Florida Senate - 2017 SB 694
By Senator Hutson
7-00482A-17 2017694__
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 409.904,
3 F.S.; authorizing any state agency or department
4 involved in providing health, social, or human
5 services to make payments for medical assistance for
6 certain persons diagnosed with Acquired Immune
7 Deficiency Syndrome (AIDS); amending s. 409.906, F.S.;
8 removing the Agency for Health Care Administration’s
9 ability to consolidate certain home and community
10 based services; amending s. 409.912, F.S.; deleting
11 the requirement that the agency implement a Medicaid
12 prescription drug management system; amending s.
13 409.979, F.S.; requiring that Medicaid recipients
14 enrolled in certain home and community-based service
15 Medicaid waivers be transitioned into the long-term
16 care managed care program by January 1, 2018;
17 requiring the agency to seek federal approval to
18 terminate certain waiver programs once all eligible
19 Medicaid recipients have transitioned into the long
20 term care managed care program; amending ss. 393.0661
21 and 409.968, F.S.; conforming cross-references;
22 providing an effective date.
23
24 Be It Enacted by the Legislature of the State of Florida:
25
26 Section 1. Subsection (11) is added to section 409.904,
27 Florida Statutes, to read:
28 409.904 Optional payments for eligible persons.—The agency
29 may make payments for medical assistance and related services on
30 behalf of the following persons who are determined to be
31 eligible subject to the income, assets, and categorical
32 eligibility tests set forth in federal and state law. Payment on
33 behalf of these Medicaid eligible persons is subject to the
34 availability of moneys and any limitations established by the
35 General Appropriations Act or chapter 216.
36 (11) Subject to federal waiver approval, a person diagnosed
37 with Acquired Immune Deficiency Syndrome (AIDS), who has an
38 AIDS-related opportunistic infection, who is at risk of
39 hospitalization as determined by the agency or its designee, and
40 whose income is at, or below, 300 percent of the federal benefit
41 rate.
42 Section 2. Paragraph (b) of subsection (13) of section
43 409.906, Florida Statutes, is amended to read:
44 409.906 Optional Medicaid services.—Subject to specific
45 appropriations, the agency may make payments for services which
46 are optional to the state under Title XIX of the Social Security
47 Act and are furnished by Medicaid providers to recipients who
48 are determined to be eligible on the dates on which the services
49 were provided. Any optional service that is provided shall be
50 provided only when medically necessary and in accordance with
51 state and federal law. Optional services rendered by providers
52 in mobile units to Medicaid recipients may be restricted or
53 prohibited by the agency. Nothing in this section shall be
54 construed to prevent or limit the agency from adjusting fees,
55 reimbursement rates, lengths of stay, number of visits, or
56 number of services, or making any other adjustments necessary to
57 comply with the availability of moneys and any limitations or
58 directions provided for in the General Appropriations Act or
59 chapter 216. If necessary to safeguard the state’s systems of
60 providing services to elderly and disabled persons and subject
61 to the notice and review provisions of s. 216.177, the Governor
62 may direct the Agency for Health Care Administration to amend
63 the Medicaid state plan to delete the optional Medicaid service
64 known as “Intermediate Care Facilities for the Developmentally
65 Disabled.” Optional services may include:
66 (13) HOME AND COMMUNITY-BASED SERVICES.—
67 (b) The agency may consolidate types of services offered in
68 the Aged and Disabled Waiver, the Channeling Waiver, the Project
69 AIDS Care Waiver, and the Traumatic Brain and Spinal Cord Injury
70 Waiver programs in order to group similar services under a
71 single service, or continue a service upon evidence of the need
72 for including a particular service type in a particular waiver.
73 The agency is authorized to seek a Medicaid state plan amendment
74 or federal waiver approval to implement this policy.
75 Section 3. Paragraph (a) of subsection (8) of section
76 409.912, Florida Statutes, is amended to read:
77 409.912 Cost-effective purchasing of health care.—The
78 agency shall purchase goods and services for Medicaid recipients
79 in the most cost-effective manner consistent with the delivery
80 of quality medical care. To ensure that medical services are
81 effectively utilized, the agency may, in any case, require a
82 confirmation or second physician’s opinion of the correct
83 diagnosis for purposes of authorizing future services under the
84 Medicaid program. This section does not restrict access to
85 emergency services or poststabilization care services as defined
86 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
87 shall be rendered in a manner approved by the agency. The agency
88 shall maximize the use of prepaid per capita and prepaid
89 aggregate fixed-sum basis services when appropriate and other
90 alternative service delivery and reimbursement methodologies,
91 including competitive bidding pursuant to s. 287.057, designed
92 to facilitate the cost-effective purchase of a case-managed
93 continuum of care. The agency shall also require providers to
94 minimize the exposure of recipients to the need for acute
95 inpatient, custodial, and other institutional care and the
96 inappropriate or unnecessary use of high-cost services. The
97 agency shall contract with a vendor to monitor and evaluate the
98 clinical practice patterns of providers in order to identify
99 trends that are outside the normal practice patterns of a
100 provider’s professional peers or the national guidelines of a
101 provider’s professional association. The vendor must be able to
102 provide information and counseling to a provider whose practice
103 patterns are outside the norms, in consultation with the agency,
104 to improve patient care and reduce inappropriate utilization.
105 The agency may mandate prior authorization, drug therapy
106 management, or disease management participation for certain
107 populations of Medicaid beneficiaries, certain drug classes, or
108 particular drugs to prevent fraud, abuse, overuse, and possible
109 dangerous drug interactions. The Pharmaceutical and Therapeutics
110 Committee shall make recommendations to the agency on drugs for
111 which prior authorization is required. The agency shall inform
112 the Pharmaceutical and Therapeutics Committee of its decisions
113 regarding drugs subject to prior authorization. The agency is
114 authorized to limit the entities it contracts with or enrolls as
115 Medicaid providers by developing a provider network through
116 provider credentialing. The agency may competitively bid single
117 source-provider contracts if procurement of goods or services
118 results in demonstrated cost savings to the state without
119 limiting access to care. The agency may limit its network based
120 on the assessment of beneficiary access to care, provider
121 availability, provider quality standards, time and distance
122 standards for access to care, the cultural competence of the
123 provider network, demographic characteristics of Medicaid
124 beneficiaries, practice and provider-to-beneficiary standards,
125 appointment wait times, beneficiary use of services, provider
126 turnover, provider profiling, provider licensure history,
127 previous program integrity investigations and findings, peer
128 review, provider Medicaid policy and billing compliance records,
129 clinical and medical record audits, and other factors. Providers
130 are not entitled to enrollment in the Medicaid provider network.
131 The agency shall determine instances in which allowing Medicaid
132 beneficiaries to purchase durable medical equipment and other
133 goods is less expensive to the Medicaid program than long-term
134 rental of the equipment or goods. The agency may establish rules
135 to facilitate purchases in lieu of long-term rentals in order to
136 protect against fraud and abuse in the Medicaid program as
137 defined in s. 409.913. The agency may seek federal waivers
138 necessary to administer these policies.
139 (8)(a) The agency shall implement a Medicaid prescribed
140 drug spending-control program that includes the following
141 components:
142 1. A Medicaid preferred drug list, which shall be a listing
143 of cost-effective therapeutic options recommended by the
144 Medicaid Pharmacy and Therapeutics Committee established
145 pursuant to s. 409.91195 and adopted by the agency for each
146 therapeutic class on the preferred drug list. At the discretion
147 of the committee, and when feasible, the preferred drug list
148 should include at least two products in a therapeutic class. The
149 agency may post the preferred drug list and updates to the list
150 on an Internet website without following the rulemaking
151 procedures of chapter 120. Antiretroviral agents are excluded
152 from the preferred drug list. The agency shall also limit the
153 amount of a prescribed drug dispensed to no more than a 34-day
154 supply unless the drug products’ smallest marketed package is
155 greater than a 34-day supply, or the drug is determined by the
156 agency to be a maintenance drug in which case a 100-day maximum
157 supply may be authorized. The agency may seek any federal
158 waivers necessary to implement these cost-control programs and
159 to continue participation in the federal Medicaid rebate
160 program, or alternatively to negotiate state-only manufacturer
161 rebates. The agency may adopt rules to administer this
162 subparagraph. The agency shall continue to provide unlimited
163 contraceptive drugs and items. The agency must establish
164 procedures to ensure that:
165 a. There is a response to a request for prior consultation
166 by telephone or other telecommunication device within 24 hours
167 after receipt of a request for prior consultation; and
168 b. A 72-hour supply of the drug prescribed is provided in
169 an emergency or when the agency does not provide a response
170 within 24 hours as required by sub-subparagraph a.
171 2. Reimbursement to pharmacies for Medicaid prescribed
172 drugs shall be set at the lowest of: the average wholesale price
173 (AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
174 plus 1.5 percent, the federal upper limit (FUL), the state
175 maximum allowable cost (SMAC), or the usual and customary (UAC)
176 charge billed by the provider.
177 3. The agency shall develop and implement a process for
178 managing the drug therapies of Medicaid recipients who are using
179 significant numbers of prescribed drugs each month. The
180 management process may include, but is not limited to,
181 comprehensive, physician-directed medical-record reviews, claims
182 analyses, and case evaluations to determine the medical
183 necessity and appropriateness of a patient’s treatment plan and
184 drug therapies. The agency may contract with a private
185 organization to provide drug-program-management services. The
186 Medicaid drug benefit management program shall include
187 initiatives to manage drug therapies for HIV/AIDS patients,
188 patients using 20 or more unique prescriptions in a 180-day
189 period, and the top 1,000 patients in annual spending. The
190 agency shall enroll any Medicaid recipient in the drug benefit
191 management program if he or she meets the specifications of this
192 provision and is not enrolled in a Medicaid health maintenance
193 organization.
194 4. The agency may limit the size of its pharmacy network
195 based on need, competitive bidding, price negotiations,
196 credentialing, or similar criteria. The agency shall give
197 special consideration to rural areas in determining the size and
198 location of pharmacies included in the Medicaid pharmacy
199 network. A pharmacy credentialing process may include criteria
200 such as a pharmacy’s full-service status, location, size,
201 patient educational programs, patient consultation, disease
202 management services, and other characteristics. The agency may
203 impose a moratorium on Medicaid pharmacy enrollment if it is
204 determined that it has a sufficient number of Medicaid
205 participating providers. The agency must allow dispensing
206 practitioners to participate as a part of the Medicaid pharmacy
207 network regardless of the practitioner’s proximity to any other
208 entity that is dispensing prescription drugs under the Medicaid
209 program. A dispensing practitioner must meet all credentialing
210 requirements applicable to his or her practice, as determined by
211 the agency.
212 5. The agency shall develop and implement a program that
213 requires Medicaid practitioners who prescribe drugs to use a
214 counterfeit-proof prescription pad for Medicaid prescriptions.
215 The agency shall require the use of standardized counterfeit
216 proof prescription pads by Medicaid-participating prescribers or
217 prescribers who write prescriptions for Medicaid recipients. The
218 agency may implement the program in targeted geographic areas or
219 statewide.
220 6. The agency may enter into arrangements that require
221 manufacturers of generic drugs prescribed to Medicaid recipients
222 to provide rebates of at least 15.1 percent of the average
223 manufacturer price for the manufacturer’s generic products.
224 These arrangements shall require that if a generic-drug
225 manufacturer pays federal rebates for Medicaid-reimbursed drugs
226 at a level below 15.1 percent, the manufacturer must provide a
227 supplemental rebate to the state in an amount necessary to
228 achieve a 15.1-percent rebate level.
229 7. The agency may establish a preferred drug list as
230 described in this subsection, and, pursuant to the establishment
231 of such preferred drug list, negotiate supplemental rebates from
232 manufacturers that are in addition to those required by Title
233 XIX of the Social Security Act and at no less than 14 percent of
234 the average manufacturer price as defined in 42 U.S.C. s. 1936
235 on the last day of a quarter unless the federal or supplemental
236 rebate, or both, equals or exceeds 29 percent. There is no upper
237 limit on the supplemental rebates the agency may negotiate. The
238 agency may determine that specific products, brand-name or
239 generic, are competitive at lower rebate percentages. Agreement
240 to pay the minimum supplemental rebate percentage guarantees a
241 manufacturer that the Medicaid Pharmaceutical and Therapeutics
242 Committee will consider a product for inclusion on the preferred
243 drug list. However, a pharmaceutical manufacturer is not
244 guaranteed placement on the preferred drug list by simply paying
245 the minimum supplemental rebate. Agency decisions will be made
246 on the clinical efficacy of a drug and recommendations of the
247 Medicaid Pharmaceutical and Therapeutics Committee, as well as
248 the price of competing products minus federal and state rebates.
249 The agency may contract with an outside agency or contractor to
250 conduct negotiations for supplemental rebates. For the purposes
251 of this section, the term “supplemental rebates” means cash
252 rebates. Value-added programs as a substitution for supplemental
253 rebates are prohibited. The agency may seek any federal waivers
254 to implement this initiative.
255 8. The agency shall expand home delivery of pharmacy
256 products. The agency may amend the state plan and issue a
257 procurement, as necessary, in order to implement this program.
258 The procurements must include agreements with a pharmacy or
259 pharmacies located in the state to provide mail order delivery
260 services at no cost to the recipients who elect to receive home
261 delivery of pharmacy products. The procurement must focus on
262 serving recipients with chronic diseases for which pharmacy
263 expenditures represent a significant portion of Medicaid
264 pharmacy expenditures or which impact a significant portion of
265 the Medicaid population. The agency may seek and implement any
266 federal waivers necessary to implement this subparagraph.
267 9. The agency shall limit to one dose per month any drug
268 prescribed to treat erectile dysfunction.
269 10.a. The agency may implement a Medicaid behavioral drug
270 management system. The agency may contract with a vendor that
271 has experience in operating behavioral drug management systems
272 to implement this program. The agency may seek federal waivers
273 to implement this program.
274 b. The agency, in conjunction with the Department of
275 Children and Families, may implement the Medicaid behavioral
276 drug management system that is designed to improve the quality
277 of care and behavioral health prescribing practices based on
278 best practice guidelines, improve patient adherence to
279 medication plans, reduce clinical risk, and lower prescribed
280 drug costs and the rate of inappropriate spending on Medicaid
281 behavioral drugs. The program may include the following
282 elements:
283 (I) Provide for the development and adoption of best
284 practice guidelines for behavioral health-related drugs such as
285 antipsychotics, antidepressants, and medications for treating
286 bipolar disorders and other behavioral conditions; translate
287 them into practice; review behavioral health prescribers and
288 compare their prescribing patterns to a number of indicators
289 that are based on national standards; and determine deviations
290 from best practice guidelines.
291 (II) Implement processes for providing feedback to and
292 educating prescribers using best practice educational materials
293 and peer-to-peer consultation.
294 (III) Assess Medicaid beneficiaries who are outliers in
295 their use of behavioral health drugs with regard to the numbers
296 and types of drugs taken, drug dosages, combination drug
297 therapies, and other indicators of improper use of behavioral
298 health drugs.
299 (IV) Alert prescribers to patients who fail to refill
300 prescriptions in a timely fashion, are prescribed multiple same
301 class behavioral health drugs, and may have other potential
302 medication problems.
303 (V) Track spending trends for behavioral health drugs and
304 deviation from best practice guidelines.
305 (VI) Use educational and technological approaches to
306 promote best practices, educate consumers, and train prescribers
307 in the use of practice guidelines.
308 (VII) Disseminate electronic and published materials.
309 (VIII) Hold statewide and regional conferences.
310 (IX) Implement a disease management program with a model
311 quality-based medication component for severely mentally ill
312 individuals and emotionally disturbed children who are high
313 users of care.
314 11. The agency shall implement a Medicaid prescription drug
315 management system.
316 a. The agency may contract with a vendor that has
317 experience in operating prescription drug management systems in
318 order to implement this system. Any management system that is
319 implemented in accordance with this subparagraph must rely on
320 cooperation between physicians and pharmacists to determine
321 appropriate practice patterns and clinical guidelines to improve
322 the prescribing, dispensing, and use of drugs in the Medicaid
323 program. The agency may seek federal waivers to implement this
324 program.
325 b. The drug management system must be designed to improve
326 the quality of care and prescribing practices based on best
327 practice guidelines, improve patient adherence to medication
328 plans, reduce clinical risk, and lower prescribed drug costs and
329 the rate of inappropriate spending on Medicaid prescription
330 drugs. The program must:
331 (I) Provide for the adoption of best practice guidelines
332 for the prescribing and use of drugs in the Medicaid program,
333 including translating best practice guidelines into practice;
334 reviewing prescriber patterns and comparing them to indicators
335 that are based on national standards and practice patterns of
336 clinical peers in their community, statewide, and nationally;
337 and determine deviations from best practice guidelines.
338 (II) Implement processes for providing feedback to and
339 educating prescribers using best practice educational materials
340 and peer-to-peer consultation.
341 (III) Assess Medicaid recipients who are outliers in their
342 use of a single or multiple prescription drugs with regard to
343 the numbers and types of drugs taken, drug dosages, combination
344 drug therapies, and other indicators of improper use of
345 prescription drugs.
346 (IV) Alert prescribers to recipients who fail to refill
347 prescriptions in a timely fashion, are prescribed multiple drugs
348 that may be redundant or contraindicated, or may have other
349 potential medication problems.
350 11.12. The agency may contract for drug rebate
351 administration, including, but not limited to, calculating
352 rebate amounts, invoicing manufacturers, negotiating disputes
353 with manufacturers, and maintaining a database of rebate
354 collections.
355 12.13. The agency may specify the preferred daily dosing
356 form or strength for the purpose of promoting best practices
357 with regard to the prescribing of certain drugs as specified in
358 the General Appropriations Act and ensuring cost-effective
359 prescribing practices.
360 13.14. The agency may require prior authorization for
361 Medicaid-covered prescribed drugs. The agency may prior
362 authorize the use of a product:
363 a. For an indication not approved in labeling;
364 b. To comply with certain clinical guidelines; or
365 c. If the product has the potential for overuse, misuse, or
366 abuse.
367
368 The agency may require the prescribing professional to provide
369 information about the rationale and supporting medical evidence
370 for the use of a drug. The agency shall post prior
371 authorization, step-edit criteria and protocol, and updates to
372 the list of drugs that are subject to prior authorization on the
373 agency’s Internet website within 21 days after the prior
374 authorization and step-edit criteria and protocol and updates
375 are approved by the agency. For purposes of this subparagraph,
376 the term “step-edit” means an automatic electronic review of
377 certain medications subject to prior authorization.
378 14.15. The agency, in conjunction with the Pharmaceutical
379 and Therapeutics Committee, may require age-related prior
380 authorizations for certain prescribed drugs. The agency may
381 preauthorize the use of a drug for a recipient who may not meet
382 the age requirement or may exceed the length of therapy for use
383 of this product as recommended by the manufacturer and approved
384 by the Food and Drug Administration. Prior authorization may
385 require the prescribing professional to provide information
386 about the rationale and supporting medical evidence for the use
387 of a drug.
388 15.16. The agency shall implement a step-therapy prior
389 authorization approval process for medications excluded from the
390 preferred drug list. Medications listed on the preferred drug
391 list must be used within the previous 12 months before the
392 alternative medications that are not listed. The step-therapy
393 prior authorization may require the prescriber to use the
394 medications of a similar drug class or for a similar medical
395 indication unless contraindicated in the Food and Drug
396 Administration labeling. The trial period between the specified
397 steps may vary according to the medical indication. The step
398 therapy approval process shall be developed in accordance with
399 the committee as stated in s. 409.91195(7) and (8). A drug
400 product may be approved without meeting the step-therapy prior
401 authorization criteria if the prescribing physician provides the
402 agency with additional written medical or clinical documentation
403 that the product is medically necessary because:
404 a. There is not a drug on the preferred drug list to treat
405 the disease or medical condition which is an acceptable clinical
406 alternative;
407 b. The alternatives have been ineffective in the treatment
408 of the beneficiary’s disease; or
409 c. Based on historic evidence and known characteristics of
410 the patient and the drug, the drug is likely to be ineffective,
411 or the number of doses have been ineffective.
412
413 The agency shall work with the physician to determine the best
414 alternative for the patient. The agency may adopt rules waiving
415 the requirements for written clinical documentation for specific
416 drugs in limited clinical situations.
417 16.17. The agency shall implement a return and reuse
418 program for drugs dispensed by pharmacies to institutional
419 recipients, which includes payment of a $5 restocking fee for
420 the implementation and operation of the program. The return and
421 reuse program shall be implemented electronically and in a
422 manner that promotes efficiency. The program must permit a
423 pharmacy to exclude drugs from the program if it is not
424 practical or cost-effective for the drug to be included and must
425 provide for the return to inventory of drugs that cannot be
426 credited or returned in a cost-effective manner. The agency
427 shall determine if the program has reduced the amount of
428 Medicaid prescription drugs that which are destroyed on an
429 annual basis and if there are additional ways to ensure more
430 prescription drugs are not destroyed which could safely be
431 reused.
432 Section 4. Subsections (1) and (2) of section 409.979,
433 Florida Statutes, are amended to read:
434 409.979 Eligibility.—
435 (1) PREREQUISITE CRITERIA FOR ELIGIBILITY.—Medicaid
436 recipients who meet all of the following criteria are eligible
437 to receive long-term care services and must receive long-term
438 care services by participating in the long-term care managed
439 care program. The recipient must be:
440 (a) Sixty-five years of age or older, or age 18 or older
441 and eligible for Medicaid by reason of a disability.
442 (b) Determined by the Comprehensive Assessment Review and
443 Evaluation for Long-Term Care Services (CARES) preadmission
444 screening program to require nursing facility care as defined in
445 s. 409.985(3) or, in the case of individuals diagnosed with
446 cystic fibrosis, determined by the CARES program to require
447 hospital-level of care.
448 (2) ENROLLMENT OFFERS.—
449 (a) Subject to the availability of funds, the Department of
450 Elderly Affairs shall make offers for enrollment to eligible
451 individuals based on a wait-list prioritization. Before making
452 enrollment offers, the agency and the Department of Elderly
453 Affairs shall determine that sufficient funds exist to support
454 additional enrollment into plans.
455 (b) Medicaid recipients enrolled in one of the following
456 home and community-based service Medicaid waivers are eligible
457 to participate in the long-term care managed care program when
458 all eligibility criteria requirements established in paragraph
459 (1) of this subsection are met and shall be transitioned into
460 the long-term care managed care program by January 1, 2018:
461 1. Traumatic Brain and Spinal Cord Injury Waiver.
462 2. Adult Cystic Fibrosis Waiver.
463 3. Project AIDS Care Waiver.
464
465 The agency shall seek federal approval to terminate the
466 Traumatic Brain and Spinal Cord Injury Waiver, the Adult Cystic
467 Fibrosis Waiver, and the Project AIDS Care Waiver after all
468 eligible Medicaid recipients have transitioned into the long
469 term care managed care program.
470 Section 5. Subsection (7) of section 393.0661, Florida
471 Statutes, is amended to read:
472 393.0661 Home and community-based services delivery system;
473 comprehensive redesign.—The Legislature finds that the home and
474 community-based services delivery system for persons with
475 developmental disabilities and the availability of appropriated
476 funds are two of the critical elements in making services
477 available. Therefore, it is the intent of the Legislature that
478 the Agency for Persons with Disabilities shall develop and
479 implement a comprehensive redesign of the system.
480 (7) The agency shall collect premiums or cost sharing
481 pursuant to s. 409.906(13)(c) s. 409.906(13)(d).
482 Section 6. Paragraph (a) of subsection (4) of section
483 409.968, Florida Statutes, is amended to read:
484 409.968 Managed care plan payments.—
485 (4)(a) Subject to a specific appropriation and federal
486 approval under s. 409.906(13)(d) s. 409.906(13)(e), the agency
487 shall establish a payment methodology to fund managed care plans
488 for flexible services for persons with severe mental illness and
489 substance use disorders, including, but not limited to,
490 temporary housing assistance. A managed care plan eligible for
491 these payments must do all of the following:
492 1. Participate as a specialty plan for severe mental
493 illness or substance use disorders or participate in counties
494 designated by the General Appropriations Act;
495 2. Include providers of behavioral health services pursuant
496 to chapters 394 and 397 in the managed care plan’s provider
497 network; and
498 3. Document a capability to provide housing assistance
499 through agreements with housing providers, relationships with
500 local housing coalitions, and other appropriate arrangements.
501 Section 7. This act shall take effect July 1, 2017.