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Amendment CaShTmL-394008.HTM
    Florida Senate - 2005            PROPOSED COMMITTEE SUBSTITUTE
    Bill No. SB 838
                        Barcode 394008
    587-1907-05
    Proposed Committee Substitute by the Committee on Health Care
 1                      A bill to be entitled
 2         An act relating to Medicaid; amending s.
 3         409.912, F.S.; requiring the Agency for Health
 4         Care Administration to contract with a vendor
 5         to monitor and evaluate the clinical practice
 6         patterns of providers; authorizing the agency
 7         to competitively bid for single-source
 8         providers for certain services; authorizing the
 9         agency to examine whether purchasing certain
10         durable medical equipment is more
11         cost-effective than long-term rental of such
12         equipment; requiring that the agency, in
13         partnership with the Department of Elderly
14         Affairs, develop an integrated, fixed-payment
15         delivery system for Medicaid recipients age 60
16         and older; deleting an obsolete provision
17         requiring the agency to develop a plan for
18         implementing emergency and crisis care;
19         requiring the agency to develop a system where
20         health care vendors may provide data
21         demonstrating that higher reimbursement for a
22         good or service will be offset by cost savings
23         in other goods or services; requiring the
24         Comprehensive Assessment and Review for
25         Long-Term Care Services (CARES) teams to
26         consult with any person making a determination
27         that a nursing home resident funded by Medicare
28         is not making progress toward rehabilitation
29         and assist in any appeals of the decision;
30         requiring the agency to contract with an entity
31         to design a clinical-utilization information
                                  1
    9:39 AM   04/05/05                             s0838p-he00-c8y

Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 database or electronic medical record for 2 Medicaid providers; requiring that the agency 3 develop a plan to expand disease-management 4 programs; requiring the agency to coordinate 5 with other entities to create emergency room 6 diversion programs for Medicaid recipients; 7 revising the Medicaid prescription drug 8 spending control program to reduce costs and 9 improve Medicaid recipient safety; requiring 10 that the agency implement a Medicaid 11 prescription drug management system; allowing 12 the agency to require age-related prior 13 authorizations for certain prescription drugs; 14 requiring the agency to determine the extent 15 that prescription drugs are returned and reused 16 in institutional settings and whether this 17 program could be expanded; requiring the agency 18 to develop an in-home, all-inclusive program of 19 services for Medicaid children with 20 life-threatening illnesses; authorizing the 21 agency to pay for emergency mental health 22 services provided through licensed crisis 23 stabilization centers; creating s. 409.91211, 24 F.S.; requiring that the agency develop a pilot 25 program for capitated managed care networks to 26 deliver Medicaid health care services for all 27 eligible Medicaid recipients in Medicaid 28 fee-for-service or the MediPass program; 29 providing legislative intent; providing powers, 30 duties, and responsibilities of the agency 31 under the pilot program; requiring that the 2 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 agency provide a plan to the Legislature for 2 implementing the pilot program; requiring that 3 the agency evaluate the pilot program and 4 report to the Governor and the Legislature on 5 whether it should be expanded statewide; 6 amending s. 409.9122, F.S.; requiring a primary 7 care physician lock-in for MediPass enrollees; 8 amending s. 409.913, F.S.; requiring 5 percent 9 of all program integrity audits to be conducted 10 on a random basis; requiring that Medicaid 11 recipients be provided with an explanation of 12 benefits; requiring that the agency report to 13 the Legislature on the legal and administrative 14 barriers to enforcing the copayment 15 requirements of s. 409.9081, F.S.; requiring 16 the agency to recommend ways to ensure that 17 Medicaid is the payer of last resort; requiring 18 the agency to conduct a study of provider 19 pay-for-performance systems; requiring the 20 Office of Program Policy Analysis and 21 Government Accountability to conduct a study of 22 the long-term care diversion programs; 23 requiring the agency to evaluate the 24 cost-saving potential of contracting with a 25 multistate prescription drug purchasing pool; 26 requiring the agency to determine how many 27 individuals in long-term care diversion 28 programs have a patient payment responsibility 29 that is not being collected and to recommend 30 how to collect such payments; requiring the 31 Office of Program Policy Analysis and 3 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 Government Accountability to conduct a study of 2 Medicaid buy-in programs to determine if these 3 programs can be created in this state without 4 expanding the overall Medicaid program budget 5 or if the Medically Needy program can be 6 changed into a Medicaid buy-in program; 7 providing an appropriation for the purpose of 8 developing infrastructure and administrative 9 resources necessary to implement the pilot 10 project as created in s. 409.91211, F.S.; 11 providing an appropriation for developing an 12 encounter data system for Medicaid managed care 13 plans; providing an effective date. 14 15 Be It Enacted by the Legislature of the State of Florida: 16 17 Section 1. Section 409.912, Florida Statutes, is 18 amended to read: 19 409.912 Cost-effective purchasing of health care.--The 20 agency shall purchase goods and services for Medicaid 21 recipients in the most cost-effective manner consistent with 22 the delivery of quality medical care. To ensure that medical 23 services are effectively utilized, the agency may, in any 24 case, require a confirmation or second physician's opinion of 25 the correct diagnosis for purposes of authorizing future 26 services under the Medicaid program. This section does not 27 restrict access to emergency services or poststabilization 28 care services as defined in 42 C.F.R. part 438.114. Such 29 confirmation or second opinion shall be rendered in a manner 30 approved by the agency. The agency shall maximize the use of 31 prepaid per capita and prepaid aggregate fixed-sum basis 4 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 services when appropriate and other alternative service 2 delivery and reimbursement methodologies, including 3 competitive bidding pursuant to s. 287.057, designed to 4 facilitate the cost-effective purchase of a case-managed 5 continuum of care. The agency shall also require providers to 6 minimize the exposure of recipients to the need for acute 7 inpatient, custodial, and other institutional care and the 8 inappropriate or unnecessary use of high-cost services. The 9 agency shall contract with a vendor to monitor and evaluate 10 the clinical practice patterns of providers in order to 11 identify trends that are outside the normal practice patterns 12 of a provider's professional peers or the national guidelines 13 of a provider's professional association. The vendor must be 14 able to provide information and counseling to a provider whose 15 practice patterns are outside the norms, in consultation with 16 the agency, to improve patient care and reduce inappropriate 17 utilization. The agency may mandate prior authorization, drug 18 therapy management, or disease management participation for 19 certain populations of Medicaid beneficiaries, certain drug 20 classes, or particular drugs to prevent fraud, abuse, overuse, 21 and possible dangerous drug interactions. The Pharmaceutical 22 and Therapeutics Committee shall make recommendations to the 23 agency on drugs for which prior authorization is required. The 24 agency shall inform the Pharmaceutical and Therapeutics 25 Committee of its decisions regarding drugs subject to prior 26 authorization. The agency is authorized to limit the entities 27 it contracts with or enrolls as Medicaid providers by 28 developing a provider network through provider credentialing. 29 The agency may competitively bid single-source-provider 30 contracts if procurement of goods or services results in 31 demonstrated cost savings to the state without limiting access 5 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 to care. The agency may limit its network based on the 2 assessment of beneficiary access to care, provider 3 availability, provider quality standards, time and distance 4 standards for access to care, the cultural competence of the 5 provider network, demographic characteristics of Medicaid 6 beneficiaries, practice and provider-to-beneficiary standards, 7 appointment wait times, beneficiary use of services, provider 8 turnover, provider profiling, provider licensure history, 9 previous program integrity investigations and findings, peer 10 review, provider Medicaid policy and billing compliance 11 records, clinical and medical record audits, and other 12 factors. Providers shall not be entitled to enrollment in the 13 Medicaid provider network. The agency shall determine 14 instances in which allowing Medicaid beneficiaries to purchase 15 durable medical equipment and other goods is less expensive to 16 the Medicaid program than long-term rental of the equipment or 17 goods. The agency may establish rules to facilitate purchases 18 in lieu of long-term rentals in order to protect against fraud 19 and abuse in the Medicaid program as defined in s. 409.913. 20 The agency may is authorized to seek federal waivers necessary 21 to administer these policies implement this policy. 22 (1) The agency shall work with the Department of 23 Children and Family Services to ensure access of children and 24 families in the child protection system to needed and 25 appropriate mental health and substance abuse services. 26 (2) The agency may enter into agreements with 27 appropriate agents of other state agencies or of any agency of 28 the Federal Government and accept such duties in respect to 29 social welfare or public aid as may be necessary to implement 30 the provisions of Title XIX of the Social Security Act and ss. 31 409.901-409.920. 6 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 (3) The agency may contract with health maintenance 2 organizations certified pursuant to part I of chapter 641 for 3 the provision of services to recipients. 4 (4) The agency may contract with: 5 (a) An entity that provides no prepaid health care 6 services other than Medicaid services under contract with the 7 agency and which is owned and operated by a county, county 8 health department, or county-owned and operated hospital to 9 provide health care services on a prepaid or fixed-sum basis 10 to recipients, which entity may provide such prepaid services 11 either directly or through arrangements with other providers. 12 Such prepaid health care services entities must be licensed 13 under parts I and III by January 1, 1998, and until then are 14 exempt from the provisions of part I of chapter 641. An entity 15 recognized under this paragraph which demonstrates to the 16 satisfaction of the Office of Insurance Regulation of the 17 Financial Services Commission that it is backed by the full 18 faith and credit of the county in which it is located may be 19 exempted from s. 641.225. 20 (b) An entity that is providing comprehensive 21 behavioral health care services to certain Medicaid recipients 22 through a capitated, prepaid arrangement pursuant to the 23 federal waiver provided for by s. 409.905(5). Such an entity 24 must be licensed under chapter 624, chapter 636, or chapter 25 641 and must possess the clinical systems and operational 26 competence to manage risk and provide comprehensive behavioral 27 health care to Medicaid recipients. As used in this paragraph, 28 the term "comprehensive behavioral health care services" means 29 covered mental health and substance abuse treatment services 30 that are available to Medicaid recipients. The secretary of 31 the Department of Children and Family Services shall approve 7 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 provisions of procurements related to children in the 2 department's care or custody prior to enrolling such children 3 in a prepaid behavioral health plan. Any contract awarded 4 under this paragraph must be competitively procured. In 5 developing the behavioral health care prepaid plan procurement 6 document, the agency shall ensure that the procurement 7 document requires the contractor to develop and implement a 8 plan to ensure compliance with s. 394.4574 related to services 9 provided to residents of licensed assisted living facilities 10 that hold a limited mental health license. Except as provided 11 in subparagraph 8., the agency shall seek federal approval to 12 contract with a single entity meeting these requirements to 13 provide comprehensive behavioral health care services to all 14 Medicaid recipients not enrolled in a managed care plan in an 15 AHCA area. Each entity must offer sufficient choice of 16 providers in its network to ensure recipient access to care 17 and the opportunity to select a provider with whom they are 18 satisfied. The network shall include all public mental health 19 hospitals. To ensure unimpaired access to behavioral health 20 care services by Medicaid recipients, all contracts issued 21 pursuant to this paragraph shall require 80 percent of the 22 capitation paid to the managed care plan, including health 23 maintenance organizations, to be expended for the provision of 24 behavioral health care services. In the event the managed care 25 plan expends less than 80 percent of the capitation paid 26 pursuant to this paragraph for the provision of behavioral 27 health care services, the difference shall be returned to the 28 agency. The agency shall provide the managed care plan with a 29 certification letter indicating the amount of capitation paid 30 during each calendar year for the provision of behavioral 31 health care services pursuant to this section. The agency may 8 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 reimburse for substance abuse treatment services on a 2 fee-for-service basis until the agency finds that adequate 3 funds are available for capitated, prepaid arrangements. 4 1. By January 1, 2001, the agency shall modify the 5 contracts with the entities providing comprehensive inpatient 6 and outpatient mental health care services to Medicaid 7 recipients in Hillsborough, Highlands, Hardee, Manatee, and 8 Polk Counties, to include substance abuse treatment services. 9 2. By July 1, 2003, the agency and the Department of 10 Children and Family Services shall execute a written agreement 11 that requires collaboration and joint development of all 12 policy, budgets, procurement documents, contracts, and 13 monitoring plans that have an impact on the state and Medicaid 14 community mental health and targeted case management programs. 15 3. Except as provided in subparagraph 8., by July 1, 16 2006, the agency and the Department of Children and Family 17 Services shall contract with managed care entities in each 18 AHCA area except area 6 or arrange to provide comprehensive 19 inpatient and outpatient mental health and substance abuse 20 services through capitated prepaid arrangements to all 21 Medicaid recipients who are eligible to participate in such 22 plans under federal law and regulation. In AHCA areas where 23 eligible individuals number less than 150,000, the agency 24 shall contract with a single managed care plan to provide 25 comprehensive behavioral health services to all recipients who 26 are not enrolled in a Medicaid health maintenance 27 organization. The agency may contract with more than one 28 comprehensive behavioral health provider to provide care to 29 recipients who are not enrolled in a Medicaid health 30 maintenance organization in AHCA areas where the eligible 31 population exceeds 150,000. Contracts for comprehensive 9 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 behavioral health providers awarded pursuant to this section 2 shall be competitively procured. Both for-profit and 3 not-for-profit corporations shall be eligible to compete. 4 Managed care plans contracting with the agency under 5 subsection (3) shall provide and receive payment for the same 6 comprehensive behavioral health benefits as provided in AHCA 7 rules, including handbooks incorporated by reference. 8 4. By October 1, 2003, the agency and the department 9 shall submit a plan to the Governor, the President of the 10 Senate, and the Speaker of the House of Representatives which 11 provides for the full implementation of capitated prepaid 12 behavioral health care in all areas of the state. 13 a. Implementation shall begin in 2003 in those AHCA 14 areas of the state where the agency is able to establish 15 sufficient capitation rates. 16 b. If the agency determines that the proposed 17 capitation rate in any area is insufficient to provide 18 appropriate services, the agency may adjust the capitation 19 rate to ensure that care will be available. The agency and the 20 department may use existing general revenue to address any 21 additional required match but may not over-obligate existing 22 funds on an annualized basis. 23 c. Subject to any limitations provided for in the 24 General Appropriations Act, the agency, in compliance with 25 appropriate federal authorization, shall develop policies and 26 procedures that allow for certification of local and state 27 funds. 28 5. Children residing in a statewide inpatient 29 psychiatric program, or in a Department of Juvenile Justice or 30 a Department of Children and Family Services residential 31 program approved as a Medicaid behavioral health overlay 10 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 services provider shall not be included in a behavioral health 2 care prepaid health plan or any other Medicaid managed care 3 plan pursuant to this paragraph. 4 6. In converting to a prepaid system of delivery, the 5 agency shall in its procurement document require an entity 6 providing only comprehensive behavioral health care services 7 to prevent the displacement of indigent care patients by 8 enrollees in the Medicaid prepaid health plan providing 9 behavioral health care services from facilities receiving 10 state funding to provide indigent behavioral health care, to 11 facilities licensed under chapter 395 which do not receive 12 state funding for indigent behavioral health care, or 13 reimburse the unsubsidized facility for the cost of behavioral 14 health care provided to the displaced indigent care patient. 15 7. Traditional community mental health providers under 16 contract with the Department of Children and Family Services 17 pursuant to part IV of chapter 394, child welfare providers 18 under contract with the Department of Children and Family 19 Services in areas 1 and 6, and inpatient mental health 20 providers licensed pursuant to chapter 395 must be offered an 21 opportunity to accept or decline a contract to participate in 22 any provider network for prepaid behavioral health services. 23 8. For fiscal year 2004-2005, all Medicaid eligible 24 children, except children in areas 1 and 6, whose cases are 25 open for child welfare services in the HomeSafeNet system, 26 shall be enrolled in MediPass or in Medicaid fee-for-service 27 and all their behavioral health care services including 28 inpatient, outpatient psychiatric, community mental health, 29 and case management shall be reimbursed on a fee-for-service 30 basis. Beginning July 1, 2005, such children, who are open for 31 child welfare services in the HomeSafeNet system, shall 11 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 receive their behavioral health care services through a 2 specialty prepaid plan operated by community-based lead 3 agencies either through a single agency or formal agreements 4 among several agencies. The specialty prepaid plan must result 5 in savings to the state comparable to savings achieved in 6 other Medicaid managed care and prepaid programs. Such plan 7 must provide mechanisms to maximize state and local revenues. 8 The specialty prepaid plan shall be developed by the agency 9 and the Department of Children and Family Services. The agency 10 is authorized to seek any federal waivers to implement this 11 initiative. 12 (c) A federally qualified health center or an entity 13 owned by one or more federally qualified health centers or an 14 entity owned by other migrant and community health centers 15 receiving non-Medicaid financial support from the Federal 16 Government to provide health care services on a prepaid or 17 fixed-sum basis to recipients. Such prepaid health care 18 services entity must be licensed under parts I and III of 19 chapter 641, but shall be prohibited from serving Medicaid 20 recipients on a prepaid basis, until such licensure has been 21 obtained. However, such an entity is exempt from s. 641.225 if 22 the entity meets the requirements specified in subsections 23 (17) and (18). 24 (d) A provider service network may be reimbursed on a 25 fee-for-service or prepaid basis. A provider service network 26 which is reimbursed by the agency on a prepaid basis shall be 27 exempt from parts I and III of chapter 641, but must meet 28 appropriate financial reserve, quality assurance, and patient 29 rights requirements as established by the agency. The agency 30 shall award contracts on a competitive bid basis and shall 31 select bidders based upon price and quality of care. Medicaid 12 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 recipients assigned to a demonstration project shall be chosen 2 equally from those who would otherwise have been assigned to 3 prepaid plans and MediPass. The agency is authorized to seek 4 federal Medicaid waivers as necessary to implement the 5 provisions of this section. 6 (e) An entity that provides only comprehensive 7 behavioral health care services to certain Medicaid recipients 8 through an administrative services organization agreement. 9 Such an entity must possess the clinical systems and 10 operational competence to provide comprehensive health care to 11 Medicaid recipients. As used in this paragraph, the term 12 "comprehensive behavioral health care services" means covered 13 mental health and substance abuse treatment services that are 14 available to Medicaid recipients. Any contract awarded under 15 this paragraph must be competitively procured. The agency must 16 ensure that Medicaid recipients have available the choice of 17 at least two managed care plans for their behavioral health 18 care services. 19 (f) An entity that provides in-home physician services 20 to test the cost-effectiveness of enhanced home-based medical 21 care to Medicaid recipients with degenerative neurological 22 diseases and other diseases or disabling conditions associated 23 with high costs to Medicaid. The program shall be designed to 24 serve very disabled persons and to reduce Medicaid reimbursed 25 costs for inpatient, outpatient, and emergency department 26 services. The agency shall contract with vendors on a 27 risk-sharing basis. 28 (g) Children's provider networks that provide care 29 coordination and care management for Medicaid-eligible 30 pediatric patients, primary care, authorization of specialty 31 care, and other urgent and emergency care through organized 13 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 providers designed to service Medicaid eligibles under age 18 2 and pediatric emergency departments' diversion programs. The 3 networks shall provide after-hour operations, including 4 evening and weekend hours, to promote, when appropriate, the 5 use of the children's networks rather than hospital emergency 6 departments. 7 (h) An entity authorized in s. 430.205 to contract 8 with the agency and the Department of Elderly Affairs to 9 provide health care and social services on a prepaid or 10 fixed-sum basis to elderly recipients. Such prepaid health 11 care services entities are exempt from the provisions of part 12 I of chapter 641 for the first 3 years of operation. An entity 13 recognized under this paragraph that demonstrates to the 14 satisfaction of the Office of Insurance Regulation that it is 15 backed by the full faith and credit of one or more counties in 16 which it operates may be exempted from s. 641.225. 17 (i) A Children's Medical Services Network, as defined 18 in s. 391.021. 19 (5) By December 1, 2005, the Agency for Health Care 20 Administration, in partnership with the Department of Elderly 21 Affairs, shall create an integrated, fixed-payment delivery 22 system for Medicaid recipients who are 60 years of age or 23 older. Eligible Medicaid recipients may participate in the 24 integrated system on a voluntary basis. The program must 25 transfer all Medicaid services for eligible elderly 26 individuals who choose to participate into an integrated-care 27 management model designed to serve Medicaid recipients in the 28 community. The program must combine all funding for Medicaid 29 services provided to individuals 60 years of age or older into 30 the integrated system, including funds for Medicaid home and 31 community-based waiver services; all Medicaid services 14 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 authorized in ss. 409.905 and 409.906, excluding funds for 2 Medicaid nursing home services unless the agency is able to 3 demonstrate how the integration of the funds will improve 4 coordinated care for these services in a less costly manner; 5 and Medicare premiums, coinsurance, and deductibles for 6 persons dually eligible for Medicaid and Medicare as 7 prescribed in s. 409.908(13). The agency and the department 8 shall select two areas of the state consistent with agency and 9 department districts to begin implementing the integrated 10 system. One area must represent an urban population and one 11 area must represent a rural population. 12 (a) Individuals who are 60 years of age or older and 13 enrolled in the the developmental disabilities waiver program, 14 the family and supported-living waiver program, the project 15 AIDS care waiver program, the traumatic brain injury and 16 spinal cord injury waiver program, the consumer-directed care 17 waiver program, and the program of all-inclusive care for the 18 elderly program, and residents of institutional care 19 facilities for the developmentally disabled, must be excluded 20 from the integrated system. 21 (b) The program must use a competitive-procurement 22 process to select entities to operate the integrated system. 23 Entities eligible to submit bids include managed care 24 organizations licensed under chapter 641 and other 25 state-certified community service networks that meet 26 comparable standards as defined by the agency, in consultation 27 with the Department of Elderly Affairs and the Office of 28 Insurance Regulation, to be financially solvent and able to 29 take on financial risk for managed care. Community service 30 networks that are certified pursuant to the comparable 31 standards defined by the agency are not required to be 15 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 licensed under chapter 641. 2 (c) The agency must ensure that the 3 capitation-rate-setting methodology for the integrated system 4 is actuarially sound and reflects the intent to provide 5 quality care in the least-restrictive setting. The agency must 6 also require integrated-system providers to develop a 7 credentialing system for service providers and to contract 8 with all Gold Seal nursing homes, where feasible, and exclude, 9 where feasible, chronically poor-performing facilities and 10 providers as defined by the agency. The integrated system must 11 provide that if the recipient resides in a noncontracted 12 residential facility licensed under chapter 400 at the time 13 the integrated system is initiated, the recipient must be 14 permitted to continue to reside in the noncontracted facility 15 as long as the recipient desires. The integrated system must 16 also provide that, in the absence of a contract between the 17 integrated-system provider and the residential facility 18 licensed under chapter 400, current Medicaid rates must 19 prevail. The agency and the Department of Elderly Affairs must 20 jointly develop procedures to manage the services provided 21 through the integrated system in order to ensure quality and 22 recipient choice. 23 (d) The agency may seek federal waivers and adopt 24 rules as necessary to administer the integrated system. By 25 October 1, 2003, the agency and the department shall, to the 26 extent feasible, develop a plan for implementing new Medicaid 27 procedure codes for emergency and crisis care, supportive 28 residential services, and other services designed to maximize 29 the use of Medicaid funds for Medicaid-eligible recipients. 30 The agency shall include in the agreement developed pursuant 31 to subsection (4) a provision that ensures that the match 16 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 requirements for these new procedure codes are met by 2 certifying eligible general revenue or local funds that are 3 currently expended on these services by the department with 4 contracted alcohol, drug abuse, and mental health providers. 5 The plan must describe specific procedure codes to be 6 implemented, a projection of the number of procedures to be 7 delivered during fiscal year 2003-2004, and a financial 8 analysis that describes the certified match procedures, and 9 accountability mechanisms, projects the earnings associated 10 with these procedures, and describes the sources of state 11 match. This plan may not be implemented in any part until 12 approved by the Legislative Budget Commission. If such 13 approval has not occurred by December 31, 2003, the plan shall 14 be submitted for consideration by the 2004 Legislature. 15 (6) The agency may contract with any public or private 16 entity otherwise authorized by this section on a prepaid or 17 fixed-sum basis for the provision of health care services to 18 recipients. An entity may provide prepaid services to 19 recipients, either directly or through arrangements with other 20 entities, if each entity involved in providing services: 21 (a) Is organized primarily for the purpose of 22 providing health care or other services of the type regularly 23 offered to Medicaid recipients; 24 (b) Ensures that services meet the standards set by 25 the agency for quality, appropriateness, and timeliness; 26 (c) Makes provisions satisfactory to the agency for 27 insolvency protection and ensures that neither enrolled 28 Medicaid recipients nor the agency will be liable for the 29 debts of the entity; 30 (d) Submits to the agency, if a private entity, a 31 financial plan that the agency finds to be fiscally sound and 17 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 that provides for working capital in the form of cash or 2 equivalent liquid assets excluding revenues from Medicaid 3 premium payments equal to at least the first 3 months of 4 operating expenses or $200,000, whichever is greater; 5 (e) Furnishes evidence satisfactory to the agency of 6 adequate liability insurance coverage or an adequate plan of 7 self-insurance to respond to claims for injuries arising out 8 of the furnishing of health care; 9 (f) Provides, through contract or otherwise, for 10 periodic review of its medical facilities and services, as 11 required by the agency; and 12 (g) Provides organizational, operational, financial, 13 and other information required by the agency. 14 (7) The agency may contract on a prepaid or fixed-sum 15 basis with any health insurer that: 16 (a) Pays for health care services provided to enrolled 17 Medicaid recipients in exchange for a premium payment paid by 18 the agency; 19 (b) Assumes the underwriting risk; and 20 (c) Is organized and licensed under applicable 21 provisions of the Florida Insurance Code and is currently in 22 good standing with the Office of Insurance Regulation. 23 (8) The agency may contract on a prepaid or fixed-sum 24 basis with an exclusive provider organization to provide 25 health care services to Medicaid recipients provided that the 26 exclusive provider organization meets applicable managed care 27 plan requirements in this section, ss. 409.9122, 409.9123, 28 409.9128, and 627.6472, and other applicable provisions of 29 law. 30 (9) The Agency for Health Care Administration may 31 provide cost-effective purchasing of chiropractic services on 18 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 a fee-for-service basis to Medicaid recipients through 2 arrangements with a statewide chiropractic preferred provider 3 organization incorporated in this state as a not-for-profit 4 corporation. The agency shall ensure that the benefit limits 5 and prior authorization requirements in the current Medicaid 6 program shall apply to the services provided by the 7 chiropractic preferred provider organization. 8 (10) The agency shall not contract on a prepaid or 9 fixed-sum basis for Medicaid services with an entity which 10 knows or reasonably should know that any officer, director, 11 agent, managing employee, or owner of stock or beneficial 12 interest in excess of 5 percent common or preferred stock, or 13 the entity itself, has been found guilty of, regardless of 14 adjudication, or entered a plea of nolo contendere, or guilty, 15 to: 16 (a) Fraud; 17 (b) Violation of federal or state antitrust statutes, 18 including those proscribing price fixing between competitors 19 and the allocation of customers among competitors; 20 (c) Commission of a felony involving embezzlement, 21 theft, forgery, income tax evasion, bribery, falsification or 22 destruction of records, making false statements, receiving 23 stolen property, making false claims, or obstruction of 24 justice; or 25 (d) Any crime in any jurisdiction which directly 26 relates to the provision of health services on a prepaid or 27 fixed-sum basis. 28 (11) The agency, after notifying the Legislature, may 29 apply for waivers of applicable federal laws and regulations 30 as necessary to implement more appropriate systems of health 31 care for Medicaid recipients and reduce the cost of the 19 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 Medicaid program to the state and federal governments and 2 shall implement such programs, after legislative approval, 3 within a reasonable period of time after federal approval. 4 These programs must be designed primarily to reduce the need 5 for inpatient care, custodial care and other long-term or 6 institutional care, and other high-cost services. 7 (a) Prior to seeking legislative approval of such a 8 waiver as authorized by this subsection, the agency shall 9 provide notice and an opportunity for public comment. Notice 10 shall be provided to all persons who have made requests of the 11 agency for advance notice and shall be published in the 12 Florida Administrative Weekly not less than 28 days prior to 13 the intended action. 14 (b) Notwithstanding s. 216.292, funds that are 15 appropriated to the Department of Elderly Affairs for the 16 Assisted Living for the Elderly Medicaid waiver and are not 17 expended shall be transferred to the agency to fund 18 Medicaid-reimbursed nursing home care. 19 (12) The agency shall establish a postpayment 20 utilization control program designed to identify recipients 21 who may inappropriately overuse or underuse Medicaid services 22 and shall provide methods to correct such misuse. 23 (13) The agency shall develop and provide coordinated 24 systems of care for Medicaid recipients and may contract with 25 public or private entities to develop and administer such 26 systems of care among public and private health care providers 27 in a given geographic area. 28 (14)(a) The agency shall operate or contract for the 29 operation of utilization management and incentive systems 30 designed to encourage cost-effective use services. 31 (b) The agency shall develop a procedure by which 20 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 health care providers and service vendors can provide the 2 Medicaid program with methodologically valid data that 3 demonstrates whether a particular good or service can offset 4 the cost of providing the good or service in an alternative 5 setting or through other means and therefore should receive a 6 higher reimbursement. Any data provided to the agency for such 7 purpose must demonstrate that for every $1 increase in 8 reimbursement rates for the good or service there will be an 9 offset of at least $2 from the decrease in the cost of 10 providing the good or service through the traditional method. 11 The agency shall be the final arbitrator of the cost-benefit 12 analysis and must determine whether the increased 13 reimbursement for a particular good or service offsets the 14 cost of other goods or services in the Medicaid program. If 15 the agency determines that the increased reimbursement is 16 cost-effective, the agency shall recommend a change in the 17 reimbursement schedule for that particular good or service. 18 If, within 12 months after implementing any rate change under 19 this procedure, the agency determines that costs were not 20 offset by the increased reimbursement schedule, the agency may 21 revert to the former reimbursement schedule for the particular 22 good or service. 23 (15)(a) The agency shall operate the Comprehensive 24 Assessment and Review for Long-Term Care Services (CARES) 25 nursing facility preadmission screening program to ensure that 26 Medicaid payment for nursing facility care is made only for 27 individuals whose conditions require such care and to ensure 28 that long-term care services are provided in the setting most 29 appropriate to the needs of the person and in the most 30 economical manner possible. The CARES program shall also 31 ensure that individuals participating in Medicaid home and 21 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 community-based waiver programs meet criteria for those 2 programs, consistent with approved federal waivers. 3 (b) The agency shall operate the CARES program through 4 an interagency agreement with the Department of Elderly 5 Affairs. The agency, in consultation with the Department of 6 Elderly Affairs, may contract for any function or activity of 7 the CARES program, including any function or activity required 8 by 42 C.F.R. part 483.20, relating to preadmission screening 9 and resident review. 10 (c) Prior to making payment for nursing facility 11 services for a Medicaid recipient, the agency must verify that 12 the nursing facility preadmission screening program has 13 determined that the individual requires nursing facility care 14 and that the individual cannot be safely served in 15 community-based programs. The nursing facility preadmission 16 screening program shall refer a Medicaid recipient to a 17 community-based program if the individual could be safely 18 served at a lower cost and the recipient chooses to 19 participate in such program. For individuals whose nursing 20 home stay is initially funded by Medicare and Medicare 21 coverage is being terminated for lack of progress towards 22 rehabilitation, CARES staff shall consult with the person 23 making the determination of progress toward rehabilitation to 24 ensure that the recipient is not being inappropriately 25 disqualified from Medicare coverage. If, in their professional 26 judgment, CARES staff believes that a Medicare beneficiary is 27 still making progress toward rehabilitation, they may assist 28 the Medicare beneficiary with an appeal of the 29 disqualification from Medicare coverage. 30 (d) For the purpose of initiating immediate 31 prescreening and diversion assistance for individuals residing 22 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 in nursing homes and in order to make families aware of 2 alternative long-term care resources so that they may choose a 3 more cost-effective setting for long-term placement, CARES 4 staff shall conduct an assessment and review of a sample of 5 individuals whose nursing home stay is expected to exceed 20 6 days, regardless of the initial funding source for the nursing 7 home placement. CARES staff shall provide counseling and 8 referral services to these individuals regarding choosing 9 appropriate long-term care alternatives. This paragraph does 10 not apply to continuing care facilities licensed under chapter 11 651 or to retirement communities that provide a combination of 12 nursing home, independent living, and other long-term care 13 services. 14 (e) By January 15 of each year, the agency shall 15 submit a report to the Legislature and the Office of 16 Long-Term-Care Policy describing the operations of the CARES 17 program. The report must describe: 18 1. Rate of diversion to community alternative 19 programs; 20 2. CARES program staffing needs to achieve additional 21 diversions; 22 3. Reasons the program is unable to place individuals 23 in less restrictive settings when such individuals desired 24 such services and could have been served in such settings; 25 4. Barriers to appropriate placement, including 26 barriers due to policies or operations of other agencies or 27 state-funded programs; and 28 5. Statutory changes necessary to ensure that 29 individuals in need of long-term care services receive care in 30 the least restrictive environment. 31 (f) The Department of Elderly Affairs shall track 23 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 individuals over time who are assessed under the CARES program 2 and who are diverted from nursing home placement. By January 3 15 of each year, the department shall submit to the 4 Legislature and the Office of Long-Term-Care Policy a 5 longitudinal study of the individuals who are diverted from 6 nursing home placement. The study must include: 7 1. The demographic characteristics of the individuals 8 assessed and diverted from nursing home placement, including, 9 but not limited to, age, race, gender, frailty, caregiver 10 status, living arrangements, and geographic location; 11 2. A summary of community services provided to 12 individuals for 1 year after assessment and diversion; 13 3. A summary of inpatient hospital admissions for 14 individuals who have been diverted; and 15 4. A summary of the length of time between diversion 16 and subsequent entry into a nursing home or death. 17 (g) By July 1, 2005, the department and the Agency for 18 Health Care Administration shall report to the President of 19 the Senate and the Speaker of the House of Representatives 20 regarding the impact to the state of modifying level-of-care 21 criteria to eliminate the Intermediate II level of care. 22 (16)(a) The agency shall identify health care 23 utilization and price patterns within the Medicaid program 24 which are not cost-effective or medically appropriate and 25 assess the effectiveness of new or alternate methods of 26 providing and monitoring service, and may implement such 27 methods as it considers appropriate. Such methods may include 28 disease management initiatives, an integrated and systematic 29 approach for managing the health care needs of recipients who 30 are at risk of or diagnosed with a specific disease by using 31 best practices, prevention strategies, clinical-practice 24 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 improvement, clinical interventions and protocols, outcomes 2 research, information technology, and other tools and 3 resources to reduce overall costs and improve measurable 4 outcomes. 5 (b) The responsibility of the agency under this 6 subsection shall include the development of capabilities to 7 identify actual and optimal practice patterns; patient and 8 provider educational initiatives; methods for determining 9 patient compliance with prescribed treatments; fraud, waste, 10 and abuse prevention and detection programs; and beneficiary 11 case management programs. 12 1. The practice pattern identification program shall 13 evaluate practitioner prescribing patterns based on national 14 and regional practice guidelines, comparing practitioners to 15 their peer groups. The agency and its Drug Utilization Review 16 Board shall consult with the Department of Health and a panel 17 of practicing health care professionals consisting of the 18 following: the Speaker of the House of Representatives and the 19 President of the Senate shall each appoint three physicians 20 licensed under chapter 458 or chapter 459; and the Governor 21 shall appoint two pharmacists licensed under chapter 465 and 22 one dentist licensed under chapter 466 who is an oral surgeon. 23 Terms of the panel members shall expire at the discretion of 24 the appointing official. The panel shall begin its work by 25 August 1, 1999, regardless of the number of appointments made 26 by that date. The advisory panel shall be responsible for 27 evaluating treatment guidelines and recommending ways to 28 incorporate their use in the practice pattern identification 29 program. Practitioners who are prescribing inappropriately or 30 inefficiently, as determined by the agency, may have their 31 prescribing of certain drugs subject to prior authorization or 25 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 may be terminated from all participation in the Medicaid 2 program. 3 2. The agency shall also develop educational 4 interventions designed to promote the proper use of 5 medications by providers and beneficiaries. 6 3. The agency shall implement a pharmacy fraud, waste, 7 and abuse initiative that may include a surety bond or letter 8 of credit requirement for participating pharmacies, enhanced 9 provider auditing practices, the use of additional fraud and 10 abuse software, recipient management programs for 11 beneficiaries inappropriately using their benefits, and other 12 steps that will eliminate provider and recipient fraud, waste, 13 and abuse. The initiative shall address enforcement efforts to 14 reduce the number and use of counterfeit prescriptions. 15 4. By September 30, 2002, the agency shall contract 16 with an entity in the state to implement a wireless handheld 17 clinical pharmacology drug information database for 18 practitioners. The initiative shall be designed to enhance the 19 agency's efforts to reduce fraud, abuse, and errors in the 20 prescription drug benefit program and to otherwise further the 21 intent of this paragraph. 22 5. By September 30, 2005, the agency shall contract 23 with an entity to design a database of clinical utilization 24 information or electronic medical records for Medicaid 25 providers. This system must be web-based and allow providers 26 to review on a real-time basis the utilization of Medicaid 27 services, including, but not limited to, physician office 28 visits, inpatient and outpatient hospitalizations, laboratory 29 and pathology services, radiological and other imaging 30 services, dental care, and patterns of dispensing prescription 31 drugs in order to coordinate care and identify potential fraud 26 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 and abuse. 2 6. By January 1, 2006, the agency shall provide 3 expanded statewide disease-management programs to provide case 4 management for persons with chronic diseases including 5 diabetes, hypertension, human immunodeficiency virus/acquired 6 immune deficiency syndrome, asthma, congestive heart failure, 7 hemophilia, end-stage renal disease or chronic kidney disease, 8 cancer, sickle cell anemia, chronic fatigue syndrome, and 9 chronic pain. In selecting disease-management vendors, 10 preference must be given to disease-management organizations 11 that are able to provide case management across disease states 12 through coordinated efforts between physicians and 13 pharmacists. The expansion must take two primary forms. The 14 first type of expansion must emphasis changes in clinical 15 practice patterns of physicians and pharmacists in order to 16 meet evidence-based medicine standards and best-practice 17 guidelines for each physician's specialty. The second 18 expansion must emphasize changes in behavior of persons with 19 chronic medical conditions. The expansion must include a 20 randomly assigned, experimental design to evaluate short-term 21 changes in utilization patterns for Medicaid services and 22 clinical outcome measures. The agency shall use an 23 independent, third party to evaluate the expansion of the 24 disease-management program. The agency shall select the 25 geographic areas in which to expand the disease-management 26 program, estimate the costs to implement each expansion, and 27 develop a timeline for statewide implementation. Based on the 28 evaluation of the expansion, the agency may recommend 29 statewide expansion of the disease-management programs having 30 the best fiscal and clinical outcomes. 31 7.5. The agency may apply for any federal waivers 27 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 needed to administer implement this paragraph. 2 (17) An entity contracting on a prepaid or fixed-sum 3 basis shall, in addition to meeting any applicable statutory 4 surplus requirements, also maintain at all times in the form 5 of cash, investments that mature in less than 180 days 6 allowable as admitted assets by the Office of Insurance 7 Regulation, and restricted funds or deposits controlled by the 8 agency or the Office of Insurance Regulation, a surplus amount 9 equal to one-and-one-half times the entity's monthly Medicaid 10 prepaid revenues. As used in this subsection, the term 11 "surplus" means the entity's total assets minus total 12 liabilities. If an entity's surplus falls below an amount 13 equal to one-and-one-half times the entity's monthly Medicaid 14 prepaid revenues, the agency shall prohibit the entity from 15 engaging in marketing and preenrollment activities, shall 16 cease to process new enrollments, and shall not renew the 17 entity's contract until the required balance is achieved. The 18 requirements of this subsection do not apply: 19 (a) Where a public entity agrees to fund any deficit 20 incurred by the contracting entity; or 21 (b) Where the entity's performance and obligations are 22 guaranteed in writing by a guaranteeing organization which: 23 1. Has been in operation for at least 5 years and has 24 assets in excess of $50 million; or 25 2. Submits a written guarantee acceptable to the 26 agency which is irrevocable during the term of the contracting 27 entity's contract with the agency and, upon termination of the 28 contract, until the agency receives proof of satisfaction of 29 all outstanding obligations incurred under the contract. 30 (18)(a) The agency may require an entity contracting 31 on a prepaid or fixed-sum basis to establish a restricted 28 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 insolvency protection account with a federally guaranteed 2 financial institution licensed to do business in this state. 3 The entity shall deposit into that account 5 percent of the 4 capitation payments made by the agency each month until a 5 maximum total of 2 percent of the total current contract 6 amount is reached. The restricted insolvency protection 7 account may be drawn upon with the authorized signatures of 8 two persons designated by the entity and two representatives 9 of the agency. If the agency finds that the entity is 10 insolvent, the agency may draw upon the account solely with 11 the two authorized signatures of representatives of the 12 agency, and the funds may be disbursed to meet financial 13 obligations incurred by the entity under the prepaid contract. 14 If the contract is terminated, expired, or not continued, the 15 account balance must be released by the agency to the entity 16 upon receipt of proof of satisfaction of all outstanding 17 obligations incurred under this contract. 18 (b) The agency may waive the insolvency protection 19 account requirement in writing when evidence is on file with 20 the agency of adequate insolvency insurance and reinsurance 21 that will protect enrollees if the entity becomes unable to 22 meet its obligations. 23 (19) An entity that contracts with the agency on a 24 prepaid or fixed-sum basis for the provision of Medicaid 25 services shall reimburse any hospital or physician that is 26 outside the entity's authorized geographic service area as 27 specified in its contract with the agency, and that provides 28 services authorized by the entity to its members, at a rate 29 negotiated with the hospital or physician for the provision of 30 services or according to the lesser of the following: 31 (a) The usual and customary charges made to the 29 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 general public by the hospital or physician; or 2 (b) The Florida Medicaid reimbursement rate 3 established for the hospital or physician. 4 (20) When a merger or acquisition of a Medicaid 5 prepaid contractor has been approved by the Office of 6 Insurance Regulation pursuant to s. 628.4615, the agency shall 7 approve the assignment or transfer of the appropriate Medicaid 8 prepaid contract upon request of the surviving entity of the 9 merger or acquisition if the contractor and the other entity 10 have been in good standing with the agency for the most recent 11 12-month period, unless the agency determines that the 12 assignment or transfer would be detrimental to the Medicaid 13 recipients or the Medicaid program. To be in good standing, an 14 entity must not have failed accreditation or committed any 15 material violation of the requirements of s. 641.52 and must 16 meet the Medicaid contract requirements. For purposes of this 17 section, a merger or acquisition means a change in controlling 18 interest of an entity, including an asset or stock purchase. 19 (21) Any entity contracting with the agency pursuant 20 to this section to provide health care services to Medicaid 21 recipients is prohibited from engaging in any of the following 22 practices or activities: 23 (a) Practices that are discriminatory, including, but 24 not limited to, attempts to discourage participation on the 25 basis of actual or perceived health status. 26 (b) Activities that could mislead or confuse 27 recipients, or misrepresent the organization, its marketing 28 representatives, or the agency. Violations of this paragraph 29 include, but are not limited to: 30 1. False or misleading claims that marketing 31 representatives are employees or representatives of the state 30 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 or county, or of anyone other than the entity or the 2 organization by whom they are reimbursed. 3 2. False or misleading claims that the entity is 4 recommended or endorsed by any state or county agency, or by 5 any other organization which has not certified its endorsement 6 in writing to the entity. 7 3. False or misleading claims that the state or county 8 recommends that a Medicaid recipient enroll with an entity. 9 4. Claims that a Medicaid recipient will lose benefits 10 under the Medicaid program, or any other health or welfare 11 benefits to which the recipient is legally entitled, if the 12 recipient does not enroll with the entity. 13 (c) Granting or offering of any monetary or other 14 valuable consideration for enrollment, except as authorized by 15 subsection (24). 16 (d) Door-to-door solicitation of recipients who have 17 not contacted the entity or who have not invited the entity to 18 make a presentation. 19 (e) Solicitation of Medicaid recipients by marketing 20 representatives stationed in state offices unless approved and 21 supervised by the agency or its agent and approved by the 22 affected state agency when solicitation occurs in an office of 23 the state agency. The agency shall ensure that marketing 24 representatives stationed in state offices shall market their 25 managed care plans to Medicaid recipients only in designated 26 areas and in such a way as to not interfere with the 27 recipients' activities in the state office. 28 (f) Enrollment of Medicaid recipients. 29 (22) The agency may impose a fine for a violation of 30 this section or the contract with the agency by a person or 31 entity that is under contract with the agency. With respect to 31 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 any nonwillful violation, such fine shall not exceed $2,500 2 per violation. In no event shall such fine exceed an aggregate 3 amount of $10,000 for all nonwillful violations arising out of 4 the same action. With respect to any knowing and willful 5 violation of this section or the contract with the agency, the 6 agency may impose a fine upon the entity in an amount not to 7 exceed $20,000 for each such violation. In no event shall such 8 fine exceed an aggregate amount of $100,000 for all knowing 9 and willful violations arising out of the same action. 10 (23) A health maintenance organization or a person or 11 entity exempt from chapter 641 that is under contract with the 12 agency for the provision of health care services to Medicaid 13 recipients may not use or distribute marketing materials used 14 to solicit Medicaid recipients, unless such materials have 15 been approved by the agency. The provisions of this subsection 16 do not apply to general advertising and marketing materials 17 used by a health maintenance organization to solicit both 18 non-Medicaid subscribers and Medicaid recipients. 19 (24) Upon approval by the agency, health maintenance 20 organizations and persons or entities exempt from chapter 641 21 that are under contract with the agency for the provision of 22 health care services to Medicaid recipients may be permitted 23 within the capitation rate to provide additional health 24 benefits that the agency has found are of high quality, are 25 practicably available, provide reasonable value to the 26 recipient, and are provided at no additional cost to the 27 state. 28 (25) The agency shall utilize the statewide health 29 maintenance organization complaint hotline for the purpose of 30 investigating and resolving Medicaid and prepaid health plan 31 complaints, maintaining a record of complaints and confirmed 32 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 problems, and receiving disenrollment requests made by 2 recipients. 3 (26) The agency shall require the publication of the 4 health maintenance organization's and the prepaid health 5 plan's consumer services telephone numbers and the "800" 6 telephone number of the statewide health maintenance 7 organization complaint hotline on each Medicaid identification 8 card issued by a health maintenance organization or prepaid 9 health plan contracting with the agency to serve Medicaid 10 recipients and on each subscriber handbook issued to a 11 Medicaid recipient. 12 (27) The agency shall establish a health care quality 13 improvement system for those entities contracting with the 14 agency pursuant to this section, incorporating all the 15 standards and guidelines developed by the Medicaid Bureau of 16 the Health Care Financing Administration as a part of the 17 quality assurance reform initiative. The system shall include, 18 but need not be limited to, the following: 19 (a) Guidelines for internal quality assurance 20 programs, including standards for: 21 1. Written quality assurance program descriptions. 22 2. Responsibilities of the governing body for 23 monitoring, evaluating, and making improvements to care. 24 3. An active quality assurance committee. 25 4. Quality assurance program supervision. 26 5. Requiring the program to have adequate resources to 27 effectively carry out its specified activities. 28 6. Provider participation in the quality assurance 29 program. 30 7. Delegation of quality assurance program activities. 31 8. Credentialing and recredentialing. 33 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 9. Enrollee rights and responsibilities. 2 10. Availability and accessibility to services and 3 care. 4 11. Ambulatory care facilities. 5 12. Accessibility and availability of medical records, 6 as well as proper recordkeeping and process for record review. 7 13. Utilization review. 8 14. A continuity of care system. 9 15. Quality assurance program documentation. 10 16. Coordination of quality assurance activity with 11 other management activity. 12 17. Delivering care to pregnant women and infants; to 13 elderly and disabled recipients, especially those who are at 14 risk of institutional placement; to persons with developmental 15 disabilities; and to adults who have chronic, high-cost 16 medical conditions. 17 (b) Guidelines which require the entities to conduct 18 quality-of-care studies which: 19 1. Target specific conditions and specific health 20 service delivery issues for focused monitoring and evaluation. 21 2. Use clinical care standards or practice guidelines 22 to objectively evaluate the care the entity delivers or fails 23 to deliver for the targeted clinical conditions and health 24 services delivery issues. 25 3. Use quality indicators derived from the clinical 26 care standards or practice guidelines to screen and monitor 27 care and services delivered. 28 (c) Guidelines for external quality review of each 29 contractor which require: focused studies of patterns of care; 30 individual care review in specific situations; and followup 31 activities on previous pattern-of-care study findings and 34 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 individual-care-review findings. In designing the external 2 quality review function and determining how it is to operate 3 as part of the state's overall quality improvement system, the 4 agency shall construct its external quality review 5 organization and entity contracts to address each of the 6 following: 7 1. Delineating the role of the external quality review 8 organization. 9 2. Length of the external quality review organization 10 contract with the state. 11 3. Participation of the contracting entities in 12 designing external quality review organization review 13 activities. 14 4. Potential variation in the type of clinical 15 conditions and health services delivery issues to be studied 16 at each plan. 17 5. Determining the number of focused pattern-of-care 18 studies to be conducted for each plan. 19 6. Methods for implementing focused studies. 20 7. Individual care review. 21 8. Followup activities. 22 (28) In order to ensure that children receive health 23 care services for which an entity has already been 24 compensated, an entity contracting with the agency pursuant to 25 this section shall achieve an annual Early and Periodic 26 Screening, Diagnosis, and Treatment (EPSDT) Service screening 27 rate of at least 60 percent for those recipients continuously 28 enrolled for at least 8 months. The agency shall develop a 29 method by which the EPSDT screening rate shall be calculated. 30 For any entity which does not achieve the annual 60 percent 31 rate, the entity must submit a corrective action plan for the 35 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 agency's approval. If the entity does not meet the standard 2 established in the corrective action plan during the specified 3 timeframe, the agency is authorized to impose appropriate 4 contract sanctions. At least annually, the agency shall 5 publicly release the EPSDT Services screening rates of each 6 entity it has contracted with on a prepaid basis to serve 7 Medicaid recipients. 8 (29) The agency shall perform enrollments and 9 disenrollments for Medicaid recipients who are eligible for 10 MediPass or managed care plans. Notwithstanding the 11 prohibition contained in paragraph (21)(f), managed care plans 12 may perform preenrollments of Medicaid recipients under the 13 supervision of the agency or its agents. For the purposes of 14 this section, "preenrollment" means the provision of marketing 15 and educational materials to a Medicaid recipient and 16 assistance in completing the application forms, but shall not 17 include actual enrollment into a managed care plan. An 18 application for enrollment shall not be deemed complete until 19 the agency or its agent verifies that the recipient made an 20 informed, voluntary choice. The agency, in cooperation with 21 the Department of Children and Family Services, may test new 22 marketing initiatives to inform Medicaid recipients about 23 their managed care options at selected sites. The agency shall 24 report to the Legislature on the effectiveness of such 25 initiatives. The agency may contract with a third party to 26 perform managed care plan and MediPass enrollment and 27 disenrollment services for Medicaid recipients and is 28 authorized to adopt rules to implement such services. The 29 agency may adjust the capitation rate only to cover the costs 30 of a third-party enrollment and disenrollment contract, and 31 for agency supervision and management of the managed care plan 36 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 enrollment and disenrollment contract. 2 (30) Any lists of providers made available to Medicaid 3 recipients, MediPass enrollees, or managed care plan enrollees 4 shall be arranged alphabetically showing the provider's name 5 and specialty and, separately, by specialty in alphabetical 6 order. 7 (31) The agency shall establish an enhanced managed 8 care quality assurance oversight function, to include at least 9 the following components: 10 (a) At least quarterly analysis and followup, 11 including sanctions as appropriate, of managed care 12 participant utilization of services. 13 (b) At least quarterly analysis and followup, 14 including sanctions as appropriate, of quality findings of the 15 Medicaid peer review organization and other external quality 16 assurance programs. 17 (c) At least quarterly analysis and followup, 18 including sanctions as appropriate, of the fiscal viability of 19 managed care plans. 20 (d) At least quarterly analysis and followup, 21 including sanctions as appropriate, of managed care 22 participant satisfaction and disenrollment surveys. 23 (e) The agency shall conduct regular and ongoing 24 Medicaid recipient satisfaction surveys. 25 26 The analyses and followup activities conducted by the agency 27 under its enhanced managed care quality assurance oversight 28 function shall not duplicate the activities of accreditation 29 reviewers for entities regulated under part III of chapter 30 641, but may include a review of the finding of such 31 reviewers. 37 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 (32) Each managed care plan that is under contract 2 with the agency to provide health care services to Medicaid 3 recipients shall annually conduct a background check with the 4 Florida Department of Law Enforcement of all persons with 5 ownership interest of 5 percent or more or executive 6 management responsibility for the managed care plan and shall 7 submit to the agency information concerning any such person 8 who has been found guilty of, regardless of adjudication, or 9 has entered a plea of nolo contendere or guilty to, any of the 10 offenses listed in s. 435.03. 11 (33) The agency shall, by rule, develop a process 12 whereby a Medicaid managed care plan enrollee who wishes to 13 enter hospice care may be disenrolled from the managed care 14 plan within 24 hours after contacting the agency regarding 15 such request. The agency rule shall include a methodology for 16 the agency to recoup managed care plan payments on a pro rata 17 basis if payment has been made for the enrollment month when 18 disenrollment occurs. 19 (34) The agency and entities that which contract with 20 the agency to provide health care services to Medicaid 21 recipients under this section or ss. 409.91211 and s. 409.9122 22 must comply with the provisions of s. 641.513 in providing 23 emergency services and care to Medicaid recipients and 24 MediPass recipients. Where feasible, safe, and cost-effective, 25 the agency shall encourage hospitals, emergency medical 26 services providers, and other public and private health care 27 providers to work together in their local communities to enter 28 into agreements or arrangements to ensure access to 29 alternatives to emergency services and care for those Medicaid 30 recipients who need nonemergent care. The agency shall 31 coordinate with hospitals, emergency medical services 38 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 providers, private health plans, capitated managed care 2 networks as established in s. 409.91211, and other public and 3 private health care providers to implement the provisions of 4 ss. 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to 5 develop and implement emergency department diversion programs 6 for Medicaid recipients. 7 (35) All entities providing health care services to 8 Medicaid recipients shall make available, and encourage all 9 pregnant women and mothers with infants to receive, and 10 provide documentation in the medical records to reflect, the 11 following: 12 (a) Healthy Start prenatal or infant screening. 13 (b) Healthy Start care coordination, when screening or 14 other factors indicate need. 15 (c) Healthy Start enhanced services in accordance with 16 the prenatal or infant screening results. 17 (d) Immunizations in accordance with recommendations 18 of the Advisory Committee on Immunization Practices of the 19 United States Public Health Service and the American Academy 20 of Pediatrics, as appropriate. 21 (e) Counseling and services for family planning to all 22 women and their partners. 23 (f) A scheduled postpartum visit for the purpose of 24 voluntary family planning, to include discussion of all 25 methods of contraception, as appropriate. 26 (g) Referral to the Special Supplemental Nutrition 27 Program for Women, Infants, and Children (WIC). 28 (36) Any entity that provides Medicaid prepaid health 29 plan services shall ensure the appropriate coordination of 30 health care services with an assisted living facility in cases 31 where a Medicaid recipient is both a member of the entity's 39 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 prepaid health plan and a resident of the assisted living 2 facility. If the entity is at risk for Medicaid targeted case 3 management and behavioral health services, the entity shall 4 inform the assisted living facility of the procedures to 5 follow should an emergent condition arise. 6 (37) The agency may seek and implement federal waivers 7 necessary to provide for cost-effective purchasing of home 8 health services, private duty nursing services, 9 transportation, independent laboratory services, and durable 10 medical equipment and supplies through competitive bidding 11 pursuant to s. 287.057. The agency may request appropriate 12 waivers from the federal Health Care Financing Administration 13 in order to competitively bid such services. The agency may 14 exclude providers not selected through the bidding process 15 from the Medicaid provider network. 16 (38) The agency shall enter into agreements with 17 not-for-profit organizations based in this state for the 18 purpose of providing vision screening. 19 (39)(a) The agency shall implement a Medicaid 20 prescribed-drug spending-control program that includes the 21 following components: 22 1. A Medicaid preferred drug list, which shall be a 23 listing of cost-effective therapeutic options recommended by 24 the Medicaid Pharmacy and Therapeutics Committee established 25 under s. 409.91195 and adopted by the agency for each 26 therapeutic class on the preferred drug list. At the 27 discretion of the committee, and when feasible, the preferred 28 drug list should include at least two products in a 29 therapeutic class. Medicaid prescribed-drug coverage for 30 brand-name drugs for adult Medicaid recipients is limited to 31 eight the dispensing of four brand-name drugs per month per 40 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 recipient. Prior authorization is required for all additional 2 prescriptions above the eight-drug limit and must meet the 3 requirements for step therapy and for listing as a preferred 4 drug. Children are exempt from this restriction. 5 Antiretroviral agents are excluded from this limitation. No 6 requirements for prior authorization or other restrictions on 7 medications used to treat mental illnesses such as 8 schizophrenia, severe depression, or bipolar disorder may be 9 imposed on Medicaid recipients. Medications that will be 10 available without restriction for persons with mental 11 illnesses include atypical antipsychotic medications, 12 conventional antipsychotic medications, selective serotonin 13 reuptake inhibitors, and other medications used for the 14 treatment of serious mental illnesses. The agency shall also 15 limit the amount of a prescribed drug dispensed to no more 16 than a 34-day supply unless the drug products' smallest 17 marketed package is greater than a 34-day supply, or the drug 18 is determined by the agency to be a maintenance drug, in which 19 case a 180-day maximum supply may be authorized. The agency 20 may seek any federal waivers necessary to implement these 21 cost-control programs and to continue participation in the 22 federal Medicaid rebate program, or alternatively to negotiate 23 state-only manufacturer rebates. The agency may adopt rules to 24 administer this subparagraph. The agency shall continue to 25 provide unlimited generic drugs, contraceptive drugs and 26 items, and diabetic supplies. Although a drug may be included 27 on the preferred drug formulary, it would not be exempt from 28 the four-brand limit. The agency may authorize exceptions to 29 the brand-name-drug restriction based upon the treatment needs 30 of the patients, only when such exceptions are based on prior 31 consultation provided by the agency or an agency contractor, 41 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 but The agency must establish procedures to ensure that: 2 a. There will be a response to a request for prior 3 consultation by telephone or other telecommunication device 4 within 24 hours after receipt of a request for prior 5 consultation; and 6 b. A 72-hour supply of the drug prescribed will be 7 provided in an emergency or when the agency does not provide a 8 response within 24 hours as required by sub-subparagraph a.; 9 and 10 c. Except for the exception for nursing home residents 11 and other institutionalized adults and except for drugs on the 12 restricted formulary for which prior authorization may be 13 sought by an institutional or community pharmacy, prior 14 authorization for an exception to the brand-name-drug 15 restriction is sought by the prescriber and not by the 16 pharmacy. When prior authorization is granted for a patient in 17 an institutional setting beyond the brand-name-drug 18 restriction, such approval is authorized for 12 months and 19 monthly prior authorization is not required for that patient. 20 2. Reimbursement to pharmacies for Medicaid prescribed 21 drugs shall be set at the lesser of: the average wholesale 22 price (AWP) minus 15.4 percent, the wholesaler acquisition 23 cost (WAC) plus 5.75 percent, the federal upper limit (FUL), 24 the state maximum allowable cost (SMAC), or the usual and 25 customary (UAC) charge billed by the provider. 26 3. The agency shall develop and implement a process 27 for managing the drug therapies of Medicaid recipients who are 28 using significant numbers of prescribed drugs each month. The 29 management process may include, but is not limited to, 30 comprehensive, physician-directed medical-record reviews, 31 claims analyses, and case evaluations to determine the medical 42 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 necessity and appropriateness of a patient's treatment plan 2 and drug therapies. The agency may contract with a private 3 organization to provide drug-program-management services. The 4 Medicaid drug benefit management program shall include 5 initiatives to manage drug therapies for HIV/AIDS patients, 6 patients using 20 or more unique prescriptions in a 180-day 7 period, and the top 1,000 patients in annual spending. The 8 agency shall enroll any Medicaid recipient in the drug benefit 9 management program if he or she meets the specifications of 10 this provision and is not enrolled in a Medicaid health 11 maintenance organization. 12 4. The agency may limit the size of its pharmacy 13 network based on need, competitive bidding, price 14 negotiations, credentialing, or similar criteria. The agency 15 shall give special consideration to rural areas in determining 16 the size and location of pharmacies included in the Medicaid 17 pharmacy network. A pharmacy credentialing process may include 18 criteria such as a pharmacy's full-service status, location, 19 size, patient educational programs, patient consultation, 20 disease-management services, and other characteristics. The 21 agency may impose a moratorium on Medicaid pharmacy enrollment 22 when it is determined that it has a sufficient number of 23 Medicaid-participating providers. The agency must allow 24 dispensing practitioners to participate as a part of the 25 Medicaid pharmacy network regardless of the practitioner's 26 proximity to any other entity that is dispensing prescription 27 drugs under the Medicaid program. A dispensing practitioner 28 must meet all credentialing requirements applicable to his or 29 her practice, as determined by the agency. 30 5. The agency shall develop and implement a program 31 that requires Medicaid practitioners who prescribe drugs to 43 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 use a counterfeit-proof prescription pad for Medicaid 2 prescriptions. The agency shall require the use of 3 standardized counterfeit-proof prescription pads by 4 Medicaid-participating prescribers or prescribers who write 5 prescriptions for Medicaid recipients. The agency may 6 implement the program in targeted geographic areas or 7 statewide. 8 6. The agency may enter into arrangements that require 9 manufacturers of generic drugs prescribed to Medicaid 10 recipients to provide rebates of at least 15.1 percent of the 11 average manufacturer price for the manufacturer's generic 12 products. These arrangements shall require that if a 13 generic-drug manufacturer pays federal rebates for 14 Medicaid-reimbursed drugs at a level below 15.1 percent, the 15 manufacturer must provide a supplemental rebate to the state 16 in an amount necessary to achieve a 15.1-percent rebate level. 17 7. The agency may establish a preferred drug list as 18 described in this subsection formulary in accordance with 42 19 U.S.C. s. 1396r-8, and, pursuant to the establishment of such 20 drug list formulary, it may is authorized to negotiate 21 supplemental rebates from manufacturers which that are in 22 addition to those required by Title XIX of the Social Security 23 Act and at no less than 14 percent of the average manufacturer 24 price as defined in 42 U.S.C. s. 1936 on the last day of a 25 quarter unless the federal or supplemental rebate, or both, 26 equals or exceeds 29 percent. There is no upper limit on the 27 supplemental rebates the agency may negotiate. The agency may 28 determine that specific products, brand-name or generic, are 29 competitive at lower rebate percentages. Agreement to pay the 30 minimum supplemental rebate percentage will guarantee a 31 manufacturer that the Medicaid Pharmaceutical and Therapeutics 44 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 Committee will consider a product for inclusion on the 2 preferred drug list formulary. However, a pharmaceutical 3 manufacturer is not guaranteed placement on the preferred drug 4 list formulary by simply paying the minimum supplemental 5 rebate. Agency decisions will be made on the clinical efficacy 6 of a drug and recommendations of the Medicaid Pharmaceutical 7 and Therapeutics Committee, as well as the price of competing 8 products minus federal and state rebates. The agency is 9 authorized to contract with an outside agency or contractor to 10 conduct negotiations for supplemental rebates. For the 11 purposes of this section, the term "supplemental rebates" 12 means cash rebates. Effective July 1, 2004, value-added 13 programs as a substitution for supplemental rebates are 14 prohibited. The agency is authorized to seek any federal 15 waivers to implement this initiative. 16 8. The agency shall establish an advisory committee 17 for the purposes of studying the feasibility of using a 18 restricted drug formulary for nursing home residents and other 19 institutionalized adults. The committee shall be comprised of 20 seven members appointed by the Secretary of Health Care 21 Administration. The committee members shall include two 22 physicians licensed under chapter 458 or chapter 459; three 23 pharmacists licensed under chapter 465 and appointed from a 24 list of recommendations provided by the Florida Long-Term Care 25 Pharmacy Alliance; and two pharmacists licensed under chapter 26 465. 27 8.9. The Agency for Health Care Administration shall 28 expand home delivery of pharmacy products. To assist Medicaid 29 patients in securing their prescriptions and reduce program 30 costs, the agency shall expand its current mail-order-pharmacy 31 diabetes-supply program to include all generic and brand-name 45 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 drugs used by Medicaid patients with diabetes. Medicaid 2 recipients in the current program may obtain nondiabetes drugs 3 on a voluntary basis. This initiative is limited to the 4 geographic area covered by the current contract. The agency 5 may seek and implement any federal waivers necessary to 6 implement this subparagraph. 7 9.10. The agency shall limit to one dose per month any 8 drug prescribed to treat erectile dysfunction. 9 10.11.a. The agency shall implement a Medicaid 10 behavioral drug management system. The agency may contract 11 with a vendor that has experience in operating behavioral drug 12 management systems to implement this program. The agency is 13 authorized to seek federal waivers to implement this program. 14 b. The agency, in conjunction with the Department of 15 Children and Family Services, may implement the Medicaid 16 behavioral drug management system that is designed to improve 17 the quality of care and behavioral health prescribing 18 practices based on best practice guidelines, improve patient 19 adherence to medication plans, reduce clinical risk, and lower 20 prescribed drug costs and the rate of inappropriate spending 21 on Medicaid behavioral drugs. The program shall include the 22 following elements: 23 (I) Provide for the development and adoption of best 24 practice guidelines for behavioral health-related drugs such 25 as antipsychotics, antidepressants, and medications for 26 treating bipolar disorders and other behavioral conditions; 27 translate them into practice; review behavioral health 28 prescribers and compare their prescribing patterns to a number 29 of indicators that are based on national standards; and 30 determine deviations from best practice guidelines. 31 (II) Implement processes for providing feedback to and 46 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 educating prescribers using best practice educational 2 materials and peer-to-peer consultation. 3 (III) Assess Medicaid beneficiaries who are outliers 4 in their use of behavioral health drugs with regard to the 5 numbers and types of drugs taken, drug dosages, combination 6 drug therapies, and other indicators of improper use of 7 behavioral health drugs. 8 (IV) Alert prescribers to patients who fail to refill 9 prescriptions in a timely fashion, are prescribed multiple 10 same-class behavioral health drugs, and may have other 11 potential medication problems. 12 (V) Track spending trends for behavioral health drugs 13 and deviation from best practice guidelines. 14 (VI) Use educational and technological approaches to 15 promote best practices, educate consumers, and train 16 prescribers in the use of practice guidelines. 17 (VII) Disseminate electronic and published materials. 18 (VIII) Hold statewide and regional conferences. 19 (IX) Implement a disease management program with a 20 model quality-based medication component for severely mentally 21 ill individuals and emotionally disturbed children who are 22 high users of care. 23 c. If the agency is unable to negotiate a contract 24 with one or more manufacturers to finance and guarantee 25 savings associated with a behavioral drug management program 26 by September 1, 2004, the four-brand drug limit and preferred 27 drug list prior-authorization requirements shall apply to 28 mental health-related drugs, notwithstanding any provision in 29 subparagraph 1. The agency is authorized to seek federal 30 waivers to implement this policy. 31 11.a. The agency shall implement a Medicaid 47 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 prescription-drug-management system. The agency may contract 2 with a vendor that has experience in operating 3 prescription-drug-management systems in order to implement 4 this system. Any management system that is implemented in 5 accordance with this subparagraph must rely on cooperation 6 between physicians and pharmacists to determine appropriate 7 practice patterns and clinical guidelines to improve the 8 prescribing, dispensing, and use of drugs in the Medicaid 9 program. The agency may seek federal waivers to implement this 10 program. 11 b. The drug-management system must be designed to 12 improve the quality of care and prescribing practices based on 13 best-practice guidelines, improve patient adherence to 14 medication plans, reduce clinical risk, and lower prescribed 15 drug costs and the rate of inappropriate spending on Medicaid 16 prescription drugs. The program must: 17 (I) Provide for the development and adoption of 18 best-practice guidelines for the prescribing and use of drugs 19 in the Medicaid program, including translating best-practice 20 guidelines into practice; reviewing prescriber patterns and 21 comparing them to indicators that are based on national 22 standards and practice patterns of clinical peers in their 23 community, statewide, and nationally; and determine deviations 24 from best-practice guidelines. 25 (II) Implement processes for providing feedback to and 26 educating prescribers using best-practice educational 27 materials and peer-to-peer consultation. 28 (III) Assess Medicaid recipients who are outliers in 29 their use of a single or multiple prescription drugs with 30 regard to the numbers and types of drugs taken, drug dosages, 31 combination drug therapies, and other indicators of improper 48 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 use of prescription drugs. 2 (IV) Alert prescribers to patients who fail to refill 3 prescriptions in a timely fashion, are prescribed multiple 4 drugs that may be redundant or contraindicated, or may have 5 other potential medication problems. 6 (V) Track spending trends for prescription drugs and 7 deviation from best practice guidelines. 8 (VI) Use educational and technological approaches to 9 promote best practices, educate consumers, and train 10 prescribers in the use of practice guidelines. 11 (VII) Disseminate electronic and published materials. 12 (VIII) Hold statewide and regional conferences. 13 (IX) Implement disease-management programs in 14 cooperation with physicians and pharmacists, along with a 15 model quality-based medication component for individuals 16 having chronic medical conditions. 17 12. The agency is authorized to contract for drug 18 rebate administration, including, but not limited to, 19 calculating rebate amounts, invoicing manufacturers, 20 negotiating disputes with manufacturers, and maintaining a 21 database of rebate collections. 22 13. The agency may specify the preferred daily dosing 23 form or strength for the purpose of promoting best practices 24 with regard to the prescribing of certain drugs as specified 25 in the General Appropriations Act and ensuring cost-effective 26 prescribing practices. 27 14. The agency may require prior authorization for the 28 off-label use of Medicaid-covered prescribed drugs as 29 specified in the General Appropriations Act. The agency may, 30 but is not required to, preauthorize the use of a product for 31 an indication not in the approved labeling. Prior 49 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 authorization may require the prescribing professional to 2 provide information about the rationale and supporting medical 3 evidence for the off-label use of a drug. 4 15. The agency, in conjunction with the Pharmaceutical 5 and Therapeutics Committee, may require age-related prior 6 authorizations for certain prescribed drugs. The agency may 7 preauthorize the use of a drug for a recipient who may not 8 meet the age requirement or may exceed the length of therapy 9 for use of this product as recommended by the manufacturer and 10 approved by the United States Food and Drug Administration. 11 Prior authorization may require the prescribing professional 12 to provide information about the rationale and supporting 13 medical evidence for the use of a drug. 14 16. The agency shall implement a step-therapy 15 prior-authorization-approval process for medications excluded 16 from the preferred drug list. Medications listed on the 17 preferred drug list must be used within the previous 12 months 18 prior to the alternative medications that are not listed. The 19 step-therapy prior authorization may require the prescriber to 20 use the medications of a similar drug class or for a similar 21 medical indication unless contraindicated in the labeling by 22 the Food and Drug Administration. The trial period between the 23 specified steps may vary according to the medical indication. 24 The step-therapy-approval process shall be developed in 25 accordance with the committee as stated in s. 409.91195(7) and 26 (8). 27 17.15. The agency shall implement a return and reuse 28 program for drugs dispensed by pharmacies to institutional 29 recipients, which includes payment of a $5 restocking fee for 30 the implementation and operation of the program. The return 31 and reuse program shall be implemented electronically and in a 50 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 manner that promotes efficiency. The program must permit a 2 pharmacy to exclude drugs from the program if it is not 3 practical or cost-effective for the drug to be included and 4 must provide for the return to inventory of drugs that cannot 5 be credited or returned in a cost-effective manner. The agency 6 shall determine if the program has reduced the amount of 7 Medicaid prescription drugs which are destroyed on an annual 8 basis and if there are additional ways to ensure more 9 prescription drugs are not destroyed which could safely be 10 reused. The agency's conclusion and recommendations shall be 11 reported to the Legislature by December 1, 2005. 12 (b) The agency shall implement this subsection to the 13 extent that funds are appropriated to administer the Medicaid 14 prescribed-drug spending-control program. The agency may 15 contract all or any part of this program to private 16 organizations. 17 (c) The agency shall submit quarterly reports to the 18 Governor, the President of the Senate, and the Speaker of the 19 House of Representatives which must include, but need not be 20 limited to, the progress made in implementing this subsection 21 and its effect on Medicaid prescribed-drug expenditures. 22 (40) Notwithstanding the provisions of chapter 287, 23 the agency may, at its discretion, renew a contract or 24 contracts for fiscal intermediary services one or more times 25 for such periods as the agency may decide; however, all such 26 renewals may not combine to exceed a total period longer than 27 the term of the original contract. 28 (41) The agency shall provide for the development of a 29 demonstration project by establishment in Miami-Dade County of 30 a long-term-care facility licensed pursuant to chapter 395 to 31 improve access to health care for a predominantly minority, 51 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 medically underserved, and medically complex population and to 2 evaluate alternatives to nursing home care and general acute 3 care for such population. Such project is to be located in a 4 health care condominium and colocated with licensed facilities 5 providing a continuum of care. The establishment of this 6 project is not subject to the provisions of s. 408.036 or s. 7 408.039. The agency shall report its findings to the Governor, 8 the President of the Senate, and the Speaker of the House of 9 Representatives by January 1, 2003. 10 (42) The agency shall develop and implement a 11 utilization management program for Medicaid-eligible 12 recipients for the management of occupational, physical, 13 respiratory, and speech therapies. The agency shall establish 14 a utilization program that may require prior authorization in 15 order to ensure medically necessary and cost-effective 16 treatments. The program shall be operated in accordance with a 17 federally approved waiver program or state plan amendment. The 18 agency may seek a federal waiver or state plan amendment to 19 implement this program. The agency may also competitively 20 procure these services from an outside vendor on a regional or 21 statewide basis. 22 (43) The agency may contract on a prepaid or fixed-sum 23 basis with appropriately licensed prepaid dental health plans 24 to provide dental services. 25 (44) The Agency for Health Care Administration shall 26 ensure that any Medicaid managed care plan as defined in s. 27 409.9122(2)(h), whether paid on a capitated basis or a shared 28 savings basis, is cost-effective. For purposes of this 29 subsection, the term "cost-effective" means that a network's 30 per-member, per-month costs to the state, including, but not 31 limited to, fee-for-service costs, administrative costs, and 52 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 case-management fees, must be no greater than the state's 2 costs associated with contracts for Medicaid services 3 established under subsection (3), which shall be actuarially 4 adjusted for case mix, model, and service area. The agency 5 shall conduct actuarially sound audits adjusted for case mix 6 and model in order to ensure such cost-effectiveness and shall 7 publish the audit results on its Internet website and submit 8 the audit results annually to the Governor, the President of 9 the Senate, and the Speaker of the House of Representatives no 10 later than December 31 of each year. Contracts established 11 pursuant to this subsection which are not cost-effective may 12 not be renewed. 13 (45) Subject to the availability of funds, the agency 14 shall mandate a recipient's participation in a provider 15 lock-in program, when appropriate, if a recipient is found by 16 the agency to have used Medicaid goods or services at a 17 frequency or amount not medically necessary, limiting the 18 receipt of goods or services to medically necessary providers 19 after the 21-day appeal process has ended, for a period of not 20 less than 1 year. The lock-in programs shall include, but are 21 not limited to, pharmacies, medical doctors, and infusion 22 clinics. The limitation does not apply to emergency services 23 and care provided to the recipient in a hospital emergency 24 department. The agency shall seek any federal waivers 25 necessary to implement this subsection. The agency shall adopt 26 any rules necessary to comply with or administer this 27 subsection. 28 (46) The agency shall seek a federal waiver for 29 permission to terminate the eligibility of a Medicaid 30 recipient who has been found to have committed fraud, through 31 judicial or administrative determination, two times in a 53 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 period of 5 years. 2 (47) The agency shall conduct a study of available 3 electronic systems for the purpose of verifying the identity 4 and eligibility of a Medicaid recipient. The agency shall 5 recommend to the Legislature a plan to implement an electronic 6 verification system for Medicaid recipients by January 31, 7 2005. 8 (48) A provider is not entitled to enrollment in the 9 Medicaid provider network. The agency may implement a Medicaid 10 fee-for-service provider network controls, including, but not 11 limited to, competitive procurement and provider 12 credentialing. If a credentialing process is used, the agency 13 may limit its provider network based upon the following 14 considerations: beneficiary access to care, provider 15 availability, provider quality standards and quality assurance 16 processes, cultural competency, demographic characteristics of 17 beneficiaries, practice standards, service wait times, 18 provider turnover, provider licensure and accreditation 19 history, program integrity history, peer review, Medicaid 20 policy and billing compliance records, clinical and medical 21 record audit findings, and such other areas that are 22 considered necessary by the agency to ensure the integrity of 23 the program. 24 (49) The agency shall contract with established 25 minority physician networks that provide services to 26 historically underserved minority patients. The networks must 27 provide cost-effective Medicaid services, comply with the 28 requirements to be a MediPass provider, and provide their 29 primary care physicians with access to data and other 30 management tools necessary to assist them in ensuring the 31 appropriate use of services, including inpatient hospital 54 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 services and pharmaceuticals. 2 (a) The agency shall provide for the development and 3 expansion of minority physician networks in each service area 4 to provide services to Medicaid recipients who are eligible to 5 participate under federal law and rules. 6 (b) The agency shall reimburse each minority physician 7 network as a fee-for-service provider, including the case 8 management fee for primary care, or as a capitated rate 9 provider for Medicaid services. Any savings shall be shared 10 with the minority physician networks pursuant to the contract. 11 (c) For purposes of this subsection, the term 12 "cost-effective" means that a network's per-member, per-month 13 costs to the state, including, but not limited to, 14 fee-for-service costs, administrative costs, and 15 case-management fees, must be no greater than the state's 16 costs associated with contracts for Medicaid services 17 established under subsection (3), which shall be actuarially 18 adjusted for case mix, model, and service area. The agency 19 shall conduct actuarially sound audits adjusted for case mix 20 and model in order to ensure such cost-effectiveness and shall 21 publish the audit results on its Internet website and submit 22 the audit results annually to the Governor, the President of 23 the Senate, and the Speaker of the House of Representatives no 24 later than December 31. Contracts established pursuant to this 25 subsection which are not cost-effective may not be renewed. 26 (d) The agency may apply for any federal waivers 27 needed to implement this subsection. 28 (50) The agency shall implement a program of 29 all-inclusive care for children. The program of all-inclusive 30 care for children shall be established in order to provide 31 in-home, hospice-like support services to children diagnosed 55 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 as having a life-threatening illness and who are enrolled in 2 the Children's Medical Services network and to reduce 3 hospitalizations as appropriate. The agency, in consultation 4 with the Department of Health, may implement the program of 5 all-inclusive care for children after obtaining approval from 6 the Centers for Medicare and Medicaid Services. 7 (51) To the extent permitted by federal law and as 8 allowed under s. 409.906, the agency shall provide 9 reimbursement for emergency mental health care services for 10 Medicaid recipients in crisis-stabilization facilities 11 licensed under s. 394.875 as long as those services are less 12 expensive than the same services provided in a hospital 13 setting. 14 Section 2. Section 409.91211, Florida Statutes, is 15 created to read: 16 409.91211 Medicaid managed care pilot program.-- 17 (1) The agency shall develop a pilot program to 18 deliver health care services specified in ss. 409.905 and 19 409.906 through capitated managed care networks under the 20 Medicaid program to persons in Medicaid fee-for-service or the 21 MediPass program, contingent upon federal approval to preserve 22 current upper-payment-level funding and the disproportionate 23 share program as provided in this chapter. 24 (2) The Legislature intends for the capitated managed 25 care pilot program to: 26 (a) Provide recipients in Medicaid fee-for-service or 27 the MediPass program a comprehensive and coordinated capitated 28 managed care system for all medically necessary health care 29 services specified in ss. 409.905 and 409.906. 30 (b) Stabilize Medicaid expenditures under the pilot 31 program compared to Medicaid expenditures for the 3 years 56 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 before implementation of the pilot program. 2 (c) Provide an opportunity to evaluate the feasibility 3 of statewide implementation of capitated managed care networks 4 as a replacement for the current Medicaid fee-for-service and 5 MediPass systems. 6 (3) The agency shall have the following powers, 7 duties, and responsibilities with respect to the development 8 of a pilot program to deliver all health care services 9 specified in ss. 409.905 and 409.906 in the form of capitated 10 managed care networks under the Medicaid program to persons in 11 Medicaid fee-for-service or the MediPass program: 12 (a) To define and recommend the medical and financial 13 eligibility standards for capitated managed care networks in 14 the pilot program. This paragraph does not relieve an entity 15 that qualifies as a capitated managed care network under this 16 section from any other licensure or regulatory requirements 17 contained in state or federal law which would otherwise apply 18 to the entity. 19 (b) To include two geographic areas in the pilot 20 program and recommend Medicaid-eligibility categories, from 21 those specified in ss. 409.903 and 409.904, which shall be 22 included in the pilot program. One pilot program must include 23 only Broward County. A second pilot program must include only 24 Baker, Clay, Duval, and Nassau Counties. A Medicaid recipient 25 may not be enrolled in or assigned to a capitated managed care 26 plan unless the capitated managed care plan has complied with 27 the standards and credentialing requirements specified in 28 paragraph (e). 29 (c) To determine and recommend how to design the 30 managed care delivery system in order to take maximum 31 advantage of all available state and federal funds, including 57 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 those obtained through intergovernmental transfers, the 2 upper-payment-level funding systems, and the disproportionate 3 share program. 4 (d) To determine and recommend actuarially sound, 5 risk-adjusted capitation rates for Medicaid recipients in the 6 pilot program which can be separated to cover comprehensive 7 care, enhanced services, and catastrophic care. 8 (e) To determine and recommend program standards and 9 credentialing requirements for capitated managed care networks 10 to participate in the pilot program, including those related 11 to fiscal solvency, quality of care, and adequacy of access to 12 health care providers. This paragraph does not relieve an 13 entity that qualifies as a capitated managed care network 14 under this section from any other licensure or regulatory 15 requirements contained in state or federal law that would 16 otherwise apply to the entity. These standards must address, 17 but are not limited to: 18 1. Compliance with the accreditation requirements as 19 provided in s. 641.512. 20 2. Compliance with early and periodic screening, 21 diagnosis, and treatment screening requirements under federal 22 law. 23 3. The percentage of voluntary disenrollments. 24 4. Immunization rates. 25 5. Standards of the National Committee for Quality 26 Assurance and other approved accrediting bodies. 27 6. Recommendations of other authoritative bodies. 28 7. Specific requirements of the Medicaid program, or 29 standards designed to specifically meet the unique needs of 30 Medicaid recipients. 31 8. Compliance with the health quality improvement 58 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 system as established by the agency, which incorporates 2 standards and guidelines developed by the Centers for Medicare 3 and Medicaid Services as part of the quality assurance reform 4 initiative. 5 (f) To develop and recommend a mechanism for providing 6 information to Medicaid recipients for the purpose of 7 selecting a capitated managed care plan. Examples of such 8 mechanisms may include, but need not be limited to, 9 interactive information systems, mailings, and mass-marketing 10 materials. Capitated managed care plans, their 11 representatives, and providers employed by or contracted with 12 the capitated managed care plans may not provide inducements 13 to Medicaid recipients to select their plans and may not 14 prejudice Medicaid recipients against other capitated managed 15 care plans. 16 (g) To develop and recommend a system to monitor the 17 provision of health care services in the pilot program, 18 including utilization and quality of health care services for 19 the purpose of ensuring access to medically necessary 20 services. This system may include an encounter 21 data-information system that collects and reports utilization 22 information. The system shall include a method for verifying 23 data integrity within the database and within the provider's 24 medical records. 25 (h) To recommend a grievance-resolution process for 26 Medicaid recipients enrolled in a capitated managed care 27 network under the pilot program modeled after the subscriber 28 assistance panel, as created in s. 408.7056. This process 29 shall include a mechanism for an expedited review of no 30 greater than 24 hours after notification of a grievance if the 31 life of a Medicaid recipient is in imminent and emergent 59 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 jeopardy. 2 (i) To recommend a grievance-resolution process for 3 health care providers employed by or contracted with a 4 capitated managed care network under the pilot program in 5 order to settle disputes among the provider and the managed 6 care network or the provider and the agency. 7 (j) To develop and recommend criteria to designate 8 health care providers as eligible to participate in the pilot 9 program. The agency and capitated managed care networks must 10 follow national guidelines for selecting health care 11 providers, whenever available. These criteria must include at 12 a minimum those criteria specified in s. 409.907. 13 (k) To develop and recommend health care provider 14 agreements for participation in the pilot program. 15 (l) To require that all health care providers under 16 contract with the pilot program be duly licensed in the state, 17 if such licensure is available, and meet other criteria as may 18 be established by the agency. These criteria shall include at 19 a minimum those criteria specified in s. 409.907. 20 (m) To develop and recommend agreements with other 21 state or local governmental programs or institutions for the 22 coordination of health care to eligible individuals receiving 23 services from such programs or institutions. 24 (n) To develop and recommend a system to oversee the 25 activities of pilot program participants, health care 26 providers, capitated managed care networks, and their 27 representatives in order to prevent fraud or abuse, 28 overutilization or duplicative utilization, underutilization 29 or inappropriate denial of services, and neglect of 30 participants and to recover overpayments as appropriate. For 31 the purposes of this paragraph, the terms "abuse" and "fraud" 60 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 have the meanings as provided in s. 409.913. The agency must 2 refer incidents of suspected fraud, abuse, overutilization and 3 duplicative utilization, and underutilization or inappropriate 4 denial of services to the appropriate regulatory agency. 5 (o) To develop and provide actuarial and benefit 6 design analyses that indicate the effect on capitation rates 7 and benefits offered in the pilot program over a prospective 8 5-year period based on the following assumptions: 9 1. Growth in capitation rates which is limited to the 10 estimated growth rate in general revenue. 11 2. Growth in capitation rates which is limited to the 12 average growth rate over the last 3 years in per-recipient 13 Medicaid expenditures. 14 3. Growth in capitation rates which is limited to the 15 growth rate of aggregate Medicaid expenditures between the 16 2003-2004 fiscal year and the 2004-2005 fiscal year. 17 (p) To develop a system whereby school districts 18 participating in the certified school match program pursuant 19 to ss. 409.908(21) and 1011.70 shall be reimbursed by 20 Medicaid, subject to the limitations of s. 1011.70(1), for a 21 Medicaid-eligible child participating in the services as 22 authorized in s. 1011.70, as provided for in s. 409.9071, 23 regardless of whether the child is enrolled in a capitated 24 managed care network. Capitated managed care networks must 25 make a good-faith effort to execute agreements with school 26 districts regarding the coordinated provision of services 27 authorized under s. 1011.70. County health departments 28 delivering school-based services pursuant to ss. 381.0056 and 29 381.0057 must be reimbursed by Medicaid for the federal share 30 for a Medicaid-eligible child who receives Medicaid-covered 31 services in a school setting, regardless of whether the child 61 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 is enrolled in a capitated managed care network. Capitated 2 managed care networks must make a good-faith effort to execute 3 agreements with county health departments regarding the 4 coordinated provision of services to a Medicaid-eligible 5 child. To ensure continuity of care for Medicaid patients, the 6 agency, the Department of Health, and the Department of 7 Education shall develop procedures for ensuring that a 8 student's capitated managed care network provider receives 9 information relating to services provided in accordance with 10 ss. 381.0056, 381.0057, 409.9071, and 1011.70. 11 (q) To develop and recommend a mechanism whereby 12 Medicaid recipients who are already enrolled in a managed care 13 plan or the MediPass program in the pilot areas shall be 14 offered the opportunity to change to capitated managed care 15 plans on a staggered basis, as defined by the agency. All 16 Medicaid recipients shall have 30 days in which to make a 17 choice of capitated managed care plans. Those Medicaid 18 recipients who do not make a choice shall be assigned to a 19 capitated managed care plan in accordance with paragraph 20 (4)(a). To facilitate continuity of care for a Medicaid 21 recipient who is also a recipient of Supplemental Security 22 Income (SSI), prior to assigning the SSI recipient to a 23 capitated managed care plan, the agency shall determine 24 whether the SSI recipient has an ongoing relationship with a 25 provider or capitated managed care plan, and if so, the agency 26 shall assign the SSI recipient to that provider or capitated 27 managed care plan where feasible. Those SSI recipients who do 28 not have such a provider relationship shall be assigned to a 29 capitated managed care plan provider in accordance with 30 paragraph (4)(a). 31 (4)(a) A Medicaid recipient in the pilot area who is 62 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 not currently enrolled in a capitated managed care plan upon 2 implementation is not eligible for services as specified in 3 ss. 409.905 and 409.906, for the amount of time that the 4 recipient does not enroll in a capitated managed care network. 5 If a Medicaid recipient has not enrolled in a capitated 6 managed care plan within 30 days after eligibility, the agency 7 shall assign the Medicaid recipient to a capitated managed 8 care plan based on the assessed needs of the recipient as 9 determined by the agency. When making assignments, the agency 10 shall take into account the following criteria: 11 1. A capitated managed care network has sufficient 12 network capacity to meet the need of members. 13 2. The capitated managed care network has previously 14 enrolled the recipient as a member, or one of the capitated 15 managed care network's primary care providers has previously 16 provided health care to the recipient. 17 3. The agency has knowledge that the member has 18 previously expressed a preference for a particular capitated 19 managed care network as indicated by Medicaid fee-for-service 20 claims data, but has failed to make a choice. 21 4. The capitated managed care network's primary care 22 providers are geographically accessible to the recipient's 23 residence. 24 (b) When more than one capitated managed care network 25 provider meets the criteria specified in paragraph (3)(j), the 26 agency shall make recipient assignments consecutively by 27 family unit. 28 (c) The agency may not engage in practices that are 29 designed to favor one capitated managed care plan over another 30 or that are designed to influence Medicaid recipients to 31 enroll in a particular capitated managed care network in order 63 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 to strengthen its particular fiscal viability. 2 (d) After a recipient has made a selection or has been 3 enrolled in a capitated managed care network, the recipient 4 shall have 90 days in which to voluntarily disenroll and 5 select another capitated managed care network. After 90 days, 6 no further changes may be made except for cause. Cause shall 7 include, but not be limited to, poor quality of care, lack of 8 access to necessary specialty services, an unreasonable delay 9 or denial of service, or fraudulent enrollment. The agency may 10 require a recipient to use the capitated managed care 11 network's grievance process as specified in paragraph (3)(h) 12 prior to the agency's determination of cause, except in cases 13 in which immediate risk of permanent damage to the recipient's 14 health is alleged. The grievance process, when used, must be 15 completed in time to permit the recipient to disenroll no 16 later than the first day of the second month after the month 17 the disenrollment request was made. If the capitated managed 18 care network, as a result of the grievance process, approves 19 an enrollee's request to disenroll, the agency is not required 20 to make a determination in the case. The agency must make a 21 determination and take final action on a recipient's request 22 so that disenrollment occurs no later than the first day of 23 the second month after the month the request was made. If the 24 agency fails to act within the specified timeframe, the 25 recipient's request to disenroll is deemed to be approved as 26 of the date agency action was required. Recipients who 27 disagree with the agency's finding that cause does not exist 28 for disenrollment shall be advised of their right to pursue a 29 Medicaid fair hearing to dispute the agency's finding. 30 (e) The agency shall apply for federal waivers from 31 the Centers for Medicare and Medicaid Services to lock 64 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 eligible Medicaid recipients into a capitated managed care 2 network for 12 months after an open enrollment period. After 3 12 months of enrollment, a recipient may select another 4 capitated managed care network. However, nothing shall prevent 5 a Medicaid recipient from changing primary care providers 6 within the capitated managed care network during the 12-month 7 period. 8 (f) The agency shall develop and submit for approval 9 applications for waivers of applicable federal laws and 10 regulations as necessary to implement the capitated managed 11 care pilot program as defined in this section. All waivers 12 submitted to and approved by the United States Centers for 13 Medicare and Medicaid Services under this section must be 14 submitted to the Senate and House of Representatives Select 15 Committees on Medicaid Reform in order to obtain authority for 16 implementation as required by s. 409.912(11) before program 17 implementation. The Select Committees on Medicaid Reform shall 18 recommend whether to approve the implementation of the waivers 19 to the Legislature or to the Legislative Budget Commission if 20 the Legislature is not in regular or special session. 21 (5) Upon review and approval of the applications for 22 waivers of applicable federal laws and regulations to 23 implement the pilot project by the Legislature, the Agency for 24 Health Care Administration may initiate adoption of rules 25 pursuant to ss. 120.536(1) and 120.54 to implement and 26 administer the managed care pilot program as provided in this 27 section. 28 Section 3. The Agency for Health Care Administration 29 shall submit an implementation plan for the managed care pilot 30 program created under section 409.91211, Florida Statutes, to 31 the Senate and House of Representatives Select Committees on 65 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 Medicaid Reform upon approval of all waivers of federal laws 2 and regulations by the United States Centers for Medicare and 3 Medicaid Services which are necessary to implement the managed 4 care pilot program. Based on the review of the implementation 5 plan, the Senate and House Select Committees on Medicaid 6 Reform shall determine whether to recommend implementation of 7 the pilot program for approval by the Legislature or by the 8 Legislative Budget Commission if the Legislature is not in 9 regular or special session. The implementation plan must 10 include all information specified in section 409.91211(3) and 11 (4), Florida Statutes. The plan must contain a detailed 12 timeline for implementation. The plan must contain budgetary 13 projections of the effect of the pilot program on the total 14 Medicaid budget for the 2006-2007 through 2009-2010 fiscal 15 years. 16 Section 4. The Agency for Health Care Administration 17 shall evaluate the two managed care pilot programs created 18 under section 409.91211, Florida Statutes, over the 24 months 19 after the two pilot programs have enrolled Medicaid recipients 20 and started providing health care services. The evaluation 21 must include assessments of cost savings and quality of care 22 in the pilot programs. The evaluation must describe 23 administrative or legal barriers to the implementation of the 24 pilot programs and include recommendations regarding statewide 25 expansion of the managed care pilot program. The agency shall 26 submit an evaluation report to the Governor, the President of 27 the Senate, and the Speaker of the House of Representatives no 28 later than June 30, 2008. The managed care pilot program may 29 not be expanded to any additional counties that are not 30 identified in this section without the authorization of the 31 Legislature. 66 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 Section 5. Paragraphs (a) and (j) of subsection (2) 2 and subsection (6) of section 409.9122, Florida Statutes, are 3 amended to read: 4 409.9122 Mandatory Medicaid managed care enrollment; 5 programs and procedures.-- 6 (2)(a) The agency shall enroll in a managed care plan 7 or MediPass all Medicaid recipients, except those Medicaid 8 recipients who are: in an institution; enrolled in the 9 Medicaid medically needy program; or eligible for both 10 Medicaid and Medicare. Upon enrollment, individuals will be 11 able to change their managed care option during the 90-day opt 12 out period required by federal Medicaid regulations. The 13 agency is authorized to seek the necessary Medicaid state plan 14 amendment to implement this policy. However, to the extent 15 permitted by federal law, the agency may enroll in a managed 16 care plan or MediPass a Medicaid recipient who is exempt from 17 mandatory managed care enrollment, provided that: 18 1. The recipient's decision to enroll in a managed 19 care plan or MediPass is voluntary; 20 2. If the recipient chooses to enroll in a managed 21 care plan, the agency has determined that the managed care 22 plan provides specific programs and services which address the 23 special health needs of the recipient; and 24 3. The agency receives any necessary waivers from the 25 federal Centers for Medicare and Medicaid Services Health Care 26 Financing Administration. 27 28 The agency shall develop rules to establish policies by which 29 exceptions to the mandatory managed care enrollment 30 requirement may be made on a case-by-case basis. The rules 31 shall include the specific criteria to be applied when making 67 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 a determination as to whether to exempt a recipient from 2 mandatory enrollment in a managed care plan or MediPass. 3 School districts participating in the certified school match 4 program pursuant to ss. 409.908(21) and 1011.70 shall be 5 reimbursed by Medicaid, subject to the limitations of s. 6 1011.70(1), for a Medicaid-eligible child participating in the 7 services as authorized in s. 1011.70, as provided for in s. 8 409.9071, regardless of whether the child is enrolled in 9 MediPass or a managed care plan. Managed care plans shall make 10 a good faith effort to execute agreements with school 11 districts regarding the coordinated provision of services 12 authorized under s. 1011.70. County health departments 13 delivering school-based services pursuant to ss. 381.0056 and 14 381.0057 shall be reimbursed by Medicaid for the federal share 15 for a Medicaid-eligible child who receives Medicaid-covered 16 services in a school setting, regardless of whether the child 17 is enrolled in MediPass or a managed care plan. Managed care 18 plans shall make a good faith effort to execute agreements 19 with county health departments regarding the coordinated 20 provision of services to a Medicaid-eligible child. To ensure 21 continuity of care for Medicaid patients, the agency, the 22 Department of Health, and the Department of Education shall 23 develop procedures for ensuring that a student's managed care 24 plan or MediPass provider receives information relating to 25 services provided in accordance with ss. 381.0056, 381.0057, 26 409.9071, and 1011.70. 27 (j) The agency shall apply for a federal waiver from 28 the Centers for Medicare and Medicaid Services Health Care 29 Financing Administration to lock eligible Medicaid recipients 30 into a managed care plan or MediPass for 12 months after an 31 open enrollment period. After 12 months' enrollment, a 68 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 recipient may select another managed care plan or MediPass 2 provider. However, nothing shall prevent a Medicaid recipient 3 from changing primary care providers within the managed care 4 plan or MediPass program during the 12-month period. 5 (6) MediPass enrolled recipients may receive only up 6 to 10 visits of reimbursable services by participating 7 Medicaid providers upon the prior-authorization approval of 8 their assigned MediPass primary care primary case physician, 9 except for those services needed to address emergency 10 illnesses and conditions physicians licensed under chapter 460 11 and up to four visits of reimbursable services by 12 participating Medicaid physicians licensed under chapter 461. 13 Any further visits must be by prior authorization by the 14 MediPass primary care provider. However, nothing in this 15 subsection may be construed to increase the total number of 16 visits or the total amount of dollars per year per person 17 under current Medicaid rules, unless otherwise provided for in 18 the General Appropriations Act. 19 Section 6. Subsection (2) of section 409.913, Florida 20 Statutes, is amended, and subsection (36) is added to that 21 section, to read: 22 409.913 Oversight of the integrity of the Medicaid 23 program.--The agency shall operate a program to oversee the 24 activities of Florida Medicaid recipients, and providers and 25 their representatives, to ensure that fraudulent and abusive 26 behavior and neglect of recipients occur to the minimum extent 27 possible, and to recover overpayments and impose sanctions as 28 appropriate. Beginning January 1, 2003, and each year 29 thereafter, the agency and the Medicaid Fraud Control Unit of 30 the Department of Legal Affairs shall submit a joint report to 31 the Legislature documenting the effectiveness of the state's 69 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 efforts to control Medicaid fraud and abuse and to recover 2 Medicaid overpayments during the previous fiscal year. The 3 report must describe the number of cases opened and 4 investigated each year; the sources of the cases opened; the 5 disposition of the cases closed each year; the amount of 6 overpayments alleged in preliminary and final audit letters; 7 the number and amount of fines or penalties imposed; any 8 reductions in overpayment amounts negotiated in settlement 9 agreements or by other means; the amount of final agency 10 determinations of overpayments; the amount deducted from 11 federal claiming as a result of overpayments; the amount of 12 overpayments recovered each year; the amount of cost of 13 investigation recovered each year; the average length of time 14 to collect from the time the case was opened until the 15 overpayment is paid in full; the amount determined as 16 uncollectible and the portion of the uncollectible amount 17 subsequently reclaimed from the Federal Government; the number 18 of providers, by type, that are terminated from participation 19 in the Medicaid program as a result of fraud and abuse; and 20 all costs associated with discovering and prosecuting cases of 21 Medicaid overpayments and making recoveries in such cases. The 22 report must also document actions taken to prevent 23 overpayments and the number of providers prevented from 24 enrolling in or reenrolling in the Medicaid program as a 25 result of documented Medicaid fraud and abuse and must 26 recommend changes necessary to prevent or recover 27 overpayments. 28 (2) The agency shall conduct, or cause to be conducted 29 by contract or otherwise, reviews, investigations, analyses, 30 audits, or any combination thereof, to determine possible 31 fraud, abuse, overpayment, or recipient neglect in the 70 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 Medicaid program and shall report the findings of any 2 overpayments in audit reports as appropriate. At least 5 3 percent of all audits shall be conducted on a random basis. 4 (36) The agency shall provide to each Medicaid 5 recipient or his or her representative an explanation of 6 benefits in the form of a letter that is mailed to the most 7 recent address of the recipient on the record with the 8 Department of Children and Family Services. The explanation of 9 benefits must include the patient's name, the name of the 10 health care provider and the address of the location where the 11 service was provided, a description of all services billed to 12 Medicaid in terminology that should be understood by a 13 reasonable person, and information on how to report 14 inappropriate or incorrect billing to the agency or other law 15 enforcement entities for review or investigation. 16 Section 7. The Agency for Health Care Administration 17 shall submit to the Legislature by December 15, 2005, a report 18 on the legal and administrative barriers to enforcing section 19 409.9081, Florida Statutes. The report must describe how many 20 services require copayments, which providers collect 21 copayments, and the total amount of copayments collected from 22 recipients for all services required under section 409.9081, 23 Florida Statutes, by provider type for the 2001-2002 through 24 2004-2005 fiscal years. The agency shall recommend a mechanism 25 to enforce the requirement for Medicaid recipients to make 26 copayments which does not shift the copayment amount to the 27 provider. The agency shall also identify the federal or state 28 laws or regulations that permit Medicaid recipients to declare 29 impoverishment in order to avoid paying the copayment and 30 extent to which these statements of impoverishment are 31 verified. If claims of impoverishment are not currently 71 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 verified, the agency shall recommend a system for such 2 verification. The report must also identify any other 3 cost-sharing measures that could be imposed on Medicaid 4 recipients. 5 Section 8. The Agency for Health Care Administration 6 shall submit to the Legislature by January 15, 2006, 7 recommendations to ensure that Medicaid is the payer of last 8 resort as required by section 409.910, Florida Statutes. The 9 report must identify the public and private entities that are 10 liable for primary payment of health care services and 11 recommend methods to improve enforcement of third-party 12 liability responsibility and repayment of benefits to the 13 state Medicaid program. The report must estimate the potential 14 recoveries that may be achieved through third-party liability 15 efforts if administrative and legal barriers are removed. The 16 report must recommend whether modifications to the agency's 17 contingency-fee contract for third-party liability could 18 enhance third-party liability for benefits provided to 19 Medicaid recipients. 20 Section 9. The Agency for Health Care Administration 21 shall study provider pay-for-performance systems developed by 22 the United States Centers for Medicare and Medicaid Services 23 for use in the federal Medicare system and those developed by 24 private health insurance market to determine if these systems 25 can be used in this state's Medicaid program to improve the 26 quality of care while reducing inappropriate utilization. The 27 study must include a cost-benefit analysis to determine the 28 fiscal viability of introducing a pay-for-performance system 29 in this state's Medicaid program. The study must identify any 30 waivers of federal laws or regulations which would be 31 necessary to implement a pay-for-performance system and any 72 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 changes in provider contracts which are necessary to implement 2 this type of incentive system. The agency shall submit a 3 report on provider pay-for-performance systems to the 4 Legislature by January 15, 2006. 5 Section 10. By January 15, 2006, the Office of Program 6 Policy Analysis and Government Accountability shall submit to 7 the Legislature a study of the nursing home diversion programs 8 of the Department of Elderly Affairs. The study may be 9 conducted by Office of Program Policy Analysis and Government 10 Accountability staff or by a consultant obtained through a 11 competitive bid. The study must use a statistically-valid 12 methodology to assess the percent of persons over a period of 13 2 years in the diversion program who would have entered a 14 nursing home without the diversion services, which services 15 are most frequently used, and which services are least 16 frequently used in the diversion programs. The study must 17 determine whether the diversion programs are cost-effective or 18 are an expansion of the Medicaid program because persons in 19 the program would not have entered a nursing home within a 20 2-year period regardless of the availability of the diversion 21 programs. 22 Section 11. The Agency for Health Care Administration 23 shall conduct an analysis of potential costs savings achieved 24 through contracting with a multistate purchasing pool approved 25 by the federal Centers for Medicare and Medicaid Services for 26 drug-rebate administration, including, but not limited to, 27 calculating rebate amounts, invoicing manufacturers, 28 negotiating prices with manufacturers, negotiating disputes 29 with manufacturers, and maintaining a database of rebate 30 collections. The agency must submit to the Legislature its 31 analysis of this state's participation in multistate 73 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 purchasing pools by December 1, 2005. 2 Section 12. The Agency for Health Care Administration 3 shall identify how many individuals in the long-term care 4 diversion programs who receive care at home have a 5 patient-responsibility payment associated with their 6 participation in the diversion program. If no system is 7 available to assess this information, the agency shall 8 determine the cost of creating a system to identify and 9 collect these payments and whether the cost of developing a 10 system for this purpose is offset by the amount of 11 patient-responsibility payments which could be collected with 12 the system. The agency shall report this information to the 13 Legislature by December 1, 2005. 14 Section 13. The Office of Program Policy Analysis and 15 Government Accountability shall conduct a study of state 16 programs that allow non-Medicaid eligible persons under a 17 certain income level to buy into the Medicaid program as if it 18 was private insurance. The study shall examine Medicaid buy-in 19 programs in other states to determine if there are any models 20 that can be implemented in Florida which would provide access 21 to uninsured Floridians and what effect this program would 22 have on Medicaid expenditures based on the experience of 23 similar states. The study must also examine whether the 24 Medically Needy program could be redesigned to be a Medicaid 25 buy-in program. The study must be submitted to the Legislature 26 by January 1, 2006. 27 Section 14. The sum of $ in nonrecurring 28 funds is appropriated from the General Revenue Fund to the 29 Agency for Health Care Administration for the purpose for 30 developing infrastructure and administrative resources 31 necessary to develop the capitated managed care pilot program 74 9:39 AM 04/05/05 s0838p-he00-c8y
Florida Senate - 2005 PROPOSED COMMITTEE SUBSTITUTE Bill No. SB 838 Barcode 394008 587-1907-05 1 established in section 2 of this act during the 2005-2006 2 fiscal year. 3 Section 15. The sum of $ in nonrecurring 4 funds is appropriated from the General Revenue Fund to the 5 Agency for Health Care Administration for the purpose for 6 developing a managed care encounter data information system 7 during the 2005-2006 fiscal year. 8 Section 16. This act shall take effect July 1, 2005. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 75 9:39 AM 04/05/05 s0838p-he00-c8y
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