Florida Senate - 2021 COMMITTEE AMENDMENT
Bill No. SB 1292
Ì385204~Î385204
LEGISLATIVE ACTION
Senate . House
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The Committee on Health Policy (Bean) recommended the following:
1 Senate Amendment (with directory and title amendments)
2
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.
383
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.
428
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.
520
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:
527
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