Florida Senate - 2025 SB 1628
By Senator Wright
8-00726-25 20251628__
1 A bill to be entitled
2 An act relating to Medicaid pharmacy services;
3 amending s. 409.973, F.S.; deleting the requirement
4 that Medicaid managed care plans cover prescription
5 drug services; amending s. 409.908, F.S.; beginning on
6 a specified date, requiring the Agency for Health Care
7 Administration to reimburse Medicaid providers for
8 pharmacy services directly through a fee-for-service
9 delivery system, regardless of whether the Medicaid
10 recipient was previously enrolled in a managed care
11 plan; requiring the agency to establish reimbursement
12 rates, dispensing fees, and any supplemental rebates
13 for pharmacy services; requiring the agency to adopt
14 rules; amending s. 409.912, F.S.; beginning on a
15 specified date, requiring the agency to administer and
16 manage pharmacy services for all Medicaid recipients
17 through a fee-for-service delivery system, including a
18 Medicaid prescribed-drug spending-control program;
19 providing an effective date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Paragraph (x) of subsection (1) of section
24 409.973, Florida Statutes, is amended to read:
25 409.973 Benefits.—
26 (1) MINIMUM BENEFITS.—Managed care plans shall cover, at a
27 minimum, the following services:
28 (x) Prescription drugs.
29 Section 2. Section 409.908, Florida Statutes, is amended to
30 read:
31 409.908 Reimbursement of Medicaid providers.—Subject to
32 specific appropriations, the agency shall reimburse Medicaid
33 providers, in accordance with state and federal law, according
34 to methodologies set forth in the rules of the agency and in
35 policy manuals and handbooks incorporated by reference therein.
36 These methodologies may include fee schedules, reimbursement
37 methods based on cost reporting, negotiated fees, competitive
38 bidding pursuant to s. 287.057, and other mechanisms the agency
39 considers efficient and effective for purchasing services or
40 goods on behalf of recipients. Effective July 1, 2025, the
41 agency shall reimburse pharmacy services directly under a fee
42 for-service delivery system, in accordance with state and
43 federal laws, regardless of whether the recipient was previously
44 enrolled in a managed care plan. The agency shall establish
45 reimbursement rates, dispensing fees, and any supplemental
46 rebates as authorized under s. 409.912 and by federal
47 guidelines. The agency shall adopt any rules necessary to
48 implement this section. If a provider is reimbursed based on
49 cost reporting and submits a cost report late and that cost
50 report would have been used to set a lower reimbursement rate
51 for a rate semester, then the provider’s rate for that semester
52 shall be retroactively calculated using the new cost report, and
53 full payment at the recalculated rate shall be effected
54 retroactively. Medicare-granted extensions for filing cost
55 reports, if applicable, shall also apply to Medicaid cost
56 reports. Payment for Medicaid compensable services made on
57 behalf of Medicaid-eligible persons is subject to the
58 availability of moneys and any limitations or directions
59 provided for in the General Appropriations Act or chapter 216.
60 Further, nothing in this section shall be construed to prevent
61 or limit the agency from adjusting fees, reimbursement rates,
62 lengths of stay, number of visits, or number of services, or
63 making any other adjustments necessary to comply with the
64 availability of moneys and any limitations or directions
65 provided for in the General Appropriations Act, provided the
66 adjustment is consistent with legislative intent.
67 (1) Reimbursement to hospitals licensed under part I of
68 chapter 395 must be made prospectively or on the basis of
69 negotiation.
70 (a) Reimbursement for inpatient care is limited as provided
71 in s. 409.905(5), except as otherwise provided in this
72 subsection.
73 1. If authorized by the General Appropriations Act, the
74 agency may modify reimbursement for specific types of services
75 or diagnoses, recipient ages, and hospital provider types.
76 2. The agency may establish an alternative methodology to
77 the DRG-based prospective payment system to set reimbursement
78 rates for:
79 a. State-owned psychiatric hospitals.
80 b. Newborn hearing screening services.
81 c. Transplant services for which the agency has established
82 a global fee.
83 d. Recipients who have tuberculosis that is resistant to
84 therapy who are in need of long-term, hospital-based treatment
85 pursuant to s. 392.62.
86 3. The agency shall modify reimbursement according to other
87 methodologies recognized in the General Appropriations Act.
88
89 The agency may receive funds from state entities, including, but
90 not limited to, the Department of Health, local governments, and
91 other local political subdivisions, for the purpose of making
92 special exception payments, including federal matching funds,
93 through the Medicaid inpatient reimbursement methodologies.
94 Funds received for this purpose shall be separately accounted
95 for and may not be commingled with other state or local funds in
96 any manner. The agency may certify all local governmental funds
97 used as state match under Title XIX of the Social Security Act,
98 to the extent and in the manner authorized under the General
99 Appropriations Act and pursuant to an agreement between the
100 agency and the local governmental entity. In order for the
101 agency to certify such local governmental funds, a local
102 governmental entity must submit a final, executed letter of
103 agreement to the agency, which must be received by October 1 of
104 each fiscal year and provide the total amount of local
105 governmental funds authorized by the entity for that fiscal year
106 under this paragraph, paragraph (b), or the General
107 Appropriations Act. The local governmental entity shall use a
108 certification form prescribed by the agency. At a minimum, the
109 certification form must identify the amount being certified and
110 describe the relationship between the certifying local
111 governmental entity and the local health care provider. The
112 agency shall prepare an annual statement of impact which
113 documents the specific activities undertaken during the previous
114 fiscal year pursuant to this paragraph, to be submitted to the
115 Legislature annually by January 1.
116 (b) Reimbursement for hospital outpatient care is limited
117 to $1,500 per state fiscal year per recipient, except for:
118 1. Such care provided to a Medicaid recipient under age 21,
119 in which case the only limitation is medical necessity.
120 2. Renal dialysis services.
121 3. Other exceptions made by the agency.
122
123 The agency is authorized to receive funds from state entities,
124 including, but not limited to, the Department of Health, the
125 Board of Governors of the State University System, local
126 governments, and other local political subdivisions, for the
127 purpose of making payments, including federal matching funds,
128 through the Medicaid outpatient reimbursement methodologies.
129 Funds received from state entities and local governments for
130 this purpose shall be separately accounted for and may shall not
131 be commingled with other state or local funds in any manner.
132 (c) The agency may receive intergovernmental transfers of
133 funds from governmental entities, including, but not limited to,
134 the Department of Health, local governments, and other local
135 political subdivisions, for the advancement of the Medicaid
136 program and for enhancing or supplementing provider
137 reimbursement under this part and part IV. The agency shall seek
138 and maintain a low-income pool in a manner authorized by federal
139 waiver and implemented under spending authority granted in the
140 General Appropriations Act. The low-income pool must be used to
141 support enhanced access to services by offsetting shortfalls in
142 Medicaid reimbursement or paying for otherwise uncompensated
143 care, and the agency shall seek waiver authority to encourage
144 the donation of intergovernmental transfers and to utilize
145 intergovernmental transfers as the state’s share of Medicaid
146 funding within the low-income pool.
147 (d) Hospitals that provide services to a disproportionate
148 share of low-income Medicaid recipients, or that participate in
149 the regional perinatal intensive care center program under
150 chapter 383, or that participate in the statutory teaching
151 hospital disproportionate share program may receive additional
152 reimbursement. The total amount of payment for disproportionate
153 share hospitals shall be fixed by the General Appropriations
154 Act. The computation of these payments must be made in
155 compliance with all federal regulations and the methodologies
156 described in ss. 409.911 and 409.9113.
157 (e) The agency is authorized to limit inflationary
158 increases for outpatient hospital services as directed by the
159 General Appropriations Act.
160 (f)1. Pursuant to chapter 120, the agency shall furnish to
161 providers written notice of the audited hospital cost-based per
162 diem reimbursement rate for inpatient and outpatient care
163 established by the agency. The written notice constitutes final
164 agency action. A substantially affected provider seeking to
165 correct or adjust the calculation of the audited hospital cost
166 based per diem reimbursement rate for inpatient and outpatient
167 care, other than a challenge to the methodologies set forth in
168 the rules of the agency and in reimbursement plans incorporated
169 by reference therein used to calculate the reimbursement rate
170 for inpatient and outpatient care, may request an administrative
171 hearing to challenge the final agency action by filing a
172 petition with the agency within 180 days after receipt of the
173 written notice by the provider. The petition must include all
174 documentation supporting the challenge upon which the provider
175 intends to rely at the administrative hearing and may not be
176 amended or supplemented except as authorized under uniform rules
177 adopted pursuant to s. 120.54(5). The failure to timely file a
178 petition in compliance with this subparagraph is deemed
179 conclusive acceptance of the audited hospital cost-based per
180 diem reimbursement rate for inpatient and outpatient care
181 established by the agency.
182 2. Any challenge to the methodologies set forth in the
183 rules of the agency and in reimbursement plans incorporated by
184 reference therein used to calculate the reimbursement rate for
185 inpatient and outpatient care may not result in a correction or
186 an adjustment of a reimbursement rate for a rate period that
187 occurred more than 5 years before the date the petition
188 initiating the proceeding was filed.
189 3. This paragraph applies to any challenge to final agency
190 action which seeks the correction or adjustment of a provider’s
191 audited hospital cost-based per diem reimbursement rate for
192 inpatient and outpatient care and to any challenge to the
193 methodologies set forth in the rules of the agency and in
194 reimbursement plans incorporated by reference therein used to
195 calculate the reimbursement rate for inpatient and outpatient
196 care, including any right to challenge which arose before July
197 1, 2015. A correction or adjustment of an audited hospital cost
198 based per diem reimbursement rate for inpatient and outpatient
199 care which is required by an administrative order or appellate
200 decision:
201 a. Must be reconciled in the first rate period after the
202 order or decision becomes final.
203 b. May not be the basis for any challenge to correct or
204 adjust hospital rates required to be paid by any Medicaid
205 managed care provider pursuant to part IV of this chapter.
206 4. The agency may not be compelled by an administrative
207 body or a court to pay additional compensation to a hospital
208 relating to the establishment of audited hospital cost-based per
209 diem reimbursement rates by the agency or for remedies relating
210 to such rates, unless an appropriation has been made by law for
211 the exclusive, specific purpose of paying such additional
212 compensation. As used in this subparagraph, the term
213 “appropriation made by law” has the same meaning as provided in
214 s. 11.066.
215 5. Any period of time specified in this paragraph is not
216 tolled by the pendency of any administrative or appellate
217 proceeding.
218 6. The exclusive means to challenge a written notice of an
219 audited hospital cost-based per diem reimbursement rate for
220 inpatient and outpatient care for the purpose of correcting or
221 adjusting such rate before, on, or after July 1, 2015, or to
222 challenge the methodologies set forth in the rules of the agency
223 and in reimbursement plans incorporated by reference therein
224 used to calculate the reimbursement rate for inpatient and
225 outpatient care is through an administrative proceeding pursuant
226 to chapter 120.
227 (2)(a)1. Reimbursement to nursing homes licensed under part
228 II of chapter 400 and state-owned-and-operated intermediate care
229 facilities for the developmentally disabled licensed under part
230 VIII of chapter 400 must be made prospectively.
231 2. Unless otherwise limited or directed in the General
232 Appropriations Act, reimbursement to hospitals licensed under
233 part I of chapter 395 for the provision of swing-bed nursing
234 home services must be made on the basis of the average statewide
235 nursing home payment, and reimbursement to a hospital licensed
236 under part I of chapter 395 for the provision of skilled nursing
237 services must be made on the basis of the average nursing home
238 payment for those services in the county in which the hospital
239 is located. When a hospital is located in a county that does not
240 have any community nursing homes, reimbursement shall be
241 determined by averaging the nursing home payments in counties
242 that surround the county in which the hospital is located.
243 Reimbursement to hospitals, including Medicaid payment of
244 Medicare copayments, for skilled nursing services shall be
245 limited to 30 days, unless a prior authorization has been
246 obtained from the agency. Medicaid reimbursement may be extended
247 by the agency beyond 30 days, and approval must be based upon
248 verification by the patient’s physician that the patient
249 requires short-term rehabilitative and recuperative services
250 only, in which case an extension of no more than 15 days may be
251 approved. Reimbursement to a hospital licensed under part I of
252 chapter 395 for the temporary provision of skilled nursing
253 services to nursing home residents who have been displaced as
254 the result of a natural disaster or other emergency may not
255 exceed the average county nursing home payment for those
256 services in the county in which the hospital is located and is
257 limited to the period of time which the agency considers
258 necessary for continued placement of the nursing home residents
259 in the hospital.
260 (b) Subject to any limitations or directions in the General
261 Appropriations Act, the agency shall establish and implement a
262 state Title XIX Long-Term Care Reimbursement Plan for nursing
263 home care in order to provide care and services in conformance
264 with the applicable state and federal laws, rules, regulations,
265 and quality and safety standards and to ensure that individuals
266 eligible for medical assistance have reasonable geographic
267 access to such care.
268 1. The agency shall amend the long-term care reimbursement
269 plan and cost reporting system to create direct care and
270 indirect care subcomponents of the patient care component of the
271 per diem rate. These two subcomponents together shall equal the
272 patient care component of the per diem rate. Separate prices
273 shall be calculated for each patient care subcomponent,
274 initially based on the September 2016 rate setting cost reports
275 and subsequently based on the most recently audited cost report
276 used during a rebasing year. The direct care subcomponent of the
277 per diem rate for any providers still being reimbursed on a cost
278 basis shall be limited by the cost-based class ceiling, and the
279 indirect care subcomponent may be limited by the lower of the
280 cost-based class ceiling, the target rate class ceiling, or the
281 individual provider target. The ceilings and targets apply only
282 to providers being reimbursed on a cost-based system. Effective
283 October 1, 2018, a prospective payment methodology shall be
284 implemented for rate setting purposes with the following
285 parameters:
286 a. Peer Groups, including:
287 (I) North-SMMC Regions 1-9, less Palm Beach and Okeechobee
288 Counties; and
289 (II) South-SMMC Regions 10-11, plus Palm Beach and
290 Okeechobee Counties.
291 b. Percentage of Median Costs based on the cost reports
292 used for September 2016 rate setting:
293 (I) Direct Care Costs........................100 percent.
294 (II) Indirect Care Costs......................92 percent.
295 (III) Operating Costs.........................86 percent.
296 c. Floors:
297 (I) Direct Care Component.....................95 percent.
298 (II) Indirect Care Component................92.5 percent.
299 (III) Operating Component...........................None.
300 d. Pass-through Payments..................Real Estate and
301 ...............................................Personal Property
302 ...................................Taxes and Property Insurance.
303 e. Quality Incentive Program Payment
304 Pool.....................................10 percent of September
305 .......................................2016 non-property related
306 ................................payments of included facilities.
307 f. Quality Score Threshold to Quality for Quality Incentive
308 Payment.....................................................20th
309 ..............................percentile of included facilities.
310 g. Fair Rental Value System Payment Parameters:
311 (I) Building Value per Square Foot based on 2018 RS Means.
312 (II) Land Valuation...10 percent of Gross Building value.
313 (III) Facility Square Footage......Actual Square Footage.
314 (IV) Movable Equipment Allowance..........$8,000 per bed.
315 (V) Obsolescence Factor......................1.5 percent.
316 (VI) Fair Rental Rate of Return................8 percent.
317 (VII) Minimum Occupancy.......................90 percent.
318 (VIII) Maximum Facility Age.....................40 years.
319 (IX) Minimum Square Footage per Bed..................350.
320 (X) Maximum Square Footage for Bed...................500.
321 (XI) Minimum Cost of a renovation/replacements$500 per bed.
322 h. Ventilator Supplemental payment of $200 per Medicaid day
323 of 40,000 ventilator Medicaid days per fiscal year.
324 2. The direct care subcomponent shall include salaries and
325 benefits of direct care staff providing nursing services
326 including registered nurses, licensed practical nurses, and
327 certified nursing assistants who deliver care directly to
328 residents in the nursing home facility, allowable therapy costs,
329 and dietary costs. This excludes nursing administration, staff
330 development, the staffing coordinator, and the administrative
331 portion of the minimum data set and care plan coordinators. The
332 direct care subcomponent also includes medically necessary
333 dental care, vision care, hearing care, and podiatric care.
334 3. All other patient care costs shall be included in the
335 indirect care cost subcomponent of the patient care per diem
336 rate, including complex medical equipment, medical supplies, and
337 other allowable ancillary costs. Costs may not be allocated
338 directly or indirectly to the direct care subcomponent from a
339 home office or management company.
340 4. On July 1 of each year, the agency shall report to the
341 Legislature direct and indirect care costs, including average
342 direct and indirect care costs per resident per facility and
343 direct care and indirect care salaries and benefits per category
344 of staff member per facility.
345 5. Every fourth year, the agency shall rebase nursing home
346 prospective payment rates to reflect changes in cost based on
347 the most recently audited cost report for each participating
348 provider.
349 6. A direct care supplemental payment may be made to
350 providers whose direct care hours per patient day are above the
351 80th percentile and who provide Medicaid services to a larger
352 percentage of Medicaid patients than the state average.
353 7. Pediatric, Florida Department of Veterans Affairs, and
354 government-owned facilities are exempt from the pricing model
355 established in this subsection and shall remain on a cost-based
356 prospective payment system. Effective October 1, 2018, the
357 agency shall set rates for all facilities remaining on a cost
358 based prospective payment system using each facility’s most
359 recently audited cost report, eliminating retroactive
360 settlements.
361
362 It is the intent of the Legislature that the reimbursement plan
363 achieve the goal of providing access to health care for nursing
364 home residents who require large amounts of care while
365 encouraging diversion services as an alternative to nursing home
366 care for residents who can be served within the community. The
367 agency shall base the establishment of any maximum rate of
368 payment, whether overall or component, on the available moneys
369 as provided for in the General Appropriations Act. The agency
370 may base the maximum rate of payment on the results of
371 scientifically valid analysis and conclusions derived from
372 objective statistical data pertinent to the particular maximum
373 rate of payment. The agency shall base the rates of payments in
374 accordance with the minimum wage requirements as provided in the
375 General Appropriations Act.
376 (3) Subject to any limitations or directions provided for
377 in the General Appropriations Act, the following Medicaid
378 services and goods may be reimbursed on a fee-for-service basis.
379 For each allowable service or goods furnished in accordance with
380 Medicaid rules, policy manuals, handbooks, and state and federal
381 law, the payment shall be the amount billed by the provider, the
382 provider’s usual and customary charge, or the maximum allowable
383 fee established by the agency, whichever amount is less, with
384 the exception of those services or goods for which the agency
385 makes payment using a methodology based on capitation rates,
386 average costs, or negotiated fees.
387 (a) Advanced practice registered nurse services.
388 (b) Birth center services.
389 (c) Chiropractic services.
390 (d) Community mental health services.
391 (e) Dental services, including oral and maxillofacial
392 surgery.
393 (f) Donor human milk bank services.
394 (g) Durable medical equipment.
395 (h) Hearing services.
396 (i) Occupational therapy for Medicaid recipients under age
397 21.
398 (j) Optometric services.
399 (k) Orthodontic services.
400 (l) Personal care for Medicaid recipients under age 21.
401 (m) Physical therapy for Medicaid recipients under age 21.
402 (n) Physician assistant services.
403 (o) Podiatric services.
404 (p) Portable X-ray services.
405 (q) Private-duty nursing for Medicaid recipients under age
406 21.
407 (r) Registered nurse first assistant services.
408 (s) Respiratory therapy for Medicaid recipients under age
409 21.
410 (t) Speech therapy for Medicaid recipients under age 21.
411 (u) Visual services.
412 (4) Subject to any limitations or directions provided for
413 in the General Appropriations Act, alternative health plans,
414 health maintenance organizations, and prepaid health plans shall
415 be reimbursed a fixed, prepaid amount negotiated, or
416 competitively bid pursuant to s. 287.057, by the agency and
417 prospectively paid to the provider monthly for each Medicaid
418 recipient enrolled. The amount may not exceed the average amount
419 the agency determines it would have paid, based on claims
420 experience, for recipients in the same or similar category of
421 eligibility. The agency shall calculate capitation rates on a
422 regional basis and, beginning September 1, 1995, shall include
423 age-band differentials in such calculations.
424 (5) Effective July 1, 2017, an ambulatory surgical center
425 shall be reimbursed pursuant to a prospective payment
426 methodology. The agency shall implement a prospective payment
427 methodology for establishing reimbursement rates for ambulatory
428 surgical centers. Rates shall be calculated annually and take
429 effect July 1, 2017, and on July 1 each year thereafter. The
430 methodology shall categorize the amount and type of services
431 used in various ambulatory visits which group together
432 procedures and medical visits that share similar characteristics
433 and resource utilization.
434 (6) A provider of early and periodic screening, diagnosis,
435 and treatment services to Medicaid recipients who are children
436 under age 21 shall be reimbursed using an all-inclusive rate
437 stipulated in a fee schedule established by the agency. A
438 provider of the visual, dental, and hearing components of such
439 services shall be reimbursed the lesser of the amount billed by
440 the provider or the Medicaid maximum allowable fee established
441 by the agency.
442 (7) A provider of family planning services shall be
443 reimbursed the lesser of the amount billed by the provider or an
444 all-inclusive amount per type of visit for physicians and
445 advanced practice registered nurses, as established by the
446 agency in a fee schedule.
447 (8) A provider of home-based or community-based services
448 rendered pursuant to a federally approved waiver shall be
449 reimbursed based on an established or negotiated rate for each
450 service. These rates shall be established according to an
451 analysis of the expenditure history and prospective budget
452 developed by each contract provider participating in the waiver
453 program, or under any other methodology adopted by the agency
454 and approved by the Federal Government in accordance with the
455 waiver. Privately owned and operated community-based residential
456 facilities which meet agency requirements and which formerly
457 received Medicaid reimbursement for the optional intermediate
458 care facility for the intellectually disabled service may
459 participate in the developmental services waiver as part of a
460 home-and-community-based continuum of care for Medicaid
461 recipients who receive waiver services.
462 (9) A provider of home health care services or of medical
463 supplies and appliances shall be reimbursed on the basis of
464 competitive bidding or for the lesser of the amount billed by
465 the provider or the agency’s established maximum allowable
466 amount, except that, in the case of the rental of durable
467 medical equipment, the total rental payments may not exceed the
468 purchase price of the equipment over its expected useful life or
469 the agency’s established maximum allowable amount, whichever
470 amount is less.
471 (10) A hospice shall be reimbursed through a prospective
472 system for each Medicaid hospice patient at Medicaid rates using
473 the methodology established for hospice reimbursement pursuant
474 to Title XVIII of the federal Social Security Act.
475 (11) A provider of independent laboratory services shall be
476 reimbursed on the basis of competitive bidding or for the least
477 of the amount billed by the provider, the provider’s usual and
478 customary charge, or the Medicaid maximum allowable fee
479 established by the agency.
480 (12)(a) A physician shall be reimbursed the lesser of the
481 amount billed by the provider or the Medicaid maximum allowable
482 fee established by the agency.
483 (b) The agency shall adopt a fee schedule, subject to any
484 limitations or directions provided for in the General
485 Appropriations Act, based on a resource-based relative value
486 scale for pricing Medicaid physician services. Under this fee
487 schedule, physicians shall be paid a dollar amount for each
488 service based on the average resources required to provide the
489 service, including, but not limited to, estimates of average
490 physician time and effort, practice expense, and the costs of
491 professional liability insurance. The fee schedule shall provide
492 increased reimbursement for preventive and primary care services
493 and lowered reimbursement for specialty services by using at
494 least two conversion factors, one for cognitive services and
495 another for procedural services. The fee schedule may shall not
496 increase total Medicaid physician expenditures unless moneys are
497 available. The Agency for Health Care Administration shall seek
498 the advice of a 16-member advisory panel in formulating and
499 adopting the fee schedule. The panel shall consist of Medicaid
500 physicians licensed under chapters 458 and 459 and shall be
501 composed of 50 percent primary care physicians and 50 percent
502 specialty care physicians.
503 (c) Notwithstanding paragraph (b), reimbursement fees to
504 physicians for providing total obstetrical services to Medicaid
505 recipients, which include prenatal, delivery, and postpartum
506 care, shall be at least $1,500 per delivery for a pregnant woman
507 with low medical risk and at least $2,000 per delivery for a
508 pregnant woman with high medical risk. However, reimbursement to
509 physicians working in Regional Perinatal Intensive Care Centers
510 designated pursuant to chapter 383, for services to certain
511 pregnant Medicaid recipients with a high medical risk, may be
512 made according to obstetrical care and neonatal care groupings
513 and rates established by the agency. Nurse midwives licensed
514 under part I of chapter 464 or midwives licensed under chapter
515 467 shall be reimbursed at no less than 80 percent of the low
516 medical risk fee. The agency shall by rule determine, for the
517 purpose of this paragraph, what constitutes a high or low
518 medical risk pregnant woman and may shall not pay more based
519 solely on the fact that a cesarean section was performed, rather
520 than a vaginal delivery. The agency shall by rule determine a
521 prorated payment for obstetrical services in cases where only
522 part of the total prenatal, delivery, or postpartum care was
523 performed. The Department of Health shall adopt rules for
524 appropriate insurance coverage for midwives licensed under
525 chapter 467. Prior to the issuance and renewal of an active
526 license, or reactivation of an inactive license for midwives
527 licensed under chapter 467, such licensees shall submit proof of
528 coverage with each application.
529 (13) Medicare premiums for persons eligible for both
530 Medicare and Medicaid coverage shall be paid at the rates
531 established by Title XVIII of the Social Security Act. For
532 Medicare services rendered to Medicaid-eligible persons,
533 Medicaid shall pay Medicare deductibles and coinsurance as
534 follows:
535 (a) Medicaid’s financial obligation for deductibles and
536 coinsurance payments shall be based on Medicare allowable fees,
537 not on a provider’s billed charges.
538 (b) Medicaid will pay no portion of Medicare deductibles
539 and coinsurance when payment that Medicare has made for the
540 service equals or exceeds what Medicaid would have paid if it
541 had been the sole payor. The combined payment of Medicare and
542 Medicaid may shall not exceed the amount Medicaid would have
543 paid had it been the sole payor. The Legislature finds that
544 there has been confusion regarding the reimbursement for
545 services rendered to dually eligible Medicare beneficiaries.
546 Accordingly, the Legislature clarifies that it has always been
547 the intent of the Legislature before and after 1991 that, in
548 reimbursing in accordance with fees established by Title XVIII
549 for premiums, deductibles, and coinsurance for Medicare services
550 rendered by physicians to Medicaid eligible persons, physicians
551 be reimbursed at the lesser of the amount billed by the
552 physician or the Medicaid maximum allowable fee established by
553 the Agency for Health Care Administration, as is permitted by
554 federal law. It has never been the intent of the Legislature
555 with regard to such services rendered by physicians that
556 Medicaid be required to provide any payment for deductibles,
557 coinsurance, or copayments for Medicare cost sharing, or any
558 expenses incurred relating thereto, in excess of the payment
559 amount provided for under the State Medicaid plan for such
560 service. This payment methodology is applicable even in those
561 situations in which the payment for Medicare cost sharing for a
562 qualified Medicare beneficiary with respect to an item or
563 service is reduced or eliminated. This expression of the
564 Legislature is in clarification of existing law and shall apply
565 to payment for, and with respect to provider agreements with
566 respect to, items or services furnished on or after the
567 effective date of this act. This paragraph applies to payment by
568 Medicaid for items and services furnished before the effective
569 date of this act if such payment is the subject of a lawsuit
570 that is based on the provisions of this section, and that is
571 pending as of, or is initiated after, the effective date of this
572 act.
573 (c) Notwithstanding paragraphs (a) and (b):
574 1. Medicaid payments for Nursing Home Medicare part A
575 coinsurance are limited to the Medicaid nursing home per diem
576 rate less any amounts paid by Medicare, but only up to the
577 amount of Medicare coinsurance. The Medicaid per diem rate shall
578 be the rate in effect for the dates of service of the crossover
579 claims and may not be subsequently adjusted due to subsequent
580 per diem rate adjustments.
581 2. Medicaid shall pay all deductibles and coinsurance for
582 Medicare-eligible recipients receiving freestanding end stage
583 renal dialysis center services.
584 3. Medicaid payments for general and specialty hospital
585 inpatient services are limited to the Medicare deductible and
586 coinsurance per spell of illness. Medicaid payments for hospital
587 Medicare Part A coinsurance shall be limited to the Medicaid
588 hospital per diem rate less any amounts paid by Medicare, but
589 only up to the amount of Medicare coinsurance. Medicaid payments
590 for coinsurance shall be limited to the Medicaid per diem rate
591 in effect for the dates of service of the crossover claims and
592 may not be subsequently adjusted due to subsequent per diem
593 adjustments.
594 4. Medicaid shall pay all deductibles and coinsurance for
595 Medicare-covered services provided to Medicare-eligible
596 recipients by ambulances licensed pursuant to chapter 401
597 according to the corresponding procedure codes for such
598 services.
599 5. Medicaid shall pay all deductibles and coinsurance for
600 portable X-ray Medicare Part B services provided in a nursing
601 home, in an assisted living facility, or in the patient’s home.
602 (14) A provider of prescribed drugs shall be reimbursed in
603 an amount not to exceed the lesser of the actual acquisition
604 cost based on the Centers for Medicare and Medicaid Services
605 National Average Drug Acquisition Cost pricing files plus a
606 professional dispensing fee, the wholesale acquisition cost plus
607 a professional dispensing fee, the state maximum allowable cost
608 plus a professional dispensing fee, or the usual and customary
609 charge billed by the provider.
610 (a) Medicaid providers must dispense generic drugs if
611 available at lower cost and the agency has not determined that
612 the branded product is more cost-effective, unless the
613 prescriber has requested and received approval to require the
614 branded product.
615 (b) The agency may establish a supplemental pharmaceutical
616 dispensing fee to be paid to providers returning unused unit
617 dose packaged medications to stock and crediting the Medicaid
618 program for the ingredient cost of those medications if the
619 ingredient costs to be credited exceed the value of the
620 supplemental dispensing fee.
621 (c) The agency may limit reimbursement for prescribed
622 medicine in order to comply with any limitations or directions
623 provided in the General Appropriations Act, which may include
624 implementing a prospective or concurrent utilization review
625 program.
626 (15) A provider of primary care case management services
627 rendered pursuant to a federally approved waiver shall be
628 reimbursed by payment of a fixed, prepaid monthly sum for each
629 Medicaid recipient enrolled with the provider.
630 (16) A provider of rural health clinic services and
631 federally qualified health center services shall be reimbursed a
632 rate per visit based on total reasonable costs of the clinic, as
633 determined by the agency in accordance with federal regulations.
634 (17) A provider of targeted case management services shall
635 be reimbursed pursuant to an established fee, except where the
636 Federal Government requires a public provider be reimbursed on
637 the basis of average actual costs.
638 (18) Unless otherwise provided for in the General
639 Appropriations Act, a provider of transportation services shall
640 be reimbursed the lesser of the amount billed by the provider or
641 the Medicaid maximum allowable fee established by the agency,
642 except when the agency has entered into a direct contract with
643 the provider, or with a community transportation coordinator,
644 for the provision of an all-inclusive service, or when services
645 are provided pursuant to an agreement negotiated between the
646 agency and the provider. The agency, as provided for in s.
647 427.0135, shall purchase transportation services through the
648 community coordinated transportation system, if available,
649 unless the agency, after consultation with the commission,
650 determines that it cannot reach mutually acceptable contract
651 terms with the commission. The agency may then contract for the
652 same transportation services provided in a more cost-effective
653 manner and of comparable or higher quality and standards.
654 Nothing in this subsection shall be construed to limit or
655 preclude the agency from contracting for services using a
656 prepaid capitation rate or from establishing maximum fee
657 schedules, individualized reimbursement policies by provider
658 type, negotiated fees, prior authorization, competitive bidding,
659 increased use of mass transit, or any other mechanism that the
660 agency considers efficient and effective for the purchase of
661 services on behalf of Medicaid clients, including implementing a
662 transportation eligibility process. The agency is shall not be
663 required to contract with any community transportation
664 coordinator or transportation operator that has been determined
665 by the agency, the Department of Legal Affairs Medicaid Fraud
666 Control Unit, or any other state or federal agency to have
667 engaged in any abusive or fraudulent billing activities. The
668 agency is authorized to competitively procure transportation
669 services or make other changes necessary to secure approval of
670 federal waivers needed to permit federal financing of Medicaid
671 transportation services at the service matching rate rather than
672 the administrative matching rate. Notwithstanding chapter 427,
673 the agency is authorized to continue contracting for Medicaid
674 nonemergency transportation services in agency service area 11
675 with managed care plans that were under contract for those
676 services before July 1, 2004.
677 (19) County health department services shall be reimbursed
678 a rate per visit based on total reasonable costs of the clinic,
679 as determined by the agency in accordance with federal
680 regulations under the authority of 42 C.F.R. s. 431.615.
681 (20) A renal dialysis facility that provides dialysis
682 services under s. 409.906(9) must be reimbursed the lesser of
683 the amount billed by the provider, the provider’s usual and
684 customary charge, or the maximum allowable fee established by
685 the agency, whichever amount is less.
686 (21) The agency shall reimburse school districts that
687 certify the state match pursuant to ss. 409.9071 and 1011.70 for
688 the federal portion of the school district’s allowable costs to
689 deliver the services, based on the reimbursement schedule. The
690 school district shall determine the costs for delivering
691 services as authorized in ss. 409.9071 and 1011.70 for which the
692 state match will be certified. Reimbursement of school-based
693 providers is contingent on such providers being enrolled as
694 Medicaid providers and meeting the qualifications contained in
695 42 C.F.R. s. 440.110, unless otherwise waived by the United
696 States Department of Health and Human Services. Speech therapy
697 providers who are certified through the Department of Education
698 pursuant to rule 6A-4.0176, Florida Administrative Code, are
699 eligible for reimbursement for services that are provided on
700 school premises. Any employee of the school district who has
701 been fingerprinted and has received a criminal background check
702 in accordance with Department of Education rules and guidelines
703 is exempt from any agency requirements relating to criminal
704 background checks.
705 (22) The agency shall request and implement Medicaid
706 waivers from the federal Health Care Financing Administration to
707 advance and treat a portion of the Medicaid nursing home per
708 diem as capital for creating and operating a risk-retention
709 group for self-insurance purposes, consistent with federal and
710 state laws and rules.
711 (23)(a) The agency shall establish rates at a level that
712 ensures no increase in statewide expenditures resulting from a
713 change in unit costs for county health departments effective
714 July 1, 2011. Reimbursement rates shall be as provided in the
715 General Appropriations Act.
716 (b)1. Base rate reimbursement for inpatient services under
717 a diagnosis-related group payment methodology shall be provided
718 in the General Appropriations Act.
719 2. Base rate reimbursement for outpatient services under an
720 enhanced ambulatory payment group methodology shall be provided
721 in the General Appropriations Act.
722 3. Prospective payment system reimbursement for nursing
723 home services shall be as provided in subsection (2) and in the
724 General Appropriations Act.
725 (24) If a provider fails to notify the agency within 5
726 business days after suspension or disenrollment from Medicare,
727 sanctions may be imposed pursuant to this chapter, and the
728 provider may be required to return funds paid to the provider
729 during the period of time that the provider was suspended or
730 disenrolled as a Medicare provider.
731 (25) In accordance with 42 C.F.R. s. 433.318(d), the agency
732 may certify that a Medicaid provider is out of business and that
733 any overpayments made to the provider cannot be collected under
734 state law and procedures.
735 (26) The agency may receive funds from state entities,
736 including, but not limited to, the Department of Health, local
737 governments, and other local political subdivisions, for the
738 purpose of making special exception payments and Low Income Pool
739 Program payments, including federal matching funds. Funds
740 received for this purpose shall be separately accounted for and
741 may not be commingled with other state or local funds in any
742 manner. The agency may certify all local governmental funds used
743 as state match under Title XIX of the Social Security Act to the
744 extent and in the manner authorized under the General
745 Appropriations Act and pursuant to an agreement between the
746 agency and the local governmental entity. In order for the
747 agency to certify such local governmental funds, a local
748 governmental entity must submit a final, executed letter of
749 agreement to the agency, which must be received by October 1 of
750 each fiscal year and provide the total amount of local
751 governmental funds authorized by the entity for that fiscal year
752 under the General Appropriations Act. The local governmental
753 entity shall use a certification form prescribed by the agency.
754 At a minimum, the certification form must identify the amount
755 being certified and describe the relationship between the
756 certifying local governmental entity and the local health care
757 provider. Local governmental funds outlined in the letters of
758 agreement must be received by the agency no later than October
759 31 of each fiscal year in which such funds are pledged, unless
760 an alternative plan is specifically approved by the agency. To
761 be eligible for low-income pool funding or other forms of
762 supplemental payments funded by intergovernmental transfers, and
763 in addition to any other applicable requirements, essential
764 providers identified in s. 409.975(1)(a)2. must offer to
765 contract with each managed care plan in their region and
766 essential providers identified in s. 409.975(1)(b)1. and 3. must
767 offer to contract with each managed care plan in the state.
768 Before releasing such supplemental payments, in the event the
769 parties have not executed network contracts, the agency shall
770 evaluate the parties’ efforts to complete negotiations. If such
771 efforts continue to fail, the agency must withhold such
772 supplemental payments beginning in the third quarter of the
773 fiscal year if it determines that, based upon the totality of
774 the circumstances, the essential provider has negotiated with
775 the managed care plan in bad faith. If the agency determines
776 that an essential provider has negotiated in bad faith, it must
777 notify the essential provider at least 90 days in advance of the
778 start of the third quarter of the fiscal year and afford the
779 essential provider hearing rights in accordance with chapter
780 120.
781 Section 3. Paragraph (a) of subsection (5) of section
782 409.912, Florida Statutes, is amended to read:
783 409.912 Cost-effective purchasing of health care.—The
784 agency shall purchase goods and services for Medicaid recipients
785 in the most cost-effective manner consistent with the delivery
786 of quality medical care. To ensure that medical services are
787 effectively utilized, the agency may, in any case, require a
788 confirmation or second physician’s opinion of the correct
789 diagnosis for purposes of authorizing future services under the
790 Medicaid program. This section does not restrict access to
791 emergency services or poststabilization care services as defined
792 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
793 shall be rendered in a manner approved by the agency. The agency
794 shall maximize the use of prepaid per capita and prepaid
795 aggregate fixed-sum basis services when appropriate and other
796 alternative service delivery and reimbursement methodologies,
797 including competitive bidding pursuant to s. 287.057, designed
798 to facilitate the cost-effective purchase of a case-managed
799 continuum of care. The agency shall also require providers to
800 minimize the exposure of recipients to the need for acute
801 inpatient, custodial, and other institutional care and the
802 inappropriate or unnecessary use of high-cost services. The
803 agency shall contract with a vendor to monitor and evaluate the
804 clinical practice patterns of providers in order to identify
805 trends that are outside the normal practice patterns of a
806 provider’s professional peers or the national guidelines of a
807 provider’s professional association. The vendor must be able to
808 provide information and counseling to a provider whose practice
809 patterns are outside the norms, in consultation with the agency,
810 to improve patient care and reduce inappropriate utilization.
811 The agency may mandate prior authorization, drug therapy
812 management, or disease management participation for certain
813 populations of Medicaid beneficiaries, certain drug classes, or
814 particular drugs to prevent fraud, abuse, overuse, and possible
815 dangerous drug interactions. The Pharmaceutical and Therapeutics
816 Committee shall make recommendations to the agency on drugs for
817 which prior authorization is required. The agency shall inform
818 the Pharmaceutical and Therapeutics Committee of its decisions
819 regarding drugs subject to prior authorization. The agency is
820 authorized to limit the entities it contracts with or enrolls as
821 Medicaid providers by developing a provider network through
822 provider credentialing. The agency may competitively bid single
823 source-provider contracts if procurement of goods or services
824 results in demonstrated cost savings to the state without
825 limiting access to care. The agency may limit its network based
826 on the assessment of beneficiary access to care, provider
827 availability, provider quality standards, time and distance
828 standards for access to care, the cultural competence of the
829 provider network, demographic characteristics of Medicaid
830 beneficiaries, practice and provider-to-beneficiary standards,
831 appointment wait times, beneficiary use of services, provider
832 turnover, provider profiling, provider licensure history,
833 previous program integrity investigations and findings, peer
834 review, provider Medicaid policy and billing compliance records,
835 clinical and medical record audits, and other factors. Providers
836 are not entitled to enrollment in the Medicaid provider network.
837 The agency shall determine instances in which allowing Medicaid
838 beneficiaries to purchase durable medical equipment and other
839 goods is less expensive to the Medicaid program than long-term
840 rental of the equipment or goods. The agency may establish rules
841 to facilitate purchases in lieu of long-term rentals in order to
842 protect against fraud and abuse in the Medicaid program as
843 defined in s. 409.913. The agency may seek federal waivers
844 necessary to administer these policies.
845 (5)(a) Notwithstanding any other law, effective July 1,
846 2025, the agency shall administer and manage pharmacy services
847 for all Medicaid recipients through a fee-for-service delivery
848 system, to include implement a Medicaid prescribed-drug
849 spending-control program that includes the following components:
850 1. A Medicaid preferred drug list, which shall be a listing
851 of cost-effective therapeutic options recommended by the
852 Medicaid Pharmacy and Therapeutics Committee established
853 pursuant to s. 409.91195 and adopted by the agency for each
854 therapeutic class on the preferred drug list. At the discretion
855 of the committee, and when feasible, the preferred drug list
856 should include at least two products in a therapeutic class. The
857 agency may post the preferred drug list and updates to the list
858 on an Internet website without following the rulemaking
859 procedures of chapter 120. Antiretroviral agents are excluded
860 from the preferred drug list. The agency shall also limit the
861 amount of a prescribed drug dispensed to no more than a 34-day
862 supply unless the drug products’ smallest marketed package is
863 greater than a 34-day supply, or the drug is determined by the
864 agency to be a maintenance drug in which case a 100-day maximum
865 supply may be authorized. The agency may seek any federal
866 waivers necessary to implement these cost-control programs and
867 to continue participation in the federal Medicaid rebate
868 program, or alternatively to negotiate state-only manufacturer
869 rebates. The agency may adopt rules to administer this
870 subparagraph. The agency shall continue to provide unlimited
871 contraceptive drugs and items. The agency must establish
872 procedures to ensure that:
873 a. There is a response to a request for prior authorization
874 by telephone or other telecommunication device within 24 hours
875 after receipt of a request for prior authorization; and
876 b. A 72-hour supply of the drug prescribed is provided in
877 an emergency or when the agency does not provide a response
878 within 24 hours as required by sub-subparagraph a.
879 2. A provider of prescribed drugs is reimbursed in an
880 amount not to exceed the lesser of the actual acquisition cost
881 based on the Centers for Medicare and Medicaid Services National
882 Average Drug Acquisition Cost pricing files plus a professional
883 dispensing fee, the wholesale acquisition cost plus a
884 professional dispensing fee, the state maximum allowable cost
885 plus a professional dispensing fee, or the usual and customary
886 charge billed by the provider.
887 3. The agency shall develop and implement a process for
888 managing the drug therapies of Medicaid recipients who are using
889 significant numbers of prescribed drugs each month. The
890 management process may include, but is not limited to,
891 comprehensive, physician-directed medical-record reviews, claims
892 analyses, and case evaluations to determine the medical
893 necessity and appropriateness of a patient’s treatment plan and
894 drug therapies. The agency may contract with a private
895 organization to provide drug-program-management services. The
896 Medicaid drug benefit management program shall include
897 initiatives to manage drug therapies for HIV/AIDS patients,
898 patients using 20 or more unique prescriptions in a 180-day
899 period, and the top 1,000 patients in annual spending. The
900 agency shall enroll any Medicaid recipient in the drug benefit
901 management program if he or she meets the specifications of this
902 provision and is not enrolled in a Medicaid health maintenance
903 organization.
904 4. The agency may limit the size of its pharmacy network
905 based on need, competitive bidding, price negotiations,
906 credentialing, or similar criteria. The agency shall give
907 special consideration to rural areas in determining the size and
908 location of pharmacies included in the Medicaid pharmacy
909 network. A pharmacy credentialing process may include criteria
910 such as a pharmacy’s full-service status, location, size,
911 patient educational programs, patient consultation, disease
912 management services, and other characteristics. The agency may
913 impose a moratorium on Medicaid pharmacy enrollment if it is
914 determined that it has a sufficient number of Medicaid
915 participating providers. The agency must allow dispensing
916 practitioners to participate as a part of the Medicaid pharmacy
917 network regardless of the practitioner’s proximity to any other
918 entity that is dispensing prescription drugs under the Medicaid
919 program. A dispensing practitioner must meet all credentialing
920 requirements applicable to his or her practice, as determined by
921 the agency.
922 5. The agency shall develop and implement a program that
923 requires Medicaid practitioners who issue written prescriptions
924 for medicinal drugs to use a counterfeit-proof prescription pad
925 for Medicaid prescriptions. The agency shall require the use of
926 standardized counterfeit-proof prescription pads by prescribers
927 who issue written prescriptions for Medicaid recipients. The
928 agency may implement the program in targeted geographic areas or
929 statewide.
930 6. The agency may enter into arrangements that require
931 manufacturers of generic drugs prescribed to Medicaid recipients
932 to provide rebates of at least 15.1 percent of the average
933 manufacturer price for the manufacturer’s generic products.
934 These arrangements shall require that if a generic-drug
935 manufacturer pays federal rebates for Medicaid-reimbursed drugs
936 at a level below 15.1 percent, the manufacturer must provide a
937 supplemental rebate to the state in an amount necessary to
938 achieve a 15.1-percent rebate level.
939 7. The agency may establish a preferred drug list as
940 described in this subsection, and, pursuant to the establishment
941 of such preferred drug list, negotiate supplemental rebates from
942 manufacturers that are in addition to those required by Title
943 XIX of the Social Security Act and at no less than 14 percent of
944 the average manufacturer price as defined in 42 U.S.C. s. 1936
945 on the last day of a quarter unless the federal or supplemental
946 rebate, or both, equals or exceeds 29 percent. There is no upper
947 limit on the supplemental rebates the agency may negotiate. The
948 agency may determine that specific products, brand-name or
949 generic, are competitive at lower rebate percentages. Agreement
950 to pay the minimum supplemental rebate percentage guarantees a
951 manufacturer that the Medicaid Pharmaceutical and Therapeutics
952 Committee will consider a product for inclusion on the preferred
953 drug list. However, a pharmaceutical manufacturer is not
954 guaranteed placement on the preferred drug list by simply paying
955 the minimum supplemental rebate. Agency decisions will be made
956 on the clinical efficacy of a drug and recommendations of the
957 Medicaid Pharmaceutical and Therapeutics Committee, as well as
958 the price of competing products minus federal and state rebates.
959 The agency may contract with an outside agency or contractor to
960 conduct negotiations for supplemental rebates. For the purposes
961 of this section, the term “supplemental rebates” means cash
962 rebates. Value-added programs as a substitution for supplemental
963 rebates are prohibited. The agency may seek any federal waivers
964 to implement this initiative.
965 8.a. The agency may implement a Medicaid behavioral drug
966 management system. The agency may contract with a vendor that
967 has experience in operating behavioral drug management systems
968 to implement this program. The agency may seek federal waivers
969 to implement this program.
970 b. The agency, in conjunction with the Department of
971 Children and Families, may implement the Medicaid behavioral
972 drug management system that is designed to improve the quality
973 of care and behavioral health prescribing practices based on
974 best practice guidelines, improve patient adherence to
975 medication plans, reduce clinical risk, and lower prescribed
976 drug costs and the rate of inappropriate spending on Medicaid
977 behavioral drugs. The program may include the following
978 elements:
979 (I) Provide for the development and adoption of best
980 practice guidelines for behavioral health-related drugs such as
981 antipsychotics, antidepressants, and medications for treating
982 bipolar disorders and other behavioral conditions; translate
983 them into practice; review behavioral health prescribers and
984 compare their prescribing patterns to a number of indicators
985 that are based on national standards; and determine deviations
986 from best practice guidelines.
987 (II) Implement processes for providing feedback to and
988 educating prescribers using best practice educational materials
989 and peer-to-peer consultation.
990 (III) Assess Medicaid beneficiaries who are outliers in
991 their use of behavioral health drugs with regard to the numbers
992 and types of drugs taken, drug dosages, combination drug
993 therapies, and other indicators of improper use of behavioral
994 health drugs.
995 (IV) Alert prescribers to patients who fail to refill
996 prescriptions in a timely fashion, are prescribed multiple same
997 class behavioral health drugs, and may have other potential
998 medication problems.
999 (V) Track spending trends for behavioral health drugs and
1000 deviation from best practice guidelines.
1001 (VI) Use educational and technological approaches to
1002 promote best practices, educate consumers, and train prescribers
1003 in the use of practice guidelines.
1004 (VII) Disseminate electronic and published materials.
1005 (VIII) Hold statewide and regional conferences.
1006 (IX) Implement a disease management program with a model
1007 quality-based medication component for severely mentally ill
1008 individuals and emotionally disturbed children who are high
1009 users of care.
1010 9. The agency shall implement a Medicaid prescription drug
1011 management system.
1012 a. The agency may contract with a vendor that has
1013 experience in operating prescription drug management systems in
1014 order to implement this system. Any management system that is
1015 implemented in accordance with this subparagraph must rely on
1016 cooperation between physicians and pharmacists to determine
1017 appropriate practice patterns and clinical guidelines to improve
1018 the prescribing, dispensing, and use of drugs in the Medicaid
1019 program. The agency may seek federal waivers to implement this
1020 program.
1021 b. The drug management system must be designed to improve
1022 the quality of care and prescribing practices based on best
1023 practice guidelines, improve patient adherence to medication
1024 plans, reduce clinical risk, and lower prescribed drug costs and
1025 the rate of inappropriate spending on Medicaid prescription
1026 drugs. The program must:
1027 (I) Provide for the adoption of best practice guidelines
1028 for the prescribing and use of drugs in the Medicaid program,
1029 including translating best practice guidelines into practice;
1030 reviewing prescriber patterns and comparing them to indicators
1031 that are based on national standards and practice patterns of
1032 clinical peers in their community, statewide, and nationally;
1033 and determine deviations from best practice guidelines.
1034 (II) Implement processes for providing feedback to and
1035 educating prescribers using best practice educational materials
1036 and peer-to-peer consultation.
1037 (III) Assess Medicaid recipients who are outliers in their
1038 use of a single or multiple prescription drugs with regard to
1039 the numbers and types of drugs taken, drug dosages, combination
1040 drug therapies, and other indicators of improper use of
1041 prescription drugs.
1042 (IV) Alert prescribers to recipients who fail to refill
1043 prescriptions in a timely fashion, are prescribed multiple drugs
1044 that may be redundant or contraindicated, or may have other
1045 potential medication problems.
1046 10. The agency may contract for drug rebate administration,
1047 including, but not limited to, calculating rebate amounts,
1048 invoicing manufacturers, negotiating disputes with
1049 manufacturers, and maintaining a database of rebate collections.
1050 11. The agency may specify the preferred daily dosing form
1051 or strength for the purpose of promoting best practices with
1052 regard to the prescribing of certain drugs as specified in the
1053 General Appropriations Act and ensuring cost-effective
1054 prescribing practices.
1055 12. The agency may require prior authorization for
1056 Medicaid-covered prescribed drugs. The agency may prior
1057 authorize the use of a product:
1058 a. For an indication not approved in labeling;
1059 b. To comply with certain clinical guidelines; or
1060 c. If the product has the potential for overuse, misuse, or
1061 abuse.
1062
1063 The agency may require the prescribing professional to provide
1064 information about the rationale and supporting medical evidence
1065 for the use of a drug. The agency shall post prior
1066 authorization, step-edit criteria and protocol, and updates to
1067 the list of drugs that are subject to prior authorization on the
1068 agency’s Internet website within 21 days after the prior
1069 authorization and step-edit criteria and protocol and updates
1070 are approved by the agency. For purposes of this subparagraph,
1071 the term “step-edit” means an automatic electronic review of
1072 certain medications subject to prior authorization.
1073 13. The agency, in conjunction with the Pharmaceutical and
1074 Therapeutics Committee, may require age-related prior
1075 authorizations for certain prescribed drugs. The agency may
1076 preauthorize the use of a drug for a recipient who may not meet
1077 the age requirement or may exceed the length of therapy for use
1078 of this product as recommended by the manufacturer and approved
1079 by the Food and Drug Administration. Prior authorization may
1080 require the prescribing professional to provide information
1081 about the rationale and supporting medical evidence for the use
1082 of a drug.
1083 14. The agency shall implement a step-therapy prior
1084 authorization approval process for medications excluded from the
1085 preferred drug list. Medications listed on the preferred drug
1086 list must be used within the previous 12 months before the
1087 alternative medications that are not listed. The step-therapy
1088 prior authorization may require the prescriber to use the
1089 medications of a similar drug class or for a similar medical
1090 indication unless contraindicated in the Food and Drug
1091 Administration labeling. The trial period between the specified
1092 steps may vary according to the medical indication. The step
1093 therapy approval process shall be developed in accordance with
1094 the committee as stated in s. 409.91195(7) and (8). A drug
1095 product may be approved without meeting the step-therapy prior
1096 authorization criteria if the prescribing physician provides the
1097 agency with additional written medical or clinical documentation
1098 that the product is medically necessary because:
1099 a. There is not a drug on the preferred drug list to treat
1100 the disease or medical condition which is an acceptable clinical
1101 alternative;
1102 b. The alternatives have been ineffective in the treatment
1103 of the beneficiary’s disease;
1104 c. The drug product or medication of a similar drug class
1105 is prescribed for the treatment of schizophrenia or schizotypal
1106 or delusional disorders; prior authorization has been granted
1107 previously for the prescribed drug; and the medication was
1108 dispensed to the patient during the previous 12 months; or
1109 d. Based on historical evidence and known characteristics
1110 of the patient and the drug, the drug is likely to be
1111 ineffective, or the number of doses has have been ineffective.
1112
1113 The agency shall work with the physician to determine the best
1114 alternative for the patient. The agency may adopt rules waiving
1115 the requirements for written clinical documentation for specific
1116 drugs in limited clinical situations.
1117 15. The agency shall implement a return and reuse program
1118 for drugs dispensed by pharmacies to institutional recipients,
1119 which includes payment of a $5 restocking fee for the
1120 implementation and operation of the program. The return and
1121 reuse program shall be implemented electronically and in a
1122 manner that promotes efficiency. The program must permit a
1123 pharmacy to exclude drugs from the program if it is not
1124 practical or cost-effective for the drug to be included and must
1125 provide for the return to inventory of drugs that cannot be
1126 credited or returned in a cost-effective manner. The agency
1127 shall determine if the program has reduced the amount of
1128 Medicaid prescription drugs which are destroyed on an annual
1129 basis and if there are additional ways to ensure more
1130 prescription drugs are not destroyed which could safely be
1131 reused.
1132 Section 4. This act shall take effect July 1, 2025.