January 19, 2021
Print This PagePrint This Page

  *
Session:
Bill #:
Session:
Chamber: View Search Tips
Search Term:
Year: View Search Tips
Search Term:
Senate Bill 0838

Senate Bill sb0838c1

CODING: Words stricken are deletions; words underlined are additions.
    Florida Senate - 2005                            CS for SB 838

    By the Committee on Health Care; and Senator Peaden





    587-2018-05

  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; providing that a contract awarded to

13         a provider service network remains in effect

14         for a certain period; defining a provider

15         service network; providing health care

16         providers with a controlling interest in the

17         governing body of the provider service network

18         organization; requiring that the agency, in

19         partnership with the Department of Elderly

20         Affairs, develop an integrated, fixed-payment

21         delivery system for Medicaid recipients age 60

22         and older; deleting an obsolete provision

23         requiring the agency to develop a plan for

24         implementing emergency and crisis care;

25         requiring the agency to develop a system where

26         health care vendors may provide data

27         demonstrating that higher reimbursement for a

28         good or service will be offset by cost savings

29         in other goods or services; requiring the

30         Comprehensive Assessment and Review for

31         Long-Term Care Services (CARES) teams to

                                  1

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         consult with any person making a determination

 2         that a nursing home resident funded by Medicare

 3         is not making progress toward rehabilitation

 4         and assist in any appeals of the decision;

 5         requiring the agency to contract with an entity

 6         to design a clinical-utilization information

 7         database or electronic medical record for

 8         Medicaid providers; requiring that the agency

 9         develop a plan to expand disease-management

10         programs; requiring the agency to coordinate

11         with other entities to create emergency room

12         diversion programs for Medicaid recipients;

13         revising the Medicaid prescription drug

14         spending control program to reduce costs and

15         improve Medicaid recipient safety; requiring

16         that the agency implement a Medicaid

17         prescription drug management system; allowing

18         the agency to require age-related prior

19         authorizations for certain prescription drugs;

20         requiring the agency to determine the extent

21         that prescription drugs are returned and reused

22         in institutional settings and whether this

23         program could be expanded; requiring the agency

24         to develop an in-home, all-inclusive program of

25         services for Medicaid children with

26         life-threatening illnesses; authorizing the

27         agency to pay for emergency mental health

28         services provided through licensed crisis

29         stabilization centers; creating s. 409.91211,

30         F.S.; requiring that the agency develop a pilot

31         program for capitated managed care networks to

                                  2

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         deliver Medicaid health care services for all

 2         eligible Medicaid recipients in Medicaid

 3         fee-for-service or the MediPass program;

 4         authorizing the agency to include an

 5         alternative methodology for making additional

 6         Medicaid payments to hospitals; providing

 7         legislative intent; providing powers, duties,

 8         and responsibilities of the agency under the

 9         pilot program; requiring that the agency

10         provide a plan to the Legislature for

11         implementing the pilot program; requiring that

12         the Office of Program Policy Analysis and

13         Government Accountability, in consultation with

14         the Auditor General, evaluate the pilot program

15         and report to the Governor and the Legislature

16         on whether it should be expanded statewide;

17         amending s. 409.9122, F.S.; revising a

18         reference; amending s. 409.913, F.S.; requiring

19         5 percent of all program integrity audits to be

20         conducted on a random basis; requiring that

21         Medicaid recipients be provided with an

22         explanation of benefits; requiring that the

23         agency report to the Legislature on the legal

24         and administrative barriers to enforcing the

25         copayment requirements of s. 409.9081, F.S.;

26         requiring the agency to recommend ways to

27         ensure that Medicaid is the payer of last

28         resort; requiring the agency to conduct a study

29         of provider pay-for-performance systems;

30         requiring the Office of Program Policy Analysis

31         and Government Accountability to conduct a

                                  3

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         study of the long-term care diversion programs;

 2         requiring the agency to evaluate the

 3         cost-saving potential of contracting with a

 4         multistate prescription drug purchasing pool;

 5         requiring the agency to determine how many

 6         individuals in long-term care diversion

 7         programs have a patient payment responsibility

 8         that is not being collected and to recommend

 9         how to collect such payments; requiring the

10         Office of Program Policy Analysis and

11         Government Accountability to conduct a study of

12         Medicaid buy-in programs to determine if these

13         programs can be created in this state without

14         expanding the overall Medicaid program budget

15         or if the Medically Needy program can be

16         changed into a Medicaid buy-in program;

17         providing an appropriation for the purpose of

18         developing infrastructure and administrative

19         resources necessary to implement the pilot

20         project as created in s. 409.91211, F.S.;

21         providing an appropriation for developing an

22         encounter data system for Medicaid managed care

23         plans; providing an effective date.

24  

25  Be It Enacted by the Legislature of the State of Florida:

26  

27         Section 1.  Section 409.912, Florida Statutes, is

28  amended to read:

29         409.912  Cost-effective purchasing of health care.--The

30  agency shall purchase goods and services for Medicaid

31  recipients in the most cost-effective manner consistent with

                                  4

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  the delivery of quality medical care. To ensure that medical

 2  services are effectively utilized, the agency may, in any

 3  case, require a confirmation or second physician's opinion of

 4  the correct diagnosis for purposes of authorizing future

 5  services under the Medicaid program. This section does not

 6  restrict access to emergency services or poststabilization

 7  care services as defined in 42 C.F.R. part 438.114. Such

 8  confirmation or second opinion shall be rendered in a manner

 9  approved by the agency. The agency shall maximize the use of

10  prepaid per capita and prepaid aggregate fixed-sum basis

11  services when appropriate and other alternative service

12  delivery and reimbursement methodologies, including

13  competitive bidding pursuant to s. 287.057, designed to

14  facilitate the cost-effective purchase of a case-managed

15  continuum of care. The agency shall also require providers to

16  minimize the exposure of recipients to the need for acute

17  inpatient, custodial, and other institutional care and the

18  inappropriate or unnecessary use of high-cost services. The

19  agency shall contract with a vendor to monitor and evaluate

20  the clinical practice patterns of providers in order to

21  identify trends that are outside the normal practice patterns

22  of a provider's professional peers or the national guidelines

23  of a provider's professional association. The vendor must be

24  able to provide information and counseling to a provider whose

25  practice patterns are outside the norms, in consultation with

26  the agency, to improve patient care and reduce inappropriate

27  utilization. The agency may mandate prior authorization, drug

28  therapy management, or disease management participation for

29  certain populations of Medicaid beneficiaries, certain drug

30  classes, or particular drugs to prevent fraud, abuse, overuse,

31  and possible dangerous drug interactions. The Pharmaceutical

                                  5

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  and Therapeutics Committee shall make recommendations to the

 2  agency on drugs for which prior authorization is required. The

 3  agency shall inform the Pharmaceutical and Therapeutics

 4  Committee of its decisions regarding drugs subject to prior

 5  authorization. The agency is authorized to limit the entities

 6  it contracts with or enrolls as Medicaid providers by

 7  developing a provider network through provider credentialing.

 8  The agency may competitively bid single-source-provider

 9  contracts if procurement of goods or services results in

10  demonstrated cost savings to the state without limiting access

11  to care. The agency may limit its network based on the

12  assessment of beneficiary access to care, provider

13  availability, provider quality standards, time and distance

14  standards for access to care, the cultural competence of the

15  provider network, demographic characteristics of Medicaid

16  beneficiaries, practice and provider-to-beneficiary standards,

17  appointment wait times, beneficiary use of services, provider

18  turnover, provider profiling, provider licensure history,

19  previous program integrity investigations and findings, peer

20  review, provider Medicaid policy and billing compliance

21  records, clinical and medical record audits, and other

22  factors. Providers shall not be entitled to enrollment in the

23  Medicaid provider network. The agency shall determine

24  instances in which allowing Medicaid beneficiaries to purchase

25  durable medical equipment and other goods is less expensive to

26  the Medicaid program than long-term rental of the equipment or

27  goods. The agency may establish rules to facilitate purchases

28  in lieu of long-term rentals in order to protect against fraud

29  and abuse in the Medicaid program as defined in s. 409.913.

30  The agency may is authorized to seek federal waivers necessary

31  to administer these policies implement this policy.

                                  6

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (1)  The agency shall work with the Department of

 2  Children and Family Services to ensure access of children and

 3  families in the child protection system to needed and

 4  appropriate mental health and substance abuse services.

 5         (2)  The agency may enter into agreements with

 6  appropriate agents of other state agencies or of any agency of

 7  the Federal Government and accept such duties in respect to

 8  social welfare or public aid as may be necessary to implement

 9  the provisions of Title XIX of the Social Security Act and ss.

10  409.901-409.920.

11         (3)  The agency may contract with health maintenance

12  organizations certified pursuant to part I of chapter 641 for

13  the provision of services to recipients.

14         (4)  The agency may contract with:

15         (a)  An entity that provides no prepaid health care

16  services other than Medicaid services under contract with the

17  agency and which is owned and operated by a county, county

18  health department, or county-owned and operated hospital to

19  provide health care services on a prepaid or fixed-sum basis

20  to recipients, which entity may provide such prepaid services

21  either directly or through arrangements with other providers.

22  Such prepaid health care services entities must be licensed

23  under parts I and III by January 1, 1998, and until then are

24  exempt from the provisions of part I of chapter 641. An entity

25  recognized under this paragraph which demonstrates to the

26  satisfaction of the Office of Insurance Regulation of the

27  Financial Services Commission that it is backed by the full

28  faith and credit of the county in which it is located may be

29  exempted from s. 641.225.

30         (b)  An entity that is providing comprehensive

31  behavioral health care services to certain Medicaid recipients

                                  7

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  through a capitated, prepaid arrangement pursuant to the

 2  federal waiver provided for by s. 409.905(5). Such an entity

 3  must be licensed under chapter 624, chapter 636, or chapter

 4  641 and must possess the clinical systems and operational

 5  competence to manage risk and provide comprehensive behavioral

 6  health care to Medicaid recipients. As used in this paragraph,

 7  the term "comprehensive behavioral health care services" means

 8  covered mental health and substance abuse treatment services

 9  that are available to Medicaid recipients. The secretary of

10  the Department of Children and Family Services shall approve

11  provisions of procurements related to children in the

12  department's care or custody prior to enrolling such children

13  in a prepaid behavioral health plan. Any contract awarded

14  under this paragraph must be competitively procured. In

15  developing the behavioral health care prepaid plan procurement

16  document, the agency shall ensure that the procurement

17  document requires the contractor to develop and implement a

18  plan to ensure compliance with s. 394.4574 related to services

19  provided to residents of licensed assisted living facilities

20  that hold a limited mental health license. Except as provided

21  in subparagraph 8., the agency shall seek federal approval to

22  contract with a single entity meeting these requirements to

23  provide comprehensive behavioral health care services to all

24  Medicaid recipients not enrolled in a managed care plan in an

25  AHCA area. Each entity must offer sufficient choice of

26  providers in its network to ensure recipient access to care

27  and the opportunity to select a provider with whom they are

28  satisfied. The network shall include all public mental health

29  hospitals. To ensure unimpaired access to behavioral health

30  care services by Medicaid recipients, all contracts issued

31  pursuant to this paragraph shall require 80 percent of the

                                  8

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  capitation paid to the managed care plan, including health

 2  maintenance organizations, to be expended for the provision of

 3  behavioral health care services. In the event the managed care

 4  plan expends less than 80 percent of the capitation paid

 5  pursuant to this paragraph for the provision of behavioral

 6  health care services, the difference shall be returned to the

 7  agency. The agency shall provide the managed care plan with a

 8  certification letter indicating the amount of capitation paid

 9  during each calendar year for the provision of behavioral

10  health care services pursuant to this section. The agency may

11  reimburse for substance abuse treatment services on a

12  fee-for-service basis until the agency finds that adequate

13  funds are available for capitated, prepaid arrangements.

14         1.  By January 1, 2001, the agency shall modify the

15  contracts with the entities providing comprehensive inpatient

16  and outpatient mental health care services to Medicaid

17  recipients in Hillsborough, Highlands, Hardee, Manatee, and

18  Polk Counties, to include substance abuse treatment services.

19         2.  By July 1, 2003, the agency and the Department of

20  Children and Family Services shall execute a written agreement

21  that requires collaboration and joint development of all

22  policy, budgets, procurement documents, contracts, and

23  monitoring plans that have an impact on the state and Medicaid

24  community mental health and targeted case management programs.

25         3.  Except as provided in subparagraph 8., by July 1,

26  2006, the agency and the Department of Children and Family

27  Services shall contract with managed care entities in each

28  AHCA area except area 6 or arrange to provide comprehensive

29  inpatient and outpatient mental health and substance abuse

30  services through capitated prepaid arrangements to all

31  Medicaid recipients who are eligible to participate in such

                                  9

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  plans under federal law and regulation. In AHCA areas where

 2  eligible individuals number less than 150,000, the agency

 3  shall contract with a single managed care plan to provide

 4  comprehensive behavioral health services to all recipients who

 5  are not enrolled in a Medicaid health maintenance

 6  organization. The agency may contract with more than one

 7  comprehensive behavioral health provider to provide care to

 8  recipients who are not enrolled in a Medicaid health

 9  maintenance organization in AHCA areas where the eligible

10  population exceeds 150,000. Contracts for comprehensive

11  behavioral health providers awarded pursuant to this section

12  shall be competitively procured. Both for-profit and

13  not-for-profit corporations shall be eligible to compete.

14  Managed care plans contracting with the agency under

15  subsection (3) shall provide and receive payment for the same

16  comprehensive behavioral health benefits as provided in AHCA

17  rules, including handbooks incorporated by reference.

18         4.  By October 1, 2003, the agency and the department

19  shall submit a plan to the Governor, the President of the

20  Senate, and the Speaker of the House of Representatives which

21  provides for the full implementation of capitated prepaid

22  behavioral health care in all areas of the state.

23         a.  Implementation shall begin in 2003 in those AHCA

24  areas of the state where the agency is able to establish

25  sufficient capitation rates.

26         b.  If the agency determines that the proposed

27  capitation rate in any area is insufficient to provide

28  appropriate services, the agency may adjust the capitation

29  rate to ensure that care will be available. The agency and the

30  department may use existing general revenue to address any

31  

                                  10

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  additional required match but may not over-obligate existing

 2  funds on an annualized basis.

 3         c.  Subject to any limitations provided for in the

 4  General Appropriations Act, the agency, in compliance with

 5  appropriate federal authorization, shall develop policies and

 6  procedures that allow for certification of local and state

 7  funds.

 8         5.  Children residing in a statewide inpatient

 9  psychiatric program, or in a Department of Juvenile Justice or

10  a Department of Children and Family Services residential

11  program approved as a Medicaid behavioral health overlay

12  services provider shall not be included in a behavioral health

13  care prepaid health plan or any other Medicaid managed care

14  plan pursuant to this paragraph.

15         6.  In converting to a prepaid system of delivery, the

16  agency shall in its procurement document require an entity

17  providing only comprehensive behavioral health care services

18  to prevent the displacement of indigent care patients by

19  enrollees in the Medicaid prepaid health plan providing

20  behavioral health care services from facilities receiving

21  state funding to provide indigent behavioral health care, to

22  facilities licensed under chapter 395 which do not receive

23  state funding for indigent behavioral health care, or

24  reimburse the unsubsidized facility for the cost of behavioral

25  health care provided to the displaced indigent care patient.

26         7.  Traditional community mental health providers under

27  contract with the Department of Children and Family Services

28  pursuant to part IV of chapter 394, child welfare providers

29  under contract with the Department of Children and Family

30  Services in areas 1 and 6, and inpatient mental health

31  providers licensed pursuant to chapter 395 must be offered an

                                  11

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  opportunity to accept or decline a contract to participate in

 2  any provider network for prepaid behavioral health services.

 3         8.  For fiscal year 2004-2005, all Medicaid eligible

 4  children, except children in areas 1 and 6, whose cases are

 5  open for child welfare services in the HomeSafeNet system,

 6  shall be enrolled in MediPass or in Medicaid fee-for-service

 7  and all their behavioral health care services including

 8  inpatient, outpatient psychiatric, community mental health,

 9  and case management shall be reimbursed on a fee-for-service

10  basis. Beginning July 1, 2005, such children, who are open for

11  child welfare services in the HomeSafeNet system, shall

12  receive their behavioral health care services through a

13  specialty prepaid plan operated by community-based lead

14  agencies either through a single agency or formal agreements

15  among several agencies. The specialty prepaid plan must result

16  in savings to the state comparable to savings achieved in

17  other Medicaid managed care and prepaid programs. Such plan

18  must provide mechanisms to maximize state and local revenues.

19  The specialty prepaid plan shall be developed by the agency

20  and the Department of Children and Family Services. The agency

21  is authorized to seek any federal waivers to implement this

22  initiative.

23         (c)  A federally qualified health center or an entity

24  owned by one or more federally qualified health centers or an

25  entity owned by other migrant and community health centers

26  receiving non-Medicaid financial support from the Federal

27  Government to provide health care services on a prepaid or

28  fixed-sum basis to recipients. Such prepaid health care

29  services entity must be licensed under parts I and III of

30  chapter 641, but shall be prohibited from serving Medicaid

31  recipients on a prepaid basis, until such licensure has been

                                  12

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  obtained. However, such an entity is exempt from s. 641.225 if

 2  the entity meets the requirements specified in subsections

 3  (17) and (18).

 4         (d)  A provider service network may be reimbursed on a

 5  fee-for-service or prepaid basis. A provider service network

 6  which is reimbursed by the agency on a prepaid basis shall be

 7  exempt from parts I and III of chapter 641, but must meet

 8  appropriate financial reserve, quality assurance, and patient

 9  rights requirements as established by the agency. The agency

10  shall award contracts on a competitive bid basis and shall

11  select bidders based upon price and quality of care. Medicaid

12  recipients assigned to a demonstration project shall be chosen

13  equally from those who would otherwise have been assigned to

14  prepaid plans and MediPass. The agency is authorized to seek

15  federal Medicaid waivers as necessary to implement the

16  provisions of this section. Any contract previously awarded to

17  a provider service network operated by a hospital pursuant to

18  this subsection shall remain in effect for a period of 3 years

19  following the current contract-expiration date, regardless of

20  any contractual provisions to the contrary. A provider service

21  network is a network established or organized and operated by

22  a health care provider, or group of affiliated health care

23  providers, which provides a substantial proportion of the

24  health care items and services under a contract directly

25  through the provider or affiliated group of providers and may

26  make arrangements with physicians or other health care

27  professionals, health care institutions, or any combination of

28  such individuals or institutions to assume all or part of the

29  financial risk on a prospective basis for the provision of

30  basic health services by the physicians, by other health

31  professionals, or through the institutions. The health care

                                  13

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  providers must have a controlling interest in the governing

 2  body of the provider service network organization.

 3         (e)  An entity that provides only comprehensive

 4  behavioral health care services to certain Medicaid recipients

 5  through an administrative services organization agreement.

 6  Such an entity must possess the clinical systems and

 7  operational competence to provide comprehensive health care to

 8  Medicaid recipients. As used in this paragraph, the term

 9  "comprehensive behavioral health care services" means covered

10  mental health and substance abuse treatment services that are

11  available to Medicaid recipients. Any contract awarded under

12  this paragraph must be competitively procured. The agency must

13  ensure that Medicaid recipients have available the choice of

14  at least two managed care plans for their behavioral health

15  care services.

16         (f)  An entity that provides in-home physician services

17  to test the cost-effectiveness of enhanced home-based medical

18  care to Medicaid recipients with degenerative neurological

19  diseases and other diseases or disabling conditions associated

20  with high costs to Medicaid. The program shall be designed to

21  serve very disabled persons and to reduce Medicaid reimbursed

22  costs for inpatient, outpatient, and emergency department

23  services. The agency shall contract with vendors on a

24  risk-sharing basis.

25         (g)  Children's provider networks that provide care

26  coordination and care management for Medicaid-eligible

27  pediatric patients, primary care, authorization of specialty

28  care, and other urgent and emergency care through organized

29  providers designed to service Medicaid eligibles under age 18

30  and pediatric emergency departments' diversion programs. The

31  networks shall provide after-hour operations, including

                                  14

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  evening and weekend hours, to promote, when appropriate, the

 2  use of the children's networks rather than hospital emergency

 3  departments.

 4         (h)  An entity authorized in s. 430.205 to contract

 5  with the agency and the Department of Elderly Affairs to

 6  provide health care and social services on a prepaid or

 7  fixed-sum basis to elderly recipients. Such prepaid health

 8  care services entities are exempt from the provisions of part

 9  I of chapter 641 for the first 3 years of operation. An entity

10  recognized under this paragraph that demonstrates to the

11  satisfaction of the Office of Insurance Regulation that it is

12  backed by the full faith and credit of one or more counties in

13  which it operates may be exempted from s. 641.225.

14         (i)  A Children's Medical Services Network, as defined

15  in s. 391.021.

16         (5)  By December 1, 2005, the Agency for Health Care

17  Administration, in partnership with the Department of Elderly

18  Affairs, shall create an integrated, fixed-payment delivery

19  system for Medicaid recipients who are 60 years of age or

20  older. Eligible Medicaid recipients may participate in the

21  integrated system on a voluntary basis. The program must

22  transfer all Medicaid services for eligible elderly

23  individuals who choose to participate into an integrated-care

24  management model designed to serve Medicaid recipients in the

25  community. The program must combine all funding for Medicaid

26  services provided to individuals 60 years of age or older into

27  the integrated system, including funds for Medicaid home and

28  community-based waiver services; all Medicaid services

29  authorized in ss. 409.905 and 409.906, excluding funds for

30  Medicaid nursing home services unless the agency is able to

31  demonstrate how the integration of the funds will improve

                                  15

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  coordinated care for these services in a less costly manner;

 2  and Medicare premiums, coinsurance, and deductibles for

 3  persons dually eligible for Medicaid and Medicare as

 4  prescribed in s. 409.908(13). The agency must begin

 5  implementing the integrated system in a pilot area that may

 6  only include Orange, Osceola, Lake, and Seminole Counties.

 7         (a)  Individuals who are 60 years of age or older and

 8  enrolled in the the developmental disabilities waiver program,

 9  the family and supported-living waiver program, the project

10  AIDS care waiver program, the traumatic brain injury and

11  spinal cord injury waiver program, the consumer-directed care

12  waiver program, and the program of all-inclusive care for the

13  elderly program, and residents of institutional care

14  facilities for the developmentally disabled, must be excluded

15  from the integrated system.

16         (b)  The program must use a competitive-procurement

17  process to select entities to operate the integrated system.

18  Entities eligible to submit bids include managed care

19  organizations licensed under chapter 641, including entities

20  eligible to participate in the nursing home diversion program,

21  other qualified providers as defined in s. 430.703(7),

22  community care for the elderly lead agencies, and other

23  state-certified community service networks that meet

24  comparable standards as defined by the agency, in consultation

25  with the Department of Elderly Affairs and the Office of

26  Insurance Regulation, to be financially solvent and able to

27  take on financial risk for managed care. Community service

28  networks that are certified pursuant to the comparable

29  standards defined by the agency are not required to be

30  licensed under chapter 641.

31  

                                  16

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (c)  The agency must ensure that the

 2  capitation-rate-setting methodology for the integrated system

 3  is actuarially sound and reflects the intent to provide

 4  quality care in the least-restrictive setting. The agency must

 5  also require integrated-system providers to develop a

 6  credentialing system for service providers and to contract

 7  with all Gold Seal nursing homes, where feasible, and exclude,

 8  where feasible, chronically poor-performing facilities and

 9  providers as defined by the agency. The integrated system must

10  provide that if the recipient resides in a noncontracted

11  residential facility licensed under chapter 400 at the time

12  the integrated system is initiated, the recipient must be

13  permitted to continue to reside in the noncontracted facility

14  as long as the recipient desires. The integrated system must

15  also provide that, in the absence of a contract between the

16  integrated-system provider and the residential facility

17  licensed under chapter 400, current Medicaid rates must

18  prevail. The agency and the Department of Elderly Affairs must

19  jointly develop procedures to manage the services provided

20  through the integrated system in order to ensure quality and

21  recipient choice.

22         (d)  The agency may seek federal waivers and adopt

23  rules as necessary to administer the integrated system. By

24  October 1, 2003, the agency and the department shall, to the

25  extent feasible, develop a plan for implementing new Medicaid

26  procedure codes for emergency and crisis care, supportive

27  residential services, and other services designed to maximize

28  the use of Medicaid funds for Medicaid-eligible recipients.

29  The agency shall include in the agreement developed pursuant

30  to subsection (4) a provision that ensures that the match

31  requirements for these new procedure codes are met by

                                  17

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  certifying eligible general revenue or local funds that are

 2  currently expended on these services by the department with

 3  contracted alcohol, drug abuse, and mental health providers.

 4  The plan must describe specific procedure codes to be

 5  implemented, a projection of the number of procedures to be

 6  delivered during fiscal year 2003-2004, and a financial

 7  analysis that describes the certified match procedures, and

 8  accountability mechanisms, projects the earnings associated

 9  with these procedures, and describes the sources of state

10  match. This plan may not be implemented in any part until

11  approved by the Legislative Budget Commission. If such

12  approval has not occurred by December 31, 2003, the plan shall

13  be submitted for consideration by the 2004 Legislature.

14         (6)  The agency may contract with any public or private

15  entity otherwise authorized by this section on a prepaid or

16  fixed-sum basis for the provision of health care services to

17  recipients. An entity may provide prepaid services to

18  recipients, either directly or through arrangements with other

19  entities, if each entity involved in providing services:

20         (a)  Is organized primarily for the purpose of

21  providing health care or other services of the type regularly

22  offered to Medicaid recipients;

23         (b)  Ensures that services meet the standards set by

24  the agency for quality, appropriateness, and timeliness;

25         (c)  Makes provisions satisfactory to the agency for

26  insolvency protection and ensures that neither enrolled

27  Medicaid recipients nor the agency will be liable for the

28  debts of the entity;

29         (d)  Submits to the agency, if a private entity, a

30  financial plan that the agency finds to be fiscally sound and

31  that provides for working capital in the form of cash or

                                  18

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  equivalent liquid assets excluding revenues from Medicaid

 2  premium payments equal to at least the first 3 months of

 3  operating expenses or $200,000, whichever is greater;

 4         (e)  Furnishes evidence satisfactory to the agency of

 5  adequate liability insurance coverage or an adequate plan of

 6  self-insurance to respond to claims for injuries arising out

 7  of the furnishing of health care;

 8         (f)  Provides, through contract or otherwise, for

 9  periodic review of its medical facilities and services, as

10  required by the agency; and

11         (g)  Provides organizational, operational, financial,

12  and other information required by the agency.

13         (7)  The agency may contract on a prepaid or fixed-sum

14  basis with any health insurer that:

15         (a)  Pays for health care services provided to enrolled

16  Medicaid recipients in exchange for a premium payment paid by

17  the agency;

18         (b)  Assumes the underwriting risk; and

19         (c)  Is organized and licensed under applicable

20  provisions of the Florida Insurance Code and is currently in

21  good standing with the Office of Insurance Regulation.

22         (8)  The agency may contract on a prepaid or fixed-sum

23  basis with an exclusive provider organization to provide

24  health care services to Medicaid recipients provided that the

25  exclusive provider organization meets applicable managed care

26  plan requirements in this section, ss. 409.9122, 409.9123,

27  409.9128, and 627.6472, and other applicable provisions of

28  law.

29         (9)  The Agency for Health Care Administration may

30  provide cost-effective purchasing of chiropractic services on

31  a fee-for-service basis to Medicaid recipients through

                                  19

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  arrangements with a statewide chiropractic preferred provider

 2  organization incorporated in this state as a not-for-profit

 3  corporation. The agency shall ensure that the benefit limits

 4  and prior authorization requirements in the current Medicaid

 5  program shall apply to the services provided by the

 6  chiropractic preferred provider organization.

 7         (10)  The agency shall not contract on a prepaid or

 8  fixed-sum basis for Medicaid services with an entity which

 9  knows or reasonably should know that any officer, director,

10  agent, managing employee, or owner of stock or beneficial

11  interest in excess of 5 percent common or preferred stock, or

12  the entity itself, has been found guilty of, regardless of

13  adjudication, or entered a plea of nolo contendere, or guilty,

14  to:

15         (a)  Fraud;

16         (b)  Violation of federal or state antitrust statutes,

17  including those proscribing price fixing between competitors

18  and the allocation of customers among competitors;

19         (c)  Commission of a felony involving embezzlement,

20  theft, forgery, income tax evasion, bribery, falsification or

21  destruction of records, making false statements, receiving

22  stolen property, making false claims, or obstruction of

23  justice; or

24         (d)  Any crime in any jurisdiction which directly

25  relates to the provision of health services on a prepaid or

26  fixed-sum basis.

27         (11)  The agency, after notifying the Legislature, may

28  apply for waivers of applicable federal laws and regulations

29  as necessary to implement more appropriate systems of health

30  care for Medicaid recipients and reduce the cost of the

31  Medicaid program to the state and federal governments and

                                  20

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  shall implement such programs, after legislative approval,

 2  within a reasonable period of time after federal approval.

 3  These programs must be designed primarily to reduce the need

 4  for inpatient care, custodial care and other long-term or

 5  institutional care, and other high-cost services.

 6         (a)  Prior to seeking legislative approval of such a

 7  waiver as authorized by this subsection, the agency shall

 8  provide notice and an opportunity for public comment. Notice

 9  shall be provided to all persons who have made requests of the

10  agency for advance notice and shall be published in the

11  Florida Administrative Weekly not less than 28 days prior to

12  the intended action.

13         (b)  Notwithstanding s. 216.292, funds that are

14  appropriated to the Department of Elderly Affairs for the

15  Assisted Living for the Elderly Medicaid waiver and are not

16  expended shall be transferred to the agency to fund

17  Medicaid-reimbursed nursing home care.

18         (12)  The agency shall establish a postpayment

19  utilization control program designed to identify recipients

20  who may inappropriately overuse or underuse Medicaid services

21  and shall provide methods to correct such misuse.

22         (13)  The agency shall develop and provide coordinated

23  systems of care for Medicaid recipients and may contract with

24  public or private entities to develop and administer such

25  systems of care among public and private health care providers

26  in a given geographic area.

27         (14)(a)  The agency shall operate or contract for the

28  operation of utilization management and incentive systems

29  designed to encourage cost-effective use services.

30         (b)  The agency shall develop a procedure by which

31  health care providers and service vendors can provide the

                                  21

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  Medicaid program with methodologically valid data that

 2  demonstrates whether a particular good or service can offset

 3  the cost of providing the good or service in an alternative

 4  setting or through other means and therefore should receive a

 5  higher reimbursement. Any data provided to the agency for such

 6  purpose must demonstrate that for every $1 increase in

 7  reimbursement rates for the good or service there will be an

 8  offset of at least $2 from the decrease in the cost of

 9  providing the good or service through the traditional method.

10  The agency shall be the final arbitrator of the cost-benefit

11  analysis and must determine whether the increased

12  reimbursement for a particular good or service offsets the

13  cost of other goods or services in the Medicaid program. If

14  the agency determines that the increased reimbursement is

15  cost-effective, the agency shall recommend a change in the

16  reimbursement schedule for that particular good or service.

17  If, within 12 months after implementing any rate change under

18  this procedure, the agency determines that costs were not

19  offset by the increased reimbursement schedule, the agency may

20  revert to the former reimbursement schedule for the particular

21  good or service.

22         (15)(a)  The agency shall operate the Comprehensive

23  Assessment and Review for Long-Term Care Services (CARES)

24  nursing facility preadmission screening program to ensure that

25  Medicaid payment for nursing facility care is made only for

26  individuals whose conditions require such care and to ensure

27  that long-term care services are provided in the setting most

28  appropriate to the needs of the person and in the most

29  economical manner possible. The CARES program shall also

30  ensure that individuals participating in Medicaid home and

31  

                                  22

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 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

                                  23

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 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  

                                  24

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (f)  The Department of Elderly Affairs shall track

 2  individuals over time who are assessed under the CARES program

 3  and who are diverted from nursing home placement. By January

 4  15 of each year, the department shall submit to the

 5  Legislature and the Office of Long-Term-Care Policy a

 6  longitudinal study of the individuals who are diverted from

 7  nursing home placement. The study must include:

 8         1.  The demographic characteristics of the individuals

 9  assessed and diverted from nursing home placement, including,

10  but not limited to, age, race, gender, frailty, caregiver

11  status, living arrangements, and geographic location;

12         2.  A summary of community services provided to

13  individuals for 1 year after assessment and diversion;

14         3.  A summary of inpatient hospital admissions for

15  individuals who have been diverted; and

16         4.  A summary of the length of time between diversion

17  and subsequent entry into a nursing home or death.

18         (g)  By July 1, 2005, the department and the Agency for

19  Health Care Administration shall report to the President of

20  the Senate and the Speaker of the House of Representatives

21  regarding the impact to the state of modifying level-of-care

22  criteria to eliminate the Intermediate II level of care.

23         (16)(a)  The agency shall identify health care

24  utilization and price patterns within the Medicaid program

25  which are not cost-effective or medically appropriate and

26  assess the effectiveness of new or alternate methods of

27  providing and monitoring service, and may implement such

28  methods as it considers appropriate. Such methods may include

29  disease management initiatives, an integrated and systematic

30  approach for managing the health care needs of recipients who

31  are at risk of or diagnosed with a specific disease by using

                                  25

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  best practices, prevention strategies, clinical-practice

 2  improvement, clinical interventions and protocols, outcomes

 3  research, information technology, and other tools and

 4  resources to reduce overall costs and improve measurable

 5  outcomes.

 6         (b)  The responsibility of the agency under this

 7  subsection shall include the development of capabilities to

 8  identify actual and optimal practice patterns; patient and

 9  provider educational initiatives; methods for determining

10  patient compliance with prescribed treatments; fraud, waste,

11  and abuse prevention and detection programs; and beneficiary

12  case management programs.

13         1.  The practice pattern identification program shall

14  evaluate practitioner prescribing patterns based on national

15  and regional practice guidelines, comparing practitioners to

16  their peer groups. The agency and its Drug Utilization Review

17  Board shall consult with the Department of Health and a panel

18  of practicing health care professionals consisting of the

19  following: the Speaker of the House of Representatives and the

20  President of the Senate shall each appoint three physicians

21  licensed under chapter 458 or chapter 459; and the Governor

22  shall appoint two pharmacists licensed under chapter 465 and

23  one dentist licensed under chapter 466 who is an oral surgeon.

24  Terms of the panel members shall expire at the discretion of

25  the appointing official. The panel shall begin its work by

26  August 1, 1999, regardless of the number of appointments made

27  by that date. The advisory panel shall be responsible for

28  evaluating treatment guidelines and recommending ways to

29  incorporate their use in the practice pattern identification

30  program. Practitioners who are prescribing inappropriately or

31  inefficiently, as determined by the agency, may have their

                                  26

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  prescribing of certain drugs subject to prior authorization or

 2  may be terminated from all participation in the Medicaid

 3  program.

 4         2.  The agency shall also develop educational

 5  interventions designed to promote the proper use of

 6  medications by providers and beneficiaries.

 7         3.  The agency shall implement a pharmacy fraud, waste,

 8  and abuse initiative that may include a surety bond or letter

 9  of credit requirement for participating pharmacies, enhanced

10  provider auditing practices, the use of additional fraud and

11  abuse software, recipient management programs for

12  beneficiaries inappropriately using their benefits, and other

13  steps that will eliminate provider and recipient fraud, waste,

14  and abuse. The initiative shall address enforcement efforts to

15  reduce the number and use of counterfeit prescriptions.

16         4.  By September 30, 2002, the agency shall contract

17  with an entity in the state to implement a wireless handheld

18  clinical pharmacology drug information database for

19  practitioners. The initiative shall be designed to enhance the

20  agency's efforts to reduce fraud, abuse, and errors in the

21  prescription drug benefit program and to otherwise further the

22  intent of this paragraph.

23         5.  By September 30, 2005, the agency shall contract

24  with an entity to design a database of clinical utilization

25  information or electronic medical records for Medicaid

26  providers. This system must be web-based and allow providers

27  to review on a real-time basis the utilization of Medicaid

28  services, including, but not limited to, physician office

29  visits, inpatient and outpatient hospitalizations, laboratory

30  and pathology services, radiological and other imaging

31  services, dental care, and patterns of dispensing prescription

                                  27

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  drugs in order to coordinate care and identify potential fraud

 2  and abuse.

 3         6.  By January 1, 2006, the agency shall provide

 4  expanded statewide disease-management programs to provide case

 5  management for persons with chronic diseases including

 6  diabetes, hypertension, human immunodeficiency virus/acquired

 7  immune deficiency syndrome, asthma, congestive heart failure,

 8  hemophilia, end-stage renal disease or chronic kidney disease,

 9  cancer, sickle cell anemia, chronic fatigue syndrome, and

10  chronic pain. In selecting disease-management vendors,

11  preference must be given to disease-management organizations

12  that are able to provide case management across disease states

13  through coordinated efforts between physicians and

14  pharmacists. The expansion must take two primary forms. The

15  first type of expansion must emphasis changes in clinical

16  practice patterns of physicians and pharmacists in order to

17  meet evidence-based medicine standards and best-practice

18  guidelines for each physician's specialty. The second

19  expansion must emphasize changes in behavior of persons with

20  chronic medical conditions. The expansion must include a

21  randomly assigned, experimental design to evaluate short-term

22  changes in utilization patterns for Medicaid services and

23  clinical outcome measures. The agency shall use an

24  independent, third party to evaluate the expansion of the

25  disease-management program. The agency shall select the

26  geographic areas in which to expand the disease-management

27  program, estimate the costs to implement each expansion, and

28  develop a timeline for statewide implementation. Based on the

29  evaluation of the expansion, the agency may recommend

30  statewide expansion of the disease-management programs having

31  the best fiscal and clinical outcomes.

                                  28

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         7.5.  The agency may apply for any federal waivers

 2  needed to administer implement this paragraph.

 3         (17)  An entity contracting on a prepaid or fixed-sum

 4  basis shall, in addition to meeting any applicable statutory

 5  surplus requirements, also maintain at all times in the form

 6  of cash, investments that mature in less than 180 days

 7  allowable as admitted assets by the Office of Insurance

 8  Regulation, and restricted funds or deposits controlled by the

 9  agency or the Office of Insurance Regulation, a surplus amount

10  equal to one-and-one-half times the entity's monthly Medicaid

11  prepaid revenues. As used in this subsection, the term

12  "surplus" means the entity's total assets minus total

13  liabilities. If an entity's surplus falls below an amount

14  equal to one-and-one-half times the entity's monthly Medicaid

15  prepaid revenues, the agency shall prohibit the entity from

16  engaging in marketing and preenrollment activities, shall

17  cease to process new enrollments, and shall not renew the

18  entity's contract until the required balance is achieved. The

19  requirements of this subsection do not apply:

20         (a)  Where a public entity agrees to fund any deficit

21  incurred by the contracting entity; or

22         (b)  Where the entity's performance and obligations are

23  guaranteed in writing by a guaranteeing organization which:

24         1.  Has been in operation for at least 5 years and has

25  assets in excess of $50 million; or

26         2.  Submits a written guarantee acceptable to the

27  agency which is irrevocable during the term of the contracting

28  entity's contract with the agency and, upon termination of the

29  contract, until the agency receives proof of satisfaction of

30  all outstanding obligations incurred under the contract.

31  

                                  29

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (18)(a)  The agency may require an entity contracting

 2  on a prepaid or fixed-sum basis to establish a restricted

 3  insolvency protection account with a federally guaranteed

 4  financial institution licensed to do business in this state.

 5  The entity shall deposit into that account 5 percent of the

 6  capitation payments made by the agency each month until a

 7  maximum total of 2 percent of the total current contract

 8  amount is reached. The restricted insolvency protection

 9  account may be drawn upon with the authorized signatures of

10  two persons designated by the entity and two representatives

11  of the agency. If the agency finds that the entity is

12  insolvent, the agency may draw upon the account solely with

13  the two authorized signatures of representatives of the

14  agency, and the funds may be disbursed to meet financial

15  obligations incurred by the entity under the prepaid contract.

16  If the contract is terminated, expired, or not continued, the

17  account balance must be released by the agency to the entity

18  upon receipt of proof of satisfaction of all outstanding

19  obligations incurred under this contract.

20         (b)  The agency may waive the insolvency protection

21  account requirement in writing when evidence is on file with

22  the agency of adequate insolvency insurance and reinsurance

23  that will protect enrollees if the entity becomes unable to

24  meet its obligations.

25         (19)  An entity that contracts with the agency on a

26  prepaid or fixed-sum basis for the provision of Medicaid

27  services shall reimburse any hospital or physician that is

28  outside the entity's authorized geographic service area as

29  specified in its contract with the agency, and that provides

30  services authorized by the entity to its members, at a rate

31  

                                  30

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  negotiated with the hospital or physician for the provision of

 2  services or according to the lesser of the following:

 3         (a)  The usual and customary charges made to the

 4  general public by the hospital or physician; or

 5         (b)  The Florida Medicaid reimbursement rate

 6  established for the hospital or physician.

 7         (20)  When a merger or acquisition of a Medicaid

 8  prepaid contractor has been approved by the Office of

 9  Insurance Regulation pursuant to s. 628.4615, the agency shall

10  approve the assignment or transfer of the appropriate Medicaid

11  prepaid contract upon request of the surviving entity of the

12  merger or acquisition if the contractor and the other entity

13  have been in good standing with the agency for the most recent

14  12-month period, unless the agency determines that the

15  assignment or transfer would be detrimental to the Medicaid

16  recipients or the Medicaid program. To be in good standing, an

17  entity must not have failed accreditation or committed any

18  material violation of the requirements of s. 641.52 and must

19  meet the Medicaid contract requirements. For purposes of this

20  section, a merger or acquisition means a change in controlling

21  interest of an entity, including an asset or stock purchase.

22         (21)  Any entity contracting with the agency pursuant

23  to this section to provide health care services to Medicaid

24  recipients is prohibited from engaging in any of the following

25  practices or activities:

26         (a)  Practices that are discriminatory, including, but

27  not limited to, attempts to discourage participation on the

28  basis of actual or perceived health status.

29         (b)  Activities that could mislead or confuse

30  recipients, or misrepresent the organization, its marketing

31  

                                  31

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  representatives, or the agency. Violations of this paragraph

 2  include, but are not limited to:

 3         1.  False or misleading claims that marketing

 4  representatives are employees or representatives of the state

 5  or county, or of anyone other than the entity or the

 6  organization by whom they are reimbursed.

 7         2.  False or misleading claims that the entity is

 8  recommended or endorsed by any state or county agency, or by

 9  any other organization which has not certified its endorsement

10  in writing to the entity.

11         3.  False or misleading claims that the state or county

12  recommends that a Medicaid recipient enroll with an entity.

13         4.  Claims that a Medicaid recipient will lose benefits

14  under the Medicaid program, or any other health or welfare

15  benefits to which the recipient is legally entitled, if the

16  recipient does not enroll with the entity.

17         (c)  Granting or offering of any monetary or other

18  valuable consideration for enrollment, except as authorized by

19  subsection (24).

20         (d)  Door-to-door solicitation of recipients who have

21  not contacted the entity or who have not invited the entity to

22  make a presentation.

23         (e)  Solicitation of Medicaid recipients by marketing

24  representatives stationed in state offices unless approved and

25  supervised by the agency or its agent and approved by the

26  affected state agency when solicitation occurs in an office of

27  the state agency. The agency shall ensure that marketing

28  representatives stationed in state offices shall market their

29  managed care plans to Medicaid recipients only in designated

30  areas and in such a way as to not interfere with the

31  recipients' activities in the state office.

                                  32

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (f)  Enrollment of Medicaid recipients.

 2         (22)  The agency may impose a fine for a violation of

 3  this section or the contract with the agency by a person or

 4  entity that is under contract with the agency. With respect to

 5  any nonwillful violation, such fine shall not exceed $2,500

 6  per violation. In no event shall such fine exceed an aggregate

 7  amount of $10,000 for all nonwillful violations arising out of

 8  the same action. With respect to any knowing and willful

 9  violation of this section or the contract with the agency, the

10  agency may impose a fine upon the entity in an amount not to

11  exceed $20,000 for each such violation. In no event shall such

12  fine exceed an aggregate amount of $100,000 for all knowing

13  and willful violations arising out of the same action.

14         (23)  A health maintenance organization or a person or

15  entity exempt from chapter 641 that is under contract with the

16  agency for the provision of health care services to Medicaid

17  recipients may not use or distribute marketing materials used

18  to solicit Medicaid recipients, unless such materials have

19  been approved by the agency. The provisions of this subsection

20  do not apply to general advertising and marketing materials

21  used by a health maintenance organization to solicit both

22  non-Medicaid subscribers and Medicaid recipients.

23         (24)  Upon approval by the agency, health maintenance

24  organizations and persons or entities exempt from chapter 641

25  that are under contract with the agency for the provision of

26  health care services to Medicaid recipients may be permitted

27  within the capitation rate to provide additional health

28  benefits that the agency has found are of high quality, are

29  practicably available, provide reasonable value to the

30  recipient, and are provided at no additional cost to the

31  state.

                                  33

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (25)  The agency shall utilize the statewide health

 2  maintenance organization complaint hotline for the purpose of

 3  investigating and resolving Medicaid and prepaid health plan

 4  complaints, maintaining a record of complaints and confirmed

 5  problems, and receiving disenrollment requests made by

 6  recipients.

 7         (26)  The agency shall require the publication of the

 8  health maintenance organization's and the prepaid health

 9  plan's consumer services telephone numbers and the "800"

10  telephone number of the statewide health maintenance

11  organization complaint hotline on each Medicaid identification

12  card issued by a health maintenance organization or prepaid

13  health plan contracting with the agency to serve Medicaid

14  recipients and on each subscriber handbook issued to a

15  Medicaid recipient.

16         (27)  The agency shall establish a health care quality

17  improvement system for those entities contracting with the

18  agency pursuant to this section, incorporating all the

19  standards and guidelines developed by the Medicaid Bureau of

20  the Health Care Financing Administration as a part of the

21  quality assurance reform initiative. The system shall include,

22  but need not be limited to, the following:

23         (a)  Guidelines for internal quality assurance

24  programs, including standards for:

25         1.  Written quality assurance program descriptions.

26         2.  Responsibilities of the governing body for

27  monitoring, evaluating, and making improvements to care.

28         3.  An active quality assurance committee.

29         4.  Quality assurance program supervision.

30         5.  Requiring the program to have adequate resources to

31  effectively carry out its specified activities.

                                  34

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         6.  Provider participation in the quality assurance

 2  program.

 3         7.  Delegation of quality assurance program activities.

 4         8.  Credentialing and recredentialing.

 5         9.  Enrollee rights and responsibilities.

 6         10.  Availability and accessibility to services and

 7  care.

 8         11.  Ambulatory care facilities.

 9         12.  Accessibility and availability of medical records,

10  as well as proper recordkeeping and process for record review.

11         13.  Utilization review.

12         14.  A continuity of care system.

13         15.  Quality assurance program documentation.

14         16.  Coordination of quality assurance activity with

15  other management activity.

16         17.  Delivering care to pregnant women and infants; to

17  elderly and disabled recipients, especially those who are at

18  risk of institutional placement; to persons with developmental

19  disabilities; and to adults who have chronic, high-cost

20  medical conditions.

21         (b)  Guidelines which require the entities to conduct

22  quality-of-care studies which:

23         1.  Target specific conditions and specific health

24  service delivery issues for focused monitoring and evaluation.

25         2.  Use clinical care standards or practice guidelines

26  to objectively evaluate the care the entity delivers or fails

27  to deliver for the targeted clinical conditions and health

28  services delivery issues.

29         3.  Use quality indicators derived from the clinical

30  care standards or practice guidelines to screen and monitor

31  care and services delivered.

                                  35

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (c)  Guidelines for external quality review of each

 2  contractor which require: focused studies of patterns of care;

 3  individual care review in specific situations; and followup

 4  activities on previous pattern-of-care study findings and

 5  individual-care-review findings. In designing the external

 6  quality review function and determining how it is to operate

 7  as part of the state's overall quality improvement system, the

 8  agency shall construct its external quality review

 9  organization and entity contracts to address each of the

10  following:

11         1.  Delineating the role of the external quality review

12  organization.

13         2.  Length of the external quality review organization

14  contract with the state.

15         3.  Participation of the contracting entities in

16  designing external quality review organization review

17  activities.

18         4.  Potential variation in the type of clinical

19  conditions and health services delivery issues to be studied

20  at each plan.

21         5.  Determining the number of focused pattern-of-care

22  studies to be conducted for each plan.

23         6.  Methods for implementing focused studies.

24         7.  Individual care review.

25         8.  Followup activities.

26         (28)  In order to ensure that children receive health

27  care services for which an entity has already been

28  compensated, an entity contracting with the agency pursuant to

29  this section shall achieve an annual Early and Periodic

30  Screening, Diagnosis, and Treatment (EPSDT) Service screening

31  rate of at least 60 percent for those recipients continuously

                                  36

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  enrolled for at least 8 months. The agency shall develop a

 2  method by which the EPSDT screening rate shall be calculated.

 3  For any entity which does not achieve the annual 60 percent

 4  rate, the entity must submit a corrective action plan for the

 5  agency's approval. If the entity does not meet the standard

 6  established in the corrective action plan during the specified

 7  timeframe, the agency is authorized to impose appropriate

 8  contract sanctions. At least annually, the agency shall

 9  publicly release the EPSDT Services screening rates of each

10  entity it has contracted with on a prepaid basis to serve

11  Medicaid recipients.

12         (29)  The agency shall perform enrollments and

13  disenrollments for Medicaid recipients who are eligible for

14  MediPass or managed care plans. Notwithstanding the

15  prohibition contained in paragraph (21)(f), managed care plans

16  may perform preenrollments of Medicaid recipients under the

17  supervision of the agency or its agents. For the purposes of

18  this section, "preenrollment" means the provision of marketing

19  and educational materials to a Medicaid recipient and

20  assistance in completing the application forms, but shall not

21  include actual enrollment into a managed care plan. An

22  application for enrollment shall not be deemed complete until

23  the agency or its agent verifies that the recipient made an

24  informed, voluntary choice. The agency, in cooperation with

25  the Department of Children and Family Services, may test new

26  marketing initiatives to inform Medicaid recipients about

27  their managed care options at selected sites. The agency shall

28  report to the Legislature on the effectiveness of such

29  initiatives. The agency may contract with a third party to

30  perform managed care plan and MediPass enrollment and

31  disenrollment services for Medicaid recipients and is

                                  37

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  authorized to adopt rules to implement such services. The

 2  agency may adjust the capitation rate only to cover the costs

 3  of a third-party enrollment and disenrollment contract, and

 4  for agency supervision and management of the managed care plan

 5  enrollment and disenrollment contract.

 6         (30)  Any lists of providers made available to Medicaid

 7  recipients, MediPass enrollees, or managed care plan enrollees

 8  shall be arranged alphabetically showing the provider's name

 9  and specialty and, separately, by specialty in alphabetical

10  order.

11         (31)  The agency shall establish an enhanced managed

12  care quality assurance oversight function, to include at least

13  the following components:

14         (a)  At least quarterly analysis and followup,

15  including sanctions as appropriate, of managed care

16  participant utilization of services.

17         (b)  At least quarterly analysis and followup,

18  including sanctions as appropriate, of quality findings of the

19  Medicaid peer review organization and other external quality

20  assurance programs.

21         (c)  At least quarterly analysis and followup,

22  including sanctions as appropriate, of the fiscal viability of

23  managed care plans.

24         (d)  At least quarterly analysis and followup,

25  including sanctions as appropriate, of managed care

26  participant satisfaction and disenrollment surveys.

27         (e)  The agency shall conduct regular and ongoing

28  Medicaid recipient satisfaction surveys.

29  

30  The analyses and followup activities conducted by the agency

31  under its enhanced managed care quality assurance oversight

                                  38

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  function shall not duplicate the activities of accreditation

 2  reviewers for entities regulated under part III of chapter

 3  641, but may include a review of the finding of such

 4  reviewers.

 5         (32)  Each managed care plan that is under contract

 6  with the agency to provide health care services to Medicaid

 7  recipients shall annually conduct a background check with the

 8  Florida Department of Law Enforcement of all persons with

 9  ownership interest of 5 percent or more or executive

10  management responsibility for the managed care plan and shall

11  submit to the agency information concerning any such person

12  who has been found guilty of, regardless of adjudication, or

13  has entered a plea of nolo contendere or guilty to, any of the

14  offenses listed in s. 435.03.

15         (33)  The agency shall, by rule, develop a process

16  whereby a Medicaid managed care plan enrollee who wishes to

17  enter hospice care may be disenrolled from the managed care

18  plan within 24 hours after contacting the agency regarding

19  such request. The agency rule shall include a methodology for

20  the agency to recoup managed care plan payments on a pro rata

21  basis if payment has been made for the enrollment month when

22  disenrollment occurs.

23         (34)  The agency and entities that which contract with

24  the agency to provide health care services to Medicaid

25  recipients under this section or ss. 409.91211 and s. 409.9122

26  must comply with the provisions of s. 641.513 in providing

27  emergency services and care to Medicaid recipients and

28  MediPass recipients. Where feasible, safe, and cost-effective,

29  the agency shall encourage hospitals, emergency medical

30  services providers, and other public and private health care

31  providers to work together in their local communities to enter

                                  39

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  into agreements or arrangements to ensure access to

 2  alternatives to emergency services and care for those Medicaid

 3  recipients who need nonemergent care. The agency shall

 4  coordinate with hospitals, emergency medical services

 5  providers, private health plans, capitated managed care

 6  networks as established in s. 409.91211, and other public and

 7  private health care providers to implement the provisions of

 8  ss. 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to

 9  develop and implement emergency department diversion programs

10  for Medicaid recipients.

11         (35)  All entities providing health care services to

12  Medicaid recipients shall make available, and encourage all

13  pregnant women and mothers with infants to receive, and

14  provide documentation in the medical records to reflect, the

15  following:

16         (a)  Healthy Start prenatal or infant screening.

17         (b)  Healthy Start care coordination, when screening or

18  other factors indicate need.

19         (c)  Healthy Start enhanced services in accordance with

20  the prenatal or infant screening results.

21         (d)  Immunizations in accordance with recommendations

22  of the Advisory Committee on Immunization Practices of the

23  United States Public Health Service and the American Academy

24  of Pediatrics, as appropriate.

25         (e)  Counseling and services for family planning to all

26  women and their partners.

27         (f)  A scheduled postpartum visit for the purpose of

28  voluntary family planning, to include discussion of all

29  methods of contraception, as appropriate.

30         (g)  Referral to the Special Supplemental Nutrition

31  Program for Women, Infants, and Children (WIC).

                                  40

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (36)  Any entity that provides Medicaid prepaid health

 2  plan services shall ensure the appropriate coordination of

 3  health care services with an assisted living facility in cases

 4  where a Medicaid recipient is both a member of the entity's

 5  prepaid health plan and a resident of the assisted living

 6  facility. If the entity is at risk for Medicaid targeted case

 7  management and behavioral health services, the entity shall

 8  inform the assisted living facility of the procedures to

 9  follow should an emergent condition arise.

10         (37)  The agency may seek and implement federal waivers

11  necessary to provide for cost-effective purchasing of home

12  health services, private duty nursing services,

13  transportation, independent laboratory services, and durable

14  medical equipment and supplies through competitive bidding

15  pursuant to s. 287.057. The agency may request appropriate

16  waivers from the federal Health Care Financing Administration

17  in order to competitively bid such services. The agency may

18  exclude providers not selected through the bidding process

19  from the Medicaid provider network.

20         (38)  The agency shall enter into agreements with

21  not-for-profit organizations based in this state for the

22  purpose of providing vision screening.

23         (39)(a)  The agency shall implement a Medicaid

24  prescribed-drug spending-control program that includes the

25  following components:

26         1.  A Medicaid preferred drug list, which shall be a

27  listing of cost-effective therapeutic options recommended by

28  the Medicaid Pharmacy and Therapeutics Committee established

29  under s. 409.91195 and adopted by the agency for each

30  therapeutic class on the preferred drug list. At the

31  discretion of the committee, and when feasible, the preferred

                                  41

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  drug list should include at least two products in a

 2  therapeutic class. Medicaid prescribed-drug coverage for

 3  brand-name drugs for adult Medicaid recipients is limited to

 4  eight the dispensing of four brand-name drugs per month per

 5  recipient. Prior authorization is required for all additional

 6  prescriptions above the eight-drug limit and must meet the

 7  requirements for step therapy and for listing as a preferred

 8  drug. Children are exempt from this restriction.

 9  Antiretroviral agents are excluded from this limitation. No

10  requirements for prior authorization or other restrictions on

11  medications used to treat mental illnesses such as

12  schizophrenia, severe depression, or bipolar disorder may be

13  imposed on Medicaid recipients. Medications that will be

14  available without restriction for persons with mental

15  illnesses include atypical antipsychotic medications,

16  conventional antipsychotic medications, selective serotonin

17  reuptake inhibitors, and other medications used for the

18  treatment of serious mental illnesses. The agency shall also

19  limit the amount of a prescribed drug dispensed to no more

20  than a 34-day supply unless the drug products' smallest

21  marketed package is greater than a 34-day supply, or the drug

22  is determined by the agency to be a maintenance drug, in which

23  case a 180-day maximum supply may be authorized. The agency

24  may seek any federal waivers necessary to implement these

25  cost-control programs and to continue participation in the

26  federal Medicaid rebate program, or alternatively to negotiate

27  state-only manufacturer rebates. The agency may adopt rules to

28  administer this subparagraph. The agency shall continue to

29  provide unlimited generic drugs, contraceptive drugs and

30  items, and diabetic supplies. Although a drug may be included

31  on the preferred drug formulary, it would not be exempt from

                                  42

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  the four-brand limit. The agency may authorize exceptions to

 2  the brand-name-drug restriction based upon the treatment needs

 3  of the patients, only when such exceptions are based on prior

 4  consultation provided by the agency or an agency contractor,

 5  but The agency must establish procedures to ensure that:

 6         a.  There will be a response to a request for prior

 7  consultation by telephone or other telecommunication device

 8  within 24 hours after receipt of a request for prior

 9  consultation; and

10         b.  A 72-hour supply of the drug prescribed will be

11  provided in an emergency or when the agency does not provide a

12  response within 24 hours as required by sub-subparagraph a.;

13  and

14         c.  Except for the exception for nursing home residents

15  and other institutionalized adults and except for drugs on the

16  restricted formulary for which prior authorization may be

17  sought by an institutional or community pharmacy, prior

18  authorization for an exception to the brand-name-drug

19  restriction is sought by the prescriber and not by the

20  pharmacy. When prior authorization is granted for a patient in

21  an institutional setting beyond the brand-name-drug

22  restriction, such approval is authorized for 12 months and

23  monthly prior authorization is not required for that patient.

24         2.  Reimbursement to pharmacies for Medicaid prescribed

25  drugs shall be set at the lesser of: the average wholesale

26  price (AWP) minus 15.4 percent, the wholesaler acquisition

27  cost (WAC) plus 5.75 percent, the federal upper limit (FUL),

28  the state maximum allowable cost (SMAC), or the usual and

29  customary (UAC) charge billed by the provider.

30         3.  The agency shall develop and implement a process

31  for managing the drug therapies of Medicaid recipients who are

                                  43

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  using significant numbers of prescribed drugs each month. The

 2  management process may include, but is not limited to,

 3  comprehensive, physician-directed medical-record reviews,

 4  claims analyses, and case evaluations to determine the medical

 5  necessity and appropriateness of a patient's treatment plan

 6  and drug therapies. The agency may contract with a private

 7  organization to provide drug-program-management services. The

 8  Medicaid drug benefit management program shall include

 9  initiatives to manage drug therapies for HIV/AIDS patients,

10  patients using 20 or more unique prescriptions in a 180-day

11  period, and the top 1,000 patients in annual spending. The

12  agency shall enroll any Medicaid recipient in the drug benefit

13  management program if he or she meets the specifications of

14  this provision and is not enrolled in a Medicaid health

15  maintenance organization.

16         4.  The agency may limit the size of its pharmacy

17  network based on need, competitive bidding, price

18  negotiations, credentialing, or similar criteria. The agency

19  shall give special consideration to rural areas in determining

20  the size and location of pharmacies included in the Medicaid

21  pharmacy network. A pharmacy credentialing process may include

22  criteria such as a pharmacy's full-service status, location,

23  size, patient educational programs, patient consultation,

24  disease-management services, and other characteristics. The

25  agency may impose a moratorium on Medicaid pharmacy enrollment

26  when it is determined that it has a sufficient number of

27  Medicaid-participating providers. The agency must allow

28  dispensing practitioners to participate as a part of the

29  Medicaid pharmacy network regardless of the practitioner's

30  proximity to any other entity that is dispensing prescription

31  drugs under the Medicaid program. A dispensing practitioner

                                  44

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  must meet all credentialing requirements applicable to his or

 2  her practice, as determined by the agency.

 3         5.  The agency shall develop and implement a program

 4  that requires Medicaid practitioners who prescribe drugs to

 5  use a counterfeit-proof prescription pad for Medicaid

 6  prescriptions. The agency shall require the use of

 7  standardized counterfeit-proof prescription pads by

 8  Medicaid-participating prescribers or prescribers who write

 9  prescriptions for Medicaid recipients. The agency may

10  implement the program in targeted geographic areas or

11  statewide.

12         6.  The agency may enter into arrangements that require

13  manufacturers of generic drugs prescribed to Medicaid

14  recipients to provide rebates of at least 15.1 percent of the

15  average manufacturer price for the manufacturer's generic

16  products. These arrangements shall require that if a

17  generic-drug manufacturer pays federal rebates for

18  Medicaid-reimbursed drugs at a level below 15.1 percent, the

19  manufacturer must provide a supplemental rebate to the state

20  in an amount necessary to achieve a 15.1-percent rebate level.

21         7.  The agency may establish a preferred drug list as

22  described in this subsection formulary in accordance with 42

23  U.S.C. s. 1396r-8, and, pursuant to the establishment of such

24  drug list formulary, it may is authorized to negotiate

25  supplemental rebates from manufacturers which that are in

26  addition to those required by Title XIX of the Social Security

27  Act and at no less than 14 percent of the average manufacturer

28  price as defined in 42 U.S.C. s. 1936 on the last day of a

29  quarter unless the federal or supplemental rebate, or both,

30  equals or exceeds 29 percent. There is no upper limit on the

31  supplemental rebates the agency may negotiate. The agency may

                                  45

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  determine that specific products, brand-name or generic, are

 2  competitive at lower rebate percentages. Agreement to pay the

 3  minimum supplemental rebate percentage will guarantee a

 4  manufacturer that the Medicaid Pharmaceutical and Therapeutics

 5  Committee will consider a product for inclusion on the

 6  preferred drug list formulary. However, a pharmaceutical

 7  manufacturer is not guaranteed placement on the preferred drug

 8  list formulary by simply paying the minimum supplemental

 9  rebate. Agency decisions will be made on the clinical efficacy

10  of a drug and recommendations of the Medicaid Pharmaceutical

11  and Therapeutics Committee, as well as the price of competing

12  products minus federal and state rebates. The agency is

13  authorized to contract with an outside agency or contractor to

14  conduct negotiations for supplemental rebates. For the

15  purposes of this section, the term "supplemental rebates"

16  means cash rebates. Effective July 1, 2004, value-added

17  programs as a substitution for supplemental rebates are

18  prohibited. The agency is authorized to seek any federal

19  waivers to implement this initiative.

20         8.  The agency shall establish an advisory committee

21  for the purposes of studying the feasibility of using a

22  restricted drug formulary for nursing home residents and other

23  institutionalized adults. The committee shall be comprised of

24  seven members appointed by the Secretary of Health Care

25  Administration. The committee members shall include two

26  physicians licensed under chapter 458 or chapter 459; three

27  pharmacists licensed under chapter 465 and appointed from a

28  list of recommendations provided by the Florida Long-Term Care

29  Pharmacy Alliance; and two pharmacists licensed under chapter

30  465.

31  

                                  46

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         8.9.  The Agency for Health Care Administration shall

 2  expand home delivery of pharmacy products. To assist Medicaid

 3  patients in securing their prescriptions and reduce program

 4  costs, the agency shall expand its current mail-order-pharmacy

 5  diabetes-supply program to include all generic and brand-name

 6  drugs used by Medicaid patients with diabetes. Medicaid

 7  recipients in the current program may obtain nondiabetes drugs

 8  on a voluntary basis. This initiative is limited to the

 9  geographic area covered by the current contract. The agency

10  may seek and implement any federal waivers necessary to

11  implement this subparagraph.

12         9.10.  The agency shall limit to one dose per month any

13  drug prescribed to treat erectile dysfunction.

14         10.11.a.  The agency shall implement a Medicaid

15  behavioral drug management system. The agency may contract

16  with a vendor that has experience in operating behavioral drug

17  management systems to implement this program. The agency is

18  authorized to seek federal waivers to implement this program.

19         b.  The agency, in conjunction with the Department of

20  Children and Family Services, may implement the Medicaid

21  behavioral drug management system that is designed to improve

22  the quality of care and behavioral health prescribing

23  practices based on best practice guidelines, improve patient

24  adherence to medication plans, reduce clinical risk, and lower

25  prescribed drug costs and the rate of inappropriate spending

26  on Medicaid behavioral drugs. The program shall include the

27  following elements:

28         (I)  Provide for the development and adoption of best

29  practice guidelines for behavioral health-related drugs such

30  as antipsychotics, antidepressants, and medications for

31  treating bipolar disorders and other behavioral conditions;

                                  47

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  translate them into practice; review behavioral health

 2  prescribers and compare their prescribing patterns to a number

 3  of indicators that are based on national standards; and

 4  determine deviations from best practice guidelines.

 5         (II)  Implement processes for providing feedback to and

 6  educating prescribers using best practice educational

 7  materials and peer-to-peer consultation.

 8         (III)  Assess Medicaid beneficiaries who are outliers

 9  in their use of behavioral health drugs with regard to the

10  numbers and types of drugs taken, drug dosages, combination

11  drug therapies, and other indicators of improper use of

12  behavioral health drugs.

13         (IV)  Alert prescribers to patients who fail to refill

14  prescriptions in a timely fashion, are prescribed multiple

15  same-class behavioral health drugs, and may have other

16  potential medication problems.

17         (V)  Track spending trends for behavioral health drugs

18  and deviation from best practice guidelines.

19         (VI)  Use educational and technological approaches to

20  promote best practices, educate consumers, and train

21  prescribers in the use of practice guidelines.

22         (VII)  Disseminate electronic and published materials.

23         (VIII)  Hold statewide and regional conferences.

24         (IX)  Implement a disease management program with a

25  model quality-based medication component for severely mentally

26  ill individuals and emotionally disturbed children who are

27  high users of care.

28         c.  If the agency is unable to negotiate a contract

29  with one or more manufacturers to finance and guarantee

30  savings associated with a behavioral drug management program

31  by September 1, 2004, the four-brand drug limit and preferred

                                  48

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  drug list prior-authorization requirements shall apply to

 2  mental health-related drugs, notwithstanding any provision in

 3  subparagraph 1. The agency is authorized to seek federal

 4  waivers to implement this policy.

 5         11.a.  The agency shall implement a Medicaid

 6  prescription-drug-management system. The agency may contract

 7  with a vendor that has experience in operating

 8  prescription-drug-management systems in order to implement

 9  this system. Any management system that is implemented in

10  accordance with this subparagraph must rely on cooperation

11  between physicians and pharmacists to determine appropriate

12  practice patterns and clinical guidelines to improve the

13  prescribing, dispensing, and use of drugs in the Medicaid

14  program. The agency may seek federal waivers to implement this

15  program.

16         b.  The drug-management system must be designed to

17  improve the quality of care and prescribing practices based on

18  best-practice guidelines, improve patient adherence to

19  medication plans, reduce clinical risk, and lower prescribed

20  drug costs and the rate of inappropriate spending on Medicaid

21  prescription drugs. The program must:

22         (I)  Provide for the development and adoption of

23  best-practice guidelines for the prescribing and use of drugs

24  in the Medicaid program, including translating best-practice

25  guidelines into practice; reviewing prescriber patterns and

26  comparing them to indicators that are based on national

27  standards and practice patterns of clinical peers in their

28  community, statewide, and nationally; and determine deviations

29  from best-practice guidelines.

30  

31  

                                  49

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (II)  Implement processes for providing feedback to and

 2  educating prescribers using best-practice educational

 3  materials and peer-to-peer consultation.

 4         (III)  Assess Medicaid recipients who are outliers in

 5  their use of a single or multiple prescription drugs with

 6  regard to the numbers and types of drugs taken, drug dosages,

 7  combination drug therapies, and other indicators of improper

 8  use of prescription drugs.

 9         (IV)  Alert prescribers to patients who fail to refill

10  prescriptions in a timely fashion, are prescribed multiple

11  drugs that may be redundant or contraindicated, or may have

12  other potential medication problems.

13         (V)  Track spending trends for prescription drugs and

14  deviation from best practice guidelines.

15         (VI)  Use educational and technological approaches to

16  promote best practices, educate consumers, and train

17  prescribers in the use of practice guidelines.

18         (VII)  Disseminate electronic and published materials.

19         (VIII)  Hold statewide and regional conferences.

20         (IX)  Implement disease-management programs in

21  cooperation with physicians and pharmacists, along with a

22  model quality-based medication component for individuals

23  having chronic medical conditions.

24         12.  The agency is authorized to contract for drug

25  rebate administration, including, but not limited to,

26  calculating rebate amounts, invoicing manufacturers,

27  negotiating disputes with manufacturers, and maintaining a

28  database of rebate collections.

29         13.  The agency may specify the preferred daily dosing

30  form or strength for the purpose of promoting best practices

31  with regard to the prescribing of certain drugs as specified

                                  50

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  in the General Appropriations Act and ensuring cost-effective

 2  prescribing practices.

 3         14.  The agency may require prior authorization for the

 4  off-label use of Medicaid-covered prescribed drugs as

 5  specified in the General Appropriations Act. The agency may,

 6  but is not required to, preauthorize the use of a product for

 7  an indication not in the approved labeling. Prior

 8  authorization may require the prescribing professional to

 9  provide information about the rationale and supporting medical

10  evidence for the off-label use of a drug.

11         15.  The agency, in conjunction with the Pharmaceutical

12  and Therapeutics Committee, may require age-related prior

13  authorizations for certain prescribed drugs. The agency may

14  preauthorize the use of a drug for a recipient who may not

15  meet the age requirement or may exceed the length of therapy

16  for use of this product as recommended by the manufacturer and

17  approved by the United States Food and Drug Administration.

18  Prior authorization may require the prescribing professional

19  to provide information about the rationale and supporting

20  medical evidence for the use of a drug.

21         16.  The agency shall implement a step-therapy

22  prior-authorization-approval process for medications excluded

23  from the preferred drug list. Medications listed on the

24  preferred drug list must be used within the previous 12 months

25  prior to the alternative medications that are not listed. The

26  step-therapy prior authorization may require the prescriber to

27  use the medications of a similar drug class or for a similar

28  medical indication unless contraindicated in the labeling by

29  the Food and Drug Administration. The trial period between the

30  specified steps may vary according to the medical indication.

31  The step-therapy-approval process shall be developed in

                                  51

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  accordance with the committee as stated in s. 409.91195(7) and

 2  (8).

 3         17.15.  The agency shall implement a return and reuse

 4  program for drugs dispensed by pharmacies to institutional

 5  recipients, which includes payment of a $5 restocking fee for

 6  the implementation and operation of the program. The return

 7  and reuse program shall be implemented electronically and in a

 8  manner that promotes efficiency. The program must permit a

 9  pharmacy to exclude drugs from the program if it is not

10  practical or cost-effective for the drug to be included and

11  must provide for the return to inventory of drugs that cannot

12  be credited or returned in a cost-effective manner. The agency

13  shall determine if the program has reduced the amount of

14  Medicaid prescription drugs which are destroyed on an annual

15  basis and if there are additional ways to ensure more

16  prescription drugs are not destroyed which could safely be

17  reused. The agency's conclusion and recommendations shall be

18  reported to the Legislature by December 1, 2005.

19         (b)  The agency shall implement this subsection to the

20  extent that funds are appropriated to administer the Medicaid

21  prescribed-drug spending-control program. The agency may

22  contract all or any part of this program to private

23  organizations.

24         (c)  The agency shall submit quarterly reports to the

25  Governor, the President of the Senate, and the Speaker of the

26  House of Representatives which must include, but need not be

27  limited to, the progress made in implementing this subsection

28  and its effect on Medicaid prescribed-drug expenditures.

29         (40)  Notwithstanding the provisions of chapter 287,

30  the agency may, at its discretion, renew a contract or

31  contracts for fiscal intermediary services one or more times

                                  52

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  for such periods as the agency may decide; however, all such

 2  renewals may not combine to exceed a total period longer than

 3  the term of the original contract.

 4         (41)  The agency shall provide for the development of a

 5  demonstration project by establishment in Miami-Dade County of

 6  a long-term-care facility licensed pursuant to chapter 395 to

 7  improve access to health care for a predominantly minority,

 8  medically underserved, and medically complex population and to

 9  evaluate alternatives to nursing home care and general acute

10  care for such population. Such project is to be located in a

11  health care condominium and colocated with licensed facilities

12  providing a continuum of care. The establishment of this

13  project is not subject to the provisions of s. 408.036 or s.

14  408.039. The agency shall report its findings to the Governor,

15  the President of the Senate, and the Speaker of the House of

16  Representatives by January 1, 2003.

17         (42)  The agency shall develop and implement a

18  utilization management program for Medicaid-eligible

19  recipients for the management of occupational, physical,

20  respiratory, and speech therapies. The agency shall establish

21  a utilization program that may require prior authorization in

22  order to ensure medically necessary and cost-effective

23  treatments. The program shall be operated in accordance with a

24  federally approved waiver program or state plan amendment. The

25  agency may seek a federal waiver or state plan amendment to

26  implement this program. The agency may also competitively

27  procure these services from an outside vendor on a regional or

28  statewide basis.

29         (43)  The agency may contract on a prepaid or fixed-sum

30  basis with appropriately licensed prepaid dental health plans

31  to provide dental services.

                                  53

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (44)  The Agency for Health Care Administration shall

 2  ensure that any Medicaid managed care plan as defined in s.

 3  409.9122(2)(h), whether paid on a capitated basis or a shared

 4  savings basis, is cost-effective. For purposes of this

 5  subsection, the term "cost-effective" means that a network's

 6  per-member, per-month costs to the state, including, but not

 7  limited to, fee-for-service costs, administrative costs, and

 8  case-management fees, must be no greater than the state's

 9  costs associated with contracts for Medicaid services

10  established under subsection (3), which shall be actuarially

11  adjusted for case mix, model, and service area. The agency

12  shall conduct actuarially sound audits adjusted for case mix

13  and model in order to ensure such cost-effectiveness and shall

14  publish the audit results on its Internet website and submit

15  the audit results annually to the Governor, the President of

16  the Senate, and the Speaker of the House of Representatives no

17  later than December 31 of each year. Contracts established

18  pursuant to this subsection which are not cost-effective may

19  not be renewed.

20         (45)  Subject to the availability of funds, the agency

21  shall mandate a recipient's participation in a provider

22  lock-in program, when appropriate, if a recipient is found by

23  the agency to have used Medicaid goods or services at a

24  frequency or amount not medically necessary, limiting the

25  receipt of goods or services to medically necessary providers

26  after the 21-day appeal process has ended, for a period of not

27  less than 1 year. The lock-in programs shall include, but are

28  not limited to, pharmacies, medical doctors, and infusion

29  clinics. The limitation does not apply to emergency services

30  and care provided to the recipient in a hospital emergency

31  department. The agency shall seek any federal waivers

                                  54

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  necessary to implement this subsection. The agency shall adopt

 2  any rules necessary to comply with or administer this

 3  subsection.

 4         (46)  The agency shall seek a federal waiver for

 5  permission to terminate the eligibility of a Medicaid

 6  recipient who has been found to have committed fraud, through

 7  judicial or administrative determination, two times in a

 8  period of 5 years.

 9         (47)  The agency shall conduct a study of available

10  electronic systems for the purpose of verifying the identity

11  and eligibility of a Medicaid recipient. The agency shall

12  recommend to the Legislature a plan to implement an electronic

13  verification system for Medicaid recipients by January 31,

14  2005.

15         (48)  A provider is not entitled to enrollment in the

16  Medicaid provider network. The agency may implement a Medicaid

17  fee-for-service provider network controls, including, but not

18  limited to, competitive procurement and provider

19  credentialing. If a credentialing process is used, the agency

20  may limit its provider network based upon the following

21  considerations: beneficiary access to care, provider

22  availability, provider quality standards and quality assurance

23  processes, cultural competency, demographic characteristics of

24  beneficiaries, practice standards, service wait times,

25  provider turnover, provider licensure and accreditation

26  history, program integrity history, peer review, Medicaid

27  policy and billing compliance records, clinical and medical

28  record audit findings, and such other areas that are

29  considered necessary by the agency to ensure the integrity of

30  the program.

31  

                                  55

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (49)  The agency shall contract with established

 2  minority physician networks that provide services to

 3  historically underserved minority patients. The networks must

 4  provide cost-effective Medicaid services, comply with the

 5  requirements to be a MediPass provider, and provide their

 6  primary care physicians with access to data and other

 7  management tools necessary to assist them in ensuring the

 8  appropriate use of services, including inpatient hospital

 9  services and pharmaceuticals.

10         (a)  The agency shall provide for the development and

11  expansion of minority physician networks in each service area

12  to provide services to Medicaid recipients who are eligible to

13  participate under federal law and rules.

14         (b)  The agency shall reimburse each minority physician

15  network as a fee-for-service provider, including the case

16  management fee for primary care, or as a capitated rate

17  provider for Medicaid services. Any savings shall be shared

18  with the minority physician networks pursuant to the contract.

19         (c)  For purposes of this subsection, the term

20  "cost-effective" means that a network's per-member, per-month

21  costs to the state, including, but not limited to,

22  fee-for-service costs, administrative costs, and

23  case-management fees, must be no greater than the state's

24  costs associated with contracts for Medicaid services

25  established under subsection (3), which shall be actuarially

26  adjusted for case mix, model, and service area. The agency

27  shall conduct actuarially sound audits adjusted for case mix

28  and model in order to ensure such cost-effectiveness and shall

29  publish the audit results on its Internet website and submit

30  the audit results annually to the Governor, the President of

31  the Senate, and the Speaker of the House of Representatives no

                                  56

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  later than December 31. Contracts established pursuant to this

 2  subsection which are not cost-effective may not be renewed.

 3         (d)  The agency may apply for any federal waivers

 4  needed to implement this subsection.

 5         (50)  The agency shall implement a program of

 6  all-inclusive care for children. The program of all-inclusive

 7  care for children shall be established in order to provide

 8  in-home, hospice-like support services to children diagnosed

 9  as having a life-threatening illness and who are enrolled in

10  the Children's Medical Services network and to reduce

11  hospitalizations as appropriate. The agency, in consultation

12  with the Department of Health, may implement the program of

13  all-inclusive care for children after obtaining approval from

14  the Centers for Medicare and Medicaid Services.

15         (51)  To the extent permitted by federal law and as

16  allowed under s. 409.906, the agency shall provide

17  reimbursement for emergency mental health care services for

18  Medicaid recipients in crisis-stabilization facilities

19  licensed under s. 394.875 as long as those services are less

20  expensive than the same services provided in a hospital

21  setting.

22         Section 2.  Section 409.91211, Florida Statutes, is

23  created to read:

24         409.91211  Medicaid managed care pilot program.--

25         (1)(a)  The agency shall develop a pilot program to

26  deliver health care services specified in ss. 409.905 and

27  409.906 through capitated managed care networks under the

28  Medicaid program to persons in Medicaid fee-for-service or the

29  MediPass program, contingent upon federal approval to preserve

30  the upper-payment-limit funding mechanism for hospitals,

31  including a guarantee of a reasonable growth factor, a

                                  57

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  methodology to allow the use of a portion of these funds to

 2  serve as risk pool for pilot sites, provisions to preserve the

 3  state's ability to use intergovernmental transfers, and

 4  provisions to protect the disproportionate share program

 5  authorized pursuant to this chapter.

 6         (b)  The agency may include, as part of the waiver

 7  request, an alternative methodology for making additional

 8  Medicaid payments to hospitals based on the level of Medicaid

 9  or care provided to the uninsured. Any alternative

10  methodology, however, must provide the same level of federal

11  funding as the current upper payment limit and include a

12  reasonable growth factor. Absent federal approval of a

13  reasonable growth factor, the Agency for Health Care

14  Administration shall provide the Legislature, pursuant to the

15  implementation plan provided for in section 3 of this act, the

16  following:

17         1.  Based on the historical growth and current federal

18  rules governing the upper-payment-limit funding, an estimate

19  of the projected growth of funding over the next 10 years and

20  an estimate of the loss of federal funding which can be

21  attributed to the implementation of any Medicaid waiver.

22         2.  An analysis showing the amount of additional

23  upper-payment-limit-funds that this state would have received

24  if it had been granted the exceptions to the

25  upper-payment-limit cap provided to other states in 42 C.F.R.

26  s. 447.272 from the 2002 through 2009 state fiscal years.

27         3.  An analysis with accompanying rationale supporting

28  the implementation of any waiver that would result in

29  hospitals in this state which provide safety net services

30  receiving less federal funds relative to the federal support

31  given to similar hospitals in other states.

                                  58

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (2)  The Legislature intends for the capitated managed

 2  care pilot program to:

 3         (a)  Provide recipients in Medicaid fee-for-service or

 4  the MediPass program a comprehensive and coordinated capitated

 5  managed care system for all health care services specified in

 6  ss. 409.905 and 409.906.

 7         (b)  Stabilize Medicaid expenditures under the pilot

 8  program compared to Medicaid expenditures in the pilot area

 9  for the 3 years before implementation of the pilot program,

10  while ensuring:

11         1.  Consumer education and choice.

12         2.  Access to medically necessary services.

13         3.  Coordination of preventative, acute, and long-term

14  care.

15         4.  Reductions in unnecessary service utilization.

16         (c)  Provide an opportunity to evaluate the feasibility

17  of statewide implementation of capitated managed care networks

18  as a replacement for the current Medicaid fee-for-service and

19  MediPass systems.

20         (3)  The agency shall have the following powers,

21  duties, and responsibilities with respect to the development

22  of a pilot program to deliver all health care services

23  specified in ss. 409.905 and 409.906 in the form of capitated

24  managed care networks under the Medicaid program to persons in

25  Medicaid fee-for-service or the MediPass program:

26         (a)  To define and recommend the medical and financial

27  eligibility standards for capitated managed care networks in

28  the pilot program. This paragraph does not relieve an entity

29  that qualifies as a capitated managed care network under this

30  section from any other licensure or regulatory requirements

31  

                                  59

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  contained in state or federal law which would otherwise apply

 2  to the entity.

 3         (b)  To include two geographic areas in the pilot

 4  program and recommend Medicaid-eligibility categories, from

 5  those specified in ss. 409.903 and 409.904, which shall be

 6  included in the pilot program. One pilot program must include

 7  only Broward County. A second pilot program must initially

 8  include Duval County and may be expanded to Baker, Clay, and

 9  Nassau Counties after the Duval County program has been

10  operating for at least 1 year. A Medicaid recipient may not be

11  enrolled in or assigned to a capitated managed care plan

12  unless the capitated managed care plan has complied with the

13  standards and credentialing requirements specified in

14  paragraph (e).

15         (c)  To determine and recommend how to design the

16  managed care delivery system in order to take maximum

17  advantage of all available state and federal funds, including

18  those obtained through intergovernmental transfers, the

19  upper-payment-level funding systems, and the disproportionate

20  share program.

21         (d)  To determine and recommend actuarially sound,

22  risk-adjusted capitation rates for Medicaid recipients in the

23  pilot program which can be separated to cover comprehensive

24  care, enhanced services, and catastrophic care.

25         (e)  To determine and recommend policies and guidelines

26  for phasing in financial risk for approved provider service

27  networks over a 3-year period. These shall include an option

28  to pay fee-for-service rates that may include a

29  savings-settlement option for at least 2 years. This model may

30  be converted to a risk adjusted capitated rate in the third

31  year of operation.

                                  60

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (f)  To determine and recommend provisions related to

 2  stop-loss requirements and the transfer of excess cost to

 3  catastrophic coverage that accommodates the risks associated

 4  with the development of the pilot projects.

 5         (g)  To determine and recommend a process to be used by

 6  the Social Services Estimating Conference to determine and

 7  validate the rate of growth of the per-member costs of

 8  providing Medicaid services under the managed care initiative.

 9         (h)  To determine and recommend descriptions of the

10  eligibility assignment processes that will be used to

11  facilitate client choice while ensuring pilot projects of

12  adequate enrollment levels. These processes shall ensure that

13  pilot sites have sufficient levels of enrollment to conduct a

14  valid test of the managed care pilot project model within a

15  2-year timeframe.

16         (i)  To determine and recommend program standards and

17  credentialing requirements for capitated managed care networks

18  to participate in the pilot program, including those related

19  to fiscal solvency, quality of care, and adequacy of access to

20  health care providers. This paragraph does not relieve an

21  entity that qualifies as a capitated managed care network

22  under this section from any other licensure or regulatory

23  requirements contained in state or federal law that would

24  otherwise apply to the entity. These standards must address,

25  but are not limited to:

26         1.  Compliance with the accreditation requirements as

27  provided in s. 641.512.

28         2.  Compliance with early and periodic screening,

29  diagnosis, and treatment screening requirements under federal

30  law.

31         3.  The percentage of voluntary disenrollments.

                                  61

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         4.  Immunization rates.

 2         5.  Standards of the National Committee for Quality

 3  Assurance and other approved accrediting bodies.

 4         6.  Recommendations of other authoritative bodies.

 5         7.  Specific requirements of the Medicaid program, or

 6  standards designed to specifically meet the unique needs of

 7  Medicaid recipients.

 8         8.  Compliance with the health quality improvement

 9  system as established by the agency, which incorporates

10  standards and guidelines developed by the Centers for Medicare

11  and Medicaid Services as part of the quality assurance reform

12  initiative.

13         (j)  To develop and recommend a mechanism for providing

14  information to Medicaid recipients for the purpose of

15  selecting a capitated managed care plan. Examples of such

16  mechanisms may include, but are not limited to, interactive

17  information systems, mailings, mass marketing materials,

18  public information and enrollment fairs, contracted one-on-one

19  counseling services, and peer counseling services.

20         (k)  To develop and recommend a system that prohibits

21  capitated managed care plans, their representatives, and

22  providers employed by or contracted with the capitated managed

23  care plans from recruiting persons eligible for or enrolled in

24  Medicaid, from providing inducements to Medicaid recipients to

25  select a particular capitated managed care plan, and from

26  prejudicing Medicaid recipients against other capitated

27  managed care plans.

28         (l)  To develop and recommend a system to monitor the

29  provision of health care services in the pilot program,

30  including utilization and quality of health care services for

31  the purpose of ensuring access to medically necessary

                                  62

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  services. This system shall include an encounter

 2  data-information system that collects and reports utilization

 3  information. The system shall include a method for verifying

 4  data integrity within the database and within the provider's

 5  medical records.

 6         (m)  To recommend a grievance-resolution process for

 7  Medicaid recipients enrolled in a capitated managed care

 8  network under the pilot program modeled after the subscriber

 9  assistance panel, as created in s. 408.7056. This process

10  shall include a mechanism for an expedited review of no

11  greater than 24 hours after notification of a grievance if the

12  life of a Medicaid recipient is in imminent and emergent

13  jeopardy.

14         (n)  To recommend a grievance-resolution process for

15  health care providers employed by or contracted with a

16  capitated managed care network under the pilot program in

17  order to settle disputes among the provider and the managed

18  care network or the provider and the agency.

19         (o)  To develop and recommend criteria to designate

20  health care providers as eligible to participate in the pilot

21  program. The agency and capitated managed care networks must

22  follow national guidelines for selecting health care

23  providers, whenever available. These criteria must include at

24  a minimum those criteria specified in s. 409.907.

25         (p)  To develop and recommend health care provider

26  agreements for participation in the pilot program.

27         (q)  To require that all health care providers under

28  contract with the pilot program be duly licensed in the state,

29  if such licensure is available, and meet other criteria as may

30  be established by the agency. These criteria shall include at

31  a minimum those criteria specified in s. 409.907.

                                  63

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         (r)  To develop and recommend agreements with other

 2  state or local governmental programs or institutions for the

 3  coordination of health care to eligible individuals receiving

 4  services from such programs or institutions.

 5         (s)  To develop and recommend a system to oversee the

 6  activities of pilot program participants, health care

 7  providers, capitated managed care networks, and their

 8  representatives in order to prevent fraud or abuse,

 9  overutilization or duplicative utilization, underutilization

10  or inappropriate denial of services, and neglect of

11  participants and to recover overpayments as appropriate. For

12  the purposes of this paragraph, the terms "abuse" and "fraud"

13  have the meanings as provided in s. 409.913. The agency must

14  refer incidents of suspected fraud, abuse, overutilization and

15  duplicative utilization, and underutilization or inappropriate

16  denial of services to the appropriate regulatory agency.

17         (t)  To develop and provide actuarial and benefit

18  design analyses that indicate the effect on capitation rates

19  and benefits offered in the pilot program over a prospective

20  5-year period based on the following assumptions:

21         1.  Growth in capitation rates which is limited to the

22  estimated growth rate in general revenue.

23         2.  Growth in capitation rates which is limited to the

24  average growth rate over the last 3 years in per-recipient

25  Medicaid expenditures.

26         3.  Growth in capitation rates which is limited to the

27  growth rate of aggregate Medicaid expenditures between the

28  2003-2004 fiscal year and the 2004-2005 fiscal year.

29         (u)  To develop a mechanism to require capitated

30  managed care plans to reimburse qualified emergency service

31  

                                  64

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  providers, including, but not limited to, ambulance services,

 2  in accordance with ss. 409.908 and 409.9128.

 3         (v)  To develop a system whereby school districts

 4  participating in the certified school match program pursuant

 5  to ss. 409.908(21) and 1011.70 shall be reimbursed by

 6  Medicaid, subject to the limitations of s. 1011.70(1), for a

 7  Medicaid-eligible child participating in the services as

 8  authorized in s. 1011.70, as provided for in s. 409.9071,

 9  regardless of whether the child is enrolled in a capitated

10  managed care network. Capitated managed care networks must

11  make a good-faith effort to execute agreements with school

12  districts regarding the coordinated provision of services

13  authorized under s. 1011.70. County health departments

14  delivering school-based services pursuant to ss. 381.0056 and

15  381.0057 must be reimbursed by Medicaid for the federal share

16  for a Medicaid-eligible child who receives Medicaid-covered

17  services in a school setting, regardless of whether the child

18  is enrolled in a capitated managed care network. Capitated

19  managed care networks must make a good-faith effort to execute

20  agreements with county health departments regarding the

21  coordinated provision of services to a Medicaid-eligible

22  child. To ensure continuity of care for Medicaid patients, the

23  agency, the Department of Health, and the Department of

24  Education shall develop procedures for ensuring that a

25  student's capitated managed care network provider receives

26  information relating to services provided in accordance with

27  ss. 381.0056, 381.0057, 409.9071, and 1011.70.

28         (w)  To develop and recommend a mechanism whereby

29  Medicaid recipients who are already enrolled in a managed care

30  plan or the MediPass program in the pilot areas shall be

31  offered the opportunity to change to capitated managed care

                                  65

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  plans on a staggered basis, as defined by the agency. All

 2  Medicaid recipients shall have 30 days in which to make a

 3  choice of capitated managed care plans. Those Medicaid

 4  recipients who do not make a choice shall be assigned to a

 5  capitated managed care plan in accordance with paragraph

 6  (4)(a). To facilitate continuity of care for a Medicaid

 7  recipient who is also a recipient of Supplemental Security

 8  Income (SSI), prior to assigning the SSI recipient to a

 9  capitated managed care plan, the agency shall determine

10  whether the SSI recipient has an ongoing relationship with a

11  provider or capitated managed care plan, and if so, the agency

12  shall assign the SSI recipient to that provider or capitated

13  managed care plan where feasible. Those SSI recipients who do

14  not have such a provider relationship shall be assigned to a

15  capitated managed care plan provider in accordance with

16  paragraph (4)(a).

17         (x)  To develop and recommend a service delivery

18  alternative for children having chronic medical conditions

19  which establishes a medical home project to provide primary

20  care services to this population. The project shall provide

21  community-based primary care services that are integrated with

22  other subspecialties to meet the medical, developmental, and

23  emotional needs for children and their families. This project

24  shall include an evaluation component to determine impacts on

25  hospitalizations, length of stays, emergency room visits,

26  costs, and access to care, including specialty care and

27  patient, and family satisfaction.

28         (4)(a)  A Medicaid recipient in the pilot area who is

29  not currently enrolled in a capitated managed care plan upon

30  implementation is not eligible for services as specified in

31  ss. 409.905 and 409.906, for the amount of time that the

                                  66

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  recipient does not enroll in a capitated managed care network.

 2  If a Medicaid recipient has not enrolled in a capitated

 3  managed care plan within 30 days after eligibility, the agency

 4  shall assign the Medicaid recipient to a capitated managed

 5  care plan based on the assessed needs of the recipient as

 6  determined by the agency. When making assignments, the agency

 7  shall take into account the following criteria:

 8         1.  A capitated managed care network has sufficient

 9  network capacity to meet the need of members.

10         2.  The capitated managed care network has previously

11  enrolled the recipient as a member, or one of the capitated

12  managed care network's primary care providers has previously

13  provided health care to the recipient.

14         3.  The agency has knowledge that the member has

15  previously expressed a preference for a particular capitated

16  managed care network as indicated by Medicaid fee-for-service

17  claims data, but has failed to make a choice.

18         4.  The capitated managed care network's primary care

19  providers are geographically accessible to the recipient's

20  residence.

21         (b)  When more than one capitated managed care network

22  provider meets the criteria specified in paragraph (3)(j), the

23  agency shall make recipient assignments consecutively by

24  family unit.

25         (c)  The agency may not engage in practices that are

26  designed to favor one capitated managed care plan over another

27  or that are designed to influence Medicaid recipients to

28  enroll in a particular capitated managed care network in order

29  to strengthen its particular fiscal viability.

30         (d)  After a recipient has made a selection or has been

31  enrolled in a capitated managed care network, the recipient

                                  67

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  shall have 90 days in which to voluntarily disenroll and

 2  select another capitated managed care network. After 90 days,

 3  no further changes may be made except for cause. Cause shall

 4  include, but not be limited to, poor quality of care, lack of

 5  access to necessary specialty services, an unreasonable delay

 6  or denial of service, inordinate or inappropriate changes of

 7  primary care providers, service access impairments due to

 8  significant changes in the geographic location of services, or

 9  fraudulent enrollment. The agency may require a recipient to

10  use the capitated managed care network's grievance process as

11  specified in paragraph (3)(h) prior to the agency's

12  determination of cause, except in cases in which immediate

13  risk of permanent damage to the recipient's health is alleged.

14  The grievance process, when used, must be completed in time to

15  permit the recipient to disenroll no later than the first day

16  of the second month after the month the disenrollment request

17  was made. If the capitated managed care network, as a result

18  of the grievance process, approves an enrollee's request to

19  disenroll, the agency is not required to make a determination

20  in the case. The agency must make a determination and take

21  final action on a recipient's request so that disenrollment

22  occurs no later than the first day of the second month after

23  the month the request was made. If the agency fails to act

24  within the specified timeframe, the recipient's request to

25  disenroll is deemed to be approved as of the date agency

26  action was required. Recipients who disagree with the agency's

27  finding that cause does not exist for disenrollment shall be

28  advised of their right to pursue a Medicaid fair hearing to

29  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

                                  68

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 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. The agency

12  shall post all waiver applications under this section on its

13  Internet website 30 days before submitting the applications to

14  the United States Centers for Medicare and Medicaid Services.

15  Notwithstanding s. 409.912(11), all waiver applications shall

16  be submitted to the Senate and House of Representatives Select

17  Committees on Medicaid Reform to be approved for submission.

18  All waivers submitted to and approved by the United States

19  Centers for Medicare and Medicaid Services under this section

20  must be submitted to the Senate and House of Representatives

21  Select Committees on Medicaid Reform in order to obtain

22  authority for implementation as required by s. 409.912(11)

23  before program implementation. The Select Committees on

24  Medicaid Reform shall recommend whether to approve the

25  implementation of the waivers to the Legislature or to the

26  Legislative Budget Commission if the Legislature is not in

27  regular or special session.

28         (5)  Upon review and approval of the applications for

29  waivers of applicable federal laws and regulations to

30  implement the pilot project by the Legislature, the Agency for

31  Health Care Administration may initiate adoption of rules

                                  69

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  pursuant to ss. 120.536(1) and 120.54 to implement and

 2  administer the managed care pilot program as provided in this

 3  section.

 4         Section 3.  The Agency for Health Care Administration

 5  shall submit an implementation plan for the managed care pilot

 6  program created under section 409.91211, Florida Statutes, to

 7  the Senate and House of Representatives Select Committees on

 8  Medicaid Reform upon approval of all waivers of federal laws

 9  and regulations by the United States Centers for Medicare and

10  Medicaid Services which are necessary to implement the managed

11  care pilot program. Based on the review of the implementation

12  plan, the Senate and House Select Committees on Medicaid

13  Reform shall determine whether to recommend implementation of

14  the pilot program for approval by the Legislature or by the

15  Legislative Budget Commission if the Legislature is not in

16  regular or special session. The implementation plan must

17  include all information specified in section 409.91211(3) and

18  (4), Florida Statutes. The plan must contain a detailed

19  timeline for implementation. The plan must contain budgetary

20  projections of the effect of the pilot program on the total

21  Medicaid budget for the 2006-2007 through 2009-2010 fiscal

22  years.

23         Section 4.  The Office of Program Policy Analysis and

24  Government Accountability, in consultation with the Auditor

25  General, shall comprehensively evaluate the two managed care

26  pilot programs created under section 409.91211, Florida

27  Statutes. The evaluation shall begin with the implementation

28  of the managed care model in the pilot areas and continue for

29  24 months after the two pilot programs have enrolled Medicaid

30  recipients and started providing health care services. The

31  evaluation must include assessments of cost savings; consumer

                                  70

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  education, choice, and access to services; coordination of

 2  care; and quality of care by each eligibility category and

 3  managed care plan in each pilot site. The evaluation must

 4  describe administrative or legal barriers to the

 5  implementation and operation of each pilot program and include

 6  recommendations regarding statewide expansion of the managed

 7  care pilot programs. The office shall submit an evaluation

 8  report to the Governor, the President of the Senate, and the

 9  Speaker of the House of Representatives no later than June 30,

10  2008. The managed care pilot program may not be expanded to

11  any additional counties that are not identified in this

12  section without the authorization of the Legislature.

13         Section 5.  Paragraphs (a) and (j) of subsection (2) of

14  section 409.9122, Florida Statutes, are amended to read:

15         409.9122  Mandatory Medicaid managed care enrollment;

16  programs and procedures.--

17         (2)(a)  The agency shall enroll in a managed care plan

18  or MediPass all Medicaid recipients, except those Medicaid

19  recipients who are: in an institution; enrolled in the

20  Medicaid medically needy program; or eligible for both

21  Medicaid and Medicare. Upon enrollment, individuals will be

22  able to change their managed care option during the 90-day opt

23  out period required by federal Medicaid regulations. The

24  agency is authorized to seek the necessary Medicaid state plan

25  amendment to implement this policy. However, to the extent

26  permitted by federal law, the agency may enroll in a managed

27  care plan or MediPass a Medicaid recipient who is exempt from

28  mandatory managed care enrollment, provided that:

29         1.  The recipient's decision to enroll in a managed

30  care plan or MediPass is voluntary;

31  

                                  71

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         2.  If the recipient chooses to enroll in a managed

 2  care plan, the agency has determined that the managed care

 3  plan provides specific programs and services which address the

 4  special health needs of the recipient; and

 5         3.  The agency receives any necessary waivers from the

 6  federal Centers for Medicare and Medicaid Services Health Care

 7  Financing Administration.

 8  

 9  The agency shall develop rules to establish policies by which

10  exceptions to the mandatory managed care enrollment

11  requirement may be made on a case-by-case basis. The rules

12  shall include the specific criteria to be applied when making

13  a determination as to whether to exempt a recipient from

14  mandatory enrollment in a managed care plan or MediPass.

15  School districts participating in the certified school match

16  program pursuant to ss. 409.908(21) and 1011.70 shall be

17  reimbursed by Medicaid, subject to the limitations of s.

18  1011.70(1), for a Medicaid-eligible child participating in the

19  services as authorized in s. 1011.70, as provided for in s.

20  409.9071, regardless of whether the child is enrolled in

21  MediPass or a managed care plan. Managed care plans shall make

22  a good faith effort to execute agreements with school

23  districts regarding the coordinated provision of services

24  authorized under s. 1011.70. County health departments

25  delivering school-based services pursuant to ss. 381.0056 and

26  381.0057 shall be reimbursed by Medicaid for the federal share

27  for a Medicaid-eligible child who receives Medicaid-covered

28  services in a school setting, regardless of whether the child

29  is enrolled in MediPass or a managed care plan. Managed care

30  plans shall make a good faith effort to execute agreements

31  with county health departments regarding the coordinated

                                  72

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  provision of services to a Medicaid-eligible child. To ensure

 2  continuity of care for Medicaid patients, the agency, the

 3  Department of Health, and the Department of Education shall

 4  develop procedures for ensuring that a student's managed care

 5  plan or MediPass provider receives information relating to

 6  services provided in accordance with ss. 381.0056, 381.0057,

 7  409.9071, and 1011.70.

 8         (j)  The agency shall apply for a federal waiver from

 9  the Centers for Medicare and Medicaid Services Health Care

10  Financing Administration to lock eligible Medicaid recipients

11  into a managed care plan or MediPass for 12 months after an

12  open enrollment period. After 12 months' enrollment, a

13  recipient may select another managed care plan or MediPass

14  provider. However, nothing shall prevent a Medicaid recipient

15  from changing primary care providers within the managed care

16  plan or MediPass program during the 12-month period.

17         Section 6.  Subsection (2) of section 409.913, Florida

18  Statutes, is amended, and subsection (36) is added to that

19  section, to read:

20         409.913  Oversight of the integrity of the Medicaid

21  program.--The agency shall operate a program to oversee the

22  activities of Florida Medicaid recipients, and providers and

23  their representatives, to ensure that fraudulent and abusive

24  behavior and neglect of recipients occur to the minimum extent

25  possible, and to recover overpayments and impose sanctions as

26  appropriate. Beginning January 1, 2003, and each year

27  thereafter, the agency and the Medicaid Fraud Control Unit of

28  the Department of Legal Affairs shall submit a joint report to

29  the Legislature documenting the effectiveness of the state's

30  efforts to control Medicaid fraud and abuse and to recover

31  Medicaid overpayments during the previous fiscal year. The

                                  73

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  report must describe the number of cases opened and

 2  investigated each year; the sources of the cases opened; the

 3  disposition of the cases closed each year; the amount of

 4  overpayments alleged in preliminary and final audit letters;

 5  the number and amount of fines or penalties imposed; any

 6  reductions in overpayment amounts negotiated in settlement

 7  agreements or by other means; the amount of final agency

 8  determinations of overpayments; the amount deducted from

 9  federal claiming as a result of overpayments; the amount of

10  overpayments recovered each year; the amount of cost of

11  investigation recovered each year; the average length of time

12  to collect from the time the case was opened until the

13  overpayment is paid in full; the amount determined as

14  uncollectible and the portion of the uncollectible amount

15  subsequently reclaimed from the Federal Government; the number

16  of providers, by type, that are terminated from participation

17  in the Medicaid program as a result of fraud and abuse; and

18  all costs associated with discovering and prosecuting cases of

19  Medicaid overpayments and making recoveries in such cases. The

20  report must also document actions taken to prevent

21  overpayments and the number of providers prevented from

22  enrolling in or reenrolling in the Medicaid program as a

23  result of documented Medicaid fraud and abuse and must

24  recommend changes necessary to prevent or recover

25  overpayments.

26         (2)  The agency shall conduct, or cause to be conducted

27  by contract or otherwise, reviews, investigations, analyses,

28  audits, or any combination thereof, to determine possible

29  fraud, abuse, overpayment, or recipient neglect in the

30  Medicaid program and shall report the findings of any

31  

                                  74

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  overpayments in audit reports as appropriate. At least 5

 2  percent of all audits shall be conducted on a random basis.

 3         (36)  The agency shall provide to each Medicaid

 4  recipient or his or her representative an explanation of

 5  benefits in the form of a letter that is mailed to the most

 6  recent address of the recipient on the record with the

 7  Department of Children and Family Services. The explanation of

 8  benefits must include the patient's name, the name of the

 9  health care provider and the address of the location where the

10  service was provided, a description of all services billed to

11  Medicaid in terminology that should be understood by a

12  reasonable person, and information on how to report

13  inappropriate or incorrect billing to the agency or other law

14  enforcement entities for review or investigation.

15         Section 7.  The Agency for Health Care Administration

16  shall submit to the Legislature by December 15, 2005, a report

17  on the legal and administrative barriers to enforcing section

18  409.9081, Florida Statutes. The report must describe how many

19  services require copayments, which providers collect

20  copayments, and the total amount of copayments collected from

21  recipients for all services required under section 409.9081,

22  Florida Statutes, by provider type for the 2001-2002 through

23  2004-2005 fiscal years. The agency shall recommend a mechanism

24  to enforce the requirement for Medicaid recipients to make

25  copayments which does not shift the copayment amount to the

26  provider. The agency shall also identify the federal or state

27  laws or regulations that permit Medicaid recipients to declare

28  impoverishment in order to avoid paying the copayment and

29  extent to which these statements of impoverishment are

30  verified. If claims of impoverishment are not currently

31  verified, the agency shall recommend a system for such

                                  75

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  verification. The report must also identify any other

 2  cost-sharing measures that could be imposed on Medicaid

 3  recipients.

 4         Section 8.  The Agency for Health Care Administration

 5  shall submit to the Legislature by January 15, 2006,

 6  recommendations to ensure that Medicaid is the payer of last

 7  resort as required by section 409.910, Florida Statutes. The

 8  report must identify the public and private entities that are

 9  liable for primary payment of health care services and

10  recommend methods to improve enforcement of third-party

11  liability responsibility and repayment of benefits to the

12  state Medicaid program. The report must estimate the potential

13  recoveries that may be achieved through third-party liability

14  efforts if administrative and legal barriers are removed. The

15  report must recommend whether modifications to the agency's

16  contingency-fee contract for third-party liability could

17  enhance third-party liability for benefits provided to

18  Medicaid recipients.

19         Section 9.  The Agency for Health Care Administration

20  shall study provider pay-for-performance systems developed by

21  the United States Centers for Medicare and Medicaid Services

22  for use in the federal Medicare system and those developed by

23  private health insurance market to determine if these systems

24  can be used in this state's Medicaid program to improve the

25  quality of care while reducing inappropriate utilization. The

26  study must include a cost-benefit analysis to determine the

27  fiscal viability of introducing a pay-for-performance system

28  in this state's Medicaid program. The study must identify any

29  waivers of federal laws or regulations which would be

30  necessary to implement a pay-for-performance system and any

31  changes in provider contracts which are necessary to implement

                                  76

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  this type of incentive system. The agency shall submit a

 2  report on provider pay-for-performance systems to the

 3  Legislature by January 15, 2006.

 4         Section 10.  By January 15, 2006, the Office of Program

 5  Policy Analysis and Government Accountability shall submit to

 6  the Legislature a study of the nursing home diversion programs

 7  of the Department of Elderly Affairs. The study may be

 8  conducted by Office of Program Policy Analysis and Government

 9  Accountability staff or by a consultant obtained through a

10  competitive bid. The study must use a statistically-valid

11  methodology to assess the percent of persons over a period of

12  2 years in the diversion program who would have entered a

13  nursing home without the diversion services, which services

14  are most frequently used, and which services are least

15  frequently used in the diversion programs. The study must

16  determine whether the diversion programs are cost-effective or

17  are an expansion of the Medicaid program because persons in

18  the program would not have entered a nursing home within a

19  2-year period regardless of the availability of the diversion

20  programs.

21         Section 11.  The Agency for Health Care Administration

22  shall conduct an analysis of potential costs savings achieved

23  through contracting with a multistate purchasing pool approved

24  by the federal Centers for Medicare and Medicaid Services for

25  drug-rebate administration, including, but not limited to,

26  calculating rebate amounts, invoicing manufacturers,

27  negotiating prices with manufacturers, negotiating disputes

28  with manufacturers, and maintaining a database of rebate

29  collections. The agency must submit to the Legislature its

30  analysis of this state's participation in multistate

31  purchasing pools by December 1, 2005.

                                  77

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1         Section 12.  The Agency for Health Care Administration

 2  shall identify how many individuals in the long-term care

 3  diversion programs who receive care at home have a

 4  patient-responsibility payment associated with their

 5  participation in the diversion program. If no system is

 6  available to assess this information, the agency shall

 7  determine the cost of creating a system to identify and

 8  collect these payments and whether the cost of developing a

 9  system for this purpose is offset by the amount of

10  patient-responsibility payments which could be collected with

11  the system. The agency shall report this information to the

12  Legislature by December 1, 2005.

13         Section 13.  The Office of Program Policy Analysis and

14  Government Accountability shall conduct a study of state

15  programs that allow non-Medicaid eligible persons under a

16  certain income level to buy into the Medicaid program as if it

17  was private insurance. The study shall examine Medicaid buy-in

18  programs in other states to determine if there are any models

19  that can be implemented in Florida which would provide access

20  to uninsured Floridians and what effect this program would

21  have on Medicaid expenditures based on the experience of

22  similar states. The study must also examine whether the

23  Medically Needy program could be redesigned to be a Medicaid

24  buy-in program. The study must be submitted to the Legislature

25  by January 1, 2006.

26         Section 14.  The sum of $            in nonrecurring

27  funds is appropriated from the General Revenue Fund to the

28  Agency for Health Care Administration for the purpose for

29  developing infrastructure and administrative resources

30  necessary to develop the capitated managed care pilot program

31  

                                  78

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 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  

                                  79

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1          STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
                       COMMITTEE SUBSTITUTE FOR
 2                         Senate Bill 838

 3                                 

 4  The committee substitute for SB 838 contains both short and
    long-term Medicaid reform activities, pilot projects, and
 5  studies designed to improve efficiency and help achieve
    sustainable growth in the Medicaid program.
 6  
    -Requires the Agency for Health Care Administration (AHCA) to
 7  contract with a vendor that will identify those providers that
    are utilization outliers.
 8  
    -Authorizes AHCA to use more single source contracting to
 9  reduce costs.

10  -Requires AHCA to determine if purchasing medical equipment is
    less expensive than rental.
11  
    -Requires any contract previously awarded to a provider
12  service network operated by a hospital to remain in effect for
    three years from the current contract expiration date; and
13  provides a definition for a provider service network.

14  -Directs AHCA to redesign and implement the capitated,
    integrated long-term care system (Senior Health Choices) in
15  the pilot area of Orange, Osceola, Lake, and Seminole
    Counties.
16  
    -Requires AHCA to consider increasing rates for certain
17  services if it reduces costs in other parts of the Medicaid
    program.
18  
    -Requires the Comprehensive Assessment and Review for
19  Long-term Care Services (CARES) staff to find ways to identify
    patients in nursing homes who can continue care under
20  Medicare.

21  -Requires AHCA to contract with an entity to develop a
    real-time utilization tracking system or electronic medical
22  record for Medicaid recipients.

23  -Requires the expansion of disease management programs through
    pilot projects.
24  
    -Requires AHCA to provide emergency department diversion
25  programs.

26  -Changes the Medicaid prescription drug cost control program
    to reduce costs, waste, and fraud, while improving recipient
27  safety.

28  -Allows mental health crisis care to be provided in a
    non-hospital setting if it is less costly.
29  
    -Authorizes AHCA to continue developing a plan to pilot the
30  Governor's proposed capitated managed care system to replace
    the fee-for-service system in Medicaid, contingent upon
31  approval of a waiver that includes a guarantee of a reasonable
    growth factor for the upper-payment-level funding mechanism
                                  80

CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2005                            CS for SB 838
    587-2018-05




 1  and other governmental transfers.

 2  -Requires AHCA to develop an implementation plan with all
    specified elements to be submitted to the Senate and House
 3  Select Committees on Medicaid Reform for consideration and
    recommendation to the Legislature for implementation approval.
 4  
    -Requires an evaluation of the pilot projects to be conducted
 5  by OPPAGA and the Auditor General and a report provided to the
    Governor and the Legislature no later than June 30, 2008, to
 6  consider statewide expansion.

 7  -Requires Medicaid recipients in the MediPass program to have
    prior authorization for any non-emergency related service.
 8  
    -Requires that at least 5 percent of Medicaid audits to detect
 9  Medicaid funds lost to fraud and abuse be conducted on a
    random basis.
10  
    -Requires that Medicaid recipients be provided explanations of
11  benefits.

12  -Requires AHCA to study the legal and program barriers to
    enforcing copayments in the Medicaid program.
13  
    -Requires AHCA to develop recommendations to improve
14  third-party liability recoveries.

15  -Requires AHCA to study ways to give financial incentives to
    physicians and other providers to reduce inappropriate
16  utilization.

17  -Requires OPPAGA to confirm the value of nursing home
    diversion programs.
18  
    -Requires AHCA to conduct an analysis of joining a multi-state
19  drug purchasing pool.

20  -Requires AHCA to explain if there is no mechanism for
    collecting the patient responsibility payments of persons in
21  the diversion programs.

22  -Requires OPPAGA to conduct a study of Medicaid buy-in
    programs.
23  
    -Provides an unspecified amount of non-recurring General
24  Revenue funds to AHCA for the purpose of developing the
    administrative infrastructure to pilot the managed care pilot
25  project and for the purpose of developing a managed care
    encounter data system.
26  

27  

28  

29  

30  

31  

                                  81

CODING: Words stricken are deletions; words underlined are additions.

Site Map
Session:   Bills ·   Calendars ·   Bound Journals ·   Citator ·   Search ·   Appropriations ·   Redistricting ·   Bill Information Reports
Committee Publications
Historical Information
Statutes:   Introduction ·   View Statutes ·   Search Statutes
Flsenate.gov
Disclaimer: The information on this system is unverified. The journals or printed bills of the respective chambers should be consulted for official purposes.    Copyright © 2000-2021 State of Florida.     Privacy Statement     Contact Us     Get Acrobat Reader