September 23, 2020
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_h7225e1
HB 7225

1
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;
5providing for an establishment of an iBudget demonstration
6project by the Agency for Persons with Disabilities, in
7consultation with the Agency for Health Care
8Administration, in specified counties; providing for
9allocation of funds; providing goals; providing for an
10allocation algorithm and methodology for development of a
11client's iBudget; providing for the seeking of federal
12approval and waivers; providing for a transition to full
13implementation; providing for inapplicability of certain
14service limitations; providing for setting rates;
15providing for client training and education; providing for
16evaluation; requiring a report; requiring rulemaking;
17requiring the Agency for Persons with Disabilities to
18establish a transition plan for current Medicaid
19recipients under certain circumstances; providing for
20expiration of the section on a specified date; creating s.
21400.0713, F.S.; requiring the Agency for Health Care
22Administration to establish a nursing home licensure
23workgroup; amending s. 408.040, F.S.; providing for
24suspension of conditions precedent to the issuance of a
25certificate of need for a nursing home, effective on a
26specified date; amending s. 408.0435, F.S.; extending the
27certificate-of-need moratorium for additional community
28nursing home beds; designating ss. 409.016-409.803, F.S.,
29as pt. I of ch. 409, F.S., and entitling the part "Social
30and Economic Assistance"; designating ss. 409.810-409.821,
31F.S., as pt. II of ch. 409, F.S., and entitling the part
32"Kidcare"; designating ss. 409.901-409.9205, F.S., as part
33III of ch. 409, F.S., and entitling the part "Medicaid";
34amending s. 409.907, F.S.; authorizing the Agency for
35Health Care Administration to enroll entities as Medicare
36crossover-only providers for payment and claims processing
37purposes only; specifying requirements for Medicare
38crossover-only agreements; amending s. 409.908, F.S.;
39providing penalties for providers that fail to report
40suspension or disenrollment from Medicare within a
41specified time; amending s. 409.912, F.S.; authorizing
42provider service networks to provide comprehensive
43behavioral health care services to certain Medicaid
44recipients; providing payment requirements for provider
45service networks; providing for the expiration of various
46provisions of the section on specified dates to conform to
47the reorganization of Medicaid managed care; requiring the
48Agency for Health Care Administration to contract on a
49prepaid or fixed-sum basis with certain prepaid dental
50health plans; requiring Medicaid-eligible children with
51open child welfare cases who reside in AHCA area 10 to be
52enrolled in specified capitated managed care plans;
53eliminating obsolete provisions and updating provisions
54within the section; amending ss. 409.91195 and 409.91196,
55F.S.; conforming cross-references; amending s. 409.91207,
56F.S.; providing authority of the Agency for Health Care
57Administration with respect to the development of a method
58for designating qualified plans as a medical home network;
59providing purposes and principles for creating medical
60home networks; providing criteria for designation of a
61qualified plan as a medical home network; providing agency
62duties with respect thereto; amending s. 409.91211, F.S.;
63providing authority of the Agency for Health Care
64Administration to implement a managed care pilot program
65based on specified waiver authority with respect to the
66Medicaid reform program; continuing the existing pilot
67program in specified counties; requiring the agency to
68seek an extension of the waiver; providing for monthly
69reports; requiring approval of the Legislative Budget
70Commission for changes to specified terms and conditions ;
71providing for expansion of the managed care pilot program
72to Miami-Dade County; specifying managed care plans that
73are qualified to participate in the Medicaid managed care
74pilot program; providing requirements for qualified
75managed care plans; requiring the agency to develop and
76seek federal approval to implement methodologies to
77preserve intergovernmental transfers of funds and
78certified public expenditures from Miami-Dade County;
79requiring the agency to submit a plan and specified
80amendment to the Legislative Budget Commission; providing
81for a report; requiring Medicaid recipients in counties in
82which the managed care pilot program has been implemented
83to be enrolled in a qualified plan; providing a time limit
84for enrollment; requiring the agency to provide choice
85counseling; providing requirements with respect to choice
86counseling information provided to Medicaid recipients;
87providing for automatic enrollment of certain Medicaid
88recipients; establishing criteria for automatic
89enrollment; providing procedures and requirements with
90respect to voluntary disenrollment of a recipient in a
91qualified plan; providing for an enrollment period;
92requiring qualified plans to establish a process for
93review of and response to grievances of enrollees;
94requiring qualified plans to submit quarterly reports;
95specifying services to be covered by qualified plans;
96authorizing qualified plans to offer specified
97customizations, variances, and coverage for additional
98services; requiring agency evaluation of proposed benefit
99packages; requiring qualified plans to reimburse the
100agency for the cost of specified enrollment changes;
101providing for access to encounter data; requiring
102participating plans to establish an incentive program to
103reward healthy behaviors; requiring the agency to continue
104budget-neutral adjustment of capitation rates for all
105prepaid plans in existing managed care pilot program
106counties; providing for transition to payment
107methodologies for Miami-Dade County plans; providing a
108phased schedule for risk-adjusted capitation rates;
109providing for immediate risk adjustment of rates for plans
110owned and operated by a public hospital in the county;
111providing a method to ensure budget neutrality until all
112rates in the county are risk-adjusted; requiring the
113agency to submit an amendment to the Legislative Budget
114Commission requesting authority for payments; requiring
115the establishment of a technical advisory panel; providing
116for distribution of funds from a low-income pool;
117specifying purposes for such distribution; requiring the
118agency to maintain and operate the Medicaid Encounter Data
119System; requiring the agency to contract with the
120University of Florida for evaluation of the pilot program;
121requiring the agency to establish a specified initiative
122and publish certain information; amending s. 409.9122,
123F.S.; eliminating outdated provisions; providing for the
124expiration of various provisions of the section on
125specified dates to conform to the reorganization of
126Medicaid managed care; requiring the Agency for Health
127Care Administration to begin a budget-neutral adjustment
128of capitation rates for all Medicaid prepaid plans in the
129state on a specified date; providing the basis for the
130adjustment; providing a phased schedule for risk adjusted
131capitation rates; providing for the establishment of a
132technical advisory panel; requiring the agency to develop
133a process to enable any recipient with access to employer
134sponsored insurance to opt out of qualified plans in the
135Medicaid program; requiring the agency, contingent on
136federal approval, to enable recipients with access to
137other insurance or related products providing access to
138specified health care services to opt out of qualified
139plans in the Medicaid program; providing a limitation on
140the amount of financial assistance provided for each
141recipient; requiring each qualified plan to establish an
142incentive program that rewards specific healthy behaviors;
143requiring plans to maintain a specified reserve account;
144requiring the agency to maintain and operate the Medicaid
145Encounter Data System; requiring the agency to conduct a
146review of encounter data and publish the results of the
147review prior to adjusting rates for prepaid plans;
148requiring the agency to establish a designated payment for
149specified Medicare Advantage Special Needs members;
150authorizing the agency to develop a designated payment for
151Medicaid-only covered services for which the state is
152responsible; requiring the agency to establish, and
153managed care plans to use, a uniform method of accounting
154for and reporting of medical and nonmedical costs;
155requiring reimbursement by Medicaid of school districts
156participating in a certified school match program for a
157Medicaid-eligible child participating in the services,
158effective on a specified date; requiring the agency, the
159Department of Health, and the Department of Education to
160develop procedures for ensuring that a student's managed
161care plan receives information relating to services
162provided; authorizing the Agency for Health Care
163Administration to create exceptions to mandatory
164enrollment in managed care under specified circumstances;
165amending s. 430.04, F.S.; eliminating outdated provisions;
166requiring the Department of Elderly Affairs to develop a
167transition plan for specified elder and disabled adults
168receiving long-term care Medicaid services when qualified
169plans become available; providing for expiration thereof;
170amending s. 430.2053, F.S.; eliminating outdated
171provisions; providing additional duties of aging resource
172centers; providing an additional exception to direct
173services that may not be provided by an aging resource
174center; providing for the cessation of specified  payments
175by the department as qualified plans become available;
176providing for a memorandum of understanding between the
177Agency for Health Care Administration and aging resource
178centers under certain circumstances; eliminating
179provisions requiring reports; amending s. 641.386, F.S.;
180conforming a cross-reference; repealing s. 430.701, F.S.,
181relating to legislative findings and intent and approval
182for action relating to provider enrollment levels;
183repealing s. 430.702, F.S., relating to the Long-Term Care
184Community Diversion Pilot Project Act; repealing s.
185430.703, F.S., relating to definitions; repealing s.
186430.7031, F.S., relating to nursing home transition
187program; repealing s. 430.704, F.S., relating to
188evaluation of long-term care through the pilot projects;
189repealing s. 430.705, F.S., relating to implementation of
190long-term care community diversion pilot projects;
191repealing s. 430.706, F.S., relating to quality of care;
192repealing s. 430.707, F.S., relating to contracts;
193repealing s. 430.708, F.S., relating to certificate of
194need; repealing s. 430.709, F.S., relating to reports and
195evaluations; renumbering ss. 409.9301, 409.942, 409.944,
196409.945, 409.946, 409.953, and 409.9531, F.S., as ss.
197402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
198402.87, F.S., respectively; amending s. 443.111, F.S.;
199conforming a cross-reference; providing contingent
200effective dates.
201
202Be It Enacted by the Legislature of the State of Florida:
203
204     Section 1.  Section 393.0661, Florida Statutes, is amended
205to read:
206     393.0661  Home and community-based services delivery
207system; comprehensive redesign.-The Legislature finds that the
208home and community-based services delivery system for persons
209with developmental disabilities and the availability of
210appropriated funds are two of the critical elements in making
211services available. Therefore, it is the intent of the
212Legislature that the Agency for Persons with Disabilities shall
213develop and implement a comprehensive redesign of the system.
214     (1)  The redesign of the home and community-based services
215system shall include, at a minimum, all actions necessary to
216achieve an appropriate rate structure, client choice within a
217specified service package, appropriate assessment strategies, an
218efficient billing process that contains reconciliation and
219monitoring components, a redefined role for support coordinators
220that avoids potential conflicts of interest, and ensures that
221family/client budgets are linked to levels of need.
222     (a)  The agency shall use an assessment instrument that is
223reliable and valid. The agency may contract with an external
224vendor or may use support coordinators to complete client
225assessments if it develops sufficient safeguards and training to
226ensure ongoing inter-rater reliability.
227     (b)  The agency, with the concurrence of the Agency for
228Health Care Administration, may contract for the determination
229of medical necessity and establishment of individual budgets.
230     (2)  A provider of services rendered to persons with
231developmental disabilities pursuant to a federally approved
232waiver shall be reimbursed according to a rate methodology based
233upon an analysis of the expenditure history and prospective
234costs of providers participating in the waiver program, or under
235any other methodology developed by the Agency for Health Care
236Administration, in consultation with the Agency for Persons with
237Disabilities, and approved by the Federal Government in
238accordance with the waiver.
239     (3)  The Agency for Health Care Administration, in
240consultation with the agency, shall seek federal approval and
241implement a four-tiered waiver system to serve eligible clients
242through the developmental disabilities and family and supported
243living waivers. The agency shall assign all clients receiving
244services through the developmental disabilities waiver to a tier
245based on a valid assessment instrument, client characteristics,
246and other appropriate assessment methods.
247     (a)  Tier one is limited to clients who have service needs
248that cannot be met in tier two, three, or four for intensive
249medical or adaptive needs and that are essential for avoiding
250institutionalization, or who possess behavioral problems that
251are exceptional in intensity, duration, or frequency and present
252a substantial risk of harm to themselves or others.
253     (b)  Tier two is limited to clients whose service needs
254include a licensed residential facility and who are authorized
255to receive a moderate level of support for standard residential
256habilitation services or a minimal level of support for behavior
257focus residential habilitation services, or clients in supported
258living who receive more than 6 hours a day of in-home support
259services. Total annual expenditures under tier two may not
260exceed $55,000 per client each year.
261     (c)  Tier three includes, but is not limited to, clients
262requiring residential placements, clients in independent or
263supported living situations, and clients who live in their
264family home. Total annual expenditures under tier three may not
265exceed $35,000 per client each year.
266     (d)  Tier four is the family and supported living waiver
267and includes, but is not limited to, clients in independent or
268supported living situations and clients who live in their family
269home. Total annual expenditures under tier four may not exceed
270$14,792 per client each year.
271     (e)  The Agency for Health Care Administration shall also
272seek federal approval to provide a consumer-directed option for
273persons with developmental disabilities which corresponds to the
274funding levels in each of the waiver tiers. The agency shall
275implement the four-tiered waiver system beginning with tiers
276one, three, and four and followed by tier two. The agency and
277the Agency for Health Care Administration may adopt rules
278necessary to administer this subsection.
279     (f)  The agency shall seek federal waivers and amend
280contracts as necessary to make changes to services defined in
281federal waiver programs administered by the agency as follows:
282     1.  Supported living coaching services may not exceed 20
283hours per month for persons who also receive in-home support
284services.
285     2.  Limited support coordination services is the only type
286of support coordination service that may be provided to persons
287under the age of 18 who live in the family home.
288     3.  Personal care assistance services are limited to 180
289hours per calendar month and may not include rate modifiers.
290Additional hours may be authorized for persons who have
291intensive physical, medical, or adaptive needs if such hours are
292essential for avoiding institutionalization.
293     4.  Residential habilitation services are limited to 8
294hours per day. Additional hours may be authorized for persons
295who have intensive medical or adaptive needs and if such hours
296are essential for avoiding institutionalization, or for persons
297who possess behavioral problems that are exceptional in
298intensity, duration, or frequency and present a substantial risk
299of harming themselves or others. This restriction shall be in
300effect until the four-tiered waiver system is fully implemented.
301     5.  Chore services, nonresidential support services, and
302homemaker services are eliminated. The agency shall expand the
303definition of in-home support services to allow the service
304provider to include activities previously provided in these
305eliminated services.
306     6.  Massage therapy, medication review, and psychological
307assessment services are eliminated.
308     7.  The agency shall conduct supplemental cost plan reviews
309to verify the medical necessity of authorized services for plans
310that have increased by more than 8 percent during either of the
3112 preceding fiscal years.
312     8.  The agency shall implement a consolidated residential
313habilitation rate structure to increase savings to the state
314through a more cost-effective payment method and establish
315uniform rates for intensive behavioral residential habilitation
316services.
317     9.  Pending federal approval, the agency may extend current
318support plans for clients receiving services under Medicaid
319waivers for 1 year beginning July 1, 2007, or from the date
320approved, whichever is later. Clients who have a substantial
321change in circumstances which threatens their health and safety
322may be reassessed during this year in order to determine the
323necessity for a change in their support plan.
324     10.  The agency shall develop a plan to eliminate
325redundancies and duplications between in-home support services,
326companion services, personal care services, and supported living
327coaching by limiting or consolidating such services.
328     11.  The agency shall develop a plan to reduce the
329intensity and frequency of supported employment services to
330clients in stable employment situations who have a documented
331history of at least 3 years' employment with the same company or
332in the same industry.
333     (4)  The geographic differential for Miami-Dade, Broward,
334and Palm Beach Counties for residential habilitation services
335shall be 7.5 percent.
336     (5)  The geographic differential for Monroe County for
337residential habilitation services shall be 20 percent.
338     (6)  Effective January 1, 2010, and except as otherwise
339provided in this section, a client served by the home and
340community-based services waiver or the family and supported
341living waiver funded through the agency shall have his or her
342cost plan adjusted to reflect the amount of expenditures for the
343previous state fiscal year plus 5 percent if such amount is less
344than the client's existing cost plan. The agency shall use
345actual paid claims for services provided during the previous
346fiscal year that are submitted by October 31 to calculate the
347revised cost plan amount. If the client was not served for the
348entire previous state fiscal year or there was any single change
349in the cost plan amount of more than 5 percent during the
350previous state fiscal year, the agency shall set the cost plan
351amount at an estimated annualized expenditure amount plus 5
352percent. The agency shall estimate the annualized expenditure
353amount by calculating the average of monthly expenditures,
354beginning in the fourth month after the client enrolled,
355interrupted services are resumed, or the cost plan was changed
356by more than 5 percent and ending on August 31, 2009, and
357multiplying the average by 12. In order to determine whether a
358client was not served for the entire year, the agency shall
359include any interruption of a waiver-funded service or services
360lasting at least 18 days. If at least 3 months of actual
361expenditure data are not available to estimate annualized
362expenditures, the agency may not rebase a cost plan pursuant to
363this subsection. The agency may not rebase the cost plan of any
364client who experiences a significant change in recipient
365condition or circumstance which results in a change of more than
3665 percent to his or her cost plan between July 1 and the date
367that a rebased cost plan would take effect pursuant to this
368subsection.
369     (7)  Nothing in this section or in any administrative rule
370shall be construed to prevent or limit the Agency for Health
371Care Administration, in consultation with the Agency for Persons
372with Disabilities, from adjusting fees, reimbursement rates,
373lengths of stay, number of visits, or number of services, or
374from limiting enrollment, or making any other adjustment
375necessary to comply with the availability of moneys and any
376limitations or directions provided for in the General
377Appropriations Act.
378     (8)  The Agency for Persons with Disabilities shall submit
379quarterly status reports to the Executive Office of the
380Governor, the chair of the Senate Ways and Means Committee or
381its successor, and the chair of the House Fiscal Council or its
382successor regarding the financial status of home and community-
383based services, including the number of enrolled individuals who
384are receiving services through one or more programs; the number
385of individuals who have requested services who are not enrolled
386but who are receiving services through one or more programs,
387with a description indicating the programs from which the
388individual is receiving services; the number of individuals who
389have refused an offer of services but who choose to remain on
390the list of individuals waiting for services; the number of
391individuals who have requested services but who are receiving no
392services; a frequency distribution indicating the length of time
393individuals have been waiting for services; and information
394concerning the actual and projected costs compared to the amount
395of the appropriation available to the program and any projected
396surpluses or deficits. If at any time an analysis by the agency,
397in consultation with the Agency for Health Care Administration,
398indicates that the cost of services is expected to exceed the
399amount appropriated, the agency shall submit a plan in
400accordance with subsection (7) to the Executive Office of the
401Governor, the chair of the Senate Ways and Means Committee or
402its successor, and the chair of the House Fiscal Council or its
403successor to remain within the amount appropriated. The agency
404shall work with the Agency for Health Care Administration to
405implement the plan so as to remain within the appropriation.
406     (9)(a)  The agency, in consultation with the Agency for
407Health Care Administration, shall establish an individual
408budget, referred to as an iBudget, demonstration project for
409each individual served through the Medicaid waiver program in
410Escambia, Okaloosa, Santa Rosa, and Walton Counties, which
411comprise area one of the agency. For the purpose of this
412subsection, the Medicaid waiver program includes the four-tiered
413waiver system established in subsection (3) or the Consumer
414Directed Care Plus Medicaid waiver program. The funds
415appropriated to the agency and used for Medicaid waiver program
416services to individuals in the demonstration project area shall
417be allocated through the iBudget system to eligible, Medicaid-
418enrolled clients. The iBudget system shall be designed to
419provide for enhanced client choice within a specified service
420package, appropriate assessment strategies, an efficient
421consumer budgeting and billing process that includes
422reconciliation and monitoring components, a redefined role for
423support coordinators that avoids potential conflicts of
424interest, a flexible and streamlined service review process, and
425a methodology and process that ensure the equitable allocation
426of available funds to each client based on the client's level of
427need, as determined by the variables in the allocation
428algorithm.
429     1.  In developing each client's iBudget, the agency shall
430use an allocation algorithm and methodology. The algorithm shall
431use variables that have been determined by the agency to have a
432statistically validated relationship to the client's level of
433need for services provided through the Medicaid waiver program.
434The algorithm and methodology may consider individual
435characteristics, including, but not limited to, a client's age
436and living situation, information from a formal assessment
437instrument that the agency determines is valid and reliable, and
438information from other assessment processes.
439     2.  The allocation methodology shall provide the algorithm
440that determines the amount of funds allocated to a client's
441iBudget. The agency may approve an increase in the amount of
442funds allocated, as determined by the algorithm, based on the
443client's having one or more of the following needs that cannot
444be accommodated within the funding as determined by the
445algorithm and having no other resources, supports, or services
446available to meet those needs:
447     a.  An extraordinary need that would place the health and
448safety of the client, the client's caregiver, or the public in
449immediate, serious jeopardy unless the increase is approved. An
450extraordinary need may include, but is not limited to:
451     (I)  A documented history of significant, potentially life-
452threatening behaviors, such as recent attempts at suicide,
453arson, nonconsensual sexual behavior, or self-injurious behavior
454requiring medical attention;
455     (II)  A complex medical condition that requires active
456intervention by a licensed nurse on an ongoing basis that cannot
457be taught or delegated to a nonlicensed person;
458     (III)  A chronic co-morbid condition. As used in this sub-
459sub-subparagraph, the term "co-morbid condition" means a medical
460condition existing simultaneously with but independently of
461another medical condition in a patient; or
462     (IV)  A need for total physical assistance with activities
463such as eating, bathing, toileting, grooming, and personal
464hygiene.
465
466However, the presence of an extraordinary need alone does not
467warrant an increase in the amount of funds allocated to a
468client's iBudget as determined by the algorithm.
469     b.  A significant need for one-time or temporary support or
470services that, if not provided, would place the health and
471safety of the client, the client's caregiver, or the public in
472serious jeopardy unless the increase is approved. A significant
473need may include, but is not limited to, the provision of
474environmental modifications, durable medical equipment, services
475to address the temporary loss of support from a caregiver, or
476special services or treatment for a serious temporary condition
477when the service or treatment is expected to ameliorate the
478underlying condition. As used in this sub-subparagraph, the term
479"temporary" means lasting for a period of less than 12
480consecutive months. However, the presence of such significant
481need for one-time or temporary support or services alone does
482not warrant an increase in the amount of funds allocated to a
483client's iBudget as determined by the algorithm.
484     c.  A significant increase in the need for services after
485the beginning of the service plan year that would place the
486health and safety of the client, the client's caregiver, or the
487public in serious jeopardy because of substantial changes in the
488client's circumstances, including, but not limited to, permanent
489or long-term loss or incapacity of a caregiver, loss of services
490authorized under the state Medicaid plan due to a change in age,
491or a significant change in medical or functional status that
492requires the provision of additional services on a permanent or
493long-term basis that cannot be accommodated within the client's
494current iBudget. As used in this sub-subparagraph, the term
495"long-term" means lasting for a period of more than 12
496continuous months. However, such significant increase in need
497for services of a permanent or long-term nature alone does not
498warrant an increase in the amount of funds allocated to a
499client's iBudget as determined by the algorithm.
500
501The agency shall reserve portions of the appropriation for the
502home and community-based services Medicaid waiver program for
503adjustments required pursuant to this subparagraph and may use
504the services of an independent actuary in determining the amount
505of the portions to be reserved.
506     3.  A client's iBudget shall be the total of the amount
507determined by the algorithm and any additional funding provided
508under subparagraph 2. A client's annual expenditures for
509Medicaid waiver services may not exceed the limits of his or her
510iBudget.
511     (b)  The Agency for Health Care Administration, in
512consultation with the agency, shall seek federal approval for
513the iBudget demonstration project and amend current waivers,
514request a new waiver if appropriate, and amend contracts as
515necessary to implement the iBudget system to serve eligible,
516enrolled clients in the demonstration project area through the
517Medicaid waiver program.
518     (c)  The agency shall transition all eligible, enrolled
519clients in the demonstration project area to the iBudget system.
520The agency may gradually phase in the iBudget system with full
521implementation by January 1, 2013.
522     1.  The agency shall design the phase-in process to ensure
523that a client does not experience more than one-half of any
524expected overall increase or decrease to his or her existing
525annualized cost plan during the first year that the client is
526provided an iBudget due solely to the transition to the iBudget
527system. However, all iBudgets in the demonstration project area
528must be fully phased in by January 1, 2013.
529     (d)  A client must use all available services authorized
530under the state Medicaid plan, school-based services, private
531insurance and other benefits, and any other resources that may
532be available to the client before using funds from his or her
533iBudget to pay for support and services.
534     (e)  The service limitations in subparagraphs (3)(f)1., 2.,
535and 3. shall not apply to the iBudget system.
536     (f)  Rates for any or all services established under rules
537of the agency shall be designated as the maximum rather than a
538fixed amount for individuals who receive an iBudget, except for
539services specifically identified in those rules that the agency
540determines are not appropriate for negotiation, which may
541include, but are not limited to, residential habilitation
542services.
543     (g)  The agency shall ensure that clients and caregivers in
544the demonstration project area have access to training and
545education to inform them about the iBudget system and enhance
546their ability for self-direction. Such training shall be offered
547in a variety of formats and, at a minimum, shall address the
548policies and processes of the iBudget system; the roles and
549responsibilities of consumers, caregivers, waiver support
550coordinators, providers, and the agency; information available
551to help the client make decisions regarding the iBudget system;
552and examples of support and resources available in the
553community.
554     (h)1.  The agency, in consultation with the Agency for
555Health Care Administration, shall prepare a design plan for the
556purchase of an evaluation by an independent contractor. The
557design plan to evaluate the iBudget demonstration project shall
558be submitted to the President of the Senate and the Speaker of
559the House of Representatives for approval not later than
560December 31, 2010.
561     2.  The agency shall prepare an evaluation that shall
562include, at a minimum, an analysis of cost savings, cost
563containment, and budget predictability. In addition, the
564evaluation shall review the demonstration with regard to
565consumer education, quality of care, affects on choice of and
566access to services, and satisfaction of demonstration project
567participants. The agency shall submit the evaluation report to
568the Governor, the President of the Senate, and the Speaker of
569the House of Representatives no later than December 31, 2013.
570     (i)  The agency shall adopt rules specifying the allocation
571algorithm and methodology; criteria and processes for clients to
572access reserved funds for extraordinary needs, temporarily or
573permanently changed needs, and one-time needs; and processes and
574requirements for selection and review of services, development
575of support and cost plans, and management of the iBudget system
576as needed to administer this subsection.
577     (10)  The agency shall develop a transition plan for
578recipients who are receiving services in one of the four waiver
579tiers at the time qualified plans are available in each
580recipient's region pursuant to s. 409.989(3) to enroll those
581recipients in qualified plans.
582     (11)  This section expires October 1, 2015.
583     Section 2.  Section 400.0713, Florida Statutes, is created
584to read:
585     400.0713  Nursing home licensure workgroup.-The agency
586shall establish a workgroup to develop a plan for licensure
587flexibility to assist nursing homes in developing comprehensive
588long-term care service capabilities.
589     Section 3.  Paragraphs (b) and (d) of subsection (1) of
590section 408.040, Florida Statutes, are amended to read:
591     408.040  Conditions and monitoring.-
592     (1)
593     (b)  The agency may consider, in addition to the other
594criteria specified in s. 408.035, a statement of intent by the
595applicant that a specified percentage of the annual patient days
596at the facility will be utilized by patients eligible for care
597under Title XIX of the Social Security Act. Any certificate of
598need issued to a nursing home in reliance upon an applicant's
599statements that a specified percentage of annual patient days
600will be utilized by residents eligible for care under Title XIX
601of the Social Security Act must include a statement that such
602certification is a condition of issuance of the certificate of
603need. The certificate-of-need program shall notify the Medicaid
604program office and the Department of Elderly Affairs when it
605imposes conditions as authorized in this paragraph in an area in
606which a community diversion pilot project is implemented.
607Effective July 1, 2011, the agency shall not consider, or impose
608conditions related to, patient day utilization by patients
609eligible for care under Title XIX the Social Security Act in
610making certificate-of-need determinations for nursing homes.
611     (d)  If a nursing home is located in a county in which a
612long-term care community diversion pilot project has been
613implemented under s. 430.705 or in a county in which an
614integrated, fixed-payment delivery program for Medicaid
615recipients who are 60 years of age or older or dually eligible
616for Medicare and Medicaid has been implemented under s.
617409.912(5), the nursing home may request a reduction in the
618percentage of annual patient days used by residents who are
619eligible for care under Title XIX of the Social Security Act,
620which is a condition of the nursing home's certificate of need.
621The agency shall automatically grant the nursing home's request
622if the reduction is not more than 15 percent of the nursing
623home's annual Medicaid-patient-days condition. A nursing home
624may submit only one request every 2 years for an automatic
625reduction. A requesting nursing home must notify the agency in
626writing at least 60 days in advance of its intent to reduce its
627annual Medicaid-patient-days condition by not more than 15
628percent. The agency must acknowledge the request in writing and
629must change its records to reflect the revised certificate-of-
630need condition. This paragraph expires June 30, 2011.
631     Section 4.  Subsection (1) of section 408.0435, Florida
632Statutes, is amended to read:
633     408.0435  Moratorium on nursing home certificates of need.-
634     (1)  Notwithstanding the establishment of need as provided
635for in this chapter, a certificate of need for additional
636community nursing home beds may not be approved by the agency
637until after Medicaid managed care is implemented statewide
638pursuant to ss. 409.961-409.992, or October 1, 2015, whichever
639is earlier July 1, 2011.
640     Section 5.  Sections 409.016 through 409.803, Florida
641Statutes, are designated as part I of chapter 409, Florida
642Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
643     Section 6.  Sections 409.810 through 409.821, Florida
644Statutes, are designated as part II of chapter 409, Florida
645Statutes, and entitled "KIDCARE."
646     Section 7.  Sections 409.901 through 409.9205, Florida
647Statutes, are designated as part III of chapter 409, Florida
648Statutes, and entitled "MEDICAID."
649     Section 8.  Subsection (5) of section 409.907, Florida
650Statutes, is amended to read:
651     409.907  Medicaid provider agreements.-The agency may make
652payments for medical assistance and related services rendered to
653Medicaid recipients only to an individual or entity who has a
654provider agreement in effect with the agency, who is performing
655services or supplying goods in accordance with federal, state,
656and local law, and who agrees that no person shall, on the
657grounds of handicap, race, color, or national origin, or for any
658other reason, be subjected to discrimination under any program
659or activity for which the provider receives payment from the
660agency.
661     (5)  The agency:
662     (a)  Is required to make timely payment at the established
663rate for services or goods furnished to a recipient by the
664provider upon receipt of a properly completed claim form. The
665claim form shall require certification that the services or
666goods have been completely furnished to the recipient and that,
667with the exception of those services or goods specified by the
668agency, the amount billed does not exceed the provider's usual
669and customary charge for the same services or goods.
670     (b)  Is prohibited from demanding repayment from the
671provider in any instance in which the Medicaid overpayment is
672attributable to error of the department in the determination of
673eligibility of a recipient.
674     (c)  May adopt, and include in the provider agreement, such
675other requirements and stipulations on either party as the
676agency finds necessary to properly and efficiently administer
677the Medicaid program.
678     (d)  May enroll entities as Medicare crossover-only
679providers for payment and claims processing purposes only. The
680provider agreement shall:
681     1.  Require that the provider is an eligible Medicare
682provider, has a current provider agreement in place with the
683Centers for Medicare and Medicaid Services, and provides
684verification that the provider is currently in good standing
685with the agency.
686     2.  Require that the provider notify the agency
687immediately, in writing, upon being suspended or disenrolled as
688a Medicare provider. If a provider does not provide such
689notification within 5 business days after suspension or
690disenrollment, sanctions may be imposed pursuant to this chapter
691and the provider may be required to return funds paid to the
692provider during the period of time that the provider was
693suspended or disenrolled as a Medicare provider.
694     3.  Require that all records pertaining to health care
695services provided to each of the provider's recipients be kept
696for a minimum of 5 years. The agreement shall also require that
697records and information relating to payments claimed by the
698provider for services under the agreement be delivered to the
699agency or the Office of the Attorney General Medicaid Fraud
700Control Unit when requested. If a provider does not provide such
701records and information when requested, sanctions may be imposed
702pursuant to this chapter.
703     4.  Disclose that the agreement is for the purposes of
704paying and processing Medicare crossover claims only.
705
706This paragraph pertains solely to Medicare crossover-only
707providers. In order to become a standard Medicaid provider, the
708other requirements of this section and applicable rules must be
709met.
710     Section 9.  Subsection (24) is added to section 409.908,
711Florida Statutes, to read:
712     409.908  Reimbursement of Medicaid providers.-Subject to
713specific appropriations, the agency shall reimburse Medicaid
714providers, in accordance with state and federal law, according
715to methodologies set forth in the rules of the agency and in
716policy manuals and handbooks incorporated by reference therein.
717These methodologies may include fee schedules, reimbursement
718methods based on cost reporting, negotiated fees, competitive
719bidding pursuant to s. 287.057, and other mechanisms the agency
720considers efficient and effective for purchasing services or
721goods on behalf of recipients. If a provider is reimbursed based
722on cost reporting and submits a cost report late and that cost
723report would have been used to set a lower reimbursement rate
724for a rate semester, then the provider's rate for that semester
725shall be retroactively calculated using the new cost report, and
726full payment at the recalculated rate shall be effected
727retroactively. Medicare-granted extensions for filing cost
728reports, if applicable, shall also apply to Medicaid cost
729reports. Payment for Medicaid compensable services made on
730behalf of Medicaid eligible persons is subject to the
731availability of moneys and any limitations or directions
732provided for in the General Appropriations Act or chapter 216.
733Further, nothing in this section shall be construed to prevent
734or limit the agency from adjusting fees, reimbursement rates,
735lengths of stay, number of visits, or number of services, or
736making any other adjustments necessary to comply with the
737availability of moneys and any limitations or directions
738provided for in the General Appropriations Act, provided the
739adjustment is consistent with legislative intent.
740     (24)  If a provider fails to notify the agency within 5
741business days after suspension or disenrollment from Medicare,
742sanctions may be imposed pursuant to this chapter and the
743provider may be required to return funds paid to the provider
744during the period of time that the provider was suspended or
745disenrolled as a Medicare provider.
746     Section 10.  Section 409.912, Florida Statutes, is amended
747to read:
748     409.912  Cost-effective purchasing of health care.-The
749agency shall purchase goods and services for Medicaid recipients
750in the most cost-effective manner consistent with the delivery
751of quality medical care. To ensure that medical services are
752effectively utilized, the agency may, in any case, require a
753confirmation or second physician's opinion of the correct
754diagnosis for purposes of authorizing future services under the
755Medicaid program. This section does not restrict access to
756emergency services or poststabilization care services as defined
757in 42 C.F.R. part 438.114. Such confirmation or second opinion
758shall be rendered in a manner approved by the agency. The agency
759shall maximize the use of prepaid per capita and prepaid
760aggregate fixed-sum basis services when appropriate and other
761alternative service delivery and reimbursement methodologies,
762including competitive bidding pursuant to s. 287.057, designed
763to facilitate the cost-effective purchase of a case-managed
764continuum of care. The agency shall also require providers to
765minimize the exposure of recipients to the need for acute
766inpatient, custodial, and other institutional care and the
767inappropriate or unnecessary use of high-cost services. The
768agency shall contract with a vendor to monitor and evaluate the
769clinical practice patterns of providers in order to identify
770trends that are outside the normal practice patterns of a
771provider's professional peers or the national guidelines of a
772provider's professional association. The vendor must be able to
773provide information and counseling to a provider whose practice
774patterns are outside the norms, in consultation with the agency,
775to improve patient care and reduce inappropriate utilization.
776The agency may mandate prior authorization, drug therapy
777management, or disease management participation for certain
778populations of Medicaid beneficiaries, certain drug classes, or
779particular drugs to prevent fraud, abuse, overuse, and possible
780dangerous drug interactions. The Pharmaceutical and Therapeutics
781Committee shall make recommendations to the agency on drugs for
782which prior authorization is required. The agency shall inform
783the Pharmaceutical and Therapeutics Committee of its decisions
784regarding drugs subject to prior authorization. The agency is
785authorized to limit the entities it contracts with or enrolls as
786Medicaid providers by developing a provider network through
787provider credentialing. The agency may competitively bid single-
788source-provider contracts if procurement of goods or services
789results in demonstrated cost savings to the state without
790limiting access to care. The agency may limit its network based
791on the assessment of beneficiary access to care, provider
792availability, provider quality standards, time and distance
793standards for access to care, the cultural competence of the
794provider network, demographic characteristics of Medicaid
795beneficiaries, practice and provider-to-beneficiary standards,
796appointment wait times, beneficiary use of services, provider
797turnover, provider profiling, provider licensure history,
798previous program integrity investigations and findings, peer
799review, provider Medicaid policy and billing compliance records,
800clinical and medical record audits, and other factors. Providers
801shall not be entitled to enrollment in the Medicaid provider
802network. The agency shall determine instances in which allowing
803Medicaid beneficiaries to purchase durable medical equipment and
804other goods is less expensive to the Medicaid program than long-
805term rental of the equipment or goods. The agency may establish
806rules to facilitate purchases in lieu of long-term rentals in
807order to protect against fraud and abuse in the Medicaid program
808as defined in s. 409.913. The agency may seek federal waivers
809necessary to administer these policies.
810     (1)  The agency shall work with the Department of Children
811and Family Services to ensure access of children and families in
812the child protection system to needed and appropriate mental
813health and substance abuse services. This subsection expires
814October 1, 2013.
815     (2)  The agency may enter into agreements with appropriate
816agents of other state agencies or of any agency of the Federal
817Government and accept such duties in respect to social welfare
818or public aid as may be necessary to implement the provisions of
819Title XIX of the Social Security Act and ss. 409.901-409.920.
820This subsection expires October 1, 2015.
821     (3)  The agency may contract with health maintenance
822organizations certified pursuant to part I of chapter 641 for
823the provision of services to recipients. This subsection expires
824October 1, 2013.
825     (4)  The agency may contract with:
826     (a)  An entity that provides no prepaid health care
827services other than Medicaid services under contract with the
828agency and which is owned and operated by a county, county
829health department, or county-owned and operated hospital to
830provide health care services on a prepaid or fixed-sum basis to
831recipients, which entity may provide such prepaid services
832either directly or through arrangements with other providers.
833Such prepaid health care services entities must be licensed
834under parts I and III of chapter 641. An entity recognized under
835this paragraph which demonstrates to the satisfaction of the
836Office of Insurance Regulation of the Financial Services
837Commission that it is backed by the full faith and credit of the
838county in which it is located may be exempted from s. 641.225.
839This paragraph expires October 1, 2013.
840     (b)  An entity that is providing comprehensive behavioral
841health care services to certain Medicaid recipients through a
842capitated, prepaid arrangement pursuant to the federal waiver
843provided for by s. 409.905(5). Such entity must be licensed
844under chapter 624, chapter 636, or chapter 641, or authorized
845under paragraph (c) or paragraph (d), and must possess the
846clinical systems and operational competence to manage risk and
847provide comprehensive behavioral health care to Medicaid
848recipients. As used in this paragraph, the term "comprehensive
849behavioral health care services" means covered mental health and
850substance abuse treatment services that are available to
851Medicaid recipients. The secretary of the Department of Children
852and Family Services shall approve provisions of procurements
853related to children in the department's care or custody before
854enrolling such children in a prepaid behavioral health plan. Any
855contract awarded under this paragraph must be competitively
856procured. In developing the behavioral health care prepaid plan
857procurement document, the agency shall ensure that the
858procurement document requires the contractor to develop and
859implement a plan to ensure compliance with s. 394.4574 related
860to services provided to residents of licensed assisted living
861facilities that hold a limited mental health license. Except as
862provided in subparagraph 5. 8., and except in counties where the
863Medicaid managed care pilot program is authorized pursuant to s.
864409.91211, the agency shall seek federal approval to contract
865with a single entity meeting these requirements to provide
866comprehensive behavioral health care services to all Medicaid
867recipients not enrolled in a Medicaid managed care plan
868authorized under s. 409.91211, a provider service network as
869described in paragraph (d), or a Medicaid health maintenance
870organization in an AHCA area. In an AHCA area where the Medicaid
871managed care pilot program is authorized pursuant to s.
872409.91211 in one or more counties, the agency may procure a
873contract with a single entity to serve the remaining counties as
874an AHCA area or the remaining counties may be included with an
875adjacent AHCA area and are subject to this paragraph. Each
876entity must offer a sufficient choice of providers in its
877network to ensure recipient access to care and the opportunity
878to select a provider with whom they are satisfied. The network
879shall include all public mental health hospitals. To ensure
880unimpaired access to behavioral health care services by Medicaid
881recipients, all contracts issued pursuant to this paragraph must
882require 80 percent of the capitation paid to the managed care
883plan, including health maintenance organizations and capitated
884provider service networks, to be expended for the provision of
885behavioral health care services. If the managed care plan
886expends less than 80 percent of the capitation paid for the
887provision of behavioral health care services, the difference
888shall be returned to the agency. The agency shall provide the
889plan with a certification letter indicating the amount of
890capitation paid during each calendar year for behavioral health
891care services pursuant to this section. The agency may reimburse
892for substance abuse treatment services on a fee-for-service
893basis until the agency finds that adequate funds are available
894for capitated, prepaid arrangements.
895     1.  By January 1, 2001, The agency shall modify the
896contracts with the entities providing comprehensive inpatient
897and outpatient mental health care services to Medicaid
898recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
899Counties, to include substance abuse treatment services.
900     2.  By July 1, 2003, the agency and the Department of
901Children and Family Services shall execute a written agreement
902that requires collaboration and joint development of all policy,
903budgets, procurement documents, contracts, and monitoring plans
904that have an impact on the state and Medicaid community mental
905health and targeted case management programs.
906     2.3.  Except as provided in subparagraph 5. 8., by July 1,
9072006, the agency and the Department of Children and Family
908Services shall contract with managed care entities in each AHCA
909area except area 6 or arrange to provide comprehensive inpatient
910and outpatient mental health and substance abuse services
911through capitated prepaid arrangements to all Medicaid
912recipients who are eligible to participate in such plans under
913federal law and regulation. In AHCA areas where eligible
914individuals number less than 150,000, the agency shall contract
915with a single managed care plan to provide comprehensive
916behavioral health services to all recipients who are not
917enrolled in a Medicaid health maintenance organization, a
918provider service network as described in paragraph (d), or a
919Medicaid capitated managed care plan authorized under s.
920409.91211. The agency may contract with more than one
921comprehensive behavioral health provider to provide care to
922recipients who are not enrolled in a Medicaid capitated managed
923care plan authorized under s. 409.91211, a provider service
924network as described in paragraph (d), or a Medicaid health
925maintenance organization in AHCA areas where the eligible
926population exceeds 150,000. In an AHCA area where the Medicaid
927managed care pilot program is authorized pursuant to s.
928409.91211 in one or more counties, the agency may procure a
929contract with a single entity to serve the remaining counties as
930an AHCA area or the remaining counties may be included with an
931adjacent AHCA area and shall be subject to this paragraph.
932Contracts for comprehensive behavioral health providers awarded
933pursuant to this section shall be competitively procured. Both
934for-profit and not-for-profit corporations are eligible to
935compete. Managed care plans contracting with the agency under
936subsection (3) or paragraph (d), shall provide and receive
937payment for the same comprehensive behavioral health benefits as
938provided in AHCA rules, including handbooks incorporated by
939reference. In AHCA area 11, the agency shall contract with at
940least two comprehensive behavioral health care providers to
941provide behavioral health care to recipients in that area who
942are enrolled in, or assigned to, the MediPass program. One of
943the behavioral health care contracts must be with the existing
944provider service network pilot project, as described in
945paragraph (d), for the purpose of demonstrating the cost-
946effectiveness of the provision of quality mental health services
947through a public hospital-operated managed care model. Payment
948shall be at an agreed-upon capitated rate to ensure cost
949savings. Of the recipients in area 11 who are assigned to
950MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
951MediPass-enrolled recipients shall be assigned to the existing
952provider service network in area 11 for their behavioral care.
953     4.  By October 1, 2003, the agency and the department shall
954submit a plan to the Governor, the President of the Senate, and
955the Speaker of the House of Representatives which provides for
956the full implementation of capitated prepaid behavioral health
957care in all areas of the state.
958     a.  Implementation shall begin in 2003 in those AHCA areas
959of the state where the agency is able to establish sufficient
960capitation rates.
961     b.  If the agency determines that the proposed capitation
962rate in any area is insufficient to provide appropriate
963services, the agency may adjust the capitation rate to ensure
964that care will be available. The agency and the department may
965use existing general revenue to address any additional required
966match but may not over-obligate existing funds on an annualized
967basis.
968     c.  Subject to any limitations provided in the General
969Appropriations Act, the agency, in compliance with appropriate
970federal authorization, shall develop policies and procedures
971that allow for certification of local and state funds.
972     3.5.  Children residing in a statewide inpatient
973psychiatric program, or in a Department of Juvenile Justice or a
974Department of Children and Family Services residential program
975approved as a Medicaid behavioral health overlay services
976provider may not be included in a behavioral health care prepaid
977health plan or any other Medicaid managed care plan pursuant to
978this paragraph.
979     6.  In converting to a prepaid system of delivery, the
980agency shall in its procurement document require an entity
981providing only comprehensive behavioral health care services to
982prevent the displacement of indigent care patients by enrollees
983in the Medicaid prepaid health plan providing behavioral health
984care services from facilities receiving state funding to provide
985indigent behavioral health care, to facilities licensed under
986chapter 395 which do not receive state funding for indigent
987behavioral health care, or reimburse the unsubsidized facility
988for the cost of behavioral health care provided to the displaced
989indigent care patient.
990     4.7.  Traditional community mental health providers under
991contract with the Department of Children and Family Services
992pursuant to part IV of chapter 394, child welfare providers
993under contract with the Department of Children and Family
994Services in areas 1 and 6, and inpatient mental health providers
995licensed pursuant to chapter 395 must be offered an opportunity
996to accept or decline a contract to participate in any provider
997network for prepaid behavioral health services.
998     5.8.  All Medicaid-eligible children, except children in
999area 1 and children in Highlands County, Hardee County, Polk
1000County, or Manatee County of area 6, that are open for child
1001welfare services in the HomeSafeNet system, shall receive their
1002behavioral health care services through a specialty prepaid plan
1003operated by community-based lead agencies through a single
1004agency or formal agreements among several agencies. The
1005specialty prepaid plan must result in savings to the state
1006comparable to savings achieved in other Medicaid managed care
1007and prepaid programs. Such plan must provide mechanisms to
1008maximize state and local revenues. The specialty prepaid plan
1009shall be developed by the agency and the Department of Children
1010and Family Services. The agency may seek federal waivers to
1011implement this initiative. Medicaid-eligible children whose
1012cases are open for child welfare services in the HomeSafeNet
1013system and who reside in AHCA area 10 shall be enrolled in
1014capitated managed care plans that, in coordination with
1015available community-based care providers specified in s.
1016409.1671, provide sufficient medical, developmental, behavioral
1017and emotional services to meet the needs of these children. are
1018exempt from the specialty prepaid plan upon the development of a
1019service delivery mechanism for children who reside in area 10 as
1020specified in s. 409.91211(3)(dd).
1021
1022This paragraph expires October 1, 2013.
1023     (c)  A federally qualified health center or an entity owned
1024by one or more federally qualified health centers or an entity
1025owned by other migrant and community health centers receiving
1026non-Medicaid financial support from the Federal Government to
1027provide health care services on a prepaid or fixed-sum basis to
1028recipients. A federally qualified health center or an entity
1029that is owned by one or more federally qualified health centers
1030and is reimbursed by the agency on a prepaid basis is exempt
1031from parts I and III of chapter 641, but must comply with the
1032solvency requirements in s. 641.2261(2) and meet the appropriate
1033requirements governing financial reserve, quality assurance, and
1034patients' rights established by the agency. This paragraph
1035expires October 1, 2013.
1036     (d)1.  A provider service network may be reimbursed on a
1037fee-for-service or prepaid basis. Prepaid provider service
1038networks receive per-member per-month payments. Provider service
1039networks that do not choose to be prepaid plans shall receive
1040fee-for-service rates with a shared savings settlement. The fee-
1041for-service option shall be available to a provider service
1042network only for the first 5 years of the plan's operation in a
1043given region or until the contract year beginning October 1,
10442015, whichever is later. The agency shall annually conduct cost
1045reconciliations to determine the amount of cost savings achieved
1046by fee-for-service provider service networks for the dates of
1047service in the period being reconciled. Only payments for
1048covered services for dates of service within the reconciliation
1049period and paid within 6 months after the last date of service
1050in the reconciliation period shall be included. The agency shall
1051perform the necessary adjustments for the inclusion of claims
1052incurred but not reported within the reconciliation for claims
1053that could be received and paid by the agency after the 6-month
1054claims processing time lag. The agency shall provide the results
1055of the reconciliations to the fee-for-service provider service
1056networks within 45 days after the end of the reconciliation
1057period. The fee-for-service provider service networks shall
1058review and provide written comments or a letter of concurrence
1059to the agency within 45 days after receipt of the reconciliation
1060results. This reconciliation shall be considered final.
1061     2.  A provider service network which is reimbursed by the
1062agency on a prepaid basis shall be exempt from parts I and III
1063of chapter 641, but must comply with the solvency requirements
1064in s. 641.2261(2) and meet appropriate financial reserve,
1065quality assurance, and patient rights requirements as
1066established by the agency.
1067     3.  Medicaid recipients assigned to a provider service
1068network shall be chosen equally from those who would otherwise
1069have been assigned to prepaid plans and MediPass. The agency is
1070authorized to seek federal Medicaid waivers as necessary to
1071implement the provisions of this section. This subparagraph
1072expires October 1, 2013. Any contract previously awarded to a
1073provider service network operated by a hospital pursuant to this
1074subsection shall remain in effect for a period of 3 years
1075following the current contract expiration date, regardless of
1076any contractual provisions to the contrary.
1077     4.  A provider service network is a network established or
1078organized and operated by a health care provider, or group of
1079affiliated health care providers, including minority physician
1080networks and emergency room diversion programs that meet the
1081requirements of s. 409.91211, which provides a substantial
1082proportion of the health care items and services under a
1083contract directly through the provider or affiliated group of
1084providers and may make arrangements with physicians or other
1085health care professionals, health care institutions, or any
1086combination of such individuals or institutions to assume all or
1087part of the financial risk on a prospective basis for the
1088provision of basic health services by the physicians, by other
1089health professionals, or through the institutions. The health
1090care providers must have a controlling interest in the governing
1091body of the provider service network organization.
1092     (e)  An entity that provides only comprehensive behavioral
1093health care services to certain Medicaid recipients through an
1094administrative services organization agreement. Such an entity
1095must possess the clinical systems and operational competence to
1096provide comprehensive health care to Medicaid recipients. As
1097used in this paragraph, the term "comprehensive behavioral
1098health care services" means covered mental health and substance
1099abuse treatment services that are available to Medicaid
1100recipients. Any contract awarded under this paragraph must be
1101competitively procured. The agency must ensure that Medicaid
1102recipients have available the choice of at least two managed
1103care plans for their behavioral health care services. This
1104paragraph expires October 1, 2013.
1105     (f)  An entity that provides in-home physician services to
1106test the cost-effectiveness of enhanced home-based medical care
1107to Medicaid recipients with degenerative neurological diseases
1108and other diseases or disabling conditions associated with high
1109costs to Medicaid. The program shall be designed to serve very
1110disabled persons and to reduce Medicaid reimbursed costs for
1111inpatient, outpatient, and emergency department services. The
1112agency shall contract with vendors on a risk-sharing basis.
1113     (g)  Children's provider networks that provide care
1114coordination and care management for Medicaid-eligible pediatric
1115patients, primary care, authorization of specialty care, and
1116other urgent and emergency care through organized providers
1117designed to service Medicaid eligibles under age 18 and
1118pediatric emergency departments' diversion programs. The
1119networks shall provide after-hour operations, including evening
1120and weekend hours, to promote, when appropriate, the use of the
1121children's networks rather than hospital emergency departments.
1122     (f)(h)  An entity authorized in s. 430.205 to contract with
1123the agency and the Department of Elderly Affairs to provide
1124health care and social services on a prepaid or fixed-sum basis
1125to elderly recipients. Such prepaid health care services
1126entities are exempt from the provisions of part I of chapter 641
1127for the first 3 years of operation. An entity recognized under
1128this paragraph that demonstrates to the satisfaction of the
1129Office of Insurance Regulation that it is backed by the full
1130faith and credit of one or more counties in which it operates
1131may be exempted from s. 641.225. This paragraph expires October
11321, 2012.
1133     (g)(i)  A Children's Medical Services Network, as defined
1134in s. 391.021. This paragraph expires October 1, 2013.
1135     (5)  The Agency for Health Care Administration, in
1136partnership with the Department of Elderly Affairs, shall create
1137an integrated, fixed-payment delivery program for Medicaid
1138recipients who are 60 years of age or older or dually eligible
1139for Medicare and Medicaid. The Agency for Health Care
1140Administration shall implement the integrated program initially
1141on a pilot basis in two areas of the state. The pilot areas
1142shall be Area 7 and Area 11 of the Agency for Health Care
1143Administration. Enrollment in the pilot areas shall be on a
1144voluntary basis and in accordance with approved federal waivers
1145and this section. The agency and its program contractors and
1146providers shall not enroll any individual in the integrated
1147program because the individual or the person legally responsible
1148for the individual fails to choose to enroll in the integrated
1149program. Enrollment in the integrated program shall be
1150exclusively by affirmative choice of the eligible individual or
1151by the person legally responsible for the individual. The
1152integrated program must transfer all Medicaid services for
1153eligible elderly individuals who choose to participate into an
1154integrated-care management model designed to serve Medicaid
1155recipients in the community. The integrated program must combine
1156all funding for Medicaid services provided to individuals who
1157are 60 years of age or older or dually eligible for Medicare and
1158Medicaid into the integrated program, including funds for
1159Medicaid home and community-based waiver services; all Medicaid
1160services authorized in ss. 409.905 and 409.906, excluding funds
1161for Medicaid nursing home services unless the agency is able to
1162demonstrate how the integration of the funds will improve
1163coordinated care for these services in a less costly manner; and
1164Medicare coinsurance and deductibles for persons dually eligible
1165for Medicaid and Medicare as prescribed in s. 409.908(13).
1166     (a)  Individuals who are 60 years of age or older or dually
1167eligible for Medicare and Medicaid and enrolled in the
1168developmental disabilities waiver program, the family and
1169supported-living waiver program, the project AIDS care waiver
1170program, the traumatic brain injury and spinal cord injury
1171waiver program, the consumer-directed care waiver program, and
1172the program of all-inclusive care for the elderly program, and
1173residents of institutional care facilities for the
1174developmentally disabled, must be excluded from the integrated
1175program.
1176     (b)  Managed care entities who meet or exceed the agency's
1177minimum standards are eligible to operate the integrated
1178program. Entities eligible to participate include managed care
1179organizations licensed under chapter 641, including entities
1180eligible to participate in the nursing home diversion program,
1181other qualified providers as defined in s. 430.703(7), community
1182care for the elderly lead agencies, and other state-certified
1183community service networks that meet comparable standards as
1184defined by the agency, in consultation with the Department of
1185Elderly Affairs and the Office of Insurance Regulation, to be
1186financially solvent and able to take on financial risk for
1187managed care. Community service networks that are certified
1188pursuant to the comparable standards defined by the agency are
1189not required to be licensed under chapter 641. Managed care
1190entities who operate the integrated program shall be subject to
1191s. 408.7056. Eligible entities shall choose to serve enrollees
1192who are dually eligible for Medicare and Medicaid, enrollees who
1193are 60 years of age or older, or both.
1194     (c)  The agency must ensure that the capitation-rate-
1195setting methodology for the integrated program is actuarially
1196sound and reflects the intent to provide quality care in the
1197least restrictive setting. The agency must also require
1198integrated-program providers to develop a credentialing system
1199for service providers and to contract with all Gold Seal nursing
1200homes, where feasible, and exclude, where feasible, chronically
1201poor-performing facilities and providers as defined by the
1202agency. The integrated program must develop and maintain an
1203informal provider grievance system that addresses provider
1204payment and contract problems. The agency shall also establish a
1205formal grievance system to address those issues that were not
1206resolved through the informal grievance system. The integrated
1207program must provide that if the recipient resides in a
1208noncontracted residential facility licensed under chapter 400 or
1209chapter 429 at the time of enrollment in the integrated program,
1210the recipient must be permitted to continue to reside in the
1211noncontracted facility as long as the recipient desires. The
1212integrated program must also provide that, in the absence of a
1213contract between the integrated-program provider and the
1214residential facility licensed under chapter 400 or chapter 429,
1215current Medicaid rates must prevail. The integrated-program
1216provider must ensure that electronic nursing home claims that
1217contain sufficient information for processing are paid within 10
1218business days after receipt. Alternately, the integrated-program
1219provider may establish a capitated payment mechanism to
1220prospectively pay nursing homes at the beginning of each month.
1221The agency and the Department of Elderly Affairs must jointly
1222develop procedures to manage the services provided through the
1223integrated program in order to ensure quality and recipient
1224choice.
1225     (d)  The Office of Program Policy Analysis and Government
1226Accountability, in consultation with the Auditor General, shall
1227comprehensively evaluate the pilot project for the integrated,
1228fixed-payment delivery program for Medicaid recipients created
1229under this subsection. The evaluation shall begin as soon as
1230Medicaid recipients are enrolled in the managed care pilot
1231program plans and shall continue for 24 months thereafter. The
1232evaluation must include assessments of each managed care plan in
1233the integrated program with regard to cost savings; consumer
1234education, choice, and access to services; coordination of care;
1235and quality of care. The evaluation must describe administrative
1236or legal barriers to the implementation and operation of the
1237pilot program and include recommendations regarding statewide
1238expansion of the pilot program. The office shall submit its
1239evaluation report to the Governor, the President of the Senate,
1240and the Speaker of the House of Representatives no later than
1241December 31, 2009.
1242     (e)  The agency may seek federal waivers or Medicaid state
1243plan amendments and adopt rules as necessary to administer the
1244integrated program. The agency may implement the approved
1245federal waivers and other provisions as specified in this
1246subsection.
1247     (f)  No later than December 31, 2007, the agency shall
1248provide a report to the Governor, the President of the Senate,
1249and the Speaker of the House of Representatives containing an
1250analysis of the merits and challenges of seeking a waiver to
1251implement a voluntary program that integrates payments and
1252services for dually enrolled Medicare and Medicaid recipients
1253who are 65 years of age or older.
1254     (g)  The implementation of the integrated, fixed-payment
1255delivery program created under this subsection is subject to an
1256appropriation in the General Appropriations Act.
1257     (5)(6)  The agency may contract with any public or private
1258entity otherwise authorized by this section on a prepaid or
1259fixed-sum basis for the provision of health care services to
1260recipients. An entity may provide prepaid services to
1261recipients, either directly or through arrangements with other
1262entities, if each entity involved in providing services:
1263     (a)  Is organized primarily for the purpose of providing
1264health care or other services of the type regularly offered to
1265Medicaid recipients;
1266     (b)  Ensures that services meet the standards set by the
1267agency for quality, appropriateness, and timeliness;
1268     (c)  Makes provisions satisfactory to the agency for
1269insolvency protection and ensures that neither enrolled Medicaid
1270recipients nor the agency will be liable for the debts of the
1271entity;
1272     (d)  Submits to the agency, if a private entity, a
1273financial plan that the agency finds to be fiscally sound and
1274that provides for working capital in the form of cash or
1275equivalent liquid assets excluding revenues from Medicaid
1276premium payments equal to at least the first 3 months of
1277operating expenses or $200,000, whichever is greater;
1278     (e)  Furnishes evidence satisfactory to the agency of
1279adequate liability insurance coverage or an adequate plan of
1280self-insurance to respond to claims for injuries arising out of
1281the furnishing of health care;
1282     (f)  Provides, through contract or otherwise, for periodic
1283review of its medical facilities and services, as required by
1284the agency; and
1285     (g)  Provides organizational, operational, financial, and
1286other information required by the agency.
1287
1288This subsection expires October 1, 2013.
1289     (6)(7)  The agency may contract on a prepaid or fixed-sum
1290basis with any health insurer that:
1291     (a)  Pays for health care services provided to enrolled
1292Medicaid recipients in exchange for a premium payment paid by
1293the agency;
1294     (b)  Assumes the underwriting risk; and
1295     (c)  Is organized and licensed under applicable provisions
1296of the Florida Insurance Code and is currently in good standing
1297with the Office of Insurance Regulation.
1298
1299This subsection expires October 1, 2013.
1300     (7)(8)(a)  The agency may contract on a prepaid or fixed-
1301sum basis with an exclusive provider organization to provide
1302health care services to Medicaid recipients provided that the
1303exclusive provider organization meets applicable managed care
1304plan requirements in this section, ss. 409.9122, 409.9123,
1305409.9128, and 627.6472, and other applicable provisions of law.
1306This subsection expires October 1, 2013.
1307     (b)  For a period of no longer than 24 months after the
1308effective date of this paragraph, when a member of an exclusive
1309provider organization that is contracted by the agency to
1310provide health care services to Medicaid recipients in rural
1311areas without a health maintenance organization obtains services
1312from a provider that participates in the Medicaid program in
1313this state, the provider shall be paid in accordance with the
1314appropriate fee schedule for services provided to eligible
1315Medicaid recipients. The agency may seek waiver authority to
1316implement this paragraph.
1317     (8)(9)  The Agency for Health Care Administration may
1318provide cost-effective purchasing of chiropractic services on a
1319fee-for-service basis to Medicaid recipients through
1320arrangements with a statewide chiropractic preferred provider
1321organization incorporated in this state as a not-for-profit
1322corporation. The agency shall ensure that the benefit limits and
1323prior authorization requirements in the current Medicaid program
1324shall apply to the services provided by the chiropractic
1325preferred provider organization. This subsection expires October
13261, 2013.
1327     (9)(10)  The agency shall not contract on a prepaid or
1328fixed-sum basis for Medicaid services with an entity which knows
1329or reasonably should know that any officer, director, agent,
1330managing employee, or owner of stock or beneficial interest in
1331excess of 5 percent common or preferred stock, or the entity
1332itself, has been found guilty of, regardless of adjudication, or
1333entered a plea of nolo contendere, or guilty, to:
1334     (a)  Fraud;
1335     (b)  Violation of federal or state antitrust statutes,
1336including those proscribing price fixing between competitors and
1337the allocation of customers among competitors;
1338     (c)  Commission of a felony involving embezzlement, theft,
1339forgery, income tax evasion, bribery, falsification or
1340destruction of records, making false statements, receiving
1341stolen property, making false claims, or obstruction of justice;
1342or
1343     (d)  Any crime in any jurisdiction which directly relates
1344to the provision of health services on a prepaid or fixed-sum
1345basis.
1346
1347This subsection expires October 1, 2013.
1348     (10)(11)  The agency, after notifying the Legislature, may
1349apply for waivers of applicable federal laws and regulations as
1350necessary to implement more appropriate systems of health care
1351for Medicaid recipients and reduce the cost of the Medicaid
1352program to the state and federal governments and shall implement
1353such programs, after legislative approval, within a reasonable
1354period of time after federal approval. These programs must be
1355designed primarily to reduce the need for inpatient care,
1356custodial care and other long-term or institutional care, and
1357other high-cost services. Prior to seeking legislative approval
1358of such a waiver as authorized by this subsection, the agency
1359shall provide notice and an opportunity for public comment.
1360Notice shall be provided to all persons who have made requests
1361of the agency for advance notice and shall be published in the
1362Florida Administrative Weekly not less than 28 days prior to the
1363intended action. This subsection expires October 1, 2015.
1364     (11)(12)  The agency shall establish a postpayment
1365utilization control program designed to identify recipients who
1366may inappropriately overuse or underuse Medicaid services and
1367shall provide methods to correct such misuse. This subsection
1368expires October 1, 2013.
1369     (12)(13)  The agency shall develop and provide coordinated
1370systems of care for Medicaid recipients and may contract with
1371public or private entities to develop and administer such
1372systems of care among public and private health care providers
1373in a given geographic area. This subsection expires October 1,
13742013.
1375     (13)(14)(a)  The agency shall operate or contract for the
1376operation of utilization management and incentive systems
1377designed to encourage cost-effective use of services and to
1378eliminate services that are medically unnecessary. The agency
1379shall track Medicaid provider prescription and billing patterns
1380and evaluate them against Medicaid medical necessity criteria
1381and coverage and limitation guidelines adopted by rule. Medical
1382necessity determination requires that service be consistent with
1383symptoms or confirmed diagnosis of illness or injury under
1384treatment and not in excess of the patient's needs. The agency
1385shall conduct reviews of provider exceptions to peer group norms
1386and shall, using statistical methodologies, provider profiling,
1387and analysis of billing patterns, detect and investigate
1388abnormal or unusual increases in billing or payment of claims
1389for Medicaid services and medically unnecessary provision of
1390services. Providers that demonstrate a pattern of submitting
1391claims for medically unnecessary services shall be referred to
1392the Medicaid program integrity unit for investigation. In its
1393annual report, required in s. 409.913, the agency shall report
1394on its efforts to control overutilization as described in this
1395subsection paragraph. This subsection expires October 1, 2013.
1396     (b)  The agency shall develop a procedure for determining
1397whether health care providers and service vendors can provide
1398the Medicaid program using a business case that demonstrates
1399whether a particular good or service can offset the cost of
1400providing the good or service in an alternative setting or
1401through other means and therefore should receive a higher
1402reimbursement. The business case must include, but need not be
1403limited to:
1404     1.  A detailed description of the good or service to be
1405provided, a description and analysis of the agency's current
1406performance of the service, and a rationale documenting how
1407providing the service in an alternative setting would be in the
1408best interest of the state, the agency, and its clients.
1409     2.  A cost-benefit analysis documenting the estimated
1410specific direct and indirect costs, savings, performance
1411improvements, risks, and qualitative and quantitative benefits
1412involved in or resulting from providing the service. The cost-
1413benefit analysis must include a detailed plan and timeline
1414identifying all actions that must be implemented to realize
1415expected benefits. The Secretary of Health Care Administration
1416shall verify that all costs, savings, and benefits are valid and
1417achievable.
1418     (c)  If the agency determines that the increased
1419reimbursement is cost-effective, the agency shall recommend a
1420change in the reimbursement schedule for that particular good or
1421service. If, within 12 months after implementing any rate change
1422under this procedure, the agency determines that costs were not
1423offset by the increased reimbursement schedule, the agency may
1424revert to the former reimbursement schedule for the particular
1425good or service.
1426     (14)(15)(a)  The agency shall operate the Comprehensive
1427Assessment and Review for Long-Term Care Services (CARES)
1428nursing facility preadmission screening program to ensure that
1429Medicaid payment for nursing facility care is made only for
1430individuals whose conditions require such care and to ensure
1431that long-term care services are provided in the setting most
1432appropriate to the needs of the person and in the most
1433economical manner possible. The CARES program shall also ensure
1434that individuals participating in Medicaid home and community-
1435based waiver programs meet criteria for those programs,
1436consistent with approved federal waivers.
1437     (b)  The agency shall operate the CARES program through an
1438interagency agreement with the Department of Elderly Affairs.
1439The agency, in consultation with the Department of Elderly
1440Affairs, may contract for any function or activity of the CARES
1441program, including any function or activity required by 42
1442C.F.R. part 483.20, relating to preadmission screening and
1443resident review.
1444     (c)  Prior to making payment for nursing facility services
1445for a Medicaid recipient, the agency must verify that the
1446nursing facility preadmission screening program has determined
1447that the individual requires nursing facility care and that the
1448individual cannot be safely served in community-based programs.
1449The nursing facility preadmission screening program shall refer
1450a Medicaid recipient to a community-based program if the
1451individual could be safely served at a lower cost and the
1452recipient chooses to participate in such program. For
1453individuals whose nursing home stay is initially funded by
1454Medicare and Medicare coverage is being terminated for lack of
1455progress towards rehabilitation, CARES staff shall consult with
1456the person making the determination of progress toward
1457rehabilitation to ensure that the recipient is not being
1458inappropriately disqualified from Medicare coverage. If, in
1459their professional judgment, CARES staff believes that a
1460Medicare beneficiary is still making progress toward
1461rehabilitation, they may assist the Medicare beneficiary with an
1462appeal of the disqualification from Medicare coverage. The use
1463of CARES teams to review Medicare denials for coverage under
1464this section is authorized only if it is determined that such
1465reviews qualify for federal matching funds through Medicaid. The
1466agency shall seek or amend federal waivers as necessary to
1467implement this section.
1468     (d)  For the purpose of initiating immediate prescreening
1469and diversion assistance for individuals residing in nursing
1470homes and in order to make families aware of alternative long-
1471term care resources so that they may choose a more cost-
1472effective setting for long-term placement, CARES staff shall
1473conduct an assessment and review of a sample of individuals
1474whose nursing home stay is expected to exceed 20 days,
1475regardless of the initial funding source for the nursing home
1476placement. CARES staff shall provide counseling and referral
1477services to these individuals regarding choosing appropriate
1478long-term care alternatives. This paragraph does not apply to
1479continuing care facilities licensed under chapter 651 or to
1480retirement communities that provide a combination of nursing
1481home, independent living, and other long-term care services.
1482     (e)  By January 15 of each year, the agency shall submit a
1483report to the Legislature describing the operations of the CARES
1484program. The report must describe:
1485     1.  Rate of diversion to community alternative programs;
1486     2.  CARES program staffing needs to achieve additional
1487diversions;
1488     3.  Reasons the program is unable to place individuals in
1489less restrictive settings when such individuals desired such
1490services and could have been served in such settings;
1491     4.  Barriers to appropriate placement, including barriers
1492due to policies or operations of other agencies or state-funded
1493programs; and
1494     5.  Statutory changes necessary to ensure that individuals
1495in need of long-term care services receive care in the least
1496restrictive environment.
1497     (f)  The Department of Elderly Affairs shall track
1498individuals over time who are assessed under the CARES program
1499and who are diverted from nursing home placement. By January 15
1500of each year, the department shall submit to the Legislature a
1501longitudinal study of the individuals who are diverted from
1502nursing home placement. The study must include:
1503     1.  The demographic characteristics of the individuals
1504assessed and diverted from nursing home placement, including,
1505but not limited to, age, race, gender, frailty, caregiver
1506status, living arrangements, and geographic location;
1507     2.  A summary of community services provided to individuals
1508for 1 year after assessment and diversion;
1509     3.  A summary of inpatient hospital admissions for
1510individuals who have been diverted; and
1511     4.  A summary of the length of time between diversion and
1512subsequent entry into a nursing home or death.
1513     (g)  By July 1, 2005, the department and the Agency for
1514Health Care Administration shall report to the President of the
1515Senate and the Speaker of the House of Representatives regarding
1516the impact to the state of modifying level-of-care criteria to
1517eliminate the Intermediate II level of care.
1518
1519This subsection expires October 1, 2012.
1520     (15)(16)(a)  The agency shall identify health care
1521utilization and price patterns within the Medicaid program which
1522are not cost-effective or medically appropriate and assess the
1523effectiveness of new or alternate methods of providing and
1524monitoring service, and may implement such methods as it
1525considers appropriate. Such methods may include disease
1526management initiatives, an integrated and systematic approach
1527for managing the health care needs of recipients who are at risk
1528of or diagnosed with a specific disease by using best practices,
1529prevention strategies, clinical-practice improvement, clinical
1530interventions and protocols, outcomes research, information
1531technology, and other tools and resources to reduce overall
1532costs and improve measurable outcomes.
1533     (b)  The responsibility of the agency under this subsection
1534shall include the development of capabilities to identify actual
1535and optimal practice patterns; patient and provider educational
1536initiatives; methods for determining patient compliance with
1537prescribed treatments; fraud, waste, and abuse prevention and
1538detection programs; and beneficiary case management programs.
1539     1.  The practice pattern identification program shall
1540evaluate practitioner prescribing patterns based on national and
1541regional practice guidelines, comparing practitioners to their
1542peer groups. The agency and its Drug Utilization Review Board
1543shall consult with the Department of Health and a panel of
1544practicing health care professionals consisting of the
1545following: the Speaker of the House of Representatives and the
1546President of the Senate shall each appoint three physicians
1547licensed under chapter 458 or chapter 459; and the Governor
1548shall appoint two pharmacists licensed under chapter 465 and one
1549dentist licensed under chapter 466 who is an oral surgeon. Terms
1550of the panel members shall expire at the discretion of the
1551appointing official. The advisory panel shall be responsible for
1552evaluating treatment guidelines and recommending ways to
1553incorporate their use in the practice pattern identification
1554program. Practitioners who are prescribing inappropriately or
1555inefficiently, as determined by the agency, may have their
1556prescribing of certain drugs subject to prior authorization or
1557may be terminated from all participation in the Medicaid
1558program.
1559     2.  The agency shall also develop educational interventions
1560designed to promote the proper use of medications by providers
1561and beneficiaries.
1562     3.  The agency shall implement a pharmacy fraud, waste, and
1563abuse initiative that may include a surety bond or letter of
1564credit requirement for participating pharmacies, enhanced
1565provider auditing practices, the use of additional fraud and
1566abuse software, recipient management programs for beneficiaries
1567inappropriately using their benefits, and other steps that will
1568eliminate provider and recipient fraud, waste, and abuse. The
1569initiative shall address enforcement efforts to reduce the
1570number and use of counterfeit prescriptions.
1571     4.  By September 30, 2002, the agency shall contract with
1572an entity in the state to implement a wireless handheld clinical
1573pharmacology drug information database for practitioners. The
1574initiative shall be designed to enhance the agency's efforts to
1575reduce fraud, abuse, and errors in the prescription drug benefit
1576program and to otherwise further the intent of this paragraph.
1577     5.  By April 1, 2006, the agency shall contract with an
1578entity to design a database of clinical utilization information
1579or electronic medical records for Medicaid providers. This
1580system must be web-based and allow providers to review on a
1581real-time basis the utilization of Medicaid services, including,
1582but not limited to, physician office visits, inpatient and
1583outpatient hospitalizations, laboratory and pathology services,
1584radiological and other imaging services, dental care, and
1585patterns of dispensing prescription drugs in order to coordinate
1586care and identify potential fraud and abuse.
1587     6.  The agency may apply for any federal waivers needed to
1588administer this paragraph.
1589
1590This subsection expires October 1, 2013.
1591     (16)(17)  An entity contracting on a prepaid or fixed-sum
1592basis shall meet the surplus requirements of s. 641.225. If an
1593entity's surplus falls below an amount equal to the surplus
1594requirements of s. 641.225, the agency shall prohibit the entity
1595from engaging in marketing and preenrollment activities, shall
1596cease to process new enrollments, and may not renew the entity's
1597contract until the required balance is achieved. The
1598requirements of this subsection do not apply:
1599     (a)  Where a public entity agrees to fund any deficit
1600incurred by the contracting entity; or
1601     (b)  Where the entity's performance and obligations are
1602guaranteed in writing by a guaranteeing organization which:
1603     1.  Has been in operation for at least 5 years and has
1604assets in excess of $50 million; or
1605     2.  Submits a written guarantee acceptable to the agency
1606which is irrevocable during the term of the contracting entity's
1607contract with the agency and, upon termination of the contract,
1608until the agency receives proof of satisfaction of all
1609outstanding obligations incurred under the contract.
1610
1611This subsection expires October 1, 2013.
1612     (17)(18)(a)  The agency may require an entity contracting
1613on a prepaid or fixed-sum basis to establish a restricted
1614insolvency protection account with a federally guaranteed
1615financial institution licensed to do business in this state. The
1616entity shall deposit into that account 5 percent of the
1617capitation payments made by the agency each month until a
1618maximum total of 2 percent of the total current contract amount
1619is reached. The restricted insolvency protection account may be
1620drawn upon with the authorized signatures of two persons
1621designated by the entity and two representatives of the agency.
1622If the agency finds that the entity is insolvent, the agency may
1623draw upon the account solely with the two authorized signatures
1624of representatives of the agency, and the funds may be disbursed
1625to meet financial obligations incurred by the entity under the
1626prepaid contract. If the contract is terminated, expired, or not
1627continued, the account balance must be released by the agency to
1628the entity upon receipt of proof of satisfaction of all
1629outstanding obligations incurred under this contract.
1630     (b)  The agency may waive the insolvency protection account
1631requirement in writing when evidence is on file with the agency
1632of adequate insolvency insurance and reinsurance that will
1633protect enrollees if the entity becomes unable to meet its
1634obligations.
1635
1636This subsection expires October 1, 2013.
1637     (18)(19)  An entity that contracts with the agency on a
1638prepaid or fixed-sum basis for the provision of Medicaid
1639services shall reimburse any hospital or physician that is
1640outside the entity's authorized geographic service area as
1641specified in its contract with the agency, and that provides
1642services authorized by the entity to its members, at a rate
1643negotiated with the hospital or physician for the provision of
1644services or according to the lesser of the following:
1645     (a)  The usual and customary charges made to the general
1646public by the hospital or physician; or
1647     (b)  The Florida Medicaid reimbursement rate established
1648for the hospital or physician.
1649
1650This subsection expires October 1, 2013.
1651     (19)(20)  When a merger or acquisition of a Medicaid
1652prepaid contractor has been approved by the Office of Insurance
1653Regulation pursuant to s. 628.4615, the agency shall approve the
1654assignment or transfer of the appropriate Medicaid prepaid
1655contract upon request of the surviving entity of the merger or
1656acquisition if the contractor and the other entity have been in
1657good standing with the agency for the most recent 12-month
1658period, unless the agency determines that the assignment or
1659transfer would be detrimental to the Medicaid recipients or the
1660Medicaid program. To be in good standing, an entity must not
1661have failed accreditation or committed any material violation of
1662the requirements of s. 641.52 and must meet the Medicaid
1663contract requirements. For purposes of this section, a merger or
1664acquisition means a change in controlling interest of an entity,
1665including an asset or stock purchase. This subsection expires
1666October 1, 2013.
1667     (20)(21)  Any entity contracting with the agency pursuant
1668to this section to provide health care services to Medicaid
1669recipients is prohibited from engaging in any of the following
1670practices or activities:
1671     (a)  Practices that are discriminatory, including, but not
1672limited to, attempts to discourage participation on the basis of
1673actual or perceived health status.
1674     (b)  Activities that could mislead or confuse recipients,
1675or misrepresent the organization, its marketing representatives,
1676or the agency. Violations of this paragraph include, but are not
1677limited to:
1678     1.  False or misleading claims that marketing
1679representatives are employees or representatives of the state or
1680county, or of anyone other than the entity or the organization
1681by whom they are reimbursed.
1682     2.  False or misleading claims that the entity is
1683recommended or endorsed by any state or county agency, or by any
1684other organization which has not certified its endorsement in
1685writing to the entity.
1686     3.  False or misleading claims that the state or county
1687recommends that a Medicaid recipient enroll with an entity.
1688     4.  Claims that a Medicaid recipient will lose benefits
1689under the Medicaid program, or any other health or welfare
1690benefits to which the recipient is legally entitled, if the
1691recipient does not enroll with the entity.
1692     (c)  Granting or offering of any monetary or other valuable
1693consideration for enrollment, except as authorized by subsection
1694(23) (24).
1695     (d)  Door-to-door solicitation of recipients who have not
1696contacted the entity or who have not invited the entity to make
1697a presentation.
1698     (e)  Solicitation of Medicaid recipients by marketing
1699representatives stationed in state offices unless approved and
1700supervised by the agency or its agent and approved by the
1701affected state agency when solicitation occurs in an office of
1702the state agency. The agency shall ensure that marketing
1703representatives stationed in state offices shall market their
1704managed care plans to Medicaid recipients only in designated
1705areas and in such a way as to not interfere with the recipients'
1706activities in the state office.
1707     (f)  Enrollment of Medicaid recipients.
1708
1709This subsection expires October 1, 2013.
1710     (21)(22)  The agency may impose a fine for a violation of
1711this section or the contract with the agency by a person or
1712entity that is under contract with the agency. With respect to
1713any nonwillful violation, such fine shall not exceed $2,500 per
1714violation. In no event shall such fine exceed an aggregate
1715amount of $10,000 for all nonwillful violations arising out of
1716the same action. With respect to any knowing and willful
1717violation of this section or the contract with the agency, the
1718agency may impose a fine upon the entity in an amount not to
1719exceed $20,000 for each such violation. In no event shall such
1720fine exceed an aggregate amount of $100,000 for all knowing and
1721willful violations arising out of the same action. This
1722subsection expires October 1, 2013.
1723     (22)(23)  A health maintenance organization or a person or
1724entity exempt from chapter 641 that is under contract with the
1725agency for the provision of health care services to Medicaid
1726recipients may not use or distribute marketing materials used to
1727solicit Medicaid recipients, unless such materials have been
1728approved by the agency. The provisions of this subsection do not
1729apply to general advertising and marketing materials used by a
1730health maintenance organization to solicit both non-Medicaid
1731subscribers and Medicaid recipients. This subsection expires
1732October 1, 2013.
1733     (23)(24)  Upon approval by the agency, health maintenance
1734organizations and persons or entities exempt from chapter 641
1735that are under contract with the agency for the provision of
1736health care services to Medicaid recipients may be permitted
1737within the capitation rate to provide additional health benefits
1738that the agency has found are of high quality, are practicably
1739available, provide reasonable value to the recipient, and are
1740provided at no additional cost to the state. This subsection
1741expires October 1, 2013.
1742     (24)(25)  The agency shall utilize the statewide health
1743maintenance organization complaint hotline for the purpose of
1744investigating and resolving Medicaid and prepaid health plan
1745complaints, maintaining a record of complaints and confirmed
1746problems, and receiving disenrollment requests made by
1747recipients. This subsection expires October 1, 2013.
1748     (25)(26)  The agency shall require the publication of the
1749health maintenance organization's and the prepaid health plan's
1750consumer services telephone numbers and the "800" telephone
1751number of the statewide health maintenance organization
1752complaint hotline on each Medicaid identification card issued by
1753a health maintenance organization or prepaid health plan
1754contracting with the agency to serve Medicaid recipients and on
1755each subscriber handbook issued to a Medicaid recipient. This
1756subsection expires October 1, 2013.
1757     (26)(27)  The agency shall establish a health care quality
1758improvement system for those entities contracting with the
1759agency pursuant to this section, incorporating all the standards
1760and guidelines developed by the Medicaid Bureau of the Health
1761Care Financing Administration as a part of the quality assurance
1762reform initiative. The system shall include, but need not be
1763limited to, the following:
1764     (a)  Guidelines for internal quality assurance programs,
1765including standards for:
1766     1.  Written quality assurance program descriptions.
1767     2.  Responsibilities of the governing body for monitoring,
1768evaluating, and making improvements to care.
1769     3.  An active quality assurance committee.
1770     4.  Quality assurance program supervision.
1771     5.  Requiring the program to have adequate resources to
1772effectively carry out its specified activities.
1773     6.  Provider participation in the quality assurance
1774program.
1775     7.  Delegation of quality assurance program activities.
1776     8.  Credentialing and recredentialing.
1777     9.  Enrollee rights and responsibilities.
1778     10.  Availability and accessibility to services and care.
1779     11.  Ambulatory care facilities.
1780     12.  Accessibility and availability of medical records, as
1781well as proper recordkeeping and process for record review.
1782     13.  Utilization review.
1783     14.  A continuity of care system.
1784     15.  Quality assurance program documentation.
1785     16.  Coordination of quality assurance activity with other
1786management activity.
1787     17.  Delivering care to pregnant women and infants; to
1788elderly and disabled recipients, especially those who are at
1789risk of institutional placement; to persons with developmental
1790disabilities; and to adults who have chronic, high-cost medical
1791conditions.
1792     (b)  Guidelines which require the entities to conduct
1793quality-of-care studies which:
1794     1.  Target specific conditions and specific health service
1795delivery issues for focused monitoring and evaluation.
1796     2.  Use clinical care standards or practice guidelines to
1797objectively evaluate the care the entity delivers or fails to
1798deliver for the targeted clinical conditions and health services
1799delivery issues.
1800     3.  Use quality indicators derived from the clinical care
1801standards or practice guidelines to screen and monitor care and
1802services delivered.
1803     (c)  Guidelines for external quality review of each
1804contractor which require: focused studies of patterns of care;
1805individual care review in specific situations; and followup
1806activities on previous pattern-of-care study findings and
1807individual-care-review findings. In designing the external
1808quality review function and determining how it is to operate as
1809part of the state's overall quality improvement system, the
1810agency shall construct its external quality review organization
1811and entity contracts to address each of the following:
1812     1.  Delineating the role of the external quality review
1813organization.
1814     2.  Length of the external quality review organization
1815contract with the state.
1816     3.  Participation of the contracting entities in designing
1817external quality review organization review activities.
1818     4.  Potential variation in the type of clinical conditions
1819and health services delivery issues to be studied at each plan.
1820     5.  Determining the number of focused pattern-of-care
1821studies to be conducted for each plan.
1822     6.  Methods for implementing focused studies.
1823     7.  Individual care review.
1824     8.  Followup activities.
1825
1826This subsection expires October 1, 2015.
1827     (27)(28)  In order to ensure that children receive health
1828care services for which an entity has already been compensated,
1829an entity contracting with the agency pursuant to this section
1830shall achieve an annual Early and Periodic Screening, Diagnosis,
1831and Treatment (EPSDT) Service screening rate of at least 60
1832percent for those recipients continuously enrolled for at least
18338 months. The agency shall develop a method by which the EPSDT
1834screening rate shall be calculated. For any entity which does
1835not achieve the annual 60 percent rate, the entity must submit a
1836corrective action plan for the agency's approval. If the entity
1837does not meet the standard established in the corrective action
1838plan during the specified timeframe, the agency is authorized to
1839impose appropriate contract sanctions. At least annually, the
1840agency shall publicly release the EPSDT Services screening rates
1841of each entity it has contracted with on a prepaid basis to
1842serve Medicaid recipients. This subsection expires October 1,
18432013.
1844     (28)(29)  The agency shall perform enrollments and
1845disenrollments for Medicaid recipients who are eligible for
1846MediPass or managed care plans. Notwithstanding the prohibition
1847contained in paragraph (20)(21)(f), managed care plans may
1848perform preenrollments of Medicaid recipients under the
1849supervision of the agency or its agents. For the purposes of
1850this section, "preenrollment" means the provision of marketing
1851and educational materials to a Medicaid recipient and assistance
1852in completing the application forms, but shall not include
1853actual enrollment into a managed care plan. An application for
1854enrollment shall not be deemed complete until the agency or its
1855agent verifies that the recipient made an informed, voluntary
1856choice. The agency, in cooperation with the Department of
1857Children and Family Services, may test new marketing initiatives
1858to inform Medicaid recipients about their managed care options
1859at selected sites. The agency shall report to the Legislature on
1860the effectiveness of such initiatives. The agency may contract
1861with a third party to perform managed care plan and MediPass
1862enrollment and disenrollment services for Medicaid recipients
1863and is authorized to adopt rules to implement such services. The
1864agency may adjust the capitation rate only to cover the costs of
1865a third-party enrollment and disenrollment contract, and for
1866agency supervision and management of the managed care plan
1867enrollment and disenrollment contract. This subsection expires
1868October 1, 2013.
1869     (29)(30)  Any lists of providers made available to Medicaid
1870recipients, MediPass enrollees, or managed care plan enrollees
1871shall be arranged alphabetically showing the provider's name and
1872specialty and, separately, by specialty in alphabetical order.
1873This subsection expires October 1, 2013.
1874     (30)(31)  The agency shall establish an enhanced managed
1875care quality assurance oversight function, to include at least
1876the following components:
1877     (a)  At least quarterly analysis and followup, including
1878sanctions as appropriate, of managed care participant
1879utilization of services.
1880     (b)  At least quarterly analysis and followup, including
1881sanctions as appropriate, of quality findings of the Medicaid
1882peer review organization and other external quality assurance
1883programs.
1884     (c)  At least quarterly analysis and followup, including
1885sanctions as appropriate, of the fiscal viability of managed
1886care plans.
1887     (d)  At least quarterly analysis and followup, including
1888sanctions as appropriate, of managed care participant
1889satisfaction and disenrollment surveys.
1890     (e)  The agency shall conduct regular and ongoing Medicaid
1891recipient satisfaction surveys.
1892
1893The analyses and followup activities conducted by the agency
1894under its enhanced managed care quality assurance oversight
1895function shall not duplicate the activities of accreditation
1896reviewers for entities regulated under part III of chapter 641,
1897but may include a review of the finding of such reviewers. This
1898subsection expires October 1, 2013.
1899     (31)(32)  Each managed care plan that is under contract
1900with the agency to provide health care services to Medicaid
1901recipients shall annually conduct a background check with the
1902Florida Department of Law Enforcement of all persons with
1903ownership interest of 5 percent or more or executive management
1904responsibility for the managed care plan and shall submit to the
1905agency information concerning any such person who has been found
1906guilty of, regardless of adjudication, or has entered a plea of
1907nolo contendere or guilty to, any of the offenses listed in s.
1908435.03. This subsection expires October 1, 2013.
1909     (32)(33)  The agency shall, by rule, develop a process
1910whereby a Medicaid managed care plan enrollee who wishes to
1911enter hospice care may be disenrolled from the managed care plan
1912within 24 hours after contacting the agency regarding such
1913request. The agency rule shall include a methodology for the
1914agency to recoup managed care plan payments on a pro rata basis
1915if payment has been made for the enrollment month when
1916disenrollment occurs. This subsection expires October 1, 2013.
1917     (33)(34)  The agency and entities that contract with the
1918agency to provide health care services to Medicaid recipients
1919under this section or ss. 409.91211 and 409.9122 must comply
1920with the provisions of s. 641.513 in providing emergency
1921services and care to Medicaid recipients and MediPass
1922recipients. Where feasible, safe, and cost-effective, the agency
1923shall encourage hospitals, emergency medical services providers,
1924and other public and private health care providers to work
1925together in their local communities to enter into agreements or
1926arrangements to ensure access to alternatives to emergency
1927services and care for those Medicaid recipients who need
1928nonemergent care. The agency shall coordinate with hospitals,
1929emergency medical services providers, private health plans,
1930capitated managed care networks as established in s. 409.91211,
1931and other public and private health care providers to implement
1932the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1933and 641.31097 to develop and implement emergency department
1934diversion programs for Medicaid recipients. This subsection
1935expires October 1, 2013.
1936     (34)(35)  All entities providing health care services to
1937Medicaid recipients shall make available, and encourage all
1938pregnant women and mothers with infants to receive, and provide
1939documentation in the medical records to reflect, the following:
1940     (a)  Healthy Start prenatal or infant screening.
1941     (b)  Healthy Start care coordination, when screening or
1942other factors indicate need.
1943     (c)  Healthy Start enhanced services in accordance with the
1944prenatal or infant screening results.
1945     (d)  Immunizations in accordance with recommendations of
1946the Advisory Committee on Immunization Practices of the United
1947States Public Health Service and the American Academy of
1948Pediatrics, as appropriate.
1949     (e)  Counseling and services for family planning to all
1950women and their partners.
1951     (f)  A scheduled postpartum visit for the purpose of
1952voluntary family planning, to include discussion of all methods
1953of contraception, as appropriate.
1954     (g)  Referral to the Special Supplemental Nutrition Program
1955for Women, Infants, and Children (WIC).
1956
1957This subsection expires October 1, 2013.
1958     (35)(36)  Any entity that provides Medicaid prepaid health
1959plan services shall ensure the appropriate coordination of
1960health care services with an assisted living facility in cases
1961where a Medicaid recipient is both a member of the entity's
1962prepaid health plan and a resident of the assisted living
1963facility. If the entity is at risk for Medicaid targeted case
1964management and behavioral health services, the entity shall
1965inform the assisted living facility of the procedures to follow
1966should an emergent condition arise. This subsection expires
1967October 1, 2013.
1968     (37)  The agency may seek and implement federal waivers
1969necessary to provide for cost-effective purchasing of home
1970health services, private duty nursing services, transportation,
1971independent laboratory services, and durable medical equipment
1972and supplies through competitive bidding pursuant to s. 287.057.
1973The agency may request appropriate waivers from the federal
1974Health Care Financing Administration in order to competitively
1975bid such services. The agency may exclude providers not selected
1976through the bidding process from the Medicaid provider network.
1977     (36)(38)  The agency shall enter into agreements with not-
1978for-profit organizations based in this state for the purpose of
1979providing vision screening. This subsection expires October 1,
19802013.
1981     (37)(39)(a)  The agency shall implement a Medicaid
1982prescribed-drug spending-control program that includes the
1983following components:
1984     1.  A Medicaid preferred drug list, which shall be a
1985listing of cost-effective therapeutic options recommended by the
1986Medicaid Pharmacy and Therapeutics Committee established
1987pursuant to s. 409.91195 and adopted by the agency for each
1988therapeutic class on the preferred drug list. At the discretion
1989of the committee, and when feasible, the preferred drug list
1990should include at least two products in a therapeutic class. The
1991agency may post the preferred drug list and updates to the
1992preferred drug list on an Internet website without following the
1993rulemaking procedures of chapter 120. Antiretroviral agents are
1994excluded from the preferred drug list. The agency shall also
1995limit the amount of a prescribed drug dispensed to no more than
1996a 34-day supply unless the drug products' smallest marketed
1997package is greater than a 34-day supply, or the drug is
1998determined by the agency to be a maintenance drug in which case
1999a 100-day maximum supply may be authorized. The agency is
2000authorized to seek any federal waivers necessary to implement
2001these cost-control programs and to continue participation in the
2002federal Medicaid rebate program, or alternatively to negotiate
2003state-only manufacturer rebates. The agency may adopt rules to
2004implement this subparagraph. The agency shall continue to
2005provide unlimited contraceptive drugs and items. The agency must
2006establish procedures to ensure that:
2007     a.  There is a response to a request for prior consultation
2008by telephone or other telecommunication device within 24 hours
2009after receipt of a request for prior consultation; and
2010     b.  A 72-hour supply of the drug prescribed is provided in
2011an emergency or when the agency does not provide a response
2012within 24 hours as required by sub-subparagraph a.
2013     2.  Reimbursement to pharmacies for Medicaid prescribed
2014drugs shall be set at the lesser of: the average wholesale price
2015(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2016plus 4.75 percent, the federal upper limit (FUL), the state
2017maximum allowable cost (SMAC), or the usual and customary (UAC)
2018charge billed by the provider.
2019     3.  The agency shall develop and implement a process for
2020managing the drug therapies of Medicaid recipients who are using
2021significant numbers of prescribed drugs each month. The
2022management process may include, but is not limited to,
2023comprehensive, physician-directed medical-record reviews, claims
2024analyses, and case evaluations to determine the medical
2025necessity and appropriateness of a patient's treatment plan and
2026drug therapies. The agency may contract with a private
2027organization to provide drug-program-management services. The
2028Medicaid drug benefit management program shall include
2029initiatives to manage drug therapies for HIV/AIDS patients,
2030patients using 20 or more unique prescriptions in a 180-day
2031period, and the top 1,000 patients in annual spending. The
2032agency shall enroll any Medicaid recipient in the drug benefit
2033management program if he or she meets the specifications of this
2034provision and is not enrolled in a Medicaid health maintenance
2035organization.
2036     4.  The agency may limit the size of its pharmacy network
2037based on need, competitive bidding, price negotiations,
2038credentialing, or similar criteria. The agency shall give
2039special consideration to rural areas in determining the size and
2040location of pharmacies included in the Medicaid pharmacy
2041network. A pharmacy credentialing process may include criteria
2042such as a pharmacy's full-service status, location, size,
2043patient educational programs, patient consultation, disease
2044management services, and other characteristics. The agency may
2045impose a moratorium on Medicaid pharmacy enrollment when it is
2046determined that it has a sufficient number of Medicaid-
2047participating providers. The agency must allow dispensing
2048practitioners to participate as a part of the Medicaid pharmacy
2049network regardless of the practitioner's proximity to any other
2050entity that is dispensing prescription drugs under the Medicaid
2051program. A dispensing practitioner must meet all credentialing
2052requirements applicable to his or her practice, as determined by
2053the agency.
2054     5.  The agency shall develop and implement a program that
2055requires Medicaid practitioners who prescribe drugs to use a
2056counterfeit-proof prescription pad for Medicaid prescriptions.
2057The agency shall require the use of standardized counterfeit-
2058proof prescription pads by Medicaid-participating prescribers or
2059prescribers who write prescriptions for Medicaid recipients. The
2060agency may implement the program in targeted geographic areas or
2061statewide.
2062     6.  The agency may enter into arrangements that require
2063manufacturers of generic drugs prescribed to Medicaid recipients
2064to provide rebates of at least 15.1 percent of the average
2065manufacturer price for the manufacturer's generic products.
2066These arrangements shall require that if a generic-drug
2067manufacturer pays federal rebates for Medicaid-reimbursed drugs
2068at a level below 15.1 percent, the manufacturer must provide a
2069supplemental rebate to the state in an amount necessary to
2070achieve a 15.1-percent rebate level.
2071     7.  The agency may establish a preferred drug list as
2072described in this subsection, and, pursuant to the establishment
2073of such preferred drug list, it is authorized to negotiate
2074supplemental rebates from manufacturers that are in addition to
2075those required by Title XIX of the Social Security Act and at no
2076less than 14 percent of the average manufacturer price as
2077defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2078the federal or supplemental rebate, or both, equals or exceeds
207929 percent. There is no upper limit on the supplemental rebates
2080the agency may negotiate. The agency may determine that specific
2081products, brand-name or generic, are competitive at lower rebate
2082percentages. Agreement to pay the minimum supplemental rebate
2083percentage will guarantee a manufacturer that the Medicaid
2084Pharmaceutical and Therapeutics Committee will consider a
2085product for inclusion on the preferred drug list. However, a
2086pharmaceutical manufacturer is not guaranteed placement on the
2087preferred drug list by simply paying the minimum supplemental
2088rebate. Agency decisions will be made on the clinical efficacy
2089of a drug and recommendations of the Medicaid Pharmaceutical and
2090Therapeutics Committee, as well as the price of competing
2091products minus federal and state rebates. The agency is
2092authorized to contract with an outside agency or contractor to
2093conduct negotiations for supplemental rebates. For the purposes
2094of this section, the term "supplemental rebates" means cash
2095rebates. Effective July 1, 2004, value-added programs as a
2096substitution for supplemental rebates are prohibited. The agency
2097is authorized to seek any federal waivers to implement this
2098initiative.
2099     8.  The Agency for Health Care Administration shall expand
2100home delivery of pharmacy products. To assist Medicaid patients
2101in securing their prescriptions and reduce program costs, the
2102agency shall expand its current mail-order-pharmacy diabetes-
2103supply program to include all generic and brand-name drugs used
2104by Medicaid patients with diabetes. Medicaid recipients in the
2105current program may obtain nondiabetes drugs on a voluntary
2106basis. This initiative is limited to the geographic area covered
2107by the current contract. The agency may seek and implement any
2108federal waivers necessary to implement this subparagraph.
2109     9.  The agency shall limit to one dose per month any drug
2110prescribed to treat erectile dysfunction.
2111     10.a.  The agency may implement a Medicaid behavioral drug
2112management system. The agency may contract with a vendor that
2113has experience in operating behavioral drug management systems
2114to implement this program. The agency is authorized to seek
2115federal waivers to implement this program.
2116     b.  The agency, in conjunction with the Department of
2117Children and Family Services, may implement the Medicaid
2118behavioral drug management system that is designed to improve
2119the quality of care and behavioral health prescribing practices
2120based on best practice guidelines, improve patient adherence to
2121medication plans, reduce clinical risk, and lower prescribed
2122drug costs and the rate of inappropriate spending on Medicaid
2123behavioral drugs. The program may include the following
2124elements:
2125     (I)  Provide for the development and adoption of best
2126practice guidelines for behavioral health-related drugs such as
2127antipsychotics, antidepressants, and medications for treating
2128bipolar disorders and other behavioral conditions; translate
2129them into practice; review behavioral health prescribers and
2130compare their prescribing patterns to a number of indicators
2131that are based on national standards; and determine deviations
2132from best practice guidelines.
2133     (II)  Implement processes for providing feedback to and
2134educating prescribers using best practice educational materials
2135and peer-to-peer consultation.
2136     (III)  Assess Medicaid beneficiaries who are outliers in
2137their use of behavioral health drugs with regard to the numbers
2138and types of drugs taken, drug dosages, combination drug
2139therapies, and other indicators of improper use of behavioral
2140health drugs.
2141     (IV)  Alert prescribers to patients who fail to refill
2142prescriptions in a timely fashion, are prescribed multiple same-
2143class behavioral health drugs, and may have other potential
2144medication problems.
2145     (V)  Track spending trends for behavioral health drugs and
2146deviation from best practice guidelines.
2147     (VI)  Use educational and technological approaches to
2148promote best practices, educate consumers, and train prescribers
2149in the use of practice guidelines.
2150     (VII)  Disseminate electronic and published materials.
2151     (VIII)  Hold statewide and regional conferences.
2152     (IX)  Implement a disease management program with a model
2153quality-based medication component for severely mentally ill
2154individuals and emotionally disturbed children who are high
2155users of care.
2156     11.a.  The agency shall implement a Medicaid prescription
2157drug management system. The agency may contract with a vendor
2158that has experience in operating prescription drug management
2159systems in order to implement this system. Any management system
2160that is implemented in accordance with this subparagraph must
2161rely on cooperation between physicians and pharmacists to
2162determine appropriate practice patterns and clinical guidelines
2163to improve the prescribing, dispensing, and use of drugs in the
2164Medicaid program. The agency may seek federal waivers to
2165implement this program.
2166     b.  The drug management system must be designed to improve
2167the quality of care and prescribing practices based on best
2168practice guidelines, improve patient adherence to medication
2169plans, reduce clinical risk, and lower prescribed drug costs and
2170the rate of inappropriate spending on Medicaid prescription
2171drugs. The program must:
2172     (I)  Provide for the development and adoption of best
2173practice guidelines for the prescribing and use of drugs in the
2174Medicaid program, including translating best practice guidelines
2175into practice; reviewing prescriber patterns and comparing them
2176to indicators that are based on national standards and practice
2177patterns of clinical peers in their community, statewide, and
2178nationally; and determine deviations from best practice
2179guidelines.
2180     (II)  Implement processes for providing feedback to and
2181educating prescribers using best practice educational materials
2182and peer-to-peer consultation.
2183     (III)  Assess Medicaid recipients who are outliers in their
2184use of a single or multiple prescription drugs with regard to
2185the numbers and types of drugs taken, drug dosages, combination
2186drug therapies, and other indicators of improper use of
2187prescription drugs.
2188     (IV)  Alert prescribers to patients who fail to refill
2189prescriptions in a timely fashion, are prescribed multiple drugs
2190that may be redundant or contraindicated, or may have other
2191potential medication problems.
2192     (V)  Track spending trends for prescription drugs and
2193deviation from best practice guidelines.
2194     (VI)  Use educational and technological approaches to
2195promote best practices, educate consumers, and train prescribers
2196in the use of practice guidelines.
2197     (VII)  Disseminate electronic and published materials.
2198     (VIII)  Hold statewide and regional conferences.
2199     (IX)  Implement disease management programs in cooperation
2200with physicians and pharmacists, along with a model quality-
2201based medication component for individuals having chronic
2202medical conditions.
2203     12.  The agency is authorized to contract for drug rebate
2204administration, including, but not limited to, calculating
2205rebate amounts, invoicing manufacturers, negotiating disputes
2206with manufacturers, and maintaining a database of rebate
2207collections.
2208     13.  The agency may specify the preferred daily dosing form
2209or strength for the purpose of promoting best practices with
2210regard to the prescribing of certain drugs as specified in the
2211General Appropriations Act and ensuring cost-effective
2212prescribing practices.
2213     14.  The agency may require prior authorization for
2214Medicaid-covered prescribed drugs. The agency may, but is not
2215required to, prior-authorize the use of a product:
2216     a.  For an indication not approved in labeling;
2217     b.  To comply with certain clinical guidelines; or
2218     c.  If the product has the potential for overuse, misuse,
2219or abuse.
2220
2221The agency may require the prescribing professional to provide
2222information about the rationale and supporting medical evidence
2223for the use of a drug. The agency may post prior authorization
2224criteria and protocol and updates to the list of drugs that are
2225subject to prior authorization on an Internet website without
2226amending its rule or engaging in additional rulemaking.
2227     15.  The agency, in conjunction with the Pharmaceutical and
2228Therapeutics Committee, may require age-related prior
2229authorizations for certain prescribed drugs. The agency may
2230preauthorize the use of a drug for a recipient who may not meet
2231the age requirement or may exceed the length of therapy for use
2232of this product as recommended by the manufacturer and approved
2233by the Food and Drug Administration. Prior authorization may
2234require the prescribing professional to provide information
2235about the rationale and supporting medical evidence for the use
2236of a drug.
2237     16.  The agency shall implement a step-therapy prior
2238authorization approval process for medications excluded from the
2239preferred drug list. Medications listed on the preferred drug
2240list must be used within the previous 12 months prior to the
2241alternative medications that are not listed. The step-therapy
2242prior authorization may require the prescriber to use the
2243medications of a similar drug class or for a similar medical
2244indication unless contraindicated in the Food and Drug
2245Administration labeling. The trial period between the specified
2246steps may vary according to the medical indication. The step-
2247therapy approval process shall be developed in accordance with
2248the committee as stated in s. 409.91195(7) and (8). A drug
2249product may be approved without meeting the step-therapy prior
2250authorization criteria if the prescribing physician provides the
2251agency with additional written medical or clinical documentation
2252that the product is medically necessary because:
2253     a.  There is not a drug on the preferred drug list to treat
2254the disease or medical condition which is an acceptable clinical
2255alternative;
2256     b.  The alternatives have been ineffective in the treatment
2257of the beneficiary's disease; or
2258     c.  Based on historic evidence and known characteristics of
2259the patient and the drug, the drug is likely to be ineffective,
2260or the number of doses have been ineffective.
2261
2262The agency shall work with the physician to determine the best
2263alternative for the patient. The agency may adopt rules waiving
2264the requirements for written clinical documentation for specific
2265drugs in limited clinical situations.
2266     17.  The agency shall implement a return and reuse program
2267for drugs dispensed by pharmacies to institutional recipients,
2268which includes payment of a $5 restocking fee for the
2269implementation and operation of the program. The return and
2270reuse program shall be implemented electronically and in a
2271manner that promotes efficiency. The program must permit a
2272pharmacy to exclude drugs from the program if it is not
2273practical or cost-effective for the drug to be included and must
2274provide for the return to inventory of drugs that cannot be
2275credited or returned in a cost-effective manner. The agency
2276shall determine if the program has reduced the amount of
2277Medicaid prescription drugs which are destroyed on an annual
2278basis and if there are additional ways to ensure more
2279prescription drugs are not destroyed which could safely be
2280reused. The agency's conclusion and recommendations shall be
2281reported to the Legislature by December 1, 2005.
2282     (b)  The agency shall implement this subsection to the
2283extent that funds are appropriated to administer the Medicaid
2284prescribed-drug spending-control program. The agency may
2285contract all or any part of this program to private
2286organizations.
2287     (c)  The agency shall submit quarterly reports to the
2288Governor, the President of the Senate, and the Speaker of the
2289House of Representatives which must include, but need not be
2290limited to, the progress made in implementing this subsection
2291and its effect on Medicaid prescribed-drug expenditures.
2292     (38)(40)  Notwithstanding the provisions of chapter 287,
2293the agency may, at its discretion, renew a contract or contracts
2294for fiscal intermediary services one or more times for such
2295periods as the agency may decide; however, all such renewals may
2296not combine to exceed a total period longer than the term of the
2297original contract.
2298     (39)(41)  The agency shall provide for the development of a
2299demonstration project by establishment in Miami-Dade County of a
2300long-term-care facility licensed pursuant to chapter 395 to
2301improve access to health care for a predominantly minority,
2302medically underserved, and medically complex population and to
2303evaluate alternatives to nursing home care and general acute
2304care for such population. Such project is to be located in a
2305health care condominium and colocated with licensed facilities
2306providing a continuum of care. The establishment of this project
2307is not subject to the provisions of s. 408.036 or s. 408.039.
2308This subsection expires October 1, 2012.
2309     (42)  The agency shall develop and implement a utilization
2310management program for Medicaid-eligible recipients for the
2311management of occupational, physical, respiratory, and speech
2312therapies. The agency shall establish a utilization program that
2313may require prior authorization in order to ensure medically
2314necessary and cost-effective treatments. The program shall be
2315operated in accordance with a federally approved waiver program
2316or state plan amendment. The agency may seek a federal waiver or
2317state plan amendment to implement this program. The agency may
2318also competitively procure these services from an outside vendor
2319on a regional or statewide basis.
2320     (40)(43)  The agency shall may contract on a prepaid or
2321fixed-sum basis with appropriately licensed prepaid dental
2322health plans to provide dental services. This subsection expires
2323October 1, 2013.
2324     (41)(44)  The Agency for Health Care Administration shall
2325ensure that any Medicaid managed care plan as defined in s.
2326409.9122(2)(f), whether paid on a capitated basis or a shared
2327savings basis, is cost-effective. For purposes of this
2328subsection, the term "cost-effective" means that a network's
2329per-member, per-month costs to the state, including, but not
2330limited to, fee-for-service costs, administrative costs, and
2331case-management fees, if any, must be no greater than the
2332state's costs associated with contracts for Medicaid services
2333established under subsection (3), which may be adjusted for
2334health status. The agency shall conduct actuarially sound
2335adjustments for health status in order to ensure such cost-
2336effectiveness and shall publish the results on its Internet
2337website and submit the results annually to the Governor, the
2338President of the Senate, and the Speaker of the House of
2339Representatives no later than December 31 of each year.
2340Contracts established pursuant to this subsection which are not
2341cost-effective may not be renewed. This subsection expires
2342October 1, 2013.
2343     (42)(45)  Subject to the availability of funds, the agency
2344shall mandate a recipient's participation in a provider lock-in
2345program, when appropriate, if a recipient is found by the agency
2346to have used Medicaid goods or services at a frequency or amount
2347not medically necessary, limiting the receipt of goods or
2348services to medically necessary providers after the 21-day
2349appeal process has ended, for a period of not less than 1 year.
2350The lock-in programs shall include, but are not limited to,
2351pharmacies, medical doctors, and infusion clinics. The
2352limitation does not apply to emergency services and care
2353provided to the recipient in a hospital emergency department.
2354The agency shall seek any federal waivers necessary to implement
2355this subsection. The agency shall adopt any rules necessary to
2356comply with or administer this subsection. This subsection
2357expires October 1, 2013.
2358     (43)(46)  The agency shall seek a federal waiver for
2359permission to terminate the eligibility of a Medicaid recipient
2360who has been found to have committed fraud, through judicial or
2361administrative determination, two times in a period of 5 years.
2362     (47)  The agency shall conduct a study of available
2363electronic systems for the purpose of verifying the identity and
2364eligibility of a Medicaid recipient. The agency shall recommend
2365to the Legislature a plan to implement an electronic
2366verification system for Medicaid recipients by January 31, 2005.
2367     (44)(48)(a)  A provider is not entitled to enrollment in
2368the Medicaid provider network. The agency may implement a
2369Medicaid fee-for-service provider network controls, including,
2370but not limited to, competitive procurement and provider
2371credentialing. If a credentialing process is used, the agency
2372may limit its provider network based upon the following
2373considerations: beneficiary access to care, provider
2374availability, provider quality standards and quality assurance
2375processes, cultural competency, demographic characteristics of
2376beneficiaries, practice standards, service wait times, provider
2377turnover, provider licensure and accreditation history, program
2378integrity history, peer review, Medicaid policy and billing
2379compliance records, clinical and medical record audit findings,
2380and such other areas that are considered necessary by the agency
2381to ensure the integrity of the program.
2382     (b)  The agency shall limit its network of durable medical
2383equipment and medical supply providers. For dates of service
2384after January 1, 2009, the agency shall limit payment for
2385durable medical equipment and supplies to providers that meet
2386all the requirements of this paragraph.
2387     1.  Providers must be accredited by a Centers for Medicare
2388and Medicaid Services deemed accreditation organization for
2389suppliers of durable medical equipment, prosthetics, orthotics,
2390and supplies. The provider must maintain accreditation and is
2391subject to unannounced reviews by the accrediting organization.
2392     2.  Providers must provide the services or supplies
2393directly to the Medicaid recipient or caregiver at the provider
2394location or recipient's residence or send the supplies directly
2395to the recipient's residence with receipt of mailed delivery.
2396Subcontracting or consignment of the service or supply to a
2397third party is prohibited.
2398     3.  Notwithstanding subparagraph 2., a durable medical
2399equipment provider may store nebulizers at a physician's office
2400for the purpose of having the physician's staff issue the
2401equipment if it meets all of the following conditions:
2402     a.  The physician must document the medical necessity and
2403need to prevent further deterioration of the patient's
2404respiratory status by the timely delivery of the nebulizer in
2405the physician's office.
2406     b.  The durable medical equipment provider must have
2407written documentation of the competency and training by a
2408Florida-licensed registered respiratory therapist of any durable
2409medical equipment staff who participate in the training of
2410physician office staff for the use of nebulizers, including
2411cleaning, warranty, and special needs of patients.
2412     c.  The physician's office must have documented the
2413training and competency of any staff member who initiates the
2414delivery of nebulizers to patients. The durable medical
2415equipment provider must maintain copies of all physician office
2416training.
2417     d.  The physician's office must maintain inventory records
2418of stored nebulizers, including documentation of the durable
2419medical equipment provider source.
2420     e.  A physician contracted with a Medicaid durable medical
2421equipment provider may not have a financial relationship with
2422that provider or receive any financial gain from the delivery of
2423nebulizers to patients.
2424     4.  Providers must have a physical business location and a
2425functional landline business phone. The location must be within
2426the state or not more than 50 miles from the Florida state line.
2427The agency may make exceptions for providers of durable medical
2428equipment or supplies not otherwise available from other
2429enrolled providers located within the state.
2430     5.  Physical business locations must be clearly identified
2431as a business that furnishes durable medical equipment or
2432medical supplies by signage that can be read from 20 feet away.
2433The location must be readily accessible to the public during
2434normal, posted business hours and must operate no less than 5
2435hours per day and no less than 5 days per week, with the
2436exception of scheduled and posted holidays. The location may not
2437be located within or at the same numbered street address as
2438another enrolled Medicaid durable medical equipment or medical
2439supply provider or as an enrolled Medicaid pharmacy that is also
2440enrolled as a durable medical equipment provider. A licensed
2441orthotist or prosthetist that provides only orthotic or
2442prosthetic devices as a Medicaid durable medical equipment
2443provider is exempt from the provisions in this paragraph.
2444     6.  Providers must maintain a stock of durable medical
2445equipment and medical supplies on site that is readily available
2446to meet the needs of the durable medical equipment business
2447location's customers.
2448     7.  Providers must provide a surety bond of $50,000 for
2449each provider location, up to a maximum of 5 bonds statewide or
2450an aggregate bond of $250,000 statewide, as identified by
2451Federal Employer Identification Number. Providers who post a
2452statewide or an aggregate bond must identify all of their
2453locations in any Medicaid durable medical equipment and medical
2454supply provider enrollment application or bond renewal. Each
2455provider location's surety bond must be renewed annually and the
2456provider must submit proof of renewal even if the original bond
2457is a continuous bond. A licensed orthotist or prosthetist that
2458provides only orthotic or prosthetic devices as a Medicaid
2459durable medical equipment provider is exempt from the provisions
2460in this paragraph.
2461     8.  Providers must obtain a level 2 background screening,
2462as provided under s. 435.04, for each provider employee in
2463direct contact with or providing direct services to recipients
2464of durable medical equipment and medical supplies in their
2465homes. This requirement includes, but is not limited to, repair
2466and service technicians, fitters, and delivery staff. The
2467provider shall pay for the cost of the background screening.
2468     9.  The following providers are exempt from the
2469requirements of subparagraphs 1. and 7.:
2470     a.  Durable medical equipment providers owned and operated
2471by a government entity.
2472     b.  Durable medical equipment providers that are operating
2473within a pharmacy that is currently enrolled as a Medicaid
2474pharmacy provider.
2475     c.  Active, Medicaid-enrolled orthopedic physician groups,
2476primarily owned by physicians, which provide only orthotic and
2477prosthetic devices.
2478     (45)(49)  The agency shall contract with established
2479minority physician networks that provide services to
2480historically underserved minority patients. The networks must
2481provide cost-effective Medicaid services, comply with the
2482requirements to be a MediPass provider, and provide their
2483primary care physicians with access to data and other management
2484tools necessary to assist them in ensuring the appropriate use
2485of services, including inpatient hospital services and
2486pharmaceuticals.
2487     (a)  The agency shall provide for the development and
2488expansion of minority physician networks in each service area to
2489provide services to Medicaid recipients who are eligible to
2490participate under federal law and rules.
2491     (b)  The agency shall reimburse each minority physician
2492network as a fee-for-service provider, including the case
2493management fee for primary care, if any, or as a capitated rate
2494provider for Medicaid services. Any savings shall be shared with
2495the minority physician networks pursuant to the contract.
2496     (c)  For purposes of this subsection, the term "cost-
2497effective" means that a network's per-member, per-month costs to
2498the state, including, but not limited to, fee-for-service costs,
2499administrative costs, and case-management fees, if any, must be
2500no greater than the state's costs associated with contracts for
2501Medicaid services established under subsection (3), which shall
2502be actuarially adjusted for case mix, model, and service area.
2503The agency shall conduct actuarially sound audits adjusted for
2504case mix and model in order to ensure such cost-effectiveness
2505and shall publish the audit results on its Internet website and
2506submit the audit results annually to the Governor, the President
2507of the Senate, and the Speaker of the House of Representatives
2508no later than December 31. Contracts established pursuant to
2509this subsection which are not cost-effective may not be renewed.
2510     (d)  The agency may apply for any federal waivers needed to
2511implement this subsection.
2512
2513This subsection expires October 1, 2013.
2514     (46)(50)  To the extent permitted by federal law and as
2515allowed under s. 409.906, the agency shall provide reimbursement
2516for emergency mental health care services for Medicaid
2517recipients in crisis stabilization facilities licensed under s.
2518394.875 as long as those services are less expensive than the
2519same services provided in a hospital setting.
2520     (47)(51)  The agency shall work with the Agency for Persons
2521with Disabilities to develop a home and community-based waiver
2522to serve children and adults who are diagnosed with familial
2523dysautonomia or Riley-Day syndrome caused by a mutation of the
2524IKBKAP gene on chromosome 9. The agency shall seek federal
2525waiver approval and implement the approved waiver subject to the
2526availability of funds and any limitations provided in the
2527General Appropriations Act. The agency may adopt rules to
2528implement this waiver program.
2529     (48)(52)  The agency shall implement a program of all-
2530inclusive care for children. The program of all-inclusive care
2531for children shall be established to provide in-home hospice-
2532like support services to children diagnosed with a life-
2533threatening illness and enrolled in the Children's Medical
2534Services network to reduce hospitalizations as appropriate. The
2535agency, in consultation with the Department of Health, may
2536implement the program of all-inclusive care for children after
2537obtaining approval from the Centers for Medicare and Medicaid
2538Services.
2539     (49)(53)  Before seeking an amendment to the state plan for
2540purposes of implementing programs authorized by the Deficit
2541Reduction Act of 2005, the agency shall notify the Legislature.
2542     Section 11.  Subsection (4) of section 409.91195, Florida
2543Statutes, is amended to read:
2544     409.91195  Medicaid Pharmaceutical and Therapeutics
2545Committee.-There is created a Medicaid Pharmaceutical and
2546Therapeutics Committee within the agency for the purpose of
2547developing a Medicaid preferred drug list.
2548     (4)  Upon recommendation of the committee, the agency shall
2549adopt a preferred drug list as described in s. 409.912(37)(39).
2550To the extent feasible, the committee shall review all drug
2551classes included on the preferred drug list every 12 months, and
2552may recommend additions to and deletions from the preferred drug
2553list, such that the preferred drug list provides for medically
2554appropriate drug therapies for Medicaid patients which achieve
2555cost savings contained in the General Appropriations Act.
2556     Section 12.  Subsection (1) of section 409.91196, Florida
2557Statutes, is amended to read:
2558     409.91196  Supplemental rebate agreements; public records
2559and public meetings exemption.-
2560     (1)  The rebate amount, percent of rebate, manufacturer's
2561pricing, and supplemental rebate, and other trade secrets as
2562defined in s. 688.002 that the agency has identified for use in
2563negotiations, held by the Agency for Health Care Administration
2564under s. 409.912(37)(39)(a)7. are confidential and exempt from
2565s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
2566     Section 13.  Section 409.91207, Florida Statutes, is
2567amended to read:
2568(Substantial rewording of section. See s. 409.91207,
2569F.S., for present text.)
2570     409.91207  Medical homes.-
2571     (1)  AUTHORITY.-The agency shall develop a method for
2572designating qualified plans as a medical home network.
2573     (2)  PURPOSE AND PRINCIPLES.-Medical home networks foster
2574and support coordinated and effective primary care through case
2575management, support to primary care providers, supplemental
2576services, and dissemination of best practices. Medical home
2577networks target patients with chronic illnesses and frequent
2578service utilization in order to coordinate services, provide
2579disease management and patient education, and improve quality of
2580care. In addition to primary care, medical home networks are
2581able to provide or arrange for pharmacy, outpatient diagnostic,
2582and specialty physician services and coordinate with inpatient
2583facilities and rehabilitative service providers.
2584     (3)  DESIGNATION.-A qualified plan may request agency
2585designation as a medical home network if the plan is accredited
2586as a medical home network by the National Committee for Quality
2587Assurance or:
2588     (a)  The plan establishes a method for its enrollees to
2589choose to participate as medical home patients and select a
2590primary care provider that is certified as a medical home.
2591     (b)  At least 85 percent of the primary care providers in a
2592medical home network are certified by the qualified plan as
2593having the following service capabilities:
2594     1.  Supply all medically necessary primary and preventive
2595services and provide all scheduled immunizations.
2596     2.  Organize clinical data in electronic form using a
2597patient-centered charting system.
2598     3.  Maintain and update a patient's medication list and
2599review all medications during each office visit.
2600     4.  Maintain a system to track diagnostic tests and provide
2601followup services regarding test results.
2602     5.  Maintain a system to track referrals, including self-
2603referrals by members.
2604     6.  Supply care coordination and continuity of care through
2605proactive contact with members and encourage family
2606participation in care.
2607     7.  Supply education and support using various materials
2608and processes appropriate for individual patient needs.
2609     8.  Communicate electronically.
2610     9.  Supply voice-to-voice telephone coverage to medical
2611home patients 24 hours per day, 7 days per week, to enable
2612medical home patients to speak to a licensed health care
2613professional who triages and forwards calls, as appropriate.
2614     10.  Maintain an office schedule of at least 30 scheduled
2615hours per week.
2616     11.  Use scheduling processes to promote continuity with
2617clinicians, including providing care for walk-in, routine, and
2618urgent care visits.
2619     12.  Implement and document behavioral health and substance
2620abuse screening procedures and make referrals as needed.
2621     13.  Use data to identify and track patients' health and
2622service use patterns.
2623     14.  Coordinate care and followup for patients receiving
2624services in inpatient and outpatient facilities.
2625     15.  Implement processes to promote access to care and
2626member communication.
2627     16.  Maintain electronic medical records.
2628     17.  Develop a health care team that provides ongoing
2629support, oversight, and guidance for all medical care received
2630by the patient and documents contact with specialists and other
2631health care providers caring for the patient.
2632     18.  Supply postvisit followup care for patients.
2633     19.  Implement specific evidence-based clinical practice
2634guidelines for preventive and chronic care.
2635     20.  Implement a medication reconciliation procedure to
2636avoid interactions or duplications.
2637     21.  Use personalized screening, brief intervention, and
2638referral to treatment procedures for appropriate patients
2639requiring specialty treatment.
2640     22.  Offer at least 4 hours per week of after-hours care to
2641patients.
2642     23.  Use health assessment tools to identify patient needs
2643and risks.
2644     (c)  The qualified plan offers support services to its
2645primary care providers, including:
2646     1.  Case management, outreach, care coordination, and other
2647targeted support services for medical home patients.
2648     2.  Ongoing assessment of spending and service utilization
2649by all medical home network patients.
2650     3.  Periodic evaluation of patient outcomes.
2651     4.  Coordination with inpatient facilities, behavioral
2652health, and rehabilitative service providers.
2653     5.  Establishing specific methods to manage pharmacy and
2654behavioral health services.
26556.  Paying primary care providers. It is the intent of the
2656Legislature that the savings that result from the implementation
2657of the medical home network model be used to enable Medicaid
2658fees to physicians participating in medical home networks to be
2659equivalent to 100 percent of Medicare rates as soon as possible.
2660     (4)  AGENCY DUTIES.-The agency shall:
2661     (a)  Maintain a record of qualified plans designated as
2662medical home networks.
2663     (b)  Develop a standard form to be used by the qualified
2664plans to certify to the agency that they meet the necessary
2665service and primary care provider support capabilities to be
2666designated a medical home.
2667     Section 14.  Section 409.91211, Florida Statutes, is
2668amended to read:
2669(Substantial rewording of section. See s. 409.91211,
2670F.S., for present text.)
2671     409.91211.-Medicaid managed care pilot program.-
2672     (1)  AUTHORITY.-The agency is authorized to implement a
2673managed care pilot program based on the Section 1115 waiver
2674approved by the Centers for Medicare and Medicaid Services on
2675October 19, 2005, including continued operation of the program
2676in Baker, Broward, Clay, Duval, and Nassau Counties. The managed
2677care pilot program shall be consistent with the provisions of
2678this section, subject to federal approval.
2679     (2)  EXTENSION.-No later than July 1, 2010, the agency
2680shall begin the process of requesting an extension of the
2681Section 1115 waiver. The agency shall report at least monthly to
2682the Legislature on progress in negotiating for the extension of
2683the waiver. Changes to the terms and conditions relating to the
2684low-income pool must be approved by the Legislative Budget
2685Commission.
2686     (3)  EXPANSION.-The agency shall expand the managed care
2687pilot program to Miami-Dade County in a manner that enrolls all
2688eligible recipients in a qualified plan no later than June 30,
26892011.
2690     (4)  QUALIFIED PLANS.-Managed care plans qualified to
2691participate in the Medicaid managed care pilot program include
2692health insurers authorized under chapter 624, exclusive provider
2693organizations authorized under chapter 627, health maintenance
2694organizations authorized under chapter 641, the Children's
2695Medical Services Network under chapter 391, and provider service
2696networks authorized pursuant to s. 409.912(4)(d).
2697     (5)  PLAN REQUIREMENTS.-The agency shall apply the
2698following requirements to all qualified plans:
2699     (a)  Prepaid rates shall be risk adjusted pursuant to
2700subsection (17).
2701     (b)  All Medicaid recipients shall be offered the
2702opportunity to use their Medicaid premium to pay for the
2703recipient's share of cost pursuant to s. 409.9122(13).
2704     (6)  INTERGOVERNMENTAL TRANSFERS.-In order to preserve
2705intergovernmental transfers of funds from Miami-Dade County, the
2706agency shall develop methodologies, including, but not limited
2707to, a supplemental capitation rate, risk pool, or incentive
2708payments, which may be paid to prepaid plans or plans owned and
2709operated by providers that contract with safety net providers,
2710trauma hospitals, children's hospitals, and statutory teaching
2711hospitals. In order to preserve certified public expenditures
2712from Miami-Dade County, the agency shall seek federal approval
2713to implement a methodology that allows supplemental payments to
2714be made directly to physicians employed by or under contract
2715with a medical school in Florida in recognition of the costs
2716associated with graduate medical education or their teaching
2717mission. Alternatively, the agency may develop additional
2718methodologies including, but not limited to, methodologies
2719mentioned above, as well as capitated rates that exclude
2720payments made to these physicians so that they may be paid
2721directly. Once methodologies and payment mechanisms are
2722approved, the agency shall submit the plan for preserving
2723intergovernmental transfers and certified public expenditures to
2724the Legislative Budget Commission. After the assignment and
2725enrollment of all mandatory eligible persons in Miami-Dade
2726County into managed care plans, an amendment shall be submitted
2727to the Legislative Budget Commission requesting authority for
2728the transfer of sufficient funds from appropriate line items
2729within the Grants and Donations Trust Fund and the Medical Care
2730Trust Fund within the Agency for Health Care Administration in
2731the General Appropriations Act to the line item for Prepaid
2732Health Plans within the General Appropriations Act. The agency
2733shall submit a report to the Legislature regarding how the
2734developed and approved methodologies and payment mechanisms may
2735be applied to other counties in the state pursuant to managed
2736care payments under s. 409.968.
2737     (7)  ENROLLMENT.-All Medicaid recipients in the counties in
2738which the managed care pilot program has been implemented shall
2739be enrolled in a qualified plan. Each recipient shall have a
2740choice of plans and may select any plan unless that plan is
2741restricted by contract to a specific population that does not
2742include the recipient. Medicaid recipients shall have 30 days in
2743which to make a choice of plans. All recipients shall be offered
2744choice counseling services in accordance with this section.
2745     (8)  CHOICE COUNSELING.-The agency shall provide choice
2746counseling and may contract for the provision of choice
2747counseling services. Choice counseling shall be provided in the
2748native or preferred language of the recipient, consistent with
2749federal requirements. The agency shall maintain a record of the
2750recipients who receive such services, identifying the scope and
2751method of the services provided. The agency shall make available
2752clear and easily understandable choice information to Medicaid
2753recipients that includes:
2754     (a)  An explanation that each recipient has the right to
2755choose a qualified plan at the time of enrollment in Medicaid
2756and again at regular intervals set by the agency and that, if a
2757recipient does not choose a qualified plan, the agency will
2758assign the recipient to a qualified plan according to the
2759criteria specified in this section.
2760     (b)  A list and description of the benefits provided in
2761each plan.
2762     (c)  Information about earning credits in the plan's
2763enhanced benefit program.
2764     (d)  An explanation of benefit limits.
2765     (e)  Information about cost-sharing requirements of each
2766plan.
2767     (f)  A current list of providers participating in the
2768network, including location and contact information.
2769     (g)  Plan performance data.
2770     (9)  AUTOMATIC ENROLLMENT.-The agency shall automatically
2771enroll Medicaid recipients who do not voluntarily choose a
2772managed care plan. Enrollment shall be distributed among all
2773qualified plans. When automatically enrolling recipients, the
2774agency shall take into account the following criteria:
2775     (a)  The plan has sufficient network capacity to meet the
2776needs of the recipients.
2777     (b)  The recipient has previously received services from
2778one of the plan's primary care providers.
2779     (c)  Primary care providers in one plan are more
2780geographically accessible to the recipient's residence.
2781
2782The agency may not engage in practices that are designed to
2783favor one qualified plan over another.
2784     (10)  DISENROLLMENT.-After a recipient has selected and
2785enrolled in a qualified plan, the recipient shall have 90 days
2786to voluntarily disenroll and select another qualified plan.
2787After 90 days, further changes may be made only for good cause.
2788"Good cause" includes, but is not limited to, poor quality of
2789care, lack of access to necessary specialty services, an
2790unreasonable delay or denial of service, or fraudulent
2791enrollment. The agency must make a determination as to whether
2792cause exists. However, the agency may require a recipient to use
2793the qualified plan's grievance process prior to the agency's
2794determination of cause, except in cases in which immediate risk
2795of permanent damage to the recipient's health is alleged.  The
2796agency must make a determination and take final action on a
2797recipient's request so that disenrollment occurs no later than
2798the first day of the second month after the month the request
2799was made. If the agency fails to act within the specified
2800timeframe, the recipient's request to disenroll is deemed to be
2801approved as of the date agency action was required. Recipients
2802who disagree with the agency's finding that cause does not exist
2803for disenrollment shall be advised of their right to pursue a
2804Medicaid fair hearing to dispute the agency's finding.
2805     (11)  ENROLLMENT PERIOD.-Medicaid recipients enrolled in a
2806qualified plan after the 90-day period shall remain in the plan
2807for 12 months. After 12 months, the recipient may select another
2808plan. However, nothing shall prevent a Medicaid recipient from
2809changing primary care providers within the qualified plan during
2810the 12-month period.
2811     (12)  GRIEVANCES.-Each qualified plan shall establish an
2812internal process for reviewing and responding to grievances from
2813enrollees. The contract shall specify timeframes for submission,
2814plan response, and resolution. Grievances not resolved by a
2815plan's internal process shall be submitted to the Subscriber
2816Assistance Panel pursuant to s. 408.7056. Each plan shall submit
2817quarterly reports on the number, description, and outcome of
2818grievances filed by enrollees. The agency shall establish a
2819similar process for provider service networks.
2820     (13)  BENEFITS.-Qualified plans operating in the Medicaid
2821managed care pilot program shall cover the services specified in
2822ss. 409.905 and 409.906, emergency services provided under s.
2823409.9128, and such other services as the plan may offer. Plans
2824may customize benefit packages for nonpregnant adults, vary
2825cost-sharing provisions, and provide coverage for additional
2826services. The agency shall evaluate the proposed benefit
2827packages to ensure services are sufficient to meet the needs of
2828the plans' enrollees and to verify actuarial equivalence.
2829     (14)  PENALTIES.-Qualified plans that reduce enrollment
2830levels or leave a county where the managed care pilot program
2831has been implemented shall reimburse the agency for the cost of
2832enrollment changes, including the cost of additional choice
2833counseling services. When more than one qualified plan leaves a
2834county at the same time, costs shall be shared by the plans
2835proportionate to their enrollments.
2836     (15)  ACCESS TO DATA.-The agency shall make encounter data
2837available to those plans accepting enrollees who are assigned to
2838them from other plans leaving a county where the managed care
2839pilot program has been implemented.
2840     (16)  ENHANCED BENEFITS.-Each plan operating in the managed
2841care pilot program shall establish an incentive program that
2842rewards specific healthy behaviors with credits in a flexible
2843spending account pursuant to s. 409.9122(14).
2844     (17)  PAYMENTS TO MANAGED CARE PLANS.-
2845     (a)  The agency shall continue the budget-neutral
2846adjustment of capitation rates for all prepaid plans in existing
2847managed care pilot program counties.
2848     (b)  Beginning September 1, 2010, the agency shall begin a
2849budget-neutral adjustment of capitation rates for all prepaid
2850plans in Miami-Dade County. The adjustment to capitation rates
2851shall be based on aggregate risk scores for each prepaid plan's
2852enrollees. During the first 2 years of the adjustment, the
2853agency shall ensure that no plan has an aggregate risk score
2854that varies by more than 10 percent from the aggregate weighted
2855average for all plans. Except as otherwise provided in this
2856paragraph, the risk adjusted capitation rates shall be phased in
2857as follows:
2858     1.  In the first fiscal year, 75 percent of the capitation
2859rate shall be based on the current methodology and 25 percent
2860shall be based on the risk-adjusted rate methodology.
2861     2.  In the second fiscal year, 50 percent of the capitation
2862rate shall be based on the current methodology and 50 percent
2863shall be based on the risk-adjusted methodology.
2864     3.  In the third fiscal year, the risk-adjusted capitation
2865methodology shall be fully implemented.
2866
2867The rates for plans owned and operated by a public hospital
2868shall be risk-adjusted immediately. In order to meet the
2869requirements of budget neutrality, and until such time as all
2870rates in the county are risk-adjusted, the rate differential is
2871contingent on the nonfederal share being provided through grants
2872and donations from allowable nonstate sources. The agency shall
2873submit an amendment to the Legislative Budget Commission
2874requesting authority for such payments.
2875     (c)  During this period, the agency shall establish a
2876technical advisory panel to obtain input from the prepaid plans
2877affected by the transition to risk adjusted rates.
2878     (18)  LOW-INCOME POOL.-Funds from a low-income pool shall
2879be distributed in accordance with the terms and conditions of
2880the 1115 waiver and in a manner authorized by the General
2881Appropriations Act. The distribution of funds is intended for
2882the following purposes:
2883     (a)  Assure a broad and fair distribution of available
2884funds based on the access provided by Medicaid participating
2885hospitals, regardless of their ownership status, through their
2886delivery of inpatient or outpatient care for Medicaid
2887beneficiaries and uninsured and underinsured individuals;
2888     (b)  Assure accessible emergency inpatient and outpatient
2889care for Medicaid beneficiaries and uninsured and underinsured
2890individuals;
2891     (c)  Enhance primary, preventive, and other ambulatory care
2892coverages for uninsured individuals;
2893     (d)  Promote teaching and specialty hospital programs;
2894     (e)  Promote the stability and viability of statutorily
2895defined rural hospitals and hospitals that serve as sole
2896community hospitals;
2897     (f)  Recognize the extent of hospital uncompensated care
2898costs;
2899     (g)  Maintain and enhance essential community hospital
2900care;
2901     (h)  Maintain incentives for local governmental entities to
2902contribute to the cost of uncompensated care;
2903     (i)  Promote measures to avoid preventable
2904hospitalizations;
2905     (j)  Account for hospital efficiency; and
2906     (k)  Contribute to a community's overall health system.
2907     (19)  ENCOUNTER DATA.-The agency shall maintain and operate
2908the Medicaid Encounter Data System pursuant to s. 409.9122(15).
2909     (20)  EVALUATION.-The agency shall contract with the
2910University of Florida to complete a comprehensive evaluation of
2911the managed care pilot program. The evaluation shall include an
2912assessment of patient satisfaction, changes in benefits and
2913coverage, implementation and impact of enhanced benefits, access
2914to care and service utilization by enrolled recipients, and
2915costs per enrollee. The agency shall establish an initiative to
2916improve recipient access to information about plan performance.  
2917The agency shall publish on its Internet website information on
2918plan performance, including, but not limited to, results of plan
2919enrollee satisfaction surveys, data reported pursuant to s.
2920409.9122(17), and information on recipient grievances. The
2921website shall be user-friendly and shall provide an opportunity
2922for recipients to give web-based feedback on plans. Plans shall
2923advise recipients of the information available on the agency's
2924website and how to access it in the initial enrollment
2925materials. The agency shall evaluate the initiative to determine
2926whether it improves recipient access to information.
2927     Section 15.  Section 409.9122, Florida Statutes, is amended
2928to read:
2929     409.9122  Mandatory Medicaid managed care enrollment;
2930programs and procedures.-
2931     (1)  It is the intent of the Legislature that the MediPass
2932program be cost-effective, provide quality health care, and
2933improve access to health services, and that the program be
2934statewide. This subsection expires October 1, 2013.
2935     (2)(a)  The agency shall enroll in a managed care plan or
2936MediPass all Medicaid recipients, except those Medicaid
2937recipients who are: in an institution; enrolled in the Medicaid
2938medically needy program; or eligible for both Medicaid and
2939Medicare. Upon enrollment, individuals will be able to change
2940their managed care option during the 90-day opt out period
2941required by federal Medicaid regulations. The agency is
2942authorized to seek the necessary Medicaid state plan amendment
2943to implement this policy. However, to the extent permitted by
2944federal law, the agency may enroll in a managed care plan or
2945MediPass a Medicaid recipient who is exempt from mandatory
2946managed care enrollment, provided that:
2947     1.  The recipient's decision to enroll in a managed care
2948plan or MediPass is voluntary;
2949     2.  If the recipient chooses to enroll in a managed care
2950plan, the agency has determined that the managed care plan
2951provides specific programs and services which address the
2952special health needs of the recipient; and
2953     3.  The agency receives any necessary waivers from the
2954federal Centers for Medicare and Medicaid Services.
2955
2956The agency shall develop rules to establish policies by which
2957exceptions to the mandatory managed care enrollment requirement
2958may be made on a case-by-case basis. The rules shall include the
2959specific criteria to be applied when making a determination as
2960to whether to exempt a recipient from mandatory enrollment in a
2961managed care plan or MediPass. School districts participating in
2962the certified school match program pursuant to ss. 409.908(21)
2963and 1011.70 shall be reimbursed by Medicaid, subject to the
2964limitations of s. 1011.70(1), for a Medicaid-eligible child
2965participating in the services as authorized in s. 1011.70, as
2966provided for in s. 409.9071, regardless of whether the child is
2967enrolled in MediPass or a managed care plan. Managed care plans
2968shall make a good faith effort to execute agreements with school
2969districts regarding the coordinated provision of services
2970authorized under s. 1011.70. County health departments
2971delivering school-based services pursuant to ss. 381.0056 and
2972381.0057 shall be reimbursed by Medicaid for the federal share
2973for a Medicaid-eligible child who receives Medicaid-covered
2974services in a school setting, regardless of whether the child is
2975enrolled in MediPass or a managed care plan. Managed care plans
2976shall make a good faith effort to execute agreements with county
2977health departments regarding the coordinated provision of
2978services to a Medicaid-eligible child. To ensure continuity of
2979care for Medicaid patients, the agency, the Department of
2980Health, and the Department of Education shall develop procedures
2981for ensuring that a student's managed care plan or MediPass
2982provider receives information relating to services provided in
2983accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2984     (b)  A Medicaid recipient shall not be enrolled in or
2985assigned to a managed care plan or MediPass unless the managed
2986care plan or MediPass has complied with the quality-of-care
2987standards specified in paragraphs (3)(a) and (b), respectively.
2988     (c)  Medicaid recipients shall have a choice of managed
2989care plans or MediPass. The Agency for Health Care
2990Administration, the Department of Health, the Department of
2991Children and Family Services, and the Department of Elderly
2992Affairs shall cooperate to ensure that each Medicaid recipient
2993receives clear and easily understandable information that meets
2994the following requirements:
2995     1.  Explains the concept of managed care, including
2996MediPass.
2997     2.  Provides information on the comparative performance of
2998managed care plans and MediPass in the areas of quality,
2999credentialing, preventive health programs, network size and
3000availability, and patient satisfaction.
3001     3.  Explains where additional information on each managed
3002care plan and MediPass in the recipient's area can be obtained.
3003     4.  Explains that recipients have the right to choose their
3004managed care coverage at the time they first enroll in Medicaid
3005and again at regular intervals set by the agency. However, if a
3006recipient does not choose a managed care plan or MediPass, the
3007agency will assign the recipient to a managed care plan or
3008MediPass according to the criteria specified in this section.
3009     5.  Explains the recipient's right to complain, file a
3010grievance, or change managed care plans or MediPass providers if
3011the recipient is not satisfied with the managed care plan or
3012MediPass.
3013     (d)  The agency shall develop a mechanism for providing
3014information to Medicaid recipients for the purpose of making a
3015managed care plan or MediPass selection. Examples of such
3016mechanisms may include, but not be limited to, interactive
3017information systems, mailings, and mass marketing materials.
3018Managed care plans and MediPass providers are prohibited from
3019providing inducements to Medicaid recipients to select their
3020plans or from prejudicing Medicaid recipients against other
3021managed care plans or MediPass providers.
3022     (e)  Medicaid recipients who are already enrolled in a
3023managed care plan or MediPass shall be offered the opportunity
3024to change managed care plans or MediPass providers on a
3025staggered basis, as defined by the agency. All Medicaid
3026recipients shall have 30 days in which to make a choice of
3027managed care plans or MediPass providers. Those Medicaid
3028recipients who do not make a choice shall be assigned in
3029accordance with paragraph (f). To facilitate continuity of care,
3030for a Medicaid recipient who is also a recipient of Supplemental
3031Security Income (SSI), prior to assigning the SSI recipient to a
3032managed care plan or MediPass, the agency shall determine
3033whether the SSI recipient has an ongoing relationship with a
3034MediPass provider or managed care plan, and if so, the agency
3035shall assign the SSI recipient to that MediPass provider or
3036managed care plan. Those SSI recipients who do not have such a
3037provider relationship shall be assigned to a managed care plan
3038or MediPass provider in accordance with paragraph (f).
3039     (f)  If a Medicaid recipient does not choose a managed care
3040plan or MediPass provider, the agency shall assign the Medicaid
3041recipient to a managed care plan or MediPass provider. Medicaid
3042recipients eligible for managed care plan enrollment who are
3043subject to mandatory assignment but who fail to make a choice
3044shall be assigned to managed care plans until an enrollment of
304535 percent in MediPass and 65 percent in managed care plans, of
3046all those eligible to choose managed care, is achieved. Once
3047this enrollment is achieved, the assignments shall be divided in
3048order to maintain an enrollment in MediPass and managed care
3049plans which is in a 35 percent and 65 percent proportion,
3050respectively. Thereafter, assignment of Medicaid recipients who
3051fail to make a choice shall be based proportionally on the
3052preferences of recipients who have made a choice in the previous
3053period. Such proportions shall be revised at least quarterly to
3054reflect an update of the preferences of Medicaid recipients. The
3055agency shall disproportionately assign Medicaid-eligible
3056recipients who are required to but have failed to make a choice
3057of managed care plan or MediPass, including children, and who
3058would be assigned to the MediPass program to children's networks
3059as described in s. 409.912(4)(g), Children's Medical Services
3060Network as defined in s. 391.021, exclusive provider
3061organizations, provider service networks, minority physician
3062networks, and pediatric emergency department diversion programs
3063authorized by this chapter or the General Appropriations Act, in
3064such manner as the agency deems appropriate, until the agency
3065has determined that the networks and programs have sufficient
3066numbers to be operated economically. For purposes of this
3067paragraph, when referring to assignment, the term "managed care
3068plans" includes health maintenance organizations, exclusive
3069provider organizations, provider service networks, minority
3070physician networks, Children's Medical Services Network, and
3071pediatric emergency department diversion programs authorized by
3072this chapter or the General Appropriations Act. When making
3073assignments, the agency shall take into account the following
3074criteria:
3075     1.  A managed care plan has sufficient network capacity to
3076meet the need of members.
3077     2.  The managed care plan or MediPass has previously
3078enrolled the recipient as a member, or one of the managed care
3079plan's primary care providers or MediPass providers has
3080previously provided health care to the recipient.
3081     3.  The agency has knowledge that the member has previously
3082expressed a preference for a particular managed care plan or
3083MediPass provider as indicated by Medicaid fee-for-service
3084claims data, but has failed to make a choice.
3085     4.  The managed care plan's or MediPass primary care
3086providers are geographically accessible to the recipient's
3087residence.
3088     (g)  When more than one managed care plan or MediPass
3089provider meets the criteria specified in paragraph (f), the
3090agency shall make recipient assignments consecutively by family
3091unit.
3092     (h)  The agency may not engage in practices that are
3093designed to favor one managed care plan over another or that are
3094designed to influence Medicaid recipients to enroll in MediPass
3095rather than in a managed care plan or to enroll in a managed
3096care plan rather than in MediPass. This subsection does not
3097prohibit the agency from reporting on the performance of
3098MediPass or any managed care plan, as measured by performance
3099criteria developed by the agency.
3100     (i)  After a recipient has made his or her selection or has
3101been enrolled in a managed care plan or MediPass, the recipient
3102shall have 90 days to exercise the opportunity to voluntarily
3103disenroll and select another managed care plan or MediPass.
3104After 90 days, no further changes may be made except for good
3105cause. Good cause includes, but is not limited to, poor quality
3106of care, lack of access to necessary specialty services, an
3107unreasonable delay or denial of service, or fraudulent
3108enrollment. The agency shall develop criteria for good cause
3109disenrollment for chronically ill and disabled populations who
3110are assigned to managed care plans if more appropriate care is
3111available through the MediPass program. The agency must make a
3112determination as to whether cause exists. However, the agency
3113may require a recipient to use the managed care plan's or
3114MediPass grievance process prior to the agency's determination
3115of cause, except in cases in which immediate risk of permanent
3116damage to the recipient's health is alleged. The grievance
3117process, when utilized, must be completed in time to permit the
3118recipient to disenroll by the first day of the second month
3119after the month the disenrollment request was made. If the
3120managed care plan or MediPass, as a result of the grievance
3121process, approves an enrollee's request to disenroll, the agency
3122is not required to make a determination in the case. The agency
3123must make a determination and take final action on a recipient's
3124request so that disenrollment occurs no later than the first day
3125of the second month after the month the request was made. If the
3126agency fails to act within the specified timeframe, the
3127recipient's request to disenroll is deemed to be approved as of
3128the date agency action was required. Recipients who disagree
3129with the agency's finding that cause does not exist for
3130disenrollment shall be advised of their right to pursue a
3131Medicaid fair hearing to dispute the agency's finding.
3132     (j)  The agency shall apply for a federal waiver from the
3133Centers for Medicare and Medicaid Services to lock eligible
3134Medicaid recipients into a managed care plan or MediPass for 12
3135months after an open enrollment period. After 12 months'
3136enrollment, a recipient may select another managed care plan or
3137MediPass provider. However, nothing shall prevent a Medicaid
3138recipient from changing primary care providers within the
3139managed care plan or MediPass program during the 12-month
3140period.
3141     (k)  When a Medicaid recipient does not choose a managed
3142care plan or MediPass provider, the agency shall assign the
3143Medicaid recipient to a managed care plan, except in those
3144counties in which there are fewer than two managed care plans
3145accepting Medicaid enrollees, in which case assignment shall be
3146to a managed care plan or a MediPass provider. Medicaid
3147recipients in counties with fewer than two managed care plans
3148accepting Medicaid enrollees who are subject to mandatory
3149assignment but who fail to make a choice shall be assigned to
3150managed care plans until an enrollment of 35 percent in MediPass
3151and 65 percent in managed care plans, of all those eligible to
3152choose managed care, is achieved. Once that enrollment is
3153achieved, the assignments shall be divided in order to maintain
3154an enrollment in MediPass and managed care plans which is in a
315535 percent and 65 percent proportion, respectively. For purposes
3156of this paragraph, when referring to assignment, the term
3157"managed care plans" includes exclusive provider organizations,
3158provider service networks, Children's Medical Services Network,
3159minority physician networks, and pediatric emergency department
3160diversion programs authorized by this chapter or the General
3161Appropriations Act. When making assignments, the agency shall
3162take into account the following criteria:
3163     1.  A managed care plan has sufficient network capacity to
3164meet the need of members.
3165     2.  The managed care plan or MediPass has previously
3166enrolled the recipient as a member, or one of the managed care
3167plan's primary care providers or MediPass providers has
3168previously provided health care to the recipient.
3169     3.  The agency has knowledge that the member has previously
3170expressed a preference for a particular managed care plan or
3171MediPass provider as indicated by Medicaid fee-for-service
3172claims data, but has failed to make a choice.
3173     4.  The managed care plan's or MediPass primary care
3174providers are geographically accessible to the recipient's
3175residence.
3176     5.  The agency has authority to make mandatory assignments
3177based on quality of service and performance of managed care
3178plans.
3179     (l)  Notwithstanding the provisions of chapter 287, the
3180agency may, at its discretion, renew cost-effective contracts
3181for choice counseling services once or more for such periods as
3182the agency may decide. However, all such renewals may not
3183combine to exceed a total period longer than the term of the
3184original contract.
3185
3186This subsection expires October 1, 2013.
3187     (3)(a)  The agency shall establish quality-of-care
3188standards for managed care plans. These standards shall be based
3189upon, but are not limited to:
3190     1.  Compliance with the accreditation requirements as
3191provided in s. 641.512.
3192     2.  Compliance with Early and Periodic Screening,
3193Diagnosis, and Treatment screening requirements.
3194     3.  The percentage of voluntary disenrollments.
3195     4.  Immunization rates.
3196     5.  Standards of the National Committee for Quality
3197Assurance and other approved accrediting bodies.
3198     6.  Recommendations of other authoritative bodies.
3199     7.  Specific requirements of the Medicaid program, or
3200standards designed to specifically assist the unique needs of
3201Medicaid recipients.
3202     8.  Compliance with the health quality improvement system
3203as established by the agency, which incorporates standards and
3204guidelines developed by the Medicaid Bureau of the Health Care
3205Financing Administration as part of the quality assurance reform
3206initiative.
3207     (b)  For the MediPass program, the agency shall establish
3208standards which are based upon, but are not limited to:
3209     1.  Quality-of-care standards which are comparable to those
3210required of managed care plans.
3211     2.  Credentialing standards for MediPass providers.
3212     3.  Compliance with Early and Periodic Screening,
3213Diagnosis, and Treatment screening requirements.
3214     4.  Immunization rates.
3215     5.  Specific requirements of the Medicaid program, or
3216standards designed to specifically assist the unique needs of
3217Medicaid recipients.
3218
3219This subsection expires October 1, 2013.
3220     (4)(a)  Each female recipient may select as her primary
3221care provider an obstetrician/gynecologist who has agreed to
3222participate as a MediPass primary care case manager.
3223     (b)  The agency shall establish a complaints and grievance
3224process to assist Medicaid recipients enrolled in the MediPass
3225program to resolve complaints and grievances. The agency shall
3226investigate reports of quality-of-care grievances which remain
3227unresolved to the satisfaction of the enrollee.
3228
3229This subsection expires October 1, 2013.
3230     (5)(a)  The agency shall work cooperatively with the Social
3231Security Administration to identify beneficiaries who are
3232jointly eligible for Medicare and Medicaid and shall develop
3233cooperative programs to encourage these beneficiaries to enroll
3234in a Medicare participating health maintenance organization or
3235prepaid health plans.
3236     (b)  The agency shall work cooperatively with the
3237Department of Elderly Affairs to assess the potential cost-
3238effectiveness of providing MediPass to beneficiaries who are
3239jointly eligible for Medicare and Medicaid on a voluntary choice
3240basis. If the agency determines that enrollment of these
3241beneficiaries in MediPass has the potential for being cost-
3242effective for the state, the agency shall offer MediPass to
3243these beneficiaries on a voluntary choice basis in the counties
3244where MediPass operates.
3245
3246This subsection expires October 1, 2013.
3247     (6)  MediPass enrolled recipients may receive up to 10
3248visits of reimbursable services by participating Medicaid
3249physicians licensed under chapter 460 and up to four visits of
3250reimbursable services by participating Medicaid physicians
3251licensed under chapter 461. Any further visits must be by prior
3252authorization by the MediPass primary care provider. However,
3253nothing in this subsection may be construed to increase the
3254total number of visits or the total amount of dollars per year
3255per person under current Medicaid rules, unless otherwise
3256provided for in the General Appropriations Act. This subsection
3257expires October 1, 2013.
3258     (7)  The agency shall investigate the feasibility of
3259developing managed care plan and MediPass options for the
3260following groups of Medicaid recipients:
3261     (a)  Pregnant women and infants.
3262     (b)  Elderly and disabled recipients, especially those who
3263are at risk of nursing home placement.
3264     (c)  Persons with developmental disabilities.
3265     (d)  Qualified Medicare beneficiaries.
3266     (e)  Adults who have chronic, high-cost medical conditions.
3267     (f)  Adults and children who have mental health problems.
3268     (g)  Other recipients for whom managed care plans and
3269MediPass offer the opportunity of more cost-effective care and
3270greater access to qualified providers.
3271     (8)(a)  The agency shall encourage the development of
3272public and private partnerships to foster the growth of health
3273maintenance organizations and prepaid health plans that will
3274provide high-quality health care to Medicaid recipients.
3275     (b)  Subject to the availability of moneys and any
3276limitations established by the General Appropriations Act or
3277chapter 216, the agency is authorized to enter into contracts
3278with traditional providers of health care to low-income persons
3279to assist such providers with the technical aspects of
3280cooperatively developing Medicaid prepaid health plans.
3281     1.  The agency may contract with disproportionate share
3282hospitals, county health departments, federally initiated or
3283federally funded community health centers, and counties that
3284operate either a hospital or a community clinic.
3285     2.  A contract may not be for more than $100,000 per year,
3286and no contract may be extended with any particular provider for
3287more than 2 years. The contract is intended only as seed or
3288development funding and requires a commitment from the
3289interested party.
3290     3.  A contract must require participation by at least one
3291community health clinic and one disproportionate share hospital.
3292     (7)(9)(a)  The agency shall develop and implement a
3293comprehensive plan to ensure that recipients are adequately
3294informed of their choices and rights under all Medicaid managed
3295care programs and that Medicaid managed care programs meet
3296acceptable standards of quality in patient care, patient
3297satisfaction, and financial solvency.
3298     (b)  The agency shall provide adequate means for informing
3299patients of their choice and rights under a managed care plan at
3300the time of eligibility determination.
3301     (c)  The agency shall require managed care plans and
3302MediPass providers to demonstrate and document plans and
3303activities, as defined by rule, including outreach and followup,
3304undertaken to ensure that Medicaid recipients receive the health
3305care service to which they are entitled.
3306
3307This subsection expires October 1, 2013.
3308     (8)(10)  The agency shall consult with Medicaid consumers
3309and their representatives on an ongoing basis regarding
3310measurements of patient satisfaction, procedures for resolving
3311patient grievances, standards for ensuring quality of care,
3312mechanisms for providing patient access to services, and
3313policies affecting patient care. This subsection expires October
33141, 2013.
3315     (9)(11)  The agency may extend eligibility for Medicaid
3316recipients enrolled in licensed and accredited health
3317maintenance organizations for the duration of the enrollment
3318period or for 6 months, whichever is earlier, provided the
3319agency certifies that such an offer will not increase state
3320expenditures. This subsection expires October 1, 2013.
3321     (10)(12)  A managed care plan that has a Medicaid contract
3322shall at least annually review each primary care physician's
3323active patient load and shall ensure that additional Medicaid
3324recipients are not assigned to physicians who have a total
3325active patient load of more than 3,000 patients. As used in this
3326subsection, the term "active patient" means a patient who is
3327seen by the same primary care physician, or by a physician
3328assistant or advanced registered nurse practitioner under the
3329supervision of the primary care physician, at least three times
3330within a calendar year. Each primary care physician shall
3331annually certify to the managed care plan whether or not his or
3332her patient load exceeds the limits established under this
3333subsection and the managed care plan shall accept such
3334certification on face value as compliance with this subsection.
3335The agency shall accept the managed care plan's representations
3336that it is in compliance with this subsection based on the
3337certification of its primary care physicians, unless the agency
3338has an objective indication that access to primary care is being
3339compromised, such as receiving complaints or grievances relating
3340to access to care. If the agency determines that an objective
3341indication exists that access to primary care is being
3342compromised, it may verify the patient load certifications
3343submitted by the managed care plan's primary care physicians and
3344that the managed care plan is not assigning Medicaid recipients
3345to primary care physicians who have an active patient load of
3346more than 3,000 patients. This subsection expires October 1,
33472013.
3348     (13)  Effective July 1, 2003, the agency shall adjust the
3349enrollee assignment process of Medicaid managed prepaid health
3350plans for those Medicaid managed prepaid plans operating in
3351Miami-Dade County which have executed a contract with the agency
3352for a minimum of 8 consecutive years in order for the Medicaid
3353managed prepaid plan to maintain a minimum enrollment level of
335415,000 members per month. When assigning enrollees pursuant to
3355this subsection, the agency shall give priority to providers
3356that initially qualified under this subsection until such
3357providers reach and maintain an enrollment level of 15,000
3358members per month. A prepaid health plan that has a statewide
3359Medicaid enrollment of 25,000 or more members is not eligible
3360for enrollee assignments under this subsection.
3361     (11)(14)  The agency shall include in its calculation of
3362the hospital inpatient component of a Medicaid health
3363maintenance organization's capitation rate any special payments,
3364including, but not limited to, upper payment limit or
3365disproportionate share hospital payments, made to qualifying
3366hospitals through the fee-for-service program. The agency may
3367seek federal waiver approval or state plan amendment as needed
3368to implement this adjustment.
3369     (12)(a)  Beginning September 1, 2010, the agency shall
3370begin a budget-neutral adjustment of capitation rates for all
3371Medicaid prepaid plans in the state. The adjustment to
3372capitation rates shall be based on aggregate risk scores for
3373each prepaid plan's enrollees. During the first 2 years of the
3374adjustment, the agency shall ensure that no plan has an
3375aggregate risk score that varies more than 10 percent from the
3376aggregate weighted average for all plans. The risk adjusted
3377capitation rates shall be phased in as follows:
3378     1.  In the first fiscal year, 75 percent of the capitation
3379rate shall be based on the current methodology and 25 percent
3380shall be based on the risk-adjusted rate methodology.
3381     2.  In the second fiscal year, 50 percent of the capitation
3382rate shall be based on the current methodology and 50 percent
3383shall be based on the risk-adjusted methodology.
3384     3.  In the third fiscal year, the risk-adjusted capitation
3385methodology shall be fully implemented.
3386     (b)  During this period, the agency shall establish a
3387technical advisory panel to obtain input from the prepaid plans
3388affected by the transition to risk adjusted rates.
3389     (13)  The agency shall develop a process to enable any
3390recipient with access to employer sponsored insurance to opt out
3391of all qualified plans in the Medicaid program and to use
3392Medicaid financial assistance to pay for the recipient's share
3393of cost in any such plan. Contingent on federal approval, the
3394agency shall also enable recipients with access to other
3395insurance or related products providing access to health care
3396services created pursuant to state law, including any plan or
3397product available pursuant to Cover Florida, the Florida Health
3398Choices Program, or any health exchange, to opt out. The amount
3399of financial assistance provided for each recipient shall not
3400exceed the amount of the Medicaid premium that would have been
3401paid to a plan for that recipient.
3402     (14)  Each qualified plan shall establish an incentive
3403program that rewards specific healthy behaviors with credits in
3404a flexible spending account pursuant to s. 409.9122(14).
3405     (a)  At the discretion of the recipient, credits shall be
3406used to purchase otherwise uncovered health and related services
3407during the entire period of and for a maximum of 3 years after
3408the recipient's Medicaid eligibility, whether or not the
3409recipient remains continuously enrolled in the plan in which the
3410credits were earned.
3411     (b)  Enhanced benefits offered by a qualified plan shall be
3412structured to provide greater incentives for those diseases
3413linked with lifestyle and conditions or behaviors associated
3414with avoidable utilization of high-cost services.
3415     (c)  To fund these credits, each plan must maintain a
3416reserve account in an amount up to 2 percent of the plan's
3417Medicaid premium revenue or benchmark premium revenue in the
3418case of provider service networks based on an actuarial
3419assessment of the value of the enhanced benefit program.
3420     (15)  The agency shall maintain and operate the Medicaid
3421Encounter Data System to collect, process, store, and report on
3422covered services provided to all Florida Medicaid recipients
3423enrolled in prepaid managed care plans. Prepaid managed care
3424plans shall submit encounter data electronically in a format
3425that complies with the Health Insurance Portability and
3426Accountability Act provisions for electronic claims and in
3427accordance with deadlines established by the agency. Prepaid
3428managed care plans must certify that the data reported is
3429accurate and complete. The agency is responsible for validating
3430the data submitted by the plans. Prior to utilizing validated
3431encounter data to adjust rates for prepaid plans, the agency
3432shall conduct a review to ensure adequate encounter data is
3433available to establish actuarially sound rates. The review shall
3434include a simulated rate-setting exercise, followed by an
3435evaluation by independent actuaries and consideration of
3436comments from the plans. The agency shall publish the results of
3437the review on its website at least 30 days prior to adjusting
3438rates.
3439     (16)  The agency may establish a per-member per-month
3440payment for Medicare Advantage Special Needs members that are
3441also eligible for Medicaid as a mechanism for meeting the
3442state's cost sharing obligation.  The agency may also develop a
3443per-member per-month payment for Medicaid only covered services
3444for which the state is responsible. The agency shall develop a
3445mechanism to ensure that such per-member per-month payment
3446enhances the value to the state and enrolled members by limiting
3447cost sharing, enhancing the scope of Medicare supplemental
3448benefits that are equal to or greater than Medicaid coverage for
3449select services, and improving care coordination.
3450     (17)  The agency shall establish, and managed care plans
3451shall use, a uniform method of accounting for and reporting
3452medical and nonmedical costs. The agency shall make such
3453information available to the public.
3454     (18)  Effective October 1, 2013, school districts
3455participating in the certified school match program pursuant to
3456ss. 409.908(21) and 1011.70 shall be reimbursed by Medicaid,
3457subject to the limitations of s. 1011.70(1), for a Medicaid-
3458eligible child participating in the services as authorized in s.
34591011.70, as provided for in s. 409.9071. Managed care plans
3460shall make a good faith effort to execute agreements with school
3461districts regarding the coordinated provision of services
3462authorized under s. 1011.70 and county health departments
3463delivering school-based services pursuant to ss. 381.0056 and
3464381.0057. To ensure continuity of care for Medicaid patients,
3465the agency, the Department of Health, and the Department of
3466Education shall develop procedures for ensuring that a student's
3467managed care plan receives information relating to services
3468provided in accordance with ss. 381.0056, 381.0057, 409.9071,
3469and 1011.70.
3470     (19)  The agency may, on a case-by-case basis, exempt a
3471recipient from mandatory enrollment in a managed care plan when
3472the recipient has a unique, time-limited disease or condition-
3473related circumstance and managed care enrollment will interfere
3474with ongoing care because the recipient's provider does not
3475participate in the managed care plans available in the
3476recipient's area.
3477     Section 16.  Subsection (18) of section 430.04, Florida
3478Statutes, is amended to read:
3479     430.04  Duties and responsibilities of the Department of
3480Elderly Affairs.-The Department of Elderly Affairs shall:
3481     (18)  Administer all Medicaid waivers and programs relating
3482to elders and their appropriations. The waivers include, but are
3483not limited to:
3484     (a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3485established in s. 430.502(7), (8), and (9).
3486     (a)(b)  The Assisted Living for the Frail Elderly Waiver.
3487     (b)(c)  The Aged and Disabled Adult Waiver.
3488     (c)(d)  The Adult Day Health Care Waiver.
3489     (d)(e)  The Consumer-Directed Care Plus Program as defined
3490in s. 409.221.
3491     (e)(f)  The Program of All-inclusive Care for the Elderly.
3492     (f)(g)  The Long-Term Care Community-Based Diversion Pilot
3493Project as described in s. 430.705.
3494     (g)(h)  The Channeling Services Waiver for Frail Elders.
3495
3496The department shall develop a transition plan for recipients
3497receiving services in long-term care Medicaid waivers for elders
3498or disabled adults on the date qualified plans become available
3499in each recipient's region pursuant to s. 409.981(2) to enroll
3500those recipients in qualified plans. This subsection expires
3501October 1, 2012.
3502     Section 17.  Section 430.2053, Florida Statutes, is amended
3503to read:
3504     430.2053  Aging resource centers.-
3505     (1)  The department, in consultation with the Agency for
3506Health Care Administration and the Department of Children and
3507Family Services, shall develop pilot projects for aging resource
3508centers. By October 31, 2004, the department, in consultation
3509with the agency and the Department of Children and Family
3510Services, shall develop an implementation plan for aging
3511resource centers and submit the plan to the Governor, the
3512President of the Senate, and the Speaker of the House of
3513Representatives. The plan must include qualifications for
3514designation as a center, the functions to be performed by each
3515center, and a process for determining that a current area agency
3516on aging is ready to assume the functions of an aging resource
3517center.
3518     (2)  Each area agency on aging shall develop, in
3519consultation with the existing community care for the elderly
3520lead agencies within their planning and service areas, a
3521proposal that describes the process the area agency on aging
3522intends to undertake to transition to an aging resource center
3523prior to July 1, 2005, and that describes the area agency's
3524compliance with the requirements of this section. The proposals
3525must be submitted to the department prior to December 31, 2004.
3526The department shall evaluate all proposals for readiness and,
3527prior to March 1, 2005, shall select three area agencies on
3528aging which meet the requirements of this section to begin the
3529transition to aging resource centers. Those area agencies on
3530aging which are not selected to begin the transition to aging
3531resource centers shall, in consultation with the department and
3532the existing community care for the elderly lead agencies within
3533their planning and service areas, amend their proposals as
3534necessary and resubmit them to the department prior to July 1,
35352005. The department may transition additional area agencies to
3536aging resource centers as it determines that area agencies are
3537in compliance with the requirements of this section.
3538     (3)  The Auditor General and the Office of Program Policy
3539Analysis and Government Accountability (OPPAGA) shall jointly
3540review and assess the department's process for determining an
3541area agency's readiness to transition to an aging resource
3542center.
3543     (a)  The review must, at a minimum, address the
3544appropriateness of the department's criteria for selection of an
3545area agency to transition to an aging resource center, the
3546instruments applied, the degree to which the department
3547accurately determined each area agency's compliance with the
3548readiness criteria, the quality of the technical assistance
3549provided by the department to an area agency in correcting any
3550weaknesses identified in the readiness assessment, and the
3551degree to which each area agency overcame any identified
3552weaknesses.
3553     (b)  Reports of these reviews must be submitted to the
3554appropriate substantive and appropriations committees in the
3555Senate and the House of Representatives on March 1 and September
35561 of each year until full transition to aging resource centers
3557has been accomplished statewide, except that the first report
3558must be submitted by February 1, 2005, and must address all
3559readiness activities undertaken through December 31, 2004. The
3560perspectives of all participants in this review process must be
3561included in each report.
3562     (2)(4)  The purposes of an aging resource center shall be:
3563     (a)  To provide Florida's elders and their families with a
3564locally focused, coordinated approach to integrating information
3565and referral for all available services for elders with the
3566eligibility determination entities for state and federally
3567funded long-term-care services.
3568     (b)  To provide for easier access to long-term-care
3569services by Florida's elders and their families by creating
3570multiple access points to the long-term-care network that flow
3571through one established entity with wide community recognition.
3572     (3)(5)  The duties of an aging resource center are to:
3573     (a)  Develop referral agreements with local community
3574service organizations, such as senior centers, existing elder
3575service providers, volunteer associations, and other similar
3576organizations, to better assist clients who do not need or do
3577not wish to enroll in programs funded by the department or the
3578agency. The referral agreements must also include a protocol,
3579developed and approved by the department, which provides
3580specific actions that an aging resource center and local
3581community service organizations must take when an elder or an
3582elder's representative seeking information on long-term-care
3583services contacts a local community service organization prior
3584to contacting the aging resource center. The protocol shall be
3585designed to ensure that elders and their families are able to
3586access information and services in the most efficient and least
3587cumbersome manner possible.
3588     (b)  Provide an initial screening of all clients who
3589request long-term-care services to determine whether the person
3590would be most appropriately served through any combination of
3591federally funded programs, state-funded programs, locally funded
3592or community volunteer programs, or private funding for
3593services.
3594     (c)  Determine eligibility for the programs and services
3595listed in subsection (9) (11) for persons residing within the
3596geographic area served by the aging resource center and
3597determine a priority ranking for services which is based upon
3598the potential recipient's frailty level and likelihood of
3599institutional placement without such services.
3600     (d)  Manage the availability of financial resources for the
3601programs and services listed in subsection (9) (11) for persons
3602residing within the geographic area served by the aging resource
3603center.
3604     (e)  When financial resources become available, refer a
3605client to the most appropriate entity to begin receiving
3606services. The aging resource center shall make referrals to lead
3607agencies for service provision that ensure that individuals who
3608are vulnerable adults in need of services pursuant to s.
3609415.104(3)(b), or who are victims of abuse, neglect, or
3610exploitation in need of immediate services to prevent further
3611harm and are referred by the adult protective services program,
3612are given primary consideration for receiving community-care-
3613for-the-elderly services in compliance with the requirements of
3614s. 430.205(5)(a) and that other referrals for services are in
3615compliance with s. 430.205(5)(b).
3616     (f)  Convene a work group to advise in the planning,
3617implementation, and evaluation of the aging resource center. The
3618work group shall be comprised of representatives of local
3619service providers, Alzheimer's Association chapters, housing
3620authorities, social service organizations, advocacy groups,
3621representatives of clients receiving services through the aging
3622resource center, and any other persons or groups as determined
3623by the department. The aging resource center, in consultation
3624with the work group, must develop annual program improvement
3625plans that shall be submitted to the department for
3626consideration. The department shall review each annual
3627improvement plan and make recommendations on how to implement
3628the components of the plan.
3629     (g)  Enhance the existing area agency on aging in each
3630planning and service area by integrating, either physically or
3631virtually, the staff and services of the area agency on aging
3632with the staff of the department's local CARES Medicaid nursing
3633home preadmission screening unit and a sufficient number of
3634staff from the Department of Children and Family Services'
3635Economic Self-Sufficiency Unit necessary to determine the
3636financial eligibility for all persons age 60 and older residing
3637within the area served by the aging resource center that are
3638seeking Medicaid services, Supplemental Security Income, and
3639food stamps.
3640     (h)  Assist clients who request long-term care services in
3641being evaluated for eligibility for enrollment in the Medicaid
3642long-term care managed care program as qualified plans become
3643available in each of the regions pursuant to s. 409.981(2).
3644     (i)  Provide choice counseling for the Medicaid long-term
3645care managed care program by integrating, either physically or
3646virtually, choice counseling staff and services as qualified
3647plans become available in each of the regions pursuant to s.
3648409.981(2). Pursuant to s. 409.984(1), the agency may contract
3649directly with the aging resource center to provide choice
3650counseling services or may contract with another vendor if the
3651aging resource center does not choose to provide such services.
3652     (j)  Assist Medicaid recipients enrolled in the Medicaid
3653long-term care managed care program with informally resolving
3654grievances with a managed care network and assist Medicaid
3655recipients in accessing the managed care network's formal
3656grievance process as qualified plans become available in each of
3657the regions pursuant to s. 409.981(2).
3658     (4)(6)  The department shall select the entities to become
3659aging resource centers based on each entity's readiness and
3660ability to perform the duties listed in subsection (3) (5) and
3661the entity's:
3662     (a)  Expertise in the needs of each target population the
3663center proposes to serve and a thorough knowledge of the
3664providers that serve these populations.
3665     (b)  Strong connections to service providers, volunteer
3666agencies, and community institutions.
3667     (c)  Expertise in information and referral activities.
3668     (d)  Knowledge of long-term-care resources, including
3669resources designed to provide services in the least restrictive
3670setting.
3671     (e)  Financial solvency and stability.
3672     (f)  Ability to collect, monitor, and analyze data in a
3673timely and accurate manner, along with systems that meet the
3674department's standards.
3675     (g)  Commitment to adequate staffing by qualified personnel
3676to effectively perform all functions.
3677     (h)  Ability to meet all performance standards established
3678by the department.
3679     (5)(7)  The aging resource center shall have a governing
3680body which shall be the same entity described in s. 20.41(7),
3681and an executive director who may be the same person as
3682described in s. 20.41(7). The governing body shall annually
3683evaluate the performance of the executive director.
3684     (6)(8)  The aging resource center may not be a provider of
3685direct services other than choice counseling as qualified plans
3686become available in each of the regions pursuant to s.
3687409.981(2), information and referral services, and screening.
3688     (7)(9)  The aging resource center must agree to allow the
3689department to review any financial information the department
3690determines is necessary for monitoring or reporting purposes,
3691including financial relationships.
3692     (8)(10)  The duties and responsibilities of the community
3693care for the elderly lead agencies within each area served by an
3694aging resource center shall be to:
3695     (a)  Develop strong community partnerships to maximize the
3696use of community resources for the purpose of assisting elders
3697to remain in their community settings for as long as it is
3698safely possible.
3699     (b)  Conduct comprehensive assessments of clients that have
3700been determined eligible and develop a care plan consistent with
3701established protocols that ensures that the unique needs of each
3702client are met.
3703     (9)(11)  The services to be administered through the aging
3704resource center shall include those funded by the following
3705programs:
3706     (a)  Community care for the elderly.
3707     (b)  Home care for the elderly.
3708     (c)  Contracted services.
3709     (d)  Alzheimer's disease initiative.
3710     (e)  Aged and disabled adult Medicaid waiver. This
3711paragraph expires October 1, 2012.
3712     (f)  Assisted living for the frail elderly Medicaid waiver.
3713This paragraph expires October 1, 2012.
3714     (g)  Older Americans Act.
3715     (10)(12)  The department shall, prior to designation of an
3716aging resource center, develop by rule operational and quality
3717assurance standards and outcome measures to ensure that clients
3718receiving services through all long-term-care programs
3719administered through an aging resource center are receiving the
3720appropriate care they require and that contractors and
3721subcontractors are adhering to the terms of their contracts and
3722are acting in the best interests of the clients they are
3723serving, consistent with the intent of the Legislature to reduce
3724the use of and cost of nursing home care. The department shall
3725by rule provide operating procedures for aging resource centers,
3726which shall include:
3727     (a)  Minimum standards for financial operation, including
3728audit procedures.
3729     (b)  Procedures for monitoring and sanctioning of service
3730providers.
3731     (c)  Minimum standards for technology utilized by the aging
3732resource center.
3733     (d)  Minimum staff requirements which shall ensure that the
3734aging resource center employs sufficient quality and quantity of
3735staff to adequately meet the needs of the elders residing within
3736the area served by the aging resource center.
3737     (e)  Minimum accessibility standards, including hours of
3738operation.
3739     (f)  Minimum oversight standards for the governing body of
3740the aging resource center to ensure its continuous involvement
3741in, and accountability for, all matters related to the
3742development, implementation, staffing, administration, and
3743operations of the aging resource center.
3744     (g)  Minimum education and experience requirements for
3745executive directors and other executive staff positions of aging
3746resource centers.
3747     (h)  Minimum requirements regarding any executive staff
3748positions that the aging resource center must employ and minimum
3749requirements that a candidate must meet in order to be eligible
3750for appointment to such positions.
3751     (11)(13)  In an area in which the department has designated
3752an area agency on aging as an aging resource center, the
3753department and the agency shall not make payments for the
3754services listed in subsection (9) (11) and the Long-Term Care
3755Community Diversion Project for such persons who were not
3756screened and enrolled through the aging resource center. The
3757department shall cease making payments for recipients in
3758qualified plans as qualified plans become available in each of
3759the regions pursuant to s. 409.981(2).
3760     (12)(14)  Each aging resource center shall enter into a
3761memorandum of understanding with the department for
3762collaboration with the CARES unit staff. The memorandum of
3763understanding shall outline the staff person responsible for
3764each function and shall provide the staffing levels necessary to
3765carry out the functions of the aging resource center.
3766     (13)(15)  Each aging resource center shall enter into a
3767memorandum of understanding with the Department of Children and
3768Family Services for collaboration with the Economic Self-
3769Sufficiency Unit staff. The memorandum of understanding shall
3770outline which staff persons are responsible for which functions
3771and shall provide the staffing levels necessary to carry out the
3772functions of the aging resource center.
3773     (14)  As qualified plans become available in each of the
3774regions pursuant to s. 409.981(2), if an aging resource center
3775does not contract with the agency to provide Medicaid long-term
3776care managed care choice counseling pursuant to s. 409.984(1),
3777the aging resource center shall enter into a memorandum of
3778understanding with the agency to coordinate staffing and
3779collaborate with the choice counseling vendor. The memorandum of
3780understanding shall identify the staff responsible for each
3781function and shall provide the staffing levels necessary to
3782carry out the functions of the aging resource center.
3783     (15)(16)  If any of the state activities described in this
3784section are outsourced, either in part or in whole, the contract
3785executing the outsourcing shall mandate that the contractor or
3786its subcontractors shall, either physically or virtually,
3787execute the provisions of the memorandum of understanding
3788instead of the state entity whose function the contractor or
3789subcontractor now performs.
3790     (16)(17)  In order to be eligible to begin transitioning to
3791an aging resource center, an area agency on aging board must
3792ensure that the area agency on aging which it oversees meets all
3793of the minimum requirements set by law and in rule.
3794     (18)  The department shall monitor the three initial
3795projects for aging resource centers and report on the progress
3796of those projects to the Governor, the President of the Senate,
3797and the Speaker of the House of Representatives by June 30,
37982005. The report must include an evaluation of the
3799implementation process.
3800     (17)(19)(a)  Once an aging resource center is operational,
3801the department, in consultation with the agency, may develop
3802capitation rates for any of the programs administered through
3803the aging resource center. Capitation rates for programs shall
3804be based on the historical cost experience of the state in
3805providing those same services to the population age 60 or older
3806residing within each area served by an aging resource center.
3807Each capitated rate may vary by geographic area as determined by
3808the department.
3809     (b)  The department and the agency may determine for each
3810area served by an aging resource center whether it is
3811appropriate, consistent with federal and state laws and
3812regulations, to develop and pay separate capitated rates for
3813each program administered through the aging resource center or
3814to develop and pay capitated rates for service packages which
3815include more than one program or service administered through
3816the aging resource center.
3817     (c)  Once capitation rates have been developed and
3818certified as actuarially sound, the department and the agency
3819may pay service providers the capitated rates for services when
3820appropriate.
3821     (d)  The department, in consultation with the agency, shall
3822annually reevaluate and recertify the capitation rates,
3823adjusting forward to account for inflation, programmatic
3824changes.
3825     (20)  The department, in consultation with the agency,
3826shall submit to the Governor, the President of the Senate, and
3827the Speaker of the House of Representatives, by December 1,
38282006, a report addressing the feasibility of administering the
3829following services through aging resource centers beginning July
38301, 2007:
3831     (a)  Medicaid nursing home services.
3832     (b)  Medicaid transportation services.
3833     (c)  Medicaid hospice care services.
3834     (d)  Medicaid intermediate care services.
3835     (e)  Medicaid prescribed drug services.
3836     (f)  Medicaid assistive care services.
3837     (g)  Any other long-term-care program or Medicaid service.
3838     (18)(21)  This section shall not be construed to allow an
3839aging resource center to restrict, manage, or impede the local
3840fundraising activities of service providers.
3841     Section 18.  Subsection (4) of section 641.386, Florida
3842Statutes, is amended to read:
3843     641.386  Agent licensing and appointment required;
3844exceptions.-
3845     (4)  All agents and health maintenance organizations shall
3846comply with and be subject to the applicable provisions of ss.
3847641.309 and 409.912(20)(21), and all companies and entities
3848appointing agents shall comply with s. 626.451, when marketing
3849for any health maintenance organization licensed pursuant to
3850this part, including those organizations under contract with the
3851Agency for Health Care Administration to provide health care
3852services to Medicaid recipients or any private entity providing
3853health care services to Medicaid recipients pursuant to a
3854prepaid health plan contract with the Agency for Health Care
3855Administration.
3856     Section 19.  Effective October 1, 2012, sections 430.701,
3857430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3858430.708, and 430.709 Florida Statutes, are repealed.
3859     Section 20.  Sections 409.9301, 409.942, 409.944, 409.945,
3860409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3861as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3862402.87, Florida Statutes, respectively.
3863     Section 21.  Paragraph (a) of subsection (1) of section
3864443.111, Florida Statutes, is amended to read:
3865     443.111  Payment of benefits.-
3866     (1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3867in accordance with rules adopted by the Agency for Workforce
3868Innovation, subject to the following requirements:
3869     (a)  Benefits are payable by mail or electronically.
3870Notwithstanding s. 402.82(4) 409.942(4), The agency may develop
3871a system for the payment of benefits by electronic funds
3872transfer, including, but not limited to, debit cards, electronic
3873payment cards, or any other means of electronic payment that the
3874agency deems to be commercially viable or cost-effective.
3875Commodities or services related to the development of such a
3876system shall be procured by competitive solicitation, unless
3877they are purchased from a state term contract pursuant to s.
3878287.056. The agency shall adopt rules necessary to administer
3879the system.
3880     Section 22.  Except as otherwise expressly provided in this
3881act, this act shall take effect July 1, 2010, if HB 7223 or
3882similar legislation is adopted in the same legislative session
3883or an extension thereof and becomes law.


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