September 28, 2020
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Senate Bill 0838

Senate Bill sb0838e3

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    CS for CS for SB 838                           Third 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


                                  1

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    CS for CS for SB 838                           Third 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.;


                                  2

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    CS for CS for SB 838                           Third 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. 409.9062, F.S.; requiring the

13         Agency for Health Care Administration to

14         reimburse lung transplant facilities a global

15         fee for services provided to Medicaid

16         recipients; providing an appropriation;

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

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

19         5 percent of all program integrity audits to be

20         conducted on a random basis; requiring that

21         Medicaid recipients be provided with an

22         explanation of benefits; requiring that the

23         agency report to the Legislature on the legal

24         and administrative barriers to enforcing the

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

26         requiring the agency to recommend ways to

27         ensure that Medicaid is the payer of last

28         resort; requiring the Office of Program Policy

29         Analysis and Government Accountability to

30         conduct a study of the long-term care diversion

31         programs; requiring the agency to determine how


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    CS for CS for SB 838                           Third Engrossed



 1         many individuals in long-term care diversion

 2         programs have a patient payment responsibility

 3         that is not being collected and to recommend

 4         how to collect such payments; requiring the

 5         Office of Program Policy Analysis and

 6         Government Accountability to conduct a study of

 7         Medicaid buy-in programs to determine if these

 8         programs can be created in this state without

 9         expanding the overall Medicaid program budget

10         or if the Medically Needy program can be

11         changed into a Medicaid buy-in program;

12         providing an appropriation and authorizing

13         positions to implement this act; requiring the

14         Office of Program Policy Analysis and

15         Government Accountability, in consultation with

16         the Office of Attorney General and the Auditor

17         General, to conduct a study to examine whether

18         state and federal dollars are lost due to fraud

19         and abuse in the Medicaid prescription drug

20         program; providing duties; requiring that a

21         report with findings and recommendations be

22         submitted to the Governor and the Legislature

23         by a specified date; repealing the amendments

24         made to ss. 393.0661, 409.907, and 409.9082,

25         F.S., and the amendments made to the

26         introductory provision of s. 409.908, F.S., by

27         the Conference Committee Report on CS for CS

28         for SB 404, relating to provider agreements and

29         provider methodologies; repealing s. 23 of the

30         Conference Committee Report on CS for CS for SB

31         404, relating to legislative intent; amending


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    CS for CS for SB 838                           Third Engrossed



 1         s. 409.9124, F.S., as amended by the Conference

 2         Committee Report on CS for CS for SB 404;

 3         revising provisions requiring the Agency for

 4         Health Care Administration to pay certain rates

 5         for managed care reimbursement; requiring that

 6         the agency make an additional adjustment in

 7         calculating the rates paid to prepaid health

 8         plans for the 2005-2006 fiscal year; requiring

 9         that the Senate Select Committee on Medicaid

10         Reform study various issues concerning Medicaid

11         provider rates and issue a report to the

12         Governor and the Legislature; providing an

13         effective date.

14  

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

16  

17         Section 1.  Section 409.912, Florida Statutes, is

18  amended to read:

19         409.912  Cost-effective purchasing of health care.--The

20  agency shall purchase goods and services for Medicaid

21  recipients in the most cost-effective manner consistent with

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

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

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

25  the correct diagnosis for purposes of authorizing future

26  services under the Medicaid program. This section does not

27  restrict access to emergency services or poststabilization

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

29  confirmation or second opinion shall be rendered in a manner

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

31  prepaid per capita and prepaid aggregate fixed-sum basis


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    CS for CS for SB 838                           Third Engrossed



 1  services when appropriate and other alternative service

 2  delivery and reimbursement methodologies, including

 3  competitive bidding pursuant to s. 287.057, designed to

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

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

 6  minimize the exposure of recipients to the need for acute

 7  inpatient, custodial, and other institutional care and the

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

 9  agency shall contract with a vendor to monitor and evaluate

10  the clinical practice patterns of providers in order to

11  identify trends that are outside the normal practice patterns

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

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

14  able to provide information and counseling to a provider whose

15  practice patterns are outside the norms, in consultation with

16  the agency, to improve patient care and reduce inappropriate

17  utilization. The agency may mandate prior authorization, drug

18  therapy management, or disease management participation for

19  certain populations of Medicaid beneficiaries, certain drug

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

21  and possible dangerous drug interactions. The Pharmaceutical

22  and Therapeutics Committee shall make recommendations to the

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

24  agency shall inform the Pharmaceutical and Therapeutics

25  Committee of its decisions regarding drugs subject to prior

26  authorization. The agency is authorized to limit the entities

27  it contracts with or enrolls as Medicaid providers by

28  developing a provider network through provider credentialing.

29  The agency may competitively bid single-source-provider

30  contracts if procurement of goods or services results in

31  demonstrated cost savings to the state without limiting access


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    CS for CS for SB 838                           Third Engrossed



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

 2  assessment of beneficiary access to care, provider

 3  availability, provider quality standards, time and distance

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

 5  provider network, demographic characteristics of Medicaid

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

 7  appointment wait times, beneficiary use of services, provider

 8  turnover, provider profiling, provider licensure history,

 9  previous program integrity investigations and findings, peer

10  review, provider Medicaid policy and billing compliance

11  records, clinical and medical record audits, and other

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

13  Medicaid provider network. The agency shall determine

14  instances in which allowing Medicaid beneficiaries to purchase

15  durable medical equipment and other goods is less expensive to

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

17  goods. The agency may establish rules to facilitate purchases

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

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

20  The agency may is authorized to seek federal waivers necessary

21  to administer these policies implement this policy.

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

23  Children and Family Services to ensure access of children and

24  families in the child protection system to needed and

25  appropriate mental health and substance abuse services.

26         (2)  The agency may enter into agreements with

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

28  the Federal Government and accept such duties in respect to

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

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

31  409.901-409.920.


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    CS for CS for SB 838                           Third Engrossed



 1         (3)  The agency may contract with health maintenance

 2  organizations certified pursuant to part I of chapter 641 for

 3  the provision of services to recipients.

 4         (4)  The agency may contract with:

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

 6  services other than Medicaid services under contract with the

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

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

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

10  to recipients, which entity may provide such prepaid services

11  either directly or through arrangements with other providers.

12  Such prepaid health care services entities must be licensed

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

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

15  recognized under this paragraph which demonstrates to the

16  satisfaction of the Office of Insurance Regulation of the

17  Financial Services Commission that it is backed by the full

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

19  exempted from s. 641.225.

20         (b)  An entity that is providing comprehensive

21  behavioral health care services to certain Medicaid recipients

22  through a capitated, prepaid arrangement pursuant to the

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

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

25  641 and must possess the clinical systems and operational

26  competence to manage risk and provide comprehensive behavioral

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

28  the term "comprehensive behavioral health care services" means

29  covered mental health and substance abuse treatment services

30  that are available to Medicaid recipients. The secretary of

31  the Department of Children and Family Services shall approve


                                  8

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    CS for CS for SB 838                           Third Engrossed



 1  provisions of procurements related to children in the

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

 3  in a prepaid behavioral health plan. Any contract awarded

 4  under this paragraph must be competitively procured. In

 5  developing the behavioral health care prepaid plan procurement

 6  document, the agency shall ensure that the procurement

 7  document requires the contractor to develop and implement a

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

 9  provided to residents of licensed assisted living facilities

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

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

12  contract with a single entity meeting these requirements to

13  provide comprehensive behavioral health care services to all

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

15  AHCA area. Each entity must offer sufficient choice of

16  providers in its network to ensure recipient access to care

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

18  satisfied. The network shall include all public mental health

19  hospitals. To ensure unimpaired access to behavioral health

20  care services by Medicaid recipients, all contracts issued

21  pursuant to this paragraph shall require 80 percent of the

22  capitation paid to the managed care plan, including health

23  maintenance organizations, to be expended for the provision of

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

25  plan expends less than 80 percent of the capitation paid

26  pursuant to this paragraph for the provision of behavioral

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

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

29  certification letter indicating the amount of capitation paid

30  during each calendar year for the provision of behavioral

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


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    CS for CS for SB 838                           Third Engrossed



 1  reimburse for substance abuse treatment services on a

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

 3  funds are available for capitated, prepaid arrangements.

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

 5  contracts with the entities providing comprehensive inpatient

 6  and outpatient mental health care services to Medicaid

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

 8  Polk Counties, to include substance abuse treatment services.

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

10  Children and Family Services shall execute a written agreement

11  that requires collaboration and joint development of all

12  policy, budgets, procurement documents, contracts, and

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

14  community mental health and targeted case management programs.

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

16  2006, the agency and the Department of Children and Family

17  Services shall contract with managed care entities in each

18  AHCA area except area 6 or arrange to provide comprehensive

19  inpatient and outpatient mental health and substance abuse

20  services through capitated prepaid arrangements to all

21  Medicaid recipients who are eligible to participate in such

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

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

24  shall contract with a single managed care plan to provide

25  comprehensive behavioral health services to all recipients who

26  are not enrolled in a Medicaid health maintenance

27  organization. The agency may contract with more than one

28  comprehensive behavioral health provider to provide care to

29  recipients who are not enrolled in a Medicaid health

30  maintenance organization in AHCA areas where the eligible

31  population exceeds 150,000. Contracts for comprehensive


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    CS for CS for SB 838                           Third Engrossed



 1  behavioral health providers awarded pursuant to this section

 2  shall be competitively procured. Both for-profit and

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

 4  Managed care plans contracting with the agency under

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

 6  comprehensive behavioral health benefits as provided in AHCA

 7  rules, including handbooks incorporated by reference.

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

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

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

11  provides for the full implementation of capitated prepaid

12  behavioral health care in all areas of the state.

13         a.  Implementation shall begin in 2003 in those AHCA

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

15  sufficient capitation rates.

16         b.  If the agency determines that the proposed

17  capitation rate in any area is insufficient to provide

18  appropriate services, the agency may adjust the capitation

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

20  department may use existing general revenue to address any

21  additional required match but may not over-obligate existing

22  funds on an annualized basis.

23         c.  Subject to any limitations provided for in the

24  General Appropriations Act, the agency, in compliance with

25  appropriate federal authorization, shall develop policies and

26  procedures that allow for certification of local and state

27  funds.

28         5.  Children residing in a statewide inpatient

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

30  a Department of Children and Family Services residential

31  program approved as a Medicaid behavioral health overlay


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    CS for CS for SB 838                           Third Engrossed



 1  services provider shall not be included in a behavioral health

 2  care prepaid health plan or any other Medicaid managed care

 3  plan pursuant to this paragraph.

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

 5  agency shall in its procurement document require an entity

 6  providing only comprehensive behavioral health care services

 7  to prevent the displacement of indigent care patients by

 8  enrollees in the Medicaid prepaid health plan providing

 9  behavioral health care services from facilities receiving

10  state funding to provide indigent behavioral health care, to

11  facilities licensed under chapter 395 which do not receive

12  state funding for indigent behavioral health care, or

13  reimburse the unsubsidized facility for the cost of behavioral

14  health care provided to the displaced indigent care patient.

15         7.  Traditional community mental health providers under

16  contract with the Department of Children and Family Services

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

18  under contract with the Department of Children and Family

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

20  providers licensed pursuant to chapter 395 must be offered an

21  opportunity to accept or decline a contract to participate in

22  any provider network for prepaid behavioral health services.

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

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

25  open for child welfare services in the HomeSafeNet system,

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

27  and all their behavioral health care services including

28  inpatient, outpatient psychiatric, community mental health,

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

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

31  child welfare services in the HomeSafeNet system, shall


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    CS for CS for SB 838                           Third Engrossed



 1  receive their behavioral health care services through a

 2  specialty prepaid plan operated by community-based lead

 3  agencies either through a single agency or formal agreements

 4  among several agencies. The specialty prepaid plan must result

 5  in savings to the state comparable to savings achieved in

 6  other Medicaid managed care and prepaid programs. Such plan

 7  must provide mechanisms to maximize state and local revenues.

 8  The specialty prepaid plan shall be developed by the agency

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

10  is authorized to seek any federal waivers to implement this

11  initiative.

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

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

14  entity owned by other migrant and community health centers

15  receiving non-Medicaid financial support from the Federal

16  Government to provide health care services on a prepaid or

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

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

19  chapter 641, but shall be prohibited from serving Medicaid

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

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

22  the entity meets the requirements specified in subsections

23  (17) and (18).

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

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

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

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

28  appropriate financial reserve, quality assurance, and patient

29  rights requirements as established by the agency. The agency

30  shall award contracts on a competitive bid basis and shall

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


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    CS for CS for SB 838                           Third Engrossed



 1  recipients assigned to a demonstration project shall be chosen

 2  equally from those who would otherwise have been assigned to

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

 4  federal Medicaid waivers as necessary to implement the

 5  provisions of this section. Any contract previously awarded to

 6  a provider service network operated by a hospital pursuant to

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

 8  following the current contract-expiration date, regardless of

 9  any contractual provisions to the contrary. A provider service

10  network is a network established or organized and operated by

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

12  providers, which provides a substantial proportion of the

13  health care items and services under a contract directly

14  through the provider or affiliated group of providers and may

15  make arrangements with physicians or other health care

16  professionals, health care institutions, or any combination of

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

18  financial risk on a prospective basis for the provision of

19  basic health services by the physicians, by other health

20  professionals, or through the institutions. The health care

21  providers must have a controlling interest in the governing

22  body of the provider service network organization.

23         (e)  An entity that provides only comprehensive

24  behavioral health care services to certain Medicaid recipients

25  through an administrative services organization agreement.

26  Such an entity must possess the clinical systems and

27  operational competence to provide comprehensive health care to

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

29  "comprehensive behavioral health care services" means covered

30  mental health and substance abuse treatment services that are

31  available to Medicaid recipients. Any contract awarded under


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    CS for CS for SB 838                           Third Engrossed



 1  this paragraph must be competitively procured. The agency must

 2  ensure that Medicaid recipients have available the choice of

 3  at least two managed care plans for their behavioral health

 4  care services.

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

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

 7  care to Medicaid recipients with degenerative neurological

 8  diseases and other diseases or disabling conditions associated

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

10  serve very disabled persons and to reduce Medicaid reimbursed

11  costs for inpatient, outpatient, and emergency department

12  services. The agency shall contract with vendors on a

13  risk-sharing basis.

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

15  coordination and care management for Medicaid-eligible

16  pediatric patients, primary care, authorization of specialty

17  care, and other urgent and emergency care through organized

18  providers designed to service Medicaid eligibles under age 18

19  and pediatric emergency departments' diversion programs. The

20  networks shall provide after-hour operations, including

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

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

23  departments.

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

25  with the agency and the Department of Elderly Affairs to

26  provide health care and social services on a prepaid or

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

28  care services entities are exempt from the provisions of part

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

30  recognized under this paragraph that demonstrates to the

31  satisfaction of the Office of Insurance Regulation that it is


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    CS for CS for SB 838                           Third Engrossed



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

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

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

 4  in s. 391.021.

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

 6  Administration, in partnership with the Department of Elderly

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

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

 9  older. The Agency for Health Care Administration shall

10  implement the integrated system initially on a pilot basis in

11  two areas of the state. In one of the areas enrollment shall

12  be on a voluntary basis. The program must transfer all

13  Medicaid services for eligible elderly individuals who choose

14  to participate into an integrated-care management model

15  designed to serve Medicaid recipients in the community. The

16  program must combine all funding for Medicaid services

17  provided to individuals 60 years of age or older into the

18  integrated system, including funds for Medicaid home and

19  community-based waiver services; all Medicaid services

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

21  Medicaid nursing home services unless the agency is able to

22  demonstrate how the integration of the funds will improve

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

24  and Medicare coinsurance and deductibles for persons dually

25  eligible for Medicaid and Medicare as prescribed in s.

26  409.908(13).

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

28  enrolled in the the developmental disabilities waiver program,

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

30  AIDS care waiver program, the traumatic brain injury and

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


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    CS for CS for SB 838                           Third Engrossed



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

 2  elderly program, and residents of institutional care

 3  facilities for the developmentally disabled, must be excluded

 4  from the integrated system.

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

 6  process to select entities to operate the integrated system.

 7  Entities eligible to submit bids include managed care

 8  organizations licensed under chapter 641, including entities

 9  eligible to participate in the nursing home diversion program,

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

11  community care for the elderly lead agencies, and other

12  state-certified community service networks that meet

13  comparable standards as defined by the agency, in consultation

14  with the Department of Elderly Affairs and the Office of

15  Insurance Regulation, to be financially solvent and able to

16  take on financial risk for managed care. Community service

17  networks that are certified pursuant to the comparable

18  standards defined by the agency are not required to be

19  licensed under chapter 641.

20         (c)  The agency must ensure that the

21  capitation-rate-setting methodology for the integrated system

22  is actuarially sound and reflects the intent to provide

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

24  also require integrated-system providers to develop a

25  credentialing system for service providers and to contract

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

27  where feasible, chronically poor-performing facilities and

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

29  provide that if the recipient resides in a noncontracted

30  residential facility licensed under chapter 400 at the time

31  the integrated system is initiated, the recipient must be


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    CS for CS for SB 838                           Third Engrossed



 1  permitted to continue to reside in the noncontracted facility

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

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

 4  integrated-system provider and the residential facility

 5  licensed under chapter 400, current Medicaid rates must

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

 7  jointly develop procedures to manage the services provided

 8  through the integrated system in order to ensure quality and

 9  recipient choice.

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

11  of Program Policy Analysis and Government Accountability, in

12  consultation with the Auditor General, shall comprehensively

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

14  delivery system for Medicaid recipients who are 60 years of

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

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

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

18  describe administrative or legal barriers to the

19  implementation and operation of the pilot program and include

20  recommendations regarding statewide expansion of the pilot

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

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

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

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

25  rules as necessary to administer the integrated system. The

26  agency must receive specific authorization from the

27  Legislature prior to implementing the waiver for the

28  integrated system. By October 1, 2003, the agency and the

29  department shall, to the extent feasible, develop a plan for

30  implementing new Medicaid procedure codes for emergency and

31  crisis care, supportive residential services, and other


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    CS for CS for SB 838                           Third Engrossed



 1  services designed to maximize the use of Medicaid funds for

 2  Medicaid-eligible recipients. The agency shall include in the

 3  agreement developed pursuant to subsection (4) a provision

 4  that ensures that the match requirements for these new

 5  procedure codes are met by certifying eligible general revenue

 6  or local funds that are currently expended on these services

 7  by the department with contracted alcohol, drug abuse, and

 8  mental health providers. The plan must describe specific

 9  procedure codes to be implemented, a projection of the number

10  of procedures to be delivered during fiscal year 2003-2004,

11  and a financial analysis that describes the certified match

12  procedures, and accountability mechanisms, projects the

13  earnings associated with these procedures, and describes the

14  sources of state match. This plan may not be implemented in

15  any part until approved by the Legislative Budget Commission.

16  If such approval has not occurred by December 31, 2003, the

17  plan shall be submitted for consideration by the 2004

18  Legislature.

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

20  entity otherwise authorized by this section on a prepaid or

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

22  recipients. An entity may provide prepaid services to

23  recipients, either directly or through arrangements with other

24  entities, if each entity involved in providing services:

25         (a)  Is organized primarily for the purpose of

26  providing health care or other services of the type regularly

27  offered to Medicaid recipients;

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

29  the agency for quality, appropriateness, and timeliness;

30         (c)  Makes provisions satisfactory to the agency for

31  insolvency protection and ensures that neither enrolled


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    CS for CS for SB 838                           Third Engrossed



 1  Medicaid recipients nor the agency will be liable for the

 2  debts of the entity;

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

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

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

 6  equivalent liquid assets excluding revenues from Medicaid

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

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

 9         (e)  Furnishes evidence satisfactory to the agency of

10  adequate liability insurance coverage or an adequate plan of

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

12  of the furnishing of health care;

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

14  periodic review of its medical facilities and services, as

15  required by the agency; and

16         (g)  Provides organizational, operational, financial,

17  and other information required by the agency.

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

19  basis with any health insurer that:

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

21  Medicaid recipients in exchange for a premium payment paid by

22  the agency;

23         (b)  Assumes the underwriting risk; and

24         (c)  Is organized and licensed under applicable

25  provisions of the Florida Insurance Code and is currently in

26  good standing with the Office of Insurance Regulation.

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

28  basis with an exclusive provider organization to provide

29  health care services to Medicaid recipients provided that the

30  exclusive provider organization meets applicable managed care

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


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    CS for CS for SB 838                           Third Engrossed



 1  409.9128, and 627.6472, and other applicable provisions of

 2  law.

 3         (9)  The Agency for Health Care Administration may

 4  provide cost-effective purchasing of chiropractic services on

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

 6  arrangements with a statewide chiropractic preferred provider

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

 8  corporation. The agency shall ensure that the benefit limits

 9  and prior authorization requirements in the current Medicaid

10  program shall apply to the services provided by the

11  chiropractic preferred provider organization.

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

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

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

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

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

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

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

19  to:

20         (a)  Fraud;

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

22  including those proscribing price fixing between competitors

23  and the allocation of customers among competitors;

24         (c)  Commission of a felony involving embezzlement,

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

26  destruction of records, making false statements, receiving

27  stolen property, making false claims, or obstruction of

28  justice; or

29         (d)  Any crime in any jurisdiction which directly

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

31  fixed-sum basis.


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    CS for CS for SB 838                           Third Engrossed



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

 2  apply for waivers of applicable federal laws and regulations

 3  as necessary to implement more appropriate systems of health

 4  care for Medicaid recipients and reduce the cost of the

 5  Medicaid program to the state and federal governments and

 6  shall implement such programs, after legislative approval,

 7  within a reasonable period of time after federal approval.

 8  These programs must be designed primarily to reduce the need

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

10  institutional care, and other high-cost services.

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

12  waiver as authorized by this subsection, the agency shall

13  provide notice and an opportunity for public comment. Notice

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

15  agency for advance notice and shall be published in the

16  Florida Administrative Weekly not less than 28 days prior to

17  the intended action.

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

19  appropriated to the Department of Elderly Affairs for the

20  Assisted Living for the Elderly Medicaid waiver and are not

21  expended shall be transferred to the agency to fund

22  Medicaid-reimbursed nursing home care.

23         (12)  The agency shall establish a postpayment

24  utilization control program designed to identify recipients

25  who may inappropriately overuse or underuse Medicaid services

26  and shall provide methods to correct such misuse.

27         (13)  The agency shall develop and provide coordinated

28  systems of care for Medicaid recipients and may contract with

29  public or private entities to develop and administer such

30  systems of care among public and private health care providers

31  in a given geographic area.


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    CS for CS for SB 838                           Third Engrossed



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

 2  operation of utilization management and incentive systems

 3  designed to encourage cost-effective use services.

 4         (b)  The agency shall develop a procedure for

 5  determining whether health care providers and service vendors

 6  can provide the Medicaid program using a business case that

 7  demonstrates whether a particular good or service can offset

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

 9  setting or through other means and therefore should receive a

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

11  not be limited to:

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

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

14  performance of the service, and a rationale documenting how

15  providing the service in an alternative setting would be in

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

17         2.  A cost-benefit analysis documenting the estimated

18  specific direct and indirect costs, savings, performance

19  improvements, risks, and qualitative and quantitative benefits

20  involved in or resulting from providing the service. The

21  cost-benefit analysis must include a detailed plan and

22  timeline identifying all actions that must be implemented to

23  realize expected benefits. The Secretary of Health Care

24  Administration shall verify that all costs, savings, and

25  benefits are valid and achievable.

26         (c)  If the agency determines that the increased

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

28  change in the reimbursement schedule for that particular good

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

30  change under this procedure, the agency determines that costs

31  were not offset by the increased reimbursement schedule, the


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    CS for CS for SB 838                           Third Engrossed



 1  agency may revert to the former reimbursement schedule for the

 2  particular good or service.

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

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

 5  nursing facility preadmission screening program to ensure that

 6  Medicaid payment for nursing facility care is made only for

 7  individuals whose conditions require such care and to ensure

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

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

10  economical manner possible. The CARES program shall also

11  ensure that individuals participating in Medicaid home and

12  community-based waiver programs meet criteria for those

13  programs, consistent with approved federal waivers.

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

15  an interagency agreement with the Department of Elderly

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

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

18  the CARES program, including any function or activity required

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

20  and resident review.

21         (c)  Prior to making payment for nursing facility

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

23  the nursing facility preadmission screening program has

24  determined that the individual requires nursing facility care

25  and that the individual cannot be safely served in

26  community-based programs. The nursing facility preadmission

27  screening program shall refer a Medicaid recipient to a

28  community-based program if the individual could be safely

29  served at a lower cost and the recipient chooses to

30  participate in such program. For individuals whose nursing

31  home stay is initially funded by Medicare and Medicare


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    CS for CS for SB 838                           Third Engrossed



 1  coverage is being terminated for lack of progress towards

 2  rehabilitation, CARES staff shall consult with the person

 3  making the determination of progress toward rehabilitation to

 4  ensure that the recipient is not being inappropriately

 5  disqualified from Medicare coverage. If, in their professional

 6  judgment, CARES staff believes that a Medicare beneficiary is

 7  still making progress toward rehabilitation, they may assist

 8  the Medicare beneficiary with an appeal of the

 9  disqualification from Medicare coverage. The use of CARES

10  teams to review Medicare denials for coverage under this

11  section is authorized only if it is determined that such

12  reviews qualify for federal matching funds through Medicaid.

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

14  implement this section.

15         (d)  For the purpose of initiating immediate

16  prescreening and diversion assistance for individuals residing

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

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

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

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

21  individuals whose nursing home stay is expected to exceed 20

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

23  home placement. CARES staff shall provide counseling and

24  referral services to these individuals regarding choosing

25  appropriate long-term care alternatives. This paragraph does

26  not apply to continuing care facilities licensed under chapter

27  651 or to retirement communities that provide a combination of

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

29  services.

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

31  submit a report to the Legislature and the Office of


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    CS for CS for SB 838                           Third Engrossed



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

 2  program. The report must describe:

 3         1.  Rate of diversion to community alternative

 4  programs;

 5         2.  CARES program staffing needs to achieve additional

 6  diversions;

 7         3.  Reasons the program is unable to place individuals

 8  in less restrictive settings when such individuals desired

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

10         4.  Barriers to appropriate placement, including

11  barriers due to policies or operations of other agencies or

12  state-funded programs; and

13         5.  Statutory changes necessary to ensure that

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

15  the least restrictive environment.

16         (f)  The Department of Elderly Affairs shall track

17  individuals over time who are assessed under the CARES program

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

19  15 of each year, the department shall submit to the

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

21  longitudinal study of the individuals who are diverted from

22  nursing home placement. The study must include:

23         1.  The demographic characteristics of the individuals

24  assessed and diverted from nursing home placement, including,

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

26  status, living arrangements, and geographic location;

27         2.  A summary of community services provided to

28  individuals for 1 year after assessment and diversion;

29         3.  A summary of inpatient hospital admissions for

30  individuals who have been diverted; and

31  


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    CS for CS for SB 838                           Third Engrossed



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

 2  and subsequent entry into a nursing home or death.

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

 4  Health Care Administration shall report to the President of

 5  the Senate and the Speaker of the House of Representatives

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

 7  criteria to eliminate the Intermediate II level of care.

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

 9  utilization and price patterns within the Medicaid program

10  which are not cost-effective or medically appropriate and

11  assess the effectiveness of new or alternate methods of

12  providing and monitoring service, and may implement such

13  methods as it considers appropriate. Such methods may include

14  disease management initiatives, an integrated and systematic

15  approach for managing the health care needs of recipients who

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

17  best practices, prevention strategies, clinical-practice

18  improvement, clinical interventions and protocols, outcomes

19  research, information technology, and other tools and

20  resources to reduce overall costs and improve measurable

21  outcomes.

22         (b)  The responsibility of the agency under this

23  subsection shall include the development of capabilities to

24  identify actual and optimal practice patterns; patient and

25  provider educational initiatives; methods for determining

26  patient compliance with prescribed treatments; fraud, waste,

27  and abuse prevention and detection programs; and beneficiary

28  case management programs.

29         1.  The practice pattern identification program shall

30  evaluate practitioner prescribing patterns based on national

31  and regional practice guidelines, comparing practitioners to


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    CS for CS for SB 838                           Third Engrossed



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

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

 3  of practicing health care professionals consisting of the

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

 5  President of the Senate shall each appoint three physicians

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

 7  shall appoint two pharmacists licensed under chapter 465 and

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

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

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

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

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

13  evaluating treatment guidelines and recommending ways to

14  incorporate their use in the practice pattern identification

15  program. Practitioners who are prescribing inappropriately or

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

17  prescribing of certain drugs subject to prior authorization or

18  may be terminated from all participation in the Medicaid

19  program.

20         2.  The agency shall also develop educational

21  interventions designed to promote the proper use of

22  medications by providers and beneficiaries.

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

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

25  of credit requirement for participating pharmacies, enhanced

26  provider auditing practices, the use of additional fraud and

27  abuse software, recipient management programs for

28  beneficiaries inappropriately using their benefits, and other

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

30  and abuse. The initiative shall address enforcement efforts to

31  reduce the number and use of counterfeit prescriptions.


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    CS for CS for SB 838                           Third Engrossed



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

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

 3  clinical pharmacology drug information database for

 4  practitioners. The initiative shall be designed to enhance the

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

 6  prescription drug benefit program and to otherwise further the

 7  intent of this paragraph.

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

 9  entity to design a database of clinical utilization

10  information or electronic medical records for Medicaid

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

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

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

14  visits, inpatient and outpatient hospitalizations, laboratory

15  and pathology services, radiological and other imaging

16  services, dental care, and patterns of dispensing prescription

17  drugs in order to coordinate care and identify potential fraud

18  and abuse.

19         6.5.  The agency may apply for any federal waivers

20  needed to administer implement this paragraph.

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

22  basis shall, in addition to meeting any applicable statutory

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

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

25  allowable as admitted assets by the Office of Insurance

26  Regulation, and restricted funds or deposits controlled by the

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

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

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

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

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


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    CS for CS for SB 838                           Third Engrossed



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

 2  prepaid revenues, the agency shall prohibit the entity from

 3  engaging in marketing and preenrollment activities, shall

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

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

 6  requirements of this subsection do not apply:

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

 8  incurred by the contracting entity; or

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

10  guaranteed in writing by a guaranteeing organization which:

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

12  assets in excess of $50 million; or

13         2.  Submits a written guarantee acceptable to the

14  agency which is irrevocable during the term of the contracting

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

16  contract, until the agency receives proof of satisfaction of

17  all outstanding obligations incurred under the contract.

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

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

20  insolvency protection account with a federally guaranteed

21  financial institution licensed to do business in this state.

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

23  capitation payments made by the agency each month until a

24  maximum total of 2 percent of the total current contract

25  amount is reached. The restricted insolvency protection

26  account may be drawn upon with the authorized signatures of

27  two persons designated by the entity and two representatives

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

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

30  the two authorized signatures of representatives of the

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


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    CS for CS for SB 838                           Third Engrossed



 1  obligations incurred by the entity under the prepaid contract.

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

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

 4  upon receipt of proof of satisfaction of all outstanding

 5  obligations incurred under this contract.

 6         (b)  The agency may waive the insolvency protection

 7  account requirement in writing when evidence is on file with

 8  the agency of adequate insolvency insurance and reinsurance

 9  that will protect enrollees if the entity becomes unable to

10  meet its obligations.

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

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

13  services shall reimburse any hospital or physician that is

14  outside the entity's authorized geographic service area as

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

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

17  negotiated with the hospital or physician for the provision of

18  services or according to the lesser of the following:

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

20  general public by the hospital or physician; or

21         (b)  The Florida Medicaid reimbursement rate

22  established for the hospital or physician.

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

24  prepaid contractor has been approved by the Office of

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

26  approve the assignment or transfer of the appropriate Medicaid

27  prepaid contract upon request of the surviving entity of the

28  merger or acquisition if the contractor and the other entity

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

30  12-month period, unless the agency determines that the

31  assignment or transfer would be detrimental to the Medicaid


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    CS for CS for SB 838                           Third Engrossed



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

 2  entity must not have failed accreditation or committed any

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

 4  meet the Medicaid contract requirements. For purposes of this

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

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

 7         (21)  Any entity contracting with the agency pursuant

 8  to this section to provide health care services to Medicaid

 9  recipients is prohibited from engaging in any of the following

10  practices or activities:

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

12  not limited to, attempts to discourage participation on the

13  basis of actual or perceived health status.

14         (b)  Activities that could mislead or confuse

15  recipients, or misrepresent the organization, its marketing

16  representatives, or the agency. Violations of this paragraph

17  include, but are not limited to:

18         1.  False or misleading claims that marketing

19  representatives are employees or representatives of the state

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

21  organization by whom they are reimbursed.

22         2.  False or misleading claims that the entity is

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

24  any other organization which has not certified its endorsement

25  in writing to the entity.

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

27  recommends that a Medicaid recipient enroll with an entity.

28         4.  Claims that a Medicaid recipient will lose benefits

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

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

31  recipient does not enroll with the entity.


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    CS for CS for SB 838                           Third Engrossed



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

 2  valuable consideration for enrollment, except as authorized by

 3  subsection (24).

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

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

 6  make a presentation.

 7         (e)  Solicitation of Medicaid recipients by marketing

 8  representatives stationed in state offices unless approved and

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

10  affected state agency when solicitation occurs in an office of

11  the state agency. The agency shall ensure that marketing

12  representatives stationed in state offices shall market their

13  managed care plans to Medicaid recipients only in designated

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

15  recipients' activities in the state office.

16         (f)  Enrollment of Medicaid recipients.

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

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

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

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

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

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

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

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

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

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

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

28  and willful violations arising out of the same action.

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

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

31  agency for the provision of health care services to Medicaid


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    CS for CS for SB 838                           Third Engrossed



 1  recipients may not use or distribute marketing materials used

 2  to solicit Medicaid recipients, unless such materials have

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

 4  do not apply to general advertising and marketing materials

 5  used by a health maintenance organization to solicit both

 6  non-Medicaid subscribers and Medicaid recipients.

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

 8  organizations and persons or entities exempt from chapter 641

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

10  health care services to Medicaid recipients may be permitted

11  within the capitation rate to provide additional health

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

13  practicably available, provide reasonable value to the

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

15  state.

16         (25)  The agency shall utilize the statewide health

17  maintenance organization complaint hotline for the purpose of

18  investigating and resolving Medicaid and prepaid health plan

19  complaints, maintaining a record of complaints and confirmed

20  problems, and receiving disenrollment requests made by

21  recipients.

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

23  health maintenance organization's and the prepaid health

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

25  telephone number of the statewide health maintenance

26  organization complaint hotline on each Medicaid identification

27  card issued by a health maintenance organization or prepaid

28  health plan contracting with the agency to serve Medicaid

29  recipients and on each subscriber handbook issued to a

30  Medicaid recipient.

31  


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    CS for CS for SB 838                           Third Engrossed



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

 2  improvement system for those entities contracting with the

 3  agency pursuant to this section, incorporating all the

 4  standards and guidelines developed by the Medicaid Bureau of

 5  the Health Care Financing Administration as a part of the

 6  quality assurance reform initiative. The system shall include,

 7  but need not be limited to, the following:

 8         (a)  Guidelines for internal quality assurance

 9  programs, including standards for:

10         1.  Written quality assurance program descriptions.

11         2.  Responsibilities of the governing body for

12  monitoring, evaluating, and making improvements to care.

13         3.  An active quality assurance committee.

14         4.  Quality assurance program supervision.

15         5.  Requiring the program to have adequate resources to

16  effectively carry out its specified activities.

17         6.  Provider participation in the quality assurance

18  program.

19         7.  Delegation of quality assurance program activities.

20         8.  Credentialing and recredentialing.

21         9.  Enrollee rights and responsibilities.

22         10.  Availability and accessibility to services and

23  care.

24         11.  Ambulatory care facilities.

25         12.  Accessibility and availability of medical records,

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

27         13.  Utilization review.

28         14.  A continuity of care system.

29         15.  Quality assurance program documentation.

30         16.  Coordination of quality assurance activity with

31  other management activity.


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    CS for CS for SB 838                           Third Engrossed



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

 2  elderly and disabled recipients, especially those who are at

 3  risk of institutional placement; to persons with developmental

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

 5  medical conditions.

 6         (b)  Guidelines which require the entities to conduct

 7  quality-of-care studies which:

 8         1.  Target specific conditions and specific health

 9  service delivery issues for focused monitoring and evaluation.

10         2.  Use clinical care standards or practice guidelines

11  to objectively evaluate the care the entity delivers or fails

12  to deliver for the targeted clinical conditions and health

13  services delivery issues.

14         3.  Use quality indicators derived from the clinical

15  care standards or practice guidelines to screen and monitor

16  care and services delivered.

17         (c)  Guidelines for external quality review of each

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

19  individual care review in specific situations; and followup

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

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

22  quality review function and determining how it is to operate

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

24  agency shall construct its external quality review

25  organization and entity contracts to address each of the

26  following:

27         1.  Delineating the role of the external quality review

28  organization.

29         2.  Length of the external quality review organization

30  contract with the state.

31  


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    CS for CS for SB 838                           Third Engrossed



 1         3.  Participation of the contracting entities in

 2  designing external quality review organization review

 3  activities.

 4         4.  Potential variation in the type of clinical

 5  conditions and health services delivery issues to be studied

 6  at each plan.

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

 8  studies to be conducted for each plan.

 9         6.  Methods for implementing focused studies.

10         7.  Individual care review.

11         8.  Followup activities.

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

13  care services for which an entity has already been

14  compensated, an entity contracting with the agency pursuant to

15  this section shall achieve an annual Early and Periodic

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

17  rate of at least 60 percent for those recipients continuously

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

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

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

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

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

23  established in the corrective action plan during the specified

24  timeframe, the agency is authorized to impose appropriate

25  contract sanctions. At least annually, the agency shall

26  publicly release the EPSDT Services screening rates of each

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

28  Medicaid recipients.

29         (29)  The agency shall perform enrollments and

30  disenrollments for Medicaid recipients who are eligible for

31  MediPass or managed care plans. Notwithstanding the


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    CS for CS for SB 838                           Third Engrossed



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

 2  may perform preenrollments of Medicaid recipients under the

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

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

 5  and educational materials to a Medicaid recipient and

 6  assistance in completing the application forms, but shall not

 7  include actual enrollment into a managed care plan. An

 8  application for enrollment shall not be deemed complete until

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

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

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

12  marketing initiatives to inform Medicaid recipients about

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

14  report to the Legislature on the effectiveness of such

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

16  perform managed care plan and MediPass enrollment and

17  disenrollment services for Medicaid recipients and is

18  authorized to adopt rules to implement such services. The

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

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

21  for agency supervision and management of the managed care plan

22  enrollment and disenrollment contract.

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

24  recipients, MediPass enrollees, or managed care plan enrollees

25  shall be arranged alphabetically showing the provider's name

26  and specialty and, separately, by specialty in alphabetical

27  order.

28         (31)  The agency shall establish an enhanced managed

29  care quality assurance oversight function, to include at least

30  the following components:

31  


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    CS for CS for SB 838                           Third Engrossed



 1         (a)  At least quarterly analysis and followup,

 2  including sanctions as appropriate, of managed care

 3  participant utilization of services.

 4         (b)  At least quarterly analysis and followup,

 5  including sanctions as appropriate, of quality findings of the

 6  Medicaid peer review organization and other external quality

 7  assurance programs.

 8         (c)  At least quarterly analysis and followup,

 9  including sanctions as appropriate, of the fiscal viability of

10  managed care plans.

11         (d)  At least quarterly analysis and followup,

12  including sanctions as appropriate, of managed care

13  participant satisfaction and disenrollment surveys.

14         (e)  The agency shall conduct regular and ongoing

15  Medicaid recipient satisfaction surveys.

16  

17  The analyses and followup activities conducted by the agency

18  under its enhanced managed care quality assurance oversight

19  function shall not duplicate the activities of accreditation

20  reviewers for entities regulated under part III of chapter

21  641, but may include a review of the finding of such

22  reviewers.

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

24  with the agency to provide health care services to Medicaid

25  recipients shall annually conduct a background check with the

26  Florida Department of Law Enforcement of all persons with

27  ownership interest of 5 percent or more or executive

28  management responsibility for the managed care plan and shall

29  submit to the agency information concerning any such person

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

31  


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    CS for CS for SB 838                           Third Engrossed



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

 2  offenses listed in s. 435.03.

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

 4  whereby a Medicaid managed care plan enrollee who wishes to

 5  enter hospice care may be disenrolled from the managed care

 6  plan within 24 hours after contacting the agency regarding

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

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

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

10  disenrollment occurs.

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

12  the agency to provide health care services to Medicaid

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

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

15  emergency services and care to Medicaid recipients and

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

17  the agency shall encourage hospitals, emergency medical

18  services providers, and other public and private health care

19  providers to work together in their local communities to enter

20  into agreements or arrangements to ensure access to

21  alternatives to emergency services and care for those Medicaid

22  recipients who need nonemergent care. The agency shall

23  coordinate with hospitals, emergency medical services

24  providers, private health plans, capitated managed care

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

26  private health care providers to implement the provisions of

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

28  develop and implement emergency department diversion programs

29  for Medicaid recipients.

30         (35)  All entities providing health care services to

31  Medicaid recipients shall make available, and encourage all


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    CS for CS for SB 838                           Third Engrossed



 1  pregnant women and mothers with infants to receive, and

 2  provide documentation in the medical records to reflect, the

 3  following:

 4         (a)  Healthy Start prenatal or infant screening.

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

 6  other factors indicate need.

 7         (c)  Healthy Start enhanced services in accordance with

 8  the prenatal or infant screening results.

 9         (d)  Immunizations in accordance with recommendations

10  of the Advisory Committee on Immunization Practices of the

11  United States Public Health Service and the American Academy

12  of Pediatrics, as appropriate.

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

14  women and their partners.

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

16  voluntary family planning, to include discussion of all

17  methods of contraception, as appropriate.

18         (g)  Referral to the Special Supplemental Nutrition

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

20         (36)  Any entity that provides Medicaid prepaid health

21  plan services shall ensure the appropriate coordination of

22  health care services with an assisted living facility in cases

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

24  prepaid health plan and a resident of the assisted living

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

26  management and behavioral health services, the entity shall

27  inform the assisted living facility of the procedures to

28  follow should an emergent condition arise.

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

30  necessary to provide for cost-effective purchasing of home

31  health services, private duty nursing services,


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    CS for CS for SB 838                           Third Engrossed



 1  transportation, independent laboratory services, and durable

 2  medical equipment and supplies through competitive bidding

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

 4  waivers from the federal Health Care Financing Administration

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

 6  exclude providers not selected through the bidding process

 7  from the Medicaid provider network.

 8         (38)  The agency shall enter into agreements with

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

10  purpose of providing vision screening.

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

12  prescribed-drug spending-control program that includes the

13  following components:

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

15  drugs for adult Medicaid recipients is limited to the

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

17  Children are exempt from this restriction. Antiretroviral

18  agents are excluded from this limitation. No requirements for

19  prior authorization or other restrictions on medications used

20  to treat mental illnesses such as schizophrenia, severe

21  depression, or bipolar disorder may be imposed on Medicaid

22  recipients. Medications that will be available without

23  restriction for persons with mental illnesses include atypical

24  antipsychotic medications, conventional antipsychotic

25  medications, selective serotonin reuptake inhibitors, and

26  other medications used for the treatment of serious mental

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

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

29  agency shall continue to provide unlimited generic drugs,

30  contraceptive drugs and items, and diabetic supplies. Although

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


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    CS for CS for SB 838                           Third Engrossed



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

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

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

 4  exceptions are based on prior consultation provided by the

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

 6  procedures to ensure that:

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

 8  consultation by telephone or other telecommunication device

 9  within 24 hours after receipt of a request for prior

10  consultation;

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

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

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

14  and

15         c.  Except for the exception for nursing home residents

16  and other institutionalized adults and except for drugs on the

17  restricted formulary for which prior authorization may be

18  sought by an institutional or community pharmacy, prior

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

20  restriction is sought by the prescriber and not by the

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

22  an institutional setting beyond the brand-name-drug

23  restriction, such approval is authorized for 12 months and

24  monthly prior authorization is not required for that patient.

25         2.  Reimbursement to pharmacies for Medicaid prescribed

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

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

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

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

30  customary (UAC) charge billed by the provider.

31  


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    CS for CS for SB 838                           Third Engrossed



 1         3.  The agency shall develop and implement a process

 2  for managing the drug therapies of Medicaid recipients who are

 3  using significant numbers of prescribed drugs each month. The

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

 5  comprehensive, physician-directed medical-record reviews,

 6  claims analyses, and case evaluations to determine the medical

 7  necessity and appropriateness of a patient's treatment plan

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

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

10  Medicaid drug benefit management program shall include

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

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

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

14  agency shall enroll any Medicaid recipient in the drug benefit

15  management program if he or she meets the specifications of

16  this provision and is not enrolled in a Medicaid health

17  maintenance organization.

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

19  network based on need, competitive bidding, price

20  negotiations, credentialing, or similar criteria. The agency

21  shall give special consideration to rural areas in determining

22  the size and location of pharmacies included in the Medicaid

23  pharmacy network. A pharmacy credentialing process may include

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

25  size, patient educational programs, patient consultation,

26  disease-management services, and other characteristics. The

27  agency may impose a moratorium on Medicaid pharmacy enrollment

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

29  Medicaid-participating providers. The agency must allow

30  dispensing practitioners to participate as a part of the

31  Medicaid pharmacy network regardless of the practitioner's


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    CS for CS for SB 838                           Third Engrossed



 1  proximity to any other entity that is dispensing prescription

 2  drugs under the Medicaid program. A dispensing practitioner

 3  must meet all credentialing requirements applicable to his or

 4  her practice, as determined by the agency.

 5         5.  The agency shall develop and implement a program

 6  that requires Medicaid practitioners who prescribe drugs to

 7  use a counterfeit-proof prescription pad for Medicaid

 8  prescriptions. The agency shall require the use of

 9  standardized counterfeit-proof prescription pads by

10  Medicaid-participating prescribers or prescribers who write

11  prescriptions for Medicaid recipients. The agency may

12  implement the program in targeted geographic areas or

13  statewide.

14         6.  The agency may enter into arrangements that require

15  manufacturers of generic drugs prescribed to Medicaid

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

17  average manufacturer price for the manufacturer's generic

18  products. These arrangements shall require that if a

19  generic-drug manufacturer pays federal rebates for

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

21  manufacturer must provide a supplemental rebate to the state

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

23         7.  The agency may establish a preferred drug formulary

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

25  establishment of such formulary, it is authorized to negotiate

26  supplemental rebates from manufacturers that are in addition

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

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

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

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

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


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    CS for CS for SB 838                           Third Engrossed



 1  supplemental rebates the agency may negotiate. The agency may

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

 3  competitive at lower rebate percentages. Agreement to pay the

 4  minimum supplemental rebate percentage will guarantee a

 5  manufacturer that the Medicaid Pharmaceutical and Therapeutics

 6  Committee will consider a product for inclusion on the

 7  preferred drug formulary. However, a pharmaceutical

 8  manufacturer is not guaranteed placement on the formulary by

 9  simply paying the minimum supplemental rebate. Agency

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

11  recommendations of the Medicaid Pharmaceutical and

12  Therapeutics Committee, as well as the price of competing

13  products minus federal and state rebates. The agency is

14  authorized to contract with an outside agency or contractor to

15  conduct negotiations for supplemental rebates. For the

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

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

18  programs as a substitution for supplemental rebates are

19  prohibited. The agency is authorized to seek any federal

20  waivers to implement this initiative.

21         8.  The agency shall establish an advisory committee

22  for the purposes of studying the feasibility of using a

23  restricted drug formulary for nursing home residents and other

24  institutionalized adults. The committee shall be comprised of

25  seven members appointed by the Secretary of Health Care

26  Administration. The committee members shall include two

27  physicians licensed under chapter 458 or chapter 459; three

28  pharmacists licensed under chapter 465 and appointed from a

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

30  Pharmacy Alliance; and two pharmacists licensed under chapter

31  465.


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    CS for CS for SB 838                           Third Engrossed



 1         9.  The Agency for Health Care Administration shall

 2  expand home delivery of pharmacy products. To assist Medicaid

 3  patients in securing their prescriptions and reduce program

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

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

 6  drugs used by Medicaid patients with diabetes. Medicaid

 7  recipients in the current program may obtain nondiabetes drugs

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

 9  geographic area covered by the current contract. The agency

10  may seek and implement any federal waivers necessary to

11  implement this subparagraph.

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

13  drug prescribed to treat erectile dysfunction.

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

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

16  that has experience in operating behavioral drug management

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

18  seek federal waivers to implement this program.

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

20  Children and Family Services, may implement the Medicaid

21  behavioral drug management system that is designed to improve

22  the quality of care and behavioral health prescribing

23  practices based on best practice guidelines, improve patient

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

25  prescribed drug costs and the rate of inappropriate spending

26  on Medicaid behavioral drugs. The program shall include the

27  following elements:

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

29  practice guidelines for behavioral health-related drugs such

30  as antipsychotics, antidepressants, and medications for

31  treating bipolar disorders and other behavioral conditions;


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    CS for CS for SB 838                           Third Engrossed



 1  translate them into practice; review behavioral health

 2  prescribers and compare their prescribing patterns to a number

 3  of indicators that are based on national standards; and

 4  determine deviations from best practice guidelines.

 5         (II)  Implement processes for providing feedback to and

 6  educating prescribers using best practice educational

 7  materials and peer-to-peer consultation.

 8         (III)  Assess Medicaid beneficiaries who are outliers

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

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

11  drug therapies, and other indicators of improper use of

12  behavioral health drugs.

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

14  prescriptions in a timely fashion, are prescribed multiple

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

16  potential medication problems.

17         (V)  Track spending trends for behavioral health drugs

18  and deviation from best practice guidelines.

19         (VI)  Use educational and technological approaches to

20  promote best practices, educate consumers, and train

21  prescribers in the use of practice guidelines.

22         (VII)  Disseminate electronic and published materials.

23         (VIII)  Hold statewide and regional conferences.

24         (IX)  Implement a disease management program with a

25  model quality-based medication component for severely mentally

26  ill individuals and emotionally disturbed children who are

27  high users of care.

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

29  with one or more manufacturers to finance and guarantee

30  savings associated with a behavioral drug management program

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


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    CS for CS for SB 838                           Third Engrossed



 1  drug list prior-authorization requirements shall apply to

 2  mental health-related drugs, notwithstanding any provision in

 3  subparagraph 1. The agency is authorized to seek federal

 4  waivers to implement this policy.

 5         12.a.  The agency shall implement a Medicaid

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

 7  with a vendor that has experience in operating

 8  prescription-drug-management systems in order to implement

 9  this system. Any management system that is implemented in

10  accordance with this subparagraph must rely on cooperation

11  between physicians and pharmacists to determine appropriate

12  practice patterns and clinical guidelines to improve the

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

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

15  program.

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

17  improve the quality of care and prescribing practices based on

18  best-practice guidelines, improve patient adherence to

19  medication plans, reduce clinical risk, and lower prescribed

20  drug costs and the rate of inappropriate spending on Medicaid

21  prescription drugs. The program must:

22         (I)  Provide for the development and adoption of

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

24  in the Medicaid program, including translating best-practice

25  guidelines into practice; reviewing prescriber patterns and

26  comparing them to indicators that are based on national

27  standards and practice patterns of clinical peers in their

28  community, statewide, and nationally; and determine deviations

29  from best-practice guidelines.

30  

31  


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    CS for CS for SB 838                           Third Engrossed



 1         (II)  Implement processes for providing feedback to and

 2  educating prescribers using best-practice educational

 3  materials and peer-to-peer consultation.

 4         (III)  Assess Medicaid recipients who are outliers in

 5  their use of a single or multiple prescription drugs with

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

 7  combination drug therapies, and other indicators of improper

 8  use of prescription drugs.

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

10  prescriptions in a timely fashion, are prescribed multiple

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

12  other potential medication problems.

13         (V)  Track spending trends for prescription drugs and

14  deviation from best-practice guidelines.

15         (VI)  Use educational and technological approaches to

16  promote best practices, educate consumers, and train

17  prescribers in the use of practice guidelines.

18         (VII)  Disseminate electronic and published materials.

19         (VIII)  Hold statewide and regional conferences.

20         (IX)  Implement disease-management programs in

21  cooperation with physicians and pharmacists, along with a

22  model quality-based medication component for individuals

23  having chronic medical conditions.

24         13.12.  The agency is authorized to contract for drug

25  rebate administration, including, but not limited to,

26  calculating rebate amounts, invoicing manufacturers,

27  negotiating disputes with manufacturers, and maintaining a

28  database of rebate collections.

29         14.13.  The agency may specify the preferred daily

30  dosing form or strength for the purpose of promoting best

31  practices with regard to the prescribing of certain drugs as


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    CS for CS for SB 838                           Third Engrossed



 1  specified in the General Appropriations Act and ensuring

 2  cost-effective prescribing practices.

 3         15.14.  The agency may require prior authorization for

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

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

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

 7  an indication not in the approved labeling. Prior

 8  authorization may require the prescribing professional to

 9  provide information about the rationale and supporting medical

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

11         16.15.  The agency shall implement a return and reuse

12  program for drugs dispensed by pharmacies to institutional

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

14  the implementation and operation of the program. The return

15  and reuse program shall be implemented electronically and in a

16  manner that promotes efficiency. The program must permit a

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

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

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

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

21  shall determine if the program has reduced the amount of

22  Medicaid prescription drugs which are destroyed on an annual

23  basis and if there are additional ways to ensure more

24  prescription drugs are not destroyed which could safely be

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

26  reported to the Legislature by December 1, 2005.

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

28  extent that funds are appropriated to administer the Medicaid

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

30  contract all or any part of this program to private

31  organizations.


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    CS for CS for SB 838                           Third Engrossed



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

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

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

 4  limited to, the progress made in implementing this subsection

 5  and its effect on Medicaid prescribed-drug expenditures.

 6         (40)  Notwithstanding the provisions of chapter 287,

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

 8  contracts for fiscal intermediary services one or more times

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

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

11  the term of the original contract.

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

13  demonstration project by establishment in Miami-Dade County of

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

15  improve access to health care for a predominantly minority,

16  medically underserved, and medically complex population and to

17  evaluate alternatives to nursing home care and general acute

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

19  health care condominium and colocated with licensed facilities

20  providing a continuum of care. The establishment of this

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

22  408.039. The agency shall report its findings to the Governor,

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

24  Representatives by January 1, 2003.

25         (42)  The agency shall develop and implement a

26  utilization management program for Medicaid-eligible

27  recipients for the management of occupational, physical,

28  respiratory, and speech therapies. The agency shall establish

29  a utilization program that may require prior authorization in

30  order to ensure medically necessary and cost-effective

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


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    CS for CS for SB 838                           Third Engrossed



 1  federally approved waiver program or state plan amendment. The

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

 3  implement this program. The agency may also competitively

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

 5  statewide basis.

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

 7  basis with appropriately licensed prepaid dental health plans

 8  to provide dental services.

 9         (44)  The Agency for Health Care Administration shall

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

11  409.9122(2)(h), whether paid on a capitated basis or a shared

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

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

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

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

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

17  costs associated with contracts for Medicaid services

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

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

20  shall conduct actuarially sound audits adjusted for case mix

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

22  publish the audit results on its Internet website and submit

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

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

25  later than December 31 of each year. Contracts established

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

27  not be renewed.

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

29  shall mandate a recipient's participation in a provider

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

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


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    CS for CS for SB 838                           Third Engrossed



 1  frequency or amount not medically necessary, limiting the

 2  receipt of goods or services to medically necessary providers

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

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

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

 6  clinics. The limitation does not apply to emergency services

 7  and care provided to the recipient in a hospital emergency

 8  department. The agency shall seek any federal waivers

 9  necessary to implement this subsection. The agency shall adopt

10  any rules necessary to comply with or administer this

11  subsection.

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

13  permission to terminate the eligibility of a Medicaid

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

15  judicial or administrative determination, two times in a

16  period of 5 years.

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

18  electronic systems for the purpose of verifying the identity

19  and eligibility of a Medicaid recipient. The agency shall

20  recommend to the Legislature a plan to implement an electronic

21  verification system for Medicaid recipients by January 31,

22  2005.

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

24  Medicaid provider network. The agency may implement a Medicaid

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

26  limited to, competitive procurement and provider

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

28  may limit its provider network based upon the following

29  considerations: beneficiary access to care, provider

30  availability, provider quality standards and quality assurance

31  processes, cultural competency, demographic characteristics of


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    CS for CS for SB 838                           Third Engrossed



 1  beneficiaries, practice standards, service wait times,

 2  provider turnover, provider licensure and accreditation

 3  history, program integrity history, peer review, Medicaid

 4  policy and billing compliance records, clinical and medical

 5  record audit findings, and such other areas that are

 6  considered necessary by the agency to ensure the integrity of

 7  the program.

 8         (49)  The agency shall contract with established

 9  minority physician networks that provide services to

10  historically underserved minority patients. The networks must

11  provide cost-effective Medicaid services, comply with the

12  requirements to be a MediPass provider, and provide their

13  primary care physicians with access to data and other

14  management tools necessary to assist them in ensuring the

15  appropriate use of services, including inpatient hospital

16  services and pharmaceuticals.

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

18  expansion of minority physician networks in each service area

19  to provide services to Medicaid recipients who are eligible to

20  participate under federal law and rules.

21         (b)  The agency shall reimburse each minority physician

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

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

24  provider for Medicaid services. Any savings shall be shared

25  with the minority physician networks pursuant to the contract.

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

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

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

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

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

31  costs associated with contracts for Medicaid services


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    CS for CS for SB 838                           Third Engrossed



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

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

 3  shall conduct actuarially sound audits adjusted for case mix

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

 5  publish the audit results on its Internet website and submit

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

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

 8  later than December 31. Contracts established pursuant to this

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

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

11  needed to implement this subsection.

12         (50)  To the extent permitted by federal law and as

13  allowed under s. 409.906, the agency shall provide

14  reimbursement for emergency mental health care services for

15  Medicaid recipients in crisis-stabilization facilities

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

17  expensive than the same services provided in a hospital

18  setting.

19         Section 2.  Section 409.91211, Florida Statutes, is

20  created to read:

21         409.91211  Medicaid managed care pilot program.--

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

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

24  of the Social Security Act, to create a statewide initiative

25  to provide for a more efficient and effective service delivery

26  system that enhances quality of care and client outcomes in

27  the Florida Medicaid program pursuant to this section. Phase

28  one of the demonstration shall be implemented in two

29  geographic areas. One demonstration site shall include only

30  Broward County. A second demonstration site shall initially

31  include Duval County and shall be expanded to include Baker,


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    CS for CS for SB 838                           Third Engrossed



 1  Clay, and Nassau Counties within 1 year after the Duval County

 2  program becomes operational. This waiver authority is

 3  contingent upon federal approval to preserve the

 4  upper-payment-limit funding mechanism for hospitals, including

 5  a guarantee of a reasonable growth factor, a methodology to

 6  allow the use of a portion of these funds to serve as a risk

 7  pool for demonstration sites, provisions to preserve the

 8  state's ability to use intergovernmental transfers, and

 9  provisions to protect the disproportionate share program

10  authorized pursuant to this chapter. Upon completion of the

11  evaluation conducted under section 3 of this act, the agency

12  may request statewide expansion of the demonstration projects.

13  Statewide phase-in to additional counties shall be contingent

14  upon review and approval by the Legislature.

15         (2)  The Legislature intends for the capitated managed

16  care pilot program to:

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

18  the MediPass program a comprehensive and coordinated capitated

19  managed care system for all health care services specified in

20  ss. 409.905 and 409.906.

21         (b)  Stabilize Medicaid expenditures under the pilot

22  program compared to Medicaid expenditures in the pilot area

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

24  while ensuring:

25         1.  Consumer education and choice.

26         2.  Access to medically necessary services.

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

28  care.

29         4.  Reductions in unnecessary service utilization.

30         (c)  Provide an opportunity to evaluate the feasibility

31  of statewide implementation of capitated managed care networks


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    CS for CS for SB 838                           Third Engrossed



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

 2  MediPass systems.

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

 4  duties, and responsibilities with respect to the development

 5  of a pilot program:

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

 7  mandatory services specified in s. 409.905 and optional

 8  services specified in s. 409.906, as approved by the Centers

 9  for Medicare and Medicaid Services and the Legislature in the

10  waiver pursuant to this section. Services to recipients under

11  plan benefits shall include emergency services provided under

12  s. 409.9128.

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

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

15  included in the pilot program.

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

17  managed care pilot program in order to take maximum advantage

18  of all available state and federal funds, including those

19  obtained through intergovernmental transfers, the

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

21  share program.

22         (d)  To determine and recommend actuarially sound,

23  risk-adjusted capitation rates for Medicaid recipients in the

24  pilot program which can be separated to cover comprehensive

25  care, enhanced services, and catastrophic care.

26         (e)  To determine and recommend policies and guidelines

27  for phasing in financial risk for approved provider service

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

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

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

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


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    CS for CS for SB 838                           Third Engrossed



 1  year of operation. Federally qualified health centers may be

 2  offered an opportunity to accept or decline a contract to

 3  participate in any provider network for prepaid primary care

 4  services.

 5         (f)  To determine and recommend provisions related to

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

 7  catastrophic coverage that accommodates the risks associated

 8  with the development of the pilot program.

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

10  the Social Services Estimating Conference to determine and

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

12  providing Medicaid services under the managed care pilot

13  program.

14         (h)  To determine and recommend program standards and

15  credentialing requirements for capitated managed care networks

16  to participate in the pilot program, including those related

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

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

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

20  the state under this section include any federally qualified

21  health center, federally qualified rural health clinic, county

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

23  funded entity that serves the geographic areas within the

24  boundaries of the pilot program that requests to participate.

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

26  capitated managed care network under this section from any

27  other licensure or regulatory requirements contained in state

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

29  standards and credentialing requirements shall be based upon,

30  but are not limited to:

31  


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    CS for CS for SB 838                           Third Engrossed



 1         1.  Compliance with the accreditation requirements as

 2  provided in s. 641.512.

 3         2.  Compliance with early and periodic screening,

 4  diagnosis, and treatment screening requirements under federal

 5  law.

 6         3.  The percentage of voluntary disenrollments.

 7         4.  Immunization rates.

 8         5.  Standards of the National Committee for Quality

 9  Assurance and other approved accrediting bodies.

10         6.  Recommendations of other authoritative bodies.

11         7.  Specific requirements of the Medicaid program, or

12  standards designed to specifically meet the unique needs of

13  Medicaid recipients.

14         8.  Compliance with the health quality improvement

15  system as established by the agency, which incorporates

16  standards and guidelines developed by the Centers for Medicare

17  and Medicaid Services as part of the quality assurance reform

18  initiative.

19         9.  The network's infrastructure capacity to manage

20  financial transactions, recordkeeping, data collection, and

21  other administrative functions.

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

23  programmatic, or patient-encounter data or other information

24  required by the agency to determine the actual services

25  provided and the cost of administering the plan.

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

27  information to Medicaid recipients for the purpose of

28  selecting a capitated managed care plan. For each plan

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

30  ensure that the recipient is provided with:

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


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    CS for CS for SB 838                           Third Engrossed



 1         2.  Information about cost sharing.

 2         3.  Plan performance data, if available.

 3         4.  An explanation of benefit limitations.

 4         5.  Contact information, including identification of

 5  providers participating in the network, geographic locations,

 6  and transportation limitations.

 7         6.  Any other information the agency determines would

 8  facilitate a recipient's understanding of the plan or

 9  insurance that would best meet his or her needs.

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

11  there is a record of recipient acknowledgment that choice

12  counseling has been provided.

13         (k)  To develop and recommend a choice counseling

14  system to ensure that the choice counseling process and

15  related material are designed to provide counseling through

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

17  through other forms of relevant media. Materials shall be

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

19  language other than English when 5 percent of the county

20  speaks a language other than English. Choice counseling shall

21  also use language lines and other services for impaired

22  recipients, such as TTD/TTY.

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

24  capitated managed care plans, their representatives, and

25  providers employed by or contracted with the capitated managed

26  care plans from recruiting persons eligible for or enrolled in

27  Medicaid, from providing inducements to Medicaid recipients to

28  select a particular capitated managed care plan, and from

29  prejudicing Medicaid recipients against other capitated

30  managed care plans. The system shall require the entity

31  performing choice counseling to determine if the recipient has


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    CS for CS for SB 838                           Third Engrossed



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

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

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

 4  entity determines that the decision to choose a plan was

 5  unlawfully influenced or a plan violated any of the provisions

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

 7  immediately report the violation to the agency's program

 8  integrity section for investigation. Verification of choice

 9  counseling by the recipient shall include a stipulation that

10  the recipient acknowledges the provisions of this subsection.

11         (m)  To develop and recommend a choice counseling

12  system that promotes health literacy and provides information

13  aimed to reduce minority health disparities through outreach

14  activities for Medicaid recipients.

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

16  to contract with entities to perform choice counseling. The

17  agency may establish standards and performance contracts,

18  including standards requiring the contractor to hire choice

19  counselors who are representative of the state's diverse

20  population and to train choice counselors in working with

21  culturally diverse populations.

22         (o)  To determine and recommend descriptions of the

23  eligibility assignment processes which will be used to

24  facilitate client choice while ensuring pilot programs of

25  adequate enrollment levels. These processes shall ensure that

26  pilot sites have sufficient levels of enrollment to conduct a

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

28  timeframe.

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

30  provision of health care services in the pilot program,

31  including utilization and quality of health care services for


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    CS for CS for SB 838                           Third Engrossed



 1  the purpose of ensuring access to medically necessary

 2  services. This system shall include an encounter

 3  data-information system that collects and reports utilization

 4  information. The system shall include a method for verifying

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

 6  medical records.

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

 8  Medicaid recipients enrolled in a capitated managed care

 9  network under the pilot program modeled after the subscriber

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

11  shall include a mechanism for an expedited review of no

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

13  life of a Medicaid recipient is in imminent and emergent

14  jeopardy.

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

16  health care providers employed by or contracted with a

17  capitated managed care network under the pilot program in

18  order to settle disputes among the provider and the managed

19  care network or the provider and the agency.

20         (s)  To develop and recommend criteria to designate

21  health care providers as eligible to participate in the pilot

22  program. The agency and capitated managed care networks must

23  follow national guidelines for selecting health care

24  providers, whenever available. These criteria must include at

25  a minimum those criteria specified in s. 409.907.

26         (t)  To develop and recommend health care provider

27  agreements for participation in the pilot program.

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

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

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

31  


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    CS for CS for SB 838                           Third Engrossed



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

 2  a minimum those criteria specified in s. 409.907.

 3         (v)  To develop and recommend agreements with other

 4  state or local governmental programs or institutions for the

 5  coordination of health care to eligible individuals receiving

 6  services from such programs or institutions.

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

 8  activities of pilot program participants, health care

 9  providers, capitated managed care networks, and their

10  representatives in order to prevent fraud or abuse,

11  overutilization or duplicative utilization, underutilization

12  or inappropriate denial of services, and neglect of

13  participants and to recover overpayments as appropriate. For

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

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

16  refer incidents of suspected fraud, abuse, overutilization and

17  duplicative utilization, and underutilization or inappropriate

18  denial of services to the appropriate regulatory agency.

19         (x)  To develop and provide actuarial and benefit

20  design analyses that indicate the effect on capitation rates

21  and benefits offered in the pilot program over a prospective

22  5-year period based on the following assumptions:

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

24  estimated growth rate in general revenue.

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

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

27  Medicaid expenditures.

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

29  growth rate of aggregate Medicaid expenditures between the

30  2003-2004 fiscal year and the 2004-2005 fiscal year.

31  


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    CS for CS for SB 838                           Third Engrossed



 1         (y)  To develop a mechanism to require capitated

 2  managed care plans to reimburse qualified emergency service

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

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

 5  must include a provision for continuing fee-for-service

 6  payments for emergency services, including but not limited to,

 7  individuals who access ambulance services or emergency

 8  departments and who are subsequently determined to be eligible

 9  for Medicaid services.

10         (z)  To develop a system whereby school districts

11  participating in the certified school match program pursuant

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

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

14  Medicaid-eligible child participating in the services as

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

16  regardless of whether the child is enrolled in a capitated

17  managed care network. Capitated managed care networks must

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

19  districts regarding the coordinated provision of services

20  authorized under s. 1011.70. County health departments

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

22  381.0057 must be reimbursed by Medicaid for the federal share

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

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

25  is enrolled in a capitated managed care network. Capitated

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

27  agreements with county health departments regarding the

28  coordinated provision of services to a Medicaid-eligible

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

30  agency, the Department of Health, and the Department of

31  Education shall develop procedures for ensuring that a


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    CS for CS for SB 838                           Third Engrossed



 1  student's capitated managed care network provider receives

 2  information relating to services provided in accordance with

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

 4         (aa)  To develop and recommend a mechanism whereby

 5  Medicaid recipients who are already enrolled in a managed care

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

 7  offered the opportunity to change to capitated managed care

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

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

10  choice of capitated managed care plans. Those Medicaid

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

12  capitated managed care plan in accordance with paragraph

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

14  recipient who is also a recipient of Supplemental Security

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

16  capitated managed care plan, the agency shall determine

17  whether the SSI recipient has an ongoing relationship with a

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

19  shall assign the SSI recipient to that provider or capitated

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

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

22  capitated managed care plan provider in accordance with

23  paragraph (4)(a).

24         (bb)  To develop and recommend a service delivery

25  alternative for children having chronic medical conditions

26  which establishes a medical home project to provide primary

27  care services to this population. The project shall provide

28  community-based primary care services that are integrated with

29  other subspecialties to meet the medical, developmental, and

30  emotional needs for children and their families. This project

31  shall include an evaluation component to determine impacts on


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    CS for CS for SB 838                           Third Engrossed



 1  hospitalizations, length of stays, emergency room visits,

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

 3  patient, and family satisfaction.

 4         (cc)  To develop and recommend service delivery

 5  mechanisms within capitated managed care plans to provide

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

 7  persons with developmental disabilities sufficient to meet the

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

 9         (dd)  To develop and recommend service delivery

10  mechanisms within capitated managed care plans to provide

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

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

13  be coordinated with community-based care providers as

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

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

16  these children.

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

18  not currently enrolled in a capitated managed care plan upon

19  implementation is not eligible for services as specified in

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

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

22  If a Medicaid recipient has not enrolled in a capitated

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

24  shall assign the Medicaid recipient to a capitated managed

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

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

27  shall take into account the following criteria:

28         1.  A capitated managed care network has sufficient

29  network capacity to meet the need of members.

30         2.  The capitated managed care network has previously

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


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    CS for CS for SB 838                           Third Engrossed



 1  managed care network's primary care providers has previously

 2  provided health care to the recipient.

 3         3.  The agency has knowledge that the member has

 4  previously expressed a preference for a particular capitated

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

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

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

 8  providers are geographically accessible to the recipient's

 9  residence.

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

11  provider meets the criteria specified in paragraph (3)(h), the

12  agency shall make recipient assignments consecutively by

13  family unit.

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

15  designed to favor one capitated managed care plan over another

16  or that are designed to influence Medicaid recipients to

17  enroll in a particular capitated managed care network in order

18  to strengthen its particular fiscal viability.

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

20  enrolled in a capitated managed care network, the recipient

21  shall have 90 days in which to voluntarily disenroll and

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

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

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

25  access to necessary specialty services, an unreasonable delay

26  or denial of service, inordinate or inappropriate changes of

27  primary care providers, service access impairments due to

28  significant changes in the geographic location of services, or

29  fraudulent enrollment. The agency may require a recipient to

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

31  specified in paragraph (3)(g) prior to the agency's


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    CS for CS for SB 838                           Third Engrossed



 1  determination of cause, except in cases in which immediate

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

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

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

 5  of the second month after the month the disenrollment request

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

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

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

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

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

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

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

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

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

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

16  finding that cause does not exist for disenrollment shall be

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

18  dispute the agency's finding.

19         (e)  The agency shall apply for federal waivers from

20  the Centers for Medicare and Medicaid Services to lock

21  eligible Medicaid recipients into a capitated managed care

22  network for 12 months after an open enrollment period. After

23  12 months of enrollment, a recipient may select another

24  capitated managed care network. However, nothing shall prevent

25  a Medicaid recipient from changing primary care providers

26  within the capitated managed care network during the 12-month

27  period.

28         (f)  The agency shall apply for federal waivers from

29  the Centers for Medicare and Medicaid Services to allow

30  recipients to purchase health care coverage through an

31  employer-sponsored health insurance plan instead of through a


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    CS for CS for SB 838                           Third Engrossed



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

 2  opt-out option.

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

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

 5  authorized under a waiver granted by the Centers for Medicare

 6  and Medicaid Services, to select and enroll in a

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

 8  employer-sponsored plan after the specified period, the

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

10  year or until the recipient no longer has access to

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

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

13  participate in employer-sponsored coverage, or until the

14  person is no longer eligible for Medicaid, whichever time

15  period is shorter.

16         2.  Notwithstanding any other provision of this

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

18  employer-sponsored health insurance shall be governed by

19  applicable state and federal laws.

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

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

22  experimental, pilot, or demonstration project waiver to reform

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

24  the two geographic areas specified in this section unless

25  approved by the Legislature.

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

27  applications for waivers of applicable federal laws and

28  regulations as necessary to implement the managed care pilot

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

30  waiver applications under this section on its Internet website

31  30 days before submitting the applications to the United


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    CS for CS for SB 838                           Third Engrossed



 1  States Centers for Medicare and Medicaid Services. All waiver

 2  applications shall be provided for review and comment to the

 3  appropriate committees of the Senate and House of

 4  Representatives for at least 10 working days prior to

 5  submission. All waivers submitted to and approved by the

 6  United States Centers for Medicare and Medicaid Services under

 7  this section must be approved by the Legislature. Federally

 8  approved waivers must be submitted to the President of the

 9  Senate and the Speaker of the House of Representatives for

10  referral to the appropriate legislative committees. The

11  appropriate committees shall recommend whether to approve the

12  implementation of any waivers to the Legislature as a whole.

13  The agency shall submit a plan containing a recommended

14  timeline for implementation of any waivers and budgetary

15  projections of the effect of the pilot program under this

16  section on the total Medicaid budget for the 2006-2007 through

17  2009-2010 state fiscal years. This implementation plan shall

18  be submitted to the President of the Senate and the Speaker of

19  the House of Representatives at the same time any waivers are

20  submitted for consideration by the Legislature.

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

22  waivers of applicable federal laws and regulations to

23  implement the managed care pilot program by the Legislature,

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

25  120.536(1) and 120.54 to implement and administer the managed

26  care pilot program as provided in this section.

27         Section 3.  The Office of Program Policy Analysis and

28  Government Accountability, in consultation with the Auditor

29  General, shall comprehensively evaluate the two managed care

30  pilot programs created under section 409.91211, Florida

31  Statutes. The evaluation shall begin with the implementation


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    CS for CS for SB 838                           Third Engrossed



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

 2  24 months after the two pilot programs have enrolled Medicaid

 3  recipients and started providing health care services. The

 4  evaluation must include assessments of cost savings; consumer

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

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

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

 8  describe administrative or legal barriers to the

 9  implementation and operation of each pilot program and include

10  recommendations regarding statewide expansion of the managed

11  care pilot programs. The office shall submit an evaluation

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

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

14  2008.

15         Section 4.  Section 409.9062, Florida Statutes, is

16  amended to read:

17         409.9062  Lung transplant services for Medicaid

18  recipients.--Subject to the availability of funds and subject

19  to any limitations or directions provided for in the General

20  Appropriations Act or chapter 216, the Agency for Health Care

21  Administration Medicaid program shall pay for medically

22  necessary lung transplant services for Medicaid recipients.

23  These payments must be used to reimburse approved lung

24  transplant facilities a global fee for providing lung

25  transplant services to Medicaid recipients.

26         Section 5.  The sums of $401,098 from the General

27  Revenue Fund and $593,058 from the Medical Care Trust Fund are

28  appropriated to the Agency for Health Care Administration for

29  the purpose of implementing section 4 during the 2005-2006

30  fiscal year.

31  


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    CS for CS for SB 838                           Third Engrossed



 1         Section 6.  Paragraphs (a) and (j) of subsection (2) of

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

 3         409.9122  Mandatory Medicaid managed care enrollment;

 4  programs and procedures.--

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

 6  or MediPass all Medicaid recipients, except those Medicaid

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

 8  Medicaid medically needy program; or eligible for both

 9  Medicaid and Medicare. Upon enrollment, individuals will be

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

11  out period required by federal Medicaid regulations. The

12  agency is authorized to seek the necessary Medicaid state plan

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

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

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

16  mandatory managed care enrollment, provided that:

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

18  care plan or MediPass is voluntary;

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

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

21  plan provides specific programs and services which address the

22  special health needs of the recipient; and

23         3.  The agency receives any necessary waivers from the

24  federal Centers for Medicare and Medicaid Services Health Care

25  Financing Administration.

26  

27  The agency shall develop rules to establish policies by which

28  exceptions to the mandatory managed care enrollment

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

30  shall include the specific criteria to be applied when making

31  a determination as to whether to exempt a recipient from


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    CS for CS for SB 838                           Third Engrossed



 1  mandatory enrollment in a managed care plan or MediPass.

 2  School districts participating in the certified school match

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

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

 5  1011.70(1), for a Medicaid-eligible child participating in the

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

 7  409.9071, regardless of whether the child is enrolled in

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

 9  a good faith effort to execute agreements with school

10  districts regarding the coordinated provision of services

11  authorized under s. 1011.70. County health departments

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

13  381.0057 shall be reimbursed by Medicaid for the federal share

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

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

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

17  plans shall make a good faith effort to execute agreements

18  with county health departments regarding the coordinated

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

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

21  Department of Health, and the Department of Education shall

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

23  plan or MediPass provider receives information relating to

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

25  409.9071, and 1011.70.

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

27  the Centers for Medicare and Medicaid Services Health Care

28  Financing Administration to lock eligible Medicaid recipients

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

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

31  recipient may select another managed care plan or MediPass


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    CS for CS for SB 838                           Third Engrossed



 1  provider. However, nothing shall prevent a Medicaid recipient

 2  from changing primary care providers within the managed care

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

 4         Section 7.  Subsection (2) of section 409.913, Florida

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

 6  section, to read:

 7         409.913  Oversight of the integrity of the Medicaid

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

 9  activities of Florida Medicaid recipients, and providers and

10  their representatives, to ensure that fraudulent and abusive

11  behavior and neglect of recipients occur to the minimum extent

12  possible, and to recover overpayments and impose sanctions as

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

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

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

16  the Legislature documenting the effectiveness of the state's

17  efforts to control Medicaid fraud and abuse and to recover

18  Medicaid overpayments during the previous fiscal year. The

19  report must describe the number of cases opened and

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

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

22  overpayments alleged in preliminary and final audit letters;

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

24  reductions in overpayment amounts negotiated in settlement

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

26  determinations of overpayments; the amount deducted from

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

28  overpayments recovered each year; the amount of cost of

29  investigation recovered each year; the average length of time

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

31  overpayment is paid in full; the amount determined as


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    CS for CS for SB 838                           Third Engrossed



 1  uncollectible and the portion of the uncollectible amount

 2  subsequently reclaimed from the Federal Government; the number

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

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

 5  all costs associated with discovering and prosecuting cases of

 6  Medicaid overpayments and making recoveries in such cases. The

 7  report must also document actions taken to prevent

 8  overpayments and the number of providers prevented from

 9  enrolling in or reenrolling in the Medicaid program as a

10  result of documented Medicaid fraud and abuse and must

11  recommend changes necessary to prevent or recover

12  overpayments.

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

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

15  audits, or any combination thereof, to determine possible

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

17  Medicaid program and shall report the findings of any

18  overpayments in audit reports as appropriate. At least 5

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

20         (36)  The agency shall provide to each Medicaid

21  recipient or his or her representative an explanation of

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

23  recent address of the recipient on the record with the

24  Department of Children and Family Services. The explanation of

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

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

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

28  Medicaid in terminology that should be understood by a

29  reasonable person, and information on how to report

30  inappropriate or incorrect billing to the agency or other law

31  enforcement entities for review or investigation.


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    CS for CS for SB 838                           Third Engrossed



 1         Section 8.  The Agency for Health Care Administration

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

 3  on the legal and administrative barriers to enforcing section

 4  409.9081, Florida Statutes. The report must describe how many

 5  services require copayments, which providers collect

 6  copayments, and the total amount of copayments collected from

 7  recipients for all services required under section 409.9081,

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

 9  2004-2005 fiscal years. The agency shall recommend a mechanism

10  to enforce the requirement for Medicaid recipients to make

11  copayments which does not shift the copayment amount to the

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

13  laws or regulations that permit Medicaid recipients to declare

14  impoverishment in order to avoid paying the copayment and

15  extent to which these statements of impoverishment are

16  verified. If claims of impoverishment are not currently

17  verified, the agency shall recommend a system for such

18  verification. The report must also identify any other

19  cost-sharing measures that could be imposed on Medicaid

20  recipients.

21         Section 9.  The Agency for Health Care Administration

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

23  recommendations to ensure that Medicaid is the payer of last

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

25  report must identify the public and private entities that are

26  liable for primary payment of health care services and

27  recommend methods to improve enforcement of third-party

28  liability responsibility and repayment of benefits to the

29  state Medicaid program. The report must estimate the potential

30  recoveries that may be achieved through third-party liability

31  efforts if administrative and legal barriers are removed. The


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    CS for CS for SB 838                           Third Engrossed



 1  report must recommend whether modifications to the agency's

 2  contingency-fee contract for third-party liability could

 3  enhance third-party liability for benefits provided to

 4  Medicaid recipients.

 5         Section 10.  By January 15, 2006, the Office of Program

 6  Policy Analysis and Government Accountability shall submit to

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

 8  diversion pilot project authorized under sections

 9  430.701-430.709, Florida Statutes. The study may be conducted

10  by staff of the Office of Program Policy Analysis and

11  Government Accountability or by a consultant obtained through

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

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

14  methodology to assess the percent of persons served in the

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

16  nursing home services without the diversion services, which

17  services are most frequently used, and which services are

18  least frequently used. The study must determine whether the

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

20  program because a preponderance of the project enrollees would

21  not have required Medicaid nursing home services within a

22  2-year period regardless of the availability of the project or

23  that the enrollees could have been safely served through

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

25         Section 11.  The Agency for Health Care Administration

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

27  diversion programs who receive care at home have a

28  patient-responsibility payment associated with their

29  participation in the diversion program. If no system is

30  available to assess this information, the agency shall

31  determine the cost of creating a system to identify and


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    CS for CS for SB 838                           Third Engrossed



 1  collect these payments and whether the cost of developing a

 2  system for this purpose is offset by the amount of

 3  patient-responsibility payments which could be collected with

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

 5  Legislature by December 1, 2005.

 6         Section 12.  The Office of Program Policy Analysis and

 7  Government Accountability shall conduct a study of state

 8  programs that allow non-Medicaid eligible persons under a

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

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

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

12  that can be implemented in Florida which would provide access

13  to uninsured Floridians and what effect this program would

14  have on Medicaid expenditures based on the experience of

15  similar states. The study must also examine whether the

16  Medically Needy program could be redesigned to be a Medicaid

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

18  by January 1, 2006.

19         Section 13.  The Office of Program Policy Analysis and

20  Government Accountability, in consultation with the Office of

21  Attorney General, Medicaid Fraud Control Unit and the Auditor

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

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

24  abuse in the Medicaid prescription drug program. The study

25  shall focus on examining whether pharmaceutical manufacturers

26  and their affiliates and wholesale pharmaceutical

27  manufacturers and their affiliates that participate in the

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

29  prescription drugs, are inflating the average wholesale price

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

31  prescription drugs for Medicaid recipients. The study shall


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    CS for CS for SB 838                           Third Engrossed



 1  also focus on examining whether the manufacturers and their

 2  affiliates are committing other deceptive pricing practices

 3  with regard to federal and state rebates for prescription

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

 5  including findings and recommendations, shall be submitted to

 6  the Governor, the President of the Senate, the Speaker of the

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

 8  and the Minority Leader of the House of Representatives by

 9  January 1, 2006.

10         Section 14.  The sums of $7,129,241 in recurring

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

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

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

14  funds from the Administrative Trust Fund are appropriated and

15  11 full time equivalent positions are authorized for the

16  purpose of implementing this act.

17         Section 15.  The amendments made to section 393.0661,

18  Florida Statutes, by the Conference Committee Report on

19  Committee Substitute for Committee Substitute for Senate Bill

20  404 are repealed.

21         Section 16.  The amendments made to section 409.907,

22  Florida Statutes, by the Conference Committee Report on

23  Committee Substitute for Committee Substitute for Senate Bill

24  404 are repealed.

25         Section 17.  The amendments made to the introductory

26  provision only of section 409.908, Florida Statutes, by the

27  Conference Committee Report on Committee Substitute for

28  Committee Substitute for Senate Bill 404 are repealed.

29         Section 18.  Section 409.9082, Florida Statutes, as

30  created by the Conference Committee Report on Committee

31  


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    CS for CS for SB 838                           Third Engrossed



 1  Substitute for Committee Substitute for Senate Bill 404, is

 2  repealed.

 3         Section 19.  Section 23 of the Conference Committee

 4  Report on Committee Substitute for Committee Substitute for

 5  Senate Bill 404 is repealed.

 6         Section 20.  Subsection (2) of section 409.9124,

 7  Florida Statutes, as amended by section 18 of the Conference

 8  Committee Report on Committee Substitute for Committee

 9  Substitute for Senate Bill 404 is amended, and subsection (6)

10  is added to that section, to read:

11         409.9124  Managed care reimbursement.--

12         (2)  Each year prior to establishing new managed care

13  rates, the agency shall review all prior year adjustments for

14  changes in trend, and shall reduce or eliminate those

15  adjustments which are not reasonable and which reflect

16  policies or programs which are not in effect. In addition, the

17  agency shall apply only those policy reductions applicable to

18  the fiscal year for which the rates are being set, which can

19  be accurately estimated and verified by an independent

20  actuary, and which have been implemented prior to or will be

21  implemented during the fiscal year. The agency shall pay rates

22  at per-member, per-month averages that equal, but do not

23  exceed, the amounts allowed for in the General Appropriations

24  Act applicable to the fiscal year for which the rates will be

25  in effect.

26         (6)  For the 2005-2006 fiscal year only, the agency

27  shall make an additional adjustment in calculating the

28  capitation payments to prepaid health plans, excluding prepaid

29  mental health plans. This adjustment must result in an

30  increase of 2.8 percent in the average per-member, per-month

31  rate paid to prepaid health plans, excluding prepaid mental


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    CS for CS for SB 838                           Third Engrossed



 1  health plans, which are funded from Specific Appropriations

 2  225 and 226 in the 2005-2006 General Appropriations Act.

 3         Section 21.  The Senate Select Committee on Medicaid

 4  Reform shall study how provider rates are established and

 5  modified, how provider agreements and administrative

 6  rulemaking effect those rates, the discretion allowed by

 7  federal law for the setting of rates by the state, and the

 8  impact of litigation on provider rates. The committee shall

 9  issue a report containing recommendations by March 1, 2006, to

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

11  the House of Representatives.

12         Section 22.  This act shall take effect July 1, 2005.

13  

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