Florida Senate - 2021                        COMMITTEE AMENDMENT
       Bill No. SB 1292
                              LEGISLATIVE ACTION                        
                    Senate             .             House              

       The Committee on Health Policy (Bean) recommended the following:
    1         Senate Amendment (with directory and title amendments)
    3         Delete lines 101 - 741
    4  and insert:
    5         (14) A provider of prescribed drugs shall be reimbursed in
    6  an amount not to exceed the lesser of the actual acquisition
    7  cost based on the Centers for Medicare and Medicaid Services
    8  National Average Drug Acquisition Cost pricing files plus a
    9  professional dispensing fee, the wholesale acquisition cost plus
   10  a professional dispensing fee, the state maximum allowable cost
   11  plus a professional dispensing fee, or the usual and customary
   12  charge billed by the provider the least of the amount billed by
   13  the provider, the provider’s usual and customary charge, or the
   14  Medicaid maximum allowable fee established by the agency, plus a
   15  dispensing fee. The Medicaid maximum allowable fee for
   16  ingredient cost must be based on the lowest of: the average
   17  wholesale price (AWP) minus 16.4 percent, the wholesaler
   18  acquisition cost (WAC) plus 1.5 percent, the federal upper limit
   19  (FUL), the state maximum allowable cost (SMAC), or the usual and
   20  customary (UAC) charge billed by the provider.
   21         (a) Medicaid providers must dispense generic drugs if
   22  available at lower cost and the agency has not determined that
   23  the branded product is more cost-effective, unless the
   24  prescriber has requested and received approval to require the
   25  branded product.
   26         (b) The agency shall implement a variable dispensing fee
   27  for prescribed medicines while ensuring continued access for
   28  Medicaid recipients. The variable dispensing fee may be based
   29  upon, but not limited to, either or both the volume of
   30  prescriptions dispensed by a specific pharmacy provider, the
   31  volume of prescriptions dispensed to an individual recipient,
   32  and dispensing of preferred-drug-list products.
   33         (c) The agency may increase the pharmacy dispensing fee
   34  authorized by statute and in the General Appropriations Act by
   35  $0.50 for the dispensing of a Medicaid preferred-drug-list
   36  product and reduce the pharmacy dispensing fee by $0.50 for the
   37  dispensing of a Medicaid product that is not included on the
   38  preferred drug list.
   39         (d) The agency may establish a supplemental pharmaceutical
   40  dispensing fee to be paid to providers returning unused unit
   41  dose packaged medications to stock and crediting the Medicaid
   42  program for the ingredient cost of those medications if the
   43  ingredient costs to be credited exceed the value of the
   44  supplemental dispensing fee.
   45         (c)(e) The agency may limit reimbursement for prescribed
   46  medicine in order to comply with any limitations or directions
   47  provided in the General Appropriations Act, which may include
   48  implementing a prospective or concurrent utilization review
   49  program.
   50         Section 4. Subsections (9) and (11) of section 409.91195,
   51  Florida Statutes, are amended, and subsection (4) of that
   52  section is reenacted for the purpose of incorporating the
   53  amendment made by this act to section 409.912, Florida Statutes,
   54  in a reference thereto, to read:
   55         409.91195 Medicaid Pharmaceutical and Therapeutics
   56  Committee.—There is created a Medicaid Pharmaceutical and
   57  Therapeutics Committee within the agency for the purpose of
   58  developing a Medicaid preferred drug list.
   59         (4) Upon recommendation of the committee, the agency shall
   60  adopt a preferred drug list as described in s. 409.912(5). To
   61  the extent feasible, the committee shall review all drug classes
   62  included on the preferred drug list every 12 months, and may
   63  recommend additions to and deletions from the preferred drug
   64  list, such that the preferred drug list provides for medically
   65  appropriate drug therapies for Medicaid patients which achieve
   66  cost savings contained in the General Appropriations Act.
   67         (9) Upon timely notice, the agency shall ensure that any
   68  therapeutic class of drugs which includes a drug that has been
   69  removed from distribution to the public by its manufacturer or
   70  the United States Food and Drug Administration or has been
   71  required to carry a black box warning label by the United States
   72  Food and Drug Administration because of safety concerns is
   73  reviewed by the committee at the next regularly scheduled
   74  meeting. After such review, the committee must recommend whether
   75  to retain the therapeutic class of drugs or subcategories of
   76  drugs within a therapeutic class on the preferred drug list and
   77  whether to institute prior authorization requirements necessary
   78  to ensure patient safety.
   79         (10)(11) Medicaid recipients may appeal agency preferred
   80  drug formulary decisions using the Medicaid fair hearing process
   81  administered by the Agency for Health Care Administration
   82  Department of Children and Families.
   83         Section 5. Paragraphs (a) and (c) of subsection (5) of
   84  section 409.912, Florida Statutes, are amended to read:
   85         409.912 Cost-effective purchasing of health care.—The
   86  agency shall purchase goods and services for Medicaid recipients
   87  in the most cost-effective manner consistent with the delivery
   88  of quality medical care. To ensure that medical services are
   89  effectively utilized, the agency may, in any case, require a
   90  confirmation or second physician’s opinion of the correct
   91  diagnosis for purposes of authorizing future services under the
   92  Medicaid program. This section does not restrict access to
   93  emergency services or poststabilization care services as defined
   94  in 42 C.F.R. s. 438.114. Such confirmation or second opinion
   95  shall be rendered in a manner approved by the agency. The agency
   96  shall maximize the use of prepaid per capita and prepaid
   97  aggregate fixed-sum basis services when appropriate and other
   98  alternative service delivery and reimbursement methodologies,
   99  including competitive bidding pursuant to s. 287.057, designed
  100  to facilitate the cost-effective purchase of a case-managed
  101  continuum of care. The agency shall also require providers to
  102  minimize the exposure of recipients to the need for acute
  103  inpatient, custodial, and other institutional care and the
  104  inappropriate or unnecessary use of high-cost services. The
  105  agency shall contract with a vendor to monitor and evaluate the
  106  clinical practice patterns of providers in order to identify
  107  trends that are outside the normal practice patterns of a
  108  provider’s professional peers or the national guidelines of a
  109  provider’s professional association. The vendor must be able to
  110  provide information and counseling to a provider whose practice
  111  patterns are outside the norms, in consultation with the agency,
  112  to improve patient care and reduce inappropriate utilization.
  113  The agency may mandate prior authorization, drug therapy
  114  management, or disease management participation for certain
  115  populations of Medicaid beneficiaries, certain drug classes, or
  116  particular drugs to prevent fraud, abuse, overuse, and possible
  117  dangerous drug interactions. The Pharmaceutical and Therapeutics
  118  Committee shall make recommendations to the agency on drugs for
  119  which prior authorization is required. The agency shall inform
  120  the Pharmaceutical and Therapeutics Committee of its decisions
  121  regarding drugs subject to prior authorization. The agency is
  122  authorized to limit the entities it contracts with or enrolls as
  123  Medicaid providers by developing a provider network through
  124  provider credentialing. The agency may competitively bid single
  125  source-provider contracts if procurement of goods or services
  126  results in demonstrated cost savings to the state without
  127  limiting access to care. The agency may limit its network based
  128  on the assessment of beneficiary access to care, provider
  129  availability, provider quality standards, time and distance
  130  standards for access to care, the cultural competence of the
  131  provider network, demographic characteristics of Medicaid
  132  beneficiaries, practice and provider-to-beneficiary standards,
  133  appointment wait times, beneficiary use of services, provider
  134  turnover, provider profiling, provider licensure history,
  135  previous program integrity investigations and findings, peer
  136  review, provider Medicaid policy and billing compliance records,
  137  clinical and medical record audits, and other factors. Providers
  138  are not entitled to enrollment in the Medicaid provider network.
  139  The agency shall determine instances in which allowing Medicaid
  140  beneficiaries to purchase durable medical equipment and other
  141  goods is less expensive to the Medicaid program than long-term
  142  rental of the equipment or goods. The agency may establish rules
  143  to facilitate purchases in lieu of long-term rentals in order to
  144  protect against fraud and abuse in the Medicaid program as
  145  defined in s. 409.913. The agency may seek federal waivers
  146  necessary to administer these policies.
  147         (5)(a) The agency shall implement a Medicaid prescribed
  148  drug spending-control program that includes the following
  149  components:
  150         1. A Medicaid preferred drug list, which shall be a listing
  151  of cost-effective therapeutic options recommended by the
  152  Medicaid Pharmacy and Therapeutics Committee established
  153  pursuant to s. 409.91195 and adopted by the agency for each
  154  therapeutic class on the preferred drug list. At the discretion
  155  of the committee, and when feasible, the preferred drug list
  156  should include at least two products in a therapeutic class. The
  157  agency may post the preferred drug list and updates to the list
  158  on an Internet website without following the rulemaking
  159  procedures of chapter 120. Antiretroviral agents are excluded
  160  from the preferred drug list. The agency shall also limit the
  161  amount of a prescribed drug dispensed to no more than a 34-day
  162  supply unless the drug products’ smallest marketed package is
  163  greater than a 34-day supply, or the drug is determined by the
  164  agency to be a maintenance drug in which case a 100-day maximum
  165  supply may be authorized. The agency may seek any federal
  166  waivers necessary to implement these cost-control programs and
  167  to continue participation in the federal Medicaid rebate
  168  program, or alternatively to negotiate state-only manufacturer
  169  rebates. The agency may adopt rules to administer this
  170  subparagraph. The agency shall continue to provide unlimited
  171  contraceptive drugs and items. The agency must establish
  172  procedures to ensure that:
  173         a. There is a response to a request for prior authorization
  174  consultation by telephone or other telecommunication device
  175  within 24 hours after receipt of a request for prior
  176  authorization consultation; and
  177         b. A 72-hour supply of the drug prescribed is provided in
  178  an emergency or when the agency does not provide a response
  179  within 24 hours as required by sub-subparagraph a.
  180         2. A provider of prescribed drugs is reimbursed in an
  181  amount not to exceed the lesser of the actual acquisition cost
  182  based on the Centers for Medicare and Medicaid Services National
  183  Average Drug Acquisition Cost pricing files plus a professional
  184  dispensing fee, the wholesale acquisition cost plus a
  185  professional dispensing fee, the state maximum allowable cost
  186  plus a professional dispensing fee, or the usual and customary
  187  charge billed by the provider Reimbursement to pharmacies for
  188  Medicaid prescribed drugs shall be set at the lowest of: the
  189  average wholesale price (AWP) minus 16.4 percent, the wholesaler
  190  acquisition cost (WAC) plus 1.5 percent, the federal upper limit
  191  (FUL), the state maximum allowable cost (SMAC), or the usual and
  192  customary (UAC) charge billed by the provider.
  193         3. The agency shall develop and implement a process for
  194  managing the drug therapies of Medicaid recipients who are using
  195  significant numbers of prescribed drugs each month. The
  196  management process may include, but is not limited to,
  197  comprehensive, physician-directed medical-record reviews, claims
  198  analyses, and case evaluations to determine the medical
  199  necessity and appropriateness of a patient’s treatment plan and
  200  drug therapies. The agency may contract with a private
  201  organization to provide drug-program-management services. The
  202  Medicaid drug benefit management program shall include
  203  initiatives to manage drug therapies for HIV/AIDS patients,
  204  patients using 20 or more unique prescriptions in a 180-day
  205  period, and the top 1,000 patients in annual spending. The
  206  agency shall enroll any Medicaid recipient in the drug benefit
  207  management program if he or she meets the specifications of this
  208  provision and is not enrolled in a Medicaid health maintenance
  209  organization.
  210         4. The agency may limit the size of its pharmacy network
  211  based on need, competitive bidding, price negotiations,
  212  credentialing, or similar criteria. The agency shall give
  213  special consideration to rural areas in determining the size and
  214  location of pharmacies included in the Medicaid pharmacy
  215  network. A pharmacy credentialing process may include criteria
  216  such as a pharmacy’s full-service status, location, size,
  217  patient educational programs, patient consultation, disease
  218  management services, and other characteristics. The agency may
  219  impose a moratorium on Medicaid pharmacy enrollment if it is
  220  determined that it has a sufficient number of Medicaid
  221  participating providers. The agency must allow dispensing
  222  practitioners to participate as a part of the Medicaid pharmacy
  223  network regardless of the practitioner’s proximity to any other
  224  entity that is dispensing prescription drugs under the Medicaid
  225  program. A dispensing practitioner must meet all credentialing
  226  requirements applicable to his or her practice, as determined by
  227  the agency.
  228         5. The agency shall develop and implement a program that
  229  requires Medicaid practitioners who issue written prescriptions
  230  for medicinal drugs to use a counterfeit-proof prescription pad
  231  for Medicaid prescriptions. The agency shall require the use of
  232  standardized counterfeit-proof prescription pads by prescribers
  233  who issue written prescriptions for Medicaid recipients. The
  234  agency may implement the program in targeted geographic areas or
  235  statewide.
  236         6. The agency may enter into arrangements that require
  237  manufacturers of generic drugs prescribed to Medicaid recipients
  238  to provide rebates of at least 15.1 percent of the average
  239  manufacturer price for the manufacturer’s generic products.
  240  These arrangements shall require that if a generic-drug
  241  manufacturer pays federal rebates for Medicaid-reimbursed drugs
  242  at a level below 15.1 percent, the manufacturer must provide a
  243  supplemental rebate to the state in an amount necessary to
  244  achieve a 15.1-percent rebate level.
  245         7. The agency may establish a preferred drug list as
  246  described in this subsection, and, pursuant to the establishment
  247  of such preferred drug list, negotiate supplemental rebates from
  248  manufacturers that are in addition to those required by Title
  249  XIX of the Social Security Act and at no less than 14 percent of
  250  the average manufacturer price as defined in 42 U.S.C. s. 1936
  251  on the last day of a quarter unless the federal or supplemental
  252  rebate, or both, equals or exceeds 29 percent. There is no upper
  253  limit on the supplemental rebates the agency may negotiate. The
  254  agency may determine that specific products, brand-name or
  255  generic, are competitive at lower rebate percentages. Agreement
  256  to pay the minimum supplemental rebate percentage guarantees a
  257  manufacturer that the Medicaid Pharmaceutical and Therapeutics
  258  Committee will consider a product for inclusion on the preferred
  259  drug list. However, a pharmaceutical manufacturer is not
  260  guaranteed placement on the preferred drug list by simply paying
  261  the minimum supplemental rebate. Agency decisions will be made
  262  on the clinical efficacy of a drug and recommendations of the
  263  Medicaid Pharmaceutical and Therapeutics Committee, as well as
  264  the price of competing products minus federal and state rebates.
  265  The agency may contract with an outside agency or contractor to
  266  conduct negotiations for supplemental rebates. For the purposes
  267  of this section, the term “supplemental rebates” means cash
  268  rebates. Value-added programs as a substitution for supplemental
  269  rebates are prohibited. The agency may seek any federal waivers
  270  to implement this initiative.
  271         8.a.The agency shall expand home delivery of pharmacy
  272  products. The agency may amend the state plan and issue a
  273  procurement, as necessary, in order to implement this program.
  274  The procurements must include agreements with a pharmacy or
  275  pharmacies located in the state to provide mail order delivery
  276  services at no cost to the recipients who elect to receive home
  277  delivery of pharmacy products. The procurement must focus on
  278  serving recipients with chronic diseases for which pharmacy
  279  expenditures represent a significant portion of Medicaid
  280  pharmacy expenditures or which impact a significant portion of
  281  the Medicaid population. The agency may seek and implement any
  282  federal waivers necessary to implement this subparagraph.
  283         9. The agency shall limit to one dose per month any drug
  284  prescribed to treat erectile dysfunction.
  285         10.a. The agency may implement a Medicaid behavioral drug
  286  management system. The agency may contract with a vendor that
  287  has experience in operating behavioral drug management systems
  288  to implement this program. The agency may seek federal waivers
  289  to implement this program.
  290         b. The agency, in conjunction with the Department of
  291  Children and Families, may implement the Medicaid behavioral
  292  drug management system that is designed to improve the quality
  293  of care and behavioral health prescribing practices based on
  294  best practice guidelines, improve patient adherence to
  295  medication plans, reduce clinical risk, and lower prescribed
  296  drug costs and the rate of inappropriate spending on Medicaid
  297  behavioral drugs. The program may include the following
  298  elements:
  299         (I) Provide for the development and adoption of best
  300  practice guidelines for behavioral health-related drugs such as
  301  antipsychotics, antidepressants, and medications for treating
  302  bipolar disorders and other behavioral conditions; translate
  303  them into practice; review behavioral health prescribers and
  304  compare their prescribing patterns to a number of indicators
  305  that are based on national standards; and determine deviations
  306  from best practice guidelines.
  307         (II) Implement processes for providing feedback to and
  308  educating prescribers using best practice educational materials
  309  and peer-to-peer consultation.
  310         (III) Assess Medicaid beneficiaries who are outliers in
  311  their use of behavioral health drugs with regard to the numbers
  312  and types of drugs taken, drug dosages, combination drug
  313  therapies, and other indicators of improper use of behavioral
  314  health drugs.
  315         (IV) Alert prescribers to patients who fail to refill
  316  prescriptions in a timely fashion, are prescribed multiple same
  317  class behavioral health drugs, and may have other potential
  318  medication problems.
  319         (V) Track spending trends for behavioral health drugs and
  320  deviation from best practice guidelines.
  321         (VI) Use educational and technological approaches to
  322  promote best practices, educate consumers, and train prescribers
  323  in the use of practice guidelines.
  324         (VII) Disseminate electronic and published materials.
  325         (VIII) Hold statewide and regional conferences.
  326         (IX) Implement a disease management program with a model
  327  quality-based medication component for severely mentally ill
  328  individuals and emotionally disturbed children who are high
  329  users of care.
  330         9.11. The agency shall implement a Medicaid prescription
  331  drug management system.
  332         a. The agency may contract with a vendor that has
  333  experience in operating prescription drug management systems in
  334  order to implement this system. Any management system that is
  335  implemented in accordance with this subparagraph must rely on
  336  cooperation between physicians and pharmacists to determine
  337  appropriate practice patterns and clinical guidelines to improve
  338  the prescribing, dispensing, and use of drugs in the Medicaid
  339  program. The agency may seek federal waivers to implement this
  340  program.
  341         b. The drug management system must be designed to improve
  342  the quality of care and prescribing practices based on best
  343  practice guidelines, improve patient adherence to medication
  344  plans, reduce clinical risk, and lower prescribed drug costs and
  345  the rate of inappropriate spending on Medicaid prescription
  346  drugs. The program must:
  347         (I) Provide for the adoption of best practice guidelines
  348  for the prescribing and use of drugs in the Medicaid program,
  349  including translating best practice guidelines into practice;
  350  reviewing prescriber patterns and comparing them to indicators
  351  that are based on national standards and practice patterns of
  352  clinical peers in their community, statewide, and nationally;
  353  and determine deviations from best practice guidelines.
  354         (II) Implement processes for providing feedback to and
  355  educating prescribers using best practice educational materials
  356  and peer-to-peer consultation.
  357         (III) Assess Medicaid recipients who are outliers in their
  358  use of a single or multiple prescription drugs with regard to
  359  the numbers and types of drugs taken, drug dosages, combination
  360  drug therapies, and other indicators of improper use of
  361  prescription drugs.
  362         (IV) Alert prescribers to recipients who fail to refill
  363  prescriptions in a timely fashion, are prescribed multiple drugs
  364  that may be redundant or contraindicated, or may have other
  365  potential medication problems.
  366         10.12. The agency may contract for drug rebate
  367  administration, including, but not limited to, calculating
  368  rebate amounts, invoicing manufacturers, negotiating disputes
  369  with manufacturers, and maintaining a database of rebate
  370  collections.
  371         11.13. The agency may specify the preferred daily dosing
  372  form or strength for the purpose of promoting best practices
  373  with regard to the prescribing of certain drugs as specified in
  374  the General Appropriations Act and ensuring cost-effective
  375  prescribing practices.
  376         12.14. The agency may require prior authorization for
  377  Medicaid-covered prescribed drugs. The agency may prior
  378  authorize the use of a product:
  379         a. For an indication not approved in labeling;
  380         b. To comply with certain clinical guidelines; or
  381         c. If the product has the potential for overuse, misuse, or
  382  abuse.
  384  The agency may require the prescribing professional to provide
  385  information about the rationale and supporting medical evidence
  386  for the use of a drug. The agency shall post prior
  387  authorization, step-edit criteria and protocol, and updates to
  388  the list of drugs that are subject to prior authorization on the
  389  agency’s Internet website within 21 days after the prior
  390  authorization and step-edit criteria and protocol and updates
  391  are approved by the agency. For purposes of this subparagraph,
  392  the term “step-edit” means an automatic electronic review of
  393  certain medications subject to prior authorization.
  394         13.15. The agency, in conjunction with the Pharmaceutical
  395  and Therapeutics Committee, may require age-related prior
  396  authorizations for certain prescribed drugs. The agency may
  397  preauthorize the use of a drug for a recipient who may not meet
  398  the age requirement or may exceed the length of therapy for use
  399  of this product as recommended by the manufacturer and approved
  400  by the Food and Drug Administration. Prior authorization may
  401  require the prescribing professional to provide information
  402  about the rationale and supporting medical evidence for the use
  403  of a drug.
  404         14.16. The agency shall implement a step-therapy prior
  405  authorization approval process for medications excluded from the
  406  preferred drug list. Medications listed on the preferred drug
  407  list must be used within the previous 12 months before the
  408  alternative medications that are not listed. The step-therapy
  409  prior authorization may require the prescriber to use the
  410  medications of a similar drug class or for a similar medical
  411  indication unless contraindicated in the Food and Drug
  412  Administration labeling. The trial period between the specified
  413  steps may vary according to the medical indication. The step
  414  therapy approval process shall be developed in accordance with
  415  the committee as stated in s. 409.91195(7) and (8). A drug
  416  product may be approved without meeting the step-therapy prior
  417  authorization criteria if the prescribing physician provides the
  418  agency with additional written medical or clinical documentation
  419  that the product is medically necessary because:
  420         a. There is not a drug on the preferred drug list to treat
  421  the disease or medical condition which is an acceptable clinical
  422  alternative;
  423         b. The alternatives have been ineffective in the treatment
  424  of the beneficiary’s disease; or
  425         c. Based on historic evidence and known characteristics of
  426  the patient and the drug, the drug is likely to be ineffective,
  427  or the number of doses have been ineffective.
  429  The agency shall work with the physician to determine the best
  430  alternative for the patient. The agency may adopt rules waiving
  431  the requirements for written clinical documentation for specific
  432  drugs in limited clinical situations.
  433         15.17. The agency shall implement a return and reuse
  434  program for drugs dispensed by pharmacies to institutional
  435  recipients, which includes payment of a $5 restocking fee for
  436  the implementation and operation of the program. The return and
  437  reuse program shall be implemented electronically and in a
  438  manner that promotes efficiency. The program must permit a
  439  pharmacy to exclude drugs from the program if it is not
  440  practical or cost-effective for the drug to be included and must
  441  provide for the return to inventory of drugs that cannot be
  442  credited or returned in a cost-effective manner. The agency
  443  shall determine if the program has reduced the amount of
  444  Medicaid prescription drugs which are destroyed on an annual
  445  basis and if there are additional ways to ensure more
  446  prescription drugs are not destroyed which could safely be
  447  reused.
  448         (c) The agency shall submit quarterly reports to the
  449  Governor, the President of the Senate, and the Speaker of the
  450  House of Representatives which must include, but need not be
  451  limited to, the progress made in implementing this subsection
  452  and its effect on Medicaid prescribed-drug expenditures.
  453         Section 6. Section 409.91213, Florida Statutes, is
  454  repealed.
  455         Section 7. Paragraph (d) of subsection (1) of section
  456  409.913, Florida Statutes, is amended to read:
  457         409.913 Oversight of the integrity of the Medicaid
  458  program.—The agency shall operate a program to oversee the
  459  activities of Florida Medicaid recipients, and providers and
  460  their representatives, to ensure that fraudulent and abusive
  461  behavior and neglect of recipients occur to the minimum extent
  462  possible, and to recover overpayments and impose sanctions as
  463  appropriate. Each January 15, the agency and the Medicaid Fraud
  464  Control Unit of the Department of Legal Affairs shall submit a
  465  report to the Legislature documenting the effectiveness of the
  466  state’s efforts to control Medicaid fraud and abuse and to
  467  recover Medicaid overpayments during the previous fiscal year.
  468  The report must describe the number of cases opened and
  469  investigated each year; the sources of the cases opened; the
  470  disposition of the cases closed each year; the amount of
  471  overpayments alleged in preliminary and final audit letters; the
  472  number and amount of fines or penalties imposed; any reductions
  473  in overpayment amounts negotiated in settlement agreements or by
  474  other means; the amount of final agency determinations of
  475  overpayments; the amount deducted from federal claiming as a
  476  result of overpayments; the amount of overpayments recovered
  477  each year; the amount of cost of investigation recovered each
  478  year; the average length of time to collect from the time the
  479  case was opened until the overpayment is paid in full; the
  480  amount determined as uncollectible and the portion of the
  481  uncollectible amount subsequently reclaimed from the Federal
  482  Government; the number of providers, by type, that are
  483  terminated from participation in the Medicaid program as a
  484  result of fraud and abuse; and all costs associated with
  485  discovering and prosecuting cases of Medicaid overpayments and
  486  making recoveries in such cases. The report must also document
  487  actions taken to prevent overpayments and the number of
  488  providers prevented from enrolling in or reenrolling in the
  489  Medicaid program as a result of documented Medicaid fraud and
  490  abuse and must include policy recommendations necessary to
  491  prevent or recover overpayments and changes necessary to prevent
  492  and detect Medicaid fraud. All policy recommendations in the
  493  report must include a detailed fiscal analysis, including, but
  494  not limited to, implementation costs, estimated savings to the
  495  Medicaid program, and the return on investment. The agency must
  496  submit the policy recommendations and fiscal analyses in the
  497  report to the appropriate estimating conference, pursuant to s.
  498  216.137, by February 15 of each year. The agency and the
  499  Medicaid Fraud Control Unit of the Department of Legal Affairs
  500  each must include detailed unit-specific performance standards,
  501  benchmarks, and metrics in the report, including projected cost
  502  savings to the state Medicaid program during the following
  503  fiscal year.
  504         (1) For the purposes of this section, the term:
  505         (d) “Medical necessity” or “medically necessary” means any
  506  goods or services necessary to palliate the effects of a
  507  terminal condition, or to prevent, diagnose, correct, cure,
  508  alleviate, or preclude deterioration of a condition that
  509  threatens life, causes pain or suffering, or results in illness
  510  or infirmity, which goods or services are provided in accordance
  511  with generally accepted standards of medical practice. For
  512  purposes of determining Medicaid reimbursement, the agency is
  513  the final arbiter of medical necessity. Determinations of
  514  medical necessity must be made by a licensed physician employed
  515  by or under contract with the agency, except for behavior
  516  analysis services, which may be determined by a licensed
  517  physician or a doctoral-level board-certified behavior analyst.
  518  Determinations and must be based upon information available at
  519  the time the goods or services are requested provided.
  521  ====== D I R E C T O R Y  C L A U S E  A M E N D M E N T ======
  522  And the directory clause is amended as follows:
  523         Delete lines 71 - 72
  524  and insert:
  525         Section 3. Subsection (14) of section 409.908, Florida
  526  Statutes, is amended to read:
  528  ================= T I T L E  A M E N D M E N T ================
  529  And the title is amended as follows:
  530         Delete lines 8 - 38
  531  and insert:
  532         amending s. 409.908, F.S.; revising the method for
  533         determining prescribed drug provider reimbursements;
  534         deleting a requirement for the agency to implement
  535         certain fees for prescribed medicines; deleting
  536         authorization for the agency to increase certain
  537         dispensing fees by certain amounts; reenacting and
  538         amending s. 409.91195, F.S., relating to the Medicaid
  539         Pharmaceutical and Therapeutics Committee; deleting a
  540         requirement for the agency to ensure that the
  541         committee reviews certain drugs under certain
  542         circumstances; designating the agency, rather than the
  543         Department of Children and Families, as the
  544         administrator for certain hearings; amending s.
  545         409.912, F.S.; requiring the agency to establish
  546         certain procedures related to prior authorization
  547         requests rather than prior consultation requests;
  548         revising the method for determining prescribed drug
  549         provider reimbursements; deleting a requirement for
  550         the agency to expand home delivery of pharmacy
  551         products; deleting a dosage limitation on certain
  552         drugs; deleting a requirement for the agency to submit
  553         certain quarterly reports to the Governor and the
  554         Legislature; repealing s. 409.91213, F.S., relating to
  555         quarterly progress reports and annual reports;
  556         amending s. 409.913, F.S.; revising the definitions of
  557         the terms “medical necessity” and “medically
  558         necessary” to provide an exception for behavior
  559         analysis services determinations; requiring that
  560         determinations be based on information available at
  561         the time goods or services are requested, rather than
  562         at the time such goods or services are provided;
  563         repealing s. 765.53, F.S., relating to the