Florida Senate - 2017                   (PROPOSED BILL) SPB 2514
       
       
        
       FOR CONSIDERATION By the Committee on Appropriations
       
       
       
       
       
       576-02557C-17                                         20172514pb
    1                        A bill to be entitled                      
    2         An act relating to health care; amending s. 210.20,
    3         F.S.; providing that a specified percentage of the
    4         cigarette tax, up to a specified amount, be paid
    5         annually to the Florida Consortium of National Cancer
    6         Institute Centers Program, rather than the Sanford
    7         Burnham Medical Research Institute; requiring that the
    8         funds be used to advance cures for cancers afflicting
    9         pediatric populations through basic or applied
   10         research; amending s. 381.922, F.S.; revising the
   11         goals of the William G. “Bill” Bankhead, Jr., and
   12         David Coley Cancer Research Program to include
   13         identifying ways to increase pediatric enrollment in
   14         cancer clinical trials; establishing the Live Like
   15         Bella Initiative to advance progress toward curing
   16         pediatric cancer, subject to an appropriation;
   17         amending s. 394.9082, F.S.; creating the Substance
   18         Abuse and Mental Health (SAMH) Safety Net Network;
   19         providing legislative intent; requiring the Department
   20         of Children and Families and the Agency for Health
   21         Care Administration to determine the scope of services
   22         to be offered through providers contracted with the
   23         SAMH Safety Net Network; authorizing the SAMH Safety
   24         Net Network to provide Medicaid reimbursable services
   25         beyond the limits of the state Medicaid plan under
   26         certain circumstances; providing that general revenue
   27         matching funds for the services shall be derived from
   28         the existing unmatched general revenue funds within
   29         the substance abuse and mental health program and
   30         documented through general revenue expenditure
   31         submissions by the department; requiring the agency,
   32         in consultation with the department, to seek federal
   33         authorization for administrative claiming pursuant to
   34         a specified federal program to fund certain
   35         interventions, case managers, and facility services;
   36         requiring the department, in collaboration with the
   37         agency, to document local funding of behavioral health
   38         services; requiring the agency to seek certain federal
   39         matching funds; amending s. 395.602, F.S.; revising
   40         the definition of the term “rural hospital” to include
   41         a hospital classified as a sole community hospital,
   42         regardless of the number of licensed beds; amending s.
   43         409.904, F.S.; authorizing the agency to make payments
   44         for medical assistance and related services on behalf
   45         of a person diagnosed with acquired immune deficiency
   46         syndrome who meets certain criteria, subject to the
   47         availability of moneys and specified limitations;
   48         amending s. 409.908, F.S.; revising requirements
   49         related to the long-term care reimbursement plan and
   50         cost reporting system; requiring the calculation of
   51         separate prices for each patient care subcomponent
   52         based on specified cost reports; providing that
   53         certain ceilings and targets apply only to providers
   54         being reimbursed on a cost-based system; expanding the
   55         direct care subcomponent to include allowable therapy
   56         and dietary costs; specifying that allowable ancillary
   57         costs are included in the indirect care cost
   58         subcomponent; requiring the agency to establish, by a
   59         specified date, a technical advisory council to assist
   60         in ongoing development and refining of quality
   61         measures used in the nursing home prospective payment
   62         system; providing for membership; requiring that
   63         nursing home prospective payment rates be rebased at a
   64         specified interval; authorizing the payment of a
   65         direct care supplemental payment to certain providers;
   66         specifying the amount providers will be reimbursed for
   67         a specified period of time, which may be a cost-based
   68         rate or a prospective payment rate; providing for
   69         expiration of this reimbursement mechanism on a
   70         specified date; requiring the agency to reimburse
   71         providers on a cost-based rate or a rebased
   72         prospective payment rate, beginning on a specified
   73         date; requiring that Medicaid pay deductibles and
   74         coinsurance for certain X-ray services provided in an
   75         assisted living facility or in the patient’s home;
   76         amending s. 409.909, F.S.; providing that the agency
   77         shall make payments and distribute funds to qualifying
   78         institutions in addition to hospitals under the
   79         Statewide Medicaid Residency Program; amending s.
   80         409.9082; revising the uses of quality assessment and
   81         federal matching funds to include the partial funding
   82         of the quality incentive payment program for nursing
   83         facilities that exceed quality benchmarks; amending s.
   84         409.911, F.S.; updating obsolete language; amending s.
   85         409.9119, F.S.; revising criteria for the
   86         participation of hospitals in the disproportionate
   87         share program for specialty hospitals for children;
   88         amending s. 409.913, F.S.; removing a requirement that
   89         the agency provide each Medicaid recipient with an
   90         explanation of benefits; authorizing the agency to
   91         provide an explanation of benefits to a sample of
   92         Medicaid recipients or their representatives; amending
   93         s. 409.975, F.S.; authorizing, rather than requiring,
   94         a managed care plan to offer a network contract to
   95         certain medical equipment and supplies providers in
   96         the region; requiring the agency to contract with the
   97         SAMH Safety Net Network; specifying that the contract
   98         must require managing entities to provide specified
   99         services to certain individuals; requiring the agency
  100         to conduct a comprehensive readiness assessment before
  101         contracting with the SAMH Safety Net Network;
  102         requiring the agency and the department to develop
  103         performance measures for the SAMH Safety Net Network;
  104         requiring the agency and the department to develop
  105         performance measures to evaluate the SAMH Safety Net
  106         Network and its services; requiring the agency, in
  107         consultation with the department and managing
  108         entities, to determine the rates for services added to
  109         the state Medicaid plan; amending s. 409.979, F.S.;
  110         expanding eligibility for long-term care services to
  111         include hospital level of care for certain individuals
  112         diagnosed with cystic fibrosis; revising eligibility
  113         for certain Medicaid recipients in the long-term care
  114         managed care program; requiring the agency to contract
  115         with an additional, not-for-profit organization that
  116         meets certain conditions and offers specified services
  117         to frail elders who reside in Miami-Dade County,
  118         subject to federal approval; exempting the
  119         organization from ch. 641, F.S., relating to health
  120         care service programs; requiring the agency, in
  121         consultation with the Department of Elderly Affairs,
  122         to approve a certain number of initial enrollees in
  123         the Program of All-inclusive Care for the Elderly
  124         (PACE); requiring the agency to contract with a
  125         specified not-for-profit organization, a not-for
  126         profit agency serving elders, and a not-for-profit
  127         hospice in Leon County to be a site for PACE, subject
  128         to federal approval; authorizing PACE to serve
  129         eligible enrollees in Gadsden, Jefferson, Leon, and
  130         Wakulla Counties; requiring the agency, in
  131         consultation with the department, to approve a certain
  132         number of initial enrollees in PACE at the new site,
  133         subject to an appropriation; amending s. 17 of chapter
  134         2011-61, Laws of Florida; requiring the agency, in
  135         consultation with the department, to approve a certain
  136         number of initial enrollees in PACE to serve frail
  137         elders who reside in certain counties; amending s. 9
  138         of chapter 2016-65, Laws of Florida; revising an
  139         effective date; revising the date that rates for
  140         hospital outpatient services must take effect;
  141         amending s. 29 of chapter 2016-65, Laws of Florida;
  142         requiring the agency, in consultation with the
  143         department, to approve a certain number of enrollees
  144         in the PACE established to serve frail elders who
  145         reside in Hospice Service Area 7; requiring the agency
  146         to contract with a not-for-profit organization that
  147         meets certain criteria to offer specified services to
  148         frail elders who reside in Alachua County, subject to
  149         federal approval; exempting the organization from ch.
  150         641, F.S., relating to health care service programs;
  151         requiring the agency, in consultation with the
  152         department, to approve a certain number of initial
  153         enrollees in PACE at the new site, subject to certain
  154         conditions; providing effective dates.
  155          
  156  Be It Enacted by the Legislature of the State of Florida:
  157  
  158         Section 1. Paragraph (c) of subsection (2) of section
  159  210.20, Florida Statutes, is amended to read:
  160         210.20 Employees and assistants; distribution of funds.—
  161         (2) As collections are received by the division from such
  162  cigarette taxes, it shall pay the same into a trust fund in the
  163  State Treasury designated “Cigarette Tax Collection Trust Fund”
  164  which shall be paid and distributed as follows:
  165         (c) Beginning July 1, 2017 2013, and continuing through
  166  June 30, 2033, the division shall from month to month certify to
  167  the Chief Financial Officer the amount derived from the
  168  cigarette tax imposed by s. 210.02, less the service charges
  169  provided for in s. 215.20 and less 0.9 percent of the amount
  170  derived from the cigarette tax imposed by s. 210.02, which shall
  171  be deposited into the Alcoholic Beverage and Tobacco Trust Fund,
  172  specifying an amount equal to 1 percent of the net collections,
  173  not to exceed $3 million annually, and that amount shall be
  174  deposited into the Biomedical Research Trust Fund in the
  175  Department of Health. These funds are appropriated annually in
  176  an amount not to exceed $3 million from the Biomedical Research
  177  Trust Fund and distributed pursuant to s. 381.915 for the
  178  advancement of cures for cancers afflicting pediatric
  179  populations through basic or applied research, including, but
  180  not limited to, clinical trials and nontoxic drug discovery
  181  Department of Health and the Sanford-Burnham Medical Research
  182  Institute to work in conjunction for the purpose of establishing
  183  activities and grant opportunities in relation to biomedical
  184  research.
  185         Section 2. Subsection (2) of section 381.922, Florida
  186  Statutes, is amended to read:
  187         381.922 William G. “Bill” Bankhead, Jr., and David Coley
  188  Cancer Research Program.—
  189         (2) The program shall provide grants for cancer research to
  190  further the search for cures for cancer.
  191         (a) Emphasis shall be given to the following goals, as
  192  those goals support the advancement of such cures:
  193         1. Efforts to significantly expand cancer research capacity
  194  in the state by:
  195         a. Identifying ways to attract new research talent and
  196  attendant national grant-producing researchers to cancer
  197  research facilities in this state;
  198         b. Implementing a peer-reviewed, competitive process to
  199  identify and fund the best proposals to expand cancer research
  200  institutes in this state;
  201         c. Funding through available resources for those proposals
  202  that demonstrate the greatest opportunity to attract federal
  203  research grants and private financial support;
  204         d. Encouraging the employment of bioinformatics in order to
  205  create a cancer informatics infrastructure that enhances
  206  information and resource exchange and integration through
  207  researchers working in diverse disciplines, to facilitate the
  208  full spectrum of cancer investigations;
  209         e. Facilitating the technical coordination, business
  210  development, and support of intellectual property as it relates
  211  to the advancement of cancer research; and
  212         f. Aiding in other multidisciplinary research-support
  213  activities as they inure to the advancement of cancer research.
  214         2. Efforts to improve both research and treatment through
  215  greater participation in clinical trials networks by:
  216         a. Identifying ways to increase pediatric and adult
  217  enrollment in cancer clinical trials;
  218         b. Supporting public and private professional education
  219  programs designed to increase the awareness and knowledge about
  220  cancer clinical trials;
  221         c. Providing tools to cancer patients and community-based
  222  oncologists to aid in the identification of cancer clinical
  223  trials available in the state; and
  224         d. Creating opportunities for the state’s academic cancer
  225  centers to collaborate with community-based oncologists in
  226  cancer clinical trials networks.
  227         3. Efforts to reduce the impact of cancer on disparate
  228  groups by:
  229         a. Identifying those cancers that disproportionately impact
  230  certain demographic groups; and
  231         b. Building collaborations designed to reduce health
  232  disparities as they relate to cancer.
  233         (b) Preference may be given to grant proposals that foster
  234  collaborations among institutions, researchers, and community
  235  practitioners, as such proposals support the advancement of
  236  cures through basic or applied research, including clinical
  237  trials involving cancer patients and related networks.
  238         (c) There is established within the program the Live Like
  239  Bella Initiative. The purpose of the initiative is to advance
  240  progress toward curing pediatric cancer by awarding grants
  241  through the peer-reviewed, competitive process established under
  242  subsection (3). This paragraph is subject to the annual
  243  appropriation of funds by the Legislature.
  244         Section 3. Subsection (11) is added to section 394.9082,
  245  Florida Statutes, to read:
  246         394.9082 Behavioral health managing entities.—
  247         (11)SUBSTANCE ABUSE AND MENTAL HEALTH (SAMH) SAFETY NET
  248  NETWORK.—
  249         (a)It is the intent of the Legislature to create the
  250  Substance Abuse and Mental Health (SAMH) Safety Net Network to
  251  support and enhance the community mental health and substance
  252  abuse services currently provided by managing entities. The SAMH
  253  Safety Net Network as used in this section means the managing
  254  entities and their contracted network of providers. Contracted
  255  providers are considered vendors and not subrecipients, as
  256  defined in s. 215.97. Managing entities and their contracted
  257  providers are not public employees for purposes of chapter 112.
  258         (b) The department and the agency shall establish the SAMH
  259  Safety Net Network by adding specific behavioral health services
  260  currently provided by managing entities to the state Medicaid
  261  plan and adjusting the amount of units of services for specific
  262  Medicaid services to better serve Medicaid-eligible individuals
  263  with severe and persistent mental health or substance use
  264  disorders, and their families, who are currently served by
  265  managing entities. It is the intent of the Legislature to have
  266  the department submit documentation of general revenue
  267  expenditures to the agency for the state match for the services
  268  and for the agency to pay managing entities the federal Medicaid
  269  portion for services provided.
  270         1. Behavioral health services currently funded by managing
  271  entities through the substance abuse and mental health program
  272  shall be added by the agency to the state Medicaid plan through
  273  a state plan amendment. These services shall be provided
  274  exclusively through the providers contracted with the SAMH
  275  Safety Net Network. The department and the agency shall
  276  determine which services are essential for individuals served by
  277  managing entities through coordinated systems of care and which
  278  services will most efficiently use state and federal resources.
  279         2. The state Medicaid plan currently limits the amount of
  280  behavioral health services that may be provided to a covered
  281  individual. However, the SAMH Safety Net Network is authorized
  282  to provide Medicaid reimbursable services beyond these limits
  283  when providing services, including, but not limited to,
  284  assessment, group therapy, individual therapy, psychosocial
  285  rehabilitation, day treatment, medication management,
  286  therapeutic onsite services, substance abuse inpatient or
  287  residential detoxification, inpatient hospital services, and
  288  crisis stabilization unit or as appropriate in lieu of services.
  289         (c) The required general revenue matching funds for the
  290  services shall be derived from the existing unmatched general
  291  revenue funds within the substance abuse and mental health
  292  program and documented through general revenue expenditure
  293  submissions by the department. The Medicaid reimbursement for
  294  services provided by the SAMH Safety Net Network shall be
  295  limited to the availability of general revenue matching funds
  296  within the substance abuse and mental health program for such
  297  purpose.
  298         (d) Except as otherwise provided in this part, the state
  299  share of funds sufficient to implement the provisions of this
  300  act shall be redirected from existing general revenue funds in
  301  the department which are used for funding mental health and
  302  substance abuse services, excluding funding for residential
  303  services. The need for these state-only funds must be offset by
  304  the infusion of federal funds made available to the SAMH Safety
  305  Net Network under the provisions of this act.
  306         Section 4. The Agency for Health Care Administration, in
  307  consultation with the Department of Children and Families, shall
  308  seek federal authorization for administrative claiming pursuant
  309  to the Medicaid Administrative Claiming program to fund:
  310         (1)The department’s team-based interventions, including,
  311  but not limited to, community action treatment teams and family
  312  intervention treatment teams, which focus on the entire family
  313  to prevent out-of-home placements in the child welfare,
  314  behavioral health, and criminal justice systems.
  315         (2)Case managers employed by the department’s child
  316  welfare community-based care lead agency who are responsible for
  317  locating, coordinating, and monitoring necessary and appropriate
  318  services extending beyond direct services for Medicaid-eligible
  319  children, including, but not limited to, outreach, referral,
  320  eligibility determination, and case management.
  321         (3)Central receiving facility services for individuals
  322  with mental health or substance use disorders.
  323         Section 5. The Department of Children and Families, in
  324  collaboration with the Agency for Health Care Administration,
  325  shall document the extent to which behavioral health services
  326  are funded with contributions from units of local government.
  327  The agency shall seek federal authority to have these funds
  328  qualify for federal matching funds as certified public
  329  expenditures.
  330         Section 6. Paragraph (e) of subsection (2) of section
  331  395.602, Florida Statutes, is amended to read:
  332         395.602 Rural hospitals.—
  333         (2) DEFINITIONS.—As used in this part, the term:
  334         (e) “Rural hospital” means an acute care hospital licensed
  335  under this chapter, having 100 or fewer licensed beds and an
  336  emergency room, which is:
  337         1. The sole provider within a county with a population
  338  density of up to 100 persons per square mile;
  339         2. An acute care hospital, in a county with a population
  340  density of up to 100 persons per square mile, which is at least
  341  30 minutes of travel time, on normally traveled roads under
  342  normal traffic conditions, from any other acute care hospital
  343  within the same county;
  344         3. A hospital supported by a tax district or subdistrict
  345  whose boundaries encompass a population of up to 100 persons per
  346  square mile;
  347         4. A hospital classified as a sole community hospital under
  348  42 C.F.R. s. 412.92, regardless of the number of which has up to
  349  175 licensed beds;
  350         5. A hospital with a service area that has a population of
  351  up to 100 persons per square mile. As used in this subparagraph,
  352  the term “service area” means the fewest number of zip codes
  353  that account for 75 percent of the hospital’s discharges for the
  354  most recent 5-year period, based on information available from
  355  the hospital inpatient discharge database in the Florida Center
  356  for Health Information and Transparency at the agency; or
  357         6. A hospital designated as a critical access hospital, as
  358  defined in s. 408.07.
  359  
  360  Population densities used in this paragraph must be based upon
  361  the most recently completed United States census. A hospital
  362  that received funds under s. 409.9116 for a quarter beginning no
  363  later than July 1, 2002, is deemed to have been and shall
  364  continue to be a rural hospital from that date through June 30,
  365  2021, if the hospital continues to have up to 100 licensed beds
  366  and an emergency room. An acute care hospital that has not
  367  previously been designated as a rural hospital and that meets
  368  the criteria of this paragraph shall be granted such designation
  369  upon application, including supporting documentation, to the
  370  agency. A hospital that was licensed as a rural hospital during
  371  the 2010-2011 or 2011-2012 fiscal year shall continue to be a
  372  rural hospital from the date of designation through June 30,
  373  2021, if the hospital continues to have up to 100 licensed beds
  374  and an emergency room.
  375         Section 7. Subsection (11) is added to section 409.904,
  376  Florida Statutes, to read:
  377         409.904 Optional payments for eligible persons.—The agency
  378  may make payments for medical assistance and related services on
  379  behalf of the following persons who are determined to be
  380  eligible subject to the income, assets, and categorical
  381  eligibility tests set forth in federal and state law. Payment on
  382  behalf of these Medicaid eligible persons is subject to the
  383  availability of moneys and any limitations established by the
  384  General Appropriations Act or chapter 216.
  385         (11) Subject to federal waiver approval, a person diagnosed
  386  with acquired immune deficiency syndrome (AIDS) who has an AIDS
  387  related opportunistic infection and is at risk of
  388  hospitalization as determined by the agency and whose income is
  389  at or below 300 percent of the Federal Benefit Rate.
  390         Section 8. Subsections (2) and (14) of section 409.908,
  391  Florida Statutes, are amended to read:
  392         409.908 Reimbursement of Medicaid providers.—Subject to
  393  specific appropriations, the agency shall reimburse Medicaid
  394  providers, in accordance with state and federal law, according
  395  to methodologies set forth in the rules of the agency and in
  396  policy manuals and handbooks incorporated by reference therein.
  397  These methodologies may include fee schedules, reimbursement
  398  methods based on cost reporting, negotiated fees, competitive
  399  bidding pursuant to s. 287.057, and other mechanisms the agency
  400  considers efficient and effective for purchasing services or
  401  goods on behalf of recipients. If a provider is reimbursed based
  402  on cost reporting and submits a cost report late and that cost
  403  report would have been used to set a lower reimbursement rate
  404  for a rate semester, then the provider’s rate for that semester
  405  shall be retroactively calculated using the new cost report, and
  406  full payment at the recalculated rate shall be effected
  407  retroactively. Medicare-granted extensions for filing cost
  408  reports, if applicable, shall also apply to Medicaid cost
  409  reports. Payment for Medicaid compensable services made on
  410  behalf of Medicaid eligible persons is subject to the
  411  availability of moneys and any limitations or directions
  412  provided for in the General Appropriations Act or chapter 216.
  413  Further, nothing in this section shall be construed to prevent
  414  or limit the agency from adjusting fees, reimbursement rates,
  415  lengths of stay, number of visits, or number of services, or
  416  making any other adjustments necessary to comply with the
  417  availability of moneys and any limitations or directions
  418  provided for in the General Appropriations Act, provided the
  419  adjustment is consistent with legislative intent.
  420         (2)(a)1. Reimbursement to nursing homes licensed under part
  421  II of chapter 400 and state-owned-and-operated intermediate care
  422  facilities for the developmentally disabled licensed under part
  423  VIII of chapter 400 must be made prospectively.
  424         2. Unless otherwise limited or directed in the General
  425  Appropriations Act, reimbursement to hospitals licensed under
  426  part I of chapter 395 for the provision of swing-bed nursing
  427  home services must be made on the basis of the average statewide
  428  nursing home payment, and reimbursement to a hospital licensed
  429  under part I of chapter 395 for the provision of skilled nursing
  430  services must be made on the basis of the average nursing home
  431  payment for those services in the county in which the hospital
  432  is located. When a hospital is located in a county that does not
  433  have any community nursing homes, reimbursement shall be
  434  determined by averaging the nursing home payments in counties
  435  that surround the county in which the hospital is located.
  436  Reimbursement to hospitals, including Medicaid payment of
  437  Medicare copayments, for skilled nursing services shall be
  438  limited to 30 days, unless a prior authorization has been
  439  obtained from the agency. Medicaid reimbursement may be extended
  440  by the agency beyond 30 days, and approval must be based upon
  441  verification by the patient’s physician that the patient
  442  requires short-term rehabilitative and recuperative services
  443  only, in which case an extension of no more than 15 days may be
  444  approved. Reimbursement to a hospital licensed under part I of
  445  chapter 395 for the temporary provision of skilled nursing
  446  services to nursing home residents who have been displaced as
  447  the result of a natural disaster or other emergency may not
  448  exceed the average county nursing home payment for those
  449  services in the county in which the hospital is located and is
  450  limited to the period of time which the agency considers
  451  necessary for continued placement of the nursing home residents
  452  in the hospital.
  453         (b) Subject to any limitations or directions in the General
  454  Appropriations Act, the agency shall establish and implement a
  455  state Title XIX Long-Term Care Reimbursement Plan for nursing
  456  home care in order to provide care and services in conformance
  457  with the applicable state and federal laws, rules, regulations,
  458  and quality and safety standards and to ensure that individuals
  459  eligible for medical assistance have reasonable geographic
  460  access to such care.
  461         1. The agency shall amend the long-term care reimbursement
  462  plan and cost reporting system to create direct care and
  463  indirect care subcomponents of the patient care component of the
  464  per diem rate. These two subcomponents together shall equal the
  465  patient care component of the per diem rate. Separate prices
  466  cost-based ceilings shall be calculated for each patient care
  467  subcomponent, initially based on the September 2016 rate setting
  468  cost reports and subsequently based on the most recently audited
  469  cost report used during a rebasing year. The direct care
  470  subcomponent of the per diem rate for any providers still being
  471  reimbursed on a cost basis shall be limited by the cost-based
  472  class ceiling, and the indirect care subcomponent may be limited
  473  by the lower of the cost-based class ceiling, the target rate
  474  class ceiling, or the individual provider target. The ceilings
  475  and targets apply only to providers being reimbursed on a cost
  476  based system.
  477         2. The direct care subcomponent shall include salaries and
  478  benefits of direct care staff providing nursing services
  479  including registered nurses, licensed practical nurses, and
  480  certified nursing assistants who deliver care directly to
  481  residents in the nursing home facility, allowable therapy costs,
  482  and dietary costs. This excludes nursing administration, staff
  483  development, the staffing coordinator, and the administrative
  484  portion of the minimum data set and care plan coordinators. The
  485  direct care subcomponent also includes medically necessary
  486  dental care, vision care, hearing care, and podiatric care.
  487         3. All other patient care costs shall be included in the
  488  indirect care cost subcomponent of the patient care per diem
  489  rate, including complex medical equipment, medical supplies, and
  490  other allowable ancillary costs. Costs may not be allocated
  491  directly or indirectly to the direct care subcomponent from a
  492  home office or management company.
  493         4. On July 1 of each year, the agency shall report to the
  494  Legislature direct and indirect care costs, including average
  495  direct and indirect care costs per resident per facility and
  496  direct care and indirect care salaries and benefits per category
  497  of staff member per facility.
  498         5. Before December 31, 2017, the agency must establish a
  499  technical advisory council to assist in ongoing development and
  500  refining of the quality measures used in the nursing home
  501  prospective payment system. The advisory council must include,
  502  but need not be limited to, representatives of nursing home
  503  providers and other interested stakeholders. In order to offset
  504  the cost of general and professional liability insurance, the
  505  agency shall amend the plan to allow for interim rate
  506  adjustments to reflect increases in the cost of general or
  507  professional liability insurance for nursing homes. This
  508  provision shall be implemented to the extent existing
  509  appropriations are available.
  510         6. Every fourth year, the agency shall rebase nursing home
  511  prospective payment rates to reflect changes in cost based on
  512  the most recently audited cost report for each participating
  513  provider.
  514         7. A direct care supplemental payment may be made to
  515  providers whose direct care hours per patient day are above the
  516  80th percentile and who provide Medicaid services to a larger
  517  percentage of Medicaid patients than the state average.
  518         8. For the period beginning on October 1, 2017, and ending
  519  on September 30, 2020, the agency shall reimburse providers the
  520  greater of their September 2016 cost-based rate or their
  521  prospective payment rate. Effective October 1, 2020, the agency
  522  shall reimburse providers the greater of 95 percent of their
  523  cost-based rate or their rebased prospective payment rate, using
  524  the most recently audited cost report for each facility. This
  525  subsection shall expire September 30, 2022.
  526         9. Pediatric, Florida Department of Veterans Affairs, and
  527  government-owned facilities are exempt from the pricing model
  528  established in this subsection and shall remain on a cost-based
  529  prospective payment system. Effective October 1, 2018, the
  530  agency shall set rates for all facilities remaining on a cost
  531  based prospective payment system using each facility’s most
  532  recently audited cost report, eliminating retroactive
  533  settlements.
  534  
  535  It is the intent of the Legislature that the reimbursement plan
  536  achieve the goal of providing access to health care for nursing
  537  home residents who require large amounts of care while
  538  encouraging diversion services as an alternative to nursing home
  539  care for residents who can be served within the community. The
  540  agency shall base the establishment of any maximum rate of
  541  payment, whether overall or component, on the available moneys
  542  as provided for in the General Appropriations Act. The agency
  543  may base the maximum rate of payment on the results of
  544  scientifically valid analysis and conclusions derived from
  545  objective statistical data pertinent to the particular maximum
  546  rate of payment.
  547         (14) Medicare premiums for persons eligible for both
  548  Medicare and Medicaid coverage shall be paid at the rates
  549  established by Title XVIII of the Social Security Act. For
  550  Medicare services rendered to Medicaid-eligible persons,
  551  Medicaid shall pay Medicare deductibles and coinsurance as
  552  follows:
  553         (a) Medicaid’s financial obligation for deductibles and
  554  coinsurance payments shall be based on Medicare allowable fees,
  555  not on a provider’s billed charges.
  556         (b) Medicaid will pay no portion of Medicare deductibles
  557  and coinsurance when payment that Medicare has made for the
  558  service equals or exceeds what Medicaid would have paid if it
  559  had been the sole payor. The combined payment of Medicare and
  560  Medicaid shall not exceed the amount Medicaid would have paid
  561  had it been the sole payor. The Legislature finds that there has
  562  been confusion regarding the reimbursement for services rendered
  563  to dually eligible Medicare beneficiaries. Accordingly, the
  564  Legislature clarifies that it has always been the intent of the
  565  Legislature before and after 1991 that, in reimbursing in
  566  accordance with fees established by Title XVIII for premiums,
  567  deductibles, and coinsurance for Medicare services rendered by
  568  physicians to Medicaid eligible persons, physicians be
  569  reimbursed at the lesser of the amount billed by the physician
  570  or the Medicaid maximum allowable fee established by the Agency
  571  for Health Care Administration, as is permitted by federal law.
  572  It has never been the intent of the Legislature with regard to
  573  such services rendered by physicians that Medicaid be required
  574  to provide any payment for deductibles, coinsurance, or
  575  copayments for Medicare cost sharing, or any expenses incurred
  576  relating thereto, in excess of the payment amount provided for
  577  under the State Medicaid plan for such service. This payment
  578  methodology is applicable even in those situations in which the
  579  payment for Medicare cost sharing for a qualified Medicare
  580  beneficiary with respect to an item or service is reduced or
  581  eliminated. This expression of the Legislature is in
  582  clarification of existing law and shall apply to payment for,
  583  and with respect to provider agreements with respect to, items
  584  or services furnished on or after the effective date of this
  585  act. This paragraph applies to payment by Medicaid for items and
  586  services furnished before the effective date of this act if such
  587  payment is the subject of a lawsuit that is based on the
  588  provisions of this section, and that is pending as of, or is
  589  initiated after, the effective date of this act.
  590         (c) Notwithstanding paragraphs (a) and (b):
  591         1. Medicaid payments for Nursing Home Medicare part A
  592  coinsurance are limited to the Medicaid nursing home per diem
  593  rate less any amounts paid by Medicare, but only up to the
  594  amount of Medicare coinsurance. The Medicaid per diem rate shall
  595  be the rate in effect for the dates of service of the crossover
  596  claims and may not be subsequently adjusted due to subsequent
  597  per diem rate adjustments.
  598         2. Medicaid shall pay all deductibles and coinsurance for
  599  Medicare-eligible recipients receiving freestanding end stage
  600  renal dialysis center services.
  601         3. Medicaid payments for general and specialty hospital
  602  inpatient services are limited to the Medicare deductible and
  603  coinsurance per spell of illness. Medicaid payments for hospital
  604  Medicare Part A coinsurance shall be limited to the Medicaid
  605  hospital per diem rate less any amounts paid by Medicare, but
  606  only up to the amount of Medicare coinsurance. Medicaid payments
  607  for coinsurance shall be limited to the Medicaid per diem rate
  608  in effect for the dates of service of the crossover claims and
  609  may not be subsequently adjusted due to subsequent per diem
  610  adjustments.
  611         4. Medicaid shall pay all deductibles and coinsurance for
  612  Medicare emergency transportation services provided by
  613  ambulances licensed pursuant to chapter 401.
  614         5. Medicaid shall pay all deductibles and coinsurance for
  615  portable X-ray Medicare Part B services provided in a nursing
  616  home, in an assisted living facility, or in the patient’s home.
  617         Section 9. Subsection (4) of section 409.9082, Florida
  618  Statutes, is amended to read:
  619         409.9082 Quality assessment on nursing home facility
  620  providers; exemptions; purpose; federal approval required;
  621  remedies.—
  622         (4) The purpose of the nursing home facility quality
  623  assessment is to ensure continued quality of care. Collected
  624  assessment funds shall be used to obtain federal financial
  625  participation through the Medicaid program to make Medicaid
  626  payments for nursing home facility services up to the amount of
  627  nursing home facility Medicaid rates as calculated in accordance
  628  with the approved state Medicaid plan in effect on December 31,
  629  2007. The quality assessment and federal matching funds shall be
  630  used exclusively for the following purposes and in the following
  631  order of priority:
  632         (a) To reimburse the Medicaid share of the quality
  633  assessment as a pass-through, Medicaid-allowable cost;
  634         (b) To increase to each nursing home facility’s Medicaid
  635  rate, as needed, an amount that restores rate reductions
  636  effective on or after January 1, 2008, as provided in the
  637  General Appropriations Act; and
  638         (c) To partially fund the quality incentive payment program
  639  for nursing facilities that exceed quality benchmarks increase
  640  each nursing home facility’s Medicaid rate that accounts for the
  641  portion of the total assessment not included in paragraphs (a)
  642  and (b) which begins a phase-in to a pricing model for the
  643  operating cost component.
  644         Section 10. Section 409.909, Florida Statutes, is amended
  645  to read:
  646         409.909 Statewide Medicaid Residency Program.—
  647         (1) The Statewide Medicaid Residency Program is established
  648  to improve the quality of care and access to care for Medicaid
  649  recipients, expand graduate medical education on an equitable
  650  basis, and increase the supply of highly trained physicians
  651  statewide. The agency shall make payments to hospitals licensed
  652  under part I of chapter 395 and to qualifying institutions as
  653  defined in paragraph (2)(c) for graduate medical education
  654  associated with the Medicaid program. This system of payments is
  655  designed to generate federal matching funds under Medicaid and
  656  distribute the resulting funds to participating hospitals on a
  657  quarterly basis in each fiscal year for which an appropriation
  658  is made.
  659         (2) On or before September 15 of each year, the agency
  660  shall calculate an allocation fraction to be used for
  661  distributing funds to participating hospitals and to qualifying
  662  institutions as defined in paragraph (2)(c). On or before the
  663  final business day of each quarter of a state fiscal year, the
  664  agency shall distribute to each participating hospital one
  665  fourth of that hospital’s annual allocation calculated under
  666  subsection (4). The allocation fraction for each participating
  667  hospital is based on the hospital’s number of full-time
  668  equivalent residents and the amount of its Medicaid payments. As
  669  used in this section, the term:
  670         (a) “Full-time equivalent,” or “FTE,” means a resident who
  671  is in his or her residency period, with the initial residency
  672  period defined as the minimum number of years of training
  673  required before the resident may become eligible for board
  674  certification by the American Osteopathic Association Bureau of
  675  Osteopathic Specialists or the American Board of Medical
  676  Specialties in the specialty in which he or she first began
  677  training, not to exceed 5 years. The residency specialty is
  678  defined as reported using the current residency type codes in
  679  the Intern and Resident Information System (IRIS), required by
  680  Medicare. A resident training beyond the initial residency
  681  period is counted as 0.5 FTE, unless his or her chosen specialty
  682  is in primary care, in which case the resident is counted as 1.0
  683  FTE. For the purposes of this section, primary care specialties
  684  include:
  685         1. Family medicine;
  686         2. General internal medicine;
  687         3. General pediatrics;
  688         4. Preventive medicine;
  689         5. Geriatric medicine;
  690         6. Osteopathic general practice;
  691         7. Obstetrics and gynecology;
  692         8. Emergency medicine;
  693         9. General surgery; and
  694         10. Psychiatry.
  695         (b) “Medicaid payments” means the estimated total payments
  696  for reimbursing a hospital for direct inpatient services for the
  697  fiscal year in which the allocation fraction is calculated based
  698  on the hospital inpatient appropriation and the parameters for
  699  the inpatient diagnosis-related group base rate, including
  700  applicable intergovernmental transfers, specified in the General
  701  Appropriations Act, as determined by the agency. Effective July
  702  1, 2017, the term “Medicaid payments” means the estimated total
  703  payments for reimbursing a hospital and qualifying institutions
  704  as defined in paragraph (2)(c) for direct inpatient and
  705  outpatient services for the fiscal year in which the allocation
  706  fraction is calculated based on the hospital inpatient
  707  appropriation and outpatient appropriation and the parameters
  708  for the inpatient diagnosis-related group base rate, including
  709  applicable intergovernmental transfers, specified in the General
  710  Appropriations Act, as determined by the agency.
  711         (c) “Qualifying institution” means a federally Qualified
  712  Health Center holding an Accreditation Council for Graduate
  713  Medical Education institutional accreditation.
  714         (d) “Resident” means a medical intern, fellow, or resident
  715  enrolled in a program accredited by the Accreditation Council
  716  for Graduate Medical Education, the American Association of
  717  Colleges of Osteopathic Medicine, or the American Osteopathic
  718  Association at the beginning of the state fiscal year during
  719  which the allocation fraction is calculated, as reported by the
  720  hospital to the agency.
  721         (3) The agency shall use the following formula to calculate
  722  a participating hospital’s and qualifying institution’s
  723  allocation fraction:
  724  
  725             HAF=[0.9 x (HFTE/TFTE)] + [0.1 x (HMP/TMP)]           
  726  
  727         Where:
  728         HAF=A hospital’s and qualifying institution’s allocation
  729  fraction.
  730         HFTE=A hospital’s and qualifying institution’s total number
  731  of FTE residents.
  732         TFTE=The total FTE residents for all participating
  733  hospitals and qualifying institutions.
  734         HMP=A hospital’s and qualifying institution’s Medicaid
  735  payments.
  736         TMP=The total Medicaid payments for all participating
  737  hospitals and qualifying institutions.
  738  
  739         (4) A hospital’s and qualifying institution’s annual
  740  allocation shall be calculated by multiplying the funds
  741  appropriated for the Statewide Medicaid Residency Program in the
  742  General Appropriations Act by that hospital’s and qualifying
  743  institution’s allocation fraction. If the calculation results in
  744  an annual allocation that exceeds two times the average per FTE
  745  resident amount for all hospitals and qualifying institutions,
  746  the hospital’s and qualifying institution’s annual allocation
  747  shall be reduced to a sum equaling no more than two times the
  748  average per FTE resident. The funds calculated for that hospital
  749  and qualifying institution in excess of two times the average
  750  per FTE resident amount for all hospitals and qualifying
  751  institutions shall be redistributed to participating hospitals
  752  and qualifying institutions whose annual allocation does not
  753  exceed two times the average per FTE resident amount for all
  754  hospitals and qualifying institutions, using the same
  755  methodology and payment schedule specified in this section.
  756         (5) The Graduate Medical Education Startup Bonus Program is
  757  established to provide resources for the education and training
  758  of physicians in specialties which are in a statewide supply
  759  and-demand deficit. Hospitals and qualifying institutions as
  760  defined in paragraph (2)(c) eligible for participation in
  761  subsection (1) are eligible to participate in the Graduate
  762  Medical Education Startup Bonus Program established under this
  763  subsection. Notwithstanding subsection (4) or an FTE’s residency
  764  period, and in any state fiscal year in which funds are
  765  appropriated for the startup bonus program, the agency shall
  766  allocate a $100,000 startup bonus for each newly created
  767  resident position that is authorized by the Accreditation
  768  Council for Graduate Medical Education or Osteopathic
  769  Postdoctoral Training Institution in an initial or established
  770  accredited training program that is in a physician specialty in
  771  statewide supply-and-demand deficit. In any year in which
  772  funding is not sufficient to provide $100,000 for each newly
  773  created resident position, funding shall be reduced pro rata
  774  across all newly created resident positions in physician
  775  specialties in statewide supply-and-demand deficit.
  776         (a) Hospitals and qualifying institutions as defined in
  777  paragraph (2)(c) applying for a startup bonus must submit to the
  778  agency by March 1 their Accreditation Council for Graduate
  779  Medical Education or Osteopathic Postdoctoral Training
  780  Institution approval validating the new resident positions
  781  approved on or after March 2 of the prior fiscal year through
  782  March 1 of the current fiscal year for the physician specialties
  783  identified in a statewide supply-and-demand deficit as provided
  784  in the current fiscal year’s General Appropriations Act. An
  785  applicant hospital or qualifying institution as defined in
  786  paragraph (2)(c) may validate a change in the number of
  787  residents by comparing the number in the prior period
  788  Accreditation Council for Graduate Medical Education or
  789  Osteopathic Postdoctoral Training Institution approval to the
  790  number in the current year.
  791         (b) Any unobligated startup bonus funds on April 15 of each
  792  fiscal year shall be proportionally allocated to hospitals and
  793  to qualifying institutions as defined in paragraph (2)(c)
  794  participating under subsection (3) for existing FTE residents in
  795  the physician specialties in statewide supply-and-demand
  796  deficit. This nonrecurring allocation shall be in addition to
  797  the funds allocated in subsection (4). Notwithstanding
  798  subsection (4), the allocation under this subsection may not
  799  exceed $100,000 per FTE resident.
  800         (c) For purposes of this subsection, physician specialties
  801  and subspecialties, both adult and pediatric, in statewide
  802  supply-and-demand deficit are those identified in the General
  803  Appropriations Act.
  804         (d) The agency shall distribute all funds authorized under
  805  the Graduate Medical Education Startup Bonus Program on or
  806  before the final business day of the fourth quarter of a state
  807  fiscal year.
  808         (6) Beginning in the 2015-2016 state fiscal year, the
  809  agency shall reconcile each participating hospital’s total
  810  number of FTE residents calculated for the state fiscal year 2
  811  years before with its most recently available Medicare cost
  812  reports covering the same time period. Reconciled FTE counts
  813  shall be prorated according to the portion of the state fiscal
  814  year covered by a Medicare cost report. Using the same
  815  definitions, methodology, and payment schedule specified in this
  816  section, the reconciliation shall apply any differences in
  817  annual allocations calculated under subsection (4) to the
  818  current year’s annual allocations.
  819         (7) The agency may adopt rules to administer this section.
  820         Section 11. Paragraph (a) of subsection (2) of section
  821  409.911, Florida Statutes, is amended, and paragraph (b) of that
  822  subsection is republished, to read:
  823         409.911 Disproportionate share program.—Subject to specific
  824  allocations established within the General Appropriations Act
  825  and any limitations established pursuant to chapter 216, the
  826  agency shall distribute, pursuant to this section, moneys to
  827  hospitals providing a disproportionate share of Medicaid or
  828  charity care services by making quarterly Medicaid payments as
  829  required. Notwithstanding the provisions of s. 409.915, counties
  830  are exempt from contributing toward the cost of this special
  831  reimbursement for hospitals serving a disproportionate share of
  832  low-income patients.
  833         (2) The Agency for Health Care Administration shall use the
  834  following actual audited data to determine the Medicaid days and
  835  charity care to be used in calculating the disproportionate
  836  share payment:
  837         (a) The average of the 2009, 2010, and 2011 2007, 2008, and
  838  2009 audited disproportionate share data to determine each
  839  hospital’s Medicaid days and charity care for the 2017-2018
  840  2015-2016 state fiscal year.
  841         (b) If the Agency for Health Care Administration does not
  842  have the prescribed 3 years of audited disproportionate share
  843  data as noted in paragraph (a) for a hospital, the agency shall
  844  use the average of the years of the audited disproportionate
  845  share data as noted in paragraph (a) which is available.
  846         Section 12. Section 409.9119, Florida Statutes, is amended
  847  to read:
  848         409.9119 Disproportionate share program for specialty
  849  hospitals for children.—In addition to the payments made under
  850  s. 409.911, the Agency for Health Care Administration shall
  851  develop and implement a system under which disproportionate
  852  share payments are made to those hospitals that are separately
  853  licensed by the state as specialty hospitals for children, have
  854  a federal Centers for Medicare and Medicaid Services
  855  certification number in the 3300-3399 range, have Medicaid days
  856  that exceed 55 percent of their total days and Medicare days
  857  that are less than 5 percent of their total days, and were
  858  licensed on January 1, 2012 January 1, 2000, as specialty
  859  hospitals for children. This system of payments must conform to
  860  federal requirements and must distribute funds in each fiscal
  861  year for which an appropriation is made by making quarterly
  862  Medicaid payments. Notwithstanding s. 409.915, counties are
  863  exempt from contributing toward the cost of this special
  864  reimbursement for hospitals that serve a disproportionate share
  865  of low-income patients. The agency may make disproportionate
  866  share payments to specialty hospitals for children as provided
  867  for in the General Appropriations Act.
  868         (1) Unless specified in the General Appropriations Act, the
  869  agency shall use the following formula to calculate the total
  870  amount earned for hospitals that participate in the specialty
  871  hospital for children disproportionate share program:
  872  
  873                        TAE = DSR x BMPD x MD                      
  874  
  875  Where:
  876         TAE = total amount earned by a specialty hospital for
  877  children.
  878         DSR = disproportionate share rate.
  879         BMPD = base Medicaid per diem.
  880         MD = Medicaid days.
  881  
  882         (2) The agency shall calculate the total additional payment
  883  for hospitals that participate in the specialty hospital for
  884  children disproportionate share program as follows:
  885  
  886                       TAP = (TAE x TA) ÷ STAE                     
  887  
  888  Where:
  889         TAP = total additional payment for a specialty hospital for
  890  children.
  891         TAE = total amount earned by a specialty hospital for
  892  children.
  893         TA = total appropriation for the specialty hospital for
  894  children disproportionate share program.
  895         STAE = sum of total amount earned by each hospital that
  896  participates in the specialty hospital for children
  897  disproportionate share program.
  898  
  899         (3) A hospital may not receive any payments under this
  900  section until it achieves full compliance with the applicable
  901  rules of the agency. A hospital that is not in compliance for
  902  two or more consecutive quarters may not receive its share of
  903  the funds. Any forfeited funds must be distributed to the
  904  remaining participating specialty hospitals for children that
  905  are in compliance.
  906         (4) Notwithstanding any provision of this section to the
  907  contrary, for the 2017-2018 2016-2017 state fiscal year, for
  908  hospitals achieving full compliance under subsection (3), the
  909  agency shall make disproportionate share payments to specialty
  910  hospitals for children as provided in the 2017-2018 2016-2017
  911  General Appropriations Act. This subsection expires July 1, 2018
  912  2017.
  913         Section 13. Subsection (36) of section 409.913, Florida
  914  Statutes, is amended to read:
  915         409.913 Oversight of the integrity of the Medicaid
  916  program.—The agency shall operate a program to oversee the
  917  activities of Florida Medicaid recipients, and providers and
  918  their representatives, to ensure that fraudulent and abusive
  919  behavior and neglect of recipients occur to the minimum extent
  920  possible, and to recover overpayments and impose sanctions as
  921  appropriate. Beginning January 1, 2003, and each year
  922  thereafter, the agency and the Medicaid Fraud Control Unit of
  923  the Department of Legal Affairs shall submit a joint report to
  924  the Legislature documenting the effectiveness of the state’s
  925  efforts to control Medicaid fraud and abuse and to recover
  926  Medicaid overpayments during the previous fiscal year. The
  927  report must describe the number of cases opened and investigated
  928  each year; the sources of the cases opened; the disposition of
  929  the cases closed each year; the amount of overpayments alleged
  930  in preliminary and final audit letters; the number and amount of
  931  fines or penalties imposed; any reductions in overpayment
  932  amounts negotiated in settlement agreements or by other means;
  933  the amount of final agency determinations of overpayments; the
  934  amount deducted from federal claiming as a result of
  935  overpayments; the amount of overpayments recovered each year;
  936  the amount of cost of investigation recovered each year; the
  937  average length of time to collect from the time the case was
  938  opened until the overpayment is paid in full; the amount
  939  determined as uncollectible and the portion of the uncollectible
  940  amount subsequently reclaimed from the Federal Government; the
  941  number of providers, by type, that are terminated from
  942  participation in the Medicaid program as a result of fraud and
  943  abuse; and all costs associated with discovering and prosecuting
  944  cases of Medicaid overpayments and making recoveries in such
  945  cases. The report must also document actions taken to prevent
  946  overpayments and the number of providers prevented from
  947  enrolling in or reenrolling in the Medicaid program as a result
  948  of documented Medicaid fraud and abuse and must include policy
  949  recommendations necessary to prevent or recover overpayments and
  950  changes necessary to prevent and detect Medicaid fraud. All
  951  policy recommendations in the report must include a detailed
  952  fiscal analysis, including, but not limited to, implementation
  953  costs, estimated savings to the Medicaid program, and the return
  954  on investment. The agency must submit the policy recommendations
  955  and fiscal analyses in the report to the appropriate estimating
  956  conference, pursuant to s. 216.137, by February 15 of each year.
  957  The agency and the Medicaid Fraud Control Unit of the Department
  958  of Legal Affairs each must include detailed unit-specific
  959  performance standards, benchmarks, and metrics in the report,
  960  including projected cost savings to the state Medicaid program
  961  during the following fiscal year.
  962         (36) At least three times a year, The agency may shall
  963  provide to a sample of each Medicaid recipients recipient or
  964  their representatives through the distribution of explanations
  965  his or her representative an explanation of benefits information
  966  about services reimbursed by the Medicaid program for goods and
  967  services to such recipients, including in the form of a letter
  968  that is mailed to the most recent address of the recipient on
  969  the record with the Department of Children and Families. The
  970  explanation of benefits must include the patient’s name, the
  971  name of the health care provider and the address of the location
  972  where the service was provided, a description of all services
  973  billed to Medicaid in terminology that should be understood by a
  974  reasonable person, and information on how to report
  975  inappropriate or incorrect billing to the agency or other law
  976  enforcement entities for review or investigation. At least once
  977  a year, the letter also must include information on how to
  978  report criminal Medicaid fraud to, the Medicaid Fraud Control
  979  Unit’s toll-free hotline number, and information about the
  980  rewards available under s. 409.9203. The explanation of benefits
  981  may not be mailed for Medicaid independent laboratory services
  982  as described in s. 409.905(7) or for Medicaid certified match
  983  services as described in ss. 409.9071 and 1011.70.
  984         Section 14. Paragraph (e) of subsection (1) of section
  985  409.975, Florida Statutes, is amended, and subsection (7) is
  986  added to that section, to read:
  987         409.975 Managed care plan accountability.—In addition to
  988  the requirements of s. 409.967, plans and providers
  989  participating in the managed medical assistance program shall
  990  comply with the requirements of this section.
  991         (1) PROVIDER NETWORKS.—Managed care plans must develop and
  992  maintain provider networks that meet the medical needs of their
  993  enrollees in accordance with standards established pursuant to
  994  s. 409.967(2)(c). Except as provided in this section, managed
  995  care plans may limit the providers in their networks based on
  996  credentials, quality indicators, and price.
  997         (e) Each managed care plan may must offer a network
  998  contract to each home medical equipment and supplies provider in
  999  the region which meets quality and fraud prevention and
 1000  detection standards established by the plan and which agrees to
 1001  accept the lowest price previously negotiated between the plan
 1002  and another such provider.
 1003         (7) SUBSTANCE ABUSE AND MENTAL HEALTH (SAMH) SAFETY NET
 1004  NETWORK.—
 1005         (a) The agency shall contract with the Substance Abuse and
 1006  Mental Health (SAMH) Safety Net Network, established under s.
 1007  394.9082(11), to plan, coordinate, and contract for delivering
 1008  certain community mental health and substance abuse services,
 1009  thereby improving access to behavioral health care, promoting
 1010  the continuity of such services, and supporting efficient and
 1011  effective delivery of such services under this section. The
 1012  contract must require managing entities to provide specified
 1013  services to Medicaid-eligible individuals with specified
 1014  behaviors, diagnoses, or addictions.
 1015         (b) Before contracting, the agency must conduct a
 1016  comprehensive readiness assessment to ensure that the SAMH
 1017  Safety Net Network has the necessary infrastructure, financial
 1018  resources, and relevant experience to implement the contract.
 1019  The agency and the department shall develop performance measures
 1020  to evaluate the impact of the SAMH Safety Net Network and to
 1021  determine the adequacy, timeliness, and quality of the services
 1022  provided for specified target populations and the efficiency of
 1023  the services in addressing mental health and substance use
 1024  disorders within a community.
 1025         (c) The agency, in consultation with the department and
 1026  managing entities, shall determine the rates for services added
 1027  to the state Medicaid plan. The rates shall be developed based
 1028  on the full cost of the services and reasonable administrative
 1029  costs for providers and managing entities.
 1030         Section 15. Subsection (1) and (2) of section 409.979,
 1031  Florida Statutes, are amended to read:
 1032         409.979 Eligibility.—
 1033         (1) PREREQUISITE CRITERIA FOR ELIGIBILITY.—Medicaid
 1034  recipients who meet all of the following criteria are eligible
 1035  to receive long-term care services and must receive long-term
 1036  care services by participating in the long-term care managed
 1037  care program. The recipient must be:
 1038         (a) Sixty-five years of age or older, or age 18 or older
 1039  and eligible for Medicaid by reason of a disability.
 1040         (b) Determined by the Comprehensive Assessment Review and
 1041  Evaluation for Long-Term Care Services (CARES) preadmission
 1042  screening program to require:
 1043         1. Nursing facility care as defined in s. 409.985(3); or
 1044         2. Hospital level of care for individuals diagnosed with
 1045  cystic fibrosis.
 1046         (2) ENROLLMENT OFFERS.—Subject to the availability of
 1047  funds, the Department of Elderly Affairs shall make offers for
 1048  enrollment to eligible individuals based on a wait-list
 1049  prioritization. Before making enrollment offers, the agency and
 1050  the Department of Elderly Affairs shall determine that
 1051  sufficient funds exist to support additional enrollment into
 1052  plans.
 1053         (a) A Medicaid recipient enrolled in one of the following
 1054  Medicaid home and community-based services waiver programs who
 1055  meets the eligibility criteria established in subsection (1) is
 1056  eligible to participate in the long-term care managed care
 1057  program and must be transitioned into the long-term care managed
 1058  care program by January 1, 2018:
 1059         1. Traumatic Brain and Spinal Cord Injury Waiver.
 1060         2. Adult Cystic Fibrosis Waiver.
 1061         3. Project AIDS Care Waiver.
 1062         (b) The agency shall seek federal approval to terminate the
 1063  Traumatic Brain and Spinal Cord Injury Waiver, the Adult Cystic
 1064  Fibrosis Waiver, and the Project AIDS Care Waiver once all
 1065  eligible Medicaid recipients have transitioned into the long
 1066  term care managed care program.
 1067         Section 16. Subject to federal approval of the application
 1068  to be a site for the Program of All-inclusive Care for the
 1069  Elderly (PACE), the Agency for Health Care Administration shall
 1070  contract with an additional not-for-profit organization to serve
 1071  individuals and families in Miami-Dade County. The not-for
 1072  profit organization must have a history of serving primarily the
 1073  Hispanic population by providing primary care services,
 1074  nutrition, meals, and adult day care to senior citizens. The
 1075  not-for-profit organization shall leverage existing community
 1076  based care providers and health care organizations to provide
 1077  PACE services to frail elders who reside in Miami-Dade County.
 1078  The organization is exempt from the requirements of chapter 641,
 1079  Florida Statutes. The agency, in consultation with the
 1080  Department of Elderly Affairs and subject to an appropriation,
 1081  shall approve up to 250 initial enrollees in the additional PACE
 1082  site established by this organization to serve frail elders who
 1083  reside in Miami-Dade County.
 1084         Section 17. Notwithstanding section 27 of chapter 2016-65,
 1085  Laws of Florida, and subject to federal approval of the
 1086  application to be a site for the Program of All-inclusive Care
 1087  for the Elderly (PACE), the Agency for Health Care
 1088  Administration shall contract with a not-for-profit
 1089  organization, formed by a partnership with a not-for-profit
 1090  hospital, a not-for-profit agency serving elders, and a not-for
 1091  profit hospice in Leon County. The not-for-profit PACE shall
 1092  serve eligible PACE enrollees in Gadsden, Jefferson, Leon, and
 1093  Wakulla Counties. The Agency for Health Care Administration, in
 1094  consultation with the Department of Elderly Affairs and subject
 1095  to an appropriation, shall approve up to 300 initial enrollees
 1096  for the additional PACE site.
 1097         Section 18. Section 17 of chapter 2011-61, Laws of Florida,
 1098  is amended to read:
 1099         Section 17. Notwithstanding s. 430.707, Florida Statutes,
 1100  and subject to federal approval of the application to be a site
 1101  for the Program of All-inclusive Care for the Elderly, the
 1102  Agency for Health Care Administration shall contract with one
 1103  private health care organization, the sole member of which is a
 1104  private, not-for-profit corporation that owns and manages health
 1105  care organizations which provide comprehensive long-term care
 1106  services, including nursing home, assisted living, independent
 1107  housing, home care, adult day care, and care management, with a
 1108  board-certified, trained geriatrician as the medical director.
 1109  This organization shall provide these services to frail and
 1110  elderly persons who reside in Indian River, Martin, Okeechobee,
 1111  Palm Beach, and St. Lucie Counties County. The organization is
 1112  exempt from the requirements of chapter 641, Florida Statutes.
 1113  The agency, in consultation with the Department of Elderly
 1114  Affairs and subject to an appropriation, shall approve up to 150
 1115  initial enrollees who reside in Palm Beach County and up to 150
 1116  initial enrollees who reside in Martin County in the Program of
 1117  All-inclusive Care for the Elderly established by this
 1118  organization to serve elderly persons who reside in Palm Beach
 1119  County.
 1120         Section 19. Effective June 30, 2017, section 9 of chapter
 1121  2016-65, Laws of Florida, is amended to read:
 1122         Section 9. Effective July 1, 2018 2017, paragraph (b) of
 1123  subsection (6) of section 409.905, Florida Statutes, is amended
 1124  to read:
 1125         409.905 Mandatory Medicaid services.—The agency may make
 1126  payments for the following services, which are required of the
 1127  state by Title XIX of the Social Security Act, furnished by
 1128  Medicaid providers to recipients who are determined to be
 1129  eligible on the dates on which the services were provided. Any
 1130  service under this section shall be provided only when medically
 1131  necessary and in accordance with state and federal law.
 1132  Mandatory services rendered by providers in mobile units to
 1133  Medicaid recipients may be restricted by the agency. Nothing in
 1134  this section shall be construed to prevent or limit the agency
 1135  from adjusting fees, reimbursement rates, lengths of stay,
 1136  number of visits, number of services, or any other adjustments
 1137  necessary to comply with the availability of moneys and any
 1138  limitations or directions provided for in the General
 1139  Appropriations Act or chapter 216.
 1140         (6) HOSPITAL OUTPATIENT SERVICES.—
 1141         (b) The agency shall implement a prospective payment
 1142  methodology for establishing reimbursement rates for outpatient
 1143  hospital services. Rates shall be calculated annually and take
 1144  effect July 1, 2018 2017, and July 1 of each year thereafter.
 1145  The methodology shall categorize the amount and type of services
 1146  used in various ambulatory visits which group together
 1147  procedures and medical visits that share similar characteristics
 1148  and resource utilization.
 1149         1. Adjustments may not be made to the rates after July 31
 1150  of the state fiscal year in which the rates take effect.
 1151         2. Errors in source data or calculations discovered after
 1152  July 31 of each state fiscal year must be reconciled in a
 1153  subsequent rate period. However, the agency may not make any
 1154  adjustment to a hospital’s reimbursement more than 5 years after
 1155  a hospital is notified of an audited rate established by the
 1156  agency. The prohibition against adjustments more than 5 years
 1157  after notification is remedial and applies to actions by
 1158  providers involving Medicaid claims for hospital services.
 1159  Hospital reimbursement is subject to such limits or ceilings as
 1160  may be established in law or described in the agency’s hospital
 1161  reimbursement plan. Specific exemptions to the limits or
 1162  ceilings may be provided in the General Appropriations Act.
 1163         Section 20. Section 29 of chapter 2016-65, Laws of Florida,
 1164  is amended to read:
 1165         Section 29. Subject to federal approval of the application
 1166  to be a site for the Program of All-inclusive Care for the
 1167  Elderly (PACE), the Agency for Health Care Administration shall
 1168  contract with one private, not-for-profit hospice organization
 1169  located in Lake County which operates health care organizations
 1170  licensed in Hospice Areas 7B and 3E and which provides
 1171  comprehensive services, including hospice and palliative care,
 1172  to frail elders who reside in these service areas. The
 1173  organization is exempt from the requirements of chapter 641,
 1174  Florida Statutes. The agency, in consultation with the
 1175  Department of Elderly Affairs and subject to the appropriation
 1176  of funds by the Legislature, shall approve up to 150 initial
 1177  enrollees in the Program of All-inclusive Care for the Elderly
 1178  established by the organization to serve frail elders who reside
 1179  in Hospice Service Areas 7B and 3E. The agency, in consultation
 1180  with the department and subject to an appropriation, shall
 1181  approve up to 150 enrollees in the Program of All-inclusive Care
 1182  for the Elderly established by this organization to serve frail
 1183  elders who reside in Hospice Service Area 7C.
 1184         Section 21. Subject to federal approval of the application
 1185  to be a site for the Program of All-inclusive Care for the
 1186  Elderly (PACE), the Agency for Health Care Administration shall
 1187  contract with one not-for-profit organization that satisfies
 1188  each of the following conditions:
 1189         (1) The organization is exempt from federal income taxation
 1190  as an entity described in s. 501(c)(3) of the Internal Revenue
 1191  Code of 1986, as amended;
 1192         (2) The organization is licensed pursuant to part IV of
 1193  chapter 400, Florida Statutes, to provide hospice services in
 1194  the Agency for Health Care Administration Areas 3 and 4 and
 1195  operates inpatient hospice care centers in each of the following
 1196  counties within those regions: Alachua, Citrus, Clay, Columbia,
 1197  and Putnam;
 1198         (3) The organization has more than 30 years of experience
 1199  as a licensed hospice provider in this state; and
 1200         (4) The organization is affiliated, through common
 1201  ownership or control, with other not-for-profit organizations
 1202  licensed by the agency to provide home health services, to
 1203  operate a nursing home, and to operate an assisted living
 1204  facility.
 1205  
 1206  The approved not-for-profit organization shall provide PACE
 1207  services to frail and elderly persons who reside in Alachua
 1208  County. The organization is exempt from the requirements of
 1209  chapter 641, Florida Statutes. The agency, in consultation with
 1210  the Department of Elder Affairs and subject to an appropriation,
 1211  shall approve up to 150 initial enrollees in the PACE site
 1212  established by this organization to serve frail and elderly
 1213  persons who reside in Alachua County.
 1214         Section 22. Except as otherwise expressly provided in this
 1215  act and except for this section, which shall take effect upon
 1216  becoming a law, this act shall take effect July 1, 2017.