October 28, 2020
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_h5105c1
CS/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; providing an
22exemption for certain home health agencies; revising
23conditions for adjustment of a hospital's inpatient per
24diem rate; amending s. 409.906, F.S., relating to optional
25Medicaid services; providing limitations on the provision
26of adult vision services; amending s. 409.9082, F.S.;
27authorizing the agency to exempt certain nursing home
28facility providers from quality assessments or apply a
29lower assessment rate to the facility; modifying
30circumstances requiring discontinuance of the quality
31assessment on nursing home facility providers; creating s.
32409.9083, F.S.; providing definitions; providing for a
33quality assessment to be imposed upon privately operated
34intermediate care facility providers for the
35developmentally disabled; requiring the agency to
36calculate the quality assessment rate annually; providing
37requirements for reporting and collecting the assessment;
38specifying the purposes of the assessment and an order of
39priority; requiring that the agency seek federal
40authorization to implement the act; specifying
41circumstances requiring discontinuance of the quality
42assessment; authorizing the agency to impose certain
43penalties against providers that fail to pay the
44assessment; requiring the agency to adopt rules; providing
45for future repeal; amending s. 409.911, F.S.; revising the
46share data used to calculate disproportionate share
47payments to hospitals; amending s. 409.9112, F.S.;
48revising the time period during which the agency is
49prohibited from distributing disproportionate share
50payments to regional perinatal intensive care centers;
51amending s. 409.9113, F.S.; requiring the agency to
52distribute moneys provided in the General Appropriations
53Act to statutorily defined teaching hospitals and family
54practice teaching hospitals under the teaching hospital
55disproportionate share program for the 2009-2010 fiscal
56year; amending s. 409.9117, F.S.; prohibiting the agency
57from distributing moneys under the primary care
58disproportionate share program for the 2009-2010 fiscal
59year; amending s. 409.912, F.S.; providing that the
60continuance of the integrated fixed-payment delivery pilot
61program for certain elderly or dually eligible recipients
62is contingent upon an appropriation; creating a pilot
63project in Miami-Dade County to monitor the delivery of
64home health services and provide for electronic claims for
65home health services; authorizing the agency to seek
66amendments to the state plan and waivers of federal law to
67implement the project; requiring the agency to award
68contracts based on a competitive solicitation process;
69requiring a report to the Governor and Legislature;
70creating a comprehensive care management pilot project in
71Miami-Dade County for home health services; authorizing
72the agency to seek amendments to the state plan and
73waivers of federal law to implement the project; amending
74s. 409.91211, F.S.; revising the date when provider
75service networks convert from fee-for-service to
76capitation rates; amending s. 430.04, F.S.; requiring the
77Department of Elderly Affairs to administer all Medicaid
78waivers and programs relating to elders and their
79appropriations; amending s. 430.707, F.S.; requiring the
80agency, in consultation with the Department of Elderly
81Affairs, to accept and forward to the Centers for Medicare
82and Medicaid Services an application for expansion of a
83pilot project from an entity that provides certain
84benefits under a federal program; providing an effective
85date.
86
87Be It Enacted by the Legislature of the State of Florida:
88
89     Section 1.  Paragraph (c) is added to subsection (8) of
90section 409.814, Florida Statutes, to read:
91     409.814  Eligibility.--A child who has not reached 19 years
92of age whose family income is equal to or below 200 percent of
93the federal poverty level is eligible for the Florida Kidcare
94program as provided in this section. For enrollment in the
95Children's Medical Services Network, a complete application
96includes the medical or behavioral health screening. If,
97subsequently, an individual is determined to be ineligible for
98coverage, he or she must immediately be disenrolled from the
99respective Florida Kidcare program component.
100     (8)  In determining the eligibility of a child, an assets
101test is not required. Each applicant shall provide written
102documentation during the application process and the
103redetermination process, including, but not limited to, the
104following:
105     (a)  Proof of family income, which must include a copy of
106the applicant's most recent federal income tax return. In the
107absence of a federal income tax return, an applicant may submit
108wages and earnings statements (pay stubs), W-2 forms, or other
109appropriate documents.
110     (b)  A statement from all family members that:
111     1.  Their employer does not sponsor a health benefit plan
112for employees; or
113     2.  The potential enrollee is not covered by the employer-
114sponsored health benefit plan because the potential enrollee is
115not eligible for coverage, or, if the potential enrollee is
116eligible but not covered, a statement of the cost to enroll the
117potential enrollee in the employer-sponsored health benefit
118plan.
119     (c)  Effective no later than January 1, 2010, verification
120of the potential enrollee's or enrollee's citizenship status to
121the extent required under Title XXI of the Social Security Act.
122     Section 2.  Paragraphs (g) and (q) of subsection (2) of
123section 409.815, Florida Statutes, are amended, and paragraph
124(w) is added to that subsection, to read:
125     409.815  Health benefits coverage; limitations.--
126     (2)  BENCHMARK BENEFITS.--In order for health benefits
127coverage to qualify for premium assistance payments for an
128eligible child under ss. 409.810-409.820, the health benefits
129coverage, except for coverage under Medicaid and Medikids, must
130include the following minimum benefits, as medically necessary.
131     (g)  Behavioral health services.--
132     1.  Mental health benefits include:
133     a.  Inpatient services, limited to not more than 30
134inpatient days per contract year for psychiatric admissions, or
135residential services in facilities licensed under s. 394.875(6)
136or s. 395.003 in lieu of inpatient psychiatric admissions;
137however, a minimum of 10 of the 30 days shall be available only
138for inpatient psychiatric services when authorized by a
139physician; and
140     b.  Outpatient services, including outpatient visits for
141psychological or psychiatric evaluation, diagnosis, and
142treatment by a licensed mental health professional, limited to a
143maximum of 40 outpatient visits each contract year.
144     2.  Substance abuse services include:
145     a.  Inpatient services, limited to not more than 7
146inpatient days per contract year for medical detoxification only
147and 30 days of residential services; and
148     b.  Outpatient services, including evaluation, diagnosis,
149and treatment by a licensed practitioner, limited to a maximum
150of 40 outpatient visits per contract year.
151     3.  Effective October 1, 2009, covered services include
152inpatient and outpatient services for mental and nervous
153disorders as defined in the most recent edition of the
154Diagnostic and Statistical Manual of Mental Disorders published
155by the American Psychiatric Association. Such benefits include
156psychological or psychiatric evaluation, diagnosis, and
157treatment by a licensed mental health professional and
158inpatient, outpatient, and residential treatment services for
159the diagnosis and treatment of substance abuse disorders. Any
160benefit limitations, including duration of services, number of
161visits, or number of days for hospitalization or residential
162services may not be any less favorable than those for physical
163illnesses generally for the care and treatment of schizophrenia
164and psychotic disorders, mood disorders, anxiety disorders,
165substance abuse disorders, eating disorders, and childhood
166attention deficit disorders. The program may also implement
167appropriate financial incentives, peer review, utilization
168requirements, and other methods used for the management of
169benefits provided for other medical conditions in order to
170reduce service costs and utilization without compromising
171quality of care.
172     (q)  Dental services.--Effective October 1, 2009, dental
173services shall be covered as required under federal law and may
174also include those dental benefits provided to children by the
175Florida Medicaid program under s. 409.906(6). Changes to the
176dental benefit in order to comply with federal law are effective
177October 1, 2009.
178     (w)  Reimbursement of federally qualified health centers
179and rural health clinics.--Effective October 1, 2009, payments
180for services provided to enrollees by federally qualified health
181centers and rural health clinics under this section shall be
182reimbursed using the Medicaid Prospective Payment System as
183provided for under s. 2107(e)(1)(D) of the Social Security Act,
18442 U.S.C. s. 1397gg(e)(1)(D), as added by Pub. L. No 105-33,
185Title IV, s. 4901(a). If such services are paid for by health
186insurers or health care providers under contract with the
187Florida Healthy Kids Corporation, such entities are responsible
188for this payment. The agency may seek any available federal
189grants to assist with this transition.
190     Section 3.  Paragraph (c) of subsection (3) of section
191409.818, Florida Statutes, is amended to read:
192     409.818  Administration.--In order to implement ss.
193409.810-409.820, the following agencies shall have the following
194duties:
195     (3)  The Agency for Health Care Administration, under the
196authority granted in s. 409.914(1), shall:
197     (c)  Monitor compliance with quality assurance and access
198standards developed under s. 409.820 and in accordance with s.
1992103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
200
201The agency is designated the lead state agency for Title XXI of
202the Social Security Act for purposes of receipt of federal
203funds, for reporting purposes, and for ensuring compliance with
204federal and state regulations and rules.
205     Section 4.  Subsections (1) and (2) of section 409.904,
206Florida Statutes, are amended to read:
207     409.904  Optional payments for eligible persons.--The
208agency may make payments for medical assistance and related
209services on behalf of the following persons who are determined
210to be eligible subject to the income, assets, and categorical
211eligibility tests set forth in federal and state law. Payment on
212behalf of these Medicaid eligible persons is subject to the
213availability of moneys and any limitations established by the
214General Appropriations Act or chapter 216.
215     (1)  Effective January 1, 2006, and subject to federal
216waiver approval, a person who is age 65 or older or is
217determined to be disabled, whose income is at or below 88
218percent of the federal poverty level, whose assets do not exceed
219established limitations, and who is not eligible for Medicare
220or, if eligible for Medicare, is also eligible for and receiving
221Medicaid-covered institutional care services, hospice services,
222or home and community-based services. The agency shall seek
223federal authorization through a waiver to provide this coverage.
224This subsection expires June 30, 2010 2009.
225     (2)(a)  A family, a pregnant woman, a child under age 21, a
226person age 65 or over, or a blind or disabled person, who would
227be eligible under any group listed in s. 409.903(1), (2), or
228(3), except that the income or assets of such family or person
229exceed established limitations. For a family or person in one of
230these coverage groups, medical expenses are deductible from
231income in accordance with federal requirements in order to make
232a determination of eligibility. A family or person eligible
233under the coverage known as the "medically needy," is eligible
234to receive the same services as other Medicaid recipients, with
235the exception of services in skilled nursing facilities and
236intermediate care facilities for the developmentally disabled.
237This paragraph subsection expires June 30, 2010 2009.
238     (b)  Effective July 1, 2010 2009, a pregnant woman or a
239child younger than 21 years of age who would be eligible under
240any group listed in s. 409.903, except that the income or assets
241of such group exceed established limitations. For a person in
242one of these coverage groups, medical expenses are deductible
243from income in accordance with federal requirements in order to
244make a determination of eligibility. A person eligible under the
245coverage known as the "medically needy" is eligible to receive
246the same services as other Medicaid recipients, with the
247exception of services in skilled nursing facilities and
248intermediate care facilities for the developmentally disabled.
249     Section 5.  Subsection (4) and paragraph (c) of subsection
250(5) of section 409.905, Florida Statutes, are amended to read:
251     409.905  Mandatory Medicaid services.--The agency may make
252payments for the following services, which are required of the
253state by Title XIX of the Social Security Act, furnished by
254Medicaid providers to recipients who are determined to be
255eligible on the dates on which the services were provided. Any
256service under this section shall be provided only when medically
257necessary and in accordance with state and federal law.
258Mandatory services rendered by providers in mobile units to
259Medicaid recipients may be restricted by the agency. Nothing in
260this section shall be construed to prevent or limit the agency
261from adjusting fees, reimbursement rates, lengths of stay,
262number of visits, number of services, or any other adjustments
263necessary to comply with the availability of moneys and any
264limitations or directions provided for in the General
265Appropriations Act or chapter 216.
266     (4)  HOME HEALTH CARE SERVICES.--The agency shall pay for
267nursing and home health aide services, supplies, appliances, and
268durable medical equipment, necessary to assist a recipient
269living at home. An entity that provides services pursuant to
270this subsection shall be licensed under part III of chapter 400.
271These services, equipment, and supplies, or reimbursement
272therefor, may be limited as provided in the General
273Appropriations Act and do not include services, equipment, or
274supplies provided to a person residing in a hospital or nursing
275facility.
276     (a)  In providing home health care services, the agency may
277require prior authorization of care based on diagnosis or
278utilization rates. Prior authorization is required for home
279health services visits not associated with a skilled nursing
280visit if the home health agency's utilization rates exceed the
281state average by 50 percent or more. The home health agency must
282submit documentation that supports the recipient's diagnosis and
283the recipient's plan of care to the agency when requesting prior
284authorization.
285     (b)  The agency shall implement a comprehensive utilization
286management program that requires prior authorization of all
287private duty nursing services, an individualized treatment plan
288that includes information about medication and treatment orders,
289treatment goals, methods of care to be used, and plans for care
290coordination by nurses and other health professionals. The
291utilization management program shall also include a process for
292periodically reviewing the ongoing use of private duty nursing
293services. For a child, the assessment of need shall be based on
294a child's condition, family support and care supplements, a
295family's ability to provide care, and a family's and child's
296schedule regarding work, school, sleep, and care for other
297family dependents. When implemented, the private duty nursing
298utilization management program shall replace the current
299authorization program used by the Agency for Health Care
300Administration and the Children's Medical Services program of
301the Department of Health. The agency may competitively bid on a
302contract to select a qualified organization to provide
303utilization management of private duty nursing services. The
304agency is authorized to seek federal waivers to implement this
305initiative.
306     (c)  The agency may provide reimbursement only for those
307home health services that are medically necessary and if:
308     1.  The services are ordered by a physician.
309     2.  The written prescription for services is signed and
310dated by the recipient's physician before the development of a
311plan of care and before any required request for prior
312authorization.
313     3.  The physician ordering the services is not employed,
314under contract with, or otherwise affiliated with the home
315health agency rendering the services. However, this provision
316does not apply to a home health agency affiliated with a
317retirement community, of which the parent corporation or a
318related legal entity owns a rural health clinic certified under
31942 C.F.R., part 491, subpart A, ss. 1-11, a nursing home
320licensed under part II of chapter 400, and apartments and
321single-family homes for independent living.
322     4.  The physician ordering the services has examined the
323recipient within 30 days before the initial request for services
324and biannually thereafter.
325     5.  The written prescription for the services includes the
326recipient's acute or chronic medical condition or diagnosis; the
327home health service required, including the minimum skill level
328required to perform the service; and the frequency and duration
329of the services.
330     6.  The national provider identifier, Medicaid
331identification number, or professional license number of the
332physician ordering the services is listed on the written
333prescription for the services, the claim for home health
334reimbursement, and the prior authorization request.
335     (5)  HOSPITAL INPATIENT SERVICES.--The agency shall pay for
336all covered services provided for the medical care and treatment
337of a recipient who is admitted as an inpatient by a licensed
338physician or dentist to a hospital licensed under part I of
339chapter 395. However, the agency shall limit the payment for
340inpatient hospital services for a Medicaid recipient 21 years of
341age or older to 45 days or the number of days necessary to
342comply with the General Appropriations Act.
343     (c)  The Agency for Health Care Administration shall adjust
344a hospital's current inpatient per diem rate to reflect the cost
345of serving the Medicaid population at that institution if:
346     1.  The hospital experiences an increase in Medicaid
347caseload by more than 25 percent in any year, primarily
348resulting from the closure of a hospital in the same service
349area occurring after July 1, 1995;
350     2.  The hospital's Medicaid per diem rate is at least 25
351percent below the Medicaid per patient cost for that year; or
352     3.  The hospital is located in a county that has six five
353or fewer acute care bed hospitals, began offering obstetrical
354services on or after September 1999, and has submitted a request
355in writing to the agency for a rate adjustment after July 1,
3562000, but before September 30, 2000, in which case such
357hospital's Medicaid inpatient per diem rate shall be adjusted to
358cost, effective July 1, 2002.
359
360No later than October 1 of each year, the agency must provide
361estimated costs for any adjustment in a hospital inpatient per
362diem pursuant to this paragraph to the Executive Office of the
363Governor, the House of Representatives General Appropriations
364Committee, and the Senate Appropriations Committee. Before the
365agency implements a change in a hospital's inpatient per diem
366rate pursuant to this paragraph, the Legislature must have
367specifically appropriated sufficient funds in the General
368Appropriations Act to support the increase in cost as estimated
369by the agency.
370     Section 6.  Subsection (23) of section 409.906, Florida
371Statutes, is amended to read:
372     409.906  Optional Medicaid services.--Subject to specific
373appropriations, the agency may make payments for services which
374are optional to the state under Title XIX of the Social Security
375Act and are furnished by Medicaid providers to recipients who
376are determined to be eligible on the dates on which the services
377were provided. Any optional service that is provided shall be
378provided only when medically necessary and in accordance with
379state and federal law. Optional services rendered by providers
380in mobile units to Medicaid recipients may be restricted or
381prohibited by the agency. Nothing in this section shall be
382construed to prevent or limit the agency from adjusting fees,
383reimbursement rates, lengths of stay, number of visits, or
384number of services, or making any other adjustments necessary to
385comply with the availability of moneys and any limitations or
386directions provided for in the General Appropriations Act or
387chapter 216. If necessary to safeguard the state's systems of
388providing services to elderly and disabled persons and subject
389to the notice and review provisions of s. 216.177, the Governor
390may direct the Agency for Health Care Administration to amend
391the Medicaid state plan to delete the optional Medicaid service
392known as "Intermediate Care Facilities for the Developmentally
393Disabled." Optional services may include:
394     (23)  VISUAL SERVICES.--The agency may pay for visual
395examinations, eyeglasses, and eyeglass repairs for a recipient
396if they are prescribed by a licensed physician specializing in
397diseases of the eye or by a licensed optometrist. Eyeglass
398frames Eyeglasses for adult recipients shall be limited to one
399pair two pairs per year per recipient every 2 years, except a
400second third pair may be provided during that period after prior
401authorization. Eyeglass lenses for adult recipients shall be
402limited to one pair per year and may only be provided after
403prior authorization.
404     Section 7.  Subsection (6) of section 409.9082, Florida
405Statutes, as created by chapter 2009-4, Laws of Florida, is
406amended, and paragraph (d) is added to subsection (3) of that
407section, to read:
408     409.9082  Quality assessment on nursing home facility
409providers; exemptions; purpose; federal approval required;
410remedies.--
411     (3)
412     (d)  The agency may exempt a qualified public nursing
413facility that is not owned or operated by the state from the
414quality assessment or apply a lower quality assessment rate to
415that facility if the facility's total annual census days for
416indigent care exceed 25 percent of the facility's total annual
417census days.
418     (6)  The quality assessment shall terminate and the agency
419shall discontinue the imposition, assessment, and collection of
420the nursing facility quality assessment if any of the following
421occur:
422     (a)  the agency does not obtain necessary federal approval
423for the nursing home facility quality assessment or the payment
424rates required by subsection (4); or
425     (b)  The weighted average Medicaid rate paid to nursing
426home facilities is reduced below the weighted average Medicaid
427rate to nursing home facilities in effect on December 31, 2008,
428plus any future annual amount of the quality assessment and the
429applicable matching federal funds.
430
431Upon termination of the quality assessment, all collected
432assessment revenues, less any amounts expended by the agency,
433shall be returned on a pro rata basis to the nursing facilities
434that paid them.
435     Section 8.  Section 409.9083, Florida Statutes, is created
436to read:
437     409.9083  Quality assessment on privately operated
438intermediate care facilities for the developmentally disabled;
439exemptions; purpose; federal approval required; remedies.--
440     (1)  As used in this section, the term:
441     (a)  "Intermediate care facility for the developmentally
442disabled" or "ICF/DD" means a privately operated intermediate
443care facility for the developmentally disabled licensed under
444part VIII of chapter 400.
445     (b)  "Net patient service revenue" means gross revenues
446from services provided to ICF/DD facility residents, less
447reductions from gross revenue resulting from an inability to
448collect payment of charges. Net patient service revenue excludes
449nonresident care revenues such as gain or loss on asset
450disposal, prior year revenue, donations, and physician billings,
451and all outpatient revenues. Reductions from gross revenue
452include bad debts; contractual adjustments; uncompensated care;
453administrative, courtesy, and policy discounts and adjustments;
454and other such revenue deductions.
455     (c)  "Resident day" means a calendar day of care provided
456to an ICF/DD facility resident, including the day of admission
457and excluding the day of discharge, except that, when admission
458and discharge occur on the same day, 1 day of care exists.
459     (2)  Effective October 1, 2009, there is imposed upon each
460intermediate care facility for the developmentally disabled a
461quality assessment. The aggregated amount of assessments for all
462ICF/DDs in a given year shall be an amount not exceeding the
463maximum percentage allowed under federal law of the total
464aggregate net patient service revenue of assessed facilities.
465The agency shall calculate the quality assessment rate annually
466on a per-resident-day basis as reported by the facilities. The
467per-resident-day assessment rate shall be uniform. Each facility
468shall report monthly to the agency its total number of resident
469days and shall remit an amount equal to the assessment rate
470times the reported number of days. The agency shall collect, and
471each facility shall pay, the quality assessment each month. The
472agency shall collect the assessment from facility providers no
473later than the 15th of the next succeeding calendar month. The
474agency shall notify providers of the quality assessment rate and
475provide a standardized form to complete and submit with
476payments. The collection of the quality assessment shall
477commence no sooner than 15 days after the agency's initial
478payment to the facilities that implement the increased Medicaid
479rates containing the elements prescribed in subsection (3) and
480monthly thereafter. Intermediate care facilities for the
481developmentally disabled may increase their rates to incorporate
482the assessment but may not create a separate line-item charge
483for the purpose of passing through the assessment to residents.
484     (3)  The purpose of the facility quality assessment is to
485ensure continued quality of care. Collected assessment funds
486shall be used to obtain federal financial participation through
487the Medicaid program to make Medicaid payments for ICF/DD
488services up to the amount of the Medicaid rates for such
489facilities as calculated in accordance with the approved state
490Medicaid plan in effect on April 1, 2008. The quality assessment
491and federal matching funds shall be used exclusively for the
492following purposes and in the following order of priority:
493     (a)  To reimburse the Medicaid share of the quality
494assessment as a pass-through, Medicaid-allowable cost.
495     (b)  To increase each privately operated ICF/DD Medicaid
496rate, as needed, by an amount that restores the rate reductions
497implemented on October 1, 2008.
498     (c)  To increase each ICF/DD Medicaid rate, as needed, by
499an amount that restores any rate reductions for the 2008-2009
500fiscal year.
501     (d)  To increase payments to such facilities to fund
502covered services to Medicaid beneficiaries.
503     (4)  The agency shall seek necessary federal approval in
504the form of state plan amendments in order to implement the
505provisions of this section.
506     (5)(a)  The quality assessment shall terminate and the
507agency shall discontinue the imposition, assessment, and
508collection of the quality assessment if the agency does not
509obtain necessary federal approval for the facility quality
510assessment or the payment rates required by subsection (3).
511     (b)  Upon termination of the quality assessment, all
512collected assessment revenues, less any amounts expended by the
513agency, shall be returned on a pro rata basis to the facilities
514that paid such assessments.
515     (6)  The agency may seek any of the following remedies for
516failure of any ICF/DD provider to timely pay its assessment:
517     (a)  Withholding any medical assistance reimbursement
518payments until the assessment amount is recovered.
519     (b)  Suspending or revoking the facility's license.
520     (c)  Imposing a fine of up to $1,000 per day for each
521delinquent payment, not to exceed the amount of the assessment.
522     (7)  The agency shall adopt rules necessary to administer
523this section.
524     (8)  This section is repealed October 1, 2011.
525     Section 9.  Paragraph (a) of subsection (2) of section
526409.911, Florida Statutes, is amended to read:
527     409.911  Disproportionate share program.--Subject to
528specific allocations established within the General
529Appropriations Act and any limitations established pursuant to
530chapter 216, the agency shall distribute, pursuant to this
531section, moneys to hospitals providing a disproportionate share
532of Medicaid or charity care services by making quarterly
533Medicaid payments as required. Notwithstanding the provisions of
534s. 409.915, counties are exempt from contributing toward the
535cost of this special reimbursement for hospitals serving a
536disproportionate share of low-income patients.
537     (2)  The Agency for Health Care Administration shall use
538the following actual audited data to determine the Medicaid days
539and charity care to be used in calculating the disproportionate
540share payment:
541     (a)  The average of the 2003, 2004, and 2005 2002, 2003,
542and 2004 audited disproportionate share data to determine each
543hospital's Medicaid days and charity care for the 2009-2010
5442008-2009 state fiscal year.
545     Section 10.  Section 409.9112, Florida Statutes, is amended
546to read:
547     409.9112  Disproportionate share program for regional
548perinatal intensive care centers.--
549     (1)  In addition to the payments made under s. 409.911, the
550Agency for Health Care Administration shall design and implement
551a system of making disproportionate share payments to those
552hospitals that participate in the regional perinatal intensive
553care center program established pursuant to chapter 383. This
554system of payments shall conform with federal requirements and
555shall distribute funds in each fiscal year for which an
556appropriation is made by making quarterly Medicaid payments.
557Notwithstanding the provisions of s. 409.915, counties are
558exempt from contributing toward the cost of this special
559reimbursement for hospitals serving a disproportionate share of
560low-income patients. For the state fiscal year 2009-2010 2008-
5612009, the agency shall not distribute moneys under the regional
562perinatal intensive care centers disproportionate share program.
563     (2)(1)  The following formula shall be used by the agency
564to calculate the total amount earned for hospitals that
565participate in the regional perinatal intensive care center
566program:
567
568TAE = HDSP/THDSP
569
570Where:
571     TAE = total amount earned by a regional perinatal intensive
572care center.
573     HDSP = the prior state fiscal year regional perinatal
574intensive care center disproportionate share payment to the
575individual hospital.
576     THDSP = the prior state fiscal year total regional
577perinatal intensive care center disproportionate share payments
578to all hospitals.
579     (3)(2)  The total additional payment for hospitals that
580participate in the regional perinatal intensive care center
581program shall be calculated by the agency as follows:
582
583TAP = TAE x TA
584
585Where:
586     TAP = total additional payment for a regional perinatal
587intensive care center.
588     TAE = total amount earned by a regional perinatal intensive
589care center.
590     TA = total appropriation for the regional perinatal
591intensive care center disproportionate share program.
592     (4)(3)  In order to receive payments under this section, a
593hospital must be participating in the regional perinatal
594intensive care center program pursuant to chapter 383 and must
595meet the following additional requirements:
596     (a)  Agree to conform to all departmental and agency
597requirements to ensure high quality in the provision of
598services, including criteria adopted by departmental and agency
599rule concerning staffing ratios, medical records, standards of
600care, equipment, space, and such other standards and criteria as
601the department and agency deem appropriate as specified by rule.
602     (b)  Agree to provide information to the department and
603agency, in a form and manner to be prescribed by rule of the
604department and agency, concerning the care provided to all
605patients in neonatal intensive care centers and high-risk
606maternity care.
607     (c)  Agree to accept all patients for neonatal intensive
608care and high-risk maternity care, regardless of ability to pay,
609on a functional space-available basis.
610     (d)  Agree to develop arrangements with other maternity and
611neonatal care providers in the hospital's region for the
612appropriate receipt and transfer of patients in need of
613specialized maternity and neonatal intensive care services.
614     (e)  Agree to establish and provide a developmental
615evaluation and services program for certain high-risk neonates,
616as prescribed and defined by rule of the department.
617     (f)  Agree to sponsor a program of continuing education in
618perinatal care for health care professionals within the region
619of the hospital, as specified by rule.
620     (g)  Agree to provide backup and referral services to the
621department's county health departments and other low-income
622perinatal providers within the hospital's region, including the
623development of written agreements between these organizations
624and the hospital.
625     (h)  Agree to arrange for transportation for high-risk
626obstetrical patients and neonates in need of transfer from the
627community to the hospital or from the hospital to another more
628appropriate facility.
629     (5)(4)  Hospitals which fail to comply with any of the
630conditions in subsection (4) (3) or the applicable rules of the
631department and agency shall not receive any payments under this
632section until full compliance is achieved. A hospital which is
633not in compliance in two or more consecutive quarters shall not
634receive its share of the funds. Any forfeited funds shall be
635distributed by the remaining participating regional perinatal
636intensive care center program hospitals.
637     Section 11.  Section 409.9113, Florida Statutes, is amended
638to read:
639     409.9113  Disproportionate share program for teaching
640hospitals.--
641     (1)  In addition to the payments made under ss. 409.911 and
642409.9112, the Agency for Health Care Administration shall make
643disproportionate share payments to statutorily defined teaching
644hospitals for their increased costs associated with medical
645education programs and for tertiary health care services
646provided to the indigent. This system of payments shall conform
647with federal requirements and shall distribute funds in each
648fiscal year for which an appropriation is made by making
649quarterly Medicaid payments. Notwithstanding s. 409.915,
650counties are exempt from contributing toward the cost of this
651special reimbursement for hospitals serving a disproportionate
652share of low-income patients. For the state fiscal year 2009-
6532010 2008-2009, the agency shall distribute the moneys provided
654in the General Appropriations Act to statutorily defined
655teaching hospitals and family practice teaching hospitals under
656the teaching hospital disproportionate share program. The funds
657provided for statutorily defined teaching hospitals shall be
658distributed in the same proportion as the state fiscal year
6592003-2004 teaching hospital disproportionate share funds were
660distributed or as otherwise provided in the General
661Appropriations Act. The funds provided for family practice
662teaching hospitals shall be distributed equally among family
663practice teaching hospitals.
664     (2)(1)  On or before September 15 of each year, the Agency
665for Health Care Administration shall calculate an allocation
666fraction to be used for distributing funds to state statutory
667teaching hospitals. Subsequent to the end of each quarter of the
668state fiscal year, the agency shall distribute to each statutory
669teaching hospital, as defined in s. 408.07, an amount determined
670by multiplying one-fourth of the funds appropriated for this
671purpose by the Legislature times such hospital's allocation
672fraction. The allocation fraction for each such hospital shall
673be determined by the sum of three primary factors, divided by
674three. The primary factors are:
675     (a)  The number of nationally accredited graduate medical
676education programs offered by the hospital, including programs
677accredited by the Accreditation Council for Graduate Medical
678Education and the combined Internal Medicine and Pediatrics
679programs acceptable to both the American Board of Internal
680Medicine and the American Board of Pediatrics at the beginning
681of the state fiscal year preceding the date on which the
682allocation fraction is calculated. The numerical value of this
683factor is the fraction that the hospital represents of the total
684number of programs, where the total is computed for all state
685statutory teaching hospitals.
686     (b)  The number of full-time equivalent trainees in the
687hospital, which comprises two components:
688     1.  The number of trainees enrolled in nationally
689accredited graduate medical education programs, as defined in
690paragraph (a). Full-time equivalents are computed using the
691fraction of the year during which each trainee is primarily
692assigned to the given institution, over the state fiscal year
693preceding the date on which the allocation fraction is
694calculated. The numerical value of this factor is the fraction
695that the hospital represents of the total number of full-time
696equivalent trainees enrolled in accredited graduate programs,
697where the total is computed for all state statutory teaching
698hospitals.
699     2.  The number of medical students enrolled in accredited
700colleges of medicine and engaged in clinical activities,
701including required clinical clerkships and clinical electives.
702Full-time equivalents are computed using the fraction of the
703year during which each trainee is primarily assigned to the
704given institution, over the course of the state fiscal year
705preceding the date on which the allocation fraction is
706calculated. The numerical value of this factor is the fraction
707that the given hospital represents of the total number of full-
708time equivalent students enrolled in accredited colleges of
709medicine, where the total is computed for all state statutory
710teaching hospitals.
711
712The primary factor for full-time equivalent trainees is computed
713as the sum of these two components, divided by two.
714     (c)  A service index that comprises three components:
715     1.  The Agency for Health Care Administration Service
716Index, computed by applying the standard Service Inventory
717Scores established by the Agency for Health Care Administration
718to services offered by the given hospital, as reported on
719Worksheet A-2 for the last fiscal year reported to the agency
720before the date on which the allocation fraction is calculated.
721The numerical value of this factor is the fraction that the
722given hospital represents of the total Agency for Health Care
723Administration Service Index values, where the total is computed
724for all state statutory teaching hospitals.
725     2.  A volume-weighted service index, computed by applying
726the standard Service Inventory Scores established by the Agency
727for Health Care Administration to the volume of each service,
728expressed in terms of the standard units of measure reported on
729Worksheet A-2 for the last fiscal year reported to the agency
730before the date on which the allocation factor is calculated.
731The numerical value of this factor is the fraction that the
732given hospital represents of the total volume-weighted service
733index values, where the total is computed for all state
734statutory teaching hospitals.
735     3.  Total Medicaid payments to each hospital for direct
736inpatient and outpatient services during the fiscal year
737preceding the date on which the allocation factor is calculated.
738This includes payments made to each hospital for such services
739by Medicaid prepaid health plans, whether the plan was
740administered by the hospital or not. The numerical value of this
741factor is the fraction that each hospital represents of the
742total of such Medicaid payments, where the total is computed for
743all state statutory teaching hospitals.
744
745The primary factor for the service index is computed as the sum
746of these three components, divided by three.
747     (3)(2)  By October 1 of each year, the agency shall use the
748following formula to calculate the maximum additional
749disproportionate share payment for statutorily defined teaching
750hospitals:
751
752TAP = THAF x A
753
754Where:
755     TAP = total additional payment.
756     THAF = teaching hospital allocation factor.
757     A = amount appropriated for a teaching hospital
758disproportionate share program.
759     Section 12.  Section 409.9117, Florida Statutes, is amended
760to read:
761     409.9117  Primary care disproportionate share program.--
762     (1)  For the state fiscal year 2009-2010 2008-2009, the
763agency shall not distribute moneys under the primary care
764disproportionate share program.
765     (2)(1)  If federal funds are available for disproportionate
766share programs in addition to those otherwise provided by law,
767there shall be created a primary care disproportionate share
768program.
769     (3)(2)  The following formula shall be used by the agency
770to calculate the total amount earned for hospitals that
771participate in the primary care disproportionate share program:
772
773TAE = HDSP/THDSP
774
775Where:
776     TAE = total amount earned by a hospital participating in
777the primary care disproportionate share program.
778     HDSP = the prior state fiscal year primary care
779disproportionate share payment to the individual hospital.
780     THDSP = the prior state fiscal year total primary care
781disproportionate share payments to all hospitals.
782     (4)(3)  The total additional payment for hospitals that
783participate in the primary care disproportionate share program
784shall be calculated by the agency as follows:
785
786TAP = TAE x TA
787
788Where:
789     TAP = total additional payment for a primary care hospital.
790     TAE = total amount earned by a primary care hospital.
791     TA = total appropriation for the primary care
792disproportionate share program.
793     (5)(4)  In the establishment and funding of this program,
794the agency shall use the following criteria in addition to those
795specified in s. 409.911, payments may not be made to a hospital
796unless the hospital agrees to:
797     (a)  Cooperate with a Medicaid prepaid health plan, if one
798exists in the community.
799     (b)  Ensure the availability of primary and specialty care
800physicians to Medicaid recipients who are not enrolled in a
801prepaid capitated arrangement and who are in need of access to
802such physicians.
803     (c)  Coordinate and provide primary care services free of
804charge, except copayments, to all persons with incomes up to 100
805percent of the federal poverty level who are not otherwise
806covered by Medicaid or another program administered by a
807governmental entity, and to provide such services based on a
808sliding fee scale to all persons with incomes up to 200 percent
809of the federal poverty level who are not otherwise covered by
810Medicaid or another program administered by a governmental
811entity, except that eligibility may be limited to persons who
812reside within a more limited area, as agreed to by the agency
813and the hospital.
814     (d)  Contract with any federally qualified health center,
815if one exists within the agreed geopolitical boundaries,
816concerning the provision of primary care services, in order to
817guarantee delivery of services in a nonduplicative fashion, and
818to provide for referral arrangements, privileges, and
819admissions, as appropriate. The hospital shall agree to provide
820at an onsite or offsite facility primary care services within 24
821hours to which all Medicaid recipients and persons eligible
822under this paragraph who do not require emergency room services
823are referred during normal daylight hours.
824     (e)  Cooperate with the agency, the county, and other
825entities to ensure the provision of certain public health
826services, case management, referral and acceptance of patients,
827and sharing of epidemiological data, as the agency and the
828hospital find mutually necessary and desirable to promote and
829protect the public health within the agreed geopolitical
830boundaries.
831     (f)  In cooperation with the county in which the hospital
832resides, develop a low-cost, outpatient, prepaid health care
833program to persons who are not eligible for the Medicaid
834program, and who reside within the area.
835     (g)  Provide inpatient services to residents within the
836area who are not eligible for Medicaid or Medicare, and who do
837not have private health insurance, regardless of ability to pay,
838on the basis of available space, except that nothing shall
839prevent the hospital from establishing bill collection programs
840based on ability to pay.
841     (h)  Work with the Florida Healthy Kids Corporation, the
842Florida Health Care Purchasing Cooperative, and business health
843coalitions, as appropriate, to develop a feasibility study and
844plan to provide a low-cost comprehensive health insurance plan
845to persons who reside within the area and who do not have access
846to such a plan.
847     (i)  Work with public health officials and other experts to
848provide community health education and prevention activities
849designed to promote healthy lifestyles and appropriate use of
850health services.
851     (j)  Work with the local health council to develop a plan
852for promoting access to affordable health care services for all
853persons who reside within the area, including, but not limited
854to, public health services, primary care services, inpatient
855services, and affordable health insurance generally.
856
857Any hospital that fails to comply with any of the provisions of
858this subsection, or any other contractual condition, may not
859receive payments under this section until full compliance is
860achieved.
861     Section 13.  Paragraph (g) is added to subsection (5) of
862section 409.912, Florida Statutes, and subsections (54) and (55)
863are added to that section, to read:
864     409.912  Cost-effective purchasing of health care.--The
865agency shall purchase goods and services for Medicaid recipients
866in the most cost-effective manner consistent with the delivery
867of quality medical care. To ensure that medical services are
868effectively utilized, the agency may, in any case, require a
869confirmation or second physician's opinion of the correct
870diagnosis for purposes of authorizing future services under the
871Medicaid program. This section does not restrict access to
872emergency services or poststabilization care services as defined
873in 42 C.F.R. part 438.114. Such confirmation or second opinion
874shall be rendered in a manner approved by the agency. The agency
875shall maximize the use of prepaid per capita and prepaid
876aggregate fixed-sum basis services when appropriate and other
877alternative service delivery and reimbursement methodologies,
878including competitive bidding pursuant to s. 287.057, designed
879to facilitate the cost-effective purchase of a case-managed
880continuum of care. The agency shall also require providers to
881minimize the exposure of recipients to the need for acute
882inpatient, custodial, and other institutional care and the
883inappropriate or unnecessary use of high-cost services. The
884agency shall contract with a vendor to monitor and evaluate the
885clinical practice patterns of providers in order to identify
886trends that are outside the normal practice patterns of a
887provider's professional peers or the national guidelines of a
888provider's professional association. The vendor must be able to
889provide information and counseling to a provider whose practice
890patterns are outside the norms, in consultation with the agency,
891to improve patient care and reduce inappropriate utilization.
892The agency may mandate prior authorization, drug therapy
893management, or disease management participation for certain
894populations of Medicaid beneficiaries, certain drug classes, or
895particular drugs to prevent fraud, abuse, overuse, and possible
896dangerous drug interactions. The Pharmaceutical and Therapeutics
897Committee shall make recommendations to the agency on drugs for
898which prior authorization is required. The agency shall inform
899the Pharmaceutical and Therapeutics Committee of its decisions
900regarding drugs subject to prior authorization. The agency is
901authorized to limit the entities it contracts with or enrolls as
902Medicaid providers by developing a provider network through
903provider credentialing. The agency may competitively bid single-
904source-provider contracts if procurement of goods or services
905results in demonstrated cost savings to the state without
906limiting access to care. The agency may limit its network based
907on the assessment of beneficiary access to care, provider
908availability, provider quality standards, time and distance
909standards for access to care, the cultural competence of the
910provider network, demographic characteristics of Medicaid
911beneficiaries, practice and provider-to-beneficiary standards,
912appointment wait times, beneficiary use of services, provider
913turnover, provider profiling, provider licensure history,
914previous program integrity investigations and findings, peer
915review, provider Medicaid policy and billing compliance records,
916clinical and medical record audits, and other factors. Providers
917shall not be entitled to enrollment in the Medicaid provider
918network. The agency shall determine instances in which allowing
919Medicaid beneficiaries to purchase durable medical equipment and
920other goods is less expensive to the Medicaid program than long-
921term rental of the equipment or goods. The agency may establish
922rules to facilitate purchases in lieu of long-term rentals in
923order to protect against fraud and abuse in the Medicaid program
924as defined in s. 409.913. The agency may seek federal waivers
925necessary to administer these policies.
926     (5)  The Agency for Health Care Administration, in
927partnership with the Department of Elderly Affairs, shall create
928an integrated, fixed-payment delivery program for Medicaid
929recipients who are 60 years of age or older or dually eligible
930for Medicare and Medicaid. The Agency for Health Care
931Administration shall implement the integrated program initially
932on a pilot basis in two areas of the state. The pilot areas
933shall be Area 7 and Area 11 of the Agency for Health Care
934Administration. Enrollment in the pilot areas shall be on a
935voluntary basis and in accordance with approved federal waivers
936and this section. The agency and its program contractors and
937providers shall not enroll any individual in the integrated
938program because the individual or the person legally responsible
939for the individual fails to choose to enroll in the integrated
940program. Enrollment in the integrated program shall be
941exclusively by affirmative choice of the eligible individual or
942by the person legally responsible for the individual. The
943integrated program must transfer all Medicaid services for
944eligible elderly individuals who choose to participate into an
945integrated-care management model designed to serve Medicaid
946recipients in the community. The integrated program must combine
947all funding for Medicaid services provided to individuals who
948are 60 years of age or older or dually eligible for Medicare and
949Medicaid into the integrated program, including funds for
950Medicaid home and community-based waiver services; all Medicaid
951services authorized in ss. 409.905 and 409.906, excluding funds
952for Medicaid nursing home services unless the agency is able to
953demonstrate how the integration of the funds will improve
954coordinated care for these services in a less costly manner; and
955Medicare coinsurance and deductibles for persons dually eligible
956for Medicaid and Medicare as prescribed in s. 409.908(13).
957     (g)  The implementation of the integrated, fixed-payment
958delivery program created under this subsection is subject to an
959appropriation in the General Appropriations Act.
960     (54)  The agency shall develop and implement a home health
961agency monitoring pilot project in Miami-Dade County by January
9621, 2010. The agency shall contract with a vendor to verify the
963utilization and the delivery of home health services and provide
964an electronic billing interface for home health services. The
965contract must require the creation of a program to submit claims
966for the home health services electronically. The program must
967verify visits for the delivery of home health services
968telephonically using voice biometrics. The agency may seek
969amendments to the Medicaid state plan and waivers of federal
970laws, as necessary, to implement the pilot project.
971Notwithstanding s. 287.057(5)(f), the agency must award the
972contract through the competitive solicitation process. The
973agency shall submit a report to the Governor, the President of
974the Senate, and the Speaker of the House of Representatives
975evaluating the pilot project by February 1, 2011.
976     (55)  The agency shall implement a comprehensive care
977management pilot project in Miami-Dade County for home health
978services by January 1, 2010, which includes face-to-face
979assessments by a state-licensed nurse, consultation with
980physicians ordering services to substantiate the medical
981necessity for services, and onsite or desk reviews of
982recipients' medical records. The agency may enter into a
983contract with a qualified organization to implement the pilot
984project. The agency may seek amendments to the Medicaid state
985plan and waivers of federal laws, as necessary, to implement the
986pilot project.
987     Section 14.  Paragraph (e) of subsection (3) and subsection
988(12) of section 409.91211, Florida Statutes, are amended to
989read:
990     409.91211  Medicaid managed care pilot program.--
991     (3)  The agency shall have the following powers, duties,
992and responsibilities with respect to the pilot program:
993     (e)  To implement policies and guidelines for phasing in
994financial risk for approved provider service networks over a 5-
995year 3-year period. These policies and guidelines must include
996an option for a provider service network to be paid fee-for-
997service rates. For any provider service network established in a
998managed care pilot area, the option to be paid fee-for-service
999rates shall include a savings-settlement mechanism that is
1000consistent with s. 409.912(44). This model shall be converted to
1001a risk-adjusted capitated rate no later than the beginning of
1002the sixth fourth year of operation, and may be converted earlier
1003at the option of the provider service network. Federally
1004qualified health centers may be offered an opportunity to accept
1005or decline a contract to participate in any provider network for
1006prepaid primary care services.
1007     (12)  For purposes of this section, the term "capitated
1008managed care plan" includes health insurers authorized under
1009chapter 624, exclusive provider organizations authorized under
1010chapter 627, health maintenance organizations authorized under
1011chapter 641, the Children's Medical Services Network under
1012chapter 391, and provider service networks that elect to be paid
1013fee-for-service for up to 5 3 years as authorized under this
1014section.
1015     Section 15.  Subsection (18) is added to section 430.04,
1016Florida Statutes, to read:
1017     430.04  Duties and responsibilities of the Department of
1018Elderly Affairs.--The Department of Elderly Affairs shall:
1019     (18)  Administer all Medicaid waivers and programs relating
1020to elders and their appropriations. The waivers include, but are
1021not limited to, the following:
1022     (a)  Alzheimer's Dementia-Specific Medicaid Waiver as
1023defined in s. 430.502(7),(8), and (9).
1024     (b)  Assisted Living for the Elderly Medicaid Waiver.
1025     (c)  Aged and Disabled Adult Medicaid Waiver.
1026     (d)  Adult Day Health Care Waiver.
1027     (e)  Consumer-directed care program as defined in s.
1028409.221.
1029     (f)  Program of All-inclusive Care for the Elderly.
1030     (g)  Long-term care community-based diversion pilot
1031projects as defined in s. 430.705.
1032     (h)  Channeling Services Waiver for Frail Elders.
1033     Section 16.  Section 430.707, Florida Statutes, is amended
1034to read:
1035     430.707  Contracts.--
1036     (1)  The department, in consultation with the agency, shall
1037select and contract with managed care organizations and, on a
1038prepaid basis, with other qualified providers as defined in s.
1039430.703(7) to provide long-term care within community diversion
1040pilot project areas. All providers shall report quarterly to the
1041department regarding the entity's compliance with all the
1042financial and quality assurance requirements of the contract.
1043     (2)  The department, in consultation with the agency, may
1044contract with entities that which have submitted an application
1045as a community nursing home diversion project as of July 1,
10461998, to provide benefits pursuant to the "Program of All-
1047inclusive Care for the Elderly" as established in Pub. L. No.
1048105-33. For the purposes of this community nursing home
1049diversion project, such entities are shall be exempt from the
1050requirements of chapter 641, if the entity is a private,
1051nonprofit, superior-rated nursing home and if with at least 50
1052percent of its residents are eligible for Medicaid. The agency,
1053in consultation with the department, shall accept and forward to
1054the Centers for Medicare and Medicaid Services an application
1055for expansion of the pilot project from an entity that provides
1056benefits pursuant to the Program of All-inclusive Care for the
1057Elderly and that is in good standing with the agency, the
1058department, and the Centers for Medicare and Medicaid Services.
1059     Section 17.  This act shall take effect July 1, 2009.


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