater
  349  ownership interest in the provider or if the provider is an
  350  assisted living facility licensed under chapter 429. The bonds
  351  permitted by this section are in addition to the bonds
  352  referenced in s. 400.179(2)(d). If the provider is a
  353  corporation, partnership, association, or other entity, the
  354  agency may require the provider to submit information concerning
  355  the background of that entity and of any principal of the
  356  entity, including any partner or shareholder having an ownership
  357  interest in the entity equal to 5 percent or greater, and any
  358  treating provider who participates in or intends to participate
  359  in Medicaid through the entity. The information must include:
  360         (a) Proof of holding a valid license or operating
  361  certificate, as applicable, if required by the state or local
  362  jurisdiction in which the provider is located or if required by
  363  the Federal Government.
  364         (b) Information concerning any prior violation, fine,
  365  suspension, termination, or other administrative action taken
  366  under the Medicaid laws, rules, or regulations of this state or
  367  of any other state or the Federal Government; any prior
  368  violation of the laws, rules, or regulations relating to the
  369  Medicare program; any prior violation of the rules or
  370  regulations of any other public or private insurer; and any
  371  prior violation of the laws, rules, or regulations of any
  372  regulatory body of this or any other state.
  373         (c) Full and accurate disclosure of any financial or
  374  ownership interest that the provider, or any principal, partner,
  375  or major shareholder thereof, may hold in any other Medicaid
  376  provider or health care related entity or any other entity that
  377  is licensed by the state to provide health or residential care
  378  and treatment to persons.
  379         (d) If a group provider, identification of all members of
  380  the group and attestation that all members of the group are
  381  enrolled in or have applied to enroll in the Medicaid program.
  382         (8)(a) Each provider, or each principal of the provider if
  383  the provider is a corporation, partnership, association, or
  384  other entity, seeking to participate in the Medicaid program
  385  must submit a complete set of his or her fingerprints to the
  386  agency for the purpose of conducting a criminal history record
  387  check. Principals of the provider include any officer, director,
  388  billing agent, managing employee, or affiliated person, or any
  389  partner or shareholder who has an ownership interest equal to 5
  390  percent or more in the provider. However, for a hospital
  391  licensed under chapter 395 or a nursing home licensed under
  392  chapter 400, principals of the provider are those who meet the
  393  definition of a controlling interest under s. 408.803. A
  394  director of a not-for-profit corporation or organization is not
  395  a principal for purposes of a background investigation as
  396  required by this section if the director: serves solely in a
  397  voluntary capacity for the corporation or organization, does not
  398  regularly take part in the day-to-day operational decisions of
  399  the corporation or organization, receives no remuneration from
  400  the not-for-profit corporation or organization for his or her
  401  service on the board of directors, has no financial interest in
  402  the not-for-profit corporation or organization, and has no
  403  family members with a financial interest in the not-for-profit
  404  corporation or organization; and if the director submits an
  405  affidavit, under penalty of perjury, to this effect to the
  406  agency and the not-for-profit corporation or organization
  407  submits an affidavit, under penalty of perjury, to this effect
  408  to the agency as part of the corporation’s or organization’s
  409  Medicaid provider agreement application.
  410         (a) Notwithstanding the above, the agency may require a
  411  background check for any person reasonably suspected by the
  412  agency to have been convicted of a crime. This subsection does
  413  not apply to:
  414         1. A hospital licensed under chapter 395;
  415         2. A nursing home licensed under chapter 400;
  416         3. A hospice licensed under chapter 400;
  417         4. An assisted living facility licensed under chapter 429;
  418         1.5. A unit of local government, except that requirements
  419  of this subsection apply to nongovernmental providers and
  420  entities contracting with the local government to provide
  421  Medicaid services. The actual cost of the state and national
  422  criminal history record checks must be borne by the
  423  nongovernmental provider or entity; or
  424         2.6. Any business that derives more than 50 percent of its
  425  revenue from the sale of goods to the final consumer, and the
  426  business or its controlling parent is required to file a form
  427  10-K or other similar statement with the Securities and Exchange
  428  Commission or has a net worth of $50 million or more.
  429         (b) Background screening shall be conducted in accordance
  430  with chapter 435 and s. 408.809. The cost of the state and
  431  national criminal record check shall be borne by the provider.
  432         (c) Proof of compliance with the requirements of level 2
  433  screening under chapter 435 conducted within 12 months before
  434  the date the Medicaid provider application is submitted to the
  435  agency fulfills the requirements of this subsection.
  436         Section 4. Present paragraphs (e) and (f) of subsection (1)
  437  of section 409.913, Florida Statutes, are redesignated as
  438  paragraphs (f) and (g), respectively, a new paragraph (e) is
  439  added to that subsection, and subsections (2), (9), (13), (15),
  440  (16), (21), (22), (25), (28), (29), (30), and (31) of that
  441  section are amended, to read:
  442         409.913 Oversight of the integrity of the Medicaid
  443  program.—The agency shall operate a program to oversee the
  444  activities of Florida Medicaid recipients, and providers and
  445  their representatives, to ensure that fraudulent and abusive
  446  behavior and neglect of recipients occur to the minimum extent
  447  possible, and to recover overpayments and impose sanctions as
  448  appropriate. Beginning January 1, 2003, and each year
  449  thereafter, the agency and the Medicaid Fraud Control Unit of
  450  the Department of Legal Affairs shall submit a joint report to
  451  the Legislature documenting the effectiveness of the state’s
  452  efforts to control Medicaid fraud and abuse and to recover
  453  Medicaid overpayments during the previous fiscal year. The
  454  report must describe the number of cases opened and investigated
  455  each year; the sources of the cases opened; the disposition of
  456  the cases closed each year; the amount of overpayments alleged
  457  in preliminary and final audit letters; the number and amount of
  458  fines or penalties imposed; any reductions in overpayment
  459  amounts negotiated in settlement agreements or by other means;
  460  the amount of final agency determinations of overpayments; the
  461  amount deducted from federal claiming as a result of
  462  overpayments; the amount of overpayments recovered each year;
  463  the amount of cost of investigation recovered each year; the
  464  average length of time to collect from the time the case was
  465  opened until the overpayment is paid in full; the amount
  466  determined as uncollectible and the portion of the uncollectible
  467  amount subsequently reclaimed from the Federal Government; the
  468  number of providers, by type, that are terminated from
  469  participation in the Medicaid program as a result of fraud and
  470  abuse; and all costs associated with discovering and prosecuting
  471  cases of Medicaid overpayments and making recoveries in such
  472  cases. The report must also document actions taken to prevent
  473  overpayments and the number of providers prevented from
  474  enrolling in or reenrolling in the Medicaid program as a result
  475  of documented Medicaid fraud and abuse and must include policy
  476  recommendations necessary to prevent or recover overpayments and
  477  changes necessary to prevent and detect Medicaid fraud. All
  478  policy recommendations in the report must include a detailed
  479  fiscal analysis, including, but not limited to, implementation
  480  costs, estimated savings to the Medicaid program, and the return
  481  on investment. The agency must submit the policy recommendations
  482  and fiscal analyses in the report to the appropriate estimating
  483  conference, pursuant to s. 216.137, by February 15 of each year.
  484  The agency and the Medicaid Fraud Control Unit of the Department
  485  of Legal Affairs each must include detailed unit-specific
  486  performance standards, benchmarks, and metrics in the report,
  487  including projected cost savings to the state Medicaid program
  488  during the following fiscal year.
  489         (1) For the purposes of this section, the term:
  490         (e) “Medicaid provider” or “provider” has the same meaning
  491  as provided in s. 409.901 and, for purposes of oversight of the
  492  integrity of the Medicaid program, also includes a participant
  493  in a Medicaid managed care provider network.
  494         (2) The agency shall conduct, or cause to be conducted by
  495  contract or otherwise, reviews, investigations, analyses,
  496  audits, or any combination thereof, to determine possible fraud,
  497  abuse, overpayment, or recipient neglect in the Medicaid program
  498  and shall report the findings of any overpayments in audit
  499  reports as appropriate. At least 5 percent of all audits must
  500  shall be conducted on a random basis. As part of its ongoing
  501  fraud detection activities, the agency shall identify and
  502  monitor, by contract or otherwise, patterns of overutilization
  503  of Medicaid services based on state averages. The agency shall
  504  track Medicaid provider prescription and billing patterns and
  505  evaluate them against Medicaid medical necessity criteria and
  506  coverage and limitation guidelines adopted by rule. Medical
  507  necessity determination requires that service be consistent with
  508  symptoms or confirmed diagnosis of illness or injury under
  509  treatment and not in excess of the patient’s needs. The agency
  510  shall conduct reviews of provider exceptions to peer group norms
  511  and shall, using statistical methodologies, provider profiling,
  512  and analysis of billing patterns, detect and investigate
  513  abnormal or unusual increases in billing or payment of claims
  514  for Medicaid services and medically unnecessary provision of
  515  services. The agency may review and analyze information from
  516  sources other than enrolled Medicaid providers in conducting its
  517  activities under this subsection.
  518         (9) A Medicaid provider shall retain medical, professional,
  519  financial, and business records pertaining to services and goods
  520  furnished to a Medicaid recipient and billed to Medicaid for 6 a
  521  period of 5 years after the date of furnishing such services or
  522  goods. The agency may investigate, review, or analyze such
  523  records, which must be made available during normal business
  524  hours. However, 24-hour notice must be provided if patient
  525  treatment would be disrupted. The provider is responsible for
  526  furnishing to the agency, and keeping the agency informed of the
  527  location of, the provider’s Medicaid-related records. The
  528  authority of the agency to obtain Medicaid-related records from
  529  a provider is neither curtailed nor limited during a period of
  530  litigation between the agency and the provider.
  531         (13) The agency shall immediately terminate participation
  532  of a Medicaid provider in the Medicaid program and may seek
  533  civil remedies or impose other administrative sanctions against
  534  a Medicaid provider, if the provider or any principal, officer,
  535  director, agent, managing employee, or affiliated person of the
  536  provider, or any partner or shareholder having an ownership
  537  interest in the provider equal to 5 percent or greater, has been
  538  convicted of a criminal offense under federal law or the law of
  539  any state relating to the practice of the provider’s profession,
  540  or an offense listed under s. 409.907(10), s. 408.809(4), or s.
  541  435.04(2) has been:
  542         (a) Convicted of a criminal offense related to the delivery
  543  of any health care goods or services, including the performance
  544  of management or administrative functions relating to the
  545  delivery of health care goods or services;
  546         (b) Convicted of a criminal offense under federal law or
  547  the law of any state relating to the practice of the provider’s
  548  profession; or
  549         (c) Found by a court of competent jurisdiction to have
  550  neglected or physically abused a patient in connection with the
  551  delivery of health care goods or services. If the agency
  552  determines that the a provider did not participate or acquiesce
  553  in the an offense specified in paragraph (a), paragraph (b), or
  554  paragraph (c), termination will not be imposed. If the agency
  555  effects a termination under this subsection, the agency shall
  556  issue an immediate final order pursuant to s. 120.569(2)(n).
  557         (15) The agency shall seek a remedy provided by law,
  558  including, but not limited to, any remedy provided in
  559  subsections (13) and (16) and s. 812.035, if:
  560         (a) The provider’s license has not been renewed, or has
  561  been revoked, suspended, or terminated, for cause, by the
  562  licensing agency of any state;
  563         (b) The provider has failed to make available or has
  564  refused access to Medicaid-related records to an auditor,
  565  investigator, or other authorized employee or agent of the
  566  agency, the Attorney General, a state attorney, or the Federal
  567  Government;
  568         (c) The provider has not furnished or has failed to make
  569  available such Medicaid-related records as the agency has found
  570  necessary to determine whether Medicaid payments are or were due
  571  and the amounts thereof;
  572         (d) The provider has failed to maintain medical records
  573  made at the time of service, or prior to service if prior
  574  authorization is required, demonstrating the necessity and
  575  appropriateness of the goods or services rendered;
  576         (e) The provider is not in compliance with provisions of
  577  Medicaid provider publications that have been adopted by
  578  reference as rules in the Florida Administrative Code; with
  579  provisions of state or federal laws, rules, or regulations; with
  580  provisions of the provider agreement between the agency and the
  581  provider; or with certifications found on claim forms or on
  582  transmittal forms for electronically submitted claims that are
  583  submitted by the provider or authorized representative, as such
  584  provisions apply to the Medicaid program;
  585         (f) The provider or person who ordered or prescribed the
  586  care, services, or supplies has furnished, or ordered, or
  587  authorized the furnishing of, goods or services to a recipient
  588  which are inappropriate, unnecessary, excessive, or harmful to
  589  the recipient or are of inferior quality;
  590         (g) The provider has demonstrated a pattern of failure to
  591  provide goods or services that are medically necessary;
  592         (h) The provider or an authorized representative of the
  593  provider, or a person who ordered or prescribed the goods or
  594  services, has submitted or caused to be submitted false or a
  595  pattern of erroneous Medicaid claims;
  596         (i) The provider or an authorized representative of the
  597  provider, or a person who has ordered, authorized, or prescribed
  598  the goods or services, has submitted or caused to be submitted a
  599  Medicaid provider enrollment application, a request for prior
  600  authorization for Medicaid services, a drug exception request,
  601  or a Medicaid cost report that contains materially false or
  602  incorrect information;
  603         (j) The provider or an authorized representative of the
  604  provider has collected from or billed a recipient or a
  605  recipient’s responsible party improperly for amounts that should
  606  not have been so collected or billed by reason of the provider’s
  607  billing the Medicaid program for the same service;
  608         (k) The provider or an authorized representative of the
  609  provider has included in a cost report costs that are not
  610  allowable under a Florida Title XIX reimbursement plan, after
  611  the provider or authorized representative had been advised in an
  612  audit exit conference or audit report that the costs were not
  613  allowable;
  614         (l) The provider is charged by information or indictment
  615  with fraudulent billing practices or any offense referenced in
  616  subsection (13). The sanction applied for this reason is limited
  617  to suspension of the provider’s participation in the Medicaid
  618  program for the duration of the indictment unless the provider
  619  is found guilty pursuant to the information or indictment;
  620         (m) The provider or a person who has ordered or prescribed
  621  the goods or services is found liable for negligent practice
  622  resulting in death or injury to the provider’s patient;
  623         (n) The provider fails to demonstrate that it had available
  624  during a specific audit or review period sufficient quantities
  625  of goods, or sufficient time in the case of services, to support
  626  the provider’s billings to the Medicaid program;
  627         (o) The provider has failed to comply with the notice and
  628  reporting requirements of s. 409.907;
  629         (p) The agency has received reliable information of patient
  630  abuse or neglect or of any act prohibited by s. 409.920; or
  631         (q) The provider has failed to comply with an agreed-upon
  632  repayment schedule.
  633  
  634  A provider is subject to sanctions for violations of this
  635  subsection as the result of actions or inactions of the
  636  provider, or actions or inactions of any principal, officer,
  637  director, agent, managing employee, or affiliated person of the
  638  provider, or any partner or shareholder having an ownership
  639  interest in the provider equal to 5 percent or greater, in which
  640  the provider participated or acquiesced.
  641         (16) The agency shall impose any of the following sanctions
  642  or disincentives on a provider or a person for any of the acts
  643  described in subsection (15):
  644         (a) Suspension for a specific period of time of not more
  645  than 1 year. Suspension precludes shall preclude participation
  646  in the Medicaid program, which includes any action that results
  647  in a claim for payment to the Medicaid program as a result of
  648  furnishing, supervising a person who is furnishing, or causing a
  649  person to furnish goods or services.
  650         (b) Termination for a specific period of time of from more
  651  than 1 year to 20 years. Termination precludes shall preclude
  652  participation in the Medicaid program, which includes any action
  653  that results in a claim for payment to the Medicaid program as a
  654  result of furnishing, supervising a person who is furnishing, or
  655  causing a person to furnish goods or services.
  656         (c) Imposition of a fine of up to $5,000 for each
  657  violation. Each day that an ongoing violation continues, such as
  658  refusing to furnish Medicaid-related records or refusing access
  659  to records, is considered, for the purposes of this section, to
  660  be a separate violation. Each instance of improper billing of a
  661  Medicaid recipient; each instance of including an unallowable
  662  cost on a hospital or nursing home Medicaid cost report after
  663  the provider or authorized representative has been advised in an
  664  audit exit conference or previous audit report of the cost
  665  unallowability; each instance of furnishing a Medicaid recipient
  666  goods or professional services that are inappropriate or of
  667  inferior quality as determined by competent peer judgment; each
  668  instance of knowingly submitting a materially false or erroneous
  669  Medicaid provider enrollment application, request for prior
  670  authorization for Medicaid services, drug exception request, or
  671  cost report; each instance of inappropriate prescribing of drugs
  672  for a Medicaid recipient as determined by competent peer
  673  judgment; and each false or erroneous Medicaid claim leading to
  674  an overpayment to a provider is considered, for the purposes of
  675  this section, to be a separate violation.
  676         (d) Immediate suspension, if the agency has received
  677  information of patient abuse or neglect or of any act prohibited
  678  by s. 409.920. Upon suspension, the agency must issue an
  679  immediate final order under s. 120.569(2)(n).
  680         (e) A fine, not to exceed $10,000, for a violation of
  681  paragraph (15)(i).
  682         (f) Imposition of liens against provider assets, including,
  683  but not limited to, financial assets and real property, not to
  684  exceed the amount of fines or recoveries sought, upon entry of
  685  an order determining that such moneys are due or recoverable.
  686         (g) Prepayment reviews of claims for a specified period of
  687  time.
  688         (h) Comprehensive followup reviews of providers every 6
  689  months to ensure that they are billing Medicaid correctly.
  690         (i) Corrective-action plans that would remain in effect for
  691  providers for up to 3 years and that are would be monitored by
  692  the agency every 6 months while in effect.
  693         (j) Other remedies as permitted by law to effect the
  694  recovery of a fine or overpayment.
  695  
  696  If a provider voluntarily relinquishes its Medicaid provider
  697  number after receiving written notice that the agency is
  698  conducting, or has conducted, an audit or investigation and the
  699  sanction of suspension or termination will be imposed for
  700  noncompliance discovered as a result of the audit or
  701  investigation, the agency shall impose the sanction of
  702  termination for cause against the provider. The Secretary of
  703  Health Care Administration may make a determination that
  704  imposition of a sanction or disincentive is not in the best
  705  interest of the Medicaid program, in which case a sanction or
  706  disincentive may shall not be imposed.
  707         (21) When making a determination that an overpayment has
  708  occurred, the agency shall prepare and issue an audit report to
  709  the provider showing the calculation of overpayments. The
  710  agency’s determination shall be based solely upon information
  711  available to it before issuance of the audit report and, in the
  712  case of documentation obtained to substantiate claims for
  713  Medicaid reimbursement, based solely upon contemporaneous
  714  records.
  715         (22) The audit report, supported by agency work papers,
  716  showing an overpayment to a provider constitutes evidence of the
  717  overpayment. A provider may not present or elicit testimony,
  718  either on direct examination or cross-examination in any court
  719  or administrative proceeding, regarding the purchase or
  720  acquisition by any means of drugs, goods, or supplies; sales or
  721  divestment by any means of drugs, goods, or supplies; or
  722  inventory of drugs, goods, or supplies, unless such acquisition,
  723  sales, divestment, or inventory is documented by written
  724  invoices, written inventory records, or other competent written
  725  documentary evidence maintained in the normal course of the
  726  provider’s business. Testimony or evidence that is not based
  727  upon contemporaneous records or that was not furnished to the
  728  agency within 21 days after the issuance of the audit report is
  729  inadmissible in an administrative hearing on a Medicaid
  730  overpayment or an administrative sanction. Notwithstanding the
  731  applicable rules of discovery, all documentation to that will be
  732  offered as evidence at an administrative hearing on a Medicaid
  733  overpayment or an administrative sanction must be exchanged by
  734  all parties at least 14 days before the administrative hearing
  735  or must be excluded from consideration.
  736         (25)(a) The agency shall withhold Medicaid payments, in
  737  whole or in part, to a provider upon receipt of reliable
  738  evidence that the circumstances giving rise to the need for a
  739  withholding of payments involve fraud, willful
  740  misrepresentation, or abuse under the Medicaid program, or a
  741  crime committed while rendering goods or services to Medicaid
  742  recipients. If it is determined that fraud, willful
  743  misrepresentation, abuse, or a crime did not occur, the payments
  744  withheld must be paid to the provider within 14 days after such
  745  determination with interest at the rate of 10 percent a year.
  746  Any money withheld in accordance with this paragraph shall be
  747  placed in a suspended account, readily accessible to the agency,
  748  so that any payment ultimately due the provider shall be made
  749  within 14 days.
  750         (b) The agency shall deny payment, or require repayment, if
  751  the goods or services were furnished, supervised, or caused to
  752  be furnished by a person who has been suspended or terminated
  753  from the Medicaid program or Medicare program by the Federal
  754  Government or any state.
  755         (c) Overpayments owed to the agency bear interest at the
  756  rate of 10 percent per year from the date of determination of
  757  the overpayment by the agency, and payment arrangements
  758  regarding overpayments and fines must be made within 30 days
  759  after the date of the final order and are not subject to further
  760  appeal at the conclusion of legal proceedings. A provider who
  761  does not enter into or adhere to an agreed-upon repayment
  762  schedule may be terminated by the agency for nonpayment or
  763  partial payment.
  764         (d) The agency, upon entry of a final agency order, a
  765  judgment or order of a court of competent jurisdiction, or a
  766  stipulation or settlement, may collect the moneys owed by all
  767  means allowable by law, including, but not limited to, notifying
  768  any fiscal intermediary of Medicare benefits that the state has
  769  a superior right of payment. Upon receipt of such written
  770  notification, the Medicare fiscal intermediary shall remit to
  771  the state the sum claimed.
  772         (e) The agency may institute amnesty programs to allow
  773  Medicaid providers the opportunity to voluntarily repay
  774  overpayments. The agency may adopt rules to administer such
  775  programs.
  776         (28) Venue for all Medicaid program integrity overpayment
  777  cases lies shall lie in Leon County, at the discretion of the
  778  agency.
  779         (29) Notwithstanding other provisions of law, the agency
  780  and the Medicaid Fraud Control Unit of the Department of Legal
  781  Affairs may review a person’s or provider’s Medicaid-related and
  782  non-Medicaid-related records in order to determine the total
  783  output of a provider’s practice to reconcile quantities of goods
  784  or services billed to Medicaid with quantities of goods or
  785  services used in the provider’s total practice.
  786         (30) The agency shall terminate a provider’s participation
  787  in the Medicaid program if the provider fails to reimburse an
  788  overpayment or fine that has been determined by final order, not
  789  subject to further appeal, within 30 35 days after the date of
  790  the final order, unless the provider and the agency have entered
  791  into a repayment agreement.
  792         (31) If a provider requests an administrative hearing
  793  pursuant to chapter 120, such hearing must be conducted within
  794  90 days following assignment of an administrative law judge,
  795  absent exceptionally good cause shown as determined by the
  796  administrative law judge or hearing officer. Upon issuance of a
  797  final order, the outstanding balance of the amount determined to
  798  constitute the overpayment and fines is shall become due. If a
  799  provider fails to make payments in full, fails to enter into a
  800  satisfactory repayment plan, or fails to comply with the terms
  801  of a repayment plan or settlement agreement, the agency shall
  802  withhold medical assistance reimbursement payments for Medicaid
  803  services until the amount due is paid in full.
  804         Section 5. Subsection (8) of section 409.920, Florida
  805  Statutes, is amended to read:
  806         409.920 Medicaid provider fraud.—
  807         (8) A person who provides the state, any state agency, any
  808  of the state’s political subdivisions, or any agency of the
  809  state’s political subdivisions with information about fraud or
  810  suspected fraudulent acts fraud by a Medicaid provider,
  811  including a managed care organization, is immune from civil
  812  liability for libel, slander, or any other relevant tort for
  813  providing any the information about fraud or suspected
  814  fraudulent acts, unless the person acted with knowledge that the
  815  information was false or with reckless disregard for the truth
  816  or falsity of the information. For purposes of this subsection,
  817  the term “fraudulent acts” includes actual or suspected fraud,
  818  abuse, or overpayment, including any fraud-related matters that
  819  a provider or health plan is required to report to the agency or
  820  a law enforcement agency. The immunity from civil liability
  821  extends to reports of fraudulent acts conveyed to the agency in
  822  any manner, including any forum and with any audience as
  823  directed by the agency, and includes all discussions subsequent
  824  to the report and subsequent inquiries from the agency, unless
  825  the person acted with knowledge that the information was false
  826  or with reckless disregard for the truth or falsity of the
  827  information.
  828         Section 6. Paragraph (c) of subsection (2) of section
  829  409.967, Florida Statutes, is amended to read:
  830         409.967 Managed care plan accountability.—
  831         (2) The agency shall establish such contract requirements
  832  as are necessary for the operation of the statewide managed care
  833  program. In addition to any other provisions the agency may deem
  834  necessary, the contract must require:
  835         (c) Access.—
  836         1. Providers.—The agency shall establish specific standards
  837  for the number, type, and regional distribution of providers in
  838  managed care plan networks to ensure access to care for both
  839  adults and children. Each plan must maintain a regionwide
  840  network of providers in sufficient numbers to meet the access
  841  standards for specific medical services for all recipients
  842  enrolled in the plan. The exclusive use of mail-order pharmacies
  843  is may not be sufficient to meet network access standards.
  844  Consistent with the standards established by the agency,
  845  provider networks may include providers located outside the
  846  region. A plan may contract with a new hospital facility before
  847  the date the hospital becomes operational if the hospital has
  848  commenced construction, will be licensed and operational by
  849  January 1, 2013, and a final order has issued in any civil or
  850  administrative challenge. Each plan shall establish and maintain
  851  an accurate and complete electronic database of contracted
  852  providers, including information about licensure or
  853  registration, locations and hours of operation, specialty
  854  credentials and other certifications, specific performance
  855  indicators, and such other information as the agency deems
  856  necessary. The database must be available online to both the
  857  agency and the public and have the capability to compare the
  858  availability of providers to network adequacy standards and to
  859  accept and display feedback from each provider’s patients. Each
  860  plan shall submit quarterly reports to the agency identifying
  861  the number of enrollees assigned to each primary care provider.
  862         2. Prescribed drugs.—
  863         a. If establishing a prescribed drug formulary or preferred
  864  drug list, a managed care plan must:
  865         (I)Provide coverage for drugs in categories and classes
  866  for all disease states and provide a broad range of therapeutic
  867  options for all therapeutic categories;
  868         (II)Include coverage for each drug newly approved by the
  869  federal Food and Drug Administration until the plan’s
  870  Pharmaceutical and Therapeutics Committee reviews such drug for
  871  inclusion on the formulary;
  872         (III)Provide a response within 24 hours after receipt of
  873  all necessary information for a request for prior authorization
  874  or override of other medical management tools; and
  875         (IV)Report all denials to the agency on a quarterly basis.
  876  For each nonformulary drug, the plan must report the total
  877  number of requests and the total number of denials.
  878         b. Each managed care plan shall must publish any prescribed
  879  drug formulary or preferred drug list on the plan’s website in a
  880  manner that is accessible to and searchable by enrollees and
  881  providers. The plan must update the list within 24 hours after
  882  making a change. Each plan must ensure that the prior
  883  authorization process for prescribed drugs is readily accessible
  884  to health care providers, including posting appropriate contact
  885  information on its website and providing timely responses to
  886  providers.
  887         c.The managed care plan must continue to permit an
  888  enrollee who was receiving a prescription drug that was on the
  889  plan’s formulary and subsequently removed or changed to continue
  890  to receive that drug if requested by the enrollee and prescriber
  891  for as long as the enrollee is a member of the plan.
  892         d.A managed care plan that imposes a step-therapy or a
  893  fail-first protocol must do so in accordance with the following:
  894         (I)If prescribed drugs for the treatment of a medical
  895  condition are restricted for use by the plan through a step
  896  therapy or fail-first protocol, the plan must provide the
  897  prescriber with access to a clear and convenient process to
  898  expeditiously request an override of such restriction from the
  899  insurer.
  900         (II)An override of the restriction must be expeditiously
  901  granted by the plan if the prescriber can demonstrate to the
  902  plan that the preferred treatment required under the step
  903  therapy or fail-first protocol:
  904         (A) Has been ineffective in the treatment of the enrollee’s
  905  disease or medical condition;
  906         (B) Is reasonably expected to be ineffective based on the
  907  known relevant physical or mental characteristics and medical
  908  history of the enrollee and known characteristics of the drug
  909  regimen; or
  910         (C) Will cause or will likely cause an adverse reaction or
  911  other physical harm to the enrollee.
  912         (III)The maximum duration of a step-therapy or fail-first
  913  protocol requirement may not be longer than the customary period
  914  for the prescribed drug if such treatment is demonstrated by the
  915  prescriber to be clinically ineffective. If the plan can
  916  demonstrate, through sound clinical evidence, that the
  917  originally prescribed drug is likely to require more than the
  918  customary period for such drug to provide any relief or
  919  amelioration to the enrollee, the step-therapy or fail-first
  920  protocol may be extended, but no longer than the original
  921  customary period for the drug, after which time the prescriber
  922  may deem such treatment as clinically ineffective for the
  923  enrollee. Once the prescriber deems the treatment to be
  924  clinically ineffective, the plan must dispense and cover the
  925  originally prescribed drug recommended by the prescriber.
  926         e. For enrollees Medicaid recipients diagnosed with
  927  hemophilia who have been prescribed anti-hemophilic-factor
  928  replacement products, the agency shall provide for those
  929  products and hemophilia overlay services through the agency’s
  930  hemophilia disease management program.
  931         3.Prior authorization.—
  932         a. Each managed care plan must ensure that the prior
  933  authorization process for prescribed drugs is readily accessible
  934  to health care providers, including posting appropriate contact
  935  information on its website and providing timely responses to
  936  providers.
  937         b. If a drug, determined to be medically necessary and
  938  prescribed for an enrollee by a physician using sound clinical
  939  judgment, is subject to prior authorization, the managed care
  940  plan must provide payment to the pharmacist for dispensing such
  941  drug without seeking prior authorization if the pharmacist
  942  confirms that:
  943         (I)The prescription is a refill or renewal of the same
  944  drug for the same beneficiary written by the same prescriber; or
  945         (II)If the drug is generally prescribed for an indication
  946  that is treated on an ongoing basis by continuous medication or
  947  as-needed, the enrollee for whom the drug is prescribed has
  948  filled a prescription for the same drug within the preceding 30
  949  to 90 days.
  950         c.If a prescribed drug requires prior authorization, the
  951  managed care plan shall reimburse the pharmacist for dispensing
  952  a 72-hour supply to the enrollee and process the prior
  953  authorization request and send a response to the requesting
  954  pharmacist within 24 hours after receiving the pharmacist’s
  955  request for prior authorization.
  956         d.3. Managed care plans, and their fiscal agents or
  957  intermediaries, must accept prior authorization requests for any
  958  service electronically.
  959         Section 7. Subsection (11) is added to section 429.23,
  960  Florida Statutes, to read:
  961         429.23 Internal risk management and quality assurance
  962  program; adverse incidents and reporting requirements.—
  963         (11) The agency shall annually submit a report to the
  964  Legislature on adverse incident reports by assisted living
  965  facilities. The report must include the following information
  966  arranged by county:
  967         (a) A total number of adverse incidents;
  968         (b) A listing, by category, of the type of adverse
  969  incidents occurring within each category and the type of staff
  970  involved;
  971         (c) A listing, by category, of the types of injuries, if
  972  any, and the number of injuries occurring within each category;
  973         (d) Types of liability claims filed based on an adverse
  974  incident report or reportable injury; and
  975         (e) Disciplinary action taken against staff, categorized by
  976  the type of staff involved.
  977         Section 8. Present subsections (9), (10), and (11) of
  978  section 429.26, Florida Statutes, are renumbered as subsections
  979  (12), (13), and (14), respectively, and new subsections (9),
  980  (10), and (11) are added to that section, to read:
  981         429.26 Appropriateness of placements; examinations of
  982  residents.—
  983         (9) If, at any time after admission to a facility, agency
  984  personnel question whether a resident needs care beyond that
  985  which the facility is licensed to provide, the agency may
  986  require the resident to be physically examined by a licensed
  987  physician, licensed physician assistant, or certified nurse
  988  practitioner. To the extent possible, the examination must be
  989  performed by the resident’s preferred physician, physician
  990  assistant, or nurse practitioner and paid for by the resident
  991  with personal funds, except as provided in s. 429.18(2). This
  992  subsection does not preclude the agency from imposing sanctions
  993  for violations of subsection (1).
  994         (a) Following examination, the examining physician,
  995  physician assistant, or nurse practitioner shall complete and
  996  sign a medical form provided by the agency. The completed
  997  medical form must be submitted to the agency within 30 days
  998  after the date the facility owner or administrator was notified
  999  by the agency that a physical examination is required.
 1000         (b) A medical review team designated by the agency shall
 1001  determine whether the resident is appropriately residing in the
 1002  facility based on the completed medical form and, if necessary,
 1003  consultation with the physician, physician assistant, or nurse
 1004  practitioner who performed the examination. Members of the
 1005  medical review team making the determination may not include the
 1006  agency personnel who initially questioned the appropriateness of
 1007  the resident’s placement. The medical review team shall base its
 1008  decision on a comprehensive review of the resident’s physical
 1009  and functional status. A determination that the resident’s
 1010  placement is not appropriate is final and binding upon the
 1011  facility and the resident.
 1012         (c) A resident who is determined by the medical review team
 1013  to be inappropriately residing in a facility shall be given 30
 1014  days’ written notice to relocate by the owner or administrator,
 1015  unless the resident’s continued residence in the facility
 1016  presents an imminent danger to the health, safety, or welfare of
 1017  the resident or a substantial probability exists that death or
 1018  serious physical harm to the resident would result if the
 1019  resident is allowed to remain in the facility.
 1020         (10) If a mental health resident appears to have needs in
 1021  addition to those identified in the community living support
 1022  plan, the agency may require an evaluation by a mental health
 1023  professional, as determined by the Department of Children and
 1024  Family Services.
 1025         (11) A facility may not be required to retain a resident
 1026  who requires more services or care than the facility is able to
 1027  provide in accordance with its policies and criteria for
 1028  admission and continued residency.
 1029         Section 9. Effective July 1, 2012, section 456.0635,
 1030  Florida Statutes, is amended to read:
 1031         456.0635 Health care Medicaid fraud; disqualification for
 1032  license, certificate, or registration.—
 1033         (1) Health care Medicaid fraud in the practice of a health
 1034  care profession is prohibited.
 1035         (2) Each board under within the jurisdiction of the
 1036  department, or the department if there is no board, shall refuse
 1037  to admit a candidate to an any examination and refuse to issue
 1038  or renew a license, certificate, or registration to an any
 1039  applicant if the candidate or applicant or any principal,
 1040  officer, agent, managing employee, or affiliated person of the
 1041  applicant, has been:
 1042         (a) Has been convicted of, or entered a plea of guilty or
 1043  nolo contendere to, regardless of adjudication, a felony under
 1044  chapter 409, chapter 817, or chapter 893, or a similar felony
 1045  offense committed in another state or jurisdiction, unless the
 1046  candidate or applicant has successfully completed a pretrial
 1047  intervention or drug diversion program for that felony. Any such
 1048  conviction or plea excludes the applicant or candidate from
 1049  licensure, examination, certification, or registration 21 U.S.C.
 1050  ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and
 1051  any subsequent period of probation for such conviction or plea
 1052  pleas ended: more than 15 years prior to the date of the
 1053  application;
 1054         1. For felonies of the first or second degree, more than 15
 1055  years before the date of application.
 1056         2. For felonies of the third degree, more than 10 years
 1057  before the date of application, except for felonies of the third
 1058  degree under s. 893.13(6)(a).
 1059         3. For felonies of the third degree under s. 893.13(6)(a),
 1060  more than 5 years before the date of application.
 1061         (b) Has been convicted of, or entered a plea of guilty or
 1062  nolo contendere to, regardless of adjudication, a felony under
 1063  21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396, unless the
 1064  sentence and any subsequent period of probation for such
 1065  conviction or plea ended more than 15 years before the date of
 1066  the application.
 1067         (c)(b)Has been terminated for cause from the Florida
 1068  Medicaid program pursuant to s. 409.913, unless the candidate or
 1069  applicant has been in good standing with the Florida Medicaid
 1070  program for the most recent 5 years.;
 1071         (d)(c)Has been terminated for cause, pursuant to the
 1072  appeals procedures established by the state or Federal
 1073  Government, from any other state Medicaid program or the federal
 1074  Medicare program, unless the candidate or applicant has been in
 1075  good standing with that a state Medicaid program or the federal
 1076  Medicare program for the most recent 5 years and the termination
 1077  occurred at least 20 years before prior to the date of the
 1078  application.
 1079         (e) Is currently listed on the United States Department of
 1080  Health and Human Services Office of Inspector General’s List of
 1081  Excluded Individuals and Entities.
 1082  
 1083  This subsection does not apply to candidates or applicants for
 1084  initial licensure or certification who were enrolled in an
 1085  educational or training program on or before July 1, 2009, which
 1086  was recognized by a board or, if there is no board, recognized
 1087  by the department, and who applied for licensure after July 1,
 1088  2012.
 1089         (3) The department shall refuse to renew a license,
 1090  certificate, or registration of any applicant if the applicant
 1091  or any principal, officer, agent, managing employee, or
 1092  affiliated person of the applicant:
 1093         (a) Has been convicted of, or entered a plea of guilty or
 1094  nolo contendere to, regardless of adjudication, a felony under
 1095  chapter 409, chapter 817, or chapter 893, or a similar felony
 1096  offense committed in another state or jurisdiction since July 1,
 1097  2009, unless the applicant is currently enrolled in or has
 1098  successfully completed a pretrial intervention or drug diversion
 1099  program for that felony. Any such conviction or plea excludes
 1100  the applicant from renewal of licensure, certification, or
 1101  registration unless the sentence and any subsequent period of
 1102  probation for such conviction or plea ended:
 1103         1. For felonies of the first or second degree, more than 15
 1104  years before the date of application.
 1105         2. For felonies of the third degree, more than 10 years
 1106  before the date of application, except for felonies of the third
 1107  degree under s. 893.13(6)(a).
 1108         3. For felonies of the third degree under s. 893.13(6)(a),
 1109  more than 5 years before the date of application.
 1110         (b) Has been convicted of, or entered a plea of guilty or
 1111  nolo contendere to, regardless of adjudication, a felony under
 1112  21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 since July 1,
 1113  2009, unless the sentence and any subsequent period of probation
 1114  for such conviction or plea ended more than 15 years before the
 1115  date of the application.
 1116         (c) Has been terminated for cause from the Florida Medicaid
 1117  program pursuant to s. 409.913, unless the applicant has been in
 1118  good standing with the Florida Medicaid program for the most
 1119  recent 5 years.
 1120         (d) Has been terminated for cause, pursuant to the appeals
 1121  procedures established by the state, from any other state
 1122  Medicaid program, unless the applicant has been in good standing
 1123  with that state Medicaid program for the most recent 5 years and
 1124  the termination occurred at least 20 years before the date of
 1125  the application.
 1126         (e) Is currently listed on the United States Department of
 1127  Health and Human Services Office of Inspector General’s List of
 1128  Excluded Individuals and Entities.
 1129         (4)(3) Licensed health care practitioners shall report
 1130  allegations of health care Medicaid fraud to the department,
 1131  regardless of the practice setting in which the alleged health
 1132  care Medicaid fraud occurred.
 1133         (5)(4) The acceptance by a licensing authority of a
 1134  licensee’s candidate’s relinquishment of a license which is
 1135  offered in response to or anticipation of the filing of
 1136  administrative charges alleging health care Medicaid fraud or
 1137  similar charges constitutes the permanent revocation of the
 1138  license.
 1139         Section 10. Effective July 1, 2012, present subsections
 1140  (14) and (15) of section 456.036, Florida Statutes, are
 1141  renumbered as subsections (15) and (16), respectively, and a new
 1142  subsection (14) is added to that section, to read:
 1143         456.036 Licenses; active and inactive status; delinquency.—
 1144         (14) A person who has been denied license renewal,
 1145  certification, or registration under s. 456.0635(3) may regain
 1146  licensure, certification, or registration only by meeting the
 1147  qualifications and completing the application process for
 1148  initial licensure as defined by the board, or the department if
 1149  there is no board. However, a person who was denied renewal of
 1150  licensure, certification, or registration under s. 24 of chapter
 1151  2009-223, Laws of Florida, between July 1, 2009, and June 30,
 1152  2012, is not required to retake and pass examinations applicable
 1153  for initial licensure, certification, or registration.
 1154         Section 11. Subsection (1) of section 456.074, Florida
 1155  Statutes, is amended to read:
 1156         456.074 Certain health care practitioners; immediate
 1157  suspension of license.—
 1158         (1) The department shall issue an emergency order
 1159  suspending the license of any person licensed under chapter 458,
 1160  chapter 459, chapter 460, chapter 461, chapter 462, chapter 463,
 1161  chapter 464, chapter 465, chapter 466, or chapter 484 who pleads
 1162  guilty to, is convicted or found guilty of, or who enters a plea
 1163  of nolo contendere to, regardless of adjudication, to:
 1164         (a) A felony under chapter 409, chapter 817, or chapter 893
 1165  or under 21 U.S.C. ss. 801-970 or under 42 U.S.C. ss. 1395-1396;
 1166  or
 1167         (b) A misdemeanor or felony under 18 U.S.C. s. 669, ss.
 1168  285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s.
 1169  1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the
 1170  Medicaid program.
 1171         Section 12. The Agency for Health Care Administration shall
 1172  prepare a report within 18 months after the implementation of an
 1173  expansion of managed care to new populations or the provision of
 1174  new items and services. The agency shall post a draft of the
 1175  report on its website and provide an opportunity for public
 1176  comment. The final report shall be submitted to the Legislature,
 1177  along with a description of the process for public input. The
 1178  report must include an assessment of:
 1179         (1) The impact of managed care on patient access to care,
 1180  including an evaluation of any new barriers to the use of
 1181  services and prescription drugs, created by the use of medical
 1182  management or cost-containment tools.
 1183         (2) The impact of the increased managed care expansion on
 1184  the utilization of services, quality of care, and patient
 1185  outcomes.
 1186         (3) The use of prior authorization and other utilization
 1187  management tools, including an assessment of whether these tools
 1188  pose an undue administrative burden for health care providers or
 1189  create barriers to needed care.
 1190         Section 13. Except as otherwise expressly provided in this
 1191  act, this act shall take effect upon becoming a law.