September 28, 2020
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Senate Bill 0838

Senate Bill sb0838e1

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    CS for CS for SB 838                           First Engrossed



  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; requiring the Office of Program

23         Policy Analysis and Government Accountability

24         to conduct an evaluation; deleting an obsolete

25         provision requiring the agency to develop a

26         plan for implementing emergency and crisis

27         care; requiring the agency to develop a system

28         where health care vendors may provide a

29         business case demonstrating that higher

30         reimbursement for a good or service will be

31         offset by cost savings in other goods or


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    CS for CS for SB 838                           First Engrossed



 1         services; requiring the Comprehensive

 2         Assessment and Review for Long-Term Care

 3         Services (CARES) teams to consult with any

 4         person making a determination that a nursing

 5         home resident funded by Medicare is not making

 6         progress toward rehabilitation and assist in

 7         any appeals of the decision; requiring the

 8         agency to contract with an entity to design a

 9         clinical-utilization information database or

10         electronic medical record for Medicaid

11         providers; requiring the agency to coordinate

12         with other entities to create emergency room

13         diversion programs for Medicaid recipients;

14         allowing dispensing practitioners to

15         participate in Medicaid; requiring that the

16         agency implement a Medicaid

17         prescription-drug-management system; requiring

18         the agency to determine the extent that

19         prescription drugs are returned and reused in

20         institutional settings and whether this program

21         could be expanded; authorizing the agency to

22         pay for emergency mental health services

23         provided through licensed crisis-stabilization

24         facilities; creating s. 409.91211, F.S.;

25         specifying waiver authority for the Agency for

26         Health Care Administration to establish a

27         Medicaid reform program contingent on federal

28         approval to preserve the upper-payment-limit

29         finding mechanism for hospitals and contingent

30         on protection of the disproportionate share

31         program authorized pursuant to ch. 409, F.S.;


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    CS for CS for SB 838                           First Engrossed



 1         providing legislative intent; providing powers,

 2         duties, and responsibilities of the agency

 3         under the pilot program; requiring that the

 4         agency submit any waivers to the Legislature

 5         for approval before implementation; allowing

 6         the agency to develop rules; requiring that the

 7         Office of Program Policy Analysis and

 8         Government Accountability, in consultation with

 9         the Auditor General, evaluate the pilot program

10         and report to the Governor and the Legislature

11         on whether it should be expanded statewide;

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

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

14         5 percent of all program integrity audits to be

15         conducted on a random basis; requiring that

16         Medicaid recipients be provided with an

17         explanation of benefits; requiring that the

18         agency report to the Legislature on the legal

19         and administrative barriers to enforcing the

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

21         requiring the agency to recommend ways to

22         ensure that Medicaid is the payer of last

23         resort; requiring the Office of Program Policy

24         Analysis and Government Accountability to

25         conduct a study of the long-term care diversion

26         programs; requiring the agency to determine how

27         many individuals in long-term care diversion

28         programs have a patient payment responsibility

29         that is not being collected and to recommend

30         how to collect such payments; requiring the

31         Office of Program Policy Analysis and


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    CS for CS for SB 838                           First Engrossed



 1         Government Accountability to conduct a study of

 2         Medicaid buy-in programs to determine if these

 3         programs can be created in this state without

 4         expanding the overall Medicaid program budget

 5         or if the Medically Needy program can be

 6         changed into a Medicaid buy-in program;

 7         providing an appropriation and authorizing

 8         positions to implement this act; requiring the

 9         Office of Program Policy Analysis and

10         Government Accountability, in consultation with

11         the Office of Attorney General and the Auditor

12         General, to conduct a study to examine whether

13         state and federal dollars are lost due to fraud

14         and abuse in the Medicaid prescription drug

15         program; providing duties; requiring that a

16         report with findings and recommendations be

17         submitted to the Governor and the Legislature

18         by a specified date; providing an effective

19         date.

20  

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

22  

23         Section 1.  Section 409.912, Florida Statutes, is

24  amended to read:

25         409.912  Cost-effective purchasing of health care.--The

26  agency shall purchase goods and services for Medicaid

27  recipients in the most cost-effective manner consistent with

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

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

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

31  the correct diagnosis for purposes of authorizing future


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    CS for CS for SB 838                           First Engrossed



 1  services under the Medicaid program. This section does not

 2  restrict access to emergency services or poststabilization

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

 4  confirmation or second opinion shall be rendered in a manner

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

 6  prepaid per capita and prepaid aggregate fixed-sum basis

 7  services when appropriate and other alternative service

 8  delivery and reimbursement methodologies, including

 9  competitive bidding pursuant to s. 287.057, designed to

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

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

12  minimize the exposure of recipients to the need for acute

13  inpatient, custodial, and other institutional care and the

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

15  agency shall contract with a vendor to monitor and evaluate

16  the clinical practice patterns of providers in order to

17  identify trends that are outside the normal practice patterns

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

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

20  able to provide information and counseling to a provider whose

21  practice patterns are outside the norms, in consultation with

22  the agency, to improve patient care and reduce inappropriate

23  utilization. The agency may mandate prior authorization, drug

24  therapy management, or disease management participation for

25  certain populations of Medicaid beneficiaries, certain drug

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

27  and possible dangerous drug interactions. The Pharmaceutical

28  and Therapeutics Committee shall make recommendations to the

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

30  agency shall inform the Pharmaceutical and Therapeutics

31  Committee of its decisions regarding drugs subject to prior


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    CS for CS for SB 838                           First Engrossed



 1  authorization. The agency is authorized to limit the entities

 2  it contracts with or enrolls as Medicaid providers by

 3  developing a provider network through provider credentialing.

 4  The agency may competitively bid single-source-provider

 5  contracts if procurement of goods or services results in

 6  demonstrated cost savings to the state without limiting access

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

 8  assessment of beneficiary access to care, provider

 9  availability, provider quality standards, time and distance

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

11  provider network, demographic characteristics of Medicaid

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

13  appointment wait times, beneficiary use of services, provider

14  turnover, provider profiling, provider licensure history,

15  previous program integrity investigations and findings, peer

16  review, provider Medicaid policy and billing compliance

17  records, clinical and medical record audits, and other

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

19  Medicaid provider network. The agency shall determine

20  instances in which allowing Medicaid beneficiaries to purchase

21  durable medical equipment and other goods is less expensive to

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

23  goods. The agency may establish rules to facilitate purchases

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

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

26  The agency may is authorized to seek federal waivers necessary

27  to administer these policies implement this policy.

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

29  Children and Family Services to ensure access of children and

30  families in the child protection system to needed and

31  appropriate mental health and substance abuse services.


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    CS for CS for SB 838                           First Engrossed



 1         (2)  The agency may enter into agreements with

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

 3  the Federal Government and accept such duties in respect to

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

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

 6  409.901-409.920.

 7         (3)  The agency may contract with health maintenance

 8  organizations certified pursuant to part I of chapter 641 for

 9  the provision of services to recipients.

10         (4)  The agency may contract with:

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

12  services other than Medicaid services under contract with the

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

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

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

16  to recipients, which entity may provide such prepaid services

17  either directly or through arrangements with other providers.

18  Such prepaid health care services entities must be licensed

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

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

21  recognized under this paragraph which demonstrates to the

22  satisfaction of the Office of Insurance Regulation of the

23  Financial Services Commission that it is backed by the full

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

25  exempted from s. 641.225.

26         (b)  An entity that is providing comprehensive

27  behavioral health care services to certain Medicaid recipients

28  through a capitated, prepaid arrangement pursuant to the

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

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

31  641 and must possess the clinical systems and operational


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    CS for CS for SB 838                           First Engrossed



 1  competence to manage risk and provide comprehensive behavioral

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

 3  the term "comprehensive behavioral health care services" means

 4  covered mental health and substance abuse treatment services

 5  that are available to Medicaid recipients. The secretary of

 6  the Department of Children and Family Services shall approve

 7  provisions of procurements related to children in the

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

 9  in a prepaid behavioral health plan. Any contract awarded

10  under this paragraph must be competitively procured. In

11  developing the behavioral health care prepaid plan procurement

12  document, the agency shall ensure that the procurement

13  document requires the contractor to develop and implement a

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

15  provided to residents of licensed assisted living facilities

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

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

18  contract with a single entity meeting these requirements to

19  provide comprehensive behavioral health care services to all

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

21  AHCA area. Each entity must offer sufficient choice of

22  providers in its network to ensure recipient access to care

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

24  satisfied. The network shall include all public mental health

25  hospitals. To ensure unimpaired access to behavioral health

26  care services by Medicaid recipients, all contracts issued

27  pursuant to this paragraph shall require 80 percent of the

28  capitation paid to the managed care plan, including health

29  maintenance organizations, to be expended for the provision of

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

31  plan expends less than 80 percent of the capitation paid


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    CS for CS for SB 838                           First Engrossed



 1  pursuant to this paragraph for the provision of behavioral

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

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

 4  certification letter indicating the amount of capitation paid

 5  during each calendar year for the provision of behavioral

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

 7  reimburse for substance abuse treatment services on a

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

 9  funds are available for capitated, prepaid arrangements.

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

11  contracts with the entities providing comprehensive inpatient

12  and outpatient mental health care services to Medicaid

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

14  Polk Counties, to include substance abuse treatment services.

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

16  Children and Family Services shall execute a written agreement

17  that requires collaboration and joint development of all

18  policy, budgets, procurement documents, contracts, and

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

20  community mental health and targeted case management programs.

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

22  2006, the agency and the Department of Children and Family

23  Services shall contract with managed care entities in each

24  AHCA area except area 6 or arrange to provide comprehensive

25  inpatient and outpatient mental health and substance abuse

26  services through capitated prepaid arrangements to all

27  Medicaid recipients who are eligible to participate in such

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

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

30  shall contract with a single managed care plan to provide

31  comprehensive behavioral health services to all recipients who


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    CS for CS for SB 838                           First Engrossed



 1  are not enrolled in a Medicaid health maintenance

 2  organization. The agency may contract with more than one

 3  comprehensive behavioral health provider to provide care to

 4  recipients who are not enrolled in a Medicaid health

 5  maintenance organization in AHCA areas where the eligible

 6  population exceeds 150,000. Contracts for comprehensive

 7  behavioral health providers awarded pursuant to this section

 8  shall be competitively procured. Both for-profit and

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

10  Managed care plans contracting with the agency under

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

12  comprehensive behavioral health benefits as provided in AHCA

13  rules, including handbooks incorporated by reference.

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

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

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

17  provides for the full implementation of capitated prepaid

18  behavioral health care in all areas of the state.

19         a.  Implementation shall begin in 2003 in those AHCA

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

21  sufficient capitation rates.

22         b.  If the agency determines that the proposed

23  capitation rate in any area is insufficient to provide

24  appropriate services, the agency may adjust the capitation

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

26  department may use existing general revenue to address any

27  additional required match but may not over-obligate existing

28  funds on an annualized basis.

29         c.  Subject to any limitations provided for in the

30  General Appropriations Act, the agency, in compliance with

31  appropriate federal authorization, shall develop policies and


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    CS for CS for SB 838                           First Engrossed



 1  procedures that allow for certification of local and state

 2  funds.

 3         5.  Children residing in a statewide inpatient

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

 5  a Department of Children and Family Services residential

 6  program approved as a Medicaid behavioral health overlay

 7  services provider shall not be included in a behavioral health

 8  care prepaid health plan or any other Medicaid managed care

 9  plan pursuant to this paragraph.

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

11  agency shall in its procurement document require an entity

12  providing only comprehensive behavioral health care services

13  to prevent the displacement of indigent care patients by

14  enrollees in the Medicaid prepaid health plan providing

15  behavioral health care services from facilities receiving

16  state funding to provide indigent behavioral health care, to

17  facilities licensed under chapter 395 which do not receive

18  state funding for indigent behavioral health care, or

19  reimburse the unsubsidized facility for the cost of behavioral

20  health care provided to the displaced indigent care patient.

21         7.  Traditional community mental health providers under

22  contract with the Department of Children and Family Services

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

24  under contract with the Department of Children and Family

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

26  providers licensed pursuant to chapter 395 must be offered an

27  opportunity to accept or decline a contract to participate in

28  any provider network for prepaid behavioral health services.

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

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

31  open for child welfare services in the HomeSafeNet system,


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    CS for CS for SB 838                           First Engrossed



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

 2  and all their behavioral health care services including

 3  inpatient, outpatient psychiatric, community mental health,

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

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

 6  child welfare services in the HomeSafeNet system, shall

 7  receive their behavioral health care services through a

 8  specialty prepaid plan operated by community-based lead

 9  agencies either through a single agency or formal agreements

10  among several agencies. The specialty prepaid plan must result

11  in savings to the state comparable to savings achieved in

12  other Medicaid managed care and prepaid programs. Such plan

13  must provide mechanisms to maximize state and local revenues.

14  The specialty prepaid plan shall be developed by the agency

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

16  is authorized to seek any federal waivers to implement this

17  initiative.

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

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

20  entity owned by other migrant and community health centers

21  receiving non-Medicaid financial support from the Federal

22  Government to provide health care services on a prepaid or

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

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

25  chapter 641, but shall be prohibited from serving Medicaid

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

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

28  the entity meets the requirements specified in subsections

29  (17) and (18).

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

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


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    CS for CS for SB 838                           First Engrossed



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

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

 3  appropriate financial reserve, quality assurance, and patient

 4  rights requirements as established by the agency. The agency

 5  shall award contracts on a competitive bid basis and shall

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

 7  recipients assigned to a demonstration project shall be chosen

 8  equally from those who would otherwise have been assigned to

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

10  federal Medicaid waivers as necessary to implement the

11  provisions of this section. Any contract previously awarded to

12  a provider service network operated by a hospital pursuant to

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

14  following the current contract-expiration date, regardless of

15  any contractual provisions to the contrary. A provider service

16  network is a network established or organized and operated by

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

18  providers, which provides a substantial proportion of the

19  health care items and services under a contract directly

20  through the provider or affiliated group of providers and may

21  make arrangements with physicians or other health care

22  professionals, health care institutions, or any combination of

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

24  financial risk on a prospective basis for the provision of

25  basic health services by the physicians, by other health

26  professionals, or through the institutions. The health care

27  providers must have a controlling interest in the governing

28  body of the provider service network organization.

29         (e)  An entity that provides only comprehensive

30  behavioral health care services to certain Medicaid recipients

31  through an administrative services organization agreement.


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    CS for CS for SB 838                           First Engrossed



 1  Such an entity must possess the clinical systems and

 2  operational competence to provide comprehensive health care to

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

 4  "comprehensive behavioral health care services" means covered

 5  mental health and substance abuse treatment services that are

 6  available to Medicaid recipients. Any contract awarded under

 7  this paragraph must be competitively procured. The agency must

 8  ensure that Medicaid recipients have available the choice of

 9  at least two managed care plans for their behavioral health

10  care services.

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

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

13  care to Medicaid recipients with degenerative neurological

14  diseases and other diseases or disabling conditions associated

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

16  serve very disabled persons and to reduce Medicaid reimbursed

17  costs for inpatient, outpatient, and emergency department

18  services. The agency shall contract with vendors on a

19  risk-sharing basis.

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

21  coordination and care management for Medicaid-eligible

22  pediatric patients, primary care, authorization of specialty

23  care, and other urgent and emergency care through organized

24  providers designed to service Medicaid eligibles under age 18

25  and pediatric emergency departments' diversion programs. The

26  networks shall provide after-hour operations, including

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

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

29  departments.

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

31  with the agency and the Department of Elderly Affairs to


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    CS for CS for SB 838                           First Engrossed



 1  provide health care and social services on a prepaid or

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

 3  care services entities are exempt from the provisions of part

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

 5  recognized under this paragraph that demonstrates to the

 6  satisfaction of the Office of Insurance Regulation that it is

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

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

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

10  in s. 391.021.

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

12  Administration, in partnership with the Department of Elderly

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

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

15  older. Eligible Medicaid recipients may participate in the

16  integrated system on a voluntary basis. The program must

17  transfer all Medicaid services for eligible elderly

18  individuals who choose to participate into an integrated-care

19  management model designed to serve Medicaid recipients in the

20  community. The program must combine all funding for Medicaid

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

22  the integrated system, including funds for Medicaid home and

23  community-based waiver services; all Medicaid services

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

25  Medicaid nursing home services unless the agency is able to

26  demonstrate how the integration of the funds will improve

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

28  and Medicare premiums, coinsurance, and deductibles for

29  persons dually eligible for Medicaid and Medicare as

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

31  


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    CS for CS for SB 838                           First Engrossed



 1  implementing the integrated system in a pilot area that may

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

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

 4  enrolled in the the developmental disabilities waiver program,

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

 6  AIDS care waiver program, the traumatic brain injury and

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

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

 9  elderly program, and residents of institutional care

10  facilities for the developmentally disabled, must be excluded

11  from the integrated system.

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

13  process to select entities to operate the integrated system.

14  Entities eligible to submit bids include managed care

15  organizations licensed under chapter 641, including entities

16  eligible to participate in the nursing home diversion program,

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

18  community care for the elderly lead agencies, and other

19  state-certified community service networks that meet

20  comparable standards as defined by the agency, in consultation

21  with the Department of Elderly Affairs and the Office of

22  Insurance Regulation, to be financially solvent and able to

23  take on financial risk for managed care. Community service

24  networks that are certified pursuant to the comparable

25  standards defined by the agency are not required to be

26  licensed under chapter 641.

27         (c)  The agency must ensure that the

28  capitation-rate-setting methodology for the integrated system

29  is actuarially sound and reflects the intent to provide

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

31  also require integrated-system providers to develop a


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    CS for CS for SB 838                           First Engrossed



 1  credentialing system for service providers and to contract

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

 3  where feasible, chronically poor-performing facilities and

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

 5  provide that if the recipient resides in a noncontracted

 6  residential facility licensed under chapter 400 at the time

 7  the integrated system is initiated, the recipient must be

 8  permitted to continue to reside in the noncontracted facility

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

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

11  integrated-system provider and the residential facility

12  licensed under chapter 400, current Medicaid rates must

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

14  jointly develop procedures to manage the services provided

15  through the integrated system in order to ensure quality and

16  recipient choice.

17         (d)  Within 24 months after implementation, the Office

18  of Program Policy Analysis and Government Accountability, in

19  consultation with the Auditor General, shall comprehensively

20  evaluate the pilot project for the integrated, fixed-payment

21  delivery system for Medicaid recipients who are 60 years of

22  age or older. The evaluation must include assessments of cost

23  savings; consumer education, choice, and access to services;

24  coordination of care; and quality of care. The evaluation must

25  describe administrative or legal barriers to the

26  implementation and operation of the pilot program and include

27  recommendations regarding statewide expansion of the pilot

28  program. The office shall submit an evaluation report to the

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

30  House of Representatives no later than June 30, 2008.

31  


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    CS for CS for SB 838                           First Engrossed



 1         (e)  The agency may seek federal waivers and adopt

 2  rules as necessary to administer the integrated system. By

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

 4  extent feasible, develop a plan for implementing new Medicaid

 5  procedure codes for emergency and crisis care, supportive

 6  residential services, and other services designed to maximize

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

 8  The agency shall include in the agreement developed pursuant

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

10  requirements for these new procedure codes are met by

11  certifying eligible general revenue or local funds that are

12  currently expended on these services by the department with

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

14  The plan must describe specific procedure codes to be

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

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

17  analysis that describes the certified match procedures, and

18  accountability mechanisms, projects the earnings associated

19  with these procedures, and describes the sources of state

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

21  approved by the Legislative Budget Commission. If such

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

23  be submitted for consideration by the 2004 Legislature.

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

25  entity otherwise authorized by this section on a prepaid or

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

27  recipients. An entity may provide prepaid services to

28  recipients, either directly or through arrangements with other

29  entities, if each entity involved in providing services:

30  

31  


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    CS for CS for SB 838                           First Engrossed



 1         (a)  Is organized primarily for the purpose of

 2  providing health care or other services of the type regularly

 3  offered to Medicaid recipients;

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

 5  the agency for quality, appropriateness, and timeliness;

 6         (c)  Makes provisions satisfactory to the agency for

 7  insolvency protection and ensures that neither enrolled

 8  Medicaid recipients nor the agency will be liable for the

 9  debts of the entity;

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

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

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

13  equivalent liquid assets excluding revenues from Medicaid

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

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

16         (e)  Furnishes evidence satisfactory to the agency of

17  adequate liability insurance coverage or an adequate plan of

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

19  of the furnishing of health care;

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

21  periodic review of its medical facilities and services, as

22  required by the agency; and

23         (g)  Provides organizational, operational, financial,

24  and other information required by the agency.

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

26  basis with any health insurer that:

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

28  Medicaid recipients in exchange for a premium payment paid by

29  the agency;

30         (b)  Assumes the underwriting risk; and

31  


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    CS for CS for SB 838                           First Engrossed



 1         (c)  Is organized and licensed under applicable

 2  provisions of the Florida Insurance Code and is currently in

 3  good standing with the Office of Insurance Regulation.

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

 5  basis with an exclusive provider organization to provide

 6  health care services to Medicaid recipients provided that the

 7  exclusive provider organization meets applicable managed care

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

 9  409.9128, and 627.6472, and other applicable provisions of

10  law.

11         (9)  The Agency for Health Care Administration may

12  provide cost-effective purchasing of chiropractic services on

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

14  arrangements with a statewide chiropractic preferred provider

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

16  corporation. The agency shall ensure that the benefit limits

17  and prior authorization requirements in the current Medicaid

18  program shall apply to the services provided by the

19  chiropractic preferred provider organization.

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

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

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

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

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

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

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

27  to:

28         (a)  Fraud;

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

30  including those proscribing price fixing between competitors

31  and the allocation of customers among competitors;


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    CS for CS for SB 838                           First Engrossed



 1         (c)  Commission of a felony involving embezzlement,

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

 3  destruction of records, making false statements, receiving

 4  stolen property, making false claims, or obstruction of

 5  justice; or

 6         (d)  Any crime in any jurisdiction which directly

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

 8  fixed-sum basis.

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

10  apply for waivers of applicable federal laws and regulations

11  as necessary to implement more appropriate systems of health

12  care for Medicaid recipients and reduce the cost of the

13  Medicaid program to the state and federal governments and

14  shall implement such programs, after legislative approval,

15  within a reasonable period of time after federal approval.

16  These programs must be designed primarily to reduce the need

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

18  institutional care, and other high-cost services.

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

20  waiver as authorized by this subsection, the agency shall

21  provide notice and an opportunity for public comment. Notice

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

23  agency for advance notice and shall be published in the

24  Florida Administrative Weekly not less than 28 days prior to

25  the intended action.

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

27  appropriated to the Department of Elderly Affairs for the

28  Assisted Living for the Elderly Medicaid waiver and are not

29  expended shall be transferred to the agency to fund

30  Medicaid-reimbursed nursing home care.

31  


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    CS for CS for SB 838                           First Engrossed



 1         (12)  The agency shall establish a postpayment

 2  utilization control program designed to identify recipients

 3  who may inappropriately overuse or underuse Medicaid services

 4  and shall provide methods to correct such misuse.

 5         (13)  The agency shall develop and provide coordinated

 6  systems of care for Medicaid recipients and may contract with

 7  public or private entities to develop and administer such

 8  systems of care among public and private health care providers

 9  in a given geographic area.

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

11  operation of utilization management and incentive systems

12  designed to encourage cost-effective use services.

13         (b)  The agency shall develop a procedure for

14  determining whether health care providers and service vendors

15  can provide the Medicaid program using a business case that

16  demonstrates whether a particular good or service can offset

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

18  setting or through other means and therefore should receive a

19  higher reimbursement. The business case must include, but need

20  not be limited to:

21         1.  A detailed description of the good or service to be

22  provided, a description and analysis of the agency's current

23  performance of the service, and a rationale documenting how

24  providing the service in an alternative setting would be in

25  the best interest of the state, the agency, and its clients.

26         2.  A cost-benefit analysis documenting the estimated

27  specific direct and indirect costs, savings, performance

28  improvements, risks, and qualitative and quantitative benefits

29  involved in or resulting from providing the service. The

30  cost-benefit analysis must include a detailed plan and

31  timeline identifying all actions that must be implemented to


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    CS for CS for SB 838                           First Engrossed



 1  realize expected benefits. The Secretary of Health Care

 2  Administration shall verify that all costs, savings, and

 3  benefits are valid and achievable.

 4         (c)  If the agency determines that the increased

 5  reimbursement is cost-effective, the agency shall recommend a

 6  change in the reimbursement schedule for that particular good

 7  or service. If, within 12 months after implementing any rate

 8  change under this procedure, the agency determines that costs

 9  were not offset by the increased reimbursement schedule, the

10  agency may revert to the former reimbursement schedule for the

11  particular good or service.

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

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

14  nursing facility preadmission screening program to ensure that

15  Medicaid payment for nursing facility care is made only for

16  individuals whose conditions require such care and to ensure

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

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

19  economical manner possible. The CARES program shall also

20  ensure that individuals participating in Medicaid home and

21  community-based waiver programs meet criteria for those

22  programs, consistent with approved federal waivers.

23         (b)  The agency shall operate the CARES program through

24  an interagency agreement with the Department of Elderly

25  Affairs. The agency, in consultation with the Department of

26  Elderly Affairs, may contract for any function or activity of

27  the CARES program, including any function or activity required

28  by 42 C.F.R. part 483.20, relating to preadmission screening

29  and resident review.

30         (c)  Prior to making payment for nursing facility

31  services for a Medicaid recipient, the agency must verify that


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    CS for CS for SB 838                           First Engrossed



 1  the nursing facility preadmission screening program has

 2  determined that the individual requires nursing facility care

 3  and that the individual cannot be safely served in

 4  community-based programs. The nursing facility preadmission

 5  screening program shall refer a Medicaid recipient to a

 6  community-based program if the individual could be safely

 7  served at a lower cost and the recipient chooses to

 8  participate in such program. For individuals whose nursing

 9  home stay is initially funded by Medicare and Medicare

10  coverage is being terminated for lack of progress towards

11  rehabilitation, CARES staff shall consult with the person

12  making the determination of progress toward rehabilitation to

13  ensure that the recipient is not being inappropriately

14  disqualified from Medicare coverage. If, in their professional

15  judgment, CARES staff believes that a Medicare beneficiary is

16  still making progress toward rehabilitation, they may assist

17  the Medicare beneficiary with an appeal of the

18  disqualification from Medicare coverage. The use of CARES

19  teams to review Medicare denials for coverage under this

20  section is authorized only if it is determined that such

21  reviews qualify for federal matching funds through Medicaid.

22  The agency shall seek or amend federal waivers as necessary to

23  implement this section.

24         (d)  For the purpose of initiating immediate

25  prescreening and diversion assistance for individuals residing

26  in nursing homes and in order to make families aware of

27  alternative long-term care resources so that they may choose a

28  more cost-effective setting for long-term placement, CARES

29  staff shall conduct an assessment and review of a sample of

30  individuals whose nursing home stay is expected to exceed 20

31  days, regardless of the initial funding source for the nursing


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    CS for CS for SB 838                           First Engrossed



 1  home placement. CARES staff shall provide counseling and

 2  referral services to these individuals regarding choosing

 3  appropriate long-term care alternatives. This paragraph does

 4  not apply to continuing care facilities licensed under chapter

 5  651 or to retirement communities that provide a combination of

 6  nursing home, independent living, and other long-term care

 7  services.

 8         (e)  By January 15 of each year, the agency shall

 9  submit a report to the Legislature and the Office of

10  Long-Term-Care Policy describing the operations of the CARES

11  program. The report must describe:

12         1.  Rate of diversion to community alternative

13  programs;

14         2.  CARES program staffing needs to achieve additional

15  diversions;

16         3.  Reasons the program is unable to place individuals

17  in less restrictive settings when such individuals desired

18  such services and could have been served in such settings;

19         4.  Barriers to appropriate placement, including

20  barriers due to policies or operations of other agencies or

21  state-funded programs; and

22         5.  Statutory changes necessary to ensure that

23  individuals in need of long-term care services receive care in

24  the least restrictive environment.

25         (f)  The Department of Elderly Affairs shall track

26  individuals over time who are assessed under the CARES program

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

28  15 of each year, the department shall submit to the

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

30  longitudinal study of the individuals who are diverted from

31  nursing home placement. The study must include:


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    CS for CS for SB 838                           First Engrossed



 1         1.  The demographic characteristics of the individuals

 2  assessed and diverted from nursing home placement, including,

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

 4  status, living arrangements, and geographic location;

 5         2.  A summary of community services provided to

 6  individuals for 1 year after assessment and diversion;

 7         3.  A summary of inpatient hospital admissions for

 8  individuals who have been diverted; and

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

10  and subsequent entry into a nursing home or death.

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

12  Health Care Administration shall report to the President of

13  the Senate and the Speaker of the House of Representatives

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

15  criteria to eliminate the Intermediate II level of care.

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

17  utilization and price patterns within the Medicaid program

18  which are not cost-effective or medically appropriate and

19  assess the effectiveness of new or alternate methods of

20  providing and monitoring service, and may implement such

21  methods as it considers appropriate. Such methods may include

22  disease management initiatives, an integrated and systematic

23  approach for managing the health care needs of recipients who

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

25  best practices, prevention strategies, clinical-practice

26  improvement, clinical interventions and protocols, outcomes

27  research, information technology, and other tools and

28  resources to reduce overall costs and improve measurable

29  outcomes.

30         (b)  The responsibility of the agency under this

31  subsection shall include the development of capabilities to


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    CS for CS for SB 838                           First Engrossed



 1  identify actual and optimal practice patterns; patient and

 2  provider educational initiatives; methods for determining

 3  patient compliance with prescribed treatments; fraud, waste,

 4  and abuse prevention and detection programs; and beneficiary

 5  case management programs.

 6         1.  The practice pattern identification program shall

 7  evaluate practitioner prescribing patterns based on national

 8  and regional practice guidelines, comparing practitioners to

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

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

11  of practicing health care professionals consisting of the

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

13  President of the Senate shall each appoint three physicians

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

15  shall appoint two pharmacists licensed under chapter 465 and

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

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

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

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

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

21  evaluating treatment guidelines and recommending ways to

22  incorporate their use in the practice pattern identification

23  program. Practitioners who are prescribing inappropriately or

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

25  prescribing of certain drugs subject to prior authorization or

26  may be terminated from all participation in the Medicaid

27  program.

28         2.  The agency shall also develop educational

29  interventions designed to promote the proper use of

30  medications by providers and beneficiaries.

31  


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    CS for CS for SB 838                           First Engrossed



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

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

 3  of credit requirement for participating pharmacies, enhanced

 4  provider auditing practices, the use of additional fraud and

 5  abuse software, recipient management programs for

 6  beneficiaries inappropriately using their benefits, and other

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

 8  and abuse. The initiative shall address enforcement efforts to

 9  reduce the number and use of counterfeit prescriptions.

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

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

12  clinical pharmacology drug information database for

13  practitioners. The initiative shall be designed to enhance the

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

15  prescription drug benefit program and to otherwise further the

16  intent of this paragraph.

17         5.  By April 1, 2006, the agency shall contract with an

18  entity to design a database of clinical utilization

19  information or electronic medical records for Medicaid

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

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

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

23  visits, inpatient and outpatient hospitalizations, laboratory

24  and pathology services, radiological and other imaging

25  services, dental care, and patterns of dispensing prescription

26  drugs in order to coordinate care and identify potential fraud

27  and abuse.

28         6.5.  The agency may apply for any federal waivers

29  needed to administer implement this paragraph.

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

31  basis shall, in addition to meeting any applicable statutory


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    CS for CS for SB 838                           First Engrossed



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

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

 3  allowable as admitted assets by the Office of Insurance

 4  Regulation, and restricted funds or deposits controlled by the

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

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

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

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

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

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

11  prepaid revenues, the agency shall prohibit the entity from

12  engaging in marketing and preenrollment activities, shall

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

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

15  requirements of this subsection do not apply:

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

17  incurred by the contracting entity; or

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

19  guaranteed in writing by a guaranteeing organization which:

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

21  assets in excess of $50 million; or

22         2.  Submits a written guarantee acceptable to the

23  agency which is irrevocable during the term of the contracting

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

25  contract, until the agency receives proof of satisfaction of

26  all outstanding obligations incurred under the contract.

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

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

29  insolvency protection account with a federally guaranteed

30  financial institution licensed to do business in this state.

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


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    CS for CS for SB 838                           First Engrossed



 1  capitation payments made by the agency each month until a

 2  maximum total of 2 percent of the total current contract

 3  amount is reached. The restricted insolvency protection

 4  account may be drawn upon with the authorized signatures of

 5  two persons designated by the entity and two representatives

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

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

 8  the two authorized signatures of representatives of the

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

10  obligations incurred by the entity under the prepaid contract.

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

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

13  upon receipt of proof of satisfaction of all outstanding

14  obligations incurred under this contract.

15         (b)  The agency may waive the insolvency protection

16  account requirement in writing when evidence is on file with

17  the agency of adequate insolvency insurance and reinsurance

18  that will protect enrollees if the entity becomes unable to

19  meet its obligations.

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

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

22  services shall reimburse any hospital or physician that is

23  outside the entity's authorized geographic service area as

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

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

26  negotiated with the hospital or physician for the provision of

27  services or according to the lesser of the following:

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

29  general public by the hospital or physician; or

30         (b)  The Florida Medicaid reimbursement rate

31  established for the hospital or physician.


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    CS for CS for SB 838                           First Engrossed



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

 2  prepaid contractor has been approved by the Office of

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

 4  approve the assignment or transfer of the appropriate Medicaid

 5  prepaid contract upon request of the surviving entity of the

 6  merger or acquisition if the contractor and the other entity

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

 8  12-month period, unless the agency determines that the

 9  assignment or transfer would be detrimental to the Medicaid

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

11  entity must not have failed accreditation or committed any

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

13  meet the Medicaid contract requirements. For purposes of this

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

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

16         (21)  Any entity contracting with the agency pursuant

17  to this section to provide health care services to Medicaid

18  recipients is prohibited from engaging in any of the following

19  practices or activities:

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

21  not limited to, attempts to discourage participation on the

22  basis of actual or perceived health status.

23         (b)  Activities that could mislead or confuse

24  recipients, or misrepresent the organization, its marketing

25  representatives, or the agency. Violations of this paragraph

26  include, but are not limited to:

27         1.  False or misleading claims that marketing

28  representatives are employees or representatives of the state

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

30  organization by whom they are reimbursed.

31  


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    CS for CS for SB 838                           First Engrossed



 1         2.  False or misleading claims that the entity is

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

 3  any other organization which has not certified its endorsement

 4  in writing to the entity.

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

 6  recommends that a Medicaid recipient enroll with an entity.

 7         4.  Claims that a Medicaid recipient will lose benefits

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

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

10  recipient does not enroll with the entity.

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

12  valuable consideration for enrollment, except as authorized by

13  subsection (24).

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

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

16  make a presentation.

17         (e)  Solicitation of Medicaid recipients by marketing

18  representatives stationed in state offices unless approved and

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

20  affected state agency when solicitation occurs in an office of

21  the state agency. The agency shall ensure that marketing

22  representatives stationed in state offices shall market their

23  managed care plans to Medicaid recipients only in designated

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

25  recipients' activities in the state office.

26         (f)  Enrollment of Medicaid recipients.

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

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

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

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

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


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    CS for CS for SB 838                           First Engrossed



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

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

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

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

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

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

 7  and willful violations arising out of the same action.

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

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

10  agency for the provision of health care services to Medicaid

11  recipients may not use or distribute marketing materials used

12  to solicit Medicaid recipients, unless such materials have

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

14  do not apply to general advertising and marketing materials

15  used by a health maintenance organization to solicit both

16  non-Medicaid subscribers and Medicaid recipients.

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

18  organizations and persons or entities exempt from chapter 641

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

20  health care services to Medicaid recipients may be permitted

21  within the capitation rate to provide additional health

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

23  practicably available, provide reasonable value to the

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

25  state.

26         (25)  The agency shall utilize the statewide health

27  maintenance organization complaint hotline for the purpose of

28  investigating and resolving Medicaid and prepaid health plan

29  complaints, maintaining a record of complaints and confirmed

30  problems, and receiving disenrollment requests made by

31  recipients.


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    CS for CS for SB 838                           First Engrossed



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

 2  health maintenance organization's and the prepaid health

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

 4  telephone number of the statewide health maintenance

 5  organization complaint hotline on each Medicaid identification

 6  card issued by a health maintenance organization or prepaid

 7  health plan contracting with the agency to serve Medicaid

 8  recipients and on each subscriber handbook issued to a

 9  Medicaid recipient.

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

11  improvement system for those entities contracting with the

12  agency pursuant to this section, incorporating all the

13  standards and guidelines developed by the Medicaid Bureau of

14  the Health Care Financing Administration as a part of the

15  quality assurance reform initiative. The system shall include,

16  but need not be limited to, the following:

17         (a)  Guidelines for internal quality assurance

18  programs, including standards for:

19         1.  Written quality assurance program descriptions.

20         2.  Responsibilities of the governing body for

21  monitoring, evaluating, and making improvements to care.

22         3.  An active quality assurance committee.

23         4.  Quality assurance program supervision.

24         5.  Requiring the program to have adequate resources to

25  effectively carry out its specified activities.

26         6.  Provider participation in the quality assurance

27  program.

28         7.  Delegation of quality assurance program activities.

29         8.  Credentialing and recredentialing.

30         9.  Enrollee rights and responsibilities.

31  


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    CS for CS for SB 838                           First Engrossed



 1         10.  Availability and accessibility to services and

 2  care.

 3         11.  Ambulatory care facilities.

 4         12.  Accessibility and availability of medical records,

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

 6         13.  Utilization review.

 7         14.  A continuity of care system.

 8         15.  Quality assurance program documentation.

 9         16.  Coordination of quality assurance activity with

10  other management activity.

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

12  elderly and disabled recipients, especially those who are at

13  risk of institutional placement; to persons with developmental

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

15  medical conditions.

16         (b)  Guidelines which require the entities to conduct

17  quality-of-care studies which:

18         1.  Target specific conditions and specific health

19  service delivery issues for focused monitoring and evaluation.

20         2.  Use clinical care standards or practice guidelines

21  to objectively evaluate the care the entity delivers or fails

22  to deliver for the targeted clinical conditions and health

23  services delivery issues.

24         3.  Use quality indicators derived from the clinical

25  care standards or practice guidelines to screen and monitor

26  care and services delivered.

27         (c)  Guidelines for external quality review of each

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

29  individual care review in specific situations; and followup

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

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


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    CS for CS for SB 838                           First Engrossed



 1  quality review function and determining how it is to operate

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

 3  agency shall construct its external quality review

 4  organization and entity contracts to address each of the

 5  following:

 6         1.  Delineating the role of the external quality review

 7  organization.

 8         2.  Length of the external quality review organization

 9  contract with the state.

10         3.  Participation of the contracting entities in

11  designing external quality review organization review

12  activities.

13         4.  Potential variation in the type of clinical

14  conditions and health services delivery issues to be studied

15  at each plan.

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

17  studies to be conducted for each plan.

18         6.  Methods for implementing focused studies.

19         7.  Individual care review.

20         8.  Followup activities.

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

22  care services for which an entity has already been

23  compensated, an entity contracting with the agency pursuant to

24  this section shall achieve an annual Early and Periodic

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

26  rate of at least 60 percent for those recipients continuously

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

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

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

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

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


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    CS for CS for SB 838                           First Engrossed



 1  established in the corrective action plan during the specified

 2  timeframe, the agency is authorized to impose appropriate

 3  contract sanctions. At least annually, the agency shall

 4  publicly release the EPSDT Services screening rates of each

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

 6  Medicaid recipients.

 7         (29)  The agency shall perform enrollments and

 8  disenrollments for Medicaid recipients who are eligible for

 9  MediPass or managed care plans. Notwithstanding the

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

11  may perform preenrollments of Medicaid recipients under the

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

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

14  and educational materials to a Medicaid recipient and

15  assistance in completing the application forms, but shall not

16  include actual enrollment into a managed care plan. An

17  application for enrollment shall not be deemed complete until

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

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

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

21  marketing initiatives to inform Medicaid recipients about

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

23  report to the Legislature on the effectiveness of such

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

25  perform managed care plan and MediPass enrollment and

26  disenrollment services for Medicaid recipients and is

27  authorized to adopt rules to implement such services. The

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

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

30  for agency supervision and management of the managed care plan

31  enrollment and disenrollment contract.


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    CS for CS for SB 838                           First Engrossed



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

 2  recipients, MediPass enrollees, or managed care plan enrollees

 3  shall be arranged alphabetically showing the provider's name

 4  and specialty and, separately, by specialty in alphabetical

 5  order.

 6         (31)  The agency shall establish an enhanced managed

 7  care quality assurance oversight function, to include at least

 8  the following components:

 9         (a)  At least quarterly analysis and followup,

10  including sanctions as appropriate, of managed care

11  participant utilization of services.

12         (b)  At least quarterly analysis and followup,

13  including sanctions as appropriate, of quality findings of the

14  Medicaid peer review organization and other external quality

15  assurance programs.

16         (c)  At least quarterly analysis and followup,

17  including sanctions as appropriate, of the fiscal viability of

18  managed care plans.

19         (d)  At least quarterly analysis and followup,

20  including sanctions as appropriate, of managed care

21  participant satisfaction and disenrollment surveys.

22         (e)  The agency shall conduct regular and ongoing

23  Medicaid recipient satisfaction surveys.

24  

25  The analyses and followup activities conducted by the agency

26  under its enhanced managed care quality assurance oversight

27  function shall not duplicate the activities of accreditation

28  reviewers for entities regulated under part III of chapter

29  641, but may include a review of the finding of such

30  reviewers.

31  


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    CS for CS for SB 838                           First Engrossed



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

 2  with the agency to provide health care services to Medicaid

 3  recipients shall annually conduct a background check with the

 4  Florida Department of Law Enforcement of all persons with

 5  ownership interest of 5 percent or more or executive

 6  management responsibility for the managed care plan and shall

 7  submit to the agency information concerning any such person

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

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

10  offenses listed in s. 435.03.

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

12  whereby a Medicaid managed care plan enrollee who wishes to

13  enter hospice care may be disenrolled from the managed care

14  plan within 24 hours after contacting the agency regarding

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

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

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

18  disenrollment occurs.

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

20  the agency to provide health care services to Medicaid

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

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

23  emergency services and care to Medicaid recipients and

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

25  the agency shall encourage hospitals, emergency medical

26  services providers, and other public and private health care

27  providers to work together in their local communities to enter

28  into agreements or arrangements to ensure access to

29  alternatives to emergency services and care for those Medicaid

30  recipients who need nonemergent care. The agency shall

31  coordinate with hospitals, emergency medical services


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    CS for CS for SB 838                           First Engrossed



 1  providers, private health plans, capitated managed care

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

 3  private health care providers to implement the provisions of

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

 5  develop and implement emergency department diversion programs

 6  for Medicaid recipients.

 7         (35)  All entities providing health care services to

 8  Medicaid recipients shall make available, and encourage all

 9  pregnant women and mothers with infants to receive, and

10  provide documentation in the medical records to reflect, the

11  following:

12         (a)  Healthy Start prenatal or infant screening.

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

14  other factors indicate need.

15         (c)  Healthy Start enhanced services in accordance with

16  the prenatal or infant screening results.

17         (d)  Immunizations in accordance with recommendations

18  of the Advisory Committee on Immunization Practices of the

19  United States Public Health Service and the American Academy

20  of Pediatrics, as appropriate.

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

22  women and their partners.

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

24  voluntary family planning, to include discussion of all

25  methods of contraception, as appropriate.

26         (g)  Referral to the Special Supplemental Nutrition

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

28         (36)  Any entity that provides Medicaid prepaid health

29  plan services shall ensure the appropriate coordination of

30  health care services with an assisted living facility in cases

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


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    CS for CS for SB 838                           First Engrossed



 1  prepaid health plan and a resident of the assisted living

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

 3  management and behavioral health services, the entity shall

 4  inform the assisted living facility of the procedures to

 5  follow should an emergent condition arise.

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

 7  necessary to provide for cost-effective purchasing of home

 8  health services, private duty nursing services,

 9  transportation, independent laboratory services, and durable

10  medical equipment and supplies through competitive bidding

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

12  waivers from the federal Health Care Financing Administration

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

14  exclude providers not selected through the bidding process

15  from the Medicaid provider network.

16         (38)  The agency shall enter into agreements with

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

18  purpose of providing vision screening.

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

20  prescribed-drug spending-control program that includes the

21  following components:

22         1.  Medicaid prescribed-drug coverage for brand-name

23  drugs for adult Medicaid recipients is limited to the

24  dispensing of four brand-name drugs per month per recipient.

25  Children are exempt from this restriction. Antiretroviral

26  agents are excluded from this limitation. No requirements for

27  prior authorization or other restrictions on medications used

28  to treat mental illnesses such as schizophrenia, severe

29  depression, or bipolar disorder may be imposed on Medicaid

30  recipients. Medications that will be available without

31  restriction for persons with mental illnesses include atypical


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    CS for CS for SB 838                           First Engrossed



 1  antipsychotic medications, conventional antipsychotic

 2  medications, selective serotonin reuptake inhibitors, and

 3  other medications used for the treatment of serious mental

 4  illnesses. The agency shall also limit the amount of a

 5  prescribed drug dispensed to no more than a 34-day supply. The

 6  agency shall continue to provide unlimited generic drugs,

 7  contraceptive drugs and items, and diabetic supplies. Although

 8  a drug may be included on the preferred drug formulary, it

 9  would not be exempt from the four-brand limit. The agency may

10  authorize exceptions to the brand-name-drug restriction based

11  upon the treatment needs of the patients, only when such

12  exceptions are based on prior consultation provided by the

13  agency or an agency contractor, but the agency must establish

14  procedures to ensure that:

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

16  consultation by telephone or other telecommunication device

17  within 24 hours after receipt of a request for prior

18  consultation;

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

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

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

22  and

23         c.  Except for the exception for nursing home residents

24  and other institutionalized adults and except for drugs on the

25  restricted formulary for which prior authorization may be

26  sought by an institutional or community pharmacy, prior

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

28  restriction is sought by the prescriber and not by the

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

30  an institutional setting beyond the brand-name-drug

31  


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    CS for CS for SB 838                           First Engrossed



 1  restriction, such approval is authorized for 12 months and

 2  monthly prior authorization is not required for that patient.

 3         2.  Reimbursement to pharmacies for Medicaid prescribed

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

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

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

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

 8  customary (UAC) charge billed by the provider.

 9         3.  The agency shall develop and implement a process

10  for managing the drug therapies of Medicaid recipients who are

11  using significant numbers of prescribed drugs each month. The

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

13  comprehensive, physician-directed medical-record reviews,

14  claims analyses, and case evaluations to determine the medical

15  necessity and appropriateness of a patient's treatment plan

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

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

18  Medicaid drug benefit management program shall include

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

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

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

22  agency shall enroll any Medicaid recipient in the drug benefit

23  management program if he or she meets the specifications of

24  this provision and is not enrolled in a Medicaid health

25  maintenance organization.

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

27  network based on need, competitive bidding, price

28  negotiations, credentialing, or similar criteria. The agency

29  shall give special consideration to rural areas in determining

30  the size and location of pharmacies included in the Medicaid

31  pharmacy network. A pharmacy credentialing process may include


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    CS for CS for SB 838                           First Engrossed



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

 2  size, patient educational programs, patient consultation,

 3  disease-management services, and other characteristics. The

 4  agency may impose a moratorium on Medicaid pharmacy enrollment

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

 6  Medicaid-participating providers. The agency must allow

 7  dispensing practitioners to participate as a part of the

 8  Medicaid pharmacy network regardless of the practitioner's

 9  proximity to any other entity that is dispensing prescription

10  drugs under the Medicaid program. A dispensing practitioner

11  must meet all credentialing requirements applicable to his or

12  her practice, as determined by the agency.

13         5.  The agency shall develop and implement a program

14  that requires Medicaid practitioners who prescribe drugs to

15  use a counterfeit-proof prescription pad for Medicaid

16  prescriptions. The agency shall require the use of

17  standardized counterfeit-proof prescription pads by

18  Medicaid-participating prescribers or prescribers who write

19  prescriptions for Medicaid recipients. The agency may

20  implement the program in targeted geographic areas or

21  statewide.

22         6.  The agency may enter into arrangements that require

23  manufacturers of generic drugs prescribed to Medicaid

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

25  average manufacturer price for the manufacturer's generic

26  products. These arrangements shall require that if a

27  generic-drug manufacturer pays federal rebates for

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

29  manufacturer must provide a supplemental rebate to the state

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

31  


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    CS for CS for SB 838                           First Engrossed



 1         7.  The agency may establish a preferred drug formulary

 2  in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the

 3  establishment of such formulary, it is authorized to negotiate

 4  supplemental rebates from manufacturers that are in addition

 5  to those required by Title XIX of the Social Security Act and

 6  at no less than 14 percent of the average manufacturer price

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

 8  unless the federal or supplemental rebate, or both, equals or

 9  exceeds 29 percent. There is no upper limit on the

10  supplemental rebates the agency may negotiate. The agency may

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

12  competitive at lower rebate percentages. Agreement to pay the

13  minimum supplemental rebate percentage will guarantee a

14  manufacturer that the Medicaid Pharmaceutical and Therapeutics

15  Committee will consider a product for inclusion on the

16  preferred drug formulary. However, a pharmaceutical

17  manufacturer is not guaranteed placement on the formulary by

18  simply paying the minimum supplemental rebate. Agency

19  decisions will be made on the clinical efficacy of a drug and

20  recommendations of the Medicaid Pharmaceutical and

21  Therapeutics Committee, as well as the price of competing

22  products minus federal and state rebates. The agency is

23  authorized to contract with an outside agency or contractor to

24  conduct negotiations for supplemental rebates. For the

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

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

27  programs as a substitution for supplemental rebates are

28  prohibited. The agency is authorized to seek any federal

29  waivers to implement this initiative.

30         8.  The agency shall establish an advisory committee

31  for the purposes of studying the feasibility of using a


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    CS for CS for SB 838                           First Engrossed



 1  restricted drug formulary for nursing home residents and other

 2  institutionalized adults. The committee shall be comprised of

 3  seven members appointed by the Secretary of Health Care

 4  Administration. The committee members shall include two

 5  physicians licensed under chapter 458 or chapter 459; three

 6  pharmacists licensed under chapter 465 and appointed from a

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

 8  Pharmacy Alliance; and two pharmacists licensed under chapter

 9  465.

10         9.  The Agency for Health Care Administration shall

11  expand home delivery of pharmacy products. To assist Medicaid

12  patients in securing their prescriptions and reduce program

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

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

15  drugs used by Medicaid patients with diabetes. Medicaid

16  recipients in the current program may obtain nondiabetes drugs

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

18  geographic area covered by the current contract. The agency

19  may seek and implement any federal waivers necessary to

20  implement this subparagraph.

21         10.  The agency shall limit to one dose per month any

22  drug prescribed to treat erectile dysfunction.

23         11.a.  The agency shall implement a Medicaid behavioral

24  drug management system. The agency may contract with a vendor

25  that has experience in operating behavioral drug management

26  systems to implement this program. The agency is authorized to

27  seek federal waivers to implement this program.

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

29  Children and Family Services, may implement the Medicaid

30  behavioral drug management system that is designed to improve

31  the quality of care and behavioral health prescribing


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    CS for CS for SB 838                           First Engrossed



 1  practices based on best practice guidelines, improve patient

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

 3  prescribed drug costs and the rate of inappropriate spending

 4  on Medicaid behavioral drugs. The program shall include the

 5  following elements:

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

 7  practice guidelines for behavioral health-related drugs such

 8  as antipsychotics, antidepressants, and medications for

 9  treating bipolar disorders and other behavioral conditions;

10  translate them into practice; review behavioral health

11  prescribers and compare their prescribing patterns to a number

12  of indicators that are based on national standards; and

13  determine deviations from best practice guidelines.

14         (II)  Implement processes for providing feedback to and

15  educating prescribers using best practice educational

16  materials and peer-to-peer consultation.

17         (III)  Assess Medicaid beneficiaries who are outliers

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

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

20  drug therapies, and other indicators of improper use of

21  behavioral health drugs.

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

23  prescriptions in a timely fashion, are prescribed multiple

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

25  potential medication problems.

26         (V)  Track spending trends for behavioral health drugs

27  and deviation from best practice guidelines.

28         (VI)  Use educational and technological approaches to

29  promote best practices, educate consumers, and train

30  prescribers in the use of practice guidelines.

31         (VII)  Disseminate electronic and published materials.


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    CS for CS for SB 838                           First Engrossed



 1         (VIII)  Hold statewide and regional conferences.

 2         (IX)  Implement a disease management program with a

 3  model quality-based medication component for severely mentally

 4  ill individuals and emotionally disturbed children who are

 5  high users of care.

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

 7  with one or more manufacturers to finance and guarantee

 8  savings associated with a behavioral drug management program

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

10  drug list prior-authorization requirements shall apply to

11  mental health-related drugs, notwithstanding any provision in

12  subparagraph 1. The agency is authorized to seek federal

13  waivers to implement this policy.

14         12.a.  The agency shall implement a Medicaid

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

16  with a vendor that has experience in operating

17  prescription-drug-management systems in order to implement

18  this system. Any management system that is implemented in

19  accordance with this subparagraph must rely on cooperation

20  between physicians and pharmacists to determine appropriate

21  practice patterns and clinical guidelines to improve the

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

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

24  program.

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

26  improve the quality of care and prescribing practices based on

27  best-practice guidelines, improve patient adherence to

28  medication plans, reduce clinical risk, and lower prescribed

29  drug costs and the rate of inappropriate spending on Medicaid

30  prescription drugs. The program must:

31  


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    CS for CS for SB 838                           First Engrossed



 1         (I)  Provide for the development and adoption of

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

 3  in the Medicaid program, including translating best-practice

 4  guidelines into practice; reviewing prescriber patterns and

 5  comparing them to indicators that are based on national

 6  standards and practice patterns of clinical peers in their

 7  community, statewide, and nationally; and determine deviations

 8  from best-practice guidelines.

 9         (II)  Implement processes for providing feedback to and

10  educating prescribers using best-practice educational

11  materials and peer-to-peer consultation.

12         (III)  Assess Medicaid recipients who are outliers in

13  their use of a single or multiple prescription drugs with

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

15  combination drug therapies, and other indicators of improper

16  use of prescription drugs.

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

18  prescriptions in a timely fashion, are prescribed multiple

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

20  other potential medication problems.

21         (V)  Track spending trends for prescription drugs and

22  deviation from best-practice guidelines.

23         (VI)  Use educational and technological approaches to

24  promote best practices, educate consumers, and train

25  prescribers in the use of practice guidelines.

26         (VII)  Disseminate electronic and published materials.

27         (VIII)  Hold statewide and regional conferences.

28         (IX)  Implement disease-management programs in

29  cooperation with physicians and pharmacists, along with a

30  model quality-based medication component for individuals

31  having chronic medical conditions.


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    CS for CS for SB 838                           First Engrossed



 1         13.12.  The agency is authorized to contract for drug

 2  rebate administration, including, but not limited to,

 3  calculating rebate amounts, invoicing manufacturers,

 4  negotiating disputes with manufacturers, and maintaining a

 5  database of rebate collections.

 6         14.13.  The agency may specify the preferred daily

 7  dosing form or strength for the purpose of promoting best

 8  practices with regard to the prescribing of certain drugs as

 9  specified in the General Appropriations Act and ensuring

10  cost-effective prescribing practices.

11         15.14.  The agency may require prior authorization for

12  the off-label use of Medicaid-covered prescribed drugs as

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

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

15  an indication not in the approved labeling. Prior

16  authorization may require the prescribing professional to

17  provide information about the rationale and supporting medical

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

19         16.15.  The agency shall implement a return and reuse

20  program for drugs dispensed by pharmacies to institutional

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

22  the implementation and operation of the program. The return

23  and reuse program shall be implemented electronically and in a

24  manner that promotes efficiency. The program must permit a

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

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

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

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

29  shall determine if the program has reduced the amount of

30  Medicaid prescription drugs which are destroyed on an annual

31  basis and if there are additional ways to ensure more


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    CS for CS for SB 838                           First Engrossed



 1  prescription drugs are not destroyed which could safely be

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

 3  reported to the Legislature by December 1, 2005.

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

 5  extent that funds are appropriated to administer the Medicaid

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

 7  contract all or any part of this program to private

 8  organizations.

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

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

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

12  limited to, the progress made in implementing this subsection

13  and its effect on Medicaid prescribed-drug expenditures.

14         (40)  Notwithstanding the provisions of chapter 287,

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

16  contracts for fiscal intermediary services one or more times

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

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

19  the term of the original contract.

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

21  demonstration project by establishment in Miami-Dade County of

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

23  improve access to health care for a predominantly minority,

24  medically underserved, and medically complex population and to

25  evaluate alternatives to nursing home care and general acute

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

27  health care condominium and colocated with licensed facilities

28  providing a continuum of care. The establishment of this

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

30  408.039. The agency shall report its findings to the Governor,

31  


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    CS for CS for SB 838                           First Engrossed



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

 2  Representatives by January 1, 2003.

 3         (42)  The agency shall develop and implement a

 4  utilization management program for Medicaid-eligible

 5  recipients for the management of occupational, physical,

 6  respiratory, and speech therapies. The agency shall establish

 7  a utilization program that may require prior authorization in

 8  order to ensure medically necessary and cost-effective

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

10  federally approved waiver program or state plan amendment. The

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

12  implement this program. The agency may also competitively

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

14  statewide basis.

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

16  basis with appropriately licensed prepaid dental health plans

17  to provide dental services.

18         (44)  The Agency for Health Care Administration shall

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

20  409.9122(2)(h), whether paid on a capitated basis or a shared

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

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

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

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

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

26  costs associated with contracts for Medicaid services

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

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

29  shall conduct actuarially sound audits adjusted for case mix

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

31  publish the audit results on its Internet website and submit


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    CS for CS for SB 838                           First Engrossed



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

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

 3  later than December 31 of each year. Contracts established

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

 5  not be renewed.

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

 7  shall mandate a recipient's participation in a provider

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

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

10  frequency or amount not medically necessary, limiting the

11  receipt of goods or services to medically necessary providers

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

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

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

15  clinics. The limitation does not apply to emergency services

16  and care provided to the recipient in a hospital emergency

17  department. The agency shall seek any federal waivers

18  necessary to implement this subsection. The agency shall adopt

19  any rules necessary to comply with or administer this

20  subsection.

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

22  permission to terminate the eligibility of a Medicaid

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

24  judicial or administrative determination, two times in a

25  period of 5 years.

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

27  electronic systems for the purpose of verifying the identity

28  and eligibility of a Medicaid recipient. The agency shall

29  recommend to the Legislature a plan to implement an electronic

30  verification system for Medicaid recipients by January 31,

31  2005.


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    CS for CS for SB 838                           First Engrossed



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

 2  Medicaid provider network. The agency may implement a Medicaid

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

 4  limited to, competitive procurement and provider

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

 6  may limit its provider network based upon the following

 7  considerations: beneficiary access to care, provider

 8  availability, provider quality standards and quality assurance

 9  processes, cultural competency, demographic characteristics of

10  beneficiaries, practice standards, service wait times,

11  provider turnover, provider licensure and accreditation

12  history, program integrity history, peer review, Medicaid

13  policy and billing compliance records, clinical and medical

14  record audit findings, and such other areas that are

15  considered necessary by the agency to ensure the integrity of

16  the program.

17         (49)  The agency shall contract with established

18  minority physician networks that provide services to

19  historically underserved minority patients. The networks must

20  provide cost-effective Medicaid services, comply with the

21  requirements to be a MediPass provider, and provide their

22  primary care physicians with access to data and other

23  management tools necessary to assist them in ensuring the

24  appropriate use of services, including inpatient hospital

25  services and pharmaceuticals.

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

27  expansion of minority physician networks in each service area

28  to provide services to Medicaid recipients who are eligible to

29  participate under federal law and rules.

30         (b)  The agency shall reimburse each minority physician

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


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    CS for CS for SB 838                           First Engrossed



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

 2  provider for Medicaid services. Any savings shall be shared

 3  with the minority physician networks pursuant to the contract.

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

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

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

 7  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. Contracts established pursuant to this

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

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

20  needed to implement this subsection.

21         (50)  The agency may contract with established

22  federally qualified health centers that provide services to

23  historically underserved and uninsured patients. The networks

24  must provide cost-effective Medicaid services, comply with the

25  requirements of a MediPass provider, and provide their primary

26  care physicians with access to data and other management tools

27  necessary to assist them in ensuring the appropriate use of

28  services, including inpatient hospital services and

29  pharmaceuticals.

30         (a)  The agency may provide for the development and

31  expansion of federally qualified health center based provider


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    CS for CS for SB 838                           First Engrossed



 1  service networks in each service area to provide services to

 2  Medicaid recipients who are eligible to participate under

 3  federal law and rules.

 4         (b)  The agency may reimburse each federally qualified

 5  health center based network as a fee-for-service provider,

 6  including the case management fee for primary care or as a

 7  capitated rate provider for Medicaid services. Any savings

 8  shall be shared with the federally qualified health center

 9  networks under the contract.

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

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

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

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

14  case-management fees must be no greater than the state's costs

15  associated with contracts for Medicaid services, which shall

16  be actuarially adjusted for case mix, model, and service area.

17  The agency shall conduct actuarially sound audits adjusted for

18  case mix and model in order to ensure such cost-effectiveness

19  and  shall publish the audit results on its Internet website

20  and submit the audit results annually to the Governor, the

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

22  Representatives no later than December 31.

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

24  needed to administer this subsection.

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

26  allowed under s. 409.906, the agency shall provide

27  reimbursement for emergency mental health care services for

28  Medicaid recipients in crisis-stabilization facilities

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

30  expensive than the same services provided in a hospital

31  setting.


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    CS for CS for SB 838                           First Engrossed



 1         Section 2.  Section 409.91211, Florida Statutes, is

 2  created to read:

 3         409.91211  Medicaid managed care pilot program.--

 4         (1)  The agency is authorized to seek experimental,

 5  pilot, or demonstration project waivers, pursuant to s. 1115

 6  of the Social Security Act, to create a more efficient and

 7  effective service delivery system that enhances quality of

 8  care and client outcomes in the Florida Medicaid program

 9  pursuant to this section in two geographic areas. One

10  demonstration site shall include only Broward County. A second

11  demonstration site shall initially include Duval County and

12  shall be expanded to include Baker, Clay, and Nassau Counties

13  within 1 year after the Duval County program becomes

14  operational. This waiver authority is contingent upon federal

15  approval to preserve the upper-payment-limit funding mechanism

16  for hospitals, including a guarantee of a reasonable growth

17  factor, a methodology to allow the use of a portion of these

18  funds to serve as a risk pool for demonstration sites,

19  provisions to preserve the state's ability to use

20  intergovernmental transfers, and provisions to protect the

21  disproportionate share program authorized pursuant to this

22  chapter.

23         (2)  The Legislature intends for the capitated managed

24  care pilot program to:

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

26  the MediPass program a comprehensive and coordinated capitated

27  managed care system for all health care services specified in

28  ss. 409.905 and 409.906.

29         (b)  Stabilize Medicaid expenditures under the pilot

30  program compared to Medicaid expenditures in the pilot area

31  


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    CS for CS for SB 838                           First Engrossed



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

 2  while ensuring:

 3         1.  Consumer education and choice.

 4         2.  Access to medically necessary services.

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

 6  care.

 7         4.  Reductions in unnecessary service utilization.

 8         (c)  Provide an opportunity to evaluate the feasibility

 9  of statewide implementation of capitated managed care networks

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

11  MediPass systems.

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

13  duties, and responsibilities with respect to the development

14  of a pilot program:

15         (a)  To develop and recommend a system to deliver all

16  health care services specified in ss. 409.905 and 409.906,

17  which shall not vary in amount, duration, or scope beyond what

18  is allowed in current managed care contracts in the form of

19  capitated managed care networks under the Medicaid program.

20         (b)  To recommend Medicaid-eligibility categories, from

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

22  included in the pilot program.

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

24  managed care pilot program in order to take maximum advantage

25  of all available state and federal funds, including those

26  obtained through intergovernmental transfers, the

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

28  share program.

29         (d)  To determine and recommend actuarially sound,

30  risk-adjusted capitation rates for Medicaid recipients in the

31  


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    CS for CS for SB 838                           First Engrossed



 1  pilot program which can be separated to cover comprehensive

 2  care, enhanced services, and catastrophic care.

 3         (e)  To determine and recommend policies and guidelines

 4  for phasing in financial risk for approved provider service

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

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

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

 8  be converted to a risk-adjusted capitated rate in the third

 9  year of operation. Federally qualified health centers may be

10  offered an opportunity to accept or decline a contract to

11  participate in any provider network for prepaid primary care

12  services.

13         (f)  To determine and recommend provisions related to

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

15  catastrophic coverage that accommodates the risks associated

16  with the development of the pilot program.

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

18  the Social Services Estimating Conference to determine and

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

20  providing Medicaid services under the managed care pilot

21  program.

22         (h)  To determine and recommend program standards and

23  credentialing requirements for capitated managed care networks

24  to participate in the pilot program, including those related

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

26  health care providers. It is the intent of the Legislature

27  that, to the extent possible, any pilot program authorized by

28  the state under this section include any federally qualified

29  health center, federally qualified rural health clinic, county

30  health department, or other federally, state, or locally

31  funded entity that serves the geographic areas within the


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    CS for CS for SB 838                           First Engrossed



 1  boundaries of the pilot program that requests to participate.

 2  This paragraph does not relieve an entity that qualifies as a

 3  capitated managed care network under this section from any

 4  other licensure or regulatory requirements contained in state

 5  or federal law which would otherwise apply to the entity. The

 6  standards and credentialing requirements shall be based upon,

 7  but are not limited to:

 8         1.  Compliance with the accreditation requirements as

 9  provided in s. 641.512.

10         2.  Compliance with early and periodic screening,

11  diagnosis, and treatment screening requirements under federal

12  law.

13         3.  The percentage of voluntary disenrollments.

14         4.  Immunization rates.

15         5.  Standards of the National Committee for Quality

16  Assurance and other approved accrediting bodies.

17         6.  Recommendations of other authoritative bodies.

18         7.  Specific requirements of the Medicaid program, or

19  standards designed to specifically meet the unique needs of

20  Medicaid recipients.

21         8.  Compliance with the health quality improvement

22  system as established by the agency, which incorporates

23  standards and guidelines developed by the Centers for Medicare

24  and Medicaid Services as part of the quality assurance reform

25  initiative.

26         9.  The network's infrastructure capacity to manage

27  financial transactions, recordkeeping, data collection, and

28  other administrative functions.

29         10.  The network's ability to submit any financial,

30  programmatic, or patient-encounter data or other information

31  


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    CS for CS for SB 838                           First Engrossed



 1  required by the agency to determine the actual services

 2  provided and the cost of administering the plan.

 3         (i)  To develop and recommend a mechanism for providing

 4  information to Medicaid recipients for the purpose of

 5  selecting a capitated managed care plan. For each plan

 6  available to a recipient, the agency, at a minimum shall

 7  ensure that the recipient is provided with:

 8         1.  A list and description of the benefits provided.

 9         2.  Information about cost sharing.

10         3.  Plan performance data, if available.

11         4.  An explanation of benefit limitations.

12         5.  Contact information, including identification of

13  providers participating in the network, geographic locations,

14  and transportation limitations.

15         6.  Any other information the agency determines would

16  facilitate a recipient's understanding of the plan or

17  insurance that would best meet his or her needs.

18         (j)  To develop and recommend a system to ensure that

19  there is a record of recipient acknowledgment that choice

20  counseling has been provided.

21         (k)  To develop and recommend a choice counseling

22  system to ensure that the choice counseling process and

23  related material are designed to provide counseling through

24  face-to-face interaction, by telephone, and in writing and

25  through other forms of relevant media. Materials shall be

26  written at the fourth-grade reading level and available in a

27  language other than English when 5 percent of the county

28  speaks a language other than English. Choice counseling shall

29  also use language lines and other services for impaired

30  recipients, such as TTD/TTY.

31  


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    CS for CS for SB 838                           First Engrossed



 1         (l)  To develop and recommend a system that prohibits

 2  capitated managed care plans, their representatives, and

 3  providers employed by or contracted with the capitated managed

 4  care plans from recruiting persons eligible for or enrolled in

 5  Medicaid, from providing inducements to Medicaid recipients to

 6  select a particular capitated managed care plan, and from

 7  prejudicing Medicaid recipients against other capitated

 8  managed care plans. The system shall require the entity

 9  performing choice counseling to determine if the recipient has

10  made a choice of a plan or has opted out because of duress,

11  threats, payment to the recipient, or incentives promised to

12  the recipient by a third party. If the choice counseling

13  entity determines that the decision to choose a plan was

14  unlawfully influenced or a plan violated any of the provisions

15  of s. 409.912(21), the choice counseling entity shall

16  immediately report the violation to the agency's program

17  integrity section for investigation.Verification of choice

18  counseling by the recipient shall include a stipulation that

19  the recipient acknowledges the provisions of this subsection.

20         (m)  To develop and recommend a choice counseling

21  system that promotes health literacy and provides information

22  aimed to reduce minority health disparities through outreach

23  activities for Medicaid recipients.

24         (n)  To develop and recommend a system for the agency

25  to contract with entities to perform choice counseling. The

26  agency may establish standards and performance contracts,

27  including standards requiring the contractor to hire choice

28  counselors who are representative of the state's diverse

29  population and to train choice counselors in working with

30  culturally diverse populations.

31  


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    CS for CS for SB 838                           First Engrossed



 1         (o)  To determine and recommend descriptions of the

 2  eligibility assignment processes which will be used to

 3  facilitate client choice while ensuring pilot programs of

 4  adequate enrollment levels. These processes shall ensure that

 5  pilot sites have sufficient levels of enrollment to conduct a

 6  valid test of the managed care pilot program within a 2-year

 7  timeframe.

 8         (p)  To develop and recommend a system to monitor the

 9  provision of health care services in the pilot program,

10  including utilization and quality of health care services for

11  the purpose of ensuring access to medically necessary

12  services. This system shall include an encounter

13  data-information system that collects and reports utilization

14  information. The system shall include a method for verifying

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

16  medical records.

17         (q)  To recommend a grievance-resolution process for

18  Medicaid recipients enrolled in a capitated managed care

19  network under the pilot program modeled after the subscriber

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

21  shall include a mechanism for an expedited review of no

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

23  life of a Medicaid recipient is in imminent and emergent

24  jeopardy.

25         (r)  To recommend a grievance-resolution process for

26  health care providers employed by or contracted with a

27  capitated managed care network under the pilot program in

28  order to settle disputes among the provider and the managed

29  care network or the provider and the agency.

30         (s)  To develop and recommend criteria to designate

31  health care providers as eligible to participate in the pilot


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    CS for CS for SB 838                           First Engrossed



 1  program. The agency and capitated managed care networks must

 2  follow national guidelines for selecting health care

 3  providers, whenever available. These criteria must include at

 4  a minimum those criteria specified in s. 409.907.

 5         (t)  To develop and recommend health care provider

 6  agreements for participation in the pilot program.

 7         (u)  To require that all health care providers under

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

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

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

11  a minimum those criteria specified in s. 409.907.

12         (v)  To develop and recommend agreements with other

13  state or local governmental programs or institutions for the

14  coordination of health care to eligible individuals receiving

15  services from such programs or institutions.

16         (w)  To develop and recommend a system to oversee the

17  activities of pilot program participants, health care

18  providers, capitated managed care networks, and their

19  representatives in order to prevent fraud or abuse,

20  overutilization or duplicative utilization, underutilization

21  or inappropriate denial of services, and neglect of

22  participants and to recover overpayments as appropriate. For

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

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

25  refer incidents of suspected fraud, abuse, overutilization and

26  duplicative utilization, and underutilization or inappropriate

27  denial of services to the appropriate regulatory agency.

28         (x)  To develop and provide actuarial and benefit

29  design analyses that indicate the effect on capitation rates

30  and benefits offered in the pilot program over a prospective

31  5-year period based on the following assumptions:


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    CS for CS for SB 838                           First Engrossed



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

 2  estimated growth rate in general revenue.

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

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

 5  Medicaid expenditures.

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

 7  growth rate of aggregate Medicaid expenditures between the

 8  2003-2004 fiscal year and the 2004-2005 fiscal year.

 9         (y)  To develop a mechanism to require capitated

10  managed care plans to reimburse qualified emergency service

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

12  in accordance with ss. 409.908 and 409.9128. The pilot program

13  must include a provision for continuation of fee-for-service

14  payments for individuals who access emergency departments and

15  subsequently are determined eligible for Medicaid services.

16  The pilot program must include a provision for continuing

17  fee-for-service payments for emergency services, including but

18  not limited to, individuals who access ambulance services or

19  emergency departments and who are subsequently determined to

20  be eligible for Medicaid services.

21         (z)  To develop a system whereby school districts

22  participating in the certified school match program pursuant

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

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

25  Medicaid-eligible child participating in the services as

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

27  regardless of whether the child is enrolled in a capitated

28  managed care network. Capitated managed care networks must

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

30  districts regarding the coordinated provision of services

31  authorized under s. 1011.70. County health departments


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    CS for CS for SB 838                           First Engrossed



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

 2  381.0057 must be reimbursed by Medicaid for the federal share

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

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

 5  is enrolled in a capitated managed care network. Capitated

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

 7  agreements with county health departments regarding the

 8  coordinated provision of services to a Medicaid-eligible

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

10  agency, the Department of Health, and the Department of

11  Education shall develop procedures for ensuring that a

12  student's capitated managed care network provider receives

13  information relating to services provided in accordance with

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

15         (aa)  To develop and recommend a mechanism whereby

16  Medicaid recipients who are already enrolled in a managed care

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

18  offered the opportunity to change to capitated managed care

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

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

21  choice of capitated managed care plans. Those Medicaid

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

23  capitated managed care plan in accordance with paragraph

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

25  recipient who is also a recipient of Supplemental Security

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

27  capitated managed care plan, the agency shall determine

28  whether the SSI recipient has an ongoing relationship with a

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

30  shall assign the SSI recipient to that provider or capitated

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


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    CS for CS for SB 838                           First Engrossed



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

 2  capitated managed care plan provider in accordance with

 3  paragraph (4)(a).

 4         (bb)  To develop and recommend a service delivery

 5  alternative for children having chronic medical conditions

 6  which establishes a medical home project to provide primary

 7  care services to this population. The project shall provide

 8  community-based primary care services that are integrated with

 9  other subspecialties to meet the medical, developmental, and

10  emotional needs for children and their families. This project

11  shall include an evaluation component to determine impacts on

12  hospitalizations, length of stays, emergency room visits,

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

14  patient, and family satisfaction.

15         (cc)  To develop and recommend service delivery

16  mechanisms within capitated managed care plans to provide

17  Medicaid services as specified in ss. 409.905 and 409.906 to

18  persons with developmental disabilities sufficient to meet the

19  medical, developmental, and emotional needs of these persons.

20         (dd)  To develop and recommend service delivery

21  mechanisms within capitated managed care plans to provide

22  Medicaid services as specified in ss. 409.905 and 409.906 to

23  Medicaid-eligible children in foster care. These services must

24  be coordinated with community-based care providers as

25  specified in s. 409.1675, where available, and be sufficient

26  to meet the medical, developmental, and emotional needs of

27  these children.

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


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    CS for CS for SB 838                           First Engrossed



 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


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    CS for CS for SB 838                           First Engrossed



 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


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    CS for CS for SB 838                           First Engrossed



 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 apply for federal waivers from

 9  the Centers for Medicare and Medicaid Services to allow

10  recipients to purchase health care coverage through an

11  employer-sponsored health insurance plan instead of through a

12  Medicaid-certified plan. This provision shall be known as the

13  opt-out option.

14         1.  A recipient who chooses the Medicaid opt-out option

15  shall have an opportunity for a specified period of time, as

16  authorized under a waiver granted by the Centers for Medicare

17  and Medicaid Services, to select and enroll in a

18  Medicaid-certified plan. If the recipient remains in the

19  employer-sponsored plan after the specified period, the

20  recipient shall remain in the opt-out program for at least 1

21  year or until the recipient no longer has access to

22  employer-sponsored coverage, until the employer's open

23  enrollment period for a person who opts out in order to

24  participate in employer-sponsored coverage, or until the

25  person is no longer eligible for Medicaid, whichever time

26  period is shorter.

27         2.  Notwithstanding any other provision of this

28  section, coverage, cost sharing, and any other component of

29  employer-sponsored health insurance shall be governed by

30  applicable state and federal laws.

31  


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    CS for CS for SB 838                           First Engrossed



 1         (5)  This section does not authorize the agency to

 2  implement any provision of s. 1115 of the Social Security Act

 3  experimental, pilot, or demonstration project waiver to reform

 4  the state Medicaid program in any part of the state other than

 5  the two geographic areas specified in this section unless

 6  approved by the Legislature.

 7         (6)  The agency shall develop and submit for approval

 8  applications for waivers of applicable federal laws and

 9  regulations as necessary to implement the managed care pilot

10  project as defined in this section. The agency shall post all

11  waiver applications under this section on its Internet website

12  30 days before submitting the applications to the United

13  States Centers for Medicare and Medicaid Services. All waiver

14  applications shall be provided for review and comment to the

15  appropriate committees of the Senate and House of

16  Representatives for at least 10 working days prior to

17  submission. All waivers submitted to and approved by the

18  United States Centers for Medicare and Medicaid Services under

19  this section must be submitted to the appropriate committees

20  of the Senate and the House of Representatives in order to

21  obtain authority for implementation as required by s.

22  409.912(11), before program implementation. The appropriate

23  committees shall recommend whether to approve the

24  implementation of the waivers to the Legislature or to the

25  Legislative Budget Commission if the Legislature is not in

26  session. The agency shall submit a plan containing a detailed

27  timeline for implementation and budgetary projections of the

28  effect of the pilot program on the total Medicaid budget for

29  the 2006-2007 through 2009-2010 fiscal years.

30         (7)  Upon review and approval of the applications for

31  waivers of applicable federal laws and regulations to


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    CS for CS for SB 838                           First Engrossed



 1  implement the managed care pilot program by the Legislature,

 2  the agency may initiate adoption of rules pursuant to ss.

 3  120.536(1) and 120.54 to implement and administer the managed

 4  care pilot program as provided in this section.

 5         Section 3.  The Office of Program Policy Analysis and

 6  Government Accountability, in consultation with the Auditor

 7  General, shall comprehensively evaluate the two managed care

 8  pilot programs created under section 409.91211, Florida

 9  Statutes. The evaluation shall begin with the implementation

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

11  24 months after the two pilot programs have enrolled Medicaid

12  recipients and started providing health care services. The

13  evaluation must include assessments of cost savings; consumer

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

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

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

17  describe administrative or legal barriers to the

18  implementation and operation of each pilot program and include

19  recommendations regarding statewide expansion of the managed

20  care pilot programs. The office shall submit an evaluation

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

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

23  2008. The managed care pilot program may not be expanded to

24  any additional counties that are not identified in this

25  section without the authorization of the Legislature.

26         Section 4.  Paragraphs (a) and (j) of subsection (2) of

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

28         409.9122  Mandatory Medicaid managed care enrollment;

29  programs and procedures.--

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

31  or MediPass all Medicaid recipients, except those Medicaid


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    CS for CS for SB 838                           First Engrossed



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

 2  Medicaid medically needy program; or eligible for both

 3  Medicaid and Medicare. Upon enrollment, individuals will be

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

 5  out period required by federal Medicaid regulations. The

 6  agency is authorized to seek the necessary Medicaid state plan

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

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

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

10  mandatory managed care enrollment, provided that:

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

12  care plan or MediPass is voluntary;

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

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

15  plan provides specific programs and services which address the

16  special health needs of the recipient; and

17         3.  The agency receives any necessary waivers from the

18  federal Centers for Medicare and Medicaid Services Health Care

19  Financing Administration.

20  

21  The agency shall develop rules to establish policies by which

22  exceptions to the mandatory managed care enrollment

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

24  shall include the specific criteria to be applied when making

25  a determination as to whether to exempt a recipient from

26  mandatory enrollment in a managed care plan or MediPass.

27  School districts participating in the certified school match

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

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

30  1011.70(1), for a Medicaid-eligible child participating in the

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


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    CS for CS for SB 838                           First Engrossed



 1  409.9071, regardless of whether the child is enrolled in

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

 3  a good faith effort to execute agreements with school

 4  districts regarding the coordinated provision of services

 5  authorized under s. 1011.70. County health departments

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

 7  381.0057 shall be reimbursed by Medicaid for the federal share

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

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

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

11  plans shall make a good faith effort to execute agreements

12  with county health departments regarding the coordinated

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

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

15  Department of Health, and the Department of Education shall

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

17  plan or MediPass provider receives information relating to

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

19  409.9071, and 1011.70.

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

21  the Centers for Medicare and Medicaid Services Health Care

22  Financing Administration to lock eligible Medicaid recipients

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

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

25  recipient may select another managed care plan or MediPass

26  provider. However, nothing shall prevent a Medicaid recipient

27  from changing primary care providers within the managed care

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

29         Section 5.  Subsection (2) of section 409.913, Florida

30  Statutes, is amended, and subsection (36) is added to that

31  section, to read:


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    CS for CS for SB 838                           First Engrossed



 1         409.913  Oversight of the integrity of the Medicaid

 2  program.--The agency shall operate a program to oversee the

 3  activities of Florida Medicaid recipients, and providers and

 4  their representatives, to ensure that fraudulent and abusive

 5  behavior and neglect of recipients occur to the minimum extent

 6  possible, and to recover overpayments and impose sanctions as

 7  appropriate. Beginning January 1, 2003, and each year

 8  thereafter, the agency and the Medicaid Fraud Control Unit of

 9  the Department of Legal Affairs shall submit a joint report to

10  the Legislature documenting the effectiveness of the state's

11  efforts to control Medicaid fraud and abuse and to recover

12  Medicaid overpayments during the previous fiscal year. The

13  report must describe the number of cases opened and

14  investigated each year; the sources of the cases opened; the

15  disposition of the cases closed each year; the amount of

16  overpayments alleged in preliminary and final audit letters;

17  the number and amount of fines or penalties imposed; any

18  reductions in overpayment amounts negotiated in settlement

19  agreements or by other means; the amount of final agency

20  determinations of overpayments; the amount deducted from

21  federal claiming as a result of overpayments; the amount of

22  overpayments recovered each year; the amount of cost of

23  investigation recovered each year; the average length of time

24  to collect from the time the case was opened until the

25  overpayment is paid in full; the amount determined as

26  uncollectible and the portion of the uncollectible amount

27  subsequently reclaimed from the Federal Government; the number

28  of providers, by type, that are terminated from participation

29  in the Medicaid program as a result of fraud and abuse; and

30  all costs associated with discovering and prosecuting cases of

31  Medicaid overpayments and making recoveries in such cases. The


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    CS for CS for SB 838                           First Engrossed



 1  report must also document actions taken to prevent

 2  overpayments and the number of providers prevented from

 3  enrolling in or reenrolling in the Medicaid program as a

 4  result of documented Medicaid fraud and abuse and must

 5  recommend changes necessary to prevent or recover

 6  overpayments.

 7         (2)  The agency shall conduct, or cause to be conducted

 8  by contract or otherwise, reviews, investigations, analyses,

 9  audits, or any combination thereof, to determine possible

10  fraud, abuse, overpayment, or recipient neglect in the

11  Medicaid program and shall report the findings of any

12  overpayments in audit reports as appropriate. At least 5

13  percent of all audits shall be conducted on a random basis.

14         (36)  The agency shall provide to each Medicaid

15  recipient or his or her representative an explanation of

16  benefits in the form of a letter that is mailed to the most

17  recent address of the recipient on the record with the

18  Department of Children and Family Services. The explanation of

19  benefits must include the patient's name, the name of the

20  health care provider and the address of the location where the

21  service was provided, a description of all services billed to

22  Medicaid in terminology that should be understood by a

23  reasonable person, and information on how to report

24  inappropriate or incorrect billing to the agency or other law

25  enforcement entities for review or investigation.

26         Section 6.  The Agency for Health Care Administration

27  shall submit to the Legislature by December 15, 2005, a report

28  on the legal and administrative barriers to enforcing section

29  409.9081, Florida Statutes. The report must describe how many

30  services require copayments, which providers collect

31  copayments, and the total amount of copayments collected from


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    CS for CS for SB 838                           First Engrossed



 1  recipients for all services required under section 409.9081,

 2  Florida Statutes, by provider type for the 2001-2002 through

 3  2004-2005 fiscal years. The agency shall recommend a mechanism

 4  to enforce the requirement for Medicaid recipients to make

 5  copayments which does not shift the copayment amount to the

 6  provider. The agency shall also identify the federal or state

 7  laws or regulations that permit Medicaid recipients to declare

 8  impoverishment in order to avoid paying the copayment and

 9  extent to which these statements of impoverishment are

10  verified. If claims of impoverishment are not currently

11  verified, the agency shall recommend a system for such

12  verification. The report must also identify any other

13  cost-sharing measures that could be imposed on Medicaid

14  recipients.

15         Section 7.  The Agency for Health Care Administration

16  shall submit to the Legislature by January 15, 2006,

17  recommendations to ensure that Medicaid is the payer of last

18  resort as required by section 409.910, Florida Statutes. The

19  report must identify the public and private entities that are

20  liable for primary payment of health care services and

21  recommend methods to improve enforcement of third-party

22  liability responsibility and repayment of benefits to the

23  state Medicaid program. The report must estimate the potential

24  recoveries that may be achieved through third-party liability

25  efforts if administrative and legal barriers are removed. The

26  report must recommend whether modifications to the agency's

27  contingency-fee contract for third-party liability could

28  enhance third-party liability for benefits provided to

29  Medicaid recipients.

30         Section 8.  By January 15, 2006, the Office of Program

31  Policy Analysis and Government Accountability shall submit to


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    CS for CS for SB 838                           First Engrossed



 1  the Legislature a study of the long-term care community

 2  diversion pilot project authorized under sections

 3  430.701-430.709, Florida Statutes. The study may be conducted

 4  by staff of the Office of Program Policy Analysis and

 5  Government Accountability or by a consultant obtained through

 6  a competitive bid pursuant to the provisions of chapter 287,

 7  Florida Statutes. The study must use a statistically-valid

 8  methodology to assess the percent of persons served in the

 9  project over a 2-year period who would have required Medicaid

10  nursing home services without the diversion services, which

11  services are most frequently used, and which services are

12  least frequently used. The study must determine whether the

13  project is cost-effective or is an expansion of the Medicaid

14  program because a preponderance of the project enrollees would

15  not have required Medicaid nursing home services within a

16  2-year period regardless of the availability of the project or

17  that the enrollees could have been safely served through

18  another Medicaid program at a lower cost to the state.

19         Section 9.  The Agency for Health Care Administration

20  shall identify how many individuals in the long-term care

21  diversion programs who receive care at home have a

22  patient-responsibility payment associated with their

23  participation in the diversion program. If no system is

24  available to assess this information, the agency shall

25  determine the cost of creating a system to identify and

26  collect these payments and whether the cost of developing a

27  system for this purpose is offset by the amount of

28  patient-responsibility payments which could be collected with

29  the system. The agency shall report this information to the

30  Legislature by December 1, 2005.

31  


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    CS for CS for SB 838                           First Engrossed



 1         Section 10.  The Office of Program Policy Analysis and

 2  Government Accountability shall conduct a study of state

 3  programs that allow non-Medicaid eligible persons under a

 4  certain income level to buy into the Medicaid program as if it

 5  was private insurance. The study shall examine Medicaid buy-in

 6  programs in other states to determine if there are any models

 7  that can be implemented in Florida which would provide access

 8  to uninsured Floridians and what effect this program would

 9  have on Medicaid expenditures based on the experience of

10  similar states. The study must also examine whether the

11  Medically Needy program could be redesigned to be a Medicaid

12  buy-in program. The study must be submitted to the Legislature

13  by January 1, 2006.

14         Section 11.  The Office of Program Policy Analysis and

15  Government Accountability, in consultation with the Office of

16  Attorney General, Medicaid Fraud Control Unit and the Auditor

17  General, shall conduct a study to examine issues related to

18  the amount of state and federal dollars lost due to fraud and

19  abuse in the Medicaid prescription drug program. The study

20  shall focus on examining whether pharmaceutical manufacturers

21  and their affiliates and wholesale pharmaceutical

22  manufacturers and their affiliates that participate in the

23  Medicaid program in this state, with respect to rebates for

24  prescription drugs, are inflating the average wholesale price

25  that is used in determining how much the state pays for

26  prescription drugs for Medicaid recipients. The study shall

27  also focus on examining whether the manufacturers and their

28  affiliates are committing other deceptive pricing practices

29  with regard to federal and state rebates for prescription

30  drugs in the Medicaid program in this state. The study,

31  including findings and recommendations, shall be submitted to


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    CS for CS for SB 838                           First Engrossed



 1  the Governor, the President of the Senate, the Speaker of the

 2  House of Representatives, the Minority Leader of the Senate,

 3  and the Minority Leader of the House of Representatives by

 4  January 1, 2006.

 5         Section 12.  The sums of $7,129,241 in recurring

 6  General Revenue Funds, $9,076,875 in nonrecurring General

 7  Revenue Funds, $8,608,242 in recurring funds from the

 8  Administrative Trust Fund, and $9,076,874 in nonrecurring

 9  funds from the Administrative Trust Fund are appropriated and

10  11 full time equivalent positions are authorized for the

11  purpose of implementing this act.

12         Section 13.  This act shall take effect July 1, 2005.

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