October 28, 2020
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_h5105__
HB 5105

1
A bill to be entitled
2An act relating to health care; amending s. 409.814, F.S.;
3providing Florida Kidcare eligibility determination
4requirements; amending s. 409.815, F.S.; revising
5mandatory benefit requirements for behavioral health and
6dental services; providing reimbursement requirements for
7federally qualified health centers and rural health
8clinics; amending s. 409.818, F.S.; requiring the Agency
9for Health Care Administration to monitor the compliance
10and quality of health insurance plans in the Florida
11Kidcare program as required by federal law; amending s.
12409.904, F.S.; revising the expiration date of provisions
13authorizing the federal waiver for certain persons age 65
14and over or who have a disability; revising the expiration
15date of provisions authorizing a specified medically needy
16program; amending s. 409.905, F.S., relating to mandatory
17Medicaid services; requiring prior authorization for
18certain home health services; requiring home health
19agencies to submit certain supporting documentation when
20requesting prior authorization; establishing reimbursement
21requirements for home health services; revising conditions
22for adjustment of a hospital's inpatient per diem rate;
23amending s. 409.906, F.S., relating to optional Medicaid
24services; providing limitations on the provision of adult
25vision services; amending s. 409.9082, F.S.; authorizing
26the agency to exempt certain nursing home facility
27providers from quality assessments or apply a lower
28assessment rate to the facility; modifying circumstances
29requiring discontinuance of the quality assessment on
30nursing home facility providers; creating s. 409.9083,
31F.S.; providing definitions; providing for a quality
32assessment to be imposed upon privately operated
33intermediate care facility providers for the
34developmentally disabled; requiring the agency to
35calculate the quality assessment rate annually; providing
36requirements for reporting and collecting the assessment;
37specifying the purposes of the assessment and an order of
38priority; requiring that the agency seek federal
39authorization to implement the act; specifying
40circumstances requiring discontinuance of the quality
41assessment; authorizing the agency to impose certain
42penalties against providers that fail to pay the
43assessment; requiring the agency to adopt rules; providing
44for future repeal; amending s. 409.911, F.S.; revising the
45share data used to calculate disproportionate share
46payments to hospitals; amending s. 409.9112, F.S.;
47revising the time period during which the agency is
48prohibited from distributing disproportionate share
49payments to regional perinatal intensive care centers;
50amending s. 409.9113, F.S.; requiring the agency to
51distribute moneys provided in the General Appropriations
52Act to statutorily defined teaching hospitals and family
53practice teaching hospitals under the teaching hospital
54disproportionate share program for the 2009-2010 fiscal
55year; amending s. 409.9117, F.S.; prohibiting the agency
56from distributing moneys under the primary care
57disproportionate share program for the 2009-2010 fiscal
58year; amending s. 409.912, F.S.; providing that the
59continuance of the integrated fixed-payment delivery pilot
60program for certain elderly or dually eligible recipients
61in Miami-Dade County is contingent upon an appropriation;
62creating a pilot project in Miami-Dade County to monitor
63the delivery of home health services and provide for
64electronic claims for home health services; authorizing
65the agency to seek amendments to the state plan and
66waivers of federal law to implement the project; requiring
67the agency to award contracts based on a competitive
68solicitation process; requiring a report to the Governor
69and Legislature; creating a comprehensive care management
70pilot project in Miami-Dade County for home health
71services; authorizing the agency to seek amendments to the
72state plan and waivers of federal law to implement the
73project; amending s. 409.91211, F.S.; revising the date
74when provider service networks convert from fee-for-
75service to capitation rates; amending s. 430.04, F.S.;
76requiring the Department of Elderly Affairs to administer
77all Medicaid waivers and programs relating to elders and
78their appropriations; amending s. 430.707, F.S.; requiring
79the agency, in consultation with the Department of Elderly
80Affairs, to accept and forward to the Centers for Medicare
81and Medicaid Services an application for expansion of a
82pilot project from an entity that provides certain
83benefits under a federal program; providing an effective
84date.
85
86Be It Enacted by the Legislature of the State of Florida:
87
88     Section 1.  Paragraph (c) is added to subsection (8) of
89section 409.814, Florida Statutes, is to read:
90     409.814  Eligibility.--A child who has not reached 19 years
91of age whose family income is equal to or below 200 percent of
92the federal poverty level is eligible for the Florida Kidcare
93program as provided in this section. For enrollment in the
94Children's Medical Services Network, a complete application
95includes the medical or behavioral health screening. If,
96subsequently, an individual is determined to be ineligible for
97coverage, he or she must immediately be disenrolled from the
98respective Florida Kidcare program component.
99     (8)  In determining the eligibility of a child, an assets
100test is not required. Each applicant shall provide written
101documentation during the application process and the
102redetermination process, including, but not limited to, the
103following:
104     (a)  Proof of family income, which must include a copy of
105the applicant's most recent federal income tax return. In the
106absence of a federal income tax return, an applicant may submit
107wages and earnings statements (pay stubs), W-2 forms, or other
108appropriate documents.
109     (b)  A statement from all family members that:
110     1.  Their employer does not sponsor a health benefit plan
111for employees; or
112     2.  The potential enrollee is not covered by the employer-
113sponsored health benefit plan because the potential enrollee is
114not eligible for coverage, or, if the potential enrollee is
115eligible but not covered, a statement of the cost to enroll the
116potential enrollee in the employer-sponsored health benefit
117plan.
118     (c)  Effective no later than January 1, 2010, verification
119of the potential enrollee's or enrollee's citizenship status to
120the extent required under Title XXI of the Social Security Act.
121     Section 2.  Paragraphs (g) and (q) of subsection (2) of
122section 409.815, Florida Statutes, are amended, and paragraph
123(w) is added to that subsection, to read:
124     409.815  Health benefits coverage; limitations.--
125     (2)  BENCHMARK BENEFITS.--In order for health benefits
126coverage to qualify for premium assistance payments for an
127eligible child under ss. 409.810-409.820, the health benefits
128coverage, except for coverage under Medicaid and Medikids, must
129include the following minimum benefits, as medically necessary.
130     (g)  Behavioral health services.--
131     1.  Mental health benefits include:
132     a.  Inpatient services, limited to not more than 30
133inpatient days per contract year for psychiatric admissions, or
134residential services in facilities licensed under s. 394.875(6)
135or s. 395.003 in lieu of inpatient psychiatric admissions;
136however, a minimum of 10 of the 30 days shall be available only
137for inpatient psychiatric services when authorized by a
138physician; and
139     b.  Outpatient services, including outpatient visits for
140psychological or psychiatric evaluation, diagnosis, and
141treatment by a licensed mental health professional, limited to a
142maximum of 40 outpatient visits each contract year.
143     2.  Substance abuse services include:
144     a.  Inpatient services, limited to not more than 7
145inpatient days per contract year for medical detoxification only
146and 30 days of residential services; and
147     b.  Outpatient services, including evaluation, diagnosis,
148and treatment by a licensed practitioner, limited to a maximum
149of 40 outpatient visits per contract year.
150     3.  Effective October 1, 2009, covered services include
151inpatient and outpatient services for mental and nervous
152disorders as defined in the most recent edition of the
153Diagnostic and Statistical Manual of Mental Disorders published
154by the American Psychiatric Association. Such benefits include
155psychological or psychiatric evaluation, diagnosis, and
156treatment by a licensed mental health professional and
157inpatient, outpatient, and residential treatment services for
158the diagnosis and treatment of substance abuse disorders. Any
159benefit limitations, including duration of services, number of
160visits, or number of days for hospitalization or residential
161services may not be any less favorable than those for physical
162illnesses generally for the care and treatment of schizophrenia
163and psychotic disorders, mood disorders, anxiety disorders,
164substance abuse disorders, eating disorders, and childhood
165attention deficit disorders. The program may also implement
166appropriate financial incentives, peer review, utilization
167requirements, and other methods used for the management of
168benefits provided for other medical conditions in order to
169reduce service costs and utilization without compromising
170quality of care.
171     (q)  Dental services.--Effective October 1, 2009, dental
172services shall be covered as required under federal law and may
173also include those dental benefits provided to children by the
174Florida Medicaid program under s. 409.906(6). Changes to the
175dental benefit in order to comply with federal law are effective
176October 1, 2009.
177     (w)  Reimbursement of federally qualified health centers
178and rural health clinics.--Effective October 1, 2009, payments
179for services provided to enrollees by federally qualified health
180centers and rural health clinics under this section shall be
181reimbursed using the Medicaid Prospective Payment System as
182provided for under s. 2107(e)(1)(D) of the Social Security Act,
18342 U.S.C. s. 1397gg(e)(1)(D), as added by Pub. L. No 105-33,
184Title IV, s. 4901(a). If such services are paid for by health
185insurers or health care providers under contract with the
186Florida Healthy Kids Corporation, such entities are responsible
187for this payment. The agency may seek any available federal
188grants to assist with this transition.
189     Section 3.  Paragraph (c) of subsection (3) of section
190409.818, Florida Statutes, is amended to read:
191     409.818  Administration.--In order to implement ss.
192409.810-409.820, the following agencies shall have the following
193duties:
194     (3)  The Agency for Health Care Administration, under the
195authority granted in s. 409.914(1), shall:
196     (c)  Monitor compliance with quality assurance and access
197standards developed under s. 409.820 and in accordance with s.
1982103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
199
200The agency is designated the lead state agency for Title XXI of
201the Social Security Act for purposes of receipt of federal
202funds, for reporting purposes, and for ensuring compliance with
203federal and state regulations and rules.
204     Section 4.  Subsections (1) and (2) of section 409.904,
205Florida Statutes, are amended to read:
206     409.904  Optional payments for eligible persons.--The
207agency may make payments for medical assistance and related
208services on behalf of the following persons who are determined
209to be eligible subject to the income, assets, and categorical
210eligibility tests set forth in federal and state law. Payment on
211behalf of these Medicaid eligible persons is subject to the
212availability of moneys and any limitations established by the
213General Appropriations Act or chapter 216.
214     (1)  Effective January 1, 2006, and subject to federal
215waiver approval, a person who is age 65 or older or is
216determined to be disabled, whose income is at or below 88
217percent of the federal poverty level, whose assets do not exceed
218established limitations, and who is not eligible for Medicare
219or, if eligible for Medicare, is also eligible for and receiving
220Medicaid-covered institutional care services, hospice services,
221or home and community-based services. The agency shall seek
222federal authorization through a waiver to provide this coverage.
223This subsection expires June 30, 2010 2009.
224     (2)(a)  A family, a pregnant woman, a child under age 21, a
225person age 65 or over, or a blind or disabled person, who would
226be eligible under any group listed in s. 409.903(1), (2), or
227(3), except that the income or assets of such family or person
228exceed established limitations. For a family or person in one of
229these coverage groups, medical expenses are deductible from
230income in accordance with federal requirements in order to make
231a determination of eligibility. A family or person eligible
232under the coverage known as the "medically needy," is eligible
233to receive the same services as other Medicaid recipients, with
234the exception of services in skilled nursing facilities and
235intermediate care facilities for the developmentally disabled.
236This paragraph subsection expires June 30, 2010 2009.
237     (b)  Effective July 1, 2010 2009, a pregnant woman or a
238child younger than 21 years of age who would be eligible under
239any group listed in s. 409.903, except that the income or assets
240of such group exceed established limitations. For a person in
241one of these coverage groups, medical expenses are deductible
242from income in accordance with federal requirements in order to
243make a determination of eligibility. A person eligible under the
244coverage known as the "medically needy" is eligible to receive
245the same services as other Medicaid recipients, with the
246exception of services in skilled nursing facilities and
247intermediate care facilities for the developmentally disabled.
248     Section 5.  Subsection (4) and paragraph (c) of subsection
249(5) of section 409.905, Florida Statutes, are amended to read:
250     409.905  Mandatory Medicaid services.--The agency may make
251payments for the following services, which are required of the
252state by Title XIX of the Social Security Act, furnished by
253Medicaid providers to recipients who are determined to be
254eligible on the dates on which the services were provided. Any
255service under this section shall be provided only when medically
256necessary and in accordance with state and federal law.
257Mandatory services rendered by providers in mobile units to
258Medicaid recipients may be restricted by the agency. Nothing in
259this section shall be construed to prevent or limit the agency
260from adjusting fees, reimbursement rates, lengths of stay,
261number of visits, number of services, or any other adjustments
262necessary to comply with the availability of moneys and any
263limitations or directions provided for in the General
264Appropriations Act or chapter 216.
265     (4)  HOME HEALTH CARE SERVICES.--The agency shall pay for
266nursing and home health aide services, supplies, appliances, and
267durable medical equipment, necessary to assist a recipient
268living at home. An entity that provides services pursuant to
269this subsection shall be licensed under part III of chapter 400.
270These services, equipment, and supplies, or reimbursement
271therefor, may be limited as provided in the General
272Appropriations Act and do not include services, equipment, or
273supplies provided to a person residing in a hospital or nursing
274facility.
275     (a)  In providing home health care services, the agency may
276require prior authorization of care based on diagnosis or
277utilization rates. Prior authorization is required for home
278health services visits not associated with a skilled nursing
279visit if the home health agency's utilization rates exceed the
280state average by 50 percent or more. The home health agency must
281submit documentation that supports the recipient's diagnosis and
282the recipient's plan of care to the agency when requesting prior
283authorization.
284     (b)  The agency shall implement a comprehensive utilization
285management program that requires prior authorization of all
286private duty nursing services, an individualized treatment plan
287that includes information about medication and treatment orders,
288treatment goals, methods of care to be used, and plans for care
289coordination by nurses and other health professionals. The
290utilization management program shall also include a process for
291periodically reviewing the ongoing use of private duty nursing
292services. For a child, the assessment of need shall be based on
293a child's condition, family support and care supplements, a
294family's ability to provide care, and a family's and child's
295schedule regarding work, school, sleep, and care for other
296family dependents. When implemented, the private duty nursing
297utilization management program shall replace the current
298authorization program used by the Agency for Health Care
299Administration and the Children's Medical Services program of
300the Department of Health. The agency may competitively bid on a
301contract to select a qualified organization to provide
302utilization management of private duty nursing services. The
303agency is authorized to seek federal waivers to implement this
304initiative.
305     (c)  The agency may provide reimbursement only for those
306home health services that are medically necessary and if:
307     1.  The services are ordered by a physician.
308     2.  The written prescription for services is signed and
309dated by the recipient's physician before the development of a
310plan of care and before any required request for prior
311authorization.
312     3.  The physician ordering the services is not employed,
313under contract with, or otherwise affiliated with the home
314health agency rendering the services.
315     4.  The physician ordering the services has examined the
316recipient within 30 days before the initial request for services
317and biannually thereafter.
318     5.  The written prescription for the services includes the
319recipient's acute or chronic medical condition or diagnosis; the
320home health service required, including the minimum skill level
321required to perform the service; and the frequency and duration
322of the services.
323     6.  The national provider identifier, Medicaid
324identification number, or professional license number of the
325physician ordering the services is listed on the written
326prescription for the services, the claim for home health
327reimbursement, and the prior authorization request.
328     (5)  HOSPITAL INPATIENT SERVICES.--The agency shall pay for
329all covered services provided for the medical care and treatment
330of a recipient who is admitted as an inpatient by a licensed
331physician or dentist to a hospital licensed under part I of
332chapter 395. However, the agency shall limit the payment for
333inpatient hospital services for a Medicaid recipient 21 years of
334age or older to 45 days or the number of days necessary to
335comply with the General Appropriations Act.
336     (c)  The Agency for Health Care Administration shall adjust
337a hospital's current inpatient per diem rate to reflect the cost
338of serving the Medicaid population at that institution if:
339     1.  The hospital experiences an increase in Medicaid
340caseload by more than 25 percent in any year, primarily
341resulting from the closure of a hospital in the same service
342area occurring after July 1, 1995;
343     2.  The hospital's Medicaid per diem rate is at least 25
344percent below the Medicaid per patient cost for that year; or
345     3.  The hospital is located in a county that has six five
346or fewer acute care bed hospitals, began offering obstetrical
347services on or after September 1999, and has submitted a request
348in writing to the agency for a rate adjustment after July 1,
3492000, but before September 30, 2000, in which case such
350hospital's Medicaid inpatient per diem rate shall be adjusted to
351cost, effective July 1, 2002.
352
353No later than October 1 of each year, the agency must provide
354estimated costs for any adjustment in a hospital inpatient per
355diem pursuant to this paragraph to the Executive Office of the
356Governor, the House of Representatives General Appropriations
357Committee, and the Senate Appropriations Committee. Before the
358agency implements a change in a hospital's inpatient per diem
359rate pursuant to this paragraph, the Legislature must have
360specifically appropriated sufficient funds in the General
361Appropriations Act to support the increase in cost as estimated
362by the agency.
363     Section 6.  Subsection (23) of section 409.906, Florida
364Statutes, is amended to read:
365     409.906  Optional Medicaid services.--Subject to specific
366appropriations, the agency may make payments for services which
367are optional to the state under Title XIX of the Social Security
368Act and are furnished by Medicaid providers to recipients who
369are determined to be eligible on the dates on which the services
370were provided. Any optional service that is provided shall be
371provided only when medically necessary and in accordance with
372state and federal law. Optional services rendered by providers
373in mobile units to Medicaid recipients may be restricted or
374prohibited by the agency. Nothing in this section shall be
375construed to prevent or limit the agency from adjusting fees,
376reimbursement rates, lengths of stay, number of visits, or
377number of services, or making any other adjustments necessary to
378comply with the availability of moneys and any limitations or
379directions provided for in the General Appropriations Act or
380chapter 216. If necessary to safeguard the state's systems of
381providing services to elderly and disabled persons and subject
382to the notice and review provisions of s. 216.177, the Governor
383may direct the Agency for Health Care Administration to amend
384the Medicaid state plan to delete the optional Medicaid service
385known as "Intermediate Care Facilities for the Developmentally
386Disabled." Optional services may include:
387     (23)  VISUAL SERVICES.--The agency may pay for visual
388examinations, eyeglasses, and eyeglass repairs for a recipient
389if they are prescribed by a licensed physician specializing in
390diseases of the eye or by a licensed optometrist. Eyeglass
391frames Eyeglasses for adult recipients shall be limited to one
392pair two pairs per year per recipient every 2 years, except a
393second third pair may be provided during that period after prior
394authorization. Eyeglass lenses for adult recipients shall be
395limited to one pair per year and may only be provided after
396prior authorization.
397     Section 7.  Subsection (6) of section 409.9082, Florida
398Statutes, as created by chapter 2009-4, Laws of Florida, is
399amended, and paragraph (d) is added to subsection (3) of that
400section, to read:
401     409.9082  Quality assessment on nursing home facility
402providers; exemptions; purpose; federal approval required;
403remedies.--
404     (3)
405     (d)  The agency may exempt a qualified public nursing
406facility that is not owned or operated by the state from the
407quality assessment or apply a lower quality assessment rate to
408that facility if the facility's total annual census days for
409indigent care exceed 25 percent of the facility's total annual
410census days.
411     (6)  The quality assessment shall terminate and the agency
412shall discontinue the imposition, assessment, and collection of
413the nursing facility quality assessment if any of the following
414occur:
415     (a)  the agency does not obtain necessary federal approval
416for the nursing home facility quality assessment or the payment
417rates required by subsection (4); or
418     (b)  The weighted average Medicaid rate paid to nursing
419home facilities is reduced below the weighted average Medicaid
420rate to nursing home facilities in effect on December 31, 2008,
421plus any future annual amount of the quality assessment and the
422applicable matching federal funds.
423
424Upon termination of the quality assessment, all collected
425assessment revenues, less any amounts expended by the agency,
426shall be returned on a pro rata basis to the nursing facilities
427that paid them.
428     Section 8.  Section 409.9083, Florida Statutes, is created
429to read:
430     409.9083  Quality assessment on privately operated
431intermediate care facilities for the developmentally disabled;
432exemptions; purpose; federal approval required; remedies.--
433     (1)  As used in this section, the term:
434     (a)  "Intermediate care facility for the developmentally
435disabled" or "ICF/DD" means a privately operated intermediate
436care facility for the developmentally disabled licensed under
437part VIII of chapter 400.
438     (b)  "Net patient service revenue" means gross revenues
439from services provided to ICF/DD facility residents, less
440reductions from gross revenue resulting from an inability to
441collect payment of charges. Net patient service revenue excludes
442nonresident care revenues such as gain or loss on asset
443disposal, prior year revenue, donations, and physician billings,
444and all outpatient revenues. Reductions from gross revenue
445include bad debts; contractual adjustments; uncompensated care;
446administrative, courtesy, and policy discounts and adjustments;
447and other such revenue deductions.
448     (c)  "Resident day" means a calendar day of care provided
449to an ICF/DD facility resident, including the day of admission
450and excluding the day of discharge, except that, when admission
451and discharge occur on the same day, 1 day of care exists.
452     (2)  Effective October 1, 2009, there is imposed upon each
453intermediate care facility for the developmentally disabled a
454quality assessment. The aggregated amount of assessments for all
455ICF/DDs in a given year shall be an amount not exceeding the
456maximum percentage allowed under federal law of the total
457aggregate net patient service revenue of assessed facilities.
458The agency shall calculate the quality assessment rate annually
459on a per-resident-day basis as reported by the facilities. The
460per-resident-day assessment rate shall be uniform. Each facility
461shall report monthly to the agency its total number of resident
462days and shall remit an amount equal to the assessment rate
463times the reported number of days. The agency shall collect, and
464each facility shall pay, the quality assessment each month. The
465agency shall collect the assessment from facility providers no
466later than the 15th of the next succeeding calendar month. The
467agency shall notify providers of the quality assessment rate and
468provide a standardized form to complete and submit with
469payments. The collection of the quality assessment shall
470commence no sooner than 15 days after the agency's initial
471payment to the facilities that implement the increased Medicaid
472rates containing the elements prescribed in subsection (3) and
473monthly thereafter. Intermediate care facilities for the
474developmentally disabled may increase their rates to incorporate
475the assessment but may not create a separate line-item charge
476for the purpose of passing through the assessment to residents.
477     (3)  The purpose of the facility quality assessment is to
478ensure continued quality of care. Collected assessment funds
479shall be used to obtain federal financial participation through
480the Medicaid program to make Medicaid payments for ICF/DD
481services up to the amount of the Medicaid rates for such
482facilities as calculated in accordance with the approved state
483Medicaid plan in effect on April 1, 2008. The quality assessment
484and federal matching funds shall be used exclusively for the
485following purposes and in the following order of priority:
486     (a)  To reimburse the Medicaid share of the quality
487assessment as a pass-through, Medicaid-allowable cost.
488     (b)  To increase each privately operated ICF/DD Medicaid
489rate, as needed, by an amount that restores the rate reductions
490implemented on October 1, 2008.
491     (c)  To increase each ICF/DD Medicaid rate, as needed, by
492an amount that restores any rate reductions for the 2008-2009
493fiscal year.
494     (d)  To increase payments to such facilities to fund
495covered services to Medicaid beneficiaries.
496     (4)  The agency shall seek necessary federal approval in
497the form of state plan amendments in order to implement the
498provisions of this section.
499     (5)(a)  The quality assessment shall terminate and the
500agency shall discontinue the imposition, assessment, and
501collection of the quality assessment if the agency does not
502obtain necessary federal approval for the facility quality
503assessment or the payment rates required by subsection (3).
504     (b)  Upon termination of the quality assessment, all
505collected assessment revenues, less any amounts expended by the
506agency, shall be returned on a pro rata basis to the facilities
507that paid such assessments.
508     (6)  The agency may seek any of the following remedies for
509failure of any ICF/DD provider to timely pay its assessment:
510     (a)  Withholding any medical assistance reimbursement
511payments until the assessment amount is recovered.
512     (b)  Suspending or revoking the facility's license.
513     (c)  Imposing a fine of up to $1,000 per day for each
514delinquent payment, not to exceed the amount of the assessment.
515     (7)  The agency shall adopt rules necessary to administer
516this section.
517     (8)  This section is repealed October 1, 2011.
518     Section 9.  Paragraph (a) of subsection (2) of section
519409.911, Florida Statutes, is amended to read:
520     409.911  Disproportionate share program.--Subject to
521specific allocations established within the General
522Appropriations Act and any limitations established pursuant to
523chapter 216, the agency shall distribute, pursuant to this
524section, moneys to hospitals providing a disproportionate share
525of Medicaid or charity care services by making quarterly
526Medicaid payments as required. Notwithstanding the provisions of
527s. 409.915, counties are exempt from contributing toward the
528cost of this special reimbursement for hospitals serving a
529disproportionate share of low-income patients.
530     (2)  The Agency for Health Care Administration shall use
531the following actual audited data to determine the Medicaid days
532and charity care to be used in calculating the disproportionate
533share payment:
534     (a)  The average of the 2003, 2004, and 2005 2002, 2003,
535and 2004 audited disproportionate share data to determine each
536hospital's Medicaid days and charity care for the 2009-2010
5372008-2009 state fiscal year.
538     Section 10.  Section 409.9112, Florida Statutes, is amended
539to read:
540     409.9112  Disproportionate share program for regional
541perinatal intensive care centers.--
542     (1)  In addition to the payments made under s. 409.911, the
543Agency for Health Care Administration shall design and implement
544a system of making disproportionate share payments to those
545hospitals that participate in the regional perinatal intensive
546care center program established pursuant to chapter 383. This
547system of payments shall conform with federal requirements and
548shall distribute funds in each fiscal year for which an
549appropriation is made by making quarterly Medicaid payments.
550Notwithstanding the provisions of s. 409.915, counties are
551exempt from contributing toward the cost of this special
552reimbursement for hospitals serving a disproportionate share of
553low-income patients. For the state fiscal year 2009-2010 2008-
5542009, the agency shall not distribute moneys under the regional
555perinatal intensive care centers disproportionate share program.
556     (2)(1)  The following formula shall be used by the agency
557to calculate the total amount earned for hospitals that
558participate in the regional perinatal intensive care center
559program:
560
561TAE = HDSP/THDSP
562
563Where:
564     TAE = total amount earned by a regional perinatal intensive
565care center.
566     HDSP = the prior state fiscal year regional perinatal
567intensive care center disproportionate share payment to the
568individual hospital.
569     THDSP = the prior state fiscal year total regional
570perinatal intensive care center disproportionate share payments
571to all hospitals.
572     (3)(2)  The total additional payment for hospitals that
573participate in the regional perinatal intensive care center
574program shall be calculated by the agency as follows:
575
576TAP = TAE x TA
577
578Where:
579     TAP = total additional payment for a regional perinatal
580intensive care center.
581     TAE = total amount earned by a regional perinatal intensive
582care center.
583     TA = total appropriation for the regional perinatal
584intensive care center disproportionate share program.
585     (4)(3)  In order to receive payments under this section, a
586hospital must be participating in the regional perinatal
587intensive care center program pursuant to chapter 383 and must
588meet the following additional requirements:
589     (a)  Agree to conform to all departmental and agency
590requirements to ensure high quality in the provision of
591services, including criteria adopted by departmental and agency
592rule concerning staffing ratios, medical records, standards of
593care, equipment, space, and such other standards and criteria as
594the department and agency deem appropriate as specified by rule.
595     (b)  Agree to provide information to the department and
596agency, in a form and manner to be prescribed by rule of the
597department and agency, concerning the care provided to all
598patients in neonatal intensive care centers and high-risk
599maternity care.
600     (c)  Agree to accept all patients for neonatal intensive
601care and high-risk maternity care, regardless of ability to pay,
602on a functional space-available basis.
603     (d)  Agree to develop arrangements with other maternity and
604neonatal care providers in the hospital's region for the
605appropriate receipt and transfer of patients in need of
606specialized maternity and neonatal intensive care services.
607     (e)  Agree to establish and provide a developmental
608evaluation and services program for certain high-risk neonates,
609as prescribed and defined by rule of the department.
610     (f)  Agree to sponsor a program of continuing education in
611perinatal care for health care professionals within the region
612of the hospital, as specified by rule.
613     (g)  Agree to provide backup and referral services to the
614department's county health departments and other low-income
615perinatal providers within the hospital's region, including the
616development of written agreements between these organizations
617and the hospital.
618     (h)  Agree to arrange for transportation for high-risk
619obstetrical patients and neonates in need of transfer from the
620community to the hospital or from the hospital to another more
621appropriate facility.
622     (5)(4)  Hospitals which fail to comply with any of the
623conditions in subsection (4) (3) or the applicable rules of the
624department and agency shall not receive any payments under this
625section until full compliance is achieved. A hospital which is
626not in compliance in two or more consecutive quarters shall not
627receive its share of the funds. Any forfeited funds shall be
628distributed by the remaining participating regional perinatal
629intensive care center program hospitals.
630     Section 11.  Section 409.9113, Florida Statutes, is amended
631to read:
632     409.9113  Disproportionate share program for teaching
633hospitals.--
634     (1)  In addition to the payments made under ss. 409.911 and
635409.9112, the Agency for Health Care Administration shall make
636disproportionate share payments to statutorily defined teaching
637hospitals for their increased costs associated with medical
638education programs and for tertiary health care services
639provided to the indigent. This system of payments shall conform
640with federal requirements and shall distribute funds in each
641fiscal year for which an appropriation is made by making
642quarterly Medicaid payments. Notwithstanding s. 409.915,
643counties are exempt from contributing toward the cost of this
644special reimbursement for hospitals serving a disproportionate
645share of low-income patients. For the state fiscal year 2009-
6462010 2008-2009, the agency shall distribute the moneys provided
647in the General Appropriations Act to statutorily defined
648teaching hospitals and family practice teaching hospitals under
649the teaching hospital disproportionate share program. The funds
650provided for statutorily defined teaching hospitals shall be
651distributed in the same proportion as the state fiscal year
6522003-2004 teaching hospital disproportionate share funds were
653distributed or as otherwise provided in the General
654Appropriations Act. The funds provided for family practice
655teaching hospitals shall be distributed equally among family
656practice teaching hospitals.
657     (2)(1)  On or before September 15 of each year, the Agency
658for Health Care Administration shall calculate an allocation
659fraction to be used for distributing funds to state statutory
660teaching hospitals. Subsequent to the end of each quarter of the
661state fiscal year, the agency shall distribute to each statutory
662teaching hospital, as defined in s. 408.07, an amount determined
663by multiplying one-fourth of the funds appropriated for this
664purpose by the Legislature times such hospital's allocation
665fraction. The allocation fraction for each such hospital shall
666be determined by the sum of three primary factors, divided by
667three. The primary factors are:
668     (a)  The number of nationally accredited graduate medical
669education programs offered by the hospital, including programs
670accredited by the Accreditation Council for Graduate Medical
671Education and the combined Internal Medicine and Pediatrics
672programs acceptable to both the American Board of Internal
673Medicine and the American Board of Pediatrics at the beginning
674of the state fiscal year preceding the date on which the
675allocation fraction is calculated. The numerical value of this
676factor is the fraction that the hospital represents of the total
677number of programs, where the total is computed for all state
678statutory teaching hospitals.
679     (b)  The number of full-time equivalent trainees in the
680hospital, which comprises two components:
681     1.  The number of trainees enrolled in nationally
682accredited graduate medical education programs, as defined in
683paragraph (a). Full-time equivalents are computed using the
684fraction of the year during which each trainee is primarily
685assigned to the given institution, over the state fiscal year
686preceding the date on which the allocation fraction is
687calculated. The numerical value of this factor is the fraction
688that the hospital represents of the total number of full-time
689equivalent trainees enrolled in accredited graduate programs,
690where the total is computed for all state statutory teaching
691hospitals.
692     2.  The number of medical students enrolled in accredited
693colleges of medicine and engaged in clinical activities,
694including required clinical clerkships and clinical electives.
695Full-time equivalents are computed using the fraction of the
696year during which each trainee is primarily assigned to the
697given institution, over the course of the state fiscal year
698preceding the date on which the allocation fraction is
699calculated. The numerical value of this factor is the fraction
700that the given hospital represents of the total number of full-
701time equivalent students enrolled in accredited colleges of
702medicine, where the total is computed for all state statutory
703teaching hospitals.
704
705The primary factor for full-time equivalent trainees is computed
706as the sum of these two components, divided by two.
707     (c)  A service index that comprises three components:
708     1.  The Agency for Health Care Administration Service
709Index, computed by applying the standard Service Inventory
710Scores established by the Agency for Health Care Administration
711to services offered by the given hospital, as reported on
712Worksheet A-2 for the last fiscal year reported to the agency
713before the date on which the allocation fraction is calculated.
714The numerical value of this factor is the fraction that the
715given hospital represents of the total Agency for Health Care
716Administration Service Index values, where the total is computed
717for all state statutory teaching hospitals.
718     2.  A volume-weighted service index, computed by applying
719the standard Service Inventory Scores established by the Agency
720for Health Care Administration to the volume of each service,
721expressed in terms of the standard units of measure reported on
722Worksheet A-2 for the last fiscal year reported to the agency
723before the date on which the allocation factor is calculated.
724The numerical value of this factor is the fraction that the
725given hospital represents of the total volume-weighted service
726index values, where the total is computed for all state
727statutory teaching hospitals.
728     3.  Total Medicaid payments to each hospital for direct
729inpatient and outpatient services during the fiscal year
730preceding the date on which the allocation factor is calculated.
731This includes payments made to each hospital for such services
732by Medicaid prepaid health plans, whether the plan was
733administered by the hospital or not. The numerical value of this
734factor is the fraction that each hospital represents of the
735total of such Medicaid payments, where the total is computed for
736all state statutory teaching hospitals.
737
738The primary factor for the service index is computed as the sum
739of these three components, divided by three.
740     (3)(2)  By October 1 of each year, the agency shall use the
741following formula to calculate the maximum additional
742disproportionate share payment for statutorily defined teaching
743hospitals:
744
745TAP = THAF x A
746
747Where:
748     TAP = total additional payment.
749     THAF = teaching hospital allocation factor.
750     A = amount appropriated for a teaching hospital
751disproportionate share program.
752     Section 12.  Section 409.9117, Florida Statutes, is amended
753to read:
754     409.9117  Primary care disproportionate share program.--
755     (1)  For the state fiscal year 2009-2010 2008-2009, the
756agency shall not distribute moneys under the primary care
757disproportionate share program.
758     (2)(1)  If federal funds are available for disproportionate
759share programs in addition to those otherwise provided by law,
760there shall be created a primary care disproportionate share
761program.
762     (3)(2)  The following formula shall be used by the agency
763to calculate the total amount earned for hospitals that
764participate in the primary care disproportionate share program:
765
766TAE = HDSP/THDSP
767
768Where:
769     TAE = total amount earned by a hospital participating in
770the primary care disproportionate share program.
771     HDSP = the prior state fiscal year primary care
772disproportionate share payment to the individual hospital.
773     THDSP = the prior state fiscal year total primary care
774disproportionate share payments to all hospitals.
775     (4)(3)  The total additional payment for hospitals that
776participate in the primary care disproportionate share program
777shall be calculated by the agency as follows:
778
779TAP = TAE x TA
780
781Where:
782     TAP = total additional payment for a primary care hospital.
783     TAE = total amount earned by a primary care hospital.
784     TA = total appropriation for the primary care
785disproportionate share program.
786     (5)(4)  In the establishment and funding of this program,
787the agency shall use the following criteria in addition to those
788specified in s. 409.911, payments may not be made to a hospital
789unless the hospital agrees to:
790     (a)  Cooperate with a Medicaid prepaid health plan, if one
791exists in the community.
792     (b)  Ensure the availability of primary and specialty care
793physicians to Medicaid recipients who are not enrolled in a
794prepaid capitated arrangement and who are in need of access to
795such physicians.
796     (c)  Coordinate and provide primary care services free of
797charge, except copayments, to all persons with incomes up to 100
798percent of the federal poverty level who are not otherwise
799covered by Medicaid or another program administered by a
800governmental entity, and to provide such services based on a
801sliding fee scale to all persons with incomes up to 200 percent
802of the federal poverty level who are not otherwise covered by
803Medicaid or another program administered by a governmental
804entity, except that eligibility may be limited to persons who
805reside within a more limited area, as agreed to by the agency
806and the hospital.
807     (d)  Contract with any federally qualified health center,
808if one exists within the agreed geopolitical boundaries,
809concerning the provision of primary care services, in order to
810guarantee delivery of services in a nonduplicative fashion, and
811to provide for referral arrangements, privileges, and
812admissions, as appropriate. The hospital shall agree to provide
813at an onsite or offsite facility primary care services within 24
814hours to which all Medicaid recipients and persons eligible
815under this paragraph who do not require emergency room services
816are referred during normal daylight hours.
817     (e)  Cooperate with the agency, the county, and other
818entities to ensure the provision of certain public health
819services, case management, referral and acceptance of patients,
820and sharing of epidemiological data, as the agency and the
821hospital find mutually necessary and desirable to promote and
822protect the public health within the agreed geopolitical
823boundaries.
824     (f)  In cooperation with the county in which the hospital
825resides, develop a low-cost, outpatient, prepaid health care
826program to persons who are not eligible for the Medicaid
827program, and who reside within the area.
828     (g)  Provide inpatient services to residents within the
829area who are not eligible for Medicaid or Medicare, and who do
830not have private health insurance, regardless of ability to pay,
831on the basis of available space, except that nothing shall
832prevent the hospital from establishing bill collection programs
833based on ability to pay.
834     (h)  Work with the Florida Healthy Kids Corporation, the
835Florida Health Care Purchasing Cooperative, and business health
836coalitions, as appropriate, to develop a feasibility study and
837plan to provide a low-cost comprehensive health insurance plan
838to persons who reside within the area and who do not have access
839to such a plan.
840     (i)  Work with public health officials and other experts to
841provide community health education and prevention activities
842designed to promote healthy lifestyles and appropriate use of
843health services.
844     (j)  Work with the local health council to develop a plan
845for promoting access to affordable health care services for all
846persons who reside within the area, including, but not limited
847to, public health services, primary care services, inpatient
848services, and affordable health insurance generally.
849
850Any hospital that fails to comply with any of the provisions of
851this subsection, or any other contractual condition, may not
852receive payments under this section until full compliance is
853achieved.
854     Section 13.  Paragraph (g) is added to subsection (5) of
855section 409.912, Florida Statutes, and subsections (54) and (55)
856are added to that section, to read:
857     409.912  Cost-effective purchasing of health care.--The
858agency shall purchase goods and services for Medicaid recipients
859in the most cost-effective manner consistent with the delivery
860of quality medical care. To ensure that medical services are
861effectively utilized, the agency may, in any case, require a
862confirmation or second physician's opinion of the correct
863diagnosis for purposes of authorizing future services under the
864Medicaid program. This section does not restrict access to
865emergency services or poststabilization care services as defined
866in 42 C.F.R. part 438.114. Such confirmation or second opinion
867shall be rendered in a manner approved by the agency. The agency
868shall maximize the use of prepaid per capita and prepaid
869aggregate fixed-sum basis services when appropriate and other
870alternative service delivery and reimbursement methodologies,
871including competitive bidding pursuant to s. 287.057, designed
872to facilitate the cost-effective purchase of a case-managed
873continuum of care. The agency shall also require providers to
874minimize the exposure of recipients to the need for acute
875inpatient, custodial, and other institutional care and the
876inappropriate or unnecessary use of high-cost services. The
877agency shall contract with a vendor to monitor and evaluate the
878clinical practice patterns of providers in order to identify
879trends that are outside the normal practice patterns of a
880provider's professional peers or the national guidelines of a
881provider's professional association. The vendor must be able to
882provide information and counseling to a provider whose practice
883patterns are outside the norms, in consultation with the agency,
884to improve patient care and reduce inappropriate utilization.
885The agency may mandate prior authorization, drug therapy
886management, or disease management participation for certain
887populations of Medicaid beneficiaries, certain drug classes, or
888particular drugs to prevent fraud, abuse, overuse, and possible
889dangerous drug interactions. The Pharmaceutical and Therapeutics
890Committee shall make recommendations to the agency on drugs for
891which prior authorization is required. The agency shall inform
892the Pharmaceutical and Therapeutics Committee of its decisions
893regarding drugs subject to prior authorization. The agency is
894authorized to limit the entities it contracts with or enrolls as
895Medicaid providers by developing a provider network through
896provider credentialing. The agency may competitively bid single-
897source-provider contracts if procurement of goods or services
898results in demonstrated cost savings to the state without
899limiting access to care. The agency may limit its network based
900on the assessment of beneficiary access to care, provider
901availability, provider quality standards, time and distance
902standards for access to care, the cultural competence of the
903provider network, demographic characteristics of Medicaid
904beneficiaries, practice and provider-to-beneficiary standards,
905appointment wait times, beneficiary use of services, provider
906turnover, provider profiling, provider licensure history,
907previous program integrity investigations and findings, peer
908review, provider Medicaid policy and billing compliance records,
909clinical and medical record audits, and other factors. Providers
910shall not be entitled to enrollment in the Medicaid provider
911network. The agency shall determine instances in which allowing
912Medicaid beneficiaries to purchase durable medical equipment and
913other goods is less expensive to the Medicaid program than long-
914term rental of the equipment or goods. The agency may establish
915rules to facilitate purchases in lieu of long-term rentals in
916order to protect against fraud and abuse in the Medicaid program
917as defined in s. 409.913. The agency may seek federal waivers
918necessary to administer these policies.
919     (5)  The Agency for Health Care Administration, in
920partnership with the Department of Elderly Affairs, shall create
921an integrated, fixed-payment delivery program for Medicaid
922recipients who are 60 years of age or older or dually eligible
923for Medicare and Medicaid. The Agency for Health Care
924Administration shall implement the integrated program initially
925on a pilot basis in two areas of the state. The pilot areas
926shall be Area 7 and Area 11 of the Agency for Health Care
927Administration. Enrollment in the pilot areas shall be on a
928voluntary basis and in accordance with approved federal waivers
929and this section. The agency and its program contractors and
930providers shall not enroll any individual in the integrated
931program because the individual or the person legally responsible
932for the individual fails to choose to enroll in the integrated
933program. Enrollment in the integrated program shall be
934exclusively by affirmative choice of the eligible individual or
935by the person legally responsible for the individual. The
936integrated program must transfer all Medicaid services for
937eligible elderly individuals who choose to participate into an
938integrated-care management model designed to serve Medicaid
939recipients in the community. The integrated program must combine
940all funding for Medicaid services provided to individuals who
941are 60 years of age or older or dually eligible for Medicare and
942Medicaid into the integrated program, including funds for
943Medicaid home and community-based waiver services; all Medicaid
944services authorized in ss. 409.905 and 409.906, excluding funds
945for Medicaid nursing home services unless the agency is able to
946demonstrate how the integration of the funds will improve
947coordinated care for these services in a less costly manner; and
948Medicare coinsurance and deductibles for persons dually eligible
949for Medicaid and Medicare as prescribed in s. 409.908(13).
950     (g)  The implementation of the integrated, fixed-payment
951delivery program created under this subsection is subject to an
952appropriation in the General Appropriations Act.
953     (54)  The agency shall develop and implement a home health
954agency monitoring pilot project in Miami-Dade County by January
9551, 2010. The agency shall contract with a vendor to verify the
956utilization and the delivery of home health services and provide
957an electronic billing interface for home health services. The
958contract must require the creation of a program to submit claims
959for the home health services electronically. The program must
960verify visits for the delivery of home health services
961telephonically using voice biometrics. The agency may seek
962amendments to the Medicaid state plan and waivers of federal
963laws, as necessary, to implement the pilot project.
964Notwithstanding s. 287.057(5)(f), the agency must award the
965contract through the competitive solicitation process. The
966agency shall submit a report to the Governor, the President of
967the Senate, and the Speaker of the House of Representatives
968evaluating the pilot project by February 1, 2011.
969     (55)  The agency shall implement a comprehensive care
970management pilot project in Miami-Dade County for home health
971services by January 1, 2010, which includes face-to-face
972assessments by a state-licensed nurse, consultation with
973physicians ordering services to substantiate the medical
974necessity for services, and onsite or desk reviews of
975recipients' medical records. The agency may enter into a
976contract with a qualified organization to implement the pilot
977project. The agency may seek amendments to the Medicaid state
978plan and waivers of federal laws, as necessary, to implement the
979pilot project.
980     Section 14.  Paragraph (e) of subsection (3) and subsection
981(12) of section 409.91211, Florida Statutes, are amended to
982read:
983     409.91211  Medicaid managed care pilot program.--
984     (3)  The agency shall have the following powers, duties,
985and responsibilities with respect to the pilot program:
986     (e)  To implement policies and guidelines for phasing in
987financial risk for approved provider service networks over a 5-
988year 3-year period. These policies and guidelines must include
989an option for a provider service network to be paid fee-for-
990service rates. For any provider service network established in a
991managed care pilot area, the option to be paid fee-for-service
992rates shall include a savings-settlement mechanism that is
993consistent with s. 409.912(44). This model shall be converted to
994a risk-adjusted capitated rate no later than the beginning of
995the sixth fourth year of operation, and may be converted earlier
996at the option of the provider service network. Federally
997qualified health centers may be offered an opportunity to accept
998or decline a contract to participate in any provider network for
999prepaid primary care services.
1000     (12)  For purposes of this section, the term "capitated
1001managed care plan" includes health insurers authorized under
1002chapter 624, exclusive provider organizations authorized under
1003chapter 627, health maintenance organizations authorized under
1004chapter 641, the Children's Medical Services Network under
1005chapter 391, and provider service networks that elect to be paid
1006fee-for-service for up to 5 3 years as authorized under this
1007section.
1008     Section 15.  Subsection (18) is added to section 430.04,
1009Florida Statutes, to read:
1010     430.04  Duties and responsibilities of the Department of
1011Elderly Affairs.--The Department of Elderly Affairs shall:
1012     (18)  Administer all Medicaid waivers and programs relating
1013to elders and their appropriations. The waivers include, but are
1014not limited to, the following:
1015     (a)  Alzheimer's Dementia-Specific Medicaid Waiver as
1016defined in s. 430.502(7),(8), and (9).
1017     (b)  Assisted Living for the Elderly Medicaid Waiver.
1018     (c)  Aged and Disabled Adult Medicaid Waiver.
1019     (d)  Adult Day Health Care Waiver.
1020     (e)  Consumer-directed care program as defined in s.
1021409.221.
1022     (f)  Program of All-inclusive Care for the Elderly.
1023     (g)  Long-term care community-based diversion pilot
1024projects as defined in s. 430.705.
1025     (h)  Channeling Services Waiver for Frail Elders.
1026     Section 16.  Section 430.707, Florida Statutes, is amended
1027to read:
1028     430.707  Contracts.--
1029     (1)  The department, in consultation with the agency, shall
1030select and contract with managed care organizations and, on a
1031prepaid basis, with other qualified providers as defined in s.
1032430.703(7) to provide long-term care within community diversion
1033pilot project areas. All providers shall report quarterly to the
1034department regarding the entity's compliance with all the
1035financial and quality assurance requirements of the contract.
1036     (2)  The department, in consultation with the agency, may
1037contract with entities that which have submitted an application
1038as a community nursing home diversion project as of July 1,
10391998, to provide benefits pursuant to the "Program of All-
1040inclusive Care for the Elderly" as established in Pub. L. No.
1041105-33. For the purposes of this community nursing home
1042diversion project, such entities are shall be exempt from the
1043requirements of chapter 641, if the entity is a private,
1044nonprofit, superior-rated nursing home and if with at least 50
1045percent of its residents are eligible for Medicaid. The agency,
1046in consultation with the department, shall accept and forward to
1047the Centers for Medicare and Medicaid Services an application
1048for expansion of the pilot project from an entity that provides
1049benefits pursuant to the Program of All-inclusive Care for the
1050Elderly and that is in good standing with the agency, the
1051department, and the Centers for Medicare and Medicaid Services.
1052     Section 17.  This act shall take effect July 1, 2009.


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