September 18, 2020
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HB 7225

A bill to be entitled
2An act relating to Medicaid; amending s. 393.0661, F.S.,
3relating to the home and community-based services delivery
4system for persons with developmental disabilities;
5requiring the Agency for Persons with Disabilities to
6establish a transition plan for current Medicaid
7recipients under certain circumstances; providing for
8expiration of the section on a specified date; creating s.
9400.0713, F.S.; requiring the Agency for Health Care
10Administration to establish a nursing home licensure
11workgroup; amending s. 408.040, F.S.; providing for
12suspension of conditions precedent to the issuance of a
13certificate of need for a nursing home, effective on a
14specified date; amending s. 408.0435, F.S.; extending the
15certificate-of-need moratorium for additional community
16nursing home beds; designating ss. 409.016-409.803, F.S.,
17as pt. I of ch. 409, F.S., and entitling the part "Social
18and Economic Assistance"; designating ss. 409.810-409.821,
19F.S., as pt. II of ch. 409, F.S., and entitling the part
20"Kidcare"; designating ss. 409.901-409.9205, F.S., as part
21III of ch. 409, F.S., and entitling the part "Medicaid";
22amending s. 409.907, F.S.; authorizing the Agency for
23Health Care Administration to enroll entities as Medicare
24crossover-only providers for payment purposes only;
25specifying requirements for Medicare crossover-only
26agreements; amending s. 409.908, F.S.; providing penalties
27for providers that fail to report suspension or
28disenrollment from Medicare within a specified time;
29amending s. 409.912, F.S.; authorizing provider service
30networks to provide comprehensive behavioral health care
31services to certain Medicaid recipients; providing payment
32requirements for provider service networks; providing for
33the expiration of various provisions of the section on
34specified dates to conform to the reorganization of
35Medicaid managed care; eliminating obsolete provisions and
36updating provisions within the section; amending ss.
37409.91195 and 409.91196, F.S.; conforming cross-
38references; amending s. 409.91207, F.S.; providing
39authority of the Agency for Health Care Administration
40with respect to the development of a method for
41designating qualified plans as a medical home network;
42providing purposes and principles for creating medical
43home networks; providing criteria for designation of a
44qualified plan as a medical home network; providing agency
45duties with respect thereto; amending s. 409.91211, F.S.;
46providing authority of the Agency for Health Care
47Administration to implement a managed care pilot program
48based on specified waiver authority with respect to the
49Medicaid reform program; continuing the existing pilot
50program in specified counties; requiring the agency to
51seek an extension of the waiver; providing for monthly
52reports; requiring approval of the Legislative Budget
53Commission for changes to specified terms and conditions ;
54providing for expansion of the managed care pilot program
55to Miami-Dade County; specifying managed care plans that
56are qualified to participate in the Medicaid managed care
57pilot program; providing requirements for qualified
58managed care plans; requiring the agency to develop and
59seek federal approval to implement methodologies to
60preserve intergovernmental transfers of funds and
61certified public expenditures from Miami-Dade County;
62requiring the agency to submit a plan and specified
63amendment to the Legislative Budget Commission; providing
64for a report; requiring Medicaid recipients in counties in
65which the managed care pilot program has been implemented
66to be enrolled in a qualified plan; providing a time limit
67for enrollment; requiring the agency to provide choice
68counseling; providing requirements with respect to choice
69counseling information provided to Medicaid recipients;
70providing for automatic enrollment of certain Medicaid
71recipients; establishing criteria for automatic
72enrollment; providing procedures and requirements with
73respect to voluntary disenrollment of a recipient in a
74qualified plan; providing for an enrollment period;
75requiring qualified plans to establish a process for
76review of and response to grievances of enrollees;
77requiring qualified plans to submit quarterly reports;
78specifying services to be covered by qualified plans;
79authorizing qualified plans to offer specified
80customizations, variances, and coverage for additional
81services; requiring agency evaluation of proposed benefit
82packages; requiring qualified plans to reimburse the
83agency for the cost of specified enrollment changes;
84providing for access to encounter data; requiring
85participating plans to establish an incentive program to
86reward healthy behaviors; requiring the agency to continue
87budget-neutral adjustment of capitation rates for all
88prepaid plans in existing managed care pilot program
89counties; providing for transition to payment
90methodologies for Miami-Dade County plans; providing a
91phased schedule for risk-adjusted capitation rates;
92requiring the establishment of a technical advisory panel;
93providing for distribution of funds from a low-income
94pool; specifying purposes for such distribution; requiring
95the agency to maintain and operate the Medicaid Encounter
96Data System; requiring the agency to contract with the
97University of Florida for evaluation of the pilot program;
98amending s. 409.9122, F.S.; eliminating outdated
99provisions; providing for the expiration of various
100provisions of the section on specified dates to conform to
101the reorganization of Medicaid managed care; requiring the
102Agency for Health Care Administration to begin a budget-
103neutral adjustment of capitation rates for all Medicaid
104prepaid plans in the state on a specified date; providing
105the basis for the adjustment; providing a phased schedule
106for risk adjusted capitation rates; providing for the
107establishment of a technical advisory panel; requiring the
108agency to develop a process to enable any recipient with
109access to employer sponsored insurance to opt out of
110qualified plans in the Medicaid program; requiring the
111agency, contingent on federal approval, to enable
112recipients with access to other insurance or related
113products providing access to specified health care
114services to opt out of qualified plans in the Medicaid
115program; providing a limitation on the amount of financial
116assistance provided for each recipient; requiring each
117qualified plan to establish an incentive program that
118rewards specific healthy behaviors; requiring plans to
119maintain a specified reserve account; requiring the agency
120to maintain and operate the Medicaid Encounter Data
121System; requiring the agency to establish a designated
122payment for specified Medicare Advantage Special Needs
123members; authorizing the agency to develop a designated
124payment for Medicaid-only covered services for which the
125state is responsible; requiring the agency to establish,
126and managed care plans to use, a uniform method of
127accounting for and reporting of medical and nonmedical
128costs; requiring reimbursement by Medicaid of school
129districts participating in a certified school match
130program for a Medicaid-eligible child participating in the
131services, effective on a specified date; requiring the
132agency, the Department of Health, and the Department of
133Education to develop procedures for ensuring that a
134student's managed care plan receives information relating
135to services provided; authorizing the Agency for Health
136Care Administration to create exceptions to mandatory
137enrollment in managed care under specified circumstances;
138amending s. 430.04, F.S.; eliminating outdated provisions;
139requiring the Department of Elderly Affairs to develop a
140transition plan for specified elder and disabled adults
141receiving long-term care Medicaid services when qualified
142plans become available; providing for expiration thereof;
143amending s. 430.2053, F.S.; eliminating outdated
144provisions; providing additional duties of aging resource
145centers; providing an additional exception to direct
146services that may not be provided by an aging resource
147center; providing for the cessation of specified  payments
148by the department as qualified plans become available;
149providing for a memorandum of understanding between the
150Agency for Health Care Administration and aging resource
151centers under certain circumstances; eliminating
152provisions requiring reports; amending s. 641.386, F.S.;
153conforming a cross-reference; repealing s. 430.701, F.S.,
154relating to legislative findings and intent and approval
155for action relating to provider enrollment levels;
156repealing s. 430.702, F.S., relating to the Long-Term Care
157Community Diversion Pilot Project Act; repealing s.
158430.703, F.S., relating to definitions; repealing s.
159430.7031, F.S., relating to nursing home transition
160program; repealing s. 430.704, F.S., relating to
161evaluation of long-term care through the pilot projects;
162repealing s. 430.705, F.S., relating to implementation of
163long-term care community diversion pilot projects;
164repealing s. 430.706, F.S., relating to quality of care;
165repealing s. 430.707, F.S., relating to contracts;
166repealing s. 430.708, F.S., relating to certificate of
167need; repealing s. 430.709, F.S., relating to reports and
168evaluations; renumbering ss. 409.9301, 409.942, 409.944,
169409.945, 409.946, 409.953, and 409.9531, F.S., as ss.
170402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
171402.87, F.S., respectively; amending s. 443.111, F.S.;
172conforming a cross-reference; providing contingent
173effective dates.
175Be It Enacted by the Legislature of the State of Florida:
177     Section 1.  Section 393.0661, Florida Statutes, is amended
178to read:
179     393.0661  Home and community-based services delivery
180system; comprehensive redesign.-The Legislature finds that the
181home and community-based services delivery system for persons
182with developmental disabilities and the availability of
183appropriated funds are two of the critical elements in making
184services available. Therefore, it is the intent of the
185Legislature that the Agency for Persons with Disabilities shall
186develop and implement a comprehensive redesign of the system.
187     (1)  The redesign of the home and community-based services
188system shall include, at a minimum, all actions necessary to
189achieve an appropriate rate structure, client choice within a
190specified service package, appropriate assessment strategies, an
191efficient billing process that contains reconciliation and
192monitoring components, a redefined role for support coordinators
193that avoids potential conflicts of interest, and ensures that
194family/client budgets are linked to levels of need.
195     (a)  The agency shall use an assessment instrument that is
196reliable and valid. The agency may contract with an external
197vendor or may use support coordinators to complete client
198assessments if it develops sufficient safeguards and training to
199ensure ongoing inter-rater reliability.
200     (b)  The agency, with the concurrence of the Agency for
201Health Care Administration, may contract for the determination
202of medical necessity and establishment of individual budgets.
203     (2)  A provider of services rendered to persons with
204developmental disabilities pursuant to a federally approved
205waiver shall be reimbursed according to a rate methodology based
206upon an analysis of the expenditure history and prospective
207costs of providers participating in the waiver program, or under
208any other methodology developed by the Agency for Health Care
209Administration, in consultation with the Agency for Persons with
210Disabilities, and approved by the Federal Government in
211accordance with the waiver.
212     (3)  The Agency for Health Care Administration, in
213consultation with the agency, shall seek federal approval and
214implement a four-tiered waiver system to serve eligible clients
215through the developmental disabilities and family and supported
216living waivers. The agency shall assign all clients receiving
217services through the developmental disabilities waiver to a tier
218based on a valid assessment instrument, client characteristics,
219and other appropriate assessment methods.
220     (a)  Tier one is limited to clients who have service needs
221that cannot be met in tier two, three, or four for intensive
222medical or adaptive needs and that are essential for avoiding
223institutionalization, or who possess behavioral problems that
224are exceptional in intensity, duration, or frequency and present
225a substantial risk of harm to themselves or others.
226     (b)  Tier two is limited to clients whose service needs
227include a licensed residential facility and who are authorized
228to receive a moderate level of support for standard residential
229habilitation services or a minimal level of support for behavior
230focus residential habilitation services, or clients in supported
231living who receive more than 6 hours a day of in-home support
232services. Total annual expenditures under tier two may not
233exceed $55,000 per client each year.
234     (c)  Tier three includes, but is not limited to, clients
235requiring residential placements, clients in independent or
236supported living situations, and clients who live in their
237family home. Total annual expenditures under tier three may not
238exceed $35,000 per client each year.
239     (d)  Tier four is the family and supported living waiver
240and includes, but is not limited to, clients in independent or
241supported living situations and clients who live in their family
242home. Total annual expenditures under tier four may not exceed
243$14,792 per client each year.
244     (e)  The Agency for Health Care Administration shall also
245seek federal approval to provide a consumer-directed option for
246persons with developmental disabilities which corresponds to the
247funding levels in each of the waiver tiers. The agency shall
248implement the four-tiered waiver system beginning with tiers
249one, three, and four and followed by tier two. The agency and
250the Agency for Health Care Administration may adopt rules
251necessary to administer this subsection.
252     (f)  The agency shall seek federal waivers and amend
253contracts as necessary to make changes to services defined in
254federal waiver programs administered by the agency as follows:
255     1.  Supported living coaching services may not exceed 20
256hours per month for persons who also receive in-home support
258     2.  Limited support coordination services is the only type
259of support coordination service that may be provided to persons
260under the age of 18 who live in the family home.
261     3.  Personal care assistance services are limited to 180
262hours per calendar month and may not include rate modifiers.
263Additional hours may be authorized for persons who have
264intensive physical, medical, or adaptive needs if such hours are
265essential for avoiding institutionalization.
266     4.  Residential habilitation services are limited to 8
267hours per day. Additional hours may be authorized for persons
268who have intensive medical or adaptive needs and if such hours
269are essential for avoiding institutionalization, or for persons
270who possess behavioral problems that are exceptional in
271intensity, duration, or frequency and present a substantial risk
272of harming themselves or others. This restriction shall be in
273effect until the four-tiered waiver system is fully implemented.
274     5.  Chore services, nonresidential support services, and
275homemaker services are eliminated. The agency shall expand the
276definition of in-home support services to allow the service
277provider to include activities previously provided in these
278eliminated services.
279     6.  Massage therapy, medication review, and psychological
280assessment services are eliminated.
281     7.  The agency shall conduct supplemental cost plan reviews
282to verify the medical necessity of authorized services for plans
283that have increased by more than 8 percent during either of the
2842 preceding fiscal years.
285     8.  The agency shall implement a consolidated residential
286habilitation rate structure to increase savings to the state
287through a more cost-effective payment method and establish
288uniform rates for intensive behavioral residential habilitation
290     9.  Pending federal approval, the agency may extend current
291support plans for clients receiving services under Medicaid
292waivers for 1 year beginning July 1, 2007, or from the date
293approved, whichever is later. Clients who have a substantial
294change in circumstances which threatens their health and safety
295may be reassessed during this year in order to determine the
296necessity for a change in their support plan.
297     10.  The agency shall develop a plan to eliminate
298redundancies and duplications between in-home support services,
299companion services, personal care services, and supported living
300coaching by limiting or consolidating such services.
301     11.  The agency shall develop a plan to reduce the
302intensity and frequency of supported employment services to
303clients in stable employment situations who have a documented
304history of at least 3 years' employment with the same company or
305in the same industry.
306     (4)  The geographic differential for Miami-Dade, Broward,
307and Palm Beach Counties for residential habilitation services
308shall be 7.5 percent.
309     (5)  The geographic differential for Monroe County for
310residential habilitation services shall be 20 percent.
311     (6)  Effective January 1, 2010, and except as otherwise
312provided in this section, a client served by the home and
313community-based services waiver or the family and supported
314living waiver funded through the agency shall have his or her
315cost plan adjusted to reflect the amount of expenditures for the
316previous state fiscal year plus 5 percent if such amount is less
317than the client's existing cost plan. The agency shall use
318actual paid claims for services provided during the previous
319fiscal year that are submitted by October 31 to calculate the
320revised cost plan amount. If the client was not served for the
321entire previous state fiscal year or there was any single change
322in the cost plan amount of more than 5 percent during the
323previous state fiscal year, the agency shall set the cost plan
324amount at an estimated annualized expenditure amount plus 5
325percent. The agency shall estimate the annualized expenditure
326amount by calculating the average of monthly expenditures,
327beginning in the fourth month after the client enrolled,
328interrupted services are resumed, or the cost plan was changed
329by more than 5 percent and ending on August 31, 2009, and
330multiplying the average by 12. In order to determine whether a
331client was not served for the entire year, the agency shall
332include any interruption of a waiver-funded service or services
333lasting at least 18 days. If at least 3 months of actual
334expenditure data are not available to estimate annualized
335expenditures, the agency may not rebase a cost plan pursuant to
336this subsection. The agency may not rebase the cost plan of any
337client who experiences a significant change in recipient
338condition or circumstance which results in a change of more than
3395 percent to his or her cost plan between July 1 and the date
340that a rebased cost plan would take effect pursuant to this
342     (7)  Nothing in this section or in any administrative rule
343shall be construed to prevent or limit the Agency for Health
344Care Administration, in consultation with the Agency for Persons
345with Disabilities, from adjusting fees, reimbursement rates,
346lengths of stay, number of visits, or number of services, or
347from limiting enrollment, or making any other adjustment
348necessary to comply with the availability of moneys and any
349limitations or directions provided for in the General
350Appropriations Act.
351     (8)  The Agency for Persons with Disabilities shall submit
352quarterly status reports to the Executive Office of the
353Governor, the chair of the Senate Ways and Means Committee or
354its successor, and the chair of the House Fiscal Council or its
355successor regarding the financial status of home and community-
356based services, including the number of enrolled individuals who
357are receiving services through one or more programs; the number
358of individuals who have requested services who are not enrolled
359but who are receiving services through one or more programs,
360with a description indicating the programs from which the
361individual is receiving services; the number of individuals who
362have refused an offer of services but who choose to remain on
363the list of individuals waiting for services; the number of
364individuals who have requested services but who are receiving no
365services; a frequency distribution indicating the length of time
366individuals have been waiting for services; and information
367concerning the actual and projected costs compared to the amount
368of the appropriation available to the program and any projected
369surpluses or deficits. If at any time an analysis by the agency,
370in consultation with the Agency for Health Care Administration,
371indicates that the cost of services is expected to exceed the
372amount appropriated, the agency shall submit a plan in
373accordance with subsection (7) to the Executive Office of the
374Governor, the chair of the Senate Ways and Means Committee or
375its successor, and the chair of the House Fiscal Council or its
376successor to remain within the amount appropriated. The agency
377shall work with the Agency for Health Care Administration to
378implement the plan so as to remain within the appropriation.
379     (9)  The agency shall develop a transition plan for
380recipients who are receiving services in one of the four waiver
381tiers at the time qualified plans are available in each
382recipient's region pursuant to s. 409.989(3) to enroll those
383recipients in qualified plans.
384     (10)  This section expires October 1, 2015.
385     Section 2.  Section 400.0713, Florida Statutes, is created
386to read:
387     400.0713  Nursing home licensure workgroup.-The agency
388shall establish a workgroup to develop a plan for licensure
389flexibility to assist nursing homes in developing comprehensive
390long-term care service capabilities.
391     Section 3.  Paragraphs (b) and (d) of subsection (1) of
392section 408.040, Florida Statutes, are amended to read:
393     408.040  Conditions and monitoring.-
394     (1)
395     (b)  The agency may consider, in addition to the other
396criteria specified in s. 408.035, a statement of intent by the
397applicant that a specified percentage of the annual patient days
398at the facility will be utilized by patients eligible for care
399under Title XIX of the Social Security Act. Any certificate of
400need issued to a nursing home in reliance upon an applicant's
401statements that a specified percentage of annual patient days
402will be utilized by residents eligible for care under Title XIX
403of the Social Security Act must include a statement that such
404certification is a condition of issuance of the certificate of
405need. The certificate-of-need program shall notify the Medicaid
406program office and the Department of Elderly Affairs when it
407imposes conditions as authorized in this paragraph in an area in
408which a community diversion pilot project is implemented.
409Effective July 1, 2011, the agency shall not consider, or impose
410conditions related to, patient day utilization by patients
411eligible for care under Title XIX the Social Security Act in
412making certificate-of-need determinations for nursing homes.
413     (d)  If a nursing home is located in a county in which a
414long-term care community diversion pilot project has been
415implemented under s. 430.705 or in a county in which an
416integrated, fixed-payment delivery program for Medicaid
417recipients who are 60 years of age or older or dually eligible
418for Medicare and Medicaid has been implemented under s.
419409.912(5), the nursing home may request a reduction in the
420percentage of annual patient days used by residents who are
421eligible for care under Title XIX of the Social Security Act,
422which is a condition of the nursing home's certificate of need.
423The agency shall automatically grant the nursing home's request
424if the reduction is not more than 15 percent of the nursing
425home's annual Medicaid-patient-days condition. A nursing home
426may submit only one request every 2 years for an automatic
427reduction. A requesting nursing home must notify the agency in
428writing at least 60 days in advance of its intent to reduce its
429annual Medicaid-patient-days condition by not more than 15
430percent. The agency must acknowledge the request in writing and
431must change its records to reflect the revised certificate-of-
432need condition. This paragraph expires June 30, 2011.
433     Section 4.  Subsection (1) of section 408.0435, Florida
434Statutes, is amended to read:
435     408.0435  Moratorium on nursing home certificates of need.-
436     (1)  Notwithstanding the establishment of need as provided
437for in this chapter, a certificate of need for additional
438community nursing home beds may not be approved by the agency
439until after Medicaid managed care is implemented statewide
440pursuant to ss. 409.961-409.992, or October 1, 2015, whichever
441is earlier July 1, 2011.
442     Section 5.  Sections 409.016 through 409.803, Florida
443Statutes, are designated as part I of chapter 409, Florida
444Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
445     Section 6.  Sections 409.810 through 409.821, Florida
446Statutes, are designated as part II of chapter 409, Florida
447Statutes, and entitled "KIDCARE."
448     Section 7.  Sections 409.901 through 409.9205, Florida
449Statutes, are designated as part III of chapter 409, Florida
450Statutes, and entitled "MEDICAID."
451     Section 8.  Subsection (5) of section 409.907, Florida
452Statutes, is amended to read:
453     409.907  Medicaid provider agreements.-The agency may make
454payments for medical assistance and related services rendered to
455Medicaid recipients only to an individual or entity who has a
456provider agreement in effect with the agency, who is performing
457services or supplying goods in accordance with federal, state,
458and local law, and who agrees that no person shall, on the
459grounds of handicap, race, color, or national origin, or for any
460other reason, be subjected to discrimination under any program
461or activity for which the provider receives payment from the
463     (5)  The agency:
464     (a)  Is required to make timely payment at the established
465rate for services or goods furnished to a recipient by the
466provider upon receipt of a properly completed claim form. The
467claim form shall require certification that the services or
468goods have been completely furnished to the recipient and that,
469with the exception of those services or goods specified by the
470agency, the amount billed does not exceed the provider's usual
471and customary charge for the same services or goods.
472     (b)  Is prohibited from demanding repayment from the
473provider in any instance in which the Medicaid overpayment is
474attributable to error of the department in the determination of
475eligibility of a recipient.
476     (c)  May adopt, and include in the provider agreement, such
477other requirements and stipulations on either party as the
478agency finds necessary to properly and efficiently administer
479the Medicaid program.
480     (d)  May enroll entities as Medicare crossover-only
481providers for payment purposes only. The provider agreement
483     1.  Require that the provider is an eligible Medicare
484provider, has a current provider agreement in place with the
485Centers for Medicare and Medicaid Services, and provides
486verification that the provider is currently in good standing
487with the agency.
488     2.  Require that the provider notify the agency
489immediately, in writing, upon being suspended or disenrolled as
490a Medicare provider. If a provider does not provide such
491notification within 5 business days after suspension or
492disenrollment, sanctions may be imposed pursuant to this chapter
493and the provider may be required to return funds paid to the
494provider during the period of time that the provider was
495suspended or disenrolled as a Medicare provider.
496     3.  Require that all records pertaining to health care
497services provided to each of the provider's recipients be kept
498for a minimum of 5 years. The agreement shall also require that
499records and information relating to payments claimed by the
500provider for services under the agreement be delivered to the
501agency or the Office of the Attorney General Medicaid Fraud
502Control Unit when requested. If a provider does not provide such
503records and information when requested, sanctions may be imposed
504pursuant to this chapter.
505     4.  Disclose that the agreement is for the purposes of
506paying Medicare crossover claims only.
508This paragraph pertains solely to Medicare crossover-only
509providers. In order to become a standard Medicaid provider, the
510other requirements of this section and applicable rules must be
512     Section 9.  Subsection (24) is added to section 409.908,
513Florida Statutes, to read:
514     409.908  Reimbursement of Medicaid providers.-Subject to
515specific appropriations, the agency shall reimburse Medicaid
516providers, in accordance with state and federal law, according
517to methodologies set forth in the rules of the agency and in
518policy manuals and handbooks incorporated by reference therein.
519These methodologies may include fee schedules, reimbursement
520methods based on cost reporting, negotiated fees, competitive
521bidding pursuant to s. 287.057, and other mechanisms the agency
522considers efficient and effective for purchasing services or
523goods on behalf of recipients. If a provider is reimbursed based
524on cost reporting and submits a cost report late and that cost
525report would have been used to set a lower reimbursement rate
526for a rate semester, then the provider's rate for that semester
527shall be retroactively calculated using the new cost report, and
528full payment at the recalculated rate shall be effected
529retroactively. Medicare-granted extensions for filing cost
530reports, if applicable, shall also apply to Medicaid cost
531reports. Payment for Medicaid compensable services made on
532behalf of Medicaid eligible persons is subject to the
533availability of moneys and any limitations or directions
534provided for in the General Appropriations Act or chapter 216.
535Further, nothing in this section shall be construed to prevent
536or limit the agency from adjusting fees, reimbursement rates,
537lengths of stay, number of visits, or number of services, or
538making any other adjustments necessary to comply with the
539availability of moneys and any limitations or directions
540provided for in the General Appropriations Act, provided the
541adjustment is consistent with legislative intent.
542     (24)  If a provider fails to notify the agency within 5
543business days after suspension or disenrollment from Medicare,
544sanctions may be imposed pursuant to this chapter and the
545provider may be required to return funds paid to the provider
546during the period of time that the provider was suspended or
547disenrolled as a Medicare provider.
548     Section 10.  Section 409.912, Florida Statutes, is amended
549to read:
550     409.912  Cost-effective purchasing of health care.-The
551agency shall purchase goods and services for Medicaid recipients
552in the most cost-effective manner consistent with the delivery
553of quality medical care. To ensure that medical services are
554effectively utilized, the agency may, in any case, require a
555confirmation or second physician's opinion of the correct
556diagnosis for purposes of authorizing future services under the
557Medicaid program. This section does not restrict access to
558emergency services or poststabilization care services as defined
559in 42 C.F.R. part 438.114. Such confirmation or second opinion
560shall be rendered in a manner approved by the agency. The agency
561shall maximize the use of prepaid per capita and prepaid
562aggregate fixed-sum basis services when appropriate and other
563alternative service delivery and reimbursement methodologies,
564including competitive bidding pursuant to s. 287.057, designed
565to facilitate the cost-effective purchase of a case-managed
566continuum of care. The agency shall also require providers to
567minimize the exposure of recipients to the need for acute
568inpatient, custodial, and other institutional care and the
569inappropriate or unnecessary use of high-cost services. The
570agency shall contract with a vendor to monitor and evaluate the
571clinical practice patterns of providers in order to identify
572trends that are outside the normal practice patterns of a
573provider's professional peers or the national guidelines of a
574provider's professional association. The vendor must be able to
575provide information and counseling to a provider whose practice
576patterns are outside the norms, in consultation with the agency,
577to improve patient care and reduce inappropriate utilization.
578The agency may mandate prior authorization, drug therapy
579management, or disease management participation for certain
580populations of Medicaid beneficiaries, certain drug classes, or
581particular drugs to prevent fraud, abuse, overuse, and possible
582dangerous drug interactions. The Pharmaceutical and Therapeutics
583Committee shall make recommendations to the agency on drugs for
584which prior authorization is required. The agency shall inform
585the Pharmaceutical and Therapeutics Committee of its decisions
586regarding drugs subject to prior authorization. The agency is
587authorized to limit the entities it contracts with or enrolls as
588Medicaid providers by developing a provider network through
589provider credentialing. The agency may competitively bid single-
590source-provider contracts if procurement of goods or services
591results in demonstrated cost savings to the state without
592limiting access to care. The agency may limit its network based
593on the assessment of beneficiary access to care, provider
594availability, provider quality standards, time and distance
595standards for access to care, the cultural competence of the
596provider network, demographic characteristics of Medicaid
597beneficiaries, practice and provider-to-beneficiary standards,
598appointment wait times, beneficiary use of services, provider
599turnover, provider profiling, provider licensure history,
600previous program integrity investigations and findings, peer
601review, provider Medicaid policy and billing compliance records,
602clinical and medical record audits, and other factors. Providers
603shall not be entitled to enrollment in the Medicaid provider
604network. The agency shall determine instances in which allowing
605Medicaid beneficiaries to purchase durable medical equipment and
606other goods is less expensive to the Medicaid program than long-
607term rental of the equipment or goods. The agency may establish
608rules to facilitate purchases in lieu of long-term rentals in
609order to protect against fraud and abuse in the Medicaid program
610as defined in s. 409.913. The agency may seek federal waivers
611necessary to administer these policies.
612     (1)  The agency shall work with the Department of Children
613and Family Services to ensure access of children and families in
614the child protection system to needed and appropriate mental
615health and substance abuse services. This subsection expires
616October 1, 2013.
617     (2)  The agency may enter into agreements with appropriate
618agents of other state agencies or of any agency of the Federal
619Government and accept such duties in respect to social welfare
620or public aid as may be necessary to implement the provisions of
621Title XIX of the Social Security Act and ss. 409.901-409.920.
622This subsection expires October 1, 2015.
623     (3)  The agency may contract with health maintenance
624organizations certified pursuant to part I of chapter 641 for
625the provision of services to recipients. This subsection expires
626October 1, 2013.
627     (4)  The agency may contract with:
628     (a)  An entity that provides no prepaid health care
629services other than Medicaid services under contract with the
630agency and which is owned and operated by a county, county
631health department, or county-owned and operated hospital to
632provide health care services on a prepaid or fixed-sum basis to
633recipients, which entity may provide such prepaid services
634either directly or through arrangements with other providers.
635Such prepaid health care services entities must be licensed
636under parts I and III of chapter 641. An entity recognized under
637this paragraph which demonstrates to the satisfaction of the
638Office of Insurance Regulation of the Financial Services
639Commission that it is backed by the full faith and credit of the
640county in which it is located may be exempted from s. 641.225.
641This paragraph expires October 1, 2013.
642     (b)  An entity that is providing comprehensive behavioral
643health care services to certain Medicaid recipients through a
644capitated, prepaid arrangement pursuant to the federal waiver
645provided for by s. 409.905(5). Such entity must be licensed
646under chapter 624, chapter 636, or chapter 641, or authorized
647under paragraph (c) or paragraph (d), and must possess the
648clinical systems and operational competence to manage risk and
649provide comprehensive behavioral health care to Medicaid
650recipients. As used in this paragraph, the term "comprehensive
651behavioral health care services" means covered mental health and
652substance abuse treatment services that are available to
653Medicaid recipients. The secretary of the Department of Children
654and Family Services shall approve provisions of procurements
655related to children in the department's care or custody before
656enrolling such children in a prepaid behavioral health plan. Any
657contract awarded under this paragraph must be competitively
658procured. In developing the behavioral health care prepaid plan
659procurement document, the agency shall ensure that the
660procurement document requires the contractor to develop and
661implement a plan to ensure compliance with s. 394.4574 related
662to services provided to residents of licensed assisted living
663facilities that hold a limited mental health license. Except as
664provided in subparagraph 5. 8., and except in counties where the
665Medicaid managed care pilot program is authorized pursuant to s.
666409.91211, the agency shall seek federal approval to contract
667with a single entity meeting these requirements to provide
668comprehensive behavioral health care services to all Medicaid
669recipients not enrolled in a Medicaid managed care plan
670authorized under s. 409.91211, a provider service network as
671described in paragraph (d), or a Medicaid health maintenance
672organization in an AHCA area. In an AHCA area where the Medicaid
673managed care pilot program is authorized pursuant to s.
674409.91211 in one or more counties, the agency may procure a
675contract with a single entity to serve the remaining counties as
676an AHCA area or the remaining counties may be included with an
677adjacent AHCA area and are subject to this paragraph. Each
678entity must offer a sufficient choice of providers in its
679network to ensure recipient access to care and the opportunity
680to select a provider with whom they are satisfied. The network
681shall include all public mental health hospitals. To ensure
682unimpaired access to behavioral health care services by Medicaid
683recipients, all contracts issued pursuant to this paragraph must
684require 80 percent of the capitation paid to the managed care
685plan, including health maintenance organizations and capitated
686provider service networks, to be expended for the provision of
687behavioral health care services. If the managed care plan
688expends less than 80 percent of the capitation paid for the
689provision of behavioral health care services, the difference
690shall be returned to the agency. The agency shall provide the
691plan with a certification letter indicating the amount of
692capitation paid during each calendar year for behavioral health
693care services pursuant to this section. The agency may reimburse
694for substance abuse treatment services on a fee-for-service
695basis until the agency finds that adequate funds are available
696for capitated, prepaid arrangements.
697     1.  By January 1, 2001, The agency shall modify the
698contracts with the entities providing comprehensive inpatient
699and outpatient mental health care services to Medicaid
700recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
701Counties, to include substance abuse treatment services.
702     2.  By July 1, 2003, the agency and the Department of
703Children and Family Services shall execute a written agreement
704that requires collaboration and joint development of all policy,
705budgets, procurement documents, contracts, and monitoring plans
706that have an impact on the state and Medicaid community mental
707health and targeted case management programs.
708     2.3.  Except as provided in subparagraph 5. 8., by July 1,
7092006, the agency and the Department of Children and Family
710Services shall contract with managed care entities in each AHCA
711area except area 6 or arrange to provide comprehensive inpatient
712and outpatient mental health and substance abuse services
713through capitated prepaid arrangements to all Medicaid
714recipients who are eligible to participate in such plans under
715federal law and regulation. In AHCA areas where eligible
716individuals number less than 150,000, the agency shall contract
717with a single managed care plan to provide comprehensive
718behavioral health services to all recipients who are not
719enrolled in a Medicaid health maintenance organization, a
720provider service network as described in paragraph (d), or a
721Medicaid capitated managed care plan authorized under s.
722409.91211. The agency may contract with more than one
723comprehensive behavioral health provider to provide care to
724recipients who are not enrolled in a Medicaid capitated managed
725care plan authorized under s. 409.91211, a provider service
726network as described in paragraph (d), or a Medicaid health
727maintenance organization in AHCA areas where the eligible
728population exceeds 150,000. In an AHCA area where the Medicaid
729managed care pilot program is authorized pursuant to s.
730409.91211 in one or more counties, the agency may procure a
731contract with a single entity to serve the remaining counties as
732an AHCA area or the remaining counties may be included with an
733adjacent AHCA area and shall be subject to this paragraph.
734Contracts for comprehensive behavioral health providers awarded
735pursuant to this section shall be competitively procured. Both
736for-profit and not-for-profit corporations are eligible to
737compete. Managed care plans contracting with the agency under
738subsection (3) or paragraph (d), shall provide and receive
739payment for the same comprehensive behavioral health benefits as
740provided in AHCA rules, including handbooks incorporated by
741reference. In AHCA area 11, the agency shall contract with at
742least two comprehensive behavioral health care providers to
743provide behavioral health care to recipients in that area who
744are enrolled in, or assigned to, the MediPass program. One of
745the behavioral health care contracts must be with the existing
746provider service network pilot project, as described in
747paragraph (d), for the purpose of demonstrating the cost-
748effectiveness of the provision of quality mental health services
749through a public hospital-operated managed care model. Payment
750shall be at an agreed-upon capitated rate to ensure cost
751savings. Of the recipients in area 11 who are assigned to
752MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
753MediPass-enrolled recipients shall be assigned to the existing
754provider service network in area 11 for their behavioral care.
755     4.  By October 1, 2003, the agency and the department shall
756submit a plan to the Governor, the President of the Senate, and
757the Speaker of the House of Representatives which provides for
758the full implementation of capitated prepaid behavioral health
759care in all areas of the state.
760     a.  Implementation shall begin in 2003 in those AHCA areas
761of the state where the agency is able to establish sufficient
762capitation rates.
763     b.  If the agency determines that the proposed capitation
764rate in any area is insufficient to provide appropriate
765services, the agency may adjust the capitation rate to ensure
766that care will be available. The agency and the department may
767use existing general revenue to address any additional required
768match but may not over-obligate existing funds on an annualized
770     c.  Subject to any limitations provided in the General
771Appropriations Act, the agency, in compliance with appropriate
772federal authorization, shall develop policies and procedures
773that allow for certification of local and state funds.
774     3.5.  Children residing in a statewide inpatient
775psychiatric program, or in a Department of Juvenile Justice or a
776Department of Children and Family Services residential program
777approved as a Medicaid behavioral health overlay services
778provider may not be included in a behavioral health care prepaid
779health plan or any other Medicaid managed care plan pursuant to
780this paragraph.
781     6.  In converting to a prepaid system of delivery, the
782agency shall in its procurement document require an entity
783providing only comprehensive behavioral health care services to
784prevent the displacement of indigent care patients by enrollees
785in the Medicaid prepaid health plan providing behavioral health
786care services from facilities receiving state funding to provide
787indigent behavioral health care, to facilities licensed under
788chapter 395 which do not receive state funding for indigent
789behavioral health care, or reimburse the unsubsidized facility
790for the cost of behavioral health care provided to the displaced
791indigent care patient.
792     4.7.  Traditional community mental health providers under
793contract with the Department of Children and Family Services
794pursuant to part IV of chapter 394, child welfare providers
795under contract with the Department of Children and Family
796Services in areas 1 and 6, and inpatient mental health providers
797licensed pursuant to chapter 395 must be offered an opportunity
798to accept or decline a contract to participate in any provider
799network for prepaid behavioral health services.
800     5.8.  All Medicaid-eligible children, except children in
801area 1 and children in Highlands County, Hardee County, Polk
802County, or Manatee County of area 6, that are open for child
803welfare services in the HomeSafeNet system, shall receive their
804behavioral health care services through a specialty prepaid plan
805operated by community-based lead agencies through a single
806agency or formal agreements among several agencies. The
807specialty prepaid plan must result in savings to the state
808comparable to savings achieved in other Medicaid managed care
809and prepaid programs. Such plan must provide mechanisms to
810maximize state and local revenues. The specialty prepaid plan
811shall be developed by the agency and the Department of Children
812and Family Services. The agency may seek federal waivers to
813implement this initiative. Medicaid-eligible children whose
814cases are open for child welfare services in the HomeSafeNet
815system and who reside in AHCA area 10 are exempt from the
816specialty prepaid plan upon the development of a service
817delivery mechanism for children who reside in area 10 as
818specified in s. 409.91211(3)(dd).
820This paragraph expires October 1, 2013.
821     (c)  A federally qualified health center or an entity owned
822by one or more federally qualified health centers or an entity
823owned by other migrant and community health centers receiving
824non-Medicaid financial support from the Federal Government to
825provide health care services on a prepaid or fixed-sum basis to
826recipients. A federally qualified health center or an entity
827that is owned by one or more federally qualified health centers
828and is reimbursed by the agency on a prepaid basis is exempt
829from parts I and III of chapter 641, but must comply with the
830solvency requirements in s. 641.2261(2) and meet the appropriate
831requirements governing financial reserve, quality assurance, and
832patients' rights established by the agency. This paragraph
833expires October 1, 2013.
834     (d)1.  A provider service network may be reimbursed on a
835fee-for-service or prepaid basis. Prepaid provider service
836networks receive per-member per-month payments. Provider service
837networks that do not choose to be prepaid plans shall receive
838fee-for-service rates with a shared savings settlement. The fee-
839for-service option shall be available to a provider service
840network only for the first 5 years of the plan's operation in a
841given region or until the contract year beginning October 1,
8422015, whichever is later. The agency shall annually conduct cost
843reconciliations to determine the amount of cost savings achieved
844by fee-for-service provider service networks for the dates of
845service in the period being reconciled. Only payments for
846covered services for dates of service within the reconciliation
847period and paid within 6 months after the last date of service
848in the reconciliation period shall be included. The agency shall
849perform the necessary adjustments for the inclusion of claims
850incurred but not reported within the reconciliation for claims
851that could be received and paid by the agency after the 6-month
852claims processing time lag. The agency shall provide the results
853of the reconciliations to the fee-for-service provider service
854networks within 45 days after the end of the reconciliation
855period. The fee-for-service provider service networks shall
856review and provide written comments or a letter of concurrence
857to the agency within 45 days after receipt of the reconciliation
858results. This reconciliation shall be considered final.
859     2.  A provider service network which is reimbursed by the
860agency on a prepaid basis shall be exempt from parts I and III
861of chapter 641, but must comply with the solvency requirements
862in s. 641.2261(2) and meet appropriate financial reserve,
863quality assurance, and patient rights requirements as
864established by the agency.
865     3.  Medicaid recipients assigned to a provider service
866network shall be chosen equally from those who would otherwise
867have been assigned to prepaid plans and MediPass. The agency is
868authorized to seek federal Medicaid waivers as necessary to
869implement the provisions of this section. This subparagraph
870expires October 1, 2013. Any contract previously awarded to a
871provider service network operated by a hospital pursuant to this
872subsection shall remain in effect for a period of 3 years
873following the current contract expiration date, regardless of
874any contractual provisions to the contrary.
875     4.  A provider service network is a network established or
876organized and operated by a health care provider, or group of
877affiliated health care providers, including minority physician
878networks and emergency room diversion programs that meet the
879requirements of s. 409.91211, which provides a substantial
880proportion of the health care items and services under a
881contract directly through the provider or affiliated group of
882providers and may make arrangements with physicians or other
883health care professionals, health care institutions, or any
884combination of such individuals or institutions to assume all or
885part of the financial risk on a prospective basis for the
886provision of basic health services by the physicians, by other
887health professionals, or through the institutions. The health
888care providers must have a controlling interest in the governing
889body of the provider service network organization.
890     (e)  An entity that provides only comprehensive behavioral
891health care services to certain Medicaid recipients through an
892administrative services organization agreement. Such an entity
893must possess the clinical systems and operational competence to
894provide comprehensive health care to Medicaid recipients. As
895used in this paragraph, the term "comprehensive behavioral
896health care services" means covered mental health and substance
897abuse treatment services that are available to Medicaid
898recipients. Any contract awarded under this paragraph must be
899competitively procured. The agency must ensure that Medicaid
900recipients have available the choice of at least two managed
901care plans for their behavioral health care services. This
902paragraph expires October 1, 2013.
903     (f)  An entity that provides in-home physician services to
904test the cost-effectiveness of enhanced home-based medical care
905to Medicaid recipients with degenerative neurological diseases
906and other diseases or disabling conditions associated with high
907costs to Medicaid. The program shall be designed to serve very
908disabled persons and to reduce Medicaid reimbursed costs for
909inpatient, outpatient, and emergency department services. The
910agency shall contract with vendors on a risk-sharing basis.
911     (g)  Children's provider networks that provide care
912coordination and care management for Medicaid-eligible pediatric
913patients, primary care, authorization of specialty care, and
914other urgent and emergency care through organized providers
915designed to service Medicaid eligibles under age 18 and
916pediatric emergency departments' diversion programs. The
917networks shall provide after-hour operations, including evening
918and weekend hours, to promote, when appropriate, the use of the
919children's networks rather than hospital emergency departments.
920     (f)(h)  An entity authorized in s. 430.205 to contract with
921the agency and the Department of Elderly Affairs to provide
922health care and social services on a prepaid or fixed-sum basis
923to elderly recipients. Such prepaid health care services
924entities are exempt from the provisions of part I of chapter 641
925for the first 3 years of operation. An entity recognized under
926this paragraph that demonstrates to the satisfaction of the
927Office of Insurance Regulation that it is backed by the full
928faith and credit of one or more counties in which it operates
929may be exempted from s. 641.225. This paragraph expires October
9301, 2012.
931     (g)(i)  A Children's Medical Services Network, as defined
932in s. 391.021. This paragraph expires October 1, 2013.
933     (5)  The Agency for Health Care Administration, in
934partnership with the Department of Elderly Affairs, shall create
935an integrated, fixed-payment delivery program for Medicaid
936recipients who are 60 years of age or older or dually eligible
937for Medicare and Medicaid. The Agency for Health Care
938Administration shall implement the integrated program initially
939on a pilot basis in two areas of the state. The pilot areas
940shall be Area 7 and Area 11 of the Agency for Health Care
941Administration. Enrollment in the pilot areas shall be on a
942voluntary basis and in accordance with approved federal waivers
943and this section. The agency and its program contractors and
944providers shall not enroll any individual in the integrated
945program because the individual or the person legally responsible
946for the individual fails to choose to enroll in the integrated
947program. Enrollment in the integrated program shall be
948exclusively by affirmative choice of the eligible individual or
949by the person legally responsible for the individual. The
950integrated program must transfer all Medicaid services for
951eligible elderly individuals who choose to participate into an
952integrated-care management model designed to serve Medicaid
953recipients in the community. The integrated program must combine
954all funding for Medicaid services provided to individuals who
955are 60 years of age or older or dually eligible for Medicare and
956Medicaid into the integrated program, including funds for
957Medicaid home and community-based waiver services; all Medicaid
958services authorized in ss. 409.905 and 409.906, excluding funds
959for Medicaid nursing home services unless the agency is able to
960demonstrate how the integration of the funds will improve
961coordinated care for these services in a less costly manner; and
962Medicare coinsurance and deductibles for persons dually eligible
963for Medicaid and Medicare as prescribed in s. 409.908(13).
964     (a)  Individuals who are 60 years of age or older or dually
965eligible for Medicare and Medicaid and enrolled in the
966developmental disabilities waiver program, the family and
967supported-living waiver program, the project AIDS care waiver
968program, the traumatic brain injury and spinal cord injury
969waiver program, the consumer-directed care waiver program, and
970the program of all-inclusive care for the elderly program, and
971residents of institutional care facilities for the
972developmentally disabled, must be excluded from the integrated
974     (b)  Managed care entities who meet or exceed the agency's
975minimum standards are eligible to operate the integrated
976program. Entities eligible to participate include managed care
977organizations licensed under chapter 641, including entities
978eligible to participate in the nursing home diversion program,
979other qualified providers as defined in s. 430.703(7), community
980care for the elderly lead agencies, and other state-certified
981community service networks that meet comparable standards as
982defined by the agency, in consultation with the Department of
983Elderly Affairs and the Office of Insurance Regulation, to be
984financially solvent and able to take on financial risk for
985managed care. Community service networks that are certified
986pursuant to the comparable standards defined by the agency are
987not required to be licensed under chapter 641. Managed care
988entities who operate the integrated program shall be subject to
989s. 408.7056. Eligible entities shall choose to serve enrollees
990who are dually eligible for Medicare and Medicaid, enrollees who
991are 60 years of age or older, or both.
992     (c)  The agency must ensure that the capitation-rate-
993setting methodology for the integrated program is actuarially
994sound and reflects the intent to provide quality care in the
995least restrictive setting. The agency must also require
996integrated-program providers to develop a credentialing system
997for service providers and to contract with all Gold Seal nursing
998homes, where feasible, and exclude, where feasible, chronically
999poor-performing facilities and providers as defined by the
1000agency. The integrated program must develop and maintain an
1001informal provider grievance system that addresses provider
1002payment and contract problems. The agency shall also establish a
1003formal grievance system to address those issues that were not
1004resolved through the informal grievance system. The integrated
1005program must provide that if the recipient resides in a
1006noncontracted residential facility licensed under chapter 400 or
1007chapter 429 at the time of enrollment in the integrated program,
1008the recipient must be permitted to continue to reside in the
1009noncontracted facility as long as the recipient desires. The
1010integrated program must also provide that, in the absence of a
1011contract between the integrated-program provider and the
1012residential facility licensed under chapter 400 or chapter 429,
1013current Medicaid rates must prevail. The integrated-program
1014provider must ensure that electronic nursing home claims that
1015contain sufficient information for processing are paid within 10
1016business days after receipt. Alternately, the integrated-program
1017provider may establish a capitated payment mechanism to
1018prospectively pay nursing homes at the beginning of each month.
1019The agency and the Department of Elderly Affairs must jointly
1020develop procedures to manage the services provided through the
1021integrated program in order to ensure quality and recipient
1023     (d)  The Office of Program Policy Analysis and Government
1024Accountability, in consultation with the Auditor General, shall
1025comprehensively evaluate the pilot project for the integrated,
1026fixed-payment delivery program for Medicaid recipients created
1027under this subsection. The evaluation shall begin as soon as
1028Medicaid recipients are enrolled in the managed care pilot
1029program plans and shall continue for 24 months thereafter. The
1030evaluation must include assessments of each managed care plan in
1031the integrated program with regard to cost savings; consumer
1032education, choice, and access to services; coordination of care;
1033and quality of care. The evaluation must describe administrative
1034or legal barriers to the implementation and operation of the
1035pilot program and include recommendations regarding statewide
1036expansion of the pilot program. The office shall submit its
1037evaluation report to the Governor, the President of the Senate,
1038and the Speaker of the House of Representatives no later than
1039December 31, 2009.
1040     (e)  The agency may seek federal waivers or Medicaid state
1041plan amendments and adopt rules as necessary to administer the
1042integrated program. The agency may implement the approved
1043federal waivers and other provisions as specified in this
1045     (f)  No later than December 31, 2007, the agency shall
1046provide a report to the Governor, the President of the Senate,
1047and the Speaker of the House of Representatives containing an
1048analysis of the merits and challenges of seeking a waiver to
1049implement a voluntary program that integrates payments and
1050services for dually enrolled Medicare and Medicaid recipients
1051who are 65 years of age or older.
1052     (g)  The implementation of the integrated, fixed-payment
1053delivery program created under this subsection is subject to an
1054appropriation in the General Appropriations Act.
1055     (5)(6)  The agency may contract with any public or private
1056entity otherwise authorized by this section on a prepaid or
1057fixed-sum basis for the provision of health care services to
1058recipients. An entity may provide prepaid services to
1059recipients, either directly or through arrangements with other
1060entities, if each entity involved in providing services:
1061     (a)  Is organized primarily for the purpose of providing
1062health care or other services of the type regularly offered to
1063Medicaid recipients;
1064     (b)  Ensures that services meet the standards set by the
1065agency for quality, appropriateness, and timeliness;
1066     (c)  Makes provisions satisfactory to the agency for
1067insolvency protection and ensures that neither enrolled Medicaid
1068recipients nor the agency will be liable for the debts of the
1070     (d)  Submits to the agency, if a private entity, a
1071financial plan that the agency finds to be fiscally sound and
1072that provides for working capital in the form of cash or
1073equivalent liquid assets excluding revenues from Medicaid
1074premium payments equal to at least the first 3 months of
1075operating expenses or $200,000, whichever is greater;
1076     (e)  Furnishes evidence satisfactory to the agency of
1077adequate liability insurance coverage or an adequate plan of
1078self-insurance to respond to claims for injuries arising out of
1079the furnishing of health care;
1080     (f)  Provides, through contract or otherwise, for periodic
1081review of its medical facilities and services, as required by
1082the agency; and
1083     (g)  Provides organizational, operational, financial, and
1084other information required by the agency.
1086This subsection expires October 1, 2013.
1087     (6)(7)  The agency may contract on a prepaid or fixed-sum
1088basis with any health insurer that:
1089     (a)  Pays for health care services provided to enrolled
1090Medicaid recipients in exchange for a premium payment paid by
1091the agency;
1092     (b)  Assumes the underwriting risk; and
1093     (c)  Is organized and licensed under applicable provisions
1094of the Florida Insurance Code and is currently in good standing
1095with the Office of Insurance Regulation.
1097This subsection expires October 1, 2013.
1098     (7)(8)(a)  The agency may contract on a prepaid or fixed-
1099sum basis with an exclusive provider organization to provide
1100health care services to Medicaid recipients provided that the
1101exclusive provider organization meets applicable managed care
1102plan requirements in this section, ss. 409.9122, 409.9123,
1103409.9128, and 627.6472, and other applicable provisions of law.
1104This subsection expires October 1, 2013.
1105     (b)  For a period of no longer than 24 months after the
1106effective date of this paragraph, when a member of an exclusive
1107provider organization that is contracted by the agency to
1108provide health care services to Medicaid recipients in rural
1109areas without a health maintenance organization obtains services
1110from a provider that participates in the Medicaid program in
1111this state, the provider shall be paid in accordance with the
1112appropriate fee schedule for services provided to eligible
1113Medicaid recipients. The agency may seek waiver authority to
1114implement this paragraph.
1115     (8)(9)  The Agency for Health Care Administration may
1116provide cost-effective purchasing of chiropractic services on a
1117fee-for-service basis to Medicaid recipients through
1118arrangements with a statewide chiropractic preferred provider
1119organization incorporated in this state as a not-for-profit
1120corporation. The agency shall ensure that the benefit limits and
1121prior authorization requirements in the current Medicaid program
1122shall apply to the services provided by the chiropractic
1123preferred provider organization. This subsection expires October
11241, 2013.
1125     (9)(10)  The agency shall not contract on a prepaid or
1126fixed-sum basis for Medicaid services with an entity which knows
1127or reasonably should know that any officer, director, agent,
1128managing employee, or owner of stock or beneficial interest in
1129excess of 5 percent common or preferred stock, or the entity
1130itself, has been found guilty of, regardless of adjudication, or
1131entered a plea of nolo contendere, or guilty, to:
1132     (a)  Fraud;
1133     (b)  Violation of federal or state antitrust statutes,
1134including those proscribing price fixing between competitors and
1135the allocation of customers among competitors;
1136     (c)  Commission of a felony involving embezzlement, theft,
1137forgery, income tax evasion, bribery, falsification or
1138destruction of records, making false statements, receiving
1139stolen property, making false claims, or obstruction of justice;
1141     (d)  Any crime in any jurisdiction which directly relates
1142to the provision of health services on a prepaid or fixed-sum
1145This subsection expires October 1, 2013.
1146     (10)(11)  The agency, after notifying the Legislature, may
1147apply for waivers of applicable federal laws and regulations as
1148necessary to implement more appropriate systems of health care
1149for Medicaid recipients and reduce the cost of the Medicaid
1150program to the state and federal governments and shall implement
1151such programs, after legislative approval, within a reasonable
1152period of time after federal approval. These programs must be
1153designed primarily to reduce the need for inpatient care,
1154custodial care and other long-term or institutional care, and
1155other high-cost services. Prior to seeking legislative approval
1156of such a waiver as authorized by this subsection, the agency
1157shall provide notice and an opportunity for public comment.
1158Notice shall be provided to all persons who have made requests
1159of the agency for advance notice and shall be published in the
1160Florida Administrative Weekly not less than 28 days prior to the
1161intended action. This subsection expires October 1, 2015.
1162     (11)(12)  The agency shall establish a postpayment
1163utilization control program designed to identify recipients who
1164may inappropriately overuse or underuse Medicaid services and
1165shall provide methods to correct such misuse. This subsection
1166expires October 1, 2013.
1167     (12)(13)  The agency shall develop and provide coordinated
1168systems of care for Medicaid recipients and may contract with
1169public or private entities to develop and administer such
1170systems of care among public and private health care providers
1171in a given geographic area. This subsection expires October 1,
1173     (13)(14)(a)  The agency shall operate or contract for the
1174operation of utilization management and incentive systems
1175designed to encourage cost-effective use of services and to
1176eliminate services that are medically unnecessary. The agency
1177shall track Medicaid provider prescription and billing patterns
1178and evaluate them against Medicaid medical necessity criteria
1179and coverage and limitation guidelines adopted by rule. Medical
1180necessity determination requires that service be consistent with
1181symptoms or confirmed diagnosis of illness or injury under
1182treatment and not in excess of the patient's needs. The agency
1183shall conduct reviews of provider exceptions to peer group norms
1184and shall, using statistical methodologies, provider profiling,
1185and analysis of billing patterns, detect and investigate
1186abnormal or unusual increases in billing or payment of claims
1187for Medicaid services and medically unnecessary provision of
1188services. Providers that demonstrate a pattern of submitting
1189claims for medically unnecessary services shall be referred to
1190the Medicaid program integrity unit for investigation. In its
1191annual report, required in s. 409.913, the agency shall report
1192on its efforts to control overutilization as described in this
1193subsection paragraph. This subsection expires October 1, 2013.
1194     (b)  The agency shall develop a procedure for determining
1195whether health care providers and service vendors can provide
1196the Medicaid program using a business case that demonstrates
1197whether a particular good or service can offset the cost of
1198providing the good or service in an alternative setting or
1199through other means and therefore should receive a higher
1200reimbursement. The business case must include, but need not be
1201limited to:
1202     1.  A detailed description of the good or service to be
1203provided, a description and analysis of the agency's current
1204performance of the service, and a rationale documenting how
1205providing the service in an alternative setting would be in the
1206best interest of the state, the agency, and its clients.
1207     2.  A cost-benefit analysis documenting the estimated
1208specific direct and indirect costs, savings, performance
1209improvements, risks, and qualitative and quantitative benefits
1210involved in or resulting from providing the service. The cost-
1211benefit analysis must include a detailed plan and timeline
1212identifying all actions that must be implemented to realize
1213expected benefits. The Secretary of Health Care Administration
1214shall verify that all costs, savings, and benefits are valid and
1216     (c)  If the agency determines that the increased
1217reimbursement is cost-effective, the agency shall recommend a
1218change in the reimbursement schedule for that particular good or
1219service. If, within 12 months after implementing any rate change
1220under this procedure, the agency determines that costs were not
1221offset by the increased reimbursement schedule, the agency may
1222revert to the former reimbursement schedule for the particular
1223good or service.
1224     (14)(15)(a)  The agency shall operate the Comprehensive
1225Assessment and Review for Long-Term Care Services (CARES)
1226nursing facility preadmission screening program to ensure that
1227Medicaid payment for nursing facility care is made only for
1228individuals whose conditions require such care and to ensure
1229that long-term care services are provided in the setting most
1230appropriate to the needs of the person and in the most
1231economical manner possible. The CARES program shall also ensure
1232that individuals participating in Medicaid home and community-
1233based waiver programs meet criteria for those programs,
1234consistent with approved federal waivers.
1235     (b)  The agency shall operate the CARES program through an
1236interagency agreement with the Department of Elderly Affairs.
1237The agency, in consultation with the Department of Elderly
1238Affairs, may contract for any function or activity of the CARES
1239program, including any function or activity required by 42
1240C.F.R. part 483.20, relating to preadmission screening and
1241resident review.
1242     (c)  Prior to making payment for nursing facility services
1243for a Medicaid recipient, the agency must verify that the
1244nursing facility preadmission screening program has determined
1245that the individual requires nursing facility care and that the
1246individual cannot be safely served in community-based programs.
1247The nursing facility preadmission screening program shall refer
1248a Medicaid recipient to a community-based program if the
1249individual could be safely served at a lower cost and the
1250recipient chooses to participate in such program. For
1251individuals whose nursing home stay is initially funded by
1252Medicare and Medicare coverage is being terminated for lack of
1253progress towards rehabilitation, CARES staff shall consult with
1254the person making the determination of progress toward
1255rehabilitation to ensure that the recipient is not being
1256inappropriately disqualified from Medicare coverage. If, in
1257their professional judgment, CARES staff believes that a
1258Medicare beneficiary is still making progress toward
1259rehabilitation, they may assist the Medicare beneficiary with an
1260appeal of the disqualification from Medicare coverage. The use
1261of CARES teams to review Medicare denials for coverage under
1262this section is authorized only if it is determined that such
1263reviews qualify for federal matching funds through Medicaid. The
1264agency shall seek or amend federal waivers as necessary to
1265implement this section.
1266     (d)  For the purpose of initiating immediate prescreening
1267and diversion assistance for individuals residing in nursing
1268homes and in order to make families aware of alternative long-
1269term care resources so that they may choose a more cost-
1270effective setting for long-term placement, CARES staff shall
1271conduct an assessment and review of a sample of individuals
1272whose nursing home stay is expected to exceed 20 days,
1273regardless of the initial funding source for the nursing home
1274placement. CARES staff shall provide counseling and referral
1275services to these individuals regarding choosing appropriate
1276long-term care alternatives. This paragraph does not apply to
1277continuing care facilities licensed under chapter 651 or to
1278retirement communities that provide a combination of nursing
1279home, independent living, and other long-term care services.
1280     (e)  By January 15 of each year, the agency shall submit a
1281report to the Legislature describing the operations of the CARES
1282program. The report must describe:
1283     1.  Rate of diversion to community alternative programs;
1284     2.  CARES program staffing needs to achieve additional
1286     3.  Reasons the program is unable to place individuals in
1287less restrictive settings when such individuals desired such
1288services and could have been served in such settings;
1289     4.  Barriers to appropriate placement, including barriers
1290due to policies or operations of other agencies or state-funded
1291programs; and
1292     5.  Statutory changes necessary to ensure that individuals
1293in need of long-term care services receive care in the least
1294restrictive environment.
1295     (f)  The Department of Elderly Affairs shall track
1296individuals over time who are assessed under the CARES program
1297and who are diverted from nursing home placement. By January 15
1298of each year, the department shall submit to the Legislature a
1299longitudinal study of the individuals who are diverted from
1300nursing home placement. The study must include:
1301     1.  The demographic characteristics of the individuals
1302assessed and diverted from nursing home placement, including,
1303but not limited to, age, race, gender, frailty, caregiver
1304status, living arrangements, and geographic location;
1305     2.  A summary of community services provided to individuals
1306for 1 year after assessment and diversion;
1307     3.  A summary of inpatient hospital admissions for
1308individuals who have been diverted; and
1309     4.  A summary of the length of time between diversion and
1310subsequent entry into a nursing home or death.
1311     (g)  By July 1, 2005, the department and the Agency for
1312Health Care Administration shall report to the President of the
1313Senate and the Speaker of the House of Representatives regarding
1314the impact to the state of modifying level-of-care criteria to
1315eliminate the Intermediate II level of care.
1317This subsection expires October 1, 2012.
1318     (15)(16)(a)  The agency shall identify health care
1319utilization and price patterns within the Medicaid program which
1320are not cost-effective or medically appropriate and assess the
1321effectiveness of new or alternate methods of providing and
1322monitoring service, and may implement such methods as it
1323considers appropriate. Such methods may include disease
1324management initiatives, an integrated and systematic approach
1325for managing the health care needs of recipients who are at risk
1326of or diagnosed with a specific disease by using best practices,
1327prevention strategies, clinical-practice improvement, clinical
1328interventions and protocols, outcomes research, information
1329technology, and other tools and resources to reduce overall
1330costs and improve measurable outcomes.
1331     (b)  The responsibility of the agency under this subsection
1332shall include the development of capabilities to identify actual
1333and optimal practice patterns; patient and provider educational
1334initiatives; methods for determining patient compliance with
1335prescribed treatments; fraud, waste, and abuse prevention and
1336detection programs; and beneficiary case management programs.
1337     1.  The practice pattern identification program shall
1338evaluate practitioner prescribing patterns based on national and
1339regional practice guidelines, comparing practitioners to their
1340peer groups. The agency and its Drug Utilization Review Board
1341shall consult with the Department of Health and a panel of
1342practicing health care professionals consisting of the
1343following: the Speaker of the House of Representatives and the
1344President of the Senate shall each appoint three physicians
1345licensed under chapter 458 or chapter 459; and the Governor
1346shall appoint two pharmacists licensed under chapter 465 and one
1347dentist licensed under chapter 466 who is an oral surgeon. Terms
1348of the panel members shall expire at the discretion of the
1349appointing official. The advisory panel shall be responsible for
1350evaluating treatment guidelines and recommending ways to
1351incorporate their use in the practice pattern identification
1352program. Practitioners who are prescribing inappropriately or
1353inefficiently, as determined by the agency, may have their
1354prescribing of certain drugs subject to prior authorization or
1355may be terminated from all participation in the Medicaid
1357     2.  The agency shall also develop educational interventions
1358designed to promote the proper use of medications by providers
1359and beneficiaries.
1360     3.  The agency shall implement a pharmacy fraud, waste, and
1361abuse initiative that may include a surety bond or letter of
1362credit requirement for participating pharmacies, enhanced
1363provider auditing practices, the use of additional fraud and
1364abuse software, recipient management programs for beneficiaries
1365inappropriately using their benefits, and other steps that will
1366eliminate provider and recipient fraud, waste, and abuse. The
1367initiative shall address enforcement efforts to reduce the
1368number and use of counterfeit prescriptions.
1369     4.  By September 30, 2002, the agency shall contract with
1370an entity in the state to implement a wireless handheld clinical
1371pharmacology drug information database for practitioners. The
1372initiative shall be designed to enhance the agency's efforts to
1373reduce fraud, abuse, and errors in the prescription drug benefit
1374program and to otherwise further the intent of this paragraph.
1375     5.  By April 1, 2006, the agency shall contract with an
1376entity to design a database of clinical utilization information
1377or electronic medical records for Medicaid providers. This
1378system must be web-based and allow providers to review on a
1379real-time basis the utilization of Medicaid services, including,
1380but not limited to, physician office visits, inpatient and
1381outpatient hospitalizations, laboratory and pathology services,
1382radiological and other imaging services, dental care, and
1383patterns of dispensing prescription drugs in order to coordinate
1384care and identify potential fraud and abuse.
1385     6.  The agency may apply for any federal waivers needed to
1386administer this paragraph.
1388This subsection expires October 1, 2013.
1389     (16)(17)  An entity contracting on a prepaid or fixed-sum
1390basis shall meet the surplus requirements of s. 641.225. If an
1391entity's surplus falls below an amount equal to the surplus
1392requirements of s. 641.225, the agency shall prohibit the entity
1393from engaging in marketing and preenrollment activities, shall
1394cease to process new enrollments, and may not renew the entity's
1395contract until the required balance is achieved. The
1396requirements of this subsection do not apply:
1397     (a)  Where a public entity agrees to fund any deficit
1398incurred by the contracting entity; or
1399     (b)  Where the entity's performance and obligations are
1400guaranteed in writing by a guaranteeing organization which:
1401     1.  Has been in operation for at least 5 years and has
1402assets in excess of $50 million; or
1403     2.  Submits a written guarantee acceptable to the agency
1404which is irrevocable during the term of the contracting entity's
1405contract with the agency and, upon termination of the contract,
1406until the agency receives proof of satisfaction of all
1407outstanding obligations incurred under the contract.
1409This subsection expires October 1, 2013.
1410     (17)(18)(a)  The agency may require an entity contracting
1411on a prepaid or fixed-sum basis to establish a restricted
1412insolvency protection account with a federally guaranteed
1413financial institution licensed to do business in this state. The
1414entity shall deposit into that account 5 percent of the
1415capitation payments made by the agency each month until a
1416maximum total of 2 percent of the total current contract amount
1417is reached. The restricted insolvency protection account may be
1418drawn upon with the authorized signatures of two persons
1419designated by the entity and two representatives of the agency.
1420If the agency finds that the entity is insolvent, the agency may
1421draw upon the account solely with the two authorized signatures
1422of representatives of the agency, and the funds may be disbursed
1423to meet financial obligations incurred by the entity under the
1424prepaid contract. If the contract is terminated, expired, or not
1425continued, the account balance must be released by the agency to
1426the entity upon receipt of proof of satisfaction of all
1427outstanding obligations incurred under this contract.
1428     (b)  The agency may waive the insolvency protection account
1429requirement in writing when evidence is on file with the agency
1430of adequate insolvency insurance and reinsurance that will
1431protect enrollees if the entity becomes unable to meet its
1434This subsection expires October 1, 2013.
1435     (18)(19)  An entity that contracts with the agency on a
1436prepaid or fixed-sum basis for the provision of Medicaid
1437services shall reimburse any hospital or physician that is
1438outside the entity's authorized geographic service area as
1439specified in its contract with the agency, and that provides
1440services authorized by the entity to its members, at a rate
1441negotiated with the hospital or physician for the provision of
1442services or according to the lesser of the following:
1443     (a)  The usual and customary charges made to the general
1444public by the hospital or physician; or
1445     (b)  The Florida Medicaid reimbursement rate established
1446for the hospital or physician.
1448This subsection expires October 1, 2013.
1449     (19)(20)  When a merger or acquisition of a Medicaid
1450prepaid contractor has been approved by the Office of Insurance
1451Regulation pursuant to s. 628.4615, the agency shall approve the
1452assignment or transfer of the appropriate Medicaid prepaid
1453contract upon request of the surviving entity of the merger or
1454acquisition if the contractor and the other entity have been in
1455good standing with the agency for the most recent 12-month
1456period, unless the agency determines that the assignment or
1457transfer would be detrimental to the Medicaid recipients or the
1458Medicaid program. To be in good standing, an entity must not
1459have failed accreditation or committed any material violation of
1460the requirements of s. 641.52 and must meet the Medicaid
1461contract requirements. For purposes of this section, a merger or
1462acquisition means a change in controlling interest of an entity,
1463including an asset or stock purchase. This subsection expires
1464October 1, 2013.
1465     (20)(21)  Any entity contracting with the agency pursuant
1466to this section to provide health care services to Medicaid
1467recipients is prohibited from engaging in any of the following
1468practices or activities:
1469     (a)  Practices that are discriminatory, including, but not
1470limited to, attempts to discourage participation on the basis of
1471actual or perceived health status.
1472     (b)  Activities that could mislead or confuse recipients,
1473or misrepresent the organization, its marketing representatives,
1474or the agency. Violations of this paragraph include, but are not
1475limited to:
1476     1.  False or misleading claims that marketing
1477representatives are employees or representatives of the state or
1478county, or of anyone other than the entity or the organization
1479by whom they are reimbursed.
1480     2.  False or misleading claims that the entity is
1481recommended or endorsed by any state or county agency, or by any
1482other organization which has not certified its endorsement in
1483writing to the entity.
1484     3.  False or misleading claims that the state or county
1485recommends that a Medicaid recipient enroll with an entity.
1486     4.  Claims that a Medicaid recipient will lose benefits
1487under the Medicaid program, or any other health or welfare
1488benefits to which the recipient is legally entitled, if the
1489recipient does not enroll with the entity.
1490     (c)  Granting or offering of any monetary or other valuable
1491consideration for enrollment, except as authorized by subsection
1492(23) (24).
1493     (d)  Door-to-door solicitation of recipients who have not
1494contacted the entity or who have not invited the entity to make
1495a presentation.
1496     (e)  Solicitation of Medicaid recipients by marketing
1497representatives stationed in state offices unless approved and
1498supervised by the agency or its agent and approved by the
1499affected state agency when solicitation occurs in an office of
1500the state agency. The agency shall ensure that marketing
1501representatives stationed in state offices shall market their
1502managed care plans to Medicaid recipients only in designated
1503areas and in such a way as to not interfere with the recipients'
1504activities in the state office.
1505     (f)  Enrollment of Medicaid recipients.
1507This subsection expires October 1, 2013.
1508     (21)(22)  The agency may impose a fine for a violation of
1509this section or the contract with the agency by a person or
1510entity that is under contract with the agency. With respect to
1511any nonwillful violation, such fine shall not exceed $2,500 per
1512violation. In no event shall such fine exceed an aggregate
1513amount of $10,000 for all nonwillful violations arising out of
1514the same action. With respect to any knowing and willful
1515violation of this section or the contract with the agency, the
1516agency may impose a fine upon the entity in an amount not to
1517exceed $20,000 for each such violation. In no event shall such
1518fine exceed an aggregate amount of $100,000 for all knowing and
1519willful violations arising out of the same action. This
1520subsection expires October 1, 2013.
1521     (22)(23)  A health maintenance organization or a person or
1522entity exempt from chapter 641 that is under contract with the
1523agency for the provision of health care services to Medicaid
1524recipients may not use or distribute marketing materials used to
1525solicit Medicaid recipients, unless such materials have been
1526approved by the agency. The provisions of this subsection do not
1527apply to general advertising and marketing materials used by a
1528health maintenance organization to solicit both non-Medicaid
1529subscribers and Medicaid recipients. This subsection expires
1530October 1, 2013.
1531     (23)(24)  Upon approval by the agency, health maintenance
1532organizations and persons or entities exempt from chapter 641
1533that are under contract with the agency for the provision of
1534health care services to Medicaid recipients may be permitted
1535within the capitation rate to provide additional health benefits
1536that the agency has found are of high quality, are practicably
1537available, provide reasonable value to the recipient, and are
1538provided at no additional cost to the state. This subsection
1539expires October 1, 2013.
1540     (24)(25)  The agency shall utilize the statewide health
1541maintenance organization complaint hotline for the purpose of
1542investigating and resolving Medicaid and prepaid health plan
1543complaints, maintaining a record of complaints and confirmed
1544problems, and receiving disenrollment requests made by
1545recipients. This subsection expires October 1, 2013.
1546     (25)(26)  The agency shall require the publication of the
1547health maintenance organization's and the prepaid health plan's
1548consumer services telephone numbers and the "800" telephone
1549number of the statewide health maintenance organization
1550complaint hotline on each Medicaid identification card issued by
1551a health maintenance organization or prepaid health plan
1552contracting with the agency to serve Medicaid recipients and on
1553each subscriber handbook issued to a Medicaid recipient. This
1554subsection expires October 1, 2013.
1555     (26)(27)  The agency shall establish a health care quality
1556improvement system for those entities contracting with the
1557agency pursuant to this section, incorporating all the standards
1558and guidelines developed by the Medicaid Bureau of the Health
1559Care Financing Administration as a part of the quality assurance
1560reform initiative. The system shall include, but need not be
1561limited to, the following:
1562     (a)  Guidelines for internal quality assurance programs,
1563including standards for:
1564     1.  Written quality assurance program descriptions.
1565     2.  Responsibilities of the governing body for monitoring,
1566evaluating, and making improvements to care.
1567     3.  An active quality assurance committee.
1568     4.  Quality assurance program supervision.
1569     5.  Requiring the program to have adequate resources to
1570effectively carry out its specified activities.
1571     6.  Provider participation in the quality assurance
1573     7.  Delegation of quality assurance program activities.
1574     8.  Credentialing and recredentialing.
1575     9.  Enrollee rights and responsibilities.
1576     10.  Availability and accessibility to services and care.
1577     11.  Ambulatory care facilities.
1578     12.  Accessibility and availability of medical records, as
1579well as proper recordkeeping and process for record review.
1580     13.  Utilization review.
1581     14.  A continuity of care system.
1582     15.  Quality assurance program documentation.
1583     16.  Coordination of quality assurance activity with other
1584management activity.
1585     17.  Delivering care to pregnant women and infants; to
1586elderly and disabled recipients, especially those who are at
1587risk of institutional placement; to persons with developmental
1588disabilities; and to adults who have chronic, high-cost medical
1590     (b)  Guidelines which require the entities to conduct
1591quality-of-care studies which:
1592     1.  Target specific conditions and specific health service
1593delivery issues for focused monitoring and evaluation.
1594     2.  Use clinical care standards or practice guidelines to
1595objectively evaluate the care the entity delivers or fails to
1596deliver for the targeted clinical conditions and health services
1597delivery issues.
1598     3.  Use quality indicators derived from the clinical care
1599standards or practice guidelines to screen and monitor care and
1600services delivered.
1601     (c)  Guidelines for external quality review of each
1602contractor which require: focused studies of patterns of care;
1603individual care review in specific situations; and followup
1604activities on previous pattern-of-care study findings and
1605individual-care-review findings. In designing the external
1606quality review function and determining how it is to operate as
1607part of the state's overall quality improvement system, the
1608agency shall construct its external quality review organization
1609and entity contracts to address each of the following:
1610     1.  Delineating the role of the external quality review
1612     2.  Length of the external quality review organization
1613contract with the state.
1614     3.  Participation of the contracting entities in designing
1615external quality review organization review activities.
1616     4.  Potential variation in the type of clinical conditions
1617and health services delivery issues to be studied at each plan.
1618     5.  Determining the number of focused pattern-of-care
1619studies to be conducted for each plan.
1620     6.  Methods for implementing focused studies.
1621     7.  Individual care review.
1622     8.  Followup activities.
1624This subsection expires October 1, 2015.
1625     (27)(28)  In order to ensure that children receive health
1626care services for which an entity has already been compensated,
1627an entity contracting with the agency pursuant to this section
1628shall achieve an annual Early and Periodic Screening, Diagnosis,
1629and Treatment (EPSDT) Service screening rate of at least 60
1630percent for those recipients continuously enrolled for at least
16318 months. The agency shall develop a method by which the EPSDT
1632screening rate shall be calculated. For any entity which does
1633not achieve the annual 60 percent rate, the entity must submit a
1634corrective action plan for the agency's approval. If the entity
1635does not meet the standard established in the corrective action
1636plan during the specified timeframe, the agency is authorized to
1637impose appropriate contract sanctions. At least annually, the
1638agency shall publicly release the EPSDT Services screening rates
1639of each entity it has contracted with on a prepaid basis to
1640serve Medicaid recipients. This subsection expires October 1,
1642     (28)(29)  The agency shall perform enrollments and
1643disenrollments for Medicaid recipients who are eligible for
1644MediPass or managed care plans. Notwithstanding the prohibition
1645contained in paragraph (20)(21)(f), managed care plans may
1646perform preenrollments of Medicaid recipients under the
1647supervision of the agency or its agents. For the purposes of
1648this section, "preenrollment" means the provision of marketing
1649and educational materials to a Medicaid recipient and assistance
1650in completing the application forms, but shall not include
1651actual enrollment into a managed care plan. An application for
1652enrollment shall not be deemed complete until the agency or its
1653agent verifies that the recipient made an informed, voluntary
1654choice. The agency, in cooperation with the Department of
1655Children and Family Services, may test new marketing initiatives
1656to inform Medicaid recipients about their managed care options
1657at selected sites. The agency shall report to the Legislature on
1658the effectiveness of such initiatives. The agency may contract
1659with a third party to perform managed care plan and MediPass
1660enrollment and disenrollment services for Medicaid recipients
1661and is authorized to adopt rules to implement such services. The
1662agency may adjust the capitation rate only to cover the costs of
1663a third-party enrollment and disenrollment contract, and for
1664agency supervision and management of the managed care plan
1665enrollment and disenrollment contract. This subsection expires
1666October 1, 2013.
1667     (29)(30)  Any lists of providers made available to Medicaid
1668recipients, MediPass enrollees, or managed care plan enrollees
1669shall be arranged alphabetically showing the provider's name and
1670specialty and, separately, by specialty in alphabetical order.
1671This subsection expires October 1, 2013.
1672     (30)(31)  The agency shall establish an enhanced managed
1673care quality assurance oversight function, to include at least
1674the following components:
1675     (a)  At least quarterly analysis and followup, including
1676sanctions as appropriate, of managed care participant
1677utilization of services.
1678     (b)  At least quarterly analysis and followup, including
1679sanctions as appropriate, of quality findings of the Medicaid
1680peer review organization and other external quality assurance
1682     (c)  At least quarterly analysis and followup, including
1683sanctions as appropriate, of the fiscal viability of managed
1684care plans.
1685     (d)  At least quarterly analysis and followup, including
1686sanctions as appropriate, of managed care participant
1687satisfaction and disenrollment surveys.
1688     (e)  The agency shall conduct regular and ongoing Medicaid
1689recipient satisfaction surveys.
1691The analyses and followup activities conducted by the agency
1692under its enhanced managed care quality assurance oversight
1693function shall not duplicate the activities of accreditation
1694reviewers for entities regulated under part III of chapter 641,
1695but may include a review of the finding of such reviewers. This
1696subsection expires October 1, 2013.
1697     (31)(32)  Each managed care plan that is under contract
1698with the agency to provide health care services to Medicaid
1699recipients shall annually conduct a background check with the
1700Florida Department of Law Enforcement of all persons with
1701ownership interest of 5 percent or more or executive management
1702responsibility for the managed care plan and shall submit to the
1703agency information concerning any such person who has been found
1704guilty of, regardless of adjudication, or has entered a plea of
1705nolo contendere or guilty to, any of the offenses listed in s.
1706435.03. This subsection expires October 1, 2013.
1707     (32)(33)  The agency shall, by rule, develop a process
1708whereby a Medicaid managed care plan enrollee who wishes to
1709enter hospice care may be disenrolled from the managed care plan
1710within 24 hours after contacting the agency regarding such
1711request. The agency rule shall include a methodology for the
1712agency to recoup managed care plan payments on a pro rata basis
1713if payment has been made for the enrollment month when
1714disenrollment occurs. This subsection expires October 1, 2013.
1715     (33)(34)  The agency and entities that contract with the
1716agency to provide health care services to Medicaid recipients
1717under this section or ss. 409.91211 and 409.9122 must comply
1718with the provisions of s. 641.513 in providing emergency
1719services and care to Medicaid recipients and MediPass
1720recipients. Where feasible, safe, and cost-effective, the agency
1721shall encourage hospitals, emergency medical services providers,
1722and other public and private health care providers to work
1723together in their local communities to enter into agreements or
1724arrangements to ensure access to alternatives to emergency
1725services and care for those Medicaid recipients who need
1726nonemergent care. The agency shall coordinate with hospitals,
1727emergency medical services providers, private health plans,
1728capitated managed care networks as established in s. 409.91211,
1729and other public and private health care providers to implement
1730the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1731and 641.31097 to develop and implement emergency department
1732diversion programs for Medicaid recipients. This subsection
1733expires October 1, 2013.
1734     (34)(35)  All entities providing health care services to
1735Medicaid recipients shall make available, and encourage all
1736pregnant women and mothers with infants to receive, and provide
1737documentation in the medical records to reflect, the following:
1738     (a)  Healthy Start prenatal or infant screening.
1739     (b)  Healthy Start care coordination, when screening or
1740other factors indicate need.
1741     (c)  Healthy Start enhanced services in accordance with the
1742prenatal or infant screening results.
1743     (d)  Immunizations in accordance with recommendations of
1744the Advisory Committee on Immunization Practices of the United
1745States Public Health Service and the American Academy of
1746Pediatrics, as appropriate.
1747     (e)  Counseling and services for family planning to all
1748women and their partners.
1749     (f)  A scheduled postpartum visit for the purpose of
1750voluntary family planning, to include discussion of all methods
1751of contraception, as appropriate.
1752     (g)  Referral to the Special Supplemental Nutrition Program
1753for Women, Infants, and Children (WIC).
1755This subsection expires October 1, 2013.
1756     (35)(36)  Any entity that provides Medicaid prepaid health
1757plan services shall ensure the appropriate coordination of
1758health care services with an assisted living facility in cases
1759where a Medicaid recipient is both a member of the entity's
1760prepaid health plan and a resident of the assisted living
1761facility. If the entity is at risk for Medicaid targeted case
1762management and behavioral health services, the entity shall
1763inform the assisted living facility of the procedures to follow
1764should an emergent condition arise. This subsection expires
1765October 1, 2013.
1766     (37)  The agency may seek and implement federal waivers
1767necessary to provide for cost-effective purchasing of home
1768health services, private duty nursing services, transportation,
1769independent laboratory services, and durable medical equipment
1770and supplies through competitive bidding pursuant to s. 287.057.
1771The agency may request appropriate waivers from the federal
1772Health Care Financing Administration in order to competitively
1773bid such services. The agency may exclude providers not selected
1774through the bidding process from the Medicaid provider network.
1775     (36)(38)  The agency shall enter into agreements with not-
1776for-profit organizations based in this state for the purpose of
1777providing vision screening. This subsection expires October 1,
1779     (37)(39)(a)  The agency shall implement a Medicaid
1780prescribed-drug spending-control program that includes the
1781following components:
1782     1.  A Medicaid preferred drug list, which shall be a
1783listing of cost-effective therapeutic options recommended by the
1784Medicaid Pharmacy and Therapeutics Committee established
1785pursuant to s. 409.91195 and adopted by the agency for each
1786therapeutic class on the preferred drug list. At the discretion
1787of the committee, and when feasible, the preferred drug list
1788should include at least two products in a therapeutic class. The
1789agency may post the preferred drug list and updates to the
1790preferred drug list on an Internet website without following the
1791rulemaking procedures of chapter 120. Antiretroviral agents are
1792excluded from the preferred drug list. The agency shall also
1793limit the amount of a prescribed drug dispensed to no more than
1794a 34-day supply unless the drug products' smallest marketed
1795package is greater than a 34-day supply, or the drug is
1796determined by the agency to be a maintenance drug in which case
1797a 100-day maximum supply may be authorized. The agency is
1798authorized to seek any federal waivers necessary to implement
1799these cost-control programs and to continue participation in the
1800federal Medicaid rebate program, or alternatively to negotiate
1801state-only manufacturer rebates. The agency may adopt rules to
1802implement this subparagraph. The agency shall continue to
1803provide unlimited contraceptive drugs and items. The agency must
1804establish procedures to ensure that:
1805     a.  There is a response to a request for prior consultation
1806by telephone or other telecommunication device within 24 hours
1807after receipt of a request for prior consultation; and
1808     b.  A 72-hour supply of the drug prescribed is provided in
1809an emergency or when the agency does not provide a response
1810within 24 hours as required by sub-subparagraph a.
1811     2.  Reimbursement to pharmacies for Medicaid prescribed
1812drugs shall be set at the lesser of: the average wholesale price
1813(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
1814plus 4.75 percent, the federal upper limit (FUL), the state
1815maximum allowable cost (SMAC), or the usual and customary (UAC)
1816charge billed by the provider.
1817     3.  The agency shall develop and implement a process for
1818managing the drug therapies of Medicaid recipients who are using
1819significant numbers of prescribed drugs each month. The
1820management process may include, but is not limited to,
1821comprehensive, physician-directed medical-record reviews, claims
1822analyses, and case evaluations to determine the medical
1823necessity and appropriateness of a patient's treatment plan and
1824drug therapies. The agency may contract with a private
1825organization to provide drug-program-management services. The
1826Medicaid drug benefit management program shall include
1827initiatives to manage drug therapies for HIV/AIDS patients,
1828patients using 20 or more unique prescriptions in a 180-day
1829period, and the top 1,000 patients in annual spending. The
1830agency shall enroll any Medicaid recipient in the drug benefit
1831management program if he or she meets the specifications of this
1832provision and is not enrolled in a Medicaid health maintenance
1834     4.  The agency may limit the size of its pharmacy network
1835based on need, competitive bidding, price negotiations,
1836credentialing, or similar criteria. The agency shall give
1837special consideration to rural areas in determining the size and
1838location of pharmacies included in the Medicaid pharmacy
1839network. A pharmacy credentialing process may include criteria
1840such as a pharmacy's full-service status, location, size,
1841patient educational programs, patient consultation, disease
1842management services, and other characteristics. The agency may
1843impose a moratorium on Medicaid pharmacy enrollment when it is
1844determined that it has a sufficient number of Medicaid-
1845participating providers. The agency must allow dispensing
1846practitioners to participate as a part of the Medicaid pharmacy
1847network regardless of the practitioner's proximity to any other
1848entity that is dispensing prescription drugs under the Medicaid
1849program. A dispensing practitioner must meet all credentialing
1850requirements applicable to his or her practice, as determined by
1851the agency.
1852     5.  The agency shall develop and implement a program that
1853requires Medicaid practitioners who prescribe drugs to use a
1854counterfeit-proof prescription pad for Medicaid prescriptions.
1855The agency shall require the use of standardized counterfeit-
1856proof prescription pads by Medicaid-participating prescribers or
1857prescribers who write prescriptions for Medicaid recipients. The
1858agency may implement the program in targeted geographic areas or
1860     6.  The agency may enter into arrangements that require
1861manufacturers of generic drugs prescribed to Medicaid recipients
1862to provide rebates of at least 15.1 percent of the average
1863manufacturer price for the manufacturer's generic products.
1864These arrangements shall require that if a generic-drug
1865manufacturer pays federal rebates for Medicaid-reimbursed drugs
1866at a level below 15.1 percent, the manufacturer must provide a
1867supplemental rebate to the state in an amount necessary to
1868achieve a 15.1-percent rebate level.
1869     7.  The agency may establish a preferred drug list as
1870described in this subsection, and, pursuant to the establishment
1871of such preferred drug list, it is authorized to negotiate
1872supplemental rebates from manufacturers that are in addition to
1873those required by Title XIX of the Social Security Act and at no
1874less than 14 percent of the average manufacturer price as
1875defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
1876the federal or supplemental rebate, or both, equals or exceeds
187729 percent. There is no upper limit on the supplemental rebates
1878the agency may negotiate. The agency may determine that specific
1879products, brand-name or generic, are competitive at lower rebate
1880percentages. Agreement to pay the minimum supplemental rebate
1881percentage will guarantee a manufacturer that the Medicaid
1882Pharmaceutical and Therapeutics Committee will consider a
1883product for inclusion on the preferred drug list. However, a
1884pharmaceutical manufacturer is not guaranteed placement on the
1885preferred drug list by simply paying the minimum supplemental
1886rebate. Agency decisions will be made on the clinical efficacy
1887of a drug and recommendations of the Medicaid Pharmaceutical and
1888Therapeutics Committee, as well as the price of competing
1889products minus federal and state rebates. The agency is
1890authorized to contract with an outside agency or contractor to
1891conduct negotiations for supplemental rebates. For the purposes
1892of this section, the term "supplemental rebates" means cash
1893rebates. Effective July 1, 2004, value-added programs as a
1894substitution for supplemental rebates are prohibited. The agency
1895is authorized to seek any federal waivers to implement this
1897     8.  The Agency for Health Care Administration shall expand
1898home delivery of pharmacy products. To assist Medicaid patients
1899in securing their prescriptions and reduce program costs, the
1900agency shall expand its current mail-order-pharmacy diabetes-
1901supply program to include all generic and brand-name drugs used
1902by Medicaid patients with diabetes. Medicaid recipients in the
1903current program may obtain nondiabetes drugs on a voluntary
1904basis. This initiative is limited to the geographic area covered
1905by the current contract. The agency may seek and implement any
1906federal waivers necessary to implement this subparagraph.
1907     9.  The agency shall limit to one dose per month any drug
1908prescribed to treat erectile dysfunction.
1909     10.a.  The agency may implement a Medicaid behavioral drug
1910management system. The agency may contract with a vendor that
1911has experience in operating behavioral drug management systems
1912to implement this program. The agency is authorized to seek
1913federal waivers to implement this program.
1914     b.  The agency, in conjunction with the Department of
1915Children and Family Services, may implement the Medicaid
1916behavioral drug management system that is designed to improve
1917the quality of care and behavioral health prescribing practices
1918based on best practice guidelines, improve patient adherence to
1919medication plans, reduce clinical risk, and lower prescribed
1920drug costs and the rate of inappropriate spending on Medicaid
1921behavioral drugs. The program may include the following
1923     (I)  Provide for the development and adoption of best
1924practice guidelines for behavioral health-related drugs such as
1925antipsychotics, antidepressants, and medications for treating
1926bipolar disorders and other behavioral conditions; translate
1927them into practice; review behavioral health prescribers and
1928compare their prescribing patterns to a number of indicators
1929that are based on national standards; and determine deviations
1930from best practice guidelines.
1931     (II)  Implement processes for providing feedback to and
1932educating prescribers using best practice educational materials
1933and peer-to-peer consultation.
1934     (III)  Assess Medicaid beneficiaries who are outliers in
1935their use of behavioral health drugs with regard to the numbers
1936and types of drugs taken, drug dosages, combination drug
1937therapies, and other indicators of improper use of behavioral
1938health drugs.
1939     (IV)  Alert prescribers to patients who fail to refill
1940prescriptions in a timely fashion, are prescribed multiple same-
1941class behavioral health drugs, and may have other potential
1942medication problems.
1943     (V)  Track spending trends for behavioral health drugs and
1944deviation from best practice guidelines.
1945     (VI)  Use educational and technological approaches to
1946promote best practices, educate consumers, and train prescribers
1947in the use of practice guidelines.
1948     (VII)  Disseminate electronic and published materials.
1949     (VIII)  Hold statewide and regional conferences.
1950     (IX)  Implement a disease management program with a model
1951quality-based medication component for severely mentally ill
1952individuals and emotionally disturbed children who are high
1953users of care.
1954     11.a.  The agency shall implement a Medicaid prescription
1955drug management system. The agency may contract with a vendor
1956that has experience in operating prescription drug management
1957systems in order to implement this system. Any management system
1958that is implemented in accordance with this subparagraph must
1959rely on cooperation between physicians and pharmacists to
1960determine appropriate practice patterns and clinical guidelines
1961to improve the prescribing, dispensing, and use of drugs in the
1962Medicaid program. The agency may seek federal waivers to
1963implement this program.
1964     b.  The drug management system must be designed to improve
1965the quality of care and prescribing practices based on best
1966practice guidelines, improve patient adherence to medication
1967plans, reduce clinical risk, and lower prescribed drug costs and
1968the rate of inappropriate spending on Medicaid prescription
1969drugs. The program must:
1970     (I)  Provide for the development and adoption of best
1971practice guidelines for the prescribing and use of drugs in the
1972Medicaid program, including translating best practice guidelines
1973into practice; reviewing prescriber patterns and comparing them
1974to indicators that are based on national standards and practice
1975patterns of clinical peers in their community, statewide, and
1976nationally; and determine deviations from best practice
1978     (II)  Implement processes for providing feedback to and
1979educating prescribers using best practice educational materials
1980and peer-to-peer consultation.
1981     (III)  Assess Medicaid recipients who are outliers in their
1982use of a single or multiple prescription drugs with regard to
1983the numbers and types of drugs taken, drug dosages, combination
1984drug therapies, and other indicators of improper use of
1985prescription drugs.
1986     (IV)  Alert prescribers to patients who fail to refill
1987prescriptions in a timely fashion, are prescribed multiple drugs
1988that may be redundant or contraindicated, or may have other
1989potential medication problems.
1990     (V)  Track spending trends for prescription drugs and
1991deviation from best practice guidelines.
1992     (VI)  Use educational and technological approaches to
1993promote best practices, educate consumers, and train prescribers
1994in the use of practice guidelines.
1995     (VII)  Disseminate electronic and published materials.
1996     (VIII)  Hold statewide and regional conferences.
1997     (IX)  Implement disease management programs in cooperation
1998with physicians and pharmacists, along with a model quality-
1999based medication component for individuals having chronic
2000medical conditions.
2001     12.  The agency is authorized to contract for drug rebate
2002administration, including, but not limited to, calculating
2003rebate amounts, invoicing manufacturers, negotiating disputes
2004with manufacturers, and maintaining a database of rebate
2006     13.  The agency may specify the preferred daily dosing form
2007or strength for the purpose of promoting best practices with
2008regard to the prescribing of certain drugs as specified in the
2009General Appropriations Act and ensuring cost-effective
2010prescribing practices.
2011     14.  The agency may require prior authorization for
2012Medicaid-covered prescribed drugs. The agency may, but is not
2013required to, prior-authorize the use of a product:
2014     a.  For an indication not approved in labeling;
2015     b.  To comply with certain clinical guidelines; or
2016     c.  If the product has the potential for overuse, misuse,
2017or abuse.
2019The agency may require the prescribing professional to provide
2020information about the rationale and supporting medical evidence
2021for the use of a drug. The agency may post prior authorization
2022criteria and protocol and updates to the list of drugs that are
2023subject to prior authorization on an Internet website without
2024amending its rule or engaging in additional rulemaking.
2025     15.  The agency, in conjunction with the Pharmaceutical and
2026Therapeutics Committee, may require age-related prior
2027authorizations for certain prescribed drugs. The agency may
2028preauthorize the use of a drug for a recipient who may not meet
2029the age requirement or may exceed the length of therapy for use
2030of this product as recommended by the manufacturer and approved
2031by the Food and Drug Administration. Prior authorization may
2032require the prescribing professional to provide information
2033about the rationale and supporting medical evidence for the use
2034of a drug.
2035     16.  The agency shall implement a step-therapy prior
2036authorization approval process for medications excluded from the
2037preferred drug list. Medications listed on the preferred drug
2038list must be used within the previous 12 months prior to the
2039alternative medications that are not listed. The step-therapy
2040prior authorization may require the prescriber to use the
2041medications of a similar drug class or for a similar medical
2042indication unless contraindicated in the Food and Drug
2043Administration labeling. The trial period between the specified
2044steps may vary according to the medical indication. The step-
2045therapy approval process shall be developed in accordance with
2046the committee as stated in s. 409.91195(7) and (8). A drug
2047product may be approved without meeting the step-therapy prior
2048authorization criteria if the prescribing physician provides the
2049agency with additional written medical or clinical documentation
2050that the product is medically necessary because:
2051     a.  There is not a drug on the preferred drug list to treat
2052the disease or medical condition which is an acceptable clinical
2054     b.  The alternatives have been ineffective in the treatment
2055of the beneficiary's disease; or
2056     c.  Based on historic evidence and known characteristics of
2057the patient and the drug, the drug is likely to be ineffective,
2058or the number of doses have been ineffective.
2060The agency shall work with the physician to determine the best
2061alternative for the patient. The agency may adopt rules waiving
2062the requirements for written clinical documentation for specific
2063drugs in limited clinical situations.
2064     17.  The agency shall implement a return and reuse program
2065for drugs dispensed by pharmacies to institutional recipients,
2066which includes payment of a $5 restocking fee for the
2067implementation and operation of the program. The return and
2068reuse program shall be implemented electronically and in a
2069manner that promotes efficiency. The program must permit a
2070pharmacy to exclude drugs from the program if it is not
2071practical or cost-effective for the drug to be included and must
2072provide for the return to inventory of drugs that cannot be
2073credited or returned in a cost-effective manner. The agency
2074shall determine if the program has reduced the amount of
2075Medicaid prescription drugs which are destroyed on an annual
2076basis and if there are additional ways to ensure more
2077prescription drugs are not destroyed which could safely be
2078reused. The agency's conclusion and recommendations shall be
2079reported to the Legislature by December 1, 2005.
2080     (b)  The agency shall implement this subsection to the
2081extent that funds are appropriated to administer the Medicaid
2082prescribed-drug spending-control program. The agency may
2083contract all or any part of this program to private
2085     (c)  The agency shall submit quarterly reports to the
2086Governor, the President of the Senate, and the Speaker of the
2087House of Representatives which must include, but need not be
2088limited to, the progress made in implementing this subsection
2089and its effect on Medicaid prescribed-drug expenditures.
2090     (38)(40)  Notwithstanding the provisions of chapter 287,
2091the agency may, at its discretion, renew a contract or contracts
2092for fiscal intermediary services one or more times for such
2093periods as the agency may decide; however, all such renewals may
2094not combine to exceed a total period longer than the term of the
2095original contract.
2096     (39)(41)  The agency shall provide for the development of a
2097demonstration project by establishment in Miami-Dade County of a
2098long-term-care facility licensed pursuant to chapter 395 to
2099improve access to health care for a predominantly minority,
2100medically underserved, and medically complex population and to
2101evaluate alternatives to nursing home care and general acute
2102care for such population. Such project is to be located in a
2103health care condominium and colocated with licensed facilities
2104providing a continuum of care. The establishment of this project
2105is not subject to the provisions of s. 408.036 or s. 408.039.
2106This subsection expires October 1, 2012.
2107     (42)  The agency shall develop and implement a utilization
2108management program for Medicaid-eligible recipients for the
2109management of occupational, physical, respiratory, and speech
2110therapies. The agency shall establish a utilization program that
2111may require prior authorization in order to ensure medically
2112necessary and cost-effective treatments. The program shall be
2113operated in accordance with a federally approved waiver program
2114or state plan amendment. The agency may seek a federal waiver or
2115state plan amendment to implement this program. The agency may
2116also competitively procure these services from an outside vendor
2117on a regional or statewide basis.
2118     (40)(43)  The agency may contract on a prepaid or fixed-sum
2119basis with appropriately licensed prepaid dental health plans to
2120provide dental services. This subsection expires October 1,
2122     (41)(44)  The Agency for Health Care Administration shall
2123ensure that any Medicaid managed care plan as defined in s.
2124409.9122(2)(f), whether paid on a capitated basis or a shared
2125savings basis, is cost-effective. For purposes of this
2126subsection, the term "cost-effective" means that a network's
2127per-member, per-month costs to the state, including, but not
2128limited to, fee-for-service costs, administrative costs, and
2129case-management fees, if any, must be no greater than the
2130state's costs associated with contracts for Medicaid services
2131established under subsection (3), which may be adjusted for
2132health status. The agency shall conduct actuarially sound
2133adjustments for health status in order to ensure such cost-
2134effectiveness and shall publish the results on its Internet
2135website and submit the results annually to the Governor, the
2136President of the Senate, and the Speaker of the House of
2137Representatives no later than December 31 of each year.
2138Contracts established pursuant to this subsection which are not
2139cost-effective may not be renewed. This subsection expires
2140October 1, 2013.
2141     (42)(45)  Subject to the availability of funds, the agency
2142shall mandate a recipient's participation in a provider lock-in
2143program, when appropriate, if a recipient is found by the agency
2144to have used Medicaid goods or services at a frequency or amount
2145not medically necessary, limiting the receipt of goods or
2146services to medically necessary providers after the 21-day
2147appeal process has ended, for a period of not less than 1 year.
2148The lock-in programs shall include, but are not limited to,
2149pharmacies, medical doctors, and infusion clinics. The
2150limitation does not apply to emergency services and care
2151provided to the recipient in a hospital emergency department.
2152The agency shall seek any federal waivers necessary to implement
2153this subsection. The agency shall adopt any rules necessary to
2154comply with or administer this subsection. This subsection
2155expires October 1, 2013.
2156     (43)(46)  The agency shall seek a federal waiver for
2157permission to terminate the eligibility of a Medicaid recipient
2158who has been found to have committed fraud, through judicial or
2159administrative determination, two times in a period of 5 years.
2160     (47)  The agency shall conduct a study of available
2161electronic systems for the purpose of verifying the identity and
2162eligibility of a Medicaid recipient. The agency shall recommend
2163to the Legislature a plan to implement an electronic
2164verification system for Medicaid recipients by January 31, 2005.
2165     (44)(48)(a)  A provider is not entitled to enrollment in
2166the Medicaid provider network. The agency may implement a
2167Medicaid fee-for-service provider network controls, including,
2168but not limited to, competitive procurement and provider
2169credentialing. If a credentialing process is used, the agency
2170may limit its provider network based upon the following
2171considerations: beneficiary access to care, provider
2172availability, provider quality standards and quality assurance
2173processes, cultural competency, demographic characteristics of
2174beneficiaries, practice standards, service wait times, provider
2175turnover, provider licensure and accreditation history, program
2176integrity history, peer review, Medicaid policy and billing
2177compliance records, clinical and medical record audit findings,
2178and such other areas that are considered necessary by the agency
2179to ensure the integrity of the program.
2180     (b)  The agency shall limit its network of durable medical
2181equipment and medical supply providers. For dates of service
2182after January 1, 2009, the agency shall limit payment for
2183durable medical equipment and supplies to providers that meet
2184all the requirements of this paragraph.
2185     1.  Providers must be accredited by a Centers for Medicare
2186and Medicaid Services deemed accreditation organization for
2187suppliers of durable medical equipment, prosthetics, orthotics,
2188and supplies. The provider must maintain accreditation and is
2189subject to unannounced reviews by the accrediting organization.
2190     2.  Providers must provide the services or supplies
2191directly to the Medicaid recipient or caregiver at the provider
2192location or recipient's residence or send the supplies directly
2193to the recipient's residence with receipt of mailed delivery.
2194Subcontracting or consignment of the service or supply to a
2195third party is prohibited.
2196     3.  Notwithstanding subparagraph 2., a durable medical
2197equipment provider may store nebulizers at a physician's office
2198for the purpose of having the physician's staff issue the
2199equipment if it meets all of the following conditions:
2200     a.  The physician must document the medical necessity and
2201need to prevent further deterioration of the patient's
2202respiratory status by the timely delivery of the nebulizer in
2203the physician's office.
2204     b.  The durable medical equipment provider must have
2205written documentation of the competency and training by a
2206Florida-licensed registered respiratory therapist of any durable
2207medical equipment staff who participate in the training of
2208physician office staff for the use of nebulizers, including
2209cleaning, warranty, and special needs of patients.
2210     c.  The physician's office must have documented the
2211training and competency of any staff member who initiates the
2212delivery of nebulizers to patients. The durable medical
2213equipment provider must maintain copies of all physician office
2215     d.  The physician's office must maintain inventory records
2216of stored nebulizers, including documentation of the durable
2217medical equipment provider source.
2218     e.  A physician contracted with a Medicaid durable medical
2219equipment provider may not have a financial relationship with
2220that provider or receive any financial gain from the delivery of
2221nebulizers to patients.
2222     4.  Providers must have a physical business location and a
2223functional landline business phone. The location must be within
2224the state or not more than 50 miles from the Florida state line.
2225The agency may make exceptions for providers of durable medical
2226equipment or supplies not otherwise available from other
2227enrolled providers located within the state.
2228     5.  Physical business locations must be clearly identified
2229as a business that furnishes durable medical equipment or
2230medical supplies by signage that can be read from 20 feet away.
2231The location must be readily accessible to the public during
2232normal, posted business hours and must operate no less than 5
2233hours per day and no less than 5 days per week, with the
2234exception of scheduled and posted holidays. The location may not
2235be located within or at the same numbered street address as
2236another enrolled Medicaid durable medical equipment or medical
2237supply provider or as an enrolled Medicaid pharmacy that is also
2238enrolled as a durable medical equipment provider. A licensed
2239orthotist or prosthetist that provides only orthotic or
2240prosthetic devices as a Medicaid durable medical equipment
2241provider is exempt from the provisions in this paragraph.
2242     6.  Providers must maintain a stock of durable medical
2243equipment and medical supplies on site that is readily available
2244to meet the needs of the durable medical equipment business
2245location's customers.
2246     7.  Providers must provide a surety bond of $50,000 for
2247each provider location, up to a maximum of 5 bonds statewide or
2248an aggregate bond of $250,000 statewide, as identified by
2249Federal Employer Identification Number. Providers who post a
2250statewide or an aggregate bond must identify all of their
2251locations in any Medicaid durable medical equipment and medical
2252supply provider enrollment application or bond renewal. Each
2253provider location's surety bond must be renewed annually and the
2254provider must submit proof of renewal even if the original bond
2255is a continuous bond. A licensed orthotist or prosthetist that
2256provides only orthotic or prosthetic devices as a Medicaid
2257durable medical equipment provider is exempt from the provisions
2258in this paragraph.
2259     8.  Providers must obtain a level 2 background screening,
2260as provided under s. 435.04, for each provider employee in
2261direct contact with or providing direct services to recipients
2262of durable medical equipment and medical supplies in their
2263homes. This requirement includes, but is not limited to, repair
2264and service technicians, fitters, and delivery staff. The
2265provider shall pay for the cost of the background screening.
2266     9.  The following providers are exempt from the
2267requirements of subparagraphs 1. and 7.:
2268     a.  Durable medical equipment providers owned and operated
2269by a government entity.
2270     b.  Durable medical equipment providers that are operating
2271within a pharmacy that is currently enrolled as a Medicaid
2272pharmacy provider.
2273     c.  Active, Medicaid-enrolled orthopedic physician groups,
2274primarily owned by physicians, which provide only orthotic and
2275prosthetic devices.
2276     (45)(49)  The agency shall contract with established
2277minority physician networks that provide services to
2278historically underserved minority patients. The networks must
2279provide cost-effective Medicaid services, comply with the
2280requirements to be a MediPass provider, and provide their
2281primary care physicians with access to data and other management
2282tools necessary to assist them in ensuring the appropriate use
2283of services, including inpatient hospital services and
2285     (a)  The agency shall provide for the development and
2286expansion of minority physician networks in each service area to
2287provide services to Medicaid recipients who are eligible to
2288participate under federal law and rules.
2289     (b)  The agency shall reimburse each minority physician
2290network as a fee-for-service provider, including the case
2291management fee for primary care, if any, or as a capitated rate
2292provider for Medicaid services. Any savings shall be shared with
2293the minority physician networks pursuant to the contract.
2294     (c)  For purposes of this subsection, the term "cost-
2295effective" means that a network's per-member, per-month costs to
2296the state, including, but not limited to, fee-for-service costs,
2297administrative costs, and case-management fees, if any, must be
2298no greater than the state's costs associated with contracts for
2299Medicaid services established under subsection (3), which shall
2300be actuarially adjusted for case mix, model, and service area.
2301The agency shall conduct actuarially sound audits adjusted for
2302case mix and model in order to ensure such cost-effectiveness
2303and shall publish the audit results on its Internet website and
2304submit the audit results annually to the Governor, the President
2305of the Senate, and the Speaker of the House of Representatives
2306no later than December 31. Contracts established pursuant to
2307this subsection which are not cost-effective may not be renewed.
2308     (d)  The agency may apply for any federal waivers needed to
2309implement this subsection.
2311This subsection expires October 1, 2013.
2312     (46)(50)  To the extent permitted by federal law and as
2313allowed under s. 409.906, the agency shall provide reimbursement
2314for emergency mental health care services for Medicaid
2315recipients in crisis stabilization facilities licensed under s.
2316394.875 as long as those services are less expensive than the
2317same services provided in a hospital setting.
2318     (47)(51)  The agency shall work with the Agency for Persons
2319with Disabilities to develop a home and community-based waiver
2320to serve children and adults who are diagnosed with familial
2321dysautonomia or Riley-Day syndrome caused by a mutation of the
2322IKBKAP gene on chromosome 9. The agency shall seek federal
2323waiver approval and implement the approved waiver subject to the
2324availability of funds and any limitations provided in the
2325General Appropriations Act. The agency may adopt rules to
2326implement this waiver program.
2327     (48)(52)  The agency shall implement a program of all-
2328inclusive care for children. The program of all-inclusive care
2329for children shall be established to provide in-home hospice-
2330like support services to children diagnosed with a life-
2331threatening illness and enrolled in the Children's Medical
2332Services network to reduce hospitalizations as appropriate. The
2333agency, in consultation with the Department of Health, may
2334implement the program of all-inclusive care for children after
2335obtaining approval from the Centers for Medicare and Medicaid
2337     (49)(53)  Before seeking an amendment to the state plan for
2338purposes of implementing programs authorized by the Deficit
2339Reduction Act of 2005, the agency shall notify the Legislature.
2340     Section 11.  Subsection (4) of section 409.91195, Florida
2341Statutes, is amended to read:
2342     409.91195  Medicaid Pharmaceutical and Therapeutics
2343Committee.-There is created a Medicaid Pharmaceutical and
2344Therapeutics Committee within the agency for the purpose of
2345developing a Medicaid preferred drug list.
2346     (4)  Upon recommendation of the committee, the agency shall
2347adopt a preferred drug list as described in s. 409.912(37)(39).
2348To the extent feasible, the committee shall review all drug
2349classes included on the preferred drug list every 12 months, and
2350may recommend additions to and deletions from the preferred drug
2351list, such that the preferred drug list provides for medically
2352appropriate drug therapies for Medicaid patients which achieve
2353cost savings contained in the General Appropriations Act.
2354     Section 12.  Subsection (1) of section 409.91196, Florida
2355Statutes, is amended to read:
2356     409.91196  Supplemental rebate agreements; public records
2357and public meetings exemption.-
2358     (1)  The rebate amount, percent of rebate, manufacturer's
2359pricing, and supplemental rebate, and other trade secrets as
2360defined in s. 688.002 that the agency has identified for use in
2361negotiations, held by the Agency for Health Care Administration
2362under s. 409.912(37)(39)(a)7. are confidential and exempt from
2363s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
2364     Section 13.  Section 409.91207, Florida Statutes, is
2365amended to read:
2366(Substantial rewording of section. See s. 409.91207,
2367F.S., for present text.)
2368     409.91207  Medical homes.-
2369     (1)  AUTHORITY.-The agency shall develop a method for
2370designating qualified plans as a medical home network.
2371     (2)  PURPOSE AND PRINCIPLES.-Medical home networks foster
2372and support coordinated and effective primary care through case
2373management, support to primary care providers, supplemental
2374services, and dissemination of best practices. Medical home
2375networks target patients with chronic illnesses and frequent
2376service utilization in order to coordinate services, provide
2377disease management and patient education, and improve quality of
2378care. In addition to primary care, medical home networks are
2379able to provide or arrange for pharmacy, outpatient diagnostic,
2380and specialty physician services and coordinate with inpatient
2381facilities and rehabilitative service providers.
2382     (3)  DESIGNATION.-A qualified plan may request agency
2383designation as a medical home network if the plan is accredited
2384as a medical home network by the National Committee for Quality
2385Assurance or:
2386     (a)  The plan establishes a method for its enrollees to
2387choose to participate as medical home patients and select a
2388primary care provider that is certified as a medical home.
2389     (b)  At least 85 percent of the primary care providers in a
2390medical home network are certified by the qualified plan as
2391having the following service capabilities:
2392     1.  Supply all medically necessary primary and preventive
2393services and provide all scheduled immunizations.
2394     2.  Organize clinical data in electronic form using a
2395patient-centered charting system.
2396     3.  Maintain and update a patient's medication list and
2397review all medications during each office visit.
2398     4.  Maintain a system to track diagnostic tests and provide
2399followup services regarding test results.
2400     5.  Maintain a system to track referrals, including self-
2401referrals by members.
2402     6.  Supply care coordination and continuity of care through
2403proactive contact with members and encourage family
2404participation in care.
2405     7.  Supply education and support using various materials
2406and processes appropriate for individual patient needs.
2407     8.  Communicate electronically.
2408     9.  Supply voice-to-voice telephone coverage to medical
2409home patients 24 hours per day, 7 days per week, to enable
2410medical home patients to speak to a licensed health care
2411professional who triages and forwards calls, as appropriate.
2412     10.  Maintain an office schedule of at least 30 scheduled
2413hours per week.
2414     11.  Use scheduling processes to promote continuity with
2415clinicians, including providing care for walk-in, routine, and
2416urgent care visits.
2417     12.  Implement and document behavioral health and substance
2418abuse screening procedures and make referrals as needed.
2419     13.  Use data to identify and track patients' health and
2420service use patterns.
2421     14.  Coordinate care and followup for patients receiving
2422services in inpatient and outpatient facilities.
2423     15.  Implement processes to promote access to care and
2424member communication.
2425     16.  Maintain electronic medical records.
2426     17.  Develop a health care team that provides ongoing
2427support, oversight, and guidance for all medical care received
2428by the patient and documents contact with specialists and other
2429health care providers caring for the patient.
2430     18.  Supply postvisit followup care for patients.
2431     19.  Implement specific evidence-based clinical practice
2432guidelines for preventive and chronic care.
2433     20.  Implement a medication reconciliation procedure to
2434avoid interactions or duplications.
2435     21.  Use personalized screening, brief intervention, and
2436referral to treatment procedures for appropriate patients
2437requiring specialty treatment.
2438     22.  Offer at least 4 hours per week of after-hours care to
2440     23.  Use health assessment tools to identify patient needs
2441and risks.
2442     (c)  The qualified plan offers support services to its
2443primary care providers, including:
2444     1.  Case management, outreach, care coordination, and other
2445targeted support services for medical home patients.
2446     2.  Ongoing assessment of spending and service utilization
2447by all medical home network patients.
2448     3.  Periodic evaluation of patient outcomes.
2449     4.  Coordination with inpatient facilities, behavioral
2450health, and rehabilitative service providers.
2451     5.  Establishing specific methods to manage pharmacy and
2452behavioral health services.
2453     6.  Paying primary care providers at rates equal to or
2454greater than 80 percent of the Medicare rate.
2455     (4)  AGENCY DUTIES.-The agency shall:
2456     (a)  Maintain a record of qualified plans designated as
2457medical home networks.
2458     (b)  Develop a standard form to be used by the qualified
2459plans to certify to the agency that they meet the necessary
2460service and primary care provider support capabilities to be
2461designated a medical home.
2462     Section 14.  Section 409.91211, Florida Statutes, is
2463amended to read:
2464(Substantial rewording of section. See s. 409.91211,
2465F.S., for present text.)
2466     409.91211.-Medicaid managed care pilot program.-
2467     (1)  AUTHORITY.-The agency is authorized to implement a
2468managed care pilot program based on the Section 1115 waiver
2469approved by the Centers for Medicare and Medicaid Services on
2470October 19, 2005, including continued operation of the program
2471in Baker, Broward, Clay, Duval, and Nassau Counties. The managed
2472care pilot program shall be consistent with the provisions of
2473this section, subject to federal approval.
2474     (2)  EXTENSION.-No later than July 1, 2010, the agency
2475shall begin the process of requesting an extension of the
2476Section 1115 waiver. The agency shall report at least monthly to
2477the Legislature on progress in negotiating for the extension of
2478the waiver. Changes to the terms and conditions relating to the
2479low-income pool must be approved by the Legislative Budget
2481     (3)  EXPANSION.-The agency shall expand the managed care
2482pilot program to Miami-Dade County in a manner that enrolls all
2483eligible recipients in a qualified plan no later than June 30,
2485     (4)  QUALIFIED PLANS.-Managed care plans qualified to
2486participate in the Medicaid managed care pilot program include
2487health insurers authorized under chapter 624, exclusive provider
2488organizations authorized under chapter 627, health maintenance
2489organizations authorized under chapter 641, the Children's
2490Medical Services Network under chapter 391, and provider service
2491networks authorized pursuant to s. 409.912(4)(d).
2492     (5)  PLAN REQUIREMENTS.-The agency shall apply the
2493following requirements to all qualified plans:
2494     (a)  Prepaid rates shall be risk adjusted pursuant to
2495subsection (17).
2496     (b)  All Medicaid recipients shall be offered the
2497opportunity to use their Medicaid premium to pay for the
2498recipient's share of cost pursuant to s. 409.9122(13).
2499     (6)  INTERGOVERNMENTAL TRANSFERS.-In order to preserve
2500intergovernmental transfers of funds from Miami-Dade County, the
2501agency shall develop methodologies, including, but not limited
2502to, a supplemental capitation rate, risk pool, or incentive
2503payments, which may be paid to prepaid plans or plans owned and
2504operated by providers that contract with safety net providers,
2505trauma hospitals, children's hospitals, and statutory teaching
2506hospitals. In order to preserve certified public expenditures
2507from Miami-Dade County, the agency shall seek federal approval
2508to implement a methodology that allows supplemental payments to
2509be made directly to physicians employed by or under contract
2510with a medical school in Florida in recognition of the costs
2511associated with graduate medical education or their teaching
2512mission. Alternatively, the agency may develop additional
2513methodologies including, but not limited to, methodologies
2514mentioned above, as well as capitated rates that exclude
2515payments made to these physicians so that they may be paid
2516directly. Once methodologies and payment mechanisms are
2517approved, the agency shall submit the plan for preserving
2518intergovernmental transfers and certified public expenditures to
2519the Legislative Budget Commission. After the assignment and
2520enrollment of all mandatory eligible persons in Miami-Dade
2521County into managed care plans, an amendment shall be submitted
2522to the Legislative Budget Commission requesting authority for
2523the transfer of sufficient funds from appropriate line items
2524within the Grants and Donations Trust Fund and the Medical Care
2525Trust Fund within the Agency for Health Care Administration in
2526the General Appropriations Act to the line item for Prepaid
2527Health Plans within the General Appropriations Act. The agency
2528shall submit a report to the Legislature regarding how the
2529developed and approved methodologies and payment mechanisms may
2530be applied to other counties in the state pursuant to managed
2531care payments under s. 409.968.
2532     (7)  ENROLLMENT.-All Medicaid recipients in the counties in
2533which the managed care pilot program has been implemented shall
2534be enrolled in a qualified plan. Each recipient shall have a
2535choice of plans and may select any plan unless that plan is
2536restricted by contract to a specific population that does not
2537include the recipient. Medicaid recipients shall have 30 days in
2538which to make a choice of plans. All recipients shall be offered
2539choice counseling services in accordance with this section.
2540     (8)  CHOICE COUNSELING.-The agency shall provide choice
2541counseling and may contract for the provision of choice
2542counseling services. Choice counseling shall be provided in the
2543native or preferred language of the recipient, consistent with
2544federal requirements. The agency shall maintain a record of the
2545recipients who receive such services, identifying the scope and
2546method of the services provided. The agency shall make available
2547clear and easily understandable choice information to Medicaid
2548recipients that includes:
2549     (a)  An explanation that each recipient has the right to
2550choose a qualified plan at the time of enrollment in Medicaid
2551and again at regular intervals set by the agency and that, if a
2552recipient does not choose a qualified plan, the agency will
2553assign the recipient to a qualified plan according to the
2554criteria specified in this section.
2555     (b)  A list and description of the benefits provided in
2556each plan.
2557     (c)  Information about earning credits in the plan's
2558enhanced benefit program.
2559     (d)  An explanation of benefit limits.
2560     (e)  Information about cost-sharing requirements of each
2562     (f)  A current list of providers participating in the
2563network, including location and contact information.
2564     (g)  Plan performance data.
2565     (9)  AUTOMATIC ENROLLMENT.-The agency shall automatically
2566enroll Medicaid recipients who do not voluntarily choose a
2567managed care plan. Enrollment shall be distributed among all
2568qualified plans. When automatically enrolling recipients, the
2569agency shall take into account the following criteria:
2570     (a)  The plan has sufficient network capacity to meet the
2571needs of the recipients.
2572     (b)  The recipient has previously received services from
2573one of the plan's primary care providers.
2574     (c)  Primary care providers in one plan are more
2575geographically accessible to the recipient's residence.
2577The agency may not engage in practices that are designed to
2578favor one qualified plan over another.
2579     (10)  DISENROLLMENT.-After a recipient has selected and
2580enrolled in a qualified plan, the recipient shall have 90 days
2581to voluntarily disenroll and select another qualified plan.
2582After 90 days, further changes may be made only for good cause.
2583"Good cause" includes, but is not limited to, poor quality of
2584care, lack of access to necessary specialty services, an
2585unreasonable delay or denial of service, or fraudulent
2586enrollment. The agency must make a determination as to whether
2587cause exists. However, the agency may require a recipient to use
2588the qualified plan's grievance process prior to the agency's
2589determination of cause, except in cases in which immediate risk
2590of permanent damage to the recipient's health is alleged.  The
2591agency must make a determination and take final action on a
2592recipient's request so that disenrollment occurs no later than
2593the first day of the second month after the month the request
2594was made. If the agency fails to act within the specified
2595timeframe, the recipient's request to disenroll is deemed to be
2596approved as of the date agency action was required. Recipients
2597who disagree with the agency's finding that cause does not exist
2598for disenrollment shall be advised of their right to pursue a
2599Medicaid fair hearing to dispute the agency's finding.
2600     (11)  ENROLLMENT PERIOD.-Medicaid recipients enrolled in a
2601qualified plan after the 90-day period shall remain in the plan
2602for 12 months. After 12 months, the recipient may select another
2603plan. However, nothing shall prevent a Medicaid recipient from
2604changing primary care providers within the qualified plan during
2605the 12-month period.
2606     (12)  GRIEVANCES.-Each qualified plan shall establish an
2607internal process for reviewing and responding to grievances from
2608enrollees. The contract shall specify timeframes for submission,
2609plan response, and resolution. Grievances not resolved by a
2610plan's internal process shall be submitted to the Subscriber
2611Assistance Panel pursuant to s. 408.7056. Each plan shall submit
2612quarterly reports on the number, description, and outcome of
2613grievances filed by enrollees. The agency shall establish a
2614similar process for provider service networks.
2615     (13)  BENEFITS.-Qualified plans operating in the Medicaid
2616managed care pilot program shall cover the services specified in
2617ss. 409.905 and 409.906, emergency services provided under s.
2618409.9128, and such other services as the plan may offer. Plans
2619may customize benefit packages for nonpregnant adults, vary
2620cost-sharing provisions, and provide coverage for additional
2621services. The agency shall evaluate the proposed benefit
2622packages to ensure services are sufficient to meet the needs of
2623the plans' enrollees and to verify actuarial equivalence.
2624     (14)  PENALTIES.-Qualified plans that reduce enrollment
2625levels or leave a county where the managed care pilot program
2626has been implemented shall reimburse the agency for the cost of
2627enrollment changes, including the cost of additional choice
2628counseling services. When more than one qualified plan leaves a
2629county at the same time, costs shall be shared by the plans
2630proportionate to their enrollments.
2631     (15)  ACCESS TO DATA.-The agency shall make encounter data
2632available to those plans accepting enrollees who are assigned to
2633them from other plans leaving a county where the managed care
2634pilot program has been implemented.
2635     (16)  ENHANCED BENEFITS.-Each plan operating in the managed
2636care pilot program shall establish an incentive program that
2637rewards specific healthy behaviors with credits in a flexible
2638spending account pursuant to s. 409.9122(14).
2640     (a)  The agency shall continue the budget-neutral
2641adjustment of capitation rates for all prepaid plans in existing
2642managed care pilot program counties.
2643     (b)  Beginning September 1, 2010, the agency shall begin a
2644budget-neutral adjustment of capitation rates for all prepaid
2645plans in Miami-Dade County. The adjustment to capitation rates
2646shall be based on aggregate risk scores for each prepaid plan's
2647enrollees. During the first 2 years of the adjustment, the
2648agency shall ensure that no plan has an aggregate risk score
2649that varies by more than 10 percent from the aggregate weighted
2650average for all plans. The risk adjusted capitation rates shall
2651be phased in as follows:
2652     1.  In the first fiscal year, 75 percent of the capitation
2653rate shall be based on the current methodology and 25 percent
2654shall be based on the risk-adjusted rate methodology.
2655     2.  In the second fiscal year, 50 percent of the capitation
2656rate shall be based on the current methodology and 50 percent
2657shall be based on the risk-adjusted methodology.
2658     3.  In the third fiscal year, the risk-adjusted capitation
2659methodology shall be fully implemented.
2660     (c)  During this period, the agency shall establish a
2661technical advisory panel to obtain input from the prepaid plans
2662affected by the transition to risk adjusted rates.
2663     (18)  LOW-INCOME POOL.-Funds from a low-income pool shall
2664be distributed in accordance with the terms and conditions of
2665the 1115 waiver and in a manner authorized by the General
2666Appropriations Act. The distribution of funds is intended for
2667the following purposes:
2668     (a)  Assure a broad and fair distribution of available
2669funds based on the access provided by Medicaid participating
2670hospitals, regardless of their ownership status, through their
2671delivery of inpatient or outpatient care for Medicaid
2672beneficiaries and uninsured and underinsured individuals;
2673     (b)  Assure accessible emergency inpatient and outpatient
2674care for Medicaid beneficiaries and uninsured and underinsured
2676     (c)  Enhance primary, preventive, and other ambulatory care
2677coverages for uninsured individuals;
2678     (d)  Promote teaching and specialty hospital programs;
2679     (e)  Promote the stability and viability of statutorily
2680defined rural hospitals and hospitals that serve as sole
2681community hospitals;
2682     (f)  Recognize the extent of hospital uncompensated care
2684     (g)  Maintain and enhance essential community hospital
2686     (h)  Maintain incentives for local governmental entities to
2687contribute to the cost of uncompensated care;
2688     (i)  Promote measures to avoid preventable
2690     (j)  Account for hospital efficiency; and
2691     (k)  Contribute to a community's overall health system.
2692     (19)  ENCOUNTER DATA.-The agency shall maintain and operate
2693the Medicaid Encounter Data System pursuant to s. 409.9122(15).
2694     (20)  EVALUATION.-The agency shall contract with the
2695University of Florida to complete a comprehensive evaluation of
2696the managed care pilot program. The evaluation shall include an
2697assessment of patient satisfaction, changes in benefits and
2698coverage, implementation and impact of enhanced benefits, access
2699to care and service utilization by enrolled recipients, and
2700costs per enrollee.
2701     Section 15.  Section 409.9122, Florida Statutes, is amended
2702to read:
2703     409.9122  Mandatory Medicaid managed care enrollment;
2704programs and procedures.-
2705     (1)  It is the intent of the Legislature that the MediPass
2706program be cost-effective, provide quality health care, and
2707improve access to health services, and that the program be
2708statewide. This subsection expires October 1, 2013.
2709     (2)(a)  The agency shall enroll in a managed care plan or
2710MediPass all Medicaid recipients, except those Medicaid
2711recipients who are: in an institution; enrolled in the Medicaid
2712medically needy program; or eligible for both Medicaid and
2713Medicare. Upon enrollment, individuals will be able to change
2714their managed care option during the 90-day opt out period
2715required by federal Medicaid regulations. The agency is
2716authorized to seek the necessary Medicaid state plan amendment
2717to implement this policy. However, to the extent permitted by
2718federal law, the agency may enroll in a managed care plan or
2719MediPass a Medicaid recipient who is exempt from mandatory
2720managed care enrollment, provided that:
2721     1.  The recipient's decision to enroll in a managed care
2722plan or MediPass is voluntary;
2723     2.  If the recipient chooses to enroll in a managed care
2724plan, the agency has determined that the managed care plan
2725provides specific programs and services which address the
2726special health needs of the recipient; and
2727     3.  The agency receives any necessary waivers from the
2728federal Centers for Medicare and Medicaid Services.
2730The agency shall develop rules to establish policies by which
2731exceptions to the mandatory managed care enrollment requirement
2732may be made on a case-by-case basis. The rules shall include the
2733specific criteria to be applied when making a determination as
2734to whether to exempt a recipient from mandatory enrollment in a
2735managed care plan or MediPass. School districts participating in
2736the certified school match program pursuant to ss. 409.908(21)
2737and 1011.70 shall be reimbursed by Medicaid, subject to the
2738limitations of s. 1011.70(1), for a Medicaid-eligible child
2739participating in the services as authorized in s. 1011.70, as
2740provided for in s. 409.9071, regardless of whether the child is
2741enrolled in MediPass or a managed care plan. Managed care plans
2742shall make a good faith effort to execute agreements with school
2743districts regarding the coordinated provision of services
2744authorized under s. 1011.70. County health departments
2745delivering school-based services pursuant to ss. 381.0056 and
2746381.0057 shall be reimbursed by Medicaid for the federal share
2747for a Medicaid-eligible child who receives Medicaid-covered
2748services in a school setting, regardless of whether the child is
2749enrolled in MediPass or a managed care plan. Managed care plans
2750shall make a good faith effort to execute agreements with county
2751health departments regarding the coordinated provision of
2752services to a Medicaid-eligible child. To ensure continuity of
2753care for Medicaid patients, the agency, the Department of
2754Health, and the Department of Education shall develop procedures
2755for ensuring that a student's managed care plan or MediPass
2756provider receives information relating to services provided in
2757accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2758     (b)  A Medicaid recipient shall not be enrolled in or
2759assigned to a managed care plan or MediPass unless the managed
2760care plan or MediPass has complied with the quality-of-care
2761standards specified in paragraphs (3)(a) and (b), respectively.
2762     (c)  Medicaid recipients shall have a choice of managed
2763care plans or MediPass. The Agency for Health Care
2764Administration, the Department of Health, the Department of
2765Children and Family Services, and the Department of Elderly
2766Affairs shall cooperate to ensure that each Medicaid recipient
2767receives clear and easily understandable information that meets
2768the following requirements:
2769     1.  Explains the concept of managed care, including
2771     2.  Provides information on the comparative performance of
2772managed care plans and MediPass in the areas of quality,
2773credentialing, preventive health programs, network size and
2774availability, and patient satisfaction.
2775     3.  Explains where additional information on each managed
2776care plan and MediPass in the recipient's area can be obtained.
2777     4.  Explains that recipients have the right to choose their
2778managed care coverage at the time they first enroll in Medicaid
2779and again at regular intervals set by the agency. However, if a
2780recipient does not choose a managed care plan or MediPass, the
2781agency will assign the recipient to a managed care plan or
2782MediPass according to the criteria specified in this section.
2783     5.  Explains the recipient's right to complain, file a
2784grievance, or change managed care plans or MediPass providers if
2785the recipient is not satisfied with the managed care plan or
2787     (d)  The agency shall develop a mechanism for providing
2788information to Medicaid recipients for the purpose of making a
2789managed care plan or MediPass selection. Examples of such
2790mechanisms may include, but not be limited to, interactive
2791information systems, mailings, and mass marketing materials.
2792Managed care plans and MediPass providers are prohibited from
2793providing inducements to Medicaid recipients to select their
2794plans or from prejudicing Medicaid recipients against other
2795managed care plans or MediPass providers.
2796     (e)  Medicaid recipients who are already enrolled in a
2797managed care plan or MediPass shall be offered the opportunity
2798to change managed care plans or MediPass providers on a
2799staggered basis, as defined by the agency. All Medicaid
2800recipients shall have 30 days in which to make a choice of
2801managed care plans or MediPass providers. Those Medicaid
2802recipients who do not make a choice shall be assigned in
2803accordance with paragraph (f). To facilitate continuity of care,
2804for a Medicaid recipient who is also a recipient of Supplemental
2805Security Income (SSI), prior to assigning the SSI recipient to a
2806managed care plan or MediPass, the agency shall determine
2807whether the SSI recipient has an ongoing relationship with a
2808MediPass provider or managed care plan, and if so, the agency
2809shall assign the SSI recipient to that MediPass provider or
2810managed care plan. Those SSI recipients who do not have such a
2811provider relationship shall be assigned to a managed care plan
2812or MediPass provider in accordance with paragraph (f).
2813     (f)  If a Medicaid recipient does not choose a managed care
2814plan or MediPass provider, the agency shall assign the Medicaid
2815recipient to a managed care plan or MediPass provider. Medicaid
2816recipients eligible for managed care plan enrollment who are
2817subject to mandatory assignment but who fail to make a choice
2818shall be assigned to managed care plans until an enrollment of
281935 percent in MediPass and 65 percent in managed care plans, of
2820all those eligible to choose managed care, is achieved. Once
2821this enrollment is achieved, the assignments shall be divided in
2822order to maintain an enrollment in MediPass and managed care
2823plans which is in a 35 percent and 65 percent proportion,
2824respectively. Thereafter, assignment of Medicaid recipients who
2825fail to make a choice shall be based proportionally on the
2826preferences of recipients who have made a choice in the previous
2827period. Such proportions shall be revised at least quarterly to
2828reflect an update of the preferences of Medicaid recipients. The
2829agency shall disproportionately assign Medicaid-eligible
2830recipients who are required to but have failed to make a choice
2831of managed care plan or MediPass, including children, and who
2832would be assigned to the MediPass program to children's networks
2833as described in s. 409.912(4)(g), Children's Medical Services
2834Network as defined in s. 391.021, exclusive provider
2835organizations, provider service networks, minority physician
2836networks, and pediatric emergency department diversion programs
2837authorized by this chapter or the General Appropriations Act, in
2838such manner as the agency deems appropriate, until the agency
2839has determined that the networks and programs have sufficient
2840numbers to be operated economically. For purposes of this
2841paragraph, when referring to assignment, the term "managed care
2842plans" includes health maintenance organizations, exclusive
2843provider organizations, provider service networks, minority
2844physician networks, Children's Medical Services Network, and
2845pediatric emergency department diversion programs authorized by
2846this chapter or the General Appropriations Act. When making
2847assignments, the agency shall take into account the following
2849     1.  A managed care plan has sufficient network capacity to
2850meet the need of members.
2851     2.  The managed care plan or MediPass has previously
2852enrolled the recipient as a member, or one of the managed care
2853plan's primary care providers or MediPass providers has
2854previously provided health care to the recipient.
2855     3.  The agency has knowledge that the member has previously
2856expressed a preference for a particular managed care plan or
2857MediPass provider as indicated by Medicaid fee-for-service
2858claims data, but has failed to make a choice.
2859     4.  The managed care plan's or MediPass primary care
2860providers are geographically accessible to the recipient's
2862     (g)  When more than one managed care plan or MediPass
2863provider meets the criteria specified in paragraph (f), the
2864agency shall make recipient assignments consecutively by family
2866     (h)  The agency may not engage in practices that are
2867designed to favor one managed care plan over another or that are
2868designed to influence Medicaid recipients to enroll in MediPass
2869rather than in a managed care plan or to enroll in a managed
2870care plan rather than in MediPass. This subsection does not
2871prohibit the agency from reporting on the performance of
2872MediPass or any managed care plan, as measured by performance
2873criteria developed by the agency.
2874     (i)  After a recipient has made his or her selection or has
2875been enrolled in a managed care plan or MediPass, the recipient
2876shall have 90 days to exercise the opportunity to voluntarily
2877disenroll and select another managed care plan or MediPass.
2878After 90 days, no further changes may be made except for good
2879cause. Good cause includes, but is not limited to, poor quality
2880of care, lack of access to necessary specialty services, an
2881unreasonable delay or denial of service, or fraudulent
2882enrollment. The agency shall develop criteria for good cause
2883disenrollment for chronically ill and disabled populations who
2884are assigned to managed care plans if more appropriate care is
2885available through the MediPass program. The agency must make a
2886determination as to whether cause exists. However, the agency
2887may require a recipient to use the managed care plan's or
2888MediPass grievance process prior to the agency's determination
2889of cause, except in cases in which immediate risk of permanent
2890damage to the recipient's health is alleged. The grievance
2891process, when utilized, must be completed in time to permit the
2892recipient to disenroll by the first day of the second month
2893after the month the disenrollment request was made. If the
2894managed care plan or MediPass, as a result of the grievance
2895process, approves an enrollee's request to disenroll, the agency
2896is not required to make a determination in the case. The agency
2897must make a determination and take final action on a recipient's
2898request so that disenrollment occurs no later than the first day
2899of the second month after the month the request was made. If the
2900agency fails to act within the specified timeframe, the
2901recipient's request to disenroll is deemed to be approved as of
2902the date agency action was required. Recipients who disagree
2903with the agency's finding that cause does not exist for
2904disenrollment shall be advised of their right to pursue a
2905Medicaid fair hearing to dispute the agency's finding.
2906     (j)  The agency shall apply for a federal waiver from the
2907Centers for Medicare and Medicaid Services to lock eligible
2908Medicaid recipients into a managed care plan or MediPass for 12
2909months after an open enrollment period. After 12 months'
2910enrollment, a recipient may select another managed care plan or
2911MediPass provider. However, nothing shall prevent a Medicaid
2912recipient from changing primary care providers within the
2913managed care plan or MediPass program during the 12-month
2915     (k)  When a Medicaid recipient does not choose a managed
2916care plan or MediPass provider, the agency shall assign the
2917Medicaid recipient to a managed care plan, except in those
2918counties in which there are fewer than two managed care plans
2919accepting Medicaid enrollees, in which case assignment shall be
2920to a managed care plan or a MediPass provider. Medicaid
2921recipients in counties with fewer than two managed care plans
2922accepting Medicaid enrollees who are subject to mandatory
2923assignment but who fail to make a choice shall be assigned to
2924managed care plans until an enrollment of 35 percent in MediPass
2925and 65 percent in managed care plans, of all those eligible to
2926choose managed care, is achieved. Once that enrollment is
2927achieved, the assignments shall be divided in order to maintain
2928an enrollment in MediPass and managed care plans which is in a
292935 percent and 65 percent proportion, respectively. For purposes
2930of this paragraph, when referring to assignment, the term
2931"managed care plans" includes exclusive provider organizations,
2932provider service networks, Children's Medical Services Network,
2933minority physician networks, and pediatric emergency department
2934diversion programs authorized by this chapter or the General
2935Appropriations Act. When making assignments, the agency shall
2936take into account the following criteria:
2937     1.  A managed care plan has sufficient network capacity to
2938meet the need of members.
2939     2.  The managed care plan or MediPass has previously
2940enrolled the recipient as a member, or one of the managed care
2941plan's primary care providers or MediPass providers has
2942previously provided health care to the recipient.
2943     3.  The agency has knowledge that the member has previously
2944expressed a preference for a particular managed care plan or
2945MediPass provider as indicated by Medicaid fee-for-service
2946claims data, but has failed to make a choice.
2947     4.  The managed care plan's or MediPass primary care
2948providers are geographically accessible to the recipient's
2950     5.  The agency has authority to make mandatory assignments
2951based on quality of service and performance of managed care
2953     (l)  Notwithstanding the provisions of chapter 287, the
2954agency may, at its discretion, renew cost-effective contracts
2955for choice counseling services once or more for such periods as
2956the agency may decide. However, all such renewals may not
2957combine to exceed a total period longer than the term of the
2958original contract.
2960This subsection expires October 1, 2013.
2961     (3)(a)  The agency shall establish quality-of-care
2962standards for managed care plans. These standards shall be based
2963upon, but are not limited to:
2964     1.  Compliance with the accreditation requirements as
2965provided in s. 641.512.
2966     2.  Compliance with Early and Periodic Screening,
2967Diagnosis, and Treatment screening requirements.
2968     3.  The percentage of voluntary disenrollments.
2969     4.  Immunization rates.
2970     5.  Standards of the National Committee for Quality
2971Assurance and other approved accrediting bodies.
2972     6.  Recommendations of other authoritative bodies.
2973     7.  Specific requirements of the Medicaid program, or
2974standards designed to specifically assist the unique needs of
2975Medicaid recipients.
2976     8.  Compliance with the health quality improvement system
2977as established by the agency, which incorporates standards and
2978guidelines developed by the Medicaid Bureau of the Health Care
2979Financing Administration as part of the quality assurance reform
2981     (b)  For the MediPass program, the agency shall establish
2982standards which are based upon, but are not limited to:
2983     1.  Quality-of-care standards which are comparable to those
2984required of managed care plans.
2985     2.  Credentialing standards for MediPass providers.
2986     3.  Compliance with Early and Periodic Screening,
2987Diagnosis, and Treatment screening requirements.
2988     4.  Immunization rates.
2989     5.  Specific requirements of the Medicaid program, or
2990standards designed to specifically assist the unique needs of
2991Medicaid recipients.
2993This subsection expires October 1, 2013.
2994     (4)(a)  Each female recipient may select as her primary
2995care provider an obstetrician/gynecologist who has agreed to
2996participate as a MediPass primary care case manager.
2997     (b)  The agency shall establish a complaints and grievance
2998process to assist Medicaid recipients enrolled in the MediPass
2999program to resolve complaints and grievances. The agency shall
3000investigate reports of quality-of-care grievances which remain
3001unresolved to the satisfaction of the enrollee.
3003This subsection expires October 1, 2013.
3004     (5)(a)  The agency shall work cooperatively with the Social
3005Security Administration to identify beneficiaries who are
3006jointly eligible for Medicare and Medicaid and shall develop
3007cooperative programs to encourage these beneficiaries to enroll
3008in a Medicare participating health maintenance organization or
3009prepaid health plans.
3010     (b)  The agency shall work cooperatively with the
3011Department of Elderly Affairs to assess the potential cost-
3012effectiveness of providing MediPass to beneficiaries who are
3013jointly eligible for Medicare and Medicaid on a voluntary choice
3014basis. If the agency determines that enrollment of these
3015beneficiaries in MediPass has the potential for being cost-
3016effective for the state, the agency shall offer MediPass to
3017these beneficiaries on a voluntary choice basis in the counties
3018where MediPass operates.
3020This subsection expires October 1, 2013.
3021     (6)  MediPass enrolled recipients may receive up to 10
3022visits of reimbursable services by participating Medicaid
3023physicians licensed under chapter 460 and up to four visits of
3024reimbursable services by participating Medicaid physicians
3025licensed under chapter 461. Any further visits must be by prior
3026authorization by the MediPass primary care provider. However,
3027nothing in this subsection may be construed to increase the
3028total number of visits or the total amount of dollars per year
3029per person under current Medicaid rules, unless otherwise
3030provided for in the General Appropriations Act. This subsection
3031expires October 1, 2013.
3032     (7)  The agency shall investigate the feasibility of
3033developing managed care plan and MediPass options for the
3034following groups of Medicaid recipients:
3035     (a)  Pregnant women and infants.
3036     (b)  Elderly and disabled recipients, especially those who
3037are at risk of nursing home placement.
3038     (c)  Persons with developmental disabilities.
3039     (d)  Qualified Medicare beneficiaries.
3040     (e)  Adults who have chronic, high-cost medical conditions.
3041     (f)  Adults and children who have mental health problems.
3042     (g)  Other recipients for whom managed care plans and
3043MediPass offer the opportunity of more cost-effective care and
3044greater access to qualified providers.
3045     (8)(a)  The agency shall encourage the development of
3046public and private partnerships to foster the growth of health
3047maintenance organizations and prepaid health plans that will
3048provide high-quality health care to Medicaid recipients.
3049     (b)  Subject to the availability of moneys and any
3050limitations established by the General Appropriations Act or
3051chapter 216, the agency is authorized to enter into contracts
3052with traditional providers of health care to low-income persons
3053to assist such providers with the technical aspects of
3054cooperatively developing Medicaid prepaid health plans.
3055     1.  The agency may contract with disproportionate share
3056hospitals, county health departments, federally initiated or
3057federally funded community health centers, and counties that
3058operate either a hospital or a community clinic.
3059     2.  A contract may not be for more than $100,000 per year,
3060and no contract may be extended with any particular provider for
3061more than 2 years. The contract is intended only as seed or
3062development funding and requires a commitment from the
3063interested party.
3064     3.  A contract must require participation by at least one
3065community health clinic and one disproportionate share hospital.
3066     (7)(9)(a)  The agency shall develop and implement a
3067comprehensive plan to ensure that recipients are adequately
3068informed of their choices and rights under all Medicaid managed
3069care programs and that Medicaid managed care programs meet
3070acceptable standards of quality in patient care, patient
3071satisfaction, and financial solvency.
3072     (b)  The agency shall provide adequate means for informing
3073patients of their choice and rights under a managed care plan at
3074the time of eligibility determination.
3075     (c)  The agency shall require managed care plans and
3076MediPass providers to demonstrate and document plans and
3077activities, as defined by rule, including outreach and followup,
3078undertaken to ensure that Medicaid recipients receive the health
3079care service to which they are entitled.
3081This subsection expires October 1, 2013.
3082     (8)(10)  The agency shall consult with Medicaid consumers
3083and their representatives on an ongoing basis regarding
3084measurements of patient satisfaction, procedures for resolving
3085patient grievances, standards for ensuring quality of care,
3086mechanisms for providing patient access to services, and
3087policies affecting patient care. This subsection expires October
30881, 2013.
3089     (9)(11)  The agency may extend eligibility for Medicaid
3090recipients enrolled in licensed and accredited health
3091maintenance organizations for the duration of the enrollment
3092period or for 6 months, whichever is earlier, provided the
3093agency certifies that such an offer will not increase state
3094expenditures. This subsection expires October 1, 2013.
3095     (10)(12)  A managed care plan that has a Medicaid contract
3096shall at least annually review each primary care physician's
3097active patient load and shall ensure that additional Medicaid
3098recipients are not assigned to physicians who have a total
3099active patient load of more than 3,000 patients. As used in this
3100subsection, the term "active patient" means a patient who is
3101seen by the same primary care physician, or by a physician
3102assistant or advanced registered nurse practitioner under the
3103supervision of the primary care physician, at least three times
3104within a calendar year. Each primary care physician shall
3105annually certify to the managed care plan whether or not his or
3106her patient load exceeds the limits established under this
3107subsection and the managed care plan shall accept such
3108certification on face value as compliance with this subsection.
3109The agency shall accept the managed care plan's representations
3110that it is in compliance with this subsection based on the
3111certification of its primary care physicians, unless the agency
3112has an objective indication that access to primary care is being
3113compromised, such as receiving complaints or grievances relating
3114to access to care. If the agency determines that an objective
3115indication exists that access to primary care is being
3116compromised, it may verify the patient load certifications
3117submitted by the managed care plan's primary care physicians and
3118that the managed care plan is not assigning Medicaid recipients
3119to primary care physicians who have an active patient load of
3120more than 3,000 patients. This subsection expires October 1,
3122     (13)  Effective July 1, 2003, the agency shall adjust the
3123enrollee assignment process of Medicaid managed prepaid health
3124plans for those Medicaid managed prepaid plans operating in
3125Miami-Dade County which have executed a contract with the agency
3126for a minimum of 8 consecutive years in order for the Medicaid
3127managed prepaid plan to maintain a minimum enrollment level of
312815,000 members per month. When assigning enrollees pursuant to
3129this subsection, the agency shall give priority to providers
3130that initially qualified under this subsection until such
3131providers reach and maintain an enrollment level of 15,000
3132members per month. A prepaid health plan that has a statewide
3133Medicaid enrollment of 25,000 or more members is not eligible
3134for enrollee assignments under this subsection.
3135     (11)(14)  The agency shall include in its calculation of
3136the hospital inpatient component of a Medicaid health
3137maintenance organization's capitation rate any special payments,
3138including, but not limited to, upper payment limit or
3139disproportionate share hospital payments, made to qualifying
3140hospitals through the fee-for-service program. The agency may
3141seek federal waiver approval or state plan amendment as needed
3142to implement this adjustment.
3143     (12)(a)  Beginning September 1, 2010, the agency shall
3144begin a budget-neutral adjustment of capitation rates for all
3145Medicaid prepaid plans in the state. The adjustment to
3146capitation rates shall be based on aggregate risk scores for
3147each prepaid plan's enrollees. During the first 2 years of the
3148adjustment, the agency shall ensure that no plan has an
3149aggregate risk score that varies more than 10 percent from the
3150aggregate weighted average for all plans. The risk adjusted
3151capitation rates shall be phased in as follows:
3152     1.  In the first fiscal year, 75 percent of the capitation
3153rate shall be based on the current methodology and 25 percent
3154shall be based on the risk-adjusted rate methodology.
3155     2.  In the second fiscal year, 50 percent of the capitation
3156rate shall be based on the current methodology and 50 percent
3157shall be based on the risk-adjusted methodology.
3158     3.  In the third fiscal year, the risk-adjusted capitation
3159methodology shall be fully implemented.
3160     (b)  During this period, the agency shall establish a
3161technical advisory panel to obtain input from the prepaid plans
3162affected by the transition to risk adjusted rates.
3163     (13)  The agency shall develop a process to enable any
3164recipient with access to employer sponsored insurance to opt out
3165of all qualified plans in the Medicaid program and to use
3166Medicaid financial assistance to pay for the recipient's share
3167of cost in any such plan. Contingent on federal approval, the
3168agency shall also enable recipients with access to other
3169insurance or related products providing access to health care
3170services created pursuant to state law, including any plan or
3171product available pursuant to Cover Florida, the Florida Health
3172Choices Program, or any health exchange, to opt out. The amount
3173of financial assistance provided for each recipient shall not
3174exceed the amount of the Medicaid premium that would have been
3175paid to a plan for that recipient.
3176     (14)  Each qualified plan shall establish an incentive
3177program that rewards specific healthy behaviors with credits in
3178a flexible spending account pursuant to s. 409.9122(14).
3179     (a)  At the discretion of the recipient, credits shall be
3180used to purchase otherwise uncovered health and related services
3181during the entire period of and for a maximum of 3 years after
3182the recipient's Medicaid eligibility, whether or not the
3183recipient remains continuously enrolled in the plan in which the
3184credits were earned.
3185     (b)  Enhanced benefits offered by a qualified plan shall be
3186structured to provide greater incentives for those diseases
3187linked with lifestyle and conditions or behaviors associated
3188with avoidable utilization of high-cost services.
3189     (c)  To fund these credits, each plan must maintain a
3190reserve account in an amount up to 2 percent of the plan's
3191Medicaid premium revenue or benchmark premium revenue in the
3192case of provider service networks based on an actuarial
3193assessment of the value of the enhanced benefit program.
3194     (15)  The agency shall maintain and operate the Medicaid
3195Encounter Data System to collect, process, store, and report on
3196covered services provided to all Florida Medicaid recipients
3197enrolled in prepaid managed care plans. Prepaid managed care
3198plans shall submit encounter data electronically in a format
3199that complies with the Health Insurance Portability and
3200Accountability Act provisions for electronic claims and in
3201accordance with deadlines established by the agency. Prepaid
3202managed care plans must certify that the data reported is
3203accurate and complete. The agency is responsible for validating
3204the data submitted by the plans.
3205     (16)  The agency may establish a per-member per-month
3206payment for Medicare Advantage Special Needs members that are
3207also eligible for Medicaid as a mechanism for meeting the
3208state's cost sharing obligation.  The agency may also develop a
3209per-member per-month payment for Medicaid only covered services
3210for which the state is responsible. The agency shall develop a
3211mechanism to ensure that such per-member per-month payment
3212enhances the value to the state and enrolled members by limiting
3213cost sharing, enhancing the scope of Medicare supplemental
3214benefits that are equal to or greater than Medicaid coverage for
3215select services, and improving care coordination.
3216     (17)  The agency shall establish, and managed care plans
3217shall use, a uniform method of accounting for and reporting
3218medical and nonmedical costs. The agency shall make such
3219information available to the public.
3220     (18)  Effective October 1, 2013, school districts
3221participating in the certified school match program pursuant to
3222ss. 409.908(21) and 1011.70 shall be reimbursed by Medicaid,
3223subject to the limitations of s. 1011.70(1), for a Medicaid-
3224eligible child participating in the services as authorized in s.
32251011.70, as provided for in s. 409.9071. Managed care plans
3226shall make a good faith effort to execute agreements with school
3227districts regarding the coordinated provision of services
3228authorized under s. 1011.70 and county health departments
3229delivering school-based services pursuant to ss. 381.0056 and
3230381.0057. To ensure continuity of care for Medicaid patients,
3231the agency, the Department of Health, and the Department of
3232Education shall develop procedures for ensuring that a student's
3233managed care plan receives information relating to services
3234provided in accordance with ss. 381.0056, 381.0057, 409.9071,
3235and 1011.70.
3236     (19)  The agency may, on a case-by-case basis, exempt a
3237recipient from mandatory enrollment in a managed care plan when
3238the recipient has a unique, time-limited disease or condition-
3239related circumstance and managed care enrollment will interfere
3240with ongoing care because the recipient's provider does not
3241participate in the managed care plans available in the
3242recipient's area.
3243     Section 16.  Subsection (18) of section 430.04, Florida
3244Statutes, is amended to read:
3245     430.04  Duties and responsibilities of the Department of
3246Elderly Affairs.-The Department of Elderly Affairs shall:
3247     (18)  Administer all Medicaid waivers and programs relating
3248to elders and their appropriations. The waivers include, but are
3249not limited to:
3250     (a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3251established in s. 430.502(7), (8), and (9).
3252     (a)(b)  The Assisted Living for the Frail Elderly Waiver.
3253     (b)(c)  The Aged and Disabled Adult Waiver.
3254     (c)(d)  The Adult Day Health Care Waiver.
3255     (d)(e)  The Consumer-Directed Care Plus Program as defined
3256in s. 409.221.
3257     (e)(f)  The Program of All-inclusive Care for the Elderly.
3258     (f)(g)  The Long-Term Care Community-Based Diversion Pilot
3259Project as described in s. 430.705.
3260     (g)(h)  The Channeling Services Waiver for Frail Elders.
3262The department shall develop a transition plan for recipients
3263receiving services in long-term care Medicaid waivers for elders
3264or disabled adults on the date qualified plans become available
3265in each recipient's region pursuant to s. 409.981(2) to enroll
3266those recipients in qualified plans. This subsection expires
3267October 1, 2012.
3268     Section 17.  Section 430.2053, Florida Statutes, is amended
3269to read:
3270     430.2053  Aging resource centers.-
3271     (1)  The department, in consultation with the Agency for
3272Health Care Administration and the Department of Children and
3273Family Services, shall develop pilot projects for aging resource
3274centers. By October 31, 2004, the department, in consultation
3275with the agency and the Department of Children and Family
3276Services, shall develop an implementation plan for aging
3277resource centers and submit the plan to the Governor, the
3278President of the Senate, and the Speaker of the House of
3279Representatives. The plan must include qualifications for
3280designation as a center, the functions to be performed by each
3281center, and a process for determining that a current area agency
3282on aging is ready to assume the functions of an aging resource
3284     (2)  Each area agency on aging shall develop, in
3285consultation with the existing community care for the elderly
3286lead agencies within their planning and service areas, a
3287proposal that describes the process the area agency on aging
3288intends to undertake to transition to an aging resource center
3289prior to July 1, 2005, and that describes the area agency's
3290compliance with the requirements of this section. The proposals
3291must be submitted to the department prior to December 31, 2004.
3292The department shall evaluate all proposals for readiness and,
3293prior to March 1, 2005, shall select three area agencies on
3294aging which meet the requirements of this section to begin the
3295transition to aging resource centers. Those area agencies on
3296aging which are not selected to begin the transition to aging
3297resource centers shall, in consultation with the department and
3298the existing community care for the elderly lead agencies within
3299their planning and service areas, amend their proposals as
3300necessary and resubmit them to the department prior to July 1,
33012005. The department may transition additional area agencies to
3302aging resource centers as it determines that area agencies are
3303in compliance with the requirements of this section.
3304     (3)  The Auditor General and the Office of Program Policy
3305Analysis and Government Accountability (OPPAGA) shall jointly
3306review and assess the department's process for determining an
3307area agency's readiness to transition to an aging resource
3309     (a)  The review must, at a minimum, address the
3310appropriateness of the department's criteria for selection of an
3311area agency to transition to an aging resource center, the
3312instruments applied, the degree to which the department
3313accurately determined each area agency's compliance with the
3314readiness criteria, the quality of the technical assistance
3315provided by the department to an area agency in correcting any
3316weaknesses identified in the readiness assessment, and the
3317degree to which each area agency overcame any identified
3319     (b)  Reports of these reviews must be submitted to the
3320appropriate substantive and appropriations committees in the
3321Senate and the House of Representatives on March 1 and September
33221 of each year until full transition to aging resource centers
3323has been accomplished statewide, except that the first report
3324must be submitted by February 1, 2005, and must address all
3325readiness activities undertaken through December 31, 2004. The
3326perspectives of all participants in this review process must be
3327included in each report.
3328     (2)(4)  The purposes of an aging resource center shall be:
3329     (a)  To provide Florida's elders and their families with a
3330locally focused, coordinated approach to integrating information
3331and referral for all available services for elders with the
3332eligibility determination entities for state and federally
3333funded long-term-care services.
3334     (b)  To provide for easier access to long-term-care
3335services by Florida's elders and their families by creating
3336multiple access points to the long-term-care network that flow
3337through one established entity with wide community recognition.
3338     (3)(5)  The duties of an aging resource center are to:
3339     (a)  Develop referral agreements with local community
3340service organizations, such as senior centers, existing elder
3341service providers, volunteer associations, and other similar
3342organizations, to better assist clients who do not need or do
3343not wish to enroll in programs funded by the department or the
3344agency. The referral agreements must also include a protocol,
3345developed and approved by the department, which provides
3346specific actions that an aging resource center and local
3347community service organizations must take when an elder or an
3348elder's representative seeking information on long-term-care
3349services contacts a local community service organization prior
3350to contacting the aging resource center. The protocol shall be
3351designed to ensure that elders and their families are able to
3352access information and services in the most efficient and least
3353cumbersome manner possible.
3354     (b)  Provide an initial screening of all clients who
3355request long-term-care services to determine whether the person
3356would be most appropriately served through any combination of
3357federally funded programs, state-funded programs, locally funded
3358or community volunteer programs, or private funding for
3360     (c)  Determine eligibility for the programs and services
3361listed in subsection (9) (11) for persons residing within the
3362geographic area served by the aging resource center and
3363determine a priority ranking for services which is based upon
3364the potential recipient's frailty level and likelihood of
3365institutional placement without such services.
3366     (d)  Manage the availability of financial resources for the
3367programs and services listed in subsection (9) (11) for persons
3368residing within the geographic area served by the aging resource
3370     (e)  When financial resources become available, refer a
3371client to the most appropriate entity to begin receiving
3372services. The aging resource center shall make referrals to lead
3373agencies for service provision that ensure that individuals who
3374are vulnerable adults in need of services pursuant to s.
3375415.104(3)(b), or who are victims of abuse, neglect, or
3376exploitation in need of immediate services to prevent further
3377harm and are referred by the adult protective services program,
3378are given primary consideration for receiving community-care-
3379for-the-elderly services in compliance with the requirements of
3380s. 430.205(5)(a) and that other referrals for services are in
3381compliance with s. 430.205(5)(b).
3382     (f)  Convene a work group to advise in the planning,
3383implementation, and evaluation of the aging resource center. The
3384work group shall be comprised of representatives of local
3385service providers, Alzheimer's Association chapters, housing
3386authorities, social service organizations, advocacy groups,
3387representatives of clients receiving services through the aging
3388resource center, and any other persons or groups as determined
3389by the department. The aging resource center, in consultation
3390with the work group, must develop annual program improvement
3391plans that shall be submitted to the department for
3392consideration. The department shall review each annual
3393improvement plan and make recommendations on how to implement
3394the components of the plan.
3395     (g)  Enhance the existing area agency on aging in each
3396planning and service area by integrating, either physically or
3397virtually, the staff and services of the area agency on aging
3398with the staff of the department's local CARES Medicaid nursing
3399home preadmission screening unit and a sufficient number of
3400staff from the Department of Children and Family Services'
3401Economic Self-Sufficiency Unit necessary to determine the
3402financial eligibility for all persons age 60 and older residing
3403within the area served by the aging resource center that are
3404seeking Medicaid services, Supplemental Security Income, and
3405food stamps.
3406     (h)  Assist clients who request long-term care services in
3407being evaluated for eligibility for enrollment in the Medicaid
3408long-term care managed care program as qualified plans become
3409available in each of the regions pursuant to s. 409.981(2).
3410     (i)  Provide choice counseling for the Medicaid long-term
3411care managed care program by integrating, either physically or
3412virtually, choice counseling staff and services as qualified
3413plans become available in each of the regions pursuant to s.
3414409.981(2). Pursuant to s. 409.984(1), the agency may contract
3415directly with the aging resource center to provide choice
3416counseling services or may contract with another vendor if the
3417aging resource center does not choose to provide such services.
3418     (j)  Assist Medicaid recipients enrolled in the Medicaid
3419long-term care managed care program with informally resolving
3420grievances with a managed care network and assist Medicaid
3421recipients in accessing the managed care network's formal
3422grievance process as qualified plans become available in each of
3423the regions pursuant to s. 409.981(2).
3424     (4)(6)  The department shall select the entities to become
3425aging resource centers based on each entity's readiness and
3426ability to perform the duties listed in subsection (3) (5) and
3427the entity's:
3428     (a)  Expertise in the needs of each target population the
3429center proposes to serve and a thorough knowledge of the
3430providers that serve these populations.
3431     (b)  Strong connections to service providers, volunteer
3432agencies, and community institutions.
3433     (c)  Expertise in information and referral activities.
3434     (d)  Knowledge of long-term-care resources, including
3435resources designed to provide services in the least restrictive
3437     (e)  Financial solvency and stability.
3438     (f)  Ability to collect, monitor, and analyze data in a
3439timely and accurate manner, along with systems that meet the
3440department's standards.
3441     (g)  Commitment to adequate staffing by qualified personnel
3442to effectively perform all functions.
3443     (h)  Ability to meet all performance standards established
3444by the department.
3445     (5)(7)  The aging resource center shall have a governing
3446body which shall be the same entity described in s. 20.41(7),
3447and an executive director who may be the same person as
3448described in s. 20.41(7). The governing body shall annually
3449evaluate the performance of the executive director.
3450     (6)(8)  The aging resource center may not be a provider of
3451direct services other than choice counseling as qualified plans
3452become available in each of the regions pursuant to s.
3453409.981(2), information and referral services, and screening.
3454     (7)(9)  The aging resource center must agree to allow the
3455department to review any financial information the department
3456determines is necessary for monitoring or reporting purposes,
3457including financial relationships.
3458     (8)(10)  The duties and responsibilities of the community
3459care for the elderly lead agencies within each area served by an
3460aging resource center shall be to:
3461     (a)  Develop strong community partnerships to maximize the
3462use of community resources for the purpose of assisting elders
3463to remain in their community settings for as long as it is
3464safely possible.
3465     (b)  Conduct comprehensive assessments of clients that have
3466been determined eligible and develop a care plan consistent with
3467established protocols that ensures that the unique needs of each
3468client are met.
3469     (9)(11)  The services to be administered through the aging
3470resource center shall include those funded by the following
3472     (a)  Community care for the elderly.
3473     (b)  Home care for the elderly.
3474     (c)  Contracted services.
3475     (d)  Alzheimer's disease initiative.
3476     (e)  Aged and disabled adult Medicaid waiver. This
3477paragraph expires October 1, 2012.
3478     (f)  Assisted living for the frail elderly Medicaid waiver.
3479This paragraph expires October 1, 2012.
3480     (g)  Older Americans Act.
3481     (10)(12)  The department shall, prior to designation of an
3482aging resource center, develop by rule operational and quality
3483assurance standards and outcome measures to ensure that clients
3484receiving services through all long-term-care programs
3485administered through an aging resource center are receiving the
3486appropriate care they require and that contractors and
3487subcontractors are adhering to the terms of their contracts and
3488are acting in the best interests of the clients they are
3489serving, consistent with the intent of the Legislature to reduce
3490the use of and cost of nursing home care. The department shall
3491by rule provide operating procedures for aging resource centers,
3492which shall include:
3493     (a)  Minimum standards for financial operation, including
3494audit procedures.
3495     (b)  Procedures for monitoring and sanctioning of service
3497     (c)  Minimum standards for technology utilized by the aging
3498resource center.
3499     (d)  Minimum staff requirements which shall ensure that the
3500aging resource center employs sufficient quality and quantity of
3501staff to adequately meet the needs of the elders residing within
3502the area served by the aging resource center.
3503     (e)  Minimum accessibility standards, including hours of
3505     (f)  Minimum oversight standards for the governing body of
3506the aging resource center to ensure its continuous involvement
3507in, and accountability for, all matters related to the
3508development, implementation, staffing, administration, and
3509operations of the aging resource center.
3510     (g)  Minimum education and experience requirements for
3511executive directors and other executive staff positions of aging
3512resource centers.
3513     (h)  Minimum requirements regarding any executive staff
3514positions that the aging resource center must employ and minimum
3515requirements that a candidate must meet in order to be eligible
3516for appointment to such positions.
3517     (11)(13)  In an area in which the department has designated
3518an area agency on aging as an aging resource center, the
3519department and the agency shall not make payments for the
3520services listed in subsection (9) (11) and the Long-Term Care
3521Community Diversion Project for such persons who were not
3522screened and enrolled through the aging resource center. The
3523department shall cease making payments for recipients in
3524qualified plans as qualified plans become available in each of
3525the regions pursuant to s. 409.981(2).
3526     (12)(14)  Each aging resource center shall enter into a
3527memorandum of understanding with the department for
3528collaboration with the CARES unit staff. The memorandum of
3529understanding shall outline the staff person responsible for
3530each function and shall provide the staffing levels necessary to
3531carry out the functions of the aging resource center.
3532     (13)(15)  Each aging resource center shall enter into a
3533memorandum of understanding with the Department of Children and
3534Family Services for collaboration with the Economic Self-
3535Sufficiency Unit staff. The memorandum of understanding shall
3536outline which staff persons are responsible for which functions
3537and shall provide the staffing levels necessary to carry out the
3538functions of the aging resource center.
3539     (14)  As qualified plans become available in each of the
3540regions pursuant to s. 409.981(2), if an aging resource center
3541does not contract with the agency to provide Medicaid long-term
3542care managed care choice counseling pursuant to s. 409.984(1),
3543the aging resource center shall enter into a memorandum of
3544understanding with the agency to coordinate staffing and
3545collaborate with the choice counseling vendor. The memorandum of
3546understanding shall identify the staff responsible for each
3547function and shall provide the staffing levels necessary to
3548carry out the functions of the aging resource center.
3549     (15)(16)  If any of the state activities described in this
3550section are outsourced, either in part or in whole, the contract
3551executing the outsourcing shall mandate that the contractor or
3552its subcontractors shall, either physically or virtually,
3553execute the provisions of the memorandum of understanding
3554instead of the state entity whose function the contractor or
3555subcontractor now performs.
3556     (16)(17)  In order to be eligible to begin transitioning to
3557an aging resource center, an area agency on aging board must
3558ensure that the area agency on aging which it oversees meets all
3559of the minimum requirements set by law and in rule.
3560     (18)  The department shall monitor the three initial
3561projects for aging resource centers and report on the progress
3562of those projects to the Governor, the President of the Senate,
3563and the Speaker of the House of Representatives by June 30,
35642005. The report must include an evaluation of the
3565implementation process.
3566     (17)(19)(a)  Once an aging resource center is operational,
3567the department, in consultation with the agency, may develop
3568capitation rates for any of the programs administered through
3569the aging resource center. Capitation rates for programs shall
3570be based on the historical cost experience of the state in
3571providing those same services to the population age 60 or older
3572residing within each area served by an aging resource center.
3573Each capitated rate may vary by geographic area as determined by
3574the department.
3575     (b)  The department and the agency may determine for each
3576area served by an aging resource center whether it is
3577appropriate, consistent with federal and state laws and
3578regulations, to develop and pay separate capitated rates for
3579each program administered through the aging resource center or
3580to develop and pay capitated rates for service packages which
3581include more than one program or service administered through
3582the aging resource center.
3583     (c)  Once capitation rates have been developed and
3584certified as actuarially sound, the department and the agency
3585may pay service providers the capitated rates for services when
3587     (d)  The department, in consultation with the agency, shall
3588annually reevaluate and recertify the capitation rates,
3589adjusting forward to account for inflation, programmatic
3591     (20)  The department, in consultation with the agency,
3592shall submit to the Governor, the President of the Senate, and
3593the Speaker of the House of Representatives, by December 1,
35942006, a report addressing the feasibility of administering the
3595following services through aging resource centers beginning July
35961, 2007:
3597     (a)  Medicaid nursing home services.
3598     (b)  Medicaid transportation services.
3599     (c)  Medicaid hospice care services.
3600     (d)  Medicaid intermediate care services.
3601     (e)  Medicaid prescribed drug services.
3602     (f)  Medicaid assistive care services.
3603     (g)  Any other long-term-care program or Medicaid service.
3604     (18)(21)  This section shall not be construed to allow an
3605aging resource center to restrict, manage, or impede the local
3606fundraising activities of service providers.
3607     Section 18.  Subsection (4) of section 641.386, Florida
3608Statutes, is amended to read:
3609     641.386  Agent licensing and appointment required;
3611     (4)  All agents and health maintenance organizations shall
3612comply with and be subject to the applicable provisions of ss.
3613641.309 and 409.912(20)(21), and all companies and entities
3614appointing agents shall comply with s. 626.451, when marketing
3615for any health maintenance organization licensed pursuant to
3616this part, including those organizations under contract with the
3617Agency for Health Care Administration to provide health care
3618services to Medicaid recipients or any private entity providing
3619health care services to Medicaid recipients pursuant to a
3620prepaid health plan contract with the Agency for Health Care
3622     Section 19.  Effective October 1, 2012, sections 430.701,
3623430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3624430.708, and 430.709 Florida Statutes, are repealed.
3625     Section 20.  Sections 409.9301, 409.942, 409.944, 409.945,
3626409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3627as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3628402.87, Florida Statutes, respectively.
3629     Section 21.  Paragraph (a) of subsection (1) of section
3630443.111, Florida Statutes, is amended to read:
3631     443.111  Payment of benefits.-
3632     (1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3633in accordance with rules adopted by the Agency for Workforce
3634Innovation, subject to the following requirements:
3635     (a)  Benefits are payable by mail or electronically.
3636Notwithstanding s. 402.82(4) 409.942(4), The agency may develop
3637a system for the payment of benefits by electronic funds
3638transfer, including, but not limited to, debit cards, electronic
3639payment cards, or any other means of electronic payment that the
3640agency deems to be commercially viable or cost-effective.
3641Commodities or services related to the development of such a
3642system shall be procured by competitive solicitation, unless
3643they are purchased from a state term contract pursuant to s.
3644287.056. The agency shall adopt rules necessary to administer
3645the system.
3646     Section 22.  Except as otherwise expressly provided in this
3647act, this act shall take effect July 1, 2010, if HB 7223 or
3648similar legislation is adopted in the same legislative session
3649or an extension thereof and becomes law.

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